Otsuka Cairan.ppt

8/10/2019 Otsuka Cairan.ppt

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RASIONALE TERAPI CAIRAN

Dr. Budhi Santoso

Medical Consultant PT Otsuka Indonesia


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Replace

Maintain

Repair

Abnormal loss: GIT, 3rdspace,Ongoing loss, septic and

Hypovolemic shock

IWL + urine

Acid base,electrolyte imbalances

BASIC PRINCIPLES


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Rational Fluid Regimen

Correct timing

Correct indications, dosage

Correct product (composition,concentration)

Tailored to patients fluid andelectrolyte status, not diagnosis

Good monitoring Cost-effective


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TERAPI CAIRAN

RESUSITASI

KOLOID NUTRISI

Menggantikan

kehilangan akut

cairan tubuh

OTSUTRAN - L

Memelihara

keseimbangan

cairan tubuh

dan nutrisi

KA-EN 1B

KA-EN 3A

KA-EN 3B

KA-EN 4AKA-EN 4B

AMIPAREN

AMINOVEL- 600

PAN- AMIN G

KA-EN MG 3

MARTOS 10

RUMATAN

KRISTALOID

ELEKTROLIT

ASERING

Otsu- RL

Otsu- NS

Repair


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Pemilihan Cairan

Dehidrasi akut, hipovolemia, syok,hiponatremia

Hiponatremia, hipokloremia (muntah-muntah hebat)

Ringer Laktat/Ringer Asetat

Normal Saline, Ringer Solution

Mengapa ? ? ?


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RL/RA NS RS(Ringer Asetat/Laktat) (NaCl 0,9%) (Ringer solution)

Na+ 130 mEq/L 154 147K+ 4 mEq/L - 4Cl- 109 mEq/L 154 155,5

Cairan Pengganti:

Cairan universal untukResusitasi, intraoperatif

Pada kasus hipokloremia(muntah refrakter)


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Asering, RL & NS

1 L

800 ml

200 ml

Syok hipovolemikDiare dengan dehidrasi beratMuntah-muntah hebatDSSPerdarahan

Luka Bakar

Kedaruratan bedah

Intraoperatif

INDIKASI


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Ringers

acetate

Ringers acetate

First Line

Fluid Resuscitation Therapy

ASERING


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LACTATE: Primarily in the liver, and to lesser degree

the kidney, lactate is metabolized to pyruvate, whichis then converted to CO2and H2O (80%) or glucose(20%), and regeneration of bicarbonate1

ACETATE: metabolized mainly in muscles and to a

lesser extent in tissues such as kidney, heart andliver2

Acetate + H+--------Acetyl-CoA

Coenzyme A

Carbonic acid --------bicarbonate

hydrogen source

Krebs cycle

Ref. 1.Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4thed 1994 p 554

2. Maxwell MH, Kleeman CR, Narins RG. Clinical Disorders of Fluid and Electrolyte Metabolism.MacGraw-Hill 1987 4thedition p 1063

ASERING& LR


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1. SODIUM LAKTAT ( HATI )

CH3CH(OH)COONa + CO2+H2ONaHCO3 + CH3CH(OH)COOH ( Laktat )

CH3CH(OH)COOH + 3 O2 3 CO2+ 3 H2O : TCA Cycle

2. SODIUM ASETAT ( OTOT )

CH3COONa + CO2+H2O

CH3COOH + 2 O2 2 CO2+ 2 H2O : TCA Cycle

NaHCO3 + CH3COOH ( Asetat )

GLUkOSA

GLIKOGENG - 6 - PL- LAKTAT

PIRUVAT

LDH

Asetil KoA

sintetase

ASETAT Asetil - KoA

2 CO2 TCA Cycle H2O

BIOMOLEKULER ASERING& RL


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Replacement fluid for resuscitationgastroenteritis, burn,hemorrhagic shock, DSS

Intraoperative

Priming solution for cardiopulmonarybypass (CPB)

Replacement fluid for children

Indications of ASERING


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Ringers lactate 6.75

ASERING 7

Normal saline 6.25

Average pH


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J Clin Anesth1998 Feb;10(1):23-7

Kashimoto S, et al

Comparative effects of Ringer's acetate and lactate solutions on

intraoperative central and peripheral temperatures.

