Maintenance Fluid

Ike Sri Redjeki

Department of Anesthesiology &

Reanimation Hasan Sadikin Hospital &
Medical Faculty of Pajajaran University
Bandung

Seorang penderita wanita usia 34 thn dengan BB

55 Kg datang ke UGD dengan trauma eksternal
didaerah tungkai ( perdarahan hebat dan ada
patahan tulang yang tampak dari luar)
a. pemeriksaan yang harus dilakukan
b. tindakan yang harus dlakukan
c. setelah syok diatasi jenis cairan apa yang akan
digunakan dan berapa jumlahnya
d. bila dilakukan pembedahan cairan mainenance
apa yg digunakan pascabedah

Fluid Therapy
To achieve normal perfusion,
electrolyte and water balance in
relation with stress condition
caused by pathologic condition

Fluid Therapy
Resuscitation

Maintenance fluid therapy

Nutrition

Maintenance Fluid Support

- Patient fasting with normal body fluid
composition
- Critically ill patients with altered body
fluid composition
- Perioperative losses ( Preoperative,
during the operation, postoperatively)

Estimating maintenance fluid requirements

Weight

Rate

For the first 10 kg

4cc/kgBW/h

For the next 10 20 kg

Add 2cc/kgBW/h

For each kg above 20kg

Add1cc/kgBW/h

Morgan , G.E, clinical Anesthesiology

2nd Ed 1996

Estimated Fluid Losses

Measurable
( Normal / Abnormal )
bleeding,diuresis, gastrointestinal, and
losses through drain
Unmeasureable :
insensible losses, sequesterisation
( third space losses)

Unmeasureable losses
Insensible losses :
1. Through the lung 0 - 8 cc/kgBW/day
2. From the skin
3. Surgical trauma / open wound

Third space losses ( Sequesterisation)

Most difficult type of fluid shift to
estimate

Fluid Intake /Output in Normal patients ( 70 Kg )

Water intake : 1400 - 1500 cc
Food

: 700 - 1000 cc

oxydation

: 300 - 400 cc

2400 - 3200

Urine : 1400 - 1800 cc

Feces :
2400 - 3200

100

cc

Skin

: 300 - 500 cc

lung

: 600 - 800 cc

Substrat nutrisi

Maintenance
fluid/electrolyte
requirements

Air cc/kgBB/hari

Jumlah
25 30 (kritis)
30 50

Energi
Kcal/kgBB/hari

25 30 (kritis)
30 50

As.Amino/prot
Gr/kgBB/hari

1 1,5

Na meq/kgBB/hari

1 -2

K meq/kgBB/hari

Glukosa : lemak

3:1 - 1;1

Normal Adult Water and Electrolyte

Requirement
(electrolyte meq/kgBW/day and water cc/m2)

Component

Minimal needs

Usual needs

Na

0,3

0,7-3,6

0,3 - 0,5

0,7 - 2,1

Ca

0,2

0,4 - 1,1

Mg

0,2 - 0,4

0,3 - 0,7

Cl

0,3

0,7 - 3,6

Water

870

1500

Composition of maintenance fluid

Type

Na

Cl

Ka En 3A

60

10

50

Ka En 3B

50

20

50

Ka En 1B

38,5

38,5

Ka En Mg3

50

50

Tuto fus ops

100

RL

131

20
18

90

112

Ca

Mg

Lact/Acet

Sugar

Lactat/20 Dext 27

4,5

Lactat/20 Dext/27
Dext/37,5
Lactat/20
-

Dext/100

Acetat 38

Sorbtl 50

Lactat/28

Patients 50 Kg Maintenance Fluid & Electrolyte

requirements

Water 35cc/Kg BW

50 x 35 = 1750 cc/day

Electrolyte :
Na 2 meq/Kg BW

100 meq/day

K 1 meq/KgBW

50 meq/day

Untuk 1750 cc Ka En Mg 3 :
Akan didapatkan :
Na 50 meq /l

1,75 x 50 =

Cl

87, 5 meq

87,5 meq

1,75 x 20 = 35 meq

Dextrose

1,75 x100 = 175 x 4 kcal = 700 kcal

l

Bila digunakan RL 1750 : Na 134 meq x 1, 750 = 245 meq

Cl 245 meq

dan

K 4 x 1,75 = 7 meq

Maintenance Fluid Therapy

Normal Maintenance Fluid requirements

+
Abnormal losses
Type of Fluid

!!!!

