Dr. Akhmad Mahmudi, Sp BA

TERAPI CAIRAN,

ELEKTROLIT

DAN ASAM BASA

KOMPOSISI KIMIA TUBUH

LEMAK

MASSA TUBUH

NON LEMAK

73 % AIR

(Data dari Beddoe dkk 1984)

PRIA UMUR 40 TAHUN

LEMAK(TG):15 KgSubkutanIntermuskularIntraabdomenIntratorakalPROTEIN:12,8 KgMINERAL & GLIKOGEN4,2 KgAIR 42,1 KG

TOTAL BODY WATER ( ASHCRAFT )

UMUR%

Gestasional 12 minggu94

12 minggu 32 minggu80

Aterm

3-5 hari78

-3 5

Neonatus 75 - 80

Children 65 - 75

Young Man60

Young Woman50

Over 60 years man50

Over 60 years women45

Gangguan Cairan, Elektrolit dan Asam-Basa Perioperatif

PreoperatifPuasa terlalu lamaKehilangan cairan/elektrolitAsam-basa (Asidosis/alkalosis metabolik)Durante operatifKehilangan cairan/elektrolitAsam-basa (Respiratorik & Metabolik)PostoperatifKehilangan cairan (NGT,drain)Iatrogenik

DIARE

KEMBUNG

PROGRAM CAIRAN :

JUMLAH CAIRANJENIS CAIRANCARA PEMBERIANMONITORING

Replacement therapy

NGT atau drainThird-Space LossThe Quadrant Scheme (educated guesses)Setiap kuadran abdomen = + maintenanceDisesuaikan dengan pantauan keluaran urin.Trauma bedahRingan : + 1 2 ml/kg/jamSedang : + 4 ml/kg/jamBerat : + 6 ml/kg/jamKehilangan cairan diganti dengan komposisi hampir sama

Jumlah cairan :

1. Defisit cairan / dehidrasi

a. Dehidrasi Ringan : 5% ( 50ml/kgbb x TBW )

b . Dehidrasi Sedang : 10% (100ml/kgbb x TBW )

c. Dehidrasi Berat : 15% (150ml/kbbb x TBW )

* Tonisitas darah:Hipotonis,isotonis,hipertonis

2. Maintenance

Neonatus: 24 jam post operatif dikurangi 30%

3. Perkiraan cairan hilang dalam 24 jam

( on going loss )

2&3 modification to Fluid intake ( see table )

Dehidrasi

Derajat dehidrasiRingan 5%Sedang 10%Berat 15%Jenis dehidrasiIsotonik (Na 130 150 mEq/L)Hipotonik (Na 150mEq/L)

Dehidrasi

Kekurangan cairan akibat puasaKebutuhan cairan perjam x lama puasaRehidrasiTanda syok (atasi syok segera)Sisa cairan rehidrasi diberikanIsotonik : cepat (

MAINTENANCE ( ASHCRAFT )

* Daily Fluid Requirements

Weight Volume

Premature (< 2kg )150 ml / kg

Neonatus & infant (2-10 kg )100ml/kg for first 10kg

Infant & children (10-20kg )1000ml+50ml/kg over 10 kg

Children ( > 20 kg )1500ml+20ml/kg over 20 kg

Maintenance therapy

Jumlah cairan menurut Holliday Segar100/50/20 ml/Kg/hari atau4/2/1 ml/kg/jamElektrolit Na : 3 4 mEq/kg/hariK : 2 3 mEq/kg/hariCl : 3 4 mEq/kg/hari

Sheet1TABLE :MODIFICATION TO FLUID INTAKEDecreaseAdjustmentHumidified Inspired airX 0.75Basal state (eg pa ralysed )X 0.7High ADH (IPPV,brain injury )X 0.7Hypothermia- 12 % per CHigh room humidityx 0.7Renal failurex 0.3 (+urine output )Sheet2Sheet3

