Fluid Management

Suparto
Anesthesia Department
Medical Faculty Christian Krida Wacana University
Perempuan, 25 tahun, 60kg, jatuh dari motor setelah
mengalami kecelakaan dengan truk
• Male, 10 yo, 20kg, for emergency debridement
and amputation Right arm, NPO 6 hr, ht 35%
• Male, 40 yo, 60kg, ht 40%, for emergency
debridement and amputation
 Osmosis
• Osmosis is the movement of water (solvent
molecules) across a semipermeable membrane
from a compartment in which the nondiffusable
solute (ion) concentration is lower to a
compartement in which the solute concentration
is higher (Ganong 2003)
 Osmotic pressure
• Is the pressure that must be applied to the
side with more solute to prevent a net
movement of water across the membrane to
dilute the solute
• Is the amount of force needed to keep water
from flowing across that membrane
• Osmolality is the number of particles (osmoles) in
a kilogram of fluid; (konsentrasi suatu larutan
yang diekspresikan sebagai sejumlah partikel per
Kg)
• Osmolarity is the number of particles in a liter of
fluid.
• These terms are often used interchangeably
because the density of water is 1 kg/L.
• Normal serum osmolarity is around 285-295
mOsm/L.
• Tonicity, describe the osmolarity of a solution relative
to plasma
• Is a measure of the osmotic pressure gradient of two
solutions seperated by a semipermiable membrane

• Isotonic, solutions that have the same osmolarity as

plasma (no transfer of fluid into or out of cells occurs)
• Hypertonic, those with higher osmolarity (cells shrink)
• Solution that has a higher solute concentration compared
to another solution
• Hypotonic, those with lower osmolarity (cells swell)
• Solution that has a lower solute concentration compared
to another solution
 Jenis dan Jumlah cairan tubuh
Cairan tubuh 60%

CES 20% CIS 40%

Plasma darah Cairan interstitial

5% 15%
• Distribusi cairan tubuh manusia dewasa:
– Total Body Water :
• (M) 60% BB (600ml/kg)
• (F) 50% BB (500ml/kg)
– Whole Blood (M) 66ml/kg, (F) 60 ml/kg
– Blood represents about 11-12% of the total body fluid
Marino PL. The ICU Book 3rd ed; 2007: 211-229
• Average blood volume(Morgan & mikhail’s Clinical Anesthesiology, 5 th Ed)
– Neonates: Premature 95 ml/kg, Full term 85 ml/kg
– Infants 80 ml/kg
– Adult: Men 75 ml/kg, Women 65 ml/kg
In nonobese individuals, the blood volume varies in
direct proportion to the body weight, averaging 70
ml/kg for lean men and woman (stoelting 4th ed; 658)
 Holliday-Segar Formula for Maintenance Fluid
Requirements by Weight

Wt (kg) Water
ml/day ml/hr
0-10 100/kg 4/kg

11-20 1000+50/kg for 40+2/kg for

each kg >10 each kg >10

>20 1500+20/kg for 60+1/kg for

each kg >20 each kg >20
 Faktor modifikasi kebutuhan cairan

Kebutuhan Ekstra Penurunan kebutuhan

• Demam (10%-12% setiap • Hipotermia (12% setiap 1ºC
1ºC >37ºC) <37ºC)
• Hiperventilasi • Kelembaban sangat tinggi
•Suhu lingkungan tinggi • Oliguria atau anuria
• Aktivitas ekstrem • Hampir tidak ada aktivitas
• Setiap kehilangan • Retensi cairan (gagal
abnormal jantung)
What Fluid?
 Pemberian Infus
Terapi Cairan