PATIENTS: 60 ASA physical status I and II patients undergoing

general surgery.

INTERVENTIONS: Following induction with 5 mg/kg of thiamylaland 0.1 mg/kg of vecuronium, patients were randomly assigned to one

of four groups (15 patients per group).

They received inhalation anesthetics (66% nitrous oxide [N2O] and

1.0% to 2.0% isoflurane or 1.3% to 2.6% sevoflurane) and LR or AR

Effect on Core Temperature


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Comparative Effects of Ringers Acetate (Asering)

and Ringers Lactate on core temperature and thefrequency of shivering in cesarean Section under

Subarachnoid Anesthesia

Susilo Chandra/Eddy Harijanto/Bram

Departement of Anesthesiology and Intensive Therapy

University of Indonesia, School of Medicine,Jakarta

2006


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Study results : Core Temperature

Minutes Ringers lacatate Ringers acetate Significance(p)

(Asering)

Before SAB 36.010 + 0.901 36.325 + 0.809 > 0.05

After SAB 35.858 + 0.778 36.165+ 0.719 > 0.05

5 35.740 + 0.769 36.215 + 0.787 < 0.05

10 35.585 + 0.755 36.120 + 0.773 > 0.05

15 35.475 + 0.747 35.940 + 0.800 > 0.05

20 35.440+ 0.715 35.800 + 0.750 > 0.05

25 35.400 + 0.715 35.675 + 0.665 > 0.05

30 35.363 + 0.501 35.670 + 0.596 > 0.05

35 35.217 + 0.547 35.522 + 0.825 > 0.05

40 35.194 + 0.563 35.576 + 0.699 > 0.05

45 35.018 + 0.615 35.476 + 0.721 > 0.05

50 34.806 + 0.725 35.465 + 0.717 < 0.05

55 34.756 + 0.841 35.481 + 0.717 < 0.05

60 35.010 + 0.829 35.350 + 0.717 > 0.05

65 34.417 + 0.674 35.282 + 0.806 < 0.05

70 34.733 + 0.404 35.225 + 0.850 > 0.05

75 34.733 + 0.379 34.833 + 0.720 > 0.05


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Incidence of shivering

* p


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Degree 0 1 2 3 4 Total

RingersAcetate(n)

15 1 1 3 0 20

Ringer s

Lactate(n)11 1 8 0 0 20

df = 3 p= 0.029

Patient Distribution based on Severity ofShivering after 20 minutes observation

Severity of shivering is less significantly in Asering group in 20 minutes


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Conclusion

Ringers Acetate (Asering) maintains coretemperature better than Ringers lactate in

pregnant women undergoing cesareansection under subarachnoid anesthesia,significantly on 5th, 50th, 55th, 65thminutes

Although there is no significant difference in

the severity of shivering between the twogroups, Ringers lactate is associated withearlier occurrence of shivering thanAsering


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Masui 1999 Sep;48(9):977-80Onizuka 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 andacid-base balance].

20patients; combined spinal and epidural

25 ml/kg/hrAcetated Ringer's solution is better thanlactated Ringer's solution in rapid infusion

before cesarean section because of the

correction of neonatal lactic acidosis.

Asering in Obstetric Use


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Anaesthesia 1994 Sep;49(9):779-81

McFarlane C, Lee A

A comparison of AR and 0.9% saline for intra-operative fluid

replacement.

The exclusive use of 0.9% saline intra-operatively can produce a

temporary hyperchloraemic acidosiswhich could be givenfalse pathological significance. In addition it may exacerbate an

acidosis resulting from an actual pathological state. The use of abalanced salt solution such as AR may avoid these complications.

AR more suitable as intraoperative fluid vs NS


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Anesthesiology 2000 Nov;93(5):1170-3Liskaser 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).

AR as priming solution in CPB


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Asering pada Bayi dan Anak

RA bisa digunakan pada anak dan bayi

Diindikasikan untuk resusitasi cairan

Ref: 1. Neonatal Hypernatremic Dehydration Secondary to Lactation Failure

J Am Board Fam Pract 14(2):159-161, 2001. 2001 American Board of Family Practice

2. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938.

3. Guidelines for treatment of DKA, Swedish Pdiatric Association 19964. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva :

World Health Organization. 1997

5. Communicable Disease Epidemiology Office of Epidemiology Washington State Department

of Health.


