1.

FLUID THERAPY
Extracellular volume deficit is the most common fluid disorder in surgical
patients and can be either acute or chronic. Acute volume deficit is associated with
cardiovascular and central nervous system signs, whereas chronic deficits display
tissue signs, such as a decrease in skin turgor and sunken eyes, in addition to
cardiovascular and central nervous system signs. Laboratory examination may
reveal an elevated blood urea nitrogen level if the deficit is severe enough to reduce
glomerular filtration and hemoconcentration. Urine osmolality usually will be higher
than serum osmolality, and urine sodium will be low, typically <20 mEq/L. Serum
sodium concentration does not necessarily reflect volume status and therefore may
be high,normal, or low when a volume deficit is present. The most common cause of
volume deficit in surgical patients is a loss of GI fluids from nasogastric suction,
vomiting, diarrhea, or enterocutaneous fistula. In addition, sequestration secondary
to soft tissue injuries, burns, and intra-abdominal processes such as peritonitis,
obstruction, or prolonged surgery can also lead to massive volume deficits.
Extracellular volume excess may be iatrogenic or secondary to renal
dysfunction, congestive heart failure, or cirrhosis. Both plasma and interstitial
volumes usually are increased. Symptoms are primarily pulmonary and
cardiovascular. In fit patients, edema and hyperdynamic circulation are common
and well tolerated. However, the elderly and patients with cardiac disease may
quickly develop congestive heart failure and pulmonary edema in response to only a
moderate volume excess. Fluid intake is derived from both exogenous (consumed
liquids) and endogenous (released during oxidation of solid foodstuffs) fluids. Fluid
losses occur by four routes:
1. Lungs. About 400 mL of water is lost in expired air each 24 hours. This is
increased in dry atmospheres or in patients with a tracheostomy, emphasising
the importance of humidification of inspired air.
2. Skin. In a temperate climate, skin (i.e. sweat) losses are between 600 and 1000
mL/day.
3. Faeces. Between 60 and 150 mL of water are lost daily in patients with normal
bowel function.
4. Urine. The normal urine output is approximately 1500 mL/day and, provided
that the kidneys are healthy, the specific gravity of urine bears a direct
relationship to volume. A minimum urine output of 400 mL/day is required to
excrete the end products of protein metabolism.
Maintenance fluid requirements are calculated approximately from an
estimation of insensible and obligatory losses. Various formulae are available for
calculating fluid replacement based on a patients weight or surface area. For
example, 3040 mL/kg gives an estimate of daily requirements. The following are
the approximate daily requirements of some electrolytes in adults:
sodium: 5090 mM/day;
potassium: 50 mM/day;
calcium: 5 mM/day;
 magnesium: 1 mM/day.
Dextrose solutions are also commonly employed. These provide water
replacement without any electrolytes and with modest calorie supplements (1 litre
of 5 per cent dextrose contains 400 kcal). A typical daily maintenance fluid regimen
would consist of a combination of 5 per cent dextrose with either Hartmanns or
normal saline to a volume of 2 litres. There has been much controversy in the
literature regarding the respective merits of crystalloid versus colloid replacement.
There is no consensus on this topic and the usual advice is to replace like with like.
If the haematocrit is below 21 per cent, blood transfusion may be required. There is
increasing recognition, however, that albumin infusions are of little value. In
addition to maintenance requirements, replacement fluids are required to correct
pre-existing deficiencies and supplemental fluids are required to compensate for
anticipated additional intestinal or other losses. The nature and volumes of these
fluids are determined by:
1. A careful assessment of the patient including pulse, blood pressure and
central venous pressure, if available. Clinical examination to assess hydration
status (peripheries, skin turgor, urine output and specific gravity of urine),
urine and serum electrolytes and haematocrit.
2. Estimation of losses already incurred and their nature: for example, vomiting,
ileus, diarrhoea, excessive sweating or fluid losses from burns or other
serious inflammatory conditions.
3. Estimation of supplemental fluids likely to be required in view of anticipated
future losses from drains, fistulae, nasogastric tubes or abnormal urine or
faecal losses.
4. When an estimate of the volumes required has been made, the appropriate
replacement fluid can be determined from a consideration of the electrolyte
composition of gastrointestinal secretions. Most intestinal losses are
adequately replaced with normal saline containing supplemental potassium.
Total enteral or parenteral nutrition necessitates the provision of the
macronutrients, carbohydrate, fat and protein, together with vitamins, trace
elements, electrolytes and water. When planning a feeding regimen, the patient
should be weighed and an assessment made of daily energy and protein
requirements. Standard tables are available to permit these calculations. Daily
needs may change depending on the patients condition. Overfeeding is the most
common cause of complications, regardless of whether nutrition is provided
enterally or parenterally. It is essential to monitor daily intake to provide an
assessment of tolerance. Failure to do so is the most common reason for inadequate
nutrition. In addition, regular biochemical monitoring is mandatory.

Macronutrient requirements
The total energy requirement of a stable patient with a normal or moderately
increased need is approximately 2030 kcal/kg per day. Very few patients require
energy intakes in excess of 2000 kcal/day. Thus, in the majority of hospitalised
patients in whom energy demands from activity are minimal, total energy
requirements are approximately 13001800 kcal/day. There is an obligatory glucose
requirement to meet the needs of the central nervous system and certain
haematopoietic cells, which is equivalent to about 2 g/kg per day. In addition, there
is a physiological maximum to the amount of glucose that can be oxidised, which is
approximately 4 mg/kg per minute (equivalent to about 1500 kcal/day in a 70-kg
person), with the nonoxidised glucose being primarily converted to fat. However,
optimal utilisation of energy during nutritional support is ensured by avoiding the
infusion of glucose at rates approximating physiological maximums. Plasma glucose
levels provide an indication of tolerance. Avoid hyperglycaemia. Provide energy as
mixtures of glucose and fat. Glucose is the preferred carbohydrate source.
Dietary fat is composed of triglycerides of predominantly four long-chain fatty
acids. There are two saturated fatty acids (palmitic (C16) and stearic (C18)) and two
unsaturated fatty acids (oleic (C18 with one double bond) and linoleic (C18 with two
double bonds)). In addition, smaller amounts of linolenic acid (C18 with three double
bonds) and medium-chain fatty acids (C6C10) are contained in the diet. The
unsaturated fatty acids, linoleic and linolenic acid, are considered essential because
they cannot be synthesised in vivo from non-dietary sources. Both soybean and
sunflower oil emulsions are rich sources of linoleic acid and provision of only 1 litre
of emulsion per week avoids deficiency. Soybean emulsions contain approximately 7
per cent alpha-linolenic acid (an omega-3 fatty acid). The provision of fat as a
soybean oil-based emulsion on a regular basis will obviate the risk of essential fatty
acid deficiency. Safe and non-toxic fat emulsions based upon long-chain
triglycerides (LCTs) have been commercially available for over 30 years. These
emulsions provide a calorically dense product (9 kcal/g) and are now routinely used
to supplement the provision of non-protein calories during parenteral nutrition.
Energy during parenteral nutrition should be given as a mixture of fat
together with glucose. There is no evidence to suggest that any particular ratio of
glucose to fat is optimal as long as under all conditions the basal requirements for
glucose (100200 g/day) and essential fatty acids (100200 g/week) are met. This
dual energy supply minimises metabolic complications during parenteral nutrition,
reduces fluid retention, enhances substrate utilisation (particularly in the septic
patient) and is associated with reduced carbon dioxide production. Concerns have
been expressed about the possible immunosuppressive effects of LCT emulsions.
These are more likely to occur if the recommended infusion rates (0.15 g/kg per
hour) are exceeded. Nonetheless, these concerns have prompted the development
of newer emulsions based upon medium-chain triglycerides, omega-3 fatty acids
and, most recently, structured triglycerides, which combine long- and medium-chain
triglycerides in the same emulsion. The evidence of clinical benefit for these
emulsions compared with conventional LCTs is tenuous, particularly if infusion rates
are appropriate and hypertriglyceridaemia is avoided.
The basic requirement for nitrogen in patients without pre-existing
malnutrition and without metabolic stress is 0.100.15 g/kg per day. In
hypermetabolic patients, the nitrogen requirements increase to 0.200.25 g/kg per
day. Although there may be a minority of patients in whom the requirements are
higher, such as after acute weight loss when the objective of therapy is long term
repletion of lean body mass, there is little evidence that the provision of nitrogen in
excess of 14 g/day is beneficial. Vitamins, minerals and trace elements Whatever
the method of feeding, these are all essential components of nutritional regimens.
The water-soluble vitamins B and C act as coenzymes in collagen formation and
wound healing. Postoperatively, the vitamin C requirement increases to 6080
mg/day. Supplemental vitamin B12 is often indicated in patients who have
undergone intestinal resection or gastric surgery and in those with a history of
alcohol dependence.
Absorption of the fat-soluble vitamins A, D, E and K is reduced in steatorrhoea
and the absence of bile. Sodium, potassium and phosphate are all subject to
significant losses, particularly in patients with diarrhoeal illness. Their levels need
daily monitoring and appropriate replacement. Trace elements may also act as
cofactors for metabolic processes. Normally, trace element requirements are met by
the delivery of food to the gut and so patients on long-term parenteral nutrition are
at particular risk of depletion. Magnesium, zinc and iron levels may all be decreased
as part of the inflammatory response. Supplementation is necessary to optimise
utilisation of amino acids and to avoid refeeding syndrome.

