1. Diare Osmotik Diare osmotik dapat terjadi dalam beberapa keadaan : 1.1.Intoleransi makanan, baik sementara maupun menetap. Situasi ini timbul bila seseorang makan berbagai jenis makanan dalam jumlah yang besar sekaligus. 1.2. Waktu pengosongan lambung yang cepat Dalam keadaan fisiologis makanan yang masuk ke lambung selalu dalam keadaan hipertonis, kemudian oleh lambung di campur dengan cairan lambung dan diaduk menjadi bahan isotonis atau hipotonis. Pada pasien yang sudah mengalami gastrektomi atau piroplasti atau gastroenterostomi, makanan yang masih hipertonik akan masuk ke usus halus akibatnya akan timbul sekresi air dan elektrolit ke usus. Keadaan ini mengakibatkan volume isi usus halus bertambah dengan tiba-tiba sehingga menimbulkan distensi usus, yang kemudian mengakibatkan diare yang berat disertai hipovolumik intravaskuler. Sindrom malabsorbsi atau kelainan proses absorbsi intestinal. 1.3. Defisiensi enzim Contoh yang terkenal adalah defisiensi enzim laktase. Laktase adalah enzim yang disekresi oleh intestin untuk mencerna disakarida laktase menjadi monosakarida glukosa dan galaktosa. Laktase diproduksi dan disekresi oleh sel epitel usus halus sejak dalam kandungan dan diproduksi maksimum pada waktu lahir sampai umur masa anak-anak kemudian menurun sejalan dengan usia. Pada orang Eropa dan Amerika, produksi enzim laktase tetap bertahan sampai usia tua, sedang pada orang Asia, Yahudi dan Indian, produksi enzim laktase cepat menurun. Hal ini dapat menerangkan mengapa banyak orang Asia tidak tahan susu, sebaliknya orang Eropa senang minum susu. 1.4. Laksan osmotik Berbagai laksan bila diminum dapat menarik air dari dinding usus ke lumen. Yang memiliki sifat ini adalah magnesium sulfat (garam Inggris). Beberapa karakteristik klinis diare osmotik ini adalah sebagai berikut: - Ileum dan kolon masih mampu menyerap natrium karena natrium diserap secara aktif. Kadar natrium dalam darah cenderung tinggi, karena itu bila didapatkan pasien dehidrasi akibat laksan harus diperhatikan keadaan hipernatremia tersebut dengan memberikan dekstrose 5 %. - Nilai pH feses menjadi bersifat asam akibat fermentasi karbohidrat oleh bakteri. - Diare berhenti bila pasien puasa. Efek berlebihan suatu laksan (intoksikasi laksan) dapat diatasi dengan puasa 24-27 jam dan hanya diberikan cairan intravena. 2. Diare sekretorik Pada diare jenis ini terjadi peningkatan sekresi cairan dan elektrolit. Ada 2 kemungkinan timbulnya diare sekretorik yaitu diare sekretorik aktif dan pasif. Diare sekretorik aktif terjadi bila terdapat gangguan aliran (absorpsi) dari lumen usus ke dalam plasma atau percepatan cairan air dari plasma ke lumen. Sperti diketahui dinding usus selain mengabsorpsi air juga mengsekresi sebagai pembawa enzim. Jadi dalam keadaan fisiologi terdapat keseimbangan dimana aliran absorpsi selalu lebih banyak dari pada aliran sekresi. Diare sekretorik pasif disebabkan oleh tekanan hidrostatik dalam jaringan karena terjadi pada ekspansi air dari jaringan ke lumen usus. Hal ini terjadi pada peninggian tekanan vena mesenterial, obstruksi sistem limfatik, iskemia usus, bahkan proses peradangan. 3. Diare akibat gangguan absorpsi elektrolit Diare jenis ini terdapat pada penyakit celiac (gluten enteropathy) dan pada penyakit sprue tropik. Kedua penyakit ini menimbulkan diare karena adanya kerusakan di atas vili mukosa usus, sehingga terjadi gangguan absorpsi elektrolit dan air. dan sangat penting untuk membuat hormon pertumbuhan dan hormon laki-laki. It helps reduce mortality rates among children with persistent diarrheal illness. zinc mungkin memiliki atribut antioksidan yang khas. Bayi berusia 0-6 bulan: sekitar 2 mg . Diare akibat hipermotilitas (hiperperistaltik) Diare ini sering terjadi pada sindrom kolon iritabel (iritatif) yang asalnya psikogen dan hipertiroidisme. Hal ini diperlukan untuk kulit sehat.4. Supplementation with zinc sulfate (2 mg per day for 10 to 14 days) reduces the incidence of diarrhea for 2 to 3 months. tablets that can be crushed and given with food are least costly.Anak berusia 9-13 tahun: 8 mg Supplemental Zinc Therapy. shigellosis. Administration of zinc sulfate supplements to children suffering