Infus akan Rasional

bila paham 4 hal:

1. Indikasinya
2. Fisiologi infus saat masuk tubuh
3. Patofisiologinya yang sering
(Resusitasi vs Rumatan)
4. Pemilihan infus yang tepat

Lobo, Professor, et all; Espen, Barcelona, Spain; 2012

 PARENTERAL FLUID THERAPY

.
.
RESUSCITATION REPAIR MAINTENANCE PN

PERFUSION & CORRECT HOMEOSTASIS/ CORRECT

OXYGENATION ELECT & AB SUPPORTIVE NUTRITION ST
Asering, RL & NS INDIKASI

1L

Syok hipovolemik
Diare dengan dehidrasi berat
Muntah-muntah hebat
DSS
Perdarahan
ISF Luka Bakar
750 ml

250 ml Kedaruratan bedah

ICF
Plasma Intraoperatif
 Dextrosa & KAEN
INDIKASI
1L
MAINTENANCE

Pasien Rawat Inap:

Interna, Pediatric, Pulmonologi,
Cardiology, Obgyn, Neurologi
(Stroke)

225 ml Post Operative:

Surgery pts, Obgyn pts,
660 ml

85 ml
 DEHIDRASI
(ringan, sedang, DBD gr 1 atau 2)

Kehilangan air >> * Na+ loss > water loss

* Capillary leakage

Osmolalitas plasma Osmolality

Hypovolemia

Haus, mulut kering

Oliguria
Cemas/gelisah

Infus maintenance
Replacement Solution
Editorship: Yasuhiko Iino, Professor of Renal Internal Medicine, Nippon Medical School
 Dehidrasi Hipovolemia
(ringan, sedang hanya kurang asupan) (dehi
berat, DBD gr 3 atau 4)

Kehilangan air >> Kehilangan Na+ > air

* Capillary leakage

Osmolaritas plasma
Osmolalitas plasma Hipovolemia

Pusing
Haus, mulut kering mual/muntah
Oliguria saat berdiri berkunang
Cemas/gelisah /mau jatuh
Hipotensi

Infus maintenance Infus Resusitasi

Editorship: Yasuhiko Iino, Professor of Renal Internal Medicine, Nippon Medical School
 Dehidrasi Hipovolemia
(ringan, sedang hanya kurang asupan) (d
berat)

Kehilangan air >> Kehilangan Na+ > air

* Capillary leakage

Osmolaritas plasma
Osmolalitas plasma Hipovolemia

Pusing
Haus, mulut kering mual/muntah
Oliguria saat berdiri berkunang
Cemas/gelisah /mau jatuh
Hipotensi

Infus maintenance Infus Resusitasi

Editorship: Yasuhiko Iino, Professor of Renal Internal Medicine, Nippon Medical School
 DESIGN TERAPI CAIRAN IV

RESUSITASI RUMATAN

Infus Natrium > 100 mEq/L Natrium rendah (50-100 mEq)

Kalium sesuai keb. Harian
atau koloid
20-30 ml/kg/jam (diare, DSS) Tambahan mikromineral, trace
2-3 L/10-15 menit (perdarahan) Element dan as. amino
4:2:1 (misal 25 kg:
4 x10+2x10+1 x5 65ml/jam
500 ml/6 jam
 Historical Perspective of Infusion Preparation

Resuscitation Maintenance
Internal data: NCE surveys Banten Province Peripheral Hospitals
Fakta Resusitasi:
CAIRAN RESUSITASI YANG LAZIM DIPAKAI

Fluid Osm Intracell Risk of Lactate

distribution Hyperchloremic
acidosis
NS 308 - + -
(Cl- 154 mEq/L)
RL 273 - - +

RA 273 - - -

D5 278 + - -

RS 310 - + -
(Cl- 155.5 mEq/L)
Otsuka NCE internal surveys data, 2010***
Fakta maintenance:

RL
5% Dextrose
5% Dextr. in Ringers

Masih digunakan secara luas untuk

Terapi cairan maintenance*****

Kenapa ?
NS is not Physiologic ?
NaCl 0.9% tidak fisiologis ?

