Otsuka Ipai 07.03.07

GATHERING WITH IPAI NATIONAL CONGGRES(JAKARTA-APRIL 7th 2007) Budhi Santoso, MD (Medical Consultant for PT Otsuka Indonesia) Pasien perlu mendapat infus ? • Tidak dapat minum cukup cairan pengganti kehilangan • Perlu koreksi ketidak-seimbangan cairan (jumlah dan komposisi elektrolit) • Perlu nutrisi intravena karena usus tidak berfungsi • Perlu jalan masuk vena untuk obat-obat (keep vein open) Prof. Eddy Rardjo, Dr.dr.SpAn KIC. Meet the expert. Nusadua,Bali. 2001 BACK TO BASIC…….WITH OTSUKA (FOR MORE THAN 30 YEARS IN INFUSION THERAPY EXPERIENCED) . 3rd space. Ongoing loss. septic and Hypovolemic shock Maintain IWL + urine Repair Acid base. electrolyte imbalances .BASIC PRINCIPLES Replace Abnormal loss: GIT. daily water & electrolyte requirements) .A B Rational fluid therapy (nutrition support. West Java Peripheral Hospitals .Internal data: NCE. not diagnosis • Good monitoring • Cost-effective DN Lobo et al.. Rational Fluid Regimen • Correct timing • Correct indications.concentration) • Tailored to patient’s fluid and electrolyte status. dosage • Correct product (composition. (UK)* . . . Kualitas Infus Plabottle • Steril • Bebas pirogen • Bebas partikel lain • Kandungan isinya terjaga . asam amino.Softbag Hanya membandingkan Suhu pd sterilisasi akhir Penyediaan air demineralisata 121-140 oC Bahan baku dengan beban mikroba dan endotoksin (pirogen) tidak melebihi batas yang ditetapkan peralatan dan fasilitas produksi (Saturated Pure Steam) 121 oC Proses sterilisasi akhir dari kemasan dan isi di otoklaf pada suhu <121 oCyang optimal dalam otoklaf sehingga tidak merusak zat-zat yang rentan seperti dekstrosa. Pembuatan botol.22 mikron Aseptic filling pengisian larutan di bawah Laminar Air Flow. dilakukan pada suhu 185 oC ` QA check . pengisian dan penutupan botol dengan Blow moulding. albumin dll <121oC Filtrasi dengan filter 0. TUV.• • • Kemasan dan isi infus Otsuka terjamin dan handal (licenced by Otsuka International Japan) Expiry date 5 tahun (melalui riset & teknologi yang dikembangkan selama bertahun-tahun dalam proses sterilisasi (bioburden) dan pengemasan produk) Mendapat kepercayaan dari dokter maupun otoritas kesehatan di berbagai negara (telah diexport)(CPOB. Awal February’2007 telah export ke Australia. SGS dll). UKAS. ISO 9001. . PNG . Tonga .Export to 14 negara Asia-Pasifik Otsuka International Asia Arab Division Korea Otsuka Dong-A Otsuka China Otsuka Egypt Otsuka Otsuka Pakistan Guang Dong Otsuka HK Otsuka Taiwan Otsuka King Car Otsuka Otsuka Philippines Thai Otsuka Export to 14 countries Fiji . Samoa. 9% Asering Dextrose 5% KAEN MG3 Amiparen KAEN 4B N/4-D5 DG2a KCL 4.7% Manitol KAEN 3B Dextran KAEN 1B KAEN 4A .Ringer laktat NaCl 0. . . . 600® PAN.AMIN G® KA-EN MG 3® MARTOS 10® Memelihara keseimbangan cairan tubuh dan nutrisi .L® Menggantikan kehilangan akut cairan tubuh ELEKTROLIT KA-EN 1B® KA-EN 3A® KA-EN 3B® KA-EN 4A® KA-EN 4B® NUTRISI ® AMIPAREN AMINOVEL.NS® KOLOID OTSUTRAN .RL® Otsu.TERAPI CAIRAN RESUSITASI Repai r RUMATAN KCl. Bicnat KRISTALOID ASERING® Otsu. Jenis larutan elektrolit berdasarkan tonisitasnya Plasma 290 Larutan elektrolit isotonik 308 273 Larutan elektrolit Hipotonik 278 290 278 Normal saline Ringer asetat/ laktat D5 KAEN 3B . Asering. RL & NS INDIKASI 1L Syok hipovolemik Diare dengan dehidrasi ber Muntah-muntah hebat DSS Perdarahan Luka Bakar 800 ml 200 ml Kedaruratan bedah Intraoperatif . Obgyn pts. 660 ml 85 ml . Cardiology. Obgyn.Dextrosa & KAEN 1L INDIKASI Pasien Rawat Inap: Interna. Neurologi (Stroke) Post Operative: 225 ml Surgery pts. Pediatric. Pulmonologi. TERAPI CAIRAN IV RESUSITASI     Infus Natrium > 100 mEq/L atau koloid 20-30 ml/kg/jam 2-3 L/10-15 menit RUMATAN  Natrium rendah  4:2:1 (misal 25 kg: 4 x10+2x10+1 x5  500 ml/6 jam 65ml/jam . First Line Ringer’s acetate ASERING® Fluid Resuscitation Therapy ® Ringer’s acetate . restore perfusion) RD5. RAD5. RL.DGAA KAEN3B KAENMG3 Maintenance