Resusitasi Rumatan

Kristaloid Koloid Elektrolit Nutrisi

Ring As Gelofusine Aminofluid Clinimix

Ring Laktat Hes KAEN Aminofluid
Ringer fundin Dextran
Albumin
• Type of Fluid
– Crystalloid (RL, NS, D5%)
• Small molecules (< 8000 dalton)
– Colloid (Albumin, Dextran, Hetastarch)
• Large molecules (> 8000 dalton)
– Red blood cells (WB, PRBC)
• To increase the oxygen carrying capacity of blood
Crystalloid VS Colloid resuscitation
• Crystalloid:
– Distributed in the
extracellular fluid
– only 25% of the infused
volume will remain in the
vascular space and expand
the plasma volume
• Crystalloids are categorized by their tonicity, a
synonym for osmolality. A fluid that's isotonic has
the same number of particles—the same osmolality
—as plasma.
• Therefore, an isotonic solution won't promote the
shift of fluids into or out of the cells, causing them to
swell or shrink.
• Ringer Asering and lactated Ringer's (LR) solution are
two of the most commonly used isotonic fluids.
• Dextrose 5% in water (D5W) is another isotonic
crystalloid. However, it's not used for resuscitation
because, as its glucose is metabolized, this fluid
quickly becomes hypotonic.
• In fact, D5W is a good source of free water. As with
other hypotonic fluids, such as 0.45% NS, the water
quickly shifts out of the vascular bed and into the
cells, by way of osmosis.
• Colloid:
– Contain large molecules 
do not readily move into
the interstitial fluid
– At least 75% will remain in
the vascular space
– More effective for
augmenting plasma volume
 Colloids
Advantages Disadvantages
• Volume expansion • Anaphylaxis
• Longer duration of • Expensive
action • Poss coagulopathy
 Crystalloids
Advantages Disadvantages
• Easily available • Shorter duration of
• Free of anaphylactic action
reaction
• Economical
SO WHAT IS SHOCK ?
 Introduction to shock
• Combination of hemodynamic parameters
– Mean Arterial Pressure < 60 mmHg
– Systolic blood Pressure < 90 mmHg
– Clinical: ↓UO
– Metabolic Acidosis
• Kegagalan sirkulasi dlm mencukupi kebutuhan
O2 jaringan tubuh
First….
Identify the cause of shock
Reverse tissue hypoperfusion
 SO..SHOCK IS NOT
HYPOTENSION BUT
HYPOPERFUSION
(REDUCED OXYGEN DELIVERY TO MEET
THE OXYGEN CONSUMPTION)
 PHYSIOLOGY OF THE DO2/VO2 RELATIONSHIP
THE OXYGEN CASCADE

Uptake in the Lung PaO2

CaO2
Carrying capacity SaO2 DO2

Delivery Flow rate

Organ distribution
Mikrosirkulasi
Diffusion
VO2

Cellular use

ATP = energy
 In Shock

1. There is an Imbalance between the oxygen demand of

the tissue and the oxygen delivery
2. Reduced oxygen delivery is the key factor
(Hypoperfusion)
RESUSCITATION FROM SHOCK
IS…

To restore the imbalance between oxygen

demand to the oxygen supply
 Cardiogenic Distributive/ Septic
Shock/Acute Heart Shock
Failure

CONTRACTILITY Vasopressor
Inotropes
SYSTEMIC VASCULAR RESISTANCE

Pump = Pipe = Vascular BP = CO x SVR

Heart

Release Cardiac Output

tamponade,etc CONTRACTILITY
PRELOAD
Volume =
Obstructive SVR
Shock Blood

PRELOAD
Hypovolemic
Fluids Shock
 Severity of blood loss
• Class I
– Loss of 15% of BV or less (≤ 10 ml/kg)
– Clinical finding are minimal or absent
– ± 5 ml/kg
• Class II
– Loss of 15-30% of BV (10-20ml/kg)
– Compensated phase (systemic vasoconstriction,
UO ↓ 20-30 ml/hr)
– ± 15 ml/kg
• Class III
– Loss 30-45% of BV (20-30ml/kg)
– Decompensated phase (hypotension, UO <15
ml/hr, depressed mentation, lactat acumulation in
blood >2 mEq/L)
– ± 25 ml/kg
• Class IV
– Loss > 45% (>30ml/kg)
– Irreversible phase (UO <5 ml/hr, refractory to
volume replacement, lactat >4 to 6 mEq/L)
– ± 35 ml/kg
 Severity of Blood Loss
Variable I II III IV

SBP Normal Normal ↓ ↓↓

Pulse <100 >100 >120 >140

RR 14-20 20-30 30-40 >35

Mental Anxious Agitated Confused Lethargic

status
BL (ml) <750 750-1500 1500-2000 >2000

BL (%) <15 15-30 30-40 >40

 Stadium Shock
• Stadium Kompensasi:
– Transcapillary refill replenish ± 15% of blood
volume (interstitial fluid into capillaries)
– Sekresi Vasopressin, RAA ↑  retensi air, sodium
dlm sirkulasi
– ↑ refleks simpatis
• Resistensi sistemik
• Resistensi Arteriol  ↑ diastolic pressure
– HR ↑
– Manifestasi: taki, gelisah, kulit pucat dan dingin,
pengisian kapiler lambat (> 2 detik)
• Stadium Dekompensasi:
– Perfusi jaringan buruk
• O2 ↓
• Metabolisme anaerob  laktat asidosis
• Penumpukan CO2  Asam Karbonat
• Kontraklititas miokardium terhambat
– Gangguan metabolisme energy Na+/K+ pump di
tingkat seluler  Kerusakan sel
– Pelepasan mediator vaskuler: histamin, serotonin,
cytokines
• Vasodilatasi arteriol
• Permiabilitas kapiler ↑  venous return ↓, Cardiac output ↓
– Manifestasi: taki, TD ↓↓, oliguria, kesadaran
menurun, asidosis, perfusi perifer buruk
• Stadium Irreversible
– Kerusakan dan kematian sel  multi organ
failure
• Manifestasi: nadi tak teraba, TD tak
terukur, anuria
• The end point of the fluid resuscitation
phase is…
restoring peripheral perfusion and BP and
returning increased heart rate toward
normal.
• Atasi penyebab
• Traditional end point of volume
resuscitation
– MAP 65-70mmHg
– Capillary refill time < 2 seconds
– UO > 0.5 ml/kg/hour (adults)
– O2 ssat > 95%
– CVP 8-12 mmHg
 Estimating the Volume Resuscitation Volume