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2. Asering pada Ketoasidosis Diabetik

Resusitasi cepat NaCl 0,9% 12.5 ml/kg/jam selama 0-2 jam

sampai sirkulasi tepi pulih

Fase rehidrasi lambat selama 48 jam dengan Ringer Asetat

(Rumatan + 5% BB/24 jam)

Rumatan

Ref. Ragnar Hanas. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996


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SECONDARY DENGUE INFECTION

VIRUS REPLICATION ANAMNESTIC ANTIBODY RESPONSE

VIRUS ANTIBODY COMPLEX

COMPLEMENT ACTIVATIONMACROPHAG

CYTOKINES:Anafilatoksin C3a, C5aIl-1, Il-6, Il-12, INF, TNF, LIF

VASCULAR PERMEABILITY

LEAKAGE OF PLASMA

HYPOVOLEMIA

SHOCK


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JENIS CAIRAN (WHO-1998)3.1. Kristaloid:

3.1.1. Ringer Laktat (RL)dekstrose 5% + RL (D5/RL)

3.1.2. Ringer asetat (RA)

dekstrose 5% + RA (D5/RA)3.1.3. NaCL 0,9%

dekstrose 5% + NaCl 0,9%

3.2. Koloid:Dekstran 40 dalam RLPlasma

3. Asering pada DBD dengan Syok


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DBDIII & IVO22-4 L/menit

RA/RL 20 ml/kg bolus dalam 30 menit

Syok teratasi Syok tidak teratasi

RA/RL 10 ml/kg/jam

Stabil dalam 24 jam

RA 5 ml/kg/jam 3 ml/kg/jam

Stop < 48 jam

Dextran 40 10-20 ml/kgTeratasi

Tidak Teratasi

Ht turun Ht tetap/naik

FFP 10 ml/kg Dextran 20 ml/kg

Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999


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KONKLUSI MANFAAT ASERING

Aman digunakan pada anak & bayi.

Diindikasikanuntuk resusitasi ( misal: kasus dehidrasi berat, Syok DBD,burn, dll)

Indikasi yang lain:3.a. Maintenance DKA pada anak3.b. Mencegah risiko bayi post sectio dari asidosis laktat

3.c. Maintain suhu sentral lebih baik3.d. Dibanding NaClRisiko hiperkloremia asidosis lebih minimized3.e. Dibanding koloid tidak ada risiko perdaraha dan lebih cost effective

References:

1. Anesthesiology 2000 Nov;93(5):1170-3 Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M.

2. Communicable Disease Epidemiology Office of Epidemiology Washington State Department of Health.3. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938.

4. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva :World Health Organization.1997

5. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996

6. McFarlane C, Lee AA comparison of AR and 0.9% saline for intra-operative fluid replacement.

7. Neonatal Hypernatremic, Dehydration Secondary to Lactation Failure, J Am Board Fam Pract 14(2):159-161, 2001. 2001 American

Board of Family Practice.

8. 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

9. Tollofsrud S, et al. Fluid balance and pulmonary functions during and after coronary artery bypass surgery: Ringer's acetate compared

with dextran, polygeline, or albumin. Acta Anaesthesiol Scand 1995 Jul;39(5):671-7


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Situasi Cairan Rumatan di

sebagian RS Penggunaan infus belum customized

Kebanyakan diserahkan ke paramedik Isi dan Pemilihan Cairan tidak jelas

Sering confused antara RLD5 dan RD5

Na+ 130 147Cl- 109 155,5

K+ 4 4

*Otsuka NCE internal data


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RESUSITASI RUMATAN

TERAPI CAIRAN IV

Infus Natrium > 100 mEq/Latau koloid20-30 ml/kg/jam2-3 L/10-15 menit

Natrium rendah4:2:1

(misal 25 kg:4 x10+2x10+1 x5 65ml/jam

500 ml/6 jam

KECEPATAN PEMBERIAN TIDAK SAMA DENGAN

DOSIS HARIAN !!