2
Usus bocor, fistel usus-kulit
Usus harus di-istirahatkan
Nutrisi harus lewat vena (NPE)
ASERING

First Line
Ringers acetate
Fluid Resuscitation Therapy

Acetate Ringers
Indications of ASERING

First line in replacement fluid for

resuscitation: gastroenteritis, burn,
hemorrhagic shock, DSS with or
whithout hepatic insufficiency
Intra operative
Priming solution for cardiopulmonary
bypass (CPB)
Safe replacement fluid for children
 KOMPOSISI

Elektrolit ( mEq ) Tek.Osmotik

+ + -
Na K Cl Ca2+ Asetat Laktat ( mOsm /L )

ASERING ( RA ) 130 4 109 3 28 - 274

RINGER LAKTAT ( RL ) 130 4 109 3 - 28 274

General Benefit

Average pH

Ringers lactate 6.75

ASERING 7

Normal saline 6.25

 Asering Benefit:

1. Komposisi mirip dengan plasma, tepat untuk menggantikan

kehilangan akut cairan ekstraseluler. ( 2 )
2. Kecepatan metabolisme asetat 250-400 mEq/jam , sedangkan
laktat 100mEq/jam, asetat lebih cepat mengkoreksi asidosis.( 3)
3. Asetat memerlukan sedikit O2 dan melepaskan sedikit CO2.( 4 )
4. Metabolisme asetat terutama di otot, tidak terganggu pada kelainan hati (1)

1. Loren A et al. Oxidation of lactate and acetate in rat skeletal muscle. Journal of Applied
Physiology 1997 ; 83 ( 1 ) : p. 32 - 39.
2. Heimberger DC,M.Roland RW. Handbook of Clinical Nutrition.Mosby 1997
3. Anderud T, Lund T. Intensive Care of Patients with Burns. Tidskr Nor Laegenforen 1989;
p.3197 - 3199.
4. Ringer acetate solution in clinical practice. Medimedia.1999
ASERING First Line
Ringers acetate Fluid Resuscitation Therapy

Direkomendasikan oleh W.H.O. untuk

pasien Demam Berdarah Dengue
(DBD).
W.H.O. SEA Dept. of Communicable Disease. Regional Guidelines
on Dengue / DHF Prevention and Controll. Regional Publ. 29. 1999.

Pada stroke akut, pemberian ASERING

sesuai dengan konsep menghindari LAKTAT.
Pencampuran ASERING dengan 20%
MgSO4 sebanyak 10 cc, akan meningkatkan
tonisitas infus menjadi ISOTONIK.
Hardi Pranata. Clinical Experience of Ringers acetate with Magnesium sulphate adminstration in
Acute Ischemic Stroke. Proceeding of PIT PERDOSSI. 2001.
Darmawan I. Parenteral Fluid Therapy in Stroke Patients. Proceeding of PIT PERDOSSI. 2001.
Rapid Water and Slow Sodium Excretion of Acetated
Ringers Solution Dehydrates Cells
Robert G. Hahn, MD, PhD, and Dan Drobin, MD, PhD
From the Department of Anesthesiology, Soder Hospital, S-118 83 Stockholm, Sweden

(Anesth Analg 2003;97:1590 4)

Acetated Ringers solution is a slightly hypotonic infusion fluid (osmolality 270

mosmol/kg) that has inspired the belief that the fluid causes a shift of water
volume to the intracellular space. We assessed the role of the kidney in
modifying this volume shift by infusing 25 mL/kg of Ringers acetate solution
(mean, 1565 mL) over a time period of 15, 30, 45, and 80 min on different
occasions in 5 healthy female volunteers. Regardless of the rate of
administration, the excreted urine contained only half as much sodium (mean,
67 mmol/L) as the infused fluid. As there was only a slight increase of
0.9 mmol/L in the serum sodium level, mass balance calculations indicated
that 274 mL of water had shifted from the intracellular to the extracellular
space 30 min after the infusions ended (P 0.001). This fluid shift
was also maintained over the subsequent 90 min.
In conclusion, infusion of Ringers acetate solution does not promote
cellular swelling as a result of the excretion of urine that is low in
sodium. A slight dehydration of fluid from the intracellular space still persisted
when our measurements ended 2 h after completing the infusion.
 AR as priming solution in CPB
Anesthesiology 2000 Nov;93(5):1170-3
Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M
Role of pump prime in the etiology and pathogenesis of
cardiopulmonary
bypass-associated acidosis.
Plasmalyte 148 vs Polygeline+ Ringer in 22 patients

With the Haemaccel-Ringer's prime, the metabolic acidosis was

hyperchloremic ( Cl-, +9.50 mEq/l; CI, 7.00-11.50).
With Plasmalyte, the acidosis was induced by an increase in unmeasured
anions, most probably acetate and gluconate. The resolution of these two
processes was different because the excretion of chloride was slower
than that of the unmeasured anions ( base excess from t1 to t3 = -1.60
for Haemaccel-Ringer's vs. +1.15 for Plasmalyte; P = 0.0062).
The metabolic comparison effects of ringers
acetate and ringers lactate on patients with
hemorrhagic shock do to trauma

Basrul Hanafi

Division of Digestive Surgery,

Faculty of Medicine, Padjadjaran University / Hasan Sadikin Hospital,
Bandung Indonesia
 Results

These result also demonstrated a tendencies for

severe shock patients (Grade III of ATLS) which had
resuscitation therapy,
that The lactate groups had lactate serum level higher
than the acetate groups.
And also demonstrated the severity of Modified
Siegels State of SIRS more higher in Lactate groups
compare to Acetate groups especially rise on patients
with grade III of ATLS.
 Obstetric Use

Acetated Ringer's solution is better than

lactated Ringer's solution
in rapid infusion before cesarean section
because of the correction of
neonatal lactic acidosis.

Onizuka S, Kawano T, Takasaki M, Sameshima H, Ikenoue T[ Comparison of the effect of

rapid infusion of lactated and that of acetated Ringer's solutions on maternal and fetal
metabolism and acid-base balance]. Masui 1999 Sep;48(9):977-80
 N Engl J Med 2012; 367:124-134July 12, 2012DOI: 10.1056/NEJMoa1204242

Hydroxyethyl Starch 130/0.42 versus Ringer's Acetate in Severe Sepsis

Anders Perner, M.D., Ph.D., Nicolai Haase, M.D., Anne B. Guttormsen, M.D., Ph.D., Jyrki Tenhunen, M.D., Ph.D., Gudmundur
Klemenzson, M.D., Anders neman, M.D., Ph.D., Kristian R. Madsen, M.D., Morten H. Mller, M.D., Ph.D., Jeanie M. Elkjr, M.D.,
Lone M. Poulsen, M.D., Asger Bendtsen, M.D., M.P.H., Robert Winding, M.D., Morten Steensen, M.D., Pawel Berezowicz, M.D., Ph.D.,
Peter Se-Jensen, M.D., Morten Bestle, M.D., Ph.D., Kristian Strand, M.D., Ph.D., Jrgen Wiis, M.D., Jonathan O. White, M.D., Klaus J.
Thornberg, M.D., Lars Quist, M.D., Jonas Nielsen, M.D., Ph.D., Lasse H. Andersen, M.D., Lars B. Holst, M.D., Katrin Thormar, M.D.,
Anne-Lene Kjldgaard, M.D., Maria L. Fabritius, M.D., Frederik Mondrup, M.D., Frank C. Pott, M.D., D.M.Sci., Thea P. Mller, M.D.,
Per Winkel, M.D., D.M.Sci., and Jrn Wetterslev, M.D., Ph.D. for the 6S Trial Group and the Scandinavian Critical Care Trials Group

In conclusion,
patients with severe sepsis who received fluid resuscitation with HES 130/0.42, as
compared with those who received Ringer's acetate, had a higher risk of death at 90
days, were more likely to receive renal-replacement therapy, and had fewer days
alive without renal-replacement therapy and fewer days alive out of the hospital.
DBD III & IV
O2 2-4 L/menit
RA/RL 20 ml/kg bolus dalam 30 menit

Syok teratasi Syok tidak teratasi

RA/RL 10 ml/kg/jam Teratasi Dextran 40 10-20 ml/kg

Tidak Teratasi
Stabil dalam 24 jam
RA 5 ml/kg/jam 3 ml/kg/jam Ht turun Ht tetap/naik
Stop < 48 jam FFP 10 ml/kg Dextran 20 ml/kg
Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999
 TERAPI CAIRAN

RESUSITASI RUMATAN

Kristaloid Koloid
Elektrolit NUTRISI

Aminofluid
Seri KA-EN

Mengganti kehilangan
1. Menjaga homeostasis harian
akut (hemorrhage,
2. Terapi suportif
GI loss, rongga ke3)
Memepercepat penyembuhan
Fakta:

RL
5% Dextrose
5% Dextr. in Ringers

are still widely used

for maintenance therapy *****

What are the impacts ?

