Terapi Cairan Resusitasi

Iyan Darmawan
 . Terapi Cairan

RESUSITASI RUMATAN

Kristaloid Koloid
Elektrolit NUTRISI
RA Dextran KAEN group
RL/NS Gelatin

Repair
Mengganti kehilangan 1. Kebutuhan normal
akut (hemorrhage, (IWL + urin+ feses)
GI loss, rongga ke3) 2. Dukungan nutrisi
Jenis-Jenis larutan elektrolit

Larutan elektrolit Larutan elektrolit

Plasma
isotonik Hipotonik

290 308 273 278 290

Normal Ringer D5 KAEN 3B

saline asetat/ laktat
 Isotonic infusion
• Ringer’s acetate
1 L of • Ringer’s lactate
• Normal saline

Replace acute/
increases ECF abnormal
loss

ICF
ICF ISF
ISF Plasma
Plasma

800 ml 200 ml
 Hypotonic infusion

1 L of 5% dextrose

Replace
Replace Normal
Normal
increases ICF > ECF loss
loss (IWL
(IWL +
+ urine)
urine)

ICF
ICF ISF
ISF Plasma
Plasma

660
660 ml
ml 255
255 ml
ml 85
85 ml
ml
 Albumin infusion

500 ml L of Albumin 5%

Hemorrhagic
Hemorrhagic shock
increases intravascular Burn
Burn

ICF
ICF ISF
ISF Plasma
Plasma

250-750
250-750 ml
ml
 Albumin infusion

100 ml L of Albumin 25%

Hemorrhagic
Hemorrhagic shock
shock
increases intravascular Burn
Burn
Reserved
Reserved for
for patients
patients
in
in whom
whom ISF
ISF expanded
expanded
but
but intravascular
intravascular and
and
albumin
albumin is
is severely
severely
depleted
depleted
ICF
ICF ISF
ISF Plasma
Plasma

300-600
300-600 ml
ml over
over 30-60
30-60 min
min
 Plasma Expander infusion
500 m L of Dextran
HES

increases intravascular Hemorrhagic

Hemorrhagic shock
shock

ICF
ICF ISF
ISF Plasma
Plasma

750 ml at 1 hour; 1050 ml at 2 hr

Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 225
 Isotonic Crystalloid
• RA/RL/NS
• Umumnya dianjurkan jika Ht >
20%
• NS berpotensi menyebabkan asidosis
hiperkloremik*
• Kombinasi dg dekstrosa 5% (misal RA-
D5, RL-D5, NS-D5) diberikan jika
kecepatan infus < 10 ml/kg/jam

Clinical
Clinical Science
Science (2003)
(2003) 104,
104, (17–24)
(17–24) (Printed
(Printed in
in Great
Great Britain)
Britain)
 Isotonic Crystalloid
• Untuk Diare dg dehidrasi berat pilihan
terbaik adalah Ringer Asetat. Jika tidak ada
RA pilih RL

• Pada Muntah-muntah pilihan terbaik Normal

Saline atau Ringer

• Pada Syok hemoragik/DBD pertimbangkan

koloid setelah resusitasi awal dengan RA/RL
 TRAUMA

DAMAGE

TISSUE BLOOD VESSEL ORGAN

EDEMA BLEEDING IMPAIRED FUNCTION

HEMODYNAMIC DISTURBANCE

SHOCK
 HCT : 45% HCT : 27% HCT : 45%

4 Plasma

HCT : 45%
Liters 3

2
Cells

Acute 1 hour Saline Whole Blood

Hemorrhage later

Resuscitation
CLASSIFICATION OF HEMORRHAGIC
SHOCK

Classes I – IV
Not absolute
Clinical guidelines only
Further treatment is governed by patient’s
response
 Table 1. ESTIMATED FLUID AND BLOOD LOSSES *)

Based on Patient’s Initial Presentation

(For a 70 kg man)
CLASS I CLASS II CLASS III CLASS IV

Blood Loss (mL) Up to 750 750 – 1500 1500 – 2000 > 2000

Blood Loss
Up to 15% 15 – 30 % 30 – 40 % > 40 %
(% Blood Vol)

Pulse Rate < 100 > 100 > 120 > 140

Blood Pressure Normal Normal  

Pulse Pressure Normal or    

Respiratory Rate 14 – 20 20 – 30 30 – 40 > 35

Urinary Output
> 30 20 – 30 5 – 15 Negligible
(ml/hr)
Slightly Anxious, Confiused,
CNS / Mental Status Mildly anxious
anxious confused lethargic
Fluid Replacement Crystalloid and Crystalloid and
Crystalloid Crystalloid
(3:1 Rule) blood blood
 ASSESSMENT & MANAGEMENT

