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Disorders of Electrolytes
(in surgical patients)
TAV/ARZ
Pendahuluan
Penatalaksanaan cairan dan elektrolit sangat
esensial dalam perawatan kasus bedah
(perioperative care)
Gangguan keseimbangan tersebut dapat terjadi
pre,intra&post (operasi)
Sering menyertai pada kasus2 critical ill
(trauma & sepsis)
Topik ini dikhususkan hanya pada gangguan
keseimbangan elektrolit
Na dan K merupakan elektrolit utama yang
perlu pembahasan
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ECF 20%
IVF
5%
Natrium
Fungsi Natrium
Regulasi osmolalitas plasma
Mengatur permeabilitas membran sel
Berperan dalam konduksi impuls dan saraf
Kadar normal : 135 -145 mEq/L
Kebutuhan per hari: 2-4 mEq/kgBB/hari
Hyponatremia
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Manifestasi klinis
Sistem organ
Central nervous system
Musculoskeletal
Gastrointestinal
Cardiovascular
Tissue
Renal
Hyponatremia
Nyeri kepala, confusion, hyper-or hypoactive deep tendon
reflexes, kejang, koma, peningkatan TIK
Kelemahan, kelelahan otot, muscle cramps/twitching
Anorexia, nausea, vomiting, diare
Hypertension and bradycardia
Lacrimation, salivation
Oliguria
Diagnostic
Approach
ECF
Osmolalitas
ECF N
ECF
Osmolalitas
N
No spesific therapy
Osmolalitas
Treatment
Urea(antinatriuretic&osmotic diuresis):40mg in 150cc
normal saline IV every 8h
Hypertonic saline
Loop diuretik
Vasopressin antagonis(aquaresis than diuresis):conivaptan
20-40 mg daily
Severe hiponatremi (Na<120meq/l): correction!
Total Na required: Na desired-Na measured X TBW
TBW : male 0,6 X weight(kg); female 0,5 X weight(kg)
*maximum correction is 8-12 meq/day or 130 meq after correction
*Asymptomatic : increase the sodium level by no more than 0.5-1
meq/L/h
*Symptomatic: (Na<120 meq/L) Increase the sodium level by no more
than 1meq/L per hour until the serum Na level reaches 130 meq/L or
neurologic symptoms are improved
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Rapid correction of
hyponatremia
Seizures, weakness/paresis,
akinetic movements,
unresponsiveness
Death
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Hypernatremia
Iatrogenic
Selalu hiperosmoler
Respon tubuh: haus dan release ADH
Etiologi
Renal
Non
Renal
Diare
Insensible losses (fever &
burn)
Free water
loss
Sodium
intake
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Manifestasi klinis
Body system
Central nervous system
Musculoskeletal
Cardiovascular
Tissue
Renal
Metabolic
hypernatremia
Restlessness, lethargy, ataxia,
irritability, tonic spasms,delirium,
seizures, coma
weakness
Tachycardia, hypotension,
syncope
Dry sticky mucous membranes,
red swollen tongue,decreased
saliva and tears
Oliguria
Fever
Diagnostic
Approach
Terapi Hipernatremia
Free water
loss
Sodium
intake
Diuretik (furosemide)
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Kalium
Kation terbanyak di tubuh(98% intraseluler)
Keseimbangannya diatur oleh Na-K ATPase
pump
Ekskresi terbanyak melalui ginjal
Uptake-nya di intraseluler dipengaruhi oleh
insulin dan beta2 reseptor
Fungsi Kalium: eksitabilitas membran dan
fungsi sel
Kadar normal kalium: 3,5 5 mEq/L
Kebutuhan per hari : 1 mEq/kgBB/hr
Kalium
Rata-rata kebutuhan K per hari: 50-100meq/d
Rata-rata ekskresi melalui ginjal: 10-700meq/d
Kadar K dipengaruhi oleh:
Surgical stress
Injury
Acidosis
Tissue catabolism
Penyebab hipokalemia
Intake yg inadekuat:
GI / renal losses:
hypokalemia
Ileus, constipation
Decreased reflexes, fatigue, weakness,
paralysis
Arrest
U-waves