Tipe Cairan Intravena

Ada 3 tipe cairan intravena berdasarkan osmolaritas cairan yaitu hipotonik,
hipertonik dan isotonik. Cairan hipotonik mempunyai osmolaritas yang lebih rendah
dibandingkan serum (konsentrasi ion Na+ lebih rendah dibandingkan serum),
sehingga larut dalam serum, dan menurunkan osmolaritas serum. Maka cairan
ditarik dari dalam pembuluh darah keluar ke jaringan sekitarnya (prinsip cairan
berpindah dari osmolaritas rendah ke osmolaritas tinggi), sampai akhirnya mengisi
sel-sel yang dituju. Digunakan pada keadaan sel mengalami dehidrasi, misalnya
pada pasien cuci darah (dialisis) dalam terapi diuretik, juga pada pasien
hiperglikemia (kadar gula darah tinggi) dengan ketoasidosis diabetik. Komplikasi
yang membahayakan adalah perpindahan tiba-tiba cairan dari dalam pembuluh
darah ke sel, menyebabkan kolaps kardiovaskular dan peningkatan tekanan
intrakranial (dalam otak) pada beberapa orang. Contohnya adalah NaCl 45% dan
Dekstrosa 2,5%.
Cairan Isotonik mempunyai osmolaritas (tingkat kepekatan) cairannya
mendekati serum (bagian cair dari komponen darah), sehingga terus berada di
dalam pembuluh darah. Bermanfaat pada pasien yang mengalami hipovolemi
(kekurangan cairan tubuh, sehingga tekanan darah terus menurun). Memiliki risiko
terjadinya overload (kelebihan cairan), khususnya pada penyakit gagal jantung
kongestif dan hipertensi. Contohnya adalah cairan Ringer-Laktat (RL), dan normal
saline/larutan garam fisiologis (NaCl 0,9%).
Untuk cairan hipertonik, osmolaritasnya lebih tinggi dibandingkan serum,
sehingga menarik cairan dan elektrolit dari jaringan dan sel ke dalam pembuluh
darah. Mampu menstabilkan tekanan darah, meningkatkan produksi urin, dan
mengurangi edema (bengkak). Penggunaannya kontradiktif dengan cairan
hipotonik. Misalnya Dextrose 5%, NaCl 45% hipertonik, Dextrose 5%+Ringer-
Lactate, Dextrose 5%+NaCl 0,9%, produk darah (darah), dan albumin.
Pembagian cairan lain adalah berdasarkan kelompoknya:
1. Kristaloid:
bersifat isotonik, maka efektif dalam mengisi sejumlah volume cairan (volume
expanders) ke dalam pembuluh darah dalam waktu yang singkat, dan berguna
pada pasien yang memerlukan cairan segera. Misalnya Ringer-Laktat dan
garam fisiologis.
2. Koloid:
ukuran molekulnya (biasanya protein) cukup besar sehingga tidak akan keluar
dari membran kapiler, dan tetap berada dalam pembuluh darah, maka
sifatnya hipertonik, dan dapat menarik cairan dari luar pembuluh darah.
Contohnya adalah albumin dan steroid.