Essential Diagnostic Tests & Procedure

Volume :
- Assess skin turgor, mucous membranes, body
weight, urine output, blood pressure, pulse
- Invasive measurements : CVP, PCWP for fine
tuning in situations with significant
abnormality : Renal Failure, Heart Failure
- Mental Status

Composition :
- Measure serum electrolytes & serum
/urine osmolality, serum Glucose
- Assessment of osmolality to define
basic problem

Composition :
- Measure serum electrolytes & serum
/urine osmolality, serum Glucose
- Assessment of osmolality to define
basic problem

40

Normal Fluid distribution

Percent Of
Body Weight

30

20

Extracellular Fluid

Resuscitation

10

0
Adolph H. Giesecke,
Lawrence D. Egbert

IntraCellular
Fluid

InterStitial
Fluid

Plasma
Volume

Delivery O2 = COxHbxSpO2x1,34 +(0,003xPaO2)

C a r d ia c O u tp u t

p r e lo a d
L e ft v e n tr ic u la r
e n d d ia s to lic v o lu m e

a fte r lo a d

in tr a th o r a c ic p r e s s u r e

SVR =

80 x ( MAP CVP )
CO

CO = Stroke vol xHR

Intravascular Volume !!!

c o n tr a c tility

Initial Therapy :
Volume :
- Restoration of circulatory volume , goals of
therapy : sufficient of Delivery O2
- Type of fluid used : could be colloid,
hypertonic saline, etc

Distribusi cairan pada pemberian 1000 cc /70Kg BB

Cairan
Albumin 5%

I.vask
1000

interst

I. sel

D5

85

255

660

RL

200

800

NaCl 0,9%

275

825

- 100

NaCl 5%

990

2690

- 2950

NaCl 0,45%

141

567

292

Jenis2 cairan untuk mengisi volume

I.vaskuler
Jenis

Na

Cl

Ca

Mg

NaCl0.9%

154

154

Ring Lakt

138

112

Expafusin 138 125

Haes st
6% ,10%

154

154

Hemacel

145

145 5,1

6,25

Gelofusin

142

80

Dextran L

130

108

NaCl 3%

500

500

Lact/Acetat lain2

Lakt/28

Lakt/20

HES/40000

HES/200000

Polygeline

1,4

2,7

Lakt/28

Dextran40

Gelatin/35000

Body Composition Changes During

Catabolic State
Component
Body weight(kg)

Normal(%)

Catabolic(%)

70,4

58,9

Extra cellular
water (ltr)

25,6(36)

31,9 (54)

Body Cell
Mass(kg)

24,7(35)

14,7(25)

20,1 (29 )

12,3(21)

Body fat (kg)

40

Critically ill patients

30
PERCENT
OF
BODY

Third
Space

20

WEIGHT
10

0
Adolph H. Giesecke,
Lawrence D. Egbert

IntraCellular
Fluid

InterStitial
Fluid

Plasma
Volume

cell

Capillary arterial end

Organ / tissue

Wider Interstitial
space
Edema formation
leakage
Capillary system O2, Nutrient, ect