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Perlu mengetahui berapa kebutuhan air, elektrolit(Na+,K+)

Perlu mengetahui status Natrium dan kalium serum

Perlu mengetahui kecepatan infus K+

, dekstrosa, lipid, AA

air 30-50 ml/kg; Na+2 mEq/kg K+1 mEq/kg

Na+135-145 mEq/L; K+3,5-5 mEq/L

K+< 20 mEq/jam*(5-10 mEq/jam); dekstrosa


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Normal Potassium intake recommended by American diet society


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Asupan K+< 10 meq/hari

Defisit Kumulatif 250-300 mEq dalam 7-10 hari

Tannen R.L: Potassium Disorders. In Kokko & Tannen. Fluid and Electrolytes.WB Saunders Company 3rded, pp 123


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Management of Severe Hypokalemia

in hospitalized Patients 866 patients with Serum K+< 3 mmol/L

at admission

55 (6.4%) had no subsequentmesurement of potassium levels

260 (30%) were discharged with

subnormal potassium level

JAMA Vol. 161 No. 8, April 23, 2001

Inadequate clinical management of hypokalemia


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Hipokalemia

Insidens 20% pada pasien rawat-inap (US)*

Pada diare & malnutrisi

Penyebab bervariasi

Implikasi pada penyakit kardiovaskular:hipertensi, potensi intoksikasi digitalis,CABG

Pemberian Infus yg mengandung kalium 20mEq/L umumnya diperlukan pada pasienrawat-inap

Zwanger M. Hypokalemia. emedicine.com/emerg/topic273.html


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Hypokalemia di Indonesia

Limitted incidence/prevalence data

Insiden di RSPAD Gatot Soebroto, bagian

penyakit dalam = 28 % Peningkatan tendency pasien rawat inap

dengan hipokalemia = 17,5 % (saat masuk27 ps, dan saat keluar menjadi 45 pasien)

Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy

vol.5. Ed: Dec 2004. Page: 115-120


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Mengapa hipokalemia kurangdiperhatikan?

Gejala tidak spesifik dan umumnya baru

muncul pada kadar K+< 3 mEq/L

Pada pasien non-kardiak tidak dimonitorketat

Fasilitas Lab tidak memadai

Awareness


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Still widely used for maintenance therapy

RL

5 Dextrose

5 Dextr. in Ringers

What are the impacts ?


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KOMPOSISI


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KOMPOSISI

ALTERNATIF PENGGANTI

Product Name Osmolarity Electrolyte (mEq / L ) Glucos

(mOsm/L) Na+ K+ Ca++ CI- Laktat- Asetat - ( g / L

DGAA 296 61 17.5 52 26.5 25

KA - EN 3B 290 50 20 50 20 27

N/2 - D2.5 (2A), 0.45% NaCl & D2.5% + KCl 10 mEq 308 77 10 77 25

KA - EN 3A 290 60 10 50 20 27

N/4 - D5 (4:1) 282 38.5 38.5 50

KA - EN 1B 285 38.5 38.5 37.5

N/4 - D5 (3:1), 0.225% NaCl & D5% 353 38.5 38.5 50

KA - EN 1B 285 38.5 38.5 37.5

N/5 - D4 353 30 30 40

KA - EN 4A 282 30 20 10 40

KA - EN 4B 284 30 8 28 10 37,5

Ringer Laktat (RL) 273 130 4 3 109 28

Ringer asetat (ASERING) 273 130 4 3 109 28

5% Dext in Ringer laktat (RLD5) 551 130 4 3 109 28 50

5% Dext in Ringer asetat (Asering 5) 551 130 4 3 109 28 50


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Takut Hiperkalemia

dengan pemberian KAEN?


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Anjuran: 10 mEq/jam*

KN3B mengandung kalium 10 mEq/500 ml

Kecepatan Rumatan 500 ml/6 jam

~ 80 ml/jam; 20 tetes/menit

atau ~ 1,6 mEq K+/jam

Dalam praktek:

Risiko Hiperkalemia minimal!