from persistent diarrhea is recommended by the WHO. kampilobacter. one RDA for a child aged 1 year is: Folate: 50 micrograms Zinc: 20 micrograms Vitamin A: 400 micrograms . and Minerals For all children with diarrhea: 20 mg zinc for 14 days Zinc deficiency is widespread among children in developing countries. dan pencernaan. As a guide. tulang. and copper. Multivitamins.Anak berusia 7 bulan – 3 tahun: 3 mg . zinc. Sindrom karsinoid sebagian juga disebabkan oleh hiperperistaltik. Para peneliti telah menemukan bahwa dosis tambahan dari zinc memiliki efek merevitalisasi fungsi kelenjar timus. yang sangat penting untuk produksi T-sel dan sistem kekebalan yang kuat. Zinc merupakan mineral penting yang membantu tubuh menjaga sistem kekebalan. including at least two recommended daily allowances (RDAs) of folate. Diare eksudatif Pada penyakit kolitif ulserosa. All children with persistent diarrhea should receive supplementary multivitamins and minerals each day for 2 weeks. vitamin A. kuku. testosteron. Micronutrient supplementation — supplementation treatment with zinc (20 mg per day until the diarrhea ceases) reduces the duration and severity of diarrheal episodes in children in developing countries. zinc dapat membantu mengurangi kerusakan yang disebabkan oleh radikal bebas. Dengan berfungsi sebagai antioksidan . Namun. reproduksi. penyakit Crohn. 5. amebiasis. yersinia dan infeksi yang mengenai mukosa menimbulkan peradangan dan eksudasi cairan serta mukus. Zinc penting untuk tubuh dengan berbagai cara. rambut. dan mata. These should provide as broad a range of vitamins and minerals as possible.Anak berusia 4-8 tahun: 5 mg . Locally available commercial preparations are often suitable. magnesium. and serious nonintestinal infections (e. However. meats. Give: An age-appropriate diet — regardless of the fluid used for ORT/maintenance Infants require more frequent breast feedings or bottle feedings — special formulas or dilutions unnecessary Older children should be given appropriately more fluids Frequent. Extrapolation from the results of even closely related strains is not possible. suspected cholera with severe dehydration. Antimicrobials are reliably helpful only for children with bloody diarrhea (most likely shigellosis). and vegetables) Increasing energy intake as tolerated following the diarrheal episode Avoid: Canned fruit juices — these are hyperosmolar and can aggravate diarrhea. and abdominal pain in traveler'sdiarrhea. Copper: 1 mg Magnesium: 80 mg Diet The practice of withholding food for >4 hours is inappropriate. Significant abdominal pain also suggests inflammatory diarrhea (this is a contraindication for loperamide use).. such as Lactobacillus GG (American Type Culture Collection [ATCC] 53103). Probiotics are specific defined live microorganisms. and significantly different effects have been reported. nausea. attapulgite Inadequate proof of efficacy in acute adult diarrhea Antimicrobials Antimicrobial therapy is not usually indicated in children. but not in adults with cholera. fruits. Adsorbents: Kaolin-pectin. Antidiarrheals have no practical benefits for children with acute/persistent diarrhea. Antiprotozoal drugs can be very effective for diarrhea in children. with nitazoxanide. It has been found useful in children with diarrhea. Entamoeba histolytica. Nonspecific Antidiarrheal Treatment None of these drugs addresses the underlying causes of diarrhea. Antiemetics are usually unnecessary in acute diarrhea management. Antimotility: Loperamide is the agent of choice for adults (4 to 6 mg/day.g. small meals throughout the day (six meals/day) Energy and micronutrient-rich foods (grains. and is now licensed in many countries in the world for use in children. Controlled clinical intervention studies and meta-analyses support the use of specific probiotic strains and products in the treatment and prevention of rotavirus diarrhea in infants. Should be avoided in bloody or suspected inflammatory diarrhea (febrile patients). Food should be started 4 hours after starting ORT or intravenous fluid. all effects are strain-specific and need to be verified for each strain in human studies. The notes below apply to adults and children unless age is specified. activated charcoal. . Inhibits intestinal peristalsis and has mild antisecretory properties. 