NaCl3% NaHCO3 Glu 20%.40% Mannitol Repair correct extreme/ symptomatic electrolyte derangement .RLD5.Fluid Therapy NS. Colloids Acute replacement (rehydrate. Asering. Average pH • Ringer’s lactate •Asering® • Normal saline 6.75 7 6.25 . heart and liver2 Coenzyme A Acetate + H+-------- Acetyl-CoA Kreb’s cycle hydrogen source Carbonic acid -------- bicarbonate Ref. McGraw-Hill 4 th ed 1994 p 554 2. lactate is metabolized to pyruvate. which is then converted to CO2 and H2O (80%) or glucose (20%).LR compare to ASERING® LACTATE: Primarily in the liver. Narins RG.Rose BD. 1. Maxwell MH. and to lesser degree the kidney. MacGraw-Hill 1987 4th edition p 1063 . Kleeman CR. Clinical Physiology of Acid-Base and Electrolyte Disorders. Clinical Disorders of Fluid and Electrolyte Metabolism. and regeneration of bicarbonate1 ACETATE: metabolized mainly in muscles and to a lesser extent in tissues such as kidney. SODIUM ASERING® LAKTAT ( HATI ) NaHCO3 + CH3CH(OH)COOH ( Laktat ) CH3CH(OH)COONa + CO2 +H2O CH3CH(OH)COOH + 3 O2 3 CO2 + 3 H2O : TCA Cycle 2.LAKTAT G-6-P GLIKOGEN Asetil KoA PIRUVAT sintetase ASETAT 2 CO2 Asetil .METABOLISME 1.KoA TCA Cycle H 2O . SODIUM ASETAT ( OTOT ) CH3COONa + CO2 +H2O NaHCO3 + CH3COOH ( Asetat ) CH3COOH + 2 O2 2 CO2 + 2 H2O : TCA Cycle GLUkOSA LDH L. ® ® LACTATE VS ASERING VS Na Na Lactate Lactate Bicarbonate Bicarbonate 100 mEq/hr Na Acetate Bicarbonat e 250-400 mEq/hr . LACTATE VS VS ® ® ASERING C3H5O3 + 3O2 ( Lactate ) 2CO2 + 2H2O + HCO3(bicarbonate) (Liver) C2H3O2.+ 2O2 ( Acetate ) CO2 + H2O + HCO3(bicarbonate) (muscle) . 1. Am J Physiol 1976. SHOCK SYNDROMES In shock states such as septic shock. 600% AR may be better alternative to LR Wolfe RR.231:892-897 . Miller HI: cardiovascular and metabolic responses during burn shock in the guinea pig. tissue hypoxia and impaired hepatic gluco neogenesis and oxidation elevate plasma lactate by approx. Effects of Ringer’s acetate solutions during transient hepatic inflow occlusion in rabbits. gluconeogenesis is inhibited and the liver fails to metabolize lactate Nakatani T. • In LR group: 75% reduction in ATP and a 7-fold increase in AMP • Conclusion: in hepatic insufficiency. • Hepatic artery. portal vein and bile duct were ligated and vessels were clamp for 20 minutes. et al.2. HEPATIC INSUFFICIENCY • AR vs LR during induced hepatic insufficiency in rabbits. • AR or LR administered within that 20 minutes. transplantation 1995.59(7):952-57 . Iwasaki H. Namiki A[Utility of acetated Ringer solution as intraoperative fluids during hepatectomy]. metabolism. Yamauchi M. Twenty patients 15 ml/kg/hr with the first 500 ml and thereafter reduced to 10 ml/kg/hr.3. Kawana S. blood gas and renal & liver functions. Intraoperative Fluid during Hepatectomy Masui 1995 Dec. Tsuchida H.44(12):1654-60 Nakayama M. Hemodynamics. . Tsuchida H. Masui 1995 Dec. Yamauchi M. Namiki A[Utility of acetated Ringer solution as intraoperative fluids during hepatectomy]. Iwasaki H.4 40 35 30 25 20 15 10 5 29.AR as intraoperative fluid in hepatectomy Lactate Level (mg/dl) 50 45 (Lactate level at the end of operation) 48.44(12):1654-60 . Kawana S.3 Ringer's lactate Ringer's acetate n = 20 0 Nakayama M.6 + 16.1 + 14. They received inhalation anesthetics (66% nitrous oxide [N 2O] and 1.Effect on Core Temperature J Clin Anesth 1998 Feb.3% to 2. PATIENTS: 60 ASA physical status I and II patients undergoing general surgery.0% to 2.1 mg/kg of vecuronium. et al Comparative effects of Ringer's acetate and lactate solutions on intraoperative central and peripheral temperatures. INTERVENTIONS: Following induction with 5 mg/kg of thiamylal and 0. patients were randomly assigned to one of four groups (15 patients per group).6% sevoflurane) and LR or AR .10(1):23-7 Kashimoto S.0% isoflurane or 1. Effect onMembrane Core Temperature Tympanic Temperature (temperature of tympanic membrane) p<0.05 . Comparative Effects of Ringer’s Acetate (Asering®) and Ringer’s Lactate on core temperature and the frequency of shivering in cesarean Section under Subarachnoid Anesthesia ISOA International Congress. Jakarta Feb: 14th 2006 Susilo Chandra/Eddy Harijanto/Bram Departement of Anesthesiology and Intensive Therapy University of Indonesia. Granmelia.Jakarta 2006 . School of Medicine. 