Budhi Santoso, MD(Medical Advisor of Otsuka Indonesia)
[email protected] SHORT CURICULUM VITAE 1.Name 2.Place/date of birth 4.Marial status 5.Alumny : : : : Budhi Santoso Jakarta, 17 Mei 1967 Married with 4 children Medical Faculty of Brawijaya University Malang East Java:1993 6.Working Experienced : 6.1. Cipete Clinic, Jakarta (1993-1994) 6.2. Puskesmas Moro Seneng-Kepri, Riau (1994-1997) 6.3. Schering AG (Med Advisor: 1998-2000) 6.4. Otsuka Indonesia (Med-Consultant: 2001-) 7.Training Experienced : 7.1. European GCP Advance Course, Schering AG-Berlin, 1998 7.2. Communication on Family Planning, Leiras-Sweden, 1999 7.3. ACOG Congress, Philadelphia-USA, 1999 7.4. Schering Internal Leadership Course, Dusit-Thailand, 2000 7.5. Critical Care Annual & Pensa Meeting, Bali: 2001, 2002, 2003 7.6. ATLS advanced, RSCM 2003 7.7. Indonesian GCP, RSCM 2004 7.8. Critically Ill in Children Course, Malang, 2005 7.9. Critical Care Workshop, Surabaya: 2006, 2007, 2008 7.10. Aminofluid Workshop,Tokushima, Japan, 2009 7.11. Compounding Infusion Course, Toho University, Tokyo, Japan 2012 7.12. Regulatory and Pharmacovigillence Meeting, Tokushima, Japan 2012 7.13. European Soc of Par and Enteral Conggess, Barcelona, Spain Sept 2012 7.14. Indonesian-Japan Symposia on Ensuring Safety and Efficacy, Jkt Feb 2013 Pendahuluan • CFR DBD (2004=2%, 2006=1,6%, 2009=3,5%) • Apa virus tambah ganas ? • Apa penyebab kematian ?? (perdarahan massif, DIC, syok tidak teratasi atau fluid overload, edema paru, dll) • Pasien yang meninggal tidak diautopsi ??? • Awareness kita ???? Misal: Simposium/Kursus DBD diadakan hanya ketika ada KLB 2006 . Tatalaksana DBD terkini. RSUD Dr Soetomo/FKUnair.Tata Laksana Prof. Soegeng. memperbaiki kekurangan plasma • Cairan kristaloid prioritas pertama • Pilihan cairan kristaloid: ringer asetat. laktat oleh sel hati • Sel hati kebanyakan terganggu pada infeksi dengue pengaruh sitokin proinflamasi Nasronudin. NaCl 0. ringer laktat.9% • Ringer asetat pilihan yang perlu didahulukan • Asetat di dalam tubuh diubah menjadi bikarbonat oleh sel otot. 2007 Divisi Tropik Infeksi FK Unair/RS Dr Sutomo .• Cairan pengganti pada SSD penatalaksanaan utama. Hypovolemic shock . 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. tra 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 . 1 . SEARO No 29 Yuichi Imai: Practice of Clinical Training.Fluid Management in DH Grade 1 Grade 2 Grade 3 Grade 4 Isotonic crystalloids (RA. 2004.RL hypotonic crystalloid (NaCl Isotonic crystalloid/colloid/ blood(component) Prevention and Control of Dengue and Dengue Haemorrhagic Fever. WHO Regional Publication. Terapi Cairan DBD grade III dan IV (disertai Syok) . Isotonic Crystalloid • Asering/RL/NS • Umumnya dianjurkan jika Ht > 20% • NS berpotensi menyebabkan asidosis hiperkloremik* • Kombinasi dg dekstrosa 5% (misal RAD5 (Asering5). RL-D5. NS-D5) diberikan jika kecepatan infus < 10 ml/kg/jam Clinical Science (2003) 104. (17–24) (Printed in Great Britain) . First Line Ringer’s acetate ASERING® Fluid Resuscitation Therapy ® Ringer’s acetate . KOMPOSISI Setiap 1 L mengandung : Elektrolit ( mEq ) + K ASERING® ( RA ) 130 4 109 3 28 - 274 RINGER LAKTAT ( RL ) 130 4 109 3 - 28 274 Na + Cl - Tek.Osmotik Ca2+ Asetat Laktat ( mOsm /L ) . 25 .75 7 6.Average pH • Ringer’s lactate • Asering® • Normal saline 6. Rose BD. Maxwell MH. Kleeman CR. which is then converted to CO2 and H2O (80%) or glucose (20%). Clinical Disorders of Fluid and Electrolyte Metabolism. MacGraw-Hill 1987 4th edition p 1063 . Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4 th ed 1994 p 554 2. 1.ASERING® & LR LACTATE: Primarily in the liver. lactate is metabolized to pyruvate. and to lesser degree the kidney. Narins RG. heart and liver2 Coenzyme A Acetate + H+-------- Acetyl-CoA Kreb’s cycle hydrogen source Carbonic acid -------- bicarbonate Ref. and regeneration of bicarbonate1 ACETATE: metabolized mainly in muscles and to a lesser extent in tissues such as kidney. KoA TCA Cycle H 2O .LAKTAT G-6-P GLIKOGEN Asetil KoA PIRUVAT sintetase ASETAT 2 CO2 Asetil . SODIUM LAKTAT ( HATI ) NaHCO3 + CH3CH(OH)COOH ( Laktat ) CH3CH(OH)COONa + CO2 +H2O CH3CH(OH)COOH + 3 O2 3 CO2 + 3 H2O : TCA Cycle 2. SODIUM ASETAT ( OTOT ) CH3COONa + CO2 +H2O NaHCO3 + CH3COOH ( Asetat ) CH3COOH + 2 O2 2 CO2 + 2 H2O : TCA Cycle GLUkOSA LDH L.METABOLISME ASERING® 1. LACTATE Na Na Lactate Lactate VS ASERING® Bicarbonate Bicarbonate 100 mEq/hr Na Acetate Bicarbonat e 250-400 mEq/hr . FKUI. Demam Berdarah Dengue. Hindra Irawan Satari.DBD III & IV O2 2-4 L/menit RA/RL 20 ml/kg bolus dalam 30 menit Syok teratasi RA/RL 10 ml/kg/jam Syok tidak teratasi Teratasi Dextran 40 10-20 ml/kg Tidak Teratasi Stabil dalam 24 jam RA 5 ml/kg/jam Stop < 48 jam 3 ml/kg/jam Ht turun Ht tetap/naik FFP 10 ml/kg Dextran 20 ml/kg Sri Rezeki.1999 . 5-4.5 jam • Dosis maksimal 30 ml/kg/hari .Dextran-40 • Koloid Standard untuk DSS • Efek volume dipertahankan 3. Terapi Cairan DBD grade I dan II (Tanpa Syok) . Dalam FKUI/RSCM 2010 .serta elektrolit sesuai kebutuhan harian • Contoh: KAEN 3B/ Aminofluid Makalah simposium DBD SubTropik Infeksi Bag Peny.Hypotonic Crystalloid • Larutan rumatan diberikan pada pasien DBD stadium I tanpa peningkatan Ht jika asupan oral tidak memungkinkan (misal muntah-muntah) • Memasok air dan suplemen kalori. Pulmonologi. 660 ml 85 ml .Dextrosa & KAEN 1L INDIKASI MAINTENANCE Pasien Rawat Inap: Interna. Obgyn. Cardiology. Obgyn pts. Neurologi (Stroke) Post Operative: 225 ml Surgery pts. Pediatric. Kebutuhan harian: Air Na+ K+ : : : 30-50 mL/kgBB 2 meq/kgBB 1 meq/kgBB . Ilustrasi BB Dewasa (Org Indonesia) : ± 50 kg Kebutuhan Air 2000 mL RL 2 L KA-EN 3B® 2 L Natrium 50 – 100 mEq 260 mEq 100 mEq Kalium 45 – 65 mEq 8 mEq 40 mEq Infus RL bukan Untuk Terapi Rumatan . Sudomo.38(4):202-5 Nasronudin et al. p 732-734 .9 52.5.Prevalences of Hypokalemia Chief Investigator Centre No of % hypokalemia patients on admission % hypokalemia on Discharge Untung Sudomo RSPAD 100 28 45 Djoko Widodo RSCM 105 22. Ed: Dec 2004. Marissa Ira. The prevalence of hypokalemia in hospitalized patients with infectious diseases problems at Ciptomangun-kusumo Hospital Jakarta.36 50. 2006. Setiawan B. Page: 115-120 Widodo D. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients.4 Nasronudin RS Sutomo 110 36.No 12. 2. Medika 2006 Vol XXXII. Untung. Khie Chen.91 1. Acta Med Indones. Gastroenterogy hepatoloy and digestive endoscopy vol. 3. RSCM 23% . 表 2 ．入退院時の血清内ｶﾘｳﾑﾚﾍﾞﾙ . How does maintenance fluid therapy evolve? . glu 27 g Na+ 77 .Na+ 35 K+ 20 Na+ 50 K+ 20. Othman N.Clinical profile of dengue infection in children versus adults. Francis A. IL-8. Daniel H. Siripen Kalayanarooj. Page S435 . Ennis. Rothman Virus-Induced Decline in Soluble Vascular Endothelial Growth Receptor 2 Is Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. telah dilaporkan pada DHF Salah satu efek pleiotropiknya adalah memperlambat pengososan lambung Pasien mungkin mengalami anoreksia karena mulut kering (dehidrasi). seperti interferon (IFN). interleukin-2 (IL-2). Sharone Green. Supplement 2. Volume 29. Chuanpis