2 to 4 mg/day for children >8 years). Should be used mostly for mild to moderate traveler's diarrhea (without clinical signs of invasive diarrhea). Loperamide is not recommended for use in children <2 years. pneumonia). which have demonstrated health effects in humans. Antisecretory agents: Bismuth subsalicylate can alleviate stool output in children or symptoms of diarrhea. Racecadotril is an enkephalinase inhibitor (nonopiate) with antisecretory activity. and now Cryptosporidium. especially for Giardia. q. Treatment for amoebiasis should. the recommended azithromycin dosage is 250 mg or 500 mg once daily for 3 to 5 days. and hygiene: Safe water Sanitation: houseflies can transfer bacterial pathogens Hygiene: hand washing Safe food: Cooking eliminates most pathogens from foods Exclusive breastfeeding for infants Weaning foods are vehicles of enteric infection . ideally. once daily for 3 to 5 days. harmful eradication of normal intestinal flora. For treating most types of common bacterial infection. Note well (N.i. or Shigellarecently isolated in the area.In adults. campylobacter. it may be necessary to use tablets and estimate the doses given in this table.i. Azithromycin is widely available and has the convenience of single dosing..): Erythromycin is hardly used for diarrhea today. sepsis. Prevention Water. in Thailand) and azithromycin is then the appropriate treatment.B. b. furazolidone (1. sanitation. An antimicrobial is recommended for patients older than 2 years with suspected cholera and severe dehydration. Rifaximin is a broad-spectrum. salmonella. use should be limited to high-risk individuals or those needing to remain well for short visits to a high-risk area. the clinical benefit should be weighed against the cost. This area is still controversial. The actual selection of an antimicrobial will depend on the known resistance/sensitivity pattern of V.d. Quinolone-resistant Campylobacter is present in several areas of South-East Asia (e. and patients with impaired resistance. or with prostheses Moderate/severe traveler's diarrhea or diarrhea with fever and/or with bloody stools — quinolones (co-trimoxazole second choice) Nitazoxanide is an antiprotozoal and may be appropriate for Cryptosporidium and other infections. immunocompromised patients. cholerae in the region. the induction of Shiga toxin production. For adults with acute diarrhea. and norfloxacin. [four times a day ] for 3 days). or parasitic infections Infections in the aged.25 mg/kg. the risk of adverse reactions. include diloxanide furoate following the metronidazole. which requires the availability of a well-established and consistent surveillance system. to get rid of the cysts that may remain after the metronidazole treatment. Alternative antimicrobials for treating cholera in children are trimethoprim/sulfamethoxazole (TMPSMX) (5 mg/kg TMP + 25 mg/kg SMX. including some bacteria. Selection of an antimicrobial should be based on the sensitivity patterns of strains of Vibrio (V. and the increase of antimicrobial resistance. there is good evidence that an ultrashort course (one or two doses) of ciprofloxacin or another fluoroquinolone reduces the severity and shortens the duration of acute traveler's diarrhea. Azithromycin dosage for children can range (depending on body weight) from 5 mg to 20 mg per kilogram of body weight per day.g. If drugs are not available in liquid form for use in young children. All doses shown are for oral administration. non-absorbed antimicrobial agent that may be useful.) cholerae O1 or O139. Antimicrobials are to be considered the drugs of choice for empirical treatment of traveler's diarrhea and of community-acquired secretory diarrhea when the pathogen is known (see Figure 11 in the original guideline document). Considerations with regard to antimicrobial treatment: Consider antimicrobial treatment for: Persistent Shigella.d. [twice a day] for 3 days). giardiasis. and their use is recommended only in complex emergencies such as epidemics. Rotavirus: In 