Increase

Full activity + oral feedsX 1.5

Fever+ 12 % per C

Room temperature > 31 C+ 30 % per C

HyperventilationX 1.2

Neonate - preterm (1-1.5 kg )X 1.2

- radiant heaterX 1.5

- photo terapyX 1.5

Burn - first day+ 4% per 1%

area burn

- Subsequently+ 2% per 1%

area burn

Sheet1STANDART PAEDIATRICMAINTENANCE SOLUTIONUMURLAR.KRISTALOID1-2 hariD10% ( tak boleh elektrolit )3-7 hariD5% NaCl 0,18 % *< 1 thD5% NaCl 0,225 % *< 10 thD5% NaCl 0,45 % ** Tambahkan Maintenance KCl 7,5 %Sheet2Sheet3

Sheet1Useful Intravenous Solutions CommerciallyAvailableSolutionDextroseNaClKLactateCagm/lmEq/lD5 %50-----D10 %100-----N/1-D550154154---N/2-D5507777---N/4-D55038.538.5---N/5-D5503131---R L-130108.74282.7Aminofusin Paed-301025-10Intra Lipid 10 %------Sheet2Sheet3

Sheet1TERAPI CAIRAN & NUTRISINAMA PRODUKElektrolit ( Meq / L )KALORIA AOsmNa +K +Ca ++Cl -( Kkal )( gr / L )( mOsm / L )ASERING13043109--273KA-EN 3 B502050108-290KA-EN MG3 ( 500 ml in 1000 ml )5020-50400-695AMIPAREN2----100888PAN ENTERAL 1 sachet----40030278ANJURAN PEMBERIAN TERAPI :HARI 1HARI 2HARI 3 - dst2 btl ASE + 2 btl KAEN 3 B4 btl KAEN 3 B2 btl KAEN 3B + SOLUMIX2 sachet PAN ENTERAL ( pagi & sore )2 sachet PAN ENTERAL ( pagi & sore )( AMI + KN MG3 )908 Kcal1016 Kcal3 sachet PAN ENT (pagi,siang,sore )1508 KcalPenggunaan OTSU NS/OTSU D5 (100 ml) utk. pemberian dgn int. IV drip :- ANTIBIOTIK- ANALGESIK- VITAMINSheet2KOMPOSISI LARUTAN ELEKTROLIT DAN NUTRISI YANG RASIONALPRODUKElektrolit ( mEq / L )DextroseSorbitolProteinBCAAVitKaloriKemasanOsmotikKeteranganNa +K +Ca++Mg++Cl -MaleatLaktatAsetatgr/Lgr/Lgr/L%Kcal/LmlmOsm/LKa En 1 B38.5---38.5---37.5----150500285RasionalKa En 3 A6010--50-20-27.0----108500290RasionalKa En 3 B5020--50-20-27.0----108500290RasionalKa En MG35020--50-20-100----400500695Rasional500/1000ASERING13043-109--28------500273RasionalPAN AMIN G----52----5027.27.9-308500507ASKESAMINOVEL 6003525-53822-35-100508.8+6005001320ASKESAMIPAREN2------120--10030-400500888ASKESNON RASIONALRASIONALKASUS PENYAKIT DALAM :N/4 - D5 ( D5 - 1/4 NS )Ka En 1 BHARI IASERING 4 BTLN/2 - D2.5 , N/2 - D5 ( D5 - 1/2 NS )Ka En 3 AHARI II + IIIKN 3B 2 BTL + PAN AMIN 2 BTLRD5, RL + D5Ka En 3 BHARI IV dstKN MG3 2 BTL+PAN AMIN / AMINOVEL / AMIPARENRL + D-10Ka En MG3( SESUAI KEBUTUHAN ) 2 BTLRLASERING ( RA )KASUS BEDAH ( POST OP ) :HARI IKN 3 B / KN MG3 4 BTLHARI II + IIIKN MG3 2 BTL + PAN AMIN G / AMIPAREN 2 BTLHARI IV dstKN MG3 2 BTL + AMIPAREN 2 BTLSheet3KOMPOSISI LARUTAN KA EN DAN ASERINGKOMPOSISI ELEKTROLIT ( mEq/L )NAMA PRODUKOSMOLARITASNa+Cl-K+Ca++AsetateLactate-GlukosaKaloriKEMASANmOsm/LKcal/LKaeN 1 B28238.538.537.5150500KaeN 3 A2906050102027108500KaeN 3 B2905050202027108500KaeN MG369550502020100400500500/1000Asering273.4130108.742.728500