Ajariyakhajorn.International Journal of Antimicrobial Agents. dan tumor necrosis factor alpha. and Alan L.Infeksi akut/ Demam Neurol ogi Post operatif Penya-kit Gastrointestinal Aminofluid Aminofluid pada DBD DBD Hiperemesis Gravidarum • Diabetes Mellitus Sepsis • • Walaupun pasien merasa haus karena dehidrasi hipertonik. Libraty. mungkin mereka tidak bisa mengkonsumsi air dan nutrien cukup akibat keluhan saluran cerna/ nyeri. March 2007. Endy. 81(4): 1592–1600. Timothy P. hepatomegali Peningkatan kadar sitokin. malaise dan fatigue di samping gejala-gejala sistemik lain Anon Srikiatkhachorn. 2007 February. 325:480-483 2. Post-infectious fatigue syndrome in dengue infection. Issue 1. et al. Pages 1-6 . Journal of Clinical Virology Volume 38. Seet RCS. Michael Sharpe BMJ 2002. January 2007.FATIGUE An underestimated and undertreated symptom (1) Post-infectious fatigue was observed in approximately 25% of hospitalized patients with dengue infection (2) 1. 8 g/kg/hari Glukosa 150 g ¥ 54 g - •kebutuhan basal untuk homeostasis K+ adalah 20-30 mEq/hari (10). • kebutuhan basal asam-aminopada pasien nonstressed.Tabel 1. Komposisi Aminofluid dibandingkan RL dan KAEN3B Komposisi Aminofluid KAEN3B Ringer’s lactate ASPEN guideline(2) Air 2000 2000 2000 30-40 ml/kg/hari Na+ 70 100 260 1-2 mEq/kg/hari K+ 40 40 8 1-2 mEq/kg*/hari Cl- 70 100 218 sesuai kebutuhan Mg++ 10 - - 8-20 mEq/hari Ca++ 10 - - 10-15 mEq/hari P 20 - - 20-40 mEq/hari Zn 10 µmol - - 2. •¥ protein-sparing effect .5-5 g Asam amino AA 60 g - - 0. 136(2): 544S . Nutr. February 1. Blomstrand A Role for Branched-Chain Amino Acids in Reducing Central Fatigue J.. 2006.547S .BCAA BBB Appetite Fatigue (Serotonin) Tryptophan 80% (Serotonin) E. moh. DENGUE GUIDELINES FOR DIAGNOSIS. New Edition 2009 Tachycardia Yip WCL.gov.Medical Progress October 1980 .Maintenance ONLY ISOTONIC INFUSION WARNING SIGNS • Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation (pleural effusion. Dengue Haemorrhagic Fever: Current Approaches to Management.my : Management of Dengue Infection in Adults. ascites) • Mucosal bleed • Restlessness or lethargy • Liver enlargement > 2 cm • Laboratory : Increase in HCT concurrent with rapid decrease in platelet COMPENSATED SHOCK ISOTONIC CRY 10 ml/kg/hr Capillary refill > 2 sec Narrowing pulse pressure www. PREVENTION AND CONTROL.2 edition 2008.TREATMENT. dyspeptic patients • Gastrointestinal diseases. colonoscopy.9% NaCl) • Stroke (after metabolic and electrolyte correction) Precautions: •Renal Failure associated with hyperkalemia •Heart Failure •Small children .Indikasi Aminofluid yang dianjurkan: • Febrile illnesses • Dehydrated and anorexic. post resuscitation of severe diarrhea. gastroparesis • Acute Infectious diseases • Early post operative maintenance (straightforward surgery) • Hyperemesis gravidarum (after 0. AMINOFLUID . . JAN’ 2012 . If hemodynamic still stable (DBD gr I and II) and patients could intake adequate orally give hypotonic solution which meet daily requirement and It has evolved from simply giving water and electrolyte in simple container to practical and complete composition in advanced dual-chamber formulation. combat fatigue. increase appetite and finally faster recovery. 3. improve sense of well-being.Aminofluid already designed for advance maintenance fluid therapy today . 4.Most important goal of maintenance therapy is to correct homeostasis.When hemodynamic patients is not stable (DBD gr III and IV) Asering for replacement therapy seems superior compare to LR or NS 2.CONCLUSION 1.