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PEMAKAIAN CAIRAN INFUS

DI RUMAH SAKIT

(Aplikasi disesuaikan dengansediaan infus yg ada dipasaran)


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PEMAKAIAN INFUS DI UGD

SYOK HIPOVOLEMIK

ASERING

20-30 ml/kg/jam

Ya TIDAK

< 3 tahun > 3 tahun

KAEN 4A KAEN 1BKecepatan: BB < 10 kg: 4 ml/kg/jam

11-20 kg : 2 ml/kg/jam

> 25 kg : 1 ml/kg.jam

Contoh : Anak 5 tahun BB 15 kg-

4 x 10 + 2 x 5 =

50 ml/jam = 12 tetes/menit

Normo/hipoKNormo/

hipoK

KAEN 4B KAEN 3B/MG3

Observasi/

monitor

nadi teraba

akral hangat

urine output +

kecepatan bisaditurunkan 1073 ml/kg/jam

KAEN 3B/3A


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KAEN 3B/3A

Na+50 mEq; K+20 mEq; Glu 27 g/L

INDIKASI:

1. Pneumonia

2. Pleural Effusion

3. Ketoasidosis diabetik (setelah rehidrasi dgNaCl 0,9%)

4. Observasi Tifoid

5. Observasi demam yang belum diketahui penyebabnya

6. Status asthmaticus

7. Fase pemulihan dari DBD

Kasus-kasus baru di mana status gizi tidak terlalu jelek, antara lain:

Kecepatan pemberian: 80 ml/jam (20 tetes/menit)

Catatan : Dosis harian maksimal 50 ml/kgBB, jika tidak dikombinasi infus lain dan

tidak ada asupan cairan per oral

KAEN MG3


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KAEN MG3

Na+50 mEq; K+20 mEq; Glu 100 g/L

INDIKASI:

1. Diare kronik

2. Tbc

4. Tifoid dengan komplikasi

5. Empiema, osteomielitis6. Keganasan

7. Sepsis,

8. Hepatitis akut

9. Ensefalopati hepatik

Kasus-kasus di mana status gizi kurang, antara lain:

Kecepatan pemberian: 80 ml/jam (kira-kira 20 tetes/menit)

Catatan :

Jika gizi jelek bisa dikombinasi dengan PanAminG (2,7% AA + sorbitol 5%) atau

Amiparen (AA 10%)


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Pan Amin G 1000 ml 200 kcal 27 g protein

KNMG3 1000 ml 400 kcal

TOTAL 2000 ml 600 kcal 27 g protein

STRES RINGAN + Gizi BAIK + kurangasupan oral

KAEN MG3 + AA


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Amiparen 1000 ml 100 g protein

KNMG3 1000 ml 400 kcal

TOTAL 2000 ml 400 kcal 100g protein

STRES SEDANG + Gizi Sedang + perlukalori dan protein lebih tinggi

KN MG3 + AMIPAREN


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Pemberian Cairan/Elektrolit

DHF/DSS : Asering, Asering-5 GE : Asering

Muntah-muntah : NaCl 0.9%

Anoreksia : KAEN MG3

Stroke : Asering + MgSO4 20% (awal), setelah 3hari KAEN 3B

Hiperemesis gravidarum: awal NaCl/D5/Asering5

disusul KAEN MG3 + PanAmin G pada hari ke 2 DKA : NaCl 0,9%, disusul KAEN 3B setelah

rehidrasi


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NUTRISI/KALORI

DM : Martos + Aminovel 600

Hati: KAEN MG3 + Aminoleban

Ginjal: D10 + Kidmin

Jantung : KAEN MG3 + Amiparen

Hipoalbuminemia: Amiparen + KAEN MG3

PASIEN BEDAH


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PASIEN BEDAH

Intraoperatif : Asering/Asering-5 Postoperatif : Asering/Asering-5

Setelah di bangsal

Tergantung status nutrisi /stres metabolisme:

Jika kondisi bagus (e.g laparoskopi, kistektomi,

apendektomi dll) infus bisa di-off pada POD1.

Jika kondisi kurang bagus (operasi lama, stresmetabolik

ada dan pasien tidak bisa asupan oral)

bisa KAEN MG3 + PanAmin G/Amiparen + lipid


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PASIEN SYOK

Asering

!!!


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TERAPI CAIRAN

Asering

Ringer Laktat

Normal Saline

RESUSITASI RUMATAN

KRISTALOID KOLOID ELEKTROLIT NUTRISI

Mengganti kehilangan akut

Otsutran- L

Memelihara keseimbangan

SERI KA-EN

AMIPAREN

AMINOVEL- 600

PAN- AMIN G

KA-EN MG 3

MARTOS 10

!!!


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TERIMA KASIH

Documents

Otsuka Cairan.ppt