Interstitial hidrostatic
press

40
Percent Of
Body Weight

Dehydration
30

20

Extracellular Fluid

Diarrhea

10

0
Adolph H. Giesecke,
Lawrence D. Egbert

IntraCellular
Fluid

InterStitial
Fluid

Plasma
Volume

Distribusi cairan pada pemberian 1000 cc /70Kg BB

Cairan
Albumin 5%

I.vask
1000

interst

I. sel

D5

85

255

660

RL

200

800

NaCl 0,9%

275

825

- 100

NaCl 5%

990

2690

- 2950

NaCl 0,45%

141

567

292

Penentuan kebutuhan cairan dan elektrolit

ditentukan oleh :

Kebutuhan cairan dan komponen elektrolit

Berdasarkan keadaan ini dapat ditentukan

jenis cairan yang diperlukan
Osmolalitas cairan yang akan diberikan turut
menentukan pemilihan jenis cairan

Ringer Laktat

Ringer Laktat
Plasma

Na

Cl

Ca

Osms

bicnat

131

111

276

29

135

105

20 menit setelah pemberian iv akan

didistribusikan ke ruang interstisial
Expansi interstisial

290 +10

24

NaCl
Na

Cl

Osm

NaCl 0,9%

154

154

308

NaCl 0,45%

77

77

NaCl 3%

513

513

Plasma

135

108

1026
290 +10

Dex 5% : 252 mOsm/l

5% Dex /RL :

526 mOsm/l

5% Dex/NaCl 0,9% :

560 mOsm/l

5% Dex/NaCl 0,45% ;

406 mOsm/l

5% Dex/NaCl 0,225% :

329 mOsm/l

Ringer Solution :

- Na 147 meq/l
- Cl 155,4 meq/l
-K

4 meq/l

- Ca 4,4 meq/l
- Osmol : 308 mOsm/l

Tanpa laktat

Ringer Asetat:
Komposisi sama dengan RL tp
Laktat diganti dg Asetat

Na : 130 meq/l, Asetat 27meq/l

mmmol Cl : 110 meq/l

Pemilihan Cairan Berdasarkan :

- Macam Cairan
- Konsentrasi zat2 terlarut
- Status Hidrasi Pasien & Kelainan
Metabolik

Cairan Kristaloid :
- BM rendah
- tekanan onkotik rendah
- Efek mengisi ruang interstisial
- harga lebih murah & mudah didapat

Cairan Gula : mengisi ruang intraselular

Cairan Koloid : mengisi ruang intravaskuler

Cairan Isotonik
-

Konsentrasi partilkel dlm larutan =

dibandingkan dg konsentrasi partikel di
Cairan intraselular

- Tidak menyebabkan pembengkakan /

pengerutan sel & tidak ada pergerakan
cairan melalui membran yang
semipermiabel

Cairan Hipertonik:

- konsentrasi partikel dlm lar >

dibandingkan di intra sel
- Menyebabkan air dari intrasel keluar &
sel akan mengkerut

Cairan Hipotonik

- Konsentrasi partikel dalam lar <

dibandingkan Intrasel
- Dapat menyebabkan cairan dari extrasel
masuk ke intrasel & menyebabkan
pembengkakan sel

Osmolalitas :
Jumlah partikel yang osmotik aktif per liter
larutan
Osmolaritas :
Jumlah partikel yang osmotik aktif per
kilogram larutan
Tonicity :
osmolalitas serum yang effective ditentukan
oleh 2 zat terlarut : Na & Glucosa

Osmolality ( 280 - 300 mOsm/L )

mOsm/L = 2 x ( Na meq/l) +

( Glukosa mg%) / 18

+ (BUN mg%) / 2,8

90%

Tonicity ( 275 - 290 )

Maintenance to Full Nutrition

in critically ill patients

Start Low Go Slow

Precaution :

In recovery Phase :
Posibility of Over Hydration

40

30
PERCENT
OF
BODY

Sequestered
Edema

20

WEIGHT
10

0
Adolph H. Giesecke,
Lawrence D. Egbert

IntraCellular
Fluid

InterStitial
Fluid

Plasma
Volume