1998. two vaccines have been approved: a live oral vaccine (RotaTeq™) made by Merck for use in children. Measles immunization can substantially reduce the incidence and severity of diarrheal diseases. cryptosporidiosis. tenesmus) Stratify subsequent management Obtain fecal specimen for analysis Epidemiological clues: food. coli (ETEC) vaccines: The most advanced ETEC vaccine candidate consists of a killed whole cell formulation plus recombinant cholera toxin B subunit. further research is needed. dysentery. Vaccines: Salmonella typhi: Two typhoid vaccines currently are approved for clinical use. bloody not inflammatory or bloody) stool. season Clinical clues: diarrhea. a rotavirus vaccine was licensed in the USA for routine immunization of infants. and GlaxoSmithKline's Rotarix™. Enterotoxigenic E. coliinfection. travel.rapid realimentation Perform ORT rapidly – within 3 to 4 hours Age. Since then. In countries where both the new ORS and zinc have been introduced. the recommendations have been adopted by more than 40 countries throughout the world. and infection with shiga toxin producingE. wasting. since the risk of cholera for the usual traveler is very low. cholerae: Oral cholera vaccines are still being investigated. salmonellosis. outbreaks. including zinc supplementation as an adjunct therapy to oral rehydration. Other rotavirus vaccines are being developed. freeze fecal and food or water specimens at -70°C Notifiable in the USA: cholera. More promising is a single-dose live-attenuated vaccine currently under development in several laboratories. shigellosis. inflammatory. Every infant should be immunized against measles at the recommended age. and preliminary trials are promising. the rate of ORS usage has dramatically increased. persistent diarrhea or if outbreak is suspected other illness. oral cholera vaccine is only recommended for those working in refugee or relief camps. Table: Principles of Appropriate Treatment for Children with Diarrhea and Dehydration Use ORS for rehydration When rehydration is corrected . or sexual activity. No vaccines are currently available for protection against Shiga toxin-producing E. abdominal pain. coli Children In 2004.appropriate unrestricted diet Continue breastfeeding . bloody. In traveler's diarrhea.Micronutrient supplementation: the effectiveness of this depends on the child's overall immunologic and nutritional state. Shigella organisms: Three vaccines have been shown to be immunogenic and protective in field trials. WHO and UNICEF revised their recommendations for the management of diarrhea. day-care attendance. Currently. No available vaccine is currently suitable for distribution to children in developing countries. In 1999. Clinical Practice Adults Table: The Approach in Adults with Acute Diarrhea Perform initial assessment Provide symptomatic treatment Dehydration Rehydration Duration (>1 day) Treatment of symptoms (if necessary consider bismuth subsalicylate or loperamide if diarrhea is Inflammation (indicated by fever. V. Parenteral vaccines may be useful for travelers and the military. Their use in endemic areas remains controversial. antibiotics. production was stopped after the vaccine was causally linked to intussusception in infants. fecal inflammation Consider antimicrobial therapy for specific Report to public health authorities pathogens In outbreaks save culture plates and isolates. but are impractical for use in developing countries. If severe. uncomplicated cases of diarrhea in children can be treated at home. usually as a result of bacterial infection (cholera. or concurrent illness o Fever >38°C for infants <3 months old or >39 C for children 3 to 36 months old Visible blood in stool High-output diarrhea including frequent and substantial volumes Persistent vomiting. (100 mL/kg) intravenously within 4 to 60 to 120 mL ORS for or resume age-appropriate 6 hours. malnutrition. Early intervention and administration of ORS reduces dehydration. or body weight over 3 to 4 mL ORS for eachdiarrheal stool or resume normal diet after initial hours vomiting episode rehydration Table: Severe Dehydration Rehydration therapy: Replacement of losses: Nutrition: Rehydrate with Ringer's lactate <10 kg body weight: Continue breastfeeding. the patient (child or adult) will not take ORS and is likely to need intravenous fluids. Severe dehydration occurs. persistent fever Suboptimal response to ORT or inability of caregiver to administer ORT No improvement in 48 hours . Rehydration therapy: Replacement of losses: Nutrition: ORS 50 to 100 mL/kg <10 kg body weight: 60 to 120 Continue breastfeeding. (See Figure 15 in the original guideline document for an algorithm for the therapeutic approach to acute bloodydiarrhea [dysentery] in children. or do not respond to treatment. chronic medical conditions.symptoms exacerbate. severe dehydration. Intravenous infusion with 5% dextrose with 1/4 normal saline will thus lead to severe hyponatremia. Five percent dextrose with 1/2 standard normal saline can only be used when Ringer's lactate is not available. then administer ORS to each diarrheal stool or normal diet after initial maintain hydration until patient vomiting episode hydration recovers Cautionary Note: Treating a patient with severe dehydration due to infectious diarrhea with 5% dextrose with 1/4 normal saline is unsafe. overall condition gets worse . which usually leads to more sodium loss in feces (60 to 110 mmol/L).Administer additional ORS for ongoing losses through diarrhea Treatment for Children Based on the Degree of Dehydration Regular formula feeding No unnecessary laboratory tests or medications Table: Minimal or No Dehydration Rehydration Replacement of losses: Nutrition: therapy: <10 kg body weight: 60 to 120 mL ORS Continue breastfeeding or age None for each diarrheal stool or vomiting appropriate normal diet episode Table: Mild to Moderate Note: If vomiting is persistent. Caregivers need proper instructions regarding signs of dehydration. and this does not balance the sodium losses. stool cultures and microscopy to guide therapy. and loss of consciousness. and frequent smaller meals with higher protein intakes. regardless of the etiologic agent.5 mmol/L.) Home Management of Acute Diarrhea With ORS. when children appear markedly ill. A 1/4 normal saline solution contains sodium (Na) 38. and other complications and leads to fewer clinic visits and potentially fewer hospitalizations and deaths. Indications for Patient Caregiver's report of signs consistent with dehydration Care Changing mental status Young age (<6 months old or <8 kg body weight) History of premature birth. convulsion. ETEC). The Therapeutic Approach to Acute Bloody Diarrhea (Dysentery) in Children The main principles are: treatment of dehydration. Where feasible. There is no evidence that it prolongs the illness. Antidiarrheal medication with loperamide (flexible dose according to loose bowel movements) may diminish diarrhea and shorten the duration. ranked by the resources available. Cascades A cascade is a hierarchical set of diagnostic or therapeutic techniques for the same disease. zinc supplementation. It does not reduce the duration of diarrhea or the number of stools. Consumption of solid food should be guided by appetite in adults — small light meals. In adults who can maintain their fluid intake. only loperamide and bismuth subsalicylate have sufficient evidence of efficacy and safety. glucose.Self-medication in otherwise healthy adults is safe. patients with severe dehydration (at risk of acute renal failure or death) should be referred to the nearest facility with intravenous fluids (levels 5 and 6 cannot replace the need for referral in case of severe dehydration). Family knowledge about diarrhea must be reinforced in areas such as prevention. as needed. Table: Cascade for Acute Watery Diarrhea – Cholera-like. Among hundreds of over-the-counter products promoted as antidiarrheal agents. Antimicrobial treatment is reserved for prescription only in residents' diarrhea or for inclusion in travel kits (add loperamide). families should be encouraged to have ORS ready-to-mix packages and zinc (syrup or tablet) readily available for use. nutrition. In developed countries. Nutritional support with continued feeding improves outcomes in children. adults with acute watery diarrhea