Sheet1Distribution Comparative :KompartemenUmurNeonatusChildrenAdultCESPlasma : 1121Intersisil : 3CIS132Transeluler : 1 % - 3 % BBSheet2Sheet3

Sheet1ADH : antidiuretic hormoneIPPH : intermittent positive pressure ventilationINSENSIBLE WATER LOSSUmur Neonatus/kgbb/hrUmr/kgbb/hrUdara bebas tanpa kelembaban28 ccBayi50-60 ccHumidified isolette14 ccAnak40 ccPemanasan40 - 45 ccRemaja30 ccSheet2Sheet3

Sheet1Doses and Formulae in Paediatric Fluid andElectrolyte Therapy1. Albumin 25 %- Undiluted : 2 - 4 ml/kg- 5% in 5 % dextrose or saline : 10-20 ml/kg2. Bicarbonate( number of mmol of deficit )< 5kg : BE X wt ( kg ) X 1/2 (give 1/2 of this )> 5kg : BE X wt ( kg ) X 1/3 (give 1/3 of this )3. PotasiumMaximum 0,5 mmol/kg/h, requirement 2-4mmol/day, 1 g KCl = 13,3 mmol K+4. SodiumDepletion : ml 20% NaCl =Weight X 0,2( 140 - serum Na + ), requirement 2-6 mmol/kg/day. 1 g NaCl = 17,1 mmol/Na+5. Calcium- Chloride 10% (0,7mmol/l Ca++) max 0,2 ml/kg/iv stat. Requirement 1,5 ml/kg/day- Gluconate 10 % (0,22mmol/ml Ca++ )Maximum 0,5 ml/kgIV, Stat.requirement5 ml/kg/day6. Magnesium- Chloride 0,48 g/5ml (1mmol/ml Mg++ ):0,4mmol (0,4ml)/kg/dose slow IV 12 hourlySulphate 50% ( 2mmol/ml Mg ++ ):0,4mmol(0,2ml )/kg/dose slow IV 12 hourlySheet2Sheet3

Kasus 1
By laki-laki 3minggu, berat 4 kg ,ileo-ileostomi karena malrotasi (volvulus),cairan keluar dari penghisap orogastrik 75 ml, hematokrit 40v%, urine 120 ml.

Maintenance:Air :100ml/hari/kg x 4 kg = 400 ml/hariNa dan Cl : 3 mEq/kg/hari = 12 mEqK : 2 mEq/kg/hari = 8 mEqReplacement (orogastrik)Air : 75 mlNa: 70mEq/l = 5 mEqCl: 100mEq/L = 7,5 mEqK : 10mEq/L = 1 mEqReplacement (third-space loss)4 kuadran = 4 x maintenance = 400 mL

Kasus 1

MaintenanceOrogastrikThird-spaceAir (ml)40075400Na (mEq)125Cl (mEq)127,5K (mEq)81Cairan400 mlD5/0,25NS + 8 mEq KCl75 mlD5/0,5 NS + 1 mEq KCl400 ml RL atau D5/RL

Kasus 2.
Anak laki, 5 tahun, 20Kg 3 hari pascabedah splenektomi, kehilangan cairan orogastrik 24 jam sebelumnya 800 ml, urin 1200 ml

Maintenance Air 100/50/20 ml/kg/hari = 1500 ml Na 60 mEq/hari Cl 60 mEq/hari K 20 mEq/hariOrogastric lossAir 800 mlNa 56 mEq/800mlCl 80 mEq/800mlK 8 mEq/800mlThird-space LossTidak ada