Airway and Breathing:

Oxygenate and ventilate
PaO2 > 80 mmHg
SaO2 > 95%

Circulation
Assess severity (Class I, II, III, IV)
Control bleeding
Treat underlying cause immediately
 ASSESSMENT & MANAGEMENT

Disability – Cerebral perfussion

Exposure/ Environment
related trauma
prevent hypothermia
Urine output (Foley catheter)
Gastric Decompression
 IV LINE MANAGEMENT

2 large-caliber peripheral IV’s (16 G)

Central lines
Femoral
Jugular
Subclavian

Intraosseous
Blood for crossmatching
 Kateter Pendek

200

Flow rate Kateter Panjang

(mL/menit)
100

Diameter 14 16 16 16 ga

Panjang 2 2 5,5 12 inci

 IV LINE MANAGEMENT

Warmed crystalloid solution

Rapid fluid bolus

Adult : 2 liters Ringer’s Acetate/ Lactate
Child : 20 ml/kg Ringer’s Acetate/ Lactate

Monitor response to initial therapy

Mencegah Menggigil!!
 15 % 40 %
5%
ISF ICF
IVF

Na K
Na
D5% Colloid

IVF ISF ICF IVF ISF ICF

RL / NS

IVF ISF ICF

 Table 2. RESPONSES TO INITIAL FLUID RESUSCITATION *)

Rapid Transient No
Response Response Response
Transient improve-
Vital Signs Return to normal ment; recurrence of Remain abnormal
 BP and  HR
Moderate and
Estimated Blood Minimal
ongoing Severe (>40%)
loss (10-20%)
(20-40%)
Need for more
Low High High
Crystalloid
Need for Blood Low Moderate to high Immediate
Type and Emergency blood
Blood Preparation Type – specific
crossmatch release
Need for Operative
Possibly Likely Highly likely
Intervension
Early Presence of
Yes Yes Yes
Surgeon

*)
*) 2000
2000 ml
ml RL
RL solution
solution in
in adults,
adults, 20
20 ml/Kg
ml/Kg RL
RL bolus
bolus in
in children
children over
over 10-15
10-15 min
min
 VOLUME REPLACEMENT

Warmed fluids
Crossmatch, PRBC
Type-specific
Type O, Rh-negative
Autotransfusion
Coagulopathy
 REEVALUATE ORGAN PERFUSION

MONITOR :
• Vital signs
• CNS Status
• Skin perfusion
• Urinary output
• Pulse oximetry
• End Tidal CO2
• Oxygen Extraction
• Acid base
 AVOIDING COMPLICATION

Fluid overload
Invasive monitoring (ICU)
CVP
Pulmonary artery catheter

Other problems :
Resuscitation induced haemorrhage
Post resuscitation injury
No – Reflow phenomenon
Reperfusion injury
 RESUSCITATION ENDPOINTS
• Adequate oxygen delivery; 1,5 kali normal
(120-160 ml/menit/m2)
• Systolic > 100 mmHg, diastolic > 50 mmHg
until orthostatic-induced changes have
disappeared
• Urine output > 0,5 ml/kg/jam
• Urine Natrium > 20 mEq/liter

Demling,
Demling, R.H; Wilson, R.F: Decision Making in Surgical Critical Care. B.C.
Decker
Decker Inc,
Inc, 1988.
1988. pp 63.
63.
 RESUSCITATION ENDPOINTS

• Hematocrit > 30; adequate peripheral perfusion

clinically
• Physiologically adequate perfusion:plasma lactate
within normal limits
(0,5-1,5 mEq/L), PO2  30 mmHg,
PAWP = 10-14 mmHg
• Maintained oxygen saturation
Demling, R.H; Wilson, R.F: Decision Making in Surgical Critical Care. B.C.
Decker Inc, 1988. p 63.
 TREATMENT OF HEMORRHAGIC SHOCK

Class II Class III, IV

Use RL/RA estimated requirement Fast bolus 3 L RL/RA (10-15 min)

(3 L)
Fast bolus 2 L RL/RA (10-15 min)
RESPONSE
BicNat when pH < 7,2

Moderate few
RESPONSE

Obvious Moderate Dextran 40 15-20 ml/kg

Transfusi Darah

RL/RA 1 L Dextran 40 3-5 ml/kg Theatre

Thank you