1. Estimate normal blood volume

2. Estimate % loss of blood volume
3. Calculate volume deficit
4. Determine resuscitation volume
• Hb and Hct
– Poor correlation between blood volume defisit
and Hb in acute hemmorrhage, dilutional
decrease in Hb and Hct, NEVER be used to
evaluate acute blood loss Marino PL. The ICU Book 3 ed; 2007:
rd

211-229

• Appropriate treatment of hypovolemia is

volume replacment!!
Kasus:
Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengan
kesadaran menurun. Riwayat diare dan muntah 3 hari
SMRS.
PF: KU: tampak lemas, Sakit berat. TD 90/45mmHg, HR
130x/min, RR 35x/min, T 38ºC, mata tampak cekung, bibir
dan mukosa mulut sangat kering, turgor kulit menurun,
lain2 dalam batas normal
DEHIDRASI
 Tanda-tanda Kehilangan Cairan (Dehidrasi)
Morgan & Mikhail’s Clinical Anesthesiology, 5th Ed

Tanda Kehilangan cairan dalam persentase berat badan

5% 10% 15%

Membran Kering Sangat kering Panas dan kering

mukosa
Sensori normal letargi melambat
Perubahan Tidak ada ada Jelas
orthostatik >15bpm ↑
>10 mmHg ↓
Denyut nadi Normal / ↑ ↑↑ >100 bpm ↑↑↑ >120bpm

Laju aliran urine ↓ ↓↓ ↓↓↓

Tek. darah normal ↓↓ dgn variasi ↓↓↓

respirasi
Back to the case….

Kasus:
Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengan
kesadaran menurun. Riwayat diare dan muntah 1 hari
SMRS.
PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR
120x/min, RR 25x/min, T 38ºC, mata tampak cekung, bibir
dan mukosa mulut sangat kering, turgor kulit menurun,
lain2 dalam batas normal
 Case…
• Defisit: 60 kg x 10% = 6 kg = 6 L = 6000 ml
• Bolus: 20 ml x 60 kg = 1200 ml/30 menit
• Membaik atau tidak??
– Membaik, Sisa defisit: 4800 ml
50% (2400 ml) dalam 8 jam pertama + cairan rumatan
50% (2400 ml) dalam 16 jam berikutnya + cairan rumatan
− Tidak membaik,
Ulangi, pikirkan penggunaan coloid, pertimbangkan
penggunaan vasopressor

• Terapi Cairan dan Elektrolit SMF Anestesi & Terapi intensif FK UNDIP dr. Ery
Leksana, Sp.An.KIC
• Step I: focus on emergency management
– IV fluid 20ml/kg isotonic crystalloid
– Additional boluses if needed
• Step II: focuses on deficit replacement
– daily fluid requirements (100-50-20) +
– Fluid deficit
• Total step II:
– ½ of the volume administered in 8 hr
– ½ of the remainder administered in 16 hr
• Check electrolyte
*Emedicine.medscape.com
Syok Anafilaktik
• Hentikan pemberian obat atau antigen penyebab
• Baringkan penderita dengan kaki lebih tinggi dari kepala
• Berikan adrenalin sediaan 1mg/1cc, dengan dosis 0.3-
0.5ml IM (Anak 0.01ml/kg) dapat diulang setiap 5 menit
• Pemberian adrenalin dengan IV, kalau pemberian IM
tidak ada respon. Dengan dosis (dewasa) 0.5ml
 Volume Infusion
A. Catheter Size
The rate of volume infusion is determined by
the dimensions of the vascular catheter, not
the size of the vein

For rapid volume resuscitation, cannulation of

peripheral veins with short catheter is
preferred to cannulation of large central veins
with long catheters
 Titik Akhir Terapeutik
Capillary refill time < 2 detik

Ekstremitas hangat & warna kulit kemerahan

Produksi urine > 1 ml/kg/jam
Status mental normal
Laktat menurun
Saturasi vena sentral > 70%
 Conclusion
• Understand the stages of hypovolemic shock
and associated pathophysiological changes
• Early detection of compensated shock so that
fluid can be given adequately
• Know how much fluid must be given
• Indication of blood transfusion
• How to know the success of resuscitation
 Terima kasih
Semoga bermanfaat
 Daftar Pustaka

• Marino PL. The ICU Book 3rd ed; 2007: 211-229

• Morgan & mikhail’s Clinical Anesthesiology, 5th Ed
• Hahn Robert G, Prough Donald S, Perioperative Fluid
Therapy; 2007: 435-446