You are on page 1of 54

Emergency Medicine Lunch Symposium

Makassar, 7th April 2013


dr. Budhi Santoso
Medical Consultan of PT Otsuka Indonesia

SHORT CURICULUM VITAE

1.Name
2.Place/date of birth
3.Address
4.Marial status
5.Alumny

:
:
:
:
:

6.Working Experienced :

Budhi Santoso
Jakarta, 17 Mei 1967
Mampang Indah II, Blok D2, Depok Sawangan
Married with 4 children
Medical Faculty of Brawijaya Univ, Malang,1993
6.1.
6.2.
6.3.
6.4.

Cipete Clinic, Jakarta (1993-1994)


Puskesmas Moro Seneng-Kepri, Riau (1994-1997)
Schering AG (Med Advisor: 1998-2000)
Otsuka Indonesia (Med-Consultant: 2001-2007)

7.Training Experienced :
7.1. GCP advance course, Schering AG-Berlin, 1998
7.2. Communication on Family Planning, Sweden 1999
7.3. AUCOGS Congress, Philadelphia-USA, 2000
7.4. Schering internal leadership course, Dusit, Thailand, 2
7.5. Critical Care Annual and Pensa Meeting: Bali 2002
7.6. ATLS advanced, RSCM 2003
7.7. Indonesian GCP, RSCM 2004
7.8. Critically ill in children: Malang, 2005.
7.9. Critical care workshop, Surabaya, 2006, 2007
7.10.Aminofluid Workshop,Tokushima, Japan, 2008, 2010
7.11.Espen Congress, Barcelona Spain, Sept 2012

7.12.Safety, Efficacy and PV joint seminar, Japan-Indonesian FDA,


2013

Cairan Infus
@#$%^&,

Wes, ewes,..ewes,
bablas angine......

Yang penting
kasih obat,
infus no.
12 ?

Ente harus makan


obat seumur hidup !!!

Waduh, lama
amat, dok !!
Enggak, lama,
Tergantung berapa
lama Ente hidup !!!

Infus Rasional bila


paham 4 hal:
1. Indikasinya
2. Fisiologi infus saat masuk tubuh
3. Patofisiologinya yang sering
(Resusitasi vs Rumatan)
4. Pemilihan infus yang tepat
Lobo, et all 2010

Facts:
CAIRAN RESUSITASI YANG LAZIM DIPAKAI
Fluid

Osm

NS

308

RL

273

Intracell
Risk of
Lactate
distribution Hyperchloremic
acidosis
+
(Cl- 154 mEq/L)
+

RA

273

D5

278

RS

310

+
(Cl- 155.5 mEq/L)

Otsuka NCE internal surveys data, 2010***

Simulasi kasus:

Pasien pria 20 th masuk RS dg keluhan utama demam


sudah 5 hari tidak turun, letih, insomnia dan dyspepsia
PF: KU somnolen pucat, BP 105/80 HR 94 RR 12;
bibir pecah-pecah, lidah kering &
agak kotor, faring tidak hiperemis. BB 70 kg TB
165
D/ demam tifoid (konfirmasi serologis)
Na+ 150; K+ 3; Cl 102;glukosa 70;Alb 3.5 BUN 20; kreat 1,5

Simulasi kasus:

demam tifoid, dimana tidak ada asupan oral


sama sekali karena pasien dispepsia dan anoreksia

Jika pasien diberi (1 L Asering + 1 L Aminofluid) + 2 Sachet PROTEN


PRODUK

AA (g)

NPC (g)

Total
kalori(kcal)

1 L ASERING

1 L AMINOFLUID

30

75

420

2 Sachet PROTEN

20

53

424*

TOTAL

50

128

844

Na+ (mEq)

K+ (mEa)

130

35

20

165*

24

* ada lemak 5,9 g/sachet

simulasi kasus :

demam tifoid, dimana tidak ada asupan oral


sama sekali karena pasien dispepsia dan anoreksia
Jika pasien diberi 1 L KAEN MG3 + 1 L Aminofluid + 2 Sachet PROTEN
PRODUK

AA (g)

NPC (g)

Total
kalori(kcal)

Na+ (mEq)

K+ (mEa)

1 L KAEN MG3

100

400

50

20

1 L AMINOFLUID

30

75

420

35

20

2 Sachet PROTEN

20

53

424*

TOTAL

50

128

1232

85

40

* ada lemak 5,9 g/sachet

DESIGN TERAPI CAIRAN IV

RESUSITASI

RUMATAN

Infus Natrium > 100 mEq/L

atau koloid
20-30 ml/kg/jam (diare, DSS)
2-3 L/10-15 menit (perdarahan)

Natrium rendah (50-100 mEq)


Kalium sesuai keb. Harian
Tambahan mikromineral, tra
Element dan as. amino
4:2:1
(misal 25 kg:
4 x10+2x10+1 x5

500 ml/6 jam

65ml/jam

Historical Perspective of Infusion Preparation

Resuscitation

Maintenance

Otsuka
could
offer to you

Hypovolemic shock

Stable
Hemodynamic

ASERING

First Line

Ringers acetate

Fluid Resuscitation Therapy

Acetate Ringers

Indications of ASERING
First line in replacement fluid for
resuscitation: gastroenteritis, burn,
hemorrhagic shock, DSS with or
whithout hepatic insufficiency
Intra operative
Priming solution for cardiopulmonary
bypass (CPB)
Safe replacement fