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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 KGTOTAL 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)IatrogenikDIARE
KEMBUNG
PROGRAM CAIRAN :
JUMLAH CAIRANJENIS CAIRANCARA PEMBERIANMONITORINGReplacement 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 samaJumlah 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/hariIncrease
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
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.
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/RLKasus 2.
Anak laki, 5 tahun, 20Kg 3 hari pascabedah splenektomi, kehilangan
cairan orogastrik 24 jam sebelumnya 800 ml, urin 1200 ml
Kasus 2
MaintenanceOrogastrikThird-spaceAir (ml)15008000Na (mEq)6056Cl (mEq)6080K (mEq)208Cairan1500 mlD5/0,25NS + 20 mEq KCl800 mlD5/0,5 NS + 8 mEq KCl0TABLE : 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