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Transcript of Klinis Praktis Cairan Resusitasi
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CLINICAL PRACTICE
OF FLUID RESUSCITATION
Ririe F Malisie
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The Fluid Management Concept
Basic treatment, necessary in all patients
crystalloid
colloid + crystalloid
Fluidmanagement
Fluid replacement
target: tissues, interstitiumindication: dehydration, maintenance
Volume replacement
target: intravascular space
indication: plasma and blood losses
F
luidmanagem
ent
Specific treatment, necessary in patients with volume (Blood) losses
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IVS
share of water: 60 %
ISS
ICS
Distribution of Fluids
The distribution of fluids within the body
depends on the physico-chemical properties
of the administered solution.
The major properties,
which influence the distribution are:
Colloid osmotic pressure (COP)
Tonicity, i. e. the sodium concentration
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Infusion Fluids
Basically we can distinguish two different types of preparations
used
in fluid therapy:
Crystalloidsare mainly electrolyte solutions like normal
saline (0.9% NaCl), Ringers solution, or balanced solutions
(eg. Ringerfundin).
Colloidsare preparations containing macromolecules like
gelatin (eg. Gelofusine) or hydroxyethyl starches (eg.
Venofundin and Tetraspan).
Crystalloids Colloids&
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Targeted fluid compartment in the body
Crystalloids
Colloids
! They administer fluid MAINLY to the whole extracellular space (ECS),
which is the IVS (intravascular space) and ISS (interstitial space)
! They administer fluid MAINLY to the intravascular space (IVS)
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Crystalloids Colloids
Fluid Therapy
Dextran
Albumin
Gelatin
HES
(Hydroxyethylstarch)
NaCl 0.9%/ 0,45%
Electrolyte
solutions like:
Other fluids
Ringerfundin
Mannitol
Glucose 5%
Lactated Ringersetc.
Ringers solutionElectrolyte
concentrates
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Advantages/ disadvantages of crystalloid fluid resuscitation
Advantages Disadvantages
Balanced electrolyte composition
Buffering capacity, lactate/ acetate
No risk of adverse reactions
No disturbance of hemostasis
Promoting diuresis
Inexpensive
Poor plasma volume support
Large quantities needed
Reduced plasma COP
Risk of overhydration
Risk of edema formation
Risk of hypothermia
Boldt et al. (2004), Table 3.1
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Problems in Colloid Therapy
We are just giving colloidto the patient!
What should happen?
Possible side effectsamongst others can be:
!
Influence on Renal Function!
Influence on coagulation
!Anaphylaxis reaction! Tissue accumulation
!
Acid base balance disturbances
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Hydroxethylstarch (HES) Classification
Tetrastarch (0.4) Pentastarch (0.5)
Hetastarch (0.7)
HES 130 /0.4
HES 130/0.42 HES 200 /0.5 HES 450 /0.7
(Based on the degree of substitution)
(Based on In Vitro Molecular weight)
High molecular weight
HES
Medium Molecular weight
HES
Low molecular weight
HES
HES 450 / 0.7
HES 470 /0.7
HES 200 /0.5
HES 200 /0.62
HES 40 /0.5
HES 70 /0,5
HES 110 /0.5HES 130 /0.4
HES 130/0.42Hemohes,
Haes-steril,Voluven
Venofundin
Tetraspan
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Effects of colloids on kidney function
Gelatins:
Dextrans:
HES:
Renal insufficiency is possible after Dextran 40
Acute renal failure after HES is possible
No negative effect! Improved kidney function!
Latent
increase of
urine viscosity
Enhanced
flow
resistance
Stop of
filtration
Decrease of glomerular
filtration
Dextran
concentration
in proximal
tubuli
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Effect on coagulation
Gelatins HES Dextrans
Factor VIII, vWF
Plateletsadhesionaggregation
Thrombusformation
Blood typing
No effect
No effect
No clinical
effect
No effectIn emergency situations
blood typing prior to infusion!
time
Gelatin dlm dosis besar tidak memperpanjang perdarahan
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Take Home Message
Electrolytes:
sodium, calcium, potassium,magnesium and chloride
The blood buffer is mainlycomposed of bicarbonate -
acetate/malateare
precursors of bicarbonate.
Plasma proteinskeep the
COP of the circulatory system- this can be taken over by
colloids like HES or Gelatin.
plasma 0.9% NaClRingerssolution
Ringer-fundin Tetraspan
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THANK YOU