Jenis Cairan Infus

1. ASERING
Indikasi:
Dehidrasi (syok hipovolemik dan asidosis) pada kondisi: gastroenteritis akut,
demam berdarah dengue (DHF), luka bakar, syok hemoragik, dehidrasi berat,
trauma.
Komposisi:
Setiap liter asering mengandung:
Na 130 mEq
K 4 mEq
Cl 109 mEq
Ca 3 mEq
Asetat (garam) 28 mEq
Keunggulan:
1. Asetat dimetabolisme di otot, dan masih dapat ditolelir pada pasien yang
mengalami gangguan hati
2. Pada pemberian sebelum operasi sesar, RA mengatasi asidosis laktat lebih
baik dibanding RL pada neonatus
3. Pada kasus bedah, asetat dapat mempertahankan suhu tubuh sentral pada
anestesi dengan isofluran
4. Mempunyai efek vasodilator
5. Pada kasus stroke akut, penambahan MgSO4 20 % sebanyak 10 ml pada
1000 ml RA, dapat meningkatkan tonisitas larutan infus sehingga
memperkecil risiko memperburuk edema serebral

2. KA-EN 1B
Indikasi:
1. Sebagai larutan awal bila status elektrolit pasien belum diketahui, misal pada
kasus emergensi (dehidrasi karena asupan oral tidak memadai, demam)
2. < 24 jam pasca operasi
 3. Dosis lazim 500-1000 ml untuk sekali pemberian secara IV. Kecepatan
sebaiknya 300-500 ml/jam (dewasa) dan 50-100 ml/jam pada anak-anak
4. Bayi prematur atau bayi baru lahir, sebaiknya tidak diberikan lebih dari 100
ml/jam

3. KA-EN 3A & KA-EN 3B

Indikasi:
1. Larutan rumatan nasional untuk memenuhi kebutuhan harian air dan
elektrolit dengan kandungan kalium cukup untuk mengganti ekskresi harian,
pada keadaan asupan oral terbatas
2. Rumatan untuk kasus pasca operasi (> 24-48 jam)
3. Mensuplai kalium sebesar 10 mEq/L untuk KA-EN 3A
4. Mensuplai kalium sebesar 20 mEq/L untuk KA-EN 3B

KA-EN MG3
Indikasi :
1. Larutan rumatan nasional untuk memenuhi kebutuhan harian air dan
elektrolit dengan kandungan kalium cukup untuk mengganti ekskresi harian,
pada keadaan asupan oral terbatas
2. Rumatan untuk kasus pasca operasi (> 24-48 jam)
3. Mensuplai kalium 20 mEq/L
4. Rumatan untuk kasus dimana suplemen NPC dibutuhkan 400 kcal/L

KA-EN 4A
Indikasi :
1. Merupakan larutan infus rumatan untuk bayi dan anak
2. Tanpa kandungan kalium, sehingga dapat diberikan pada pasien dengan
berbagai kadar konsentrasi kalium serum normal
3. Tepat digunakan untuk dehidrasi hipertonik
Komposisi (per 1000 ml):
Na 30 mEq/L
K 0 mEq/L
Cl 20 mEq/L
Laktat 10 mEq/L
Glukosa 40 gr/L

KA-EN 4B
Indikasi:
1. Merupakan larutan infus rumatan untuk bayi dan anak usia kurang 3 tahun
2. Mensuplai 8 mEq/L kalium pada pasien sehingga meminimalkan risiko
hipokalemia
3. Tepat digunakan untuk dehidrasi hipertonik
Komposisi:
Na 30 mEq/L
K 8 mEq/L
Cl 28 mEq/L
Laktat 10 mEq/L
Glukosa 37,5 gr/L
AMIPAREN
Indikasi:
1. Stres metabolik berat
2. Luka bakar
3. Infeksi berat
4. Kwasiokor
5. Pasca operasi
6. Total Parenteral Nutrition
7. Dosis dewasa 100 ml selama 60 menit

AMINOVEL-600
Indikasi:
1. Nutrisi tambahan pada gangguan saluran GI
2. Penderita GI yang dipuasakan
3. Kebutuhan metabolik yang meningkat (misal luka bakar, trauma dan pasca
operasi)
4. Stres metabolik sedang
5. Dosis dewasa 500 ml selama 4-6 jam (20-30 tpm)