should be encouraged to drink fluids and take in salt in soups and salted crackers. fluoroquinolone or other + stool microscopy/culture Level 2 Intravenous fluids + antibiotics Empirical: tetracycline. with Severe Dehydration Level 1 Intravenous fluids + antibiotics + diagnostic tests Tests: tetracycline. ORT/ORS use. and when and where to seek care (see "Indications for In-Patient Care" above). Principles of self-medication: Maintain adequate fluid intake. orange juice dissolved in water Cautions: If facilities for referral are available. fluoroquinolone or other Level 3 Intravenous fluids + ORS Level 4 Nasogastric tube ORS (if persistent) (vomiting) Level 5 Oral ORS Level 6 Oral 'home made' ORS Salt. Levels 5 and 6 must be seen as interim measures and are better than no treatment if no intravenous facilities are available. . It relieves discomfort and social dysfunction. ORS does not provide any benefits. Notes: Tetracycline is not recommended in children. NG feeding requires skilled staff. culture Level 2 Oral ORS + antibiotics consider for: Empirical antibiotics for moderate/severe illness Level 3 Oral ORS Level 4 Oral 'home made' ORS Salt. orange juice dissolved in water Table: Acute Bloody Diarrhea. Often. Table: Cascade for Acute Watery Diarrhea. to avoid the risk of hepatitis B and C. dysenteriae E. with Mild/Moderate Dehydration Level 1 Intravenous fluids (consider) + ORS Level 2 Nasogastric tube ORS (if persistent vomiting) Level 3 Oral ORS Level 4 Oral 'home made' ORS Salt. glucose. It is in the mother's interest to avoid the unnecessary complications that may be associated with using intravenous therapy. intravenous fluid treatment is more easily available than NG tube feeding. NG feeding (ORS and diet) is especially helpful in long-term severely malnourished children (anorexia). Do not diagnose moderate dehydration as severe dehydration and thus initiate referral for intravenous feeding because oral rehydration is more time-consuming. histolitica Severe bacterial colitis + diagnostic tests Stool microscopy. but it is suitable for malnourished. glucose. When intravenous facilities are used. orange juice dissolved in water Clinical Algorithm(s) . with Mild/Moderate Dehydration Level 1 Oral ORS + antibiotics consider for: S. Nasogastric (NG) feeding is not very feasible for healthy and active older children. lethargic children. it must be ensured that needles are sterile and that needles and drip sets are never reused. Mild/Moderate. ATPase. 99% kalsium tubuh terdapat ditulang.5 mM/L (10mg/dL). Banyak faktor yang berperan dalam termoregulasi seperti umur . dan hipotrmia berat (dibawah 320C) Mekanisme terjadinya hipotermia yang berkaitan denagn kemampuantubuh untuk menjaga keseimbangan antara produksi panas dan kehilanagan panas. Kalsium Pada sema tahap kehidupan. dan 2.K. otot rangka dan jantung. Karena kontribusi osmotik intrasellulernya. dan cairan ekstraseluler yang semuanya mengandung sejumlah besar natrium.00C. Penurunan konsentrasi albumin serum menurunkan penurunan kadar kalsium serum total. Kalium sangat penting untuk ekstabilitas sel sel saraf dan otot. Sekitar 43% dari keseluruhan natrium tubuh berada dalam tulang.0-36. Komponen yang dapat dipertukarkan meliputi kalium intraselluler (89.0%). dua pertiganya dapat dipertukarkan. dan 950 mEq/kg berat badan pada dewasa. sebab janin mengandung relatif lebih banyak kartilago. • Penurunan produksi panas .8 mg/dl) dalam bentuk ion kaslium bebas.6%) dan kalium ekstraselluler plasma (0. dibandingkan dengan nilainya pada orang dewasa.16 mg. 29% pada cairan limfe interstitial.5 0C Hipotermia Hipotermia dapat disebabkan oleh karena terpapar dengan lingkungan yang dingin (suhu lingkungan rendah. kalium juga penting untuk mempertahankan volume sel. Suhu normal dari bayi baru lahir sekitar 36. Konsentrasi kalium intrasellulr sekitar 150 mEq/L air sel. tulang (7. Perbedaan kalium intraselluler dan ekstrasellular yang dipertahankan oleh aktivasi Na. Konsumsi harian kalium yang disarankan 2 mEq/L berat badan 3. Karena 1 gr albumin mengikat 0. Dari kaslium yang berbentuk ultrafiltrasi. Karena tulang bayi lebih renggang mineralisasinya daripada tulang