Kasus 2

MaintenanceOrogastrikThird-spaceAir (ml)15008000Na (mEq)6056Cl (mEq)6080K (mEq)208Cairan1500 mlD5/0,25NS + 20 mEq KCl800 mlD5/0,5 NS + 8 mEq KCl0

TABLE : MODIFICATION TO FLUID INTAKE

Decrease Adjustment

Humidified Inspired air X 0.75

Basal state (eg pa ralysed ) X 0.7

High ADH (IPPV,brain injury ) X 0.7

Hypothermia - 12 % per C

High room humidity x 0.7

Renal failure x 0.3 (+urine output )

STANDART PAEDIATRIC

MAINTENANCE SOLUTION

UMURLAR.KRISTALOID

1-2 hariD10% ( tak boleh elektrolit )

3-7 hariD5% NaCl 0,18 % *

< 1 th D5% NaCl 0,225 % *

< 10 thD5% NaCl 0,45 % *

* Tambahkan Maintenance KCl 7,5 %

Useful Intravenous Solutions Commercially

Available

SolutionDextroseNaClKLactateCa

gm/lmEq/l

D5 %50-----

D10 %100-----

N/1-D550154154---

N/2-D5507777---

N/4-D55038.538.5---

N/5-D5503131---

R L-130108.74282.7

Aminofusin Paed-301025-10

Intra Lipid 10 %------

NAMA PRODUKOSMOLARITASNa+Cl-K+Ca++AsetateLactate-GlukosaKaloriKEMASAN

mOsm/LKcal/L

KaeN 1 B28238.538.537.5150500

KaeN 3 A2906050102027108500

KaeN 3 B2905050202027108500

KaeN MG369550502020100400500

500/1000

Asering273.4130108.742.728500

KOMPOSISI ELEKTROLIT ( mEq/L )

KOMPOSISI LARUTAN KA EN DAN ASERING

Distribution Comparative :

KompartemenUmur

NeonatusChildrenAdult

CESPlasma : 1121

Intersisil : 3

CIS132

Transeluler : 1 % - 3 % BB

ADH : antidiuretic hormone

IPPH : intermittent positive pressure ventilation

INSENSIBLE WATER LOSS

Umur Neonatus/kgbb/hrUmr/kgbb/hr

Udara bebas tanpa kelembaban28 ccBayi50-60 cc

Humidified isolette14 ccAnak 40 cc

Pemanasan 40 - 45 ccRemaja30 cc

Doses and Formulae in Paediatric Fluid and

Electrolyte Therapy

1. Albumin 25 %- Undiluted : 2 - 4 ml/kg

- 5% in 5 % dextrose or saline : 10-20 ml/kg

2. Bicarbonate( number of mmol of deficit )

< 5kg : BE X wt ( kg ) X 1/2 (give 1/2 of this )

> 5kg : BE X wt ( kg ) X 1/3 (give 1/3 of this )

3. PotasiumMaximum 0,5 mmol/kg/h, requirement 2-4

mmol/day, 1 g KCl = 13,3 mmol K+

4. SodiumDepletion : ml 20% NaCl =Weight X 0,2

( 140 - serum Na + ), requirement 2-6 mmol

/kg/day. 1 g NaCl = 17,1 mmol/Na+

5. Calcium- Chloride 10% (0,7mmol/l Ca++) max 0,2 ml

/kg/iv stat. Requirement 1,5 ml/kg/day

- Gluconate 10 % (0,22mmol/ml Ca++ )

Maximum 0,5 ml/kgIV, Stat.requirement

5 ml/kg/day

6. Magnesium- Chloride 0,48 g/5ml (1mmol/ml Mg++ ):0,4

mmol (0,4ml)/kg/dose slow IV 12 hourly

Sulphate 50% ( 2mmol/ml Mg ++ ):0,4mmol

(0,2ml )/kg/dose slow IV 12 hourly