Hypovolemic shock

Stable
Hemodynamic
Ilustrasi BB Dewasa (Org Indonesia) : 50 kg
Kebutuhan Air 2000 mL RL 2L KAEN 3B 2L
Natrium (1-2) 50 100 mEq 260 mEq 100 mEq
Kalium (1) 50 mEq 8 mEq 40 mEq

Infus RL bukan
Untuk Terapi Rumatan
1. Menata kebutuhan harian Kalium?
Renal Tubular Absorption
Na+K
K+ ALdosteron menyebabkan
retensi Na dan ekskresi K
Tubuh akan memprioritaskan
Na+ (air)
Juga ada feedback system,
di mana pada hiperkalemia
produksi aldosteron akan
distimulasi
Ini menjelaskan mengapa
pada muntah, kalium hilang
bukan hanya melalui muntah
melainkan juga ginjal
Deplesi kalium jarang terjadi
Bukan masalah bila pasien
makan pisang atau jeruk ???
 Intake kalium dari makanan rata-rata
orang Indonesia kurang adequate ??
(ilustrasi 200 mg setara dengan 60 mEq)

1. Sayuran
Kentang, buncis 500 gr
Kacang 5000 gr

2. Buah
Pisang 800 gr
Jeruk 1200 gr

3. Daging
Sapi atau ayam 600 gr
Halperin & Goldtstein. Fluid, Electrolyte and Acid Base Physiology.
WB Saunders Co. 2nd ed.p 358
 Prevalences of Hypokalemia
Chief Investigator Centre No of % hypokalemia % hypokalemia
patients on admission on Discharge

Untung Sudomo RSPAD 100 28 45

Djoko Widodo RSCM 105 22.9 52.4

Nasronudin RS Sutomo 110 36.36 50.91

1. Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy vol.5. Ed: Dec 2004. Page: 115-120
2. Widodo D, Setiawan B, Khie Chen. The prevalence of hypokalemia in hospitalized patients with infectious diseases problems at
Ciptomangun-kusumo Hospital Jakarta. Acta Med Indones, 2006;38(4):202-5
3. Nasronudin et al. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients. Medika 2006 Vol
XXXII,No 12, p 732-734
 RSCM
23%
 2

Departemen Neurologi FKUI/RSUPN Cipto Mangunkusumo

Prevalensi Hipokalemia pada Pasien dengan Kegawatan Neurologi di

Ruang Rawat Neurologi RSUPN Cipto Mangunkusumo
Aninditha T, Sitorus F, Ranakusuma TAS

Majalah Neurona, Vol.26, N0.2 Januari 2009, page: 11-17

Ditemukan pula 13 sampel mengalami hipokalemia (23,6%) pada hari

pertama dan 17 sampel pada hari kelima perawatan (30,9%).

Kesimpulan:
1. Prevalensi hipokalemia cukup sering terjadi pada pasien dengan kegawatan
neurologi.
2. Perlunya manajemen pemilihan jenis cairan yang mengandung K+ yang
cukup seperti KAEN 3B untuk menghindari perburukan neurologis lebih lanjut.
 Aminofluid

12/12/17
 AMINOFLUID

Glucose Amino acids

7.5 3%

Aminofluid

Electrolytes
(Na, K, Cl, Mg, Ca, P)
Zinc
By SS 2006-2007 53
 The First Line Maintenance Fluid Therapy for Hospitalized Patients

AMINOFLUID
Electrolytes, 7.5% Glucose, 3% Amino Acids
Practical and Complete Maintenance Solution for Better Clinical Outcome

Peran dan manfaat BCAA ( Leucine, Isoleucine & Valine ) :

Prekursor penting dalam sintesis glutamin dan

alanin di otot rangka

Leucine memacu sintesis protein

BCAA meningkatkan nafsu makan

(Kebutuhan harian BCAA : 144 mg/Kg/hari *)
* Roya Riazi all . The total BCAA Req. in young healthy adult men determined by indicator AA Oxid Phenylalanine. J.Nutr. 133 : 1383 1389 May 2003
 Take Home Message

1. Agar rasional memberikan infus pahami 4 hal: Indikasi, Fisiologi,

Patofisiologi dehidrasi dan hipovolemi, Sediaan infus yang ada
dipasaran.
2. Asering (AR) pilihan utama infus resusitasi dan memiliki kelebihan
dibanding RL atau NS, seperti: maintain suhu utama perioperatif,
DKA, CPB, mencegah asidosis laktat pada neonatus saat SC, Luka
bakar, dll
3. Kaen series di desain memenuhi kebutuhan maintenance dasar,
misal: KAEN 3B (Na+ 50 mEq, K+: 20mEq and glucose 27 gr) dan
Aminofluid maintenance lanjutan yang bisa mencegah anoreksia
serta fatique
4. Asering, KAEN 3B dan Aminofluid sudah masuk BPJS