dewasa. luas permukaan tubuh dan kondisi lingkungan. Konsentrasi intraseluller dipertahankan sekitar 10 mEq/L. Sisa (10%) kalium tubuh total tidak dapat ditukarkan dan berada pada jaringan ikat padat dan tulang rawan (0. Sekitar 40 % terikat protein dan sisanya 60% lainnya dalam bentuk ultrafiltrasi.Natrium Merupakan kation terbesar cairan ekstraseluler. yang hanya mengandung sedikit natrium Meskipun membran sel relatif permeabel terhadap natrium. Rendahnya konsentrasi intraseluller dicapai dengan dorongan keluar aktif atrium dari dalam sel oleh sistem ATPase yang diaktivasi oleh natrium kalium dan magnesium. Konsentrasi kalium ekstraselluler (4mEq/L) menimbulkan perbedaan konsentrasi yang tinggi antara kedua sisi membran sel. sedangkan 46% sisanya (1.4%).8 mg kalsium. permukaan yang dingin atau basah) atau dalam keadaan basah atau tidak berpakaian. seperti fosfat dan sitrat.40 mEq/kg.tapi hanya sepertiga natrium dalam tulang yang dapat ditukarkan. Dari seluruh natrium dalam tubuh. maka 80-90% kalsium terikat berikatan dengan albumin. 90% kalium tubuh total dapat dipertukarkan. Suhu pada terjadi hipotermia sekitar dibawah 36. hipotermia sedang (32-360C). Kalium Kalium terletak pada intraselluler. sekitar 400 mEq/kg berat badan pada bayi. sedangkan konsentrasi ekstraseluller sekitar 140 mEq/L. sangat penting untuk mempertahankan perbedan potensial membran istirahat antar sisi membran sel. 14% dalam bentuk kompleks dengan anion. berat badan. 11% berada dalam kelompok natrium plasma.5% pada cairan intraselluler. Hipotermia sendiri dibagi 3 yaitu hipotermia ringan (36.4%) dan limfa interstitial (1. dan hanya memiliki relatif sedikit massa sel otot. Termoregulasi Suhu tubuh normal dihasilkan dari keseimbangan antara produksi dan kehilanagn panas tubuh. natrium terutama terdistribusi dalam ruang ekstraseluler. Konsentrasi kalsium serum juga dipertahankan dalam batas batas yang sempit sekitar 2.6%) dan sedikit sebagai kalium intraseluler (2%). Kandungan natrium janin yang dapat dipertukarkan adalah rata rata 85 mEq/kg.0 – 36. kandungan kalsium tubuh bayi dan dewasa snagatlah berbeda. karena terikat pada jaringan yang sulit dimobilisasi. Pada orang dewasa. jaringan ikat. adalah solut utama yang secara osmotik aktif bertanggung jawab mempertahankan volume intravaskuler dan interstisial. 2. lebih dari 30 % nya tidak dapat ditukarkan atau hanya dapat dipertukarkan perlahan. Dari seluruh natrium tubuh.50C). dan untuk kontraktilitas otot polos.2mM/L atau 4. Jaringan ikat padat dan kartilago mengandung 12% natrium tubuh. sedangkan 1 gr globulin hanya mengikat 0. ataupun pituitari. Kehilangan panas terjadi saat kontak langsung antara kulit dengan permukaan yang lebih dingin Konveksi Transfer panas yang terjadi secara sederhana dari selisih suhu antara permukaan kulit dan aliran udara yang dingin di permukaan tubuh. dehidrasi atau perubahan mekaisme pengaturan panas sentral yang berhubungan dengan trauma lahir pada otak. sehingga timbul proses penurunan produksi panas.Hal ini dapat disebabkan kegagalan dalam sistem endokrin dan terjadi penurunan basa metabolsme tubuh.50C. • Peningkatan panas yang hilang Terjadi bila panas tubuh berpindah ke lingkukangan sekitar. adrenal. melalui permukaan kulit dan tacktus respiratorius • Kegagalan termoregulasi Karena egagalan hipotalamus dalam menjalankan fungsinya dikarenakan berbagai penyebab Hipertermia Hipertermia dapat disebabkan oleh karena terpapar oleh lingkungan yang panas ( suhu lingkungan panas. Adapun mekanisme tubuh kehilangan panas dapat terjadi secara Konduksi Yaitu perpindahan panas yang terjadi sebagai akibat perbedaan suhu antara kedua obyek. paparan sinar matahari atau paparan panas yang berlebihan. dan tubuh kehilngan panas. malformasi dan obat obatan). peningkatan rata rata metabolisme tubuh dan peningkatan kehilangan cairan tubuh . Hipertermia adalah peningkatan suhu tubuh diatas 37. infeksi. misalnya pada keadaan disfungsi kelenjar tiroid. hal ini menyebabkan terjadinya vasodilatasi. Sumber kehilangan panas dapat berupa suhu lingkungan yang dingin Evaporasi Panas terbuang akibat penguapan. Radiasi Perpindahan suhu dari suatu objek panas ke objek yang dingin.