596 > 0.547 35.674 35.800 + 0.615 35.829 35.740 + 0.563 35.717 < 0.165+ 0.806 + 0.018 + 0.778 5 36.717 < 0.715 35.769 36.733 + 0.120 + 0.773 > 0.05 .010 + 0.675 + 0.010 + 0.282 + 0.05 20 35.481 + 0.350 + 0.475 + 0.379 34.720 > 0.05 40 35.522 + 0.217 + 0.787 10 35.719 35.501 35.05 50 34.05 70 34.670 + 0.05 75 34.363 + 0.665 > 0.194 + 0.05 65 34.05 45 35.215 + 0.755 36.05 > 0.576 + 0.841 35.800 > 0.747 35.717 > 0.833 + 0.725 35.05 > 0.715 35.756 + 0.325 + 0.806 < 0.750 < 0.858 + 0.05 25 35.476 + 0.440+ 0.809 36.225 + 0.05 30 35.05 55 34.721 > 0.05 > 0.850 > 0.Study results : Core Temperature Minutes Ringer’s lacatate Ringer’s acetate Significance (p) (Asering) Before SAB 36.404 35.05 60 35.940 + 0.825 > 0.417 + 0.585 + 0.400 + 0.699 > 0.05 15 35.733 + 0.465 + 0.05 35 35.901 After SAB 35. 55th. 50th. significantly on 5th. Although there is no significant difference in the severity of shivering between the two groups.Conclusion 1. 65th minutes 2. Ringer’s Acetate (Asering) maintains core temperature better than Ringer’s lactate in pregnant women undergoing cesarean section under subarachnoid anesthesia. Ringer’s lactate is associated with earlier occurrence of shivering than Asering . 20 patients. 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]. combined spinal and epidural 25 ml/kg/hr 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.48(9):977-80 Onizuka S.Obstetric Use Masui 1999 Sep. . Takasaki M. Sameshima H. Kawano T. Untuk drip 1 amp dilarutkan dalam 500 + ml 1 Asering g/jam • MgSO4(4 g bolus/15 menit) • Jumlah cairan infus 1500-2000 ml/24 jam • Bila terdapat hipovolemia berikan Dextran 40: 500 ml/24jam • Pantau jumlah urin (N >30 ml/jam) Osama Salha and James J Walker Management options: Modern management of eclampsia Postgrad.82. J.. . 75: 78 . Jadi 1 ampul 25 ml berisi 5 g.Preeclampsia/Eclampsia • Asering + MgSO4 20% MgSO4 20% artinya dalam 100 ml ada 20 g. Feb 1999. Med. ASERING® in acute stroke patients . Lee A A comparison of AR and 0. .49(9):779-81 McFarlane C. The exclusive use of 0.9% saline intra-operatively can produce a temporary hyperchloraemic acidosis which could be given false pathological significance. In addition it may exacerbate an acidosis resulting from an actual pathological state. The use of a balanced salt solution such as AR may avoid these complications.AR more suitable as intraoperative fluid vs NS Anaesthesia 1994 Sep.9% saline for intra-operative fluid replacement. 50). Smith B. Bellomo R. +1. most probably acetate and gluconate. Plasmalyte 148 vs Polygeline+ Ringer in 22 patients With the Haemaccel-Ringer's prime. the metabolic acidosis was hyperchloremic ( Cl-. Poustie S.60 for Haemaccel-Ringer's vs. Bennett M Role of pump prime in the etiology and pathogenesis of cardiopulmonary bypass-associated acidosis. Letis A. 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 = -1.0062).50 mEq/l. . +9. the acidosis was induced by an increase in unmeasured anions. CI. P = 0. Hayhoe M. 7. Story D. With Plasmalyte.AR as priming solution in CPB Anesthesiology 2000 Nov.93(5):1170-3 Liskaser FJ.15 for Plasmalyte.00-11. . = 154 mEq/L SID = 0 mEq/L 1 liter SID : 38  1 liter .9% Na+ = 140 mEq/L Cl.PLASMA + NaCl 0.= 102 mEq/L SID = 38 mEq/L Na+ = 154 mEq/L Cl.9% Plasma NaCl 0. ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN NaCl 0.9% Plasma = Na+ = (140+154)/2 mEq/L= 147 mEq/L Cl.= (102+ 154)/2 mEq/L= 128 mEq/L SID = 19 mEq/L 2 liter SID : 19  Asidosis . PLASMA + Larutan ASERING® Plasma Ringer asetat Asetat cepat dimetabolisme Na = 140 mEq/L Cl.= 28 mEq/L SID = 0 mEq/L 1 liter .