T-wave flattening
ST-segment changes
Arrhythmias
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Penyebab hiperkalemia
Peningkatan intake:
Potassium supplementation
Blood transfusions
Endogenous load/destruction:
Hemolysis atau rhabdomyolysis
Crush injury
Gastrointestinal hemorrhage
peningkatan release:
Acidosis
Rapid rise of extracellular osmolality (hyperglycemia or mannitol)
Impaired excretion:
Potassium-sparing diuretics
Renal insufficiency/failure
System
hyperkalemia
Gastrointestinal
Neuromuscular
Cardiovascular
ECG changes
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Shift potassium
Glucose 1 vial of D50% and regular insulin 5-10 units intravenous
Bicarbonate 1 vial intravenous
Calcium
Fungsi utama:
Transmisi impuls saraf
Kontraksi otot jantung
Faktor pembekuan darah
Pembentukan gigi dan tulang
Kontraksi otot
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http://lpi.oregonstate.edu/infocenter/minerals/calcium/capth.html
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Kalsium
Hiperkalsemia
Gejala: Gangguan neurologis, kelemahan otot dan nyeri, disfungsi renal, mual,
muntah, nyeri perut, hipertensi, aritmia, peningkatan toksisitas terhadap obat2an
digitalis
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Hipokalsemia
penyebab: pancreatitis, infeksi soft tissue yang luas, gagal
ginjal,fistula enteral, hypoparathyroidism, tumor lysis syndrome,
massive blood transfusion with citrate binding
Gejala: parestesia wajah dan ekstremitas, kram otot, stridor,
tetani, kejang, hyperreflexia, Trousseaus sign, Chvosteks sign,
penurunan kontraktilitas jantung, gagal jantung
EKG : prolonged QT interval, T wave inversion, heart block, Vfib
Koreksi hipokalsemia
Normalized calcium level <4.0 mg/dL:
With gastric access and tolerating enteral
nutrition:
Calcium carbonate suspension 1250 mg/5 mL q6h
per gastric access;
Recheck ionized calcium level in 3 d
Without gastric access or not tolerating enteral
nutrition:
Calcium gluconate 2 g IV over 1 h x 1 dose;
Recheck ionized calcium level in 3 d
IVF Composition
Solution
Na CL K
HCO3 Ca
Mg mOsm
Extracellular
fluid
142 103 4
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Lactated
Ringer's
130 109 4
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0.9% Sodium
chloride
154 154
280310
273
308
D50.45%
77 77
Sodium chloride
407
D5W
253
3% Sodium
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Kebutuhan harian
Sodium: 1-2 mEq/kg/d
Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/d
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Diagnosis?
HYPERKALEMIA
Treatment
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HYPOCALCEMIA
Chvosteks sign facial muscle spasm
Trousseaus sign - carpal spasm
Treatment
monitor ECG
IV calcium (ca gluk. 10cc)
follow up labs
oral calcium supplements
normal is 1 gram/day
(800-1200mg/d)
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Na 115 mEq/L
HIPONATREMIA
dilutional(hiper
volemi)
Terapi:
1. 0,6 x 70kg x (125-115)= 420 meq (kebutuhan total)
2. kecepatan pemberian perjam tidak boleh lebih dari 0.5 meq/L/jam
: 0.6 x 70kg x 0.5 meq/l/jam = 21 meq/jam (maksimal)
3. 3% Nacl mengandung Na 513 meq/Liter
[ rate/jam ]/513 x 1000= # ml/hr
Maka : 21 meq/jam x 1000 ml = 40,93 ml/jam
513 meq/L
Lama pemberian = 420 meq : 21 meq/jam = 20 jam
Order: infuse Nacl 3% 40 ml/jam selama 20 jam. (800ml/20jam)
4. selesai koreksi lanjutkan dengan restriksi cairan
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HIPERNATREMIA
(Insensibl
e loss)