= 102 mEq/L SID= 38 mEq/L + 1 liter SID : 38 Cation+ = 137 mEq/L Cl.= 109 mEq/L Asetat. 9% .= (102+ 109)/2 mEq/L = 105 mEq/L Asetat.Normal pH setelah pemberian ASERING® Plasma = Na+ = (140+137)/2 mEq/L= 139 mEq/L Cl.(termetabolisme) = 0 mEq/L SID = 34 mEq/L 2 liter SID : 34  lebih alkalosis (dianggap N) dibandingkan pemberian NaCl 0. The final volume of the prime was completed to 2000 ml with Ringer's acetate in the HES groups.000) or Ringer's acetate 2000 ml. Plasma levels of von Willebrand factor antigen and factor VIII procoagulant activity were significantly more depressed after CPB in both HES-groups as compared with the crystalloid prime group.AR superior to HES as CPB Prime Acta Anaesthesiol Scand 1993 Oct.kg-1 HMW-HES (Mw 400. et al. APTT was more prolonged and the maximal amplitude of thromboelastographic tracing was more decreased in the HES-groups.kg-1 LMW-HES (Mw 120. It is concluded that it may be advisable to avoid HES solutions in the CPB prime. especially in patients with an increased risk for bleeding after cardiac operations. Hydroxyethyl starch as a prime for cardiopulmonary bypass: effects of two different solutions on haemostasis.37(7):652-8 Kuitunen A.` . 20 ml.000). In addition. Forty-five patients undergoing coronary bypass grafting were prospectively randomised to three groups and received in a double-blind manner as their CPB prime either 20 ml. Anaesthesia and CPB management were standardised. This does not affect pulmonary functions adversely. or albumin. and with a lower serum colloid osmotic pressure and net lung capillary filtration pressure postoperatively. We conclude that Ringer's acetate for volume replacement to stabilize haemodynamics during and after CAB surgery is associated with increased fluid retention only during the intraoperative period. polygeline. The most expensive colloid fluid regimen (albumin) cost about 230 US$ more per patient than the RAc fluid regimen. compared with all three colloid groups. Fluid balance and pulmonary functions during and after coronary arterybypass surgery: Ringer's acetate compared with dextran.39(5):671-7 Tollofsrud S.AR more cost-effective than colloids Acta Anaesthesiol Scand 1995 Jul. . et al. compared with dextran 70 or polygeline. O. W.H. Regional Publ. Regional Guidelines on Dengue / DHF Prevention and Controll. 2001. . Parenteral Fluid Therapy in Stroke Patients.® ASERING Ringer’s acetate First Line Fluid Resuscitation Therapy Manfaat lain dari ASERING • Direkomendasikan oleh W. Proceeding of PIT PERDOSSI.O. of Communicable Disease. Hardi Pranata. 1999. Proceeding of PIT PERDOSSI. 2001. pemberian ASERING sesuai dengan konsep menghindari LAKTAT. • Pencampuran ASERING dengan 20% MgSO4 sebanyak 10 cc.H. untuk pasien Demam Berdarah Dengue (DBD). • Pada stroke akut. Clinical Experience of Ringer’s acetate with Magnesium sulphate adminstration in Acute Ischemic Stroke. 29. akan meningkatkan tonisitas infus menjadi ISOTONIK. Darmawan I. SEA Dept. Sameshima H.c. Darrow DC.b. Swedish Pdiatric Association 1996 McFarlane C. Story D.e. 5. burn. Lee AA comparison of AR and 0. Aman digunakan pada anak & bayi. Am J Dis Child 1938. Fluid balance and pulmonary functions during and after coronary artery bypass surgery: Ringer's acetate compared with dextran. Dehydration Secondary to Lactation Failure. Geneva :World Health Organization.93(5):1170-3 Liskaser FJ. Acta Anaesthesiol Scand 1995 Jul. Smith B. © 2001 American Board of Family Practice. dll) 3. Diindikasikan untuk resusitasi ( misal: kasus dehidrasi berat. Dengue haemorrhagic fever: diagnosis. 2.39(5):671-7 . Bellomo R.d. Indikasi yang lain: 3. 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]. polygeline. Kawano T. Neonatal Hypernatremic. 2001. Onizuka S. Poustie S. Dibanding koloid tidak ada risiko perdarahan dan lebih cost effective References: 1. 9. 3. 6.a. Letis A.48(9):977-80 Tollofsrud S.1997 Guidelines for treatment of DKA. ped Clin North Am 1959 & Talbot FB. prevention and control. Anesthesiology 2000 Nov.1. et al. Mencegah risiko asidosis laktat bayi post sectio 3. 2. J Am Board Fam Pract 14(2):159-161. Maintain suhu sentral lebih baik dibanding RL 3. Takasaki M.9% saline for intra-operative fluid replacement. Syok DBD. 8. Maintenance DKA pada anak 3. 2nd edition. Masui 1999 Sep. or albumin. Communicable Disease Epidemiology Office of Epidemiology Washington State Department of Health. treatment. Bennett M. Dibanding NaCl mencegah hiperkloremia asidosis 3. Hayhoe M. 7. 4. DSS • Intraoperative • Priming solution for cardiopulmonary bypass (CPB) • Replacement fluid for children . burn.Indications of ASERING® • Replacement fluid for resuscitation gastroenteritis.hemorrhagic shock. . Dukungan nutrisi . rongga ke3) 1. Kebutuhan normal (IWL + urin+ feses) 2.TERAPI CAIRAN RESUSITASI Kristaloid Koloid RUMATAN Elektrolit NUTRISI Seri KA-EN Mengganti kehilangan akut (hemorrhage. GI loss. AGE-RELATED BODY PROPORTION Embryo (97%) Newborn (70-80%) Adults 55-60% Elderly (45-55%) . Rationale of maintenance solutions DN LOBO. et al Fluid redistribution Basal requirement of potassium & sodium Electrolyte concentration in infusion solutions ‘Ready for use’ solutions minimizes risk of contamination . Kebutuhan harian: Air Na+ K+ 30-50 mL/kgBB 2 meq/kgBB 1 meq/kgBB . 2. A primer 2nd Ed. RP. Thomas C.1. V.20 kg > 20 kg Daily Body Fluid Homeostasis3 100 ml water / kg 1000 ml + 50 ml / kg for each kg above 10 kg 1500 ml + 20 ml /kg for each kg above 20 kg ± 20 .0 .3 1. .Potassium and Sodium Homeostasis and Daily Requirement Potassium Sodium (mEq/kgBW/day) (mEq/kgBW/day) Adult1 0. MD.G. and George M. and Dehydration in Family Practice Handbook 3rd Ed.P.7 For infant to children 2 : based on 100 ml of water for each 100 kcal expended. Pediatrics : Vomiting. Maintenance elect.0 (minimum) 1..30 (minimum) ± 1. up to 10 kg 11 . Nutritional Assessment and Support. Diarrhea. Page C. Kokko and Tannen. 3. requirement : 100 ml and 2-4 mEq of Na and K for every 100 kcal expended. USA..9 . Martinez-Bianchi. MD. 1994. Mark A.1. P : 26. MD. WB Saunders.. Michelle..H. Fluid and Electrolyte 3rd Ed. K < 20 mEq/jam*(5-10 mEq/jam). Note: •Pada hipokalemia berat (<2 mEq/L) kec bisa 40 mEq/jam •Fungsi ginjal dBN ~ produksi urin sudah 0. dekstrosa. + elektrolit(Na .5 g/kg/jam.5 mL/kgBB/jam .K+)ml/kg.• Perlu mengetahui berapa kebutuhan air. Na+ 2 mEq/kg K+ 1 mEq/kg air 30-50 + + • Perlu Na 135-145 mEq/L. AA dekstrosa <0. 3.5-5 mEq/L mengetahui status KNatrium dan kalium serum • Perlu +mengetahui syarat kecepatan K+. lipid. Asal Larutan Rumatan Larutan Normal Saline (Na+ 154 mEq/L) Larutan 1/2 NS Na+ 77 mEq/L Larutan KAEN 1 A Mixing Larutan 1/3 NS Na+ 51mEq/L Larutan KAEN 2 Suplementasi elektrolit Larutan Glukosa 5% Larutan 1/4 NS Na+ 38 mEq/L Larutan KAEN 3 Larutan 1/5 NS Na+ 31 mEq/L Larutan KAEN 4 Suplementasi air . . . . in Ringers are still widely used for maintenance therapy What are the impacts ? .Facts: • RL • 5% Dextrose • 5% Dextr. 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 – 63mEq 8 mEq 40 mEq Infus RL bukan Untuk Terapi Rumatan . 50 mEq 6 mEq 30 mEq Ref.5 L KA-EN 3B®. Neonatology Considerations for the Pediatric Surgeon.emedicine. www. www. Rice H.htm 2.com/ped/topic2954.5 L Natrium 60 – 100 mEq 195 mEq 75 mEq Kalium 20 .5 L RL 1. Emedicine. and Michael G.emedicine.C. : 1.KA-EN 3A® KA-EN 3B® Rational infusion solution for maintenance therapy (age > 3 years) KA-EN 4B® Rational infusion solution for maintenance therapy (age < 3 years) Anak BB = 20 kg Kebutuhan Air 1. J.htm Infus RL bukan Untuk Terapi Rumatan .G. 2003 July. 2004.com/ped/topic2982. Piwko. Emedicine. 1. Fluid Therapy for the Pediatric Surgical Patient. tidak rasional .……..TETAPI.TAHU KEBUTUHAN HARIAN. Terapi maintenance tidak adekuat.…….. . 1. Menata kebutuhan harian Kalium? . 7 For infant to children 2 : based on 100 ml of water for each 100 kcal expended. .P. WB Saunders. 1994.H.Potassium and Sodium Homeostasis and Daily Requirement Potassium Sodium (mEq/kgBW/day) (mEq/kgBW/day) Adult1 0. and George M.. Maintenance elect. up to 10 kg 11 .9 . 2. MD.0 (minimum) 1.3 1. Diarrhea.30 (minimum) ± 1. Page C. Kokko and Tannen. P : 26. RP. and Dehydration in Family Practice Handbook 3rd Ed.. Fluid and Electrolyte 3rd Ed. Nutritional Assessment and Support. Martinez-Bianchi.1.G. MD.20 kg > 20 kg Daily Body Fluid Homeostasis3 100 ml water / kg 1000 ml + 50 ml / kg for each kg above 10 kg 1500 ml + 20 ml /kg for each kg above 20 kg ± 20 . Thomas C. requirement : 100 ml and 2-4 mEq of Na and K for every 100 kcal expended. Pediatrics : Vomiting.0 . USA.1. MD. A primer 2nd Ed. 3. V. Mark A.. Michelle.. POTASSIUM FUNCTION • The principal intracellular cation • Membrane repolarization • Neuro-autonomic • Neuromuscular excitability • Glycogen deposition & Protein metabolism • Release of pancreatic hormone • Intracellular pH . Renal Tubular Absorption Na+ K+ . Renal Tubular Absorption . . L: Potassium Disorders.Asupan K+ < 10 meq/hari Defisit Kumulatif 250-300 mEq dalam 7-10 hari Tannen R. Fluid and Electrolytes. In Kokko & Tannen. pp 123 . WB Saunders Company 3rd ed. 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 20 mEq/L umumnya diperlukan pada pasien rawatinap Zwanger M. Hypokalemia. emedicine.com/emerg/topic273.html Management of Severe Hypokalemia in hospitalized Patients JAMA Vol. 161 No. 8, April 23, 2001 • 866 patients with Serum K+ < 3 mmol/L at admission • 55 (6.4%) had no subsequent mesurement of potassium levels • 260 (30%) were discharged with subnormal potassium level Inadequate clinical management of hypokalemia Hypokalemia di Indonesia 1. RSPAD GATOT SOEBROTO-JAKARTA • Limitted incidence/prevalence data (3 centers) • Insiden di RSPAD Gatot Soebroto, bagian penyakit dalam = 26 % • Peningkatan tendency pasien rawat inap dengan hipokalemia = 17,5 % (saat masuk 27 ps, dan saat keluar menjadi 45 pasien) Sudomo, Untung. Marissa Ira. The Indonesian Journal of: Gastroenterology, Hepatology and Digestive Endoscopy. December 2004. Vol.5, No.3. P.115-120. The Prevalence Of Hypokalemia in Hospitalized Pts with Infectious Diseases Problem at Cipto Mangunkusumo Hospital Jakarta. October 2006. . Budi Setiawan. SUB.BAG TR0PIK INFEKSI. keluar menjadi 39 pasien) Djoko Widodo. BAGIAN PENYAKIT DALAM RSCMJAKARTA • Prevalens = 24 % • Peningkatan tendency hypokalemia pasien saat rawat inap (saat masuk 24 pasien. page 202-204. Leonard Naenggolan. No4. Widayat Djoko Santoso.Hypokalemia di Indonesia 2. Acta Medica Indonesiana Vol38. Khie Chen. page:732-734. Eddy Suwandojo. keluar menjadi 56 pasien) Nasronudin. . The prevalence of Hypokalemia in Infectious Diseases Hospitalized Patients.BAG TR0PIK INFEKSI BAGIAN PENYAKIT DALAM RSUD SOETOMOSURABAYA • Prevalens hypokalemia pts = 40 % • Peningkatan tendency hypokalemia pasien saat rawat inap (saat masuk 40 pasien.Hypokalemia di Indonesia 3. Suharto. SUB. Medika Vol 32 December 2006. Ida Bagus Krisna. Hamidah. Mengapa hipokalemia kurang diperhatikan?  Gejala tidak spesifik dan umumnya baru muncul pada kadar K+ < 3 mEq/L  Pada pasien non-kardiak tidak dimonitor ketat  Fasilitas Lab tidak memadai  Awareness << . Deplesi kalium jarang terjadi Bukan masalah bila pasien makan pisang atau jeruk ??? . Berapa Banyak K+ diperoleh dari makanan (Note: 2000 mg ~ 60 mEq) Sayuran Kentang. Electrolyte and Acid Base Physiology. Fluid. buncis Kacang Buah Pisang Jeruk Daging Sapi atau ayam 500 gr 5000 gr 800 gr 1200 gr 600 gr Halperin & Goldtstein. WB Saunders Co. 2nd ed.p 358 . Takut Hiperkalemia dengan pemberian KAEN? . 20 tetes/menit atau ~ 1.6 mEq K+/jam Risiko Hiperkalemia minimal! .KAEN3B mengandung kalium 10 mEq/500 ml Anjuran: 10 mEq/jam* Dalam praktek: Kecepatan Rumatan 500 ml/6 jam ~ 80 ml/jam. Bagaimana menata kebutuhan harian Natrium? . Page C. Maintenance elect. MD. Fluid and Electrolyte 3rd Ed. Diarrhea. Thomas C. and George M. 2.9 .P.. 1994. P : 26.H. A primer 2nd Ed. V. Nutritional Assessment and Support.3 1.. up to 10 kg 11 .1. 3.7 For infant to children 2 : based on 100 ml of water for each 100 kcal expended. Martinez-Bianchi.0 . Michelle. USA.G. Kokko and Tannen.1. MD.20 kg > 20 kg Daily Body Fluid Homeostasis3 100 ml water / kg 1000 ml + 50 ml / kg for each kg above 10 kg 1500 ml + 20 ml /kg for each kg above 20 kg ± 20 . and Dehydration in Family Practice Handbook 3rd Ed. .0 (minimum) 1. RP. WB Saunders.. MD. Pediatrics : Vomiting.30 (minimum) ± 1.Potassium and Sodium Homeostasis and Daily Requirement Potassium Sodium (mEq/kgBW/day) (mEq/kgBW/day) Adult1 0. requirement : 100 ml and 2-4 mEq of Na and K for every 100 kcal expended. Mark A.. Air dan Na Tidak Bisa Dipisahkan ?? Air Pengaturan Jumlah Na Na+ = Pengaturan Vol Cairan Ekstraselu = Pengaturan Vol Cairan Tubuh . . < 60-100 mEq sodium • Hypoalbuminemic patient may require low sodium .Postoperative Maintenance • Most common problem in postoperative fluid balance is fluid overload • NS may aggravate water retention • Current recommendation: < 2 L fluid postoperatively. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection.•Edema paru bisa terjadi dalam 36 jam pasca bedah bila retensi cairan melebihi 67 ml/kg/d sebaiknya intake air < 2000 ml •Pemulihan Fungsi saluran cerna lebih cepat pada kelompok pasien reseksi usus yang mendapat cairan postop < 2 L.115:1371-1377 Lobo DN et al. 4. 3. Robert N. ROWLAND Sand Simon P. Lancet 2002 May 25.L. CHEST 1999. Disorders of nutrition and metabolism in clinical surgery. WILLIAMS.359(5320):1792-3 Hill G. LOBO. pemberian natrium tinggi menyebabkan luka operasi sulit sembuh •Ekskresi air dan natrium lebih lambat pada pasien postop yang mendapat cairan dengan kandungan natrium yang lebih tinggi •Kalori minimal 600 kcal memiliki efek menghemat protein (Protein-sparing effect) 1. 77 mEq Na dibandingkan kelompok > 3 L. Dileep N. Fatal Postoperative Pulmonary Edema. ALLISON (Ab)normal saline and physiological Hartmann's solution: a randomized double-blind crossover study Clinical Science (2003) 104. (17–24) . 2. 154 mEq Na sebaiknya asupan + Na pasca bedah < 60-100 mEq •Pasien hipoalbuminemia mengalami ekspansi cairan ke interstisial. Arieff Allen L. Brian J. Pathogenesis & Literature Review. Churchill Livingstone 1990 Fiona REID. IV Fluid Overload • Decrease muscular oxygen tension and delay recovery of gastrointestinal function • Cause general edema • Impede tissue healing and cardiopulmonary function . Malnutrisi dalam populasi Indonesia 1998 TARGET / capita : kalori 2500 + protein 55 gm SKRT 1998 : kalori 2150 + protein 46 gm “Orang Indonesia sebelum jatuh sakit” sudah menderita defisit nutrisi 15% . Usus bocor. fistel usus-kulit Usus harus di-istirahatkan Nutrisi harus lewat vena (NPE) . EDEMA ANASARKA + HEPATOMEGALI . HARUS BAGAIMANA DONK ?? . Fluid balance is ideally determined by weighing your patients pre and postoperatively? . Or by comparation/experienced pre and postoperatively? . p 60 2500 ml : 1 NS + 4 D5 ditambahkan K+ = 1 mmol/kg/24 jam (diberikan setelah 48 jam pasca beda) NS D5 KCl Vol Na Cl K+ Kcal 500 2000 50 77 - 77 50 400 50 2550 77 127 50 400 . Chruchill Lvingstone 1992.Ilustrasi Rumatan Paska Bedah G. Disorders of Nutrition and Metabolism in Clinical Surgery.L.Hill. NS D5 KCl Vol Na Cl K+ Kcal 500 2000 50 77 - 77 50 400 50 2550 77 127 50 400 KAEN 3B 2000ml 100 100 40 216 KAEN MG3 2000ml 100 100 40 800 G. Chruchill Lvingstone 1992.L. Disorders of Nutrition and Metabolism in Clinical Surgery.Hill. p 60 . Bila memberikan 2 Lt “infus maintenance” RL+D5 RD5 Infus lain KAEN MG3 Na+ 260 294 200 100 K+ Kalori 8 400 8 400 36 400 40 800 Na+ K+ Kalori RL+D5 agak tinggi RD5 sangat tinggi kurang kurang kurang pas-pasan Infus lain sangat tinggi cukup pas-pasan KAEN MG adekuat adekuat adekuat . . ASERING & KAEN 3B kompatibel dengan obat dibawah ini: ••Nicholin Nicholin ••Trental Trental ••Sermion Sermion ••Tagamet Tagamet ••Primperan Primperan * Internal Laboratory Data (QA OI Factory) ••MgSO4 MgSO4 ••Neurobion Neurobion ••Syntocinon Syntocinon ••Aminophylline Aminophylline . PEMAKAIAN CAIRAN INFUS DI RUMAH SAKIT disesuaikan dengan sediaan infus yg ada dipasaran PEMAKAIAN INFUS DI UGD SYOK HIPOVOLEMIK Ya ASERING 20-30 ml/kg/jam Observasi/ monitor nadi teraba akral hangat urine output + kecepatan bisa diturunkan 10 73 ml/kg/jam TIDAK < 3 tahun > 3 tahun KAEN 4A KAEN 1B Kecepatan: BB < 10 kg: 4 ml/kg/jam 11-20 kg : 2 ml/kg/jam > 25 kg : 1 ml/kg.jam Normo/hipoK Contoh : Anak 5 tahun BB 15 kg- 4 x 10 + 2 x 5 = 50 ml/jam = 12 tetes/menit KAEN 4B Normo/ hipoK KAEN 3B/MG3 PASIEN SYOK Asering TRIFLUID etc. especially KAEN 3B/MG3 which contain per liter ( Na + 50 mEq. such: maintain perioperative core temp. Maintenance fluid therapy must measure the IWL and sodium/potassium daily requirement. K+: 20mEq and glucose 27/100 gr. maintenance for diabetes ketoacidosis.operative fluid therapy in various surgical settings. intra. Kaen series designed more rasionale for maintenance. 3. Further publication.Take home messages 1. Asering (AR) is an alternative to LR/NS as resuscitation fluid. CPB. 2. Trifluid The Only Carbohydrate Solution Supplemented with Zinc for PPN . . . . TERIMA . Terima Kasih . PLASMA + NaCl 0.9% Plasma NaCl 0.9% Na+ = 140 mEq/L Cl- = 102 mEq/L SID = 38 mEq/L Na+ = 154 mEq/L Cl- = 154 mEq/L SID = 0 mEq/L 1 liter SID : 38  1 liter Pada DSS, DKA pemberian NaCl 0.9% dalam jumlah besar bisa menyebabkan asidosis ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN Na Cl 0.9% hiperkloremik Plasma Na+ = (140+154)/2 mEq/L= 147 mEq/L Cl- = (102+ 154)/2 mEq/L= 128 mEq/L SID = 19 mEq/L 2 liter SID : 19  Asidosis PLASMA + NaCl 0.9% Plasma NaCl 0.9% Na+ = 140 mEq/L Cl- = 102 mEq/L SID = 38 mEq/L Na+ = 154 mEq/L Cl- = 154 mEq/L SID = 0 mEq/L 1 liter SID : 38  1 liter DKA pemberian NaCl 0.= (102+ 154)/2 mEq/L= 128 mEq/L SID = 19 mEq/L 2 liter SID : 19  Asidosis .9% dalam jumlah besar bisa menyebabkan asidosis ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN Na Cl 0.Pada DSS.9% hiperkloremik Plasma = Na+ = (140+154)/2 mEq/L= 147 mEq/L Cl. = 102 mEq/L SID= 38 mEq/L + 1 liter SID : 38 Cation+ = 137 mEq/L Cl.= 28 mEq/L SID = 0 mEq/L 1 liter .= 109 mEq/L Asetat.PLASMA + Larutan RINGER ASETAT Plasma Ringer Asetat Asetat cepat dimetabolisme Na = 140 mEq/L Cl. 9% 2 liter .= (102+ 109)/2 mEq/L = 105 mEq/L Asetat.RINGER ASETAT garis pertama dalam resusitasi cairan pada diare dg dehidrasi berat.DBD dan DKA RINGER ASETAT Plasma = Na+ = (140+137)/2 mEq/L= 139 mEq/L Cl.(termetabolisme) = 0 mEq/L SID = 34 mEq/L SID : 34  lebih alkalosis dibanding jika diberikan NaCl 0. = 77 mEq/L + 1 liter SID : 38 SID = 0 mEq/L 1 liter .PLASMA + Larutan N/2-D5 Plasma Na = 140 mEq/L Cl.= 102 mEq/L SID= 38 mEq/L N2/D5 Cation+ = 77 mEq/L Cl. (termetabolisme) = 0 mEq/L SID = 19 mEq/L SID : 19  lebih asidosis dibanding jika diberikan RA 2 liter .= (102+ 77)/2 mEq/L = 89.5 mEq/L Laktat.Normal pH setelah pemberian N2/D5 Plasma = Na+ = (140+77)/2 mEq/L= 108.5 mEq/L Cl. SOL Plasma Na+ = 140 mEq/L Cl.5 mEq/L SID : 38 SID = -1.5 mEq/L 1 liter .= 155.PLASMA + Larutan R.= 102 mEq/L SID= 38 mEq/L R.Sol 1 liter Na++K++Ca++ = 154 mEq/L Cl. = (102+ 155.25  potensi asidosis > 2 liter .SOL Plasma = Na+ = (140+154)/2 mEq/L= 147 mEq/L Cl.Setelah pemberian R.75 mEq/L SID = 20.5)/2 mEq/L = 128.25 mEq/L SID : 20. = 20 mEq/L SID = 0 mEq/L Laktat cepat dimetabolisme 1 liter .= 102 mEq/L SID= 38 mEq/L KAEN3B + 1 liter SID : 38 Cation+ = 70 mEq/L Cl.= 50 mEq/L Laktat.PLASMA + Larutan KAEN3B Plasma Na = 140 mEq/L Cl. 45%-D5 2 liter .= (102+ 50)/2 mEq/L = 76 mEq/L Laktatt.Normal pH setelah pemberian KAEN3B Plasma = Cation = (140+70)/2 mEq/L= 105 mEq/L Cl.(termetabolisme) = 0 mEq/L SID = 29 mEq/L SID : 29  lebih alkalosis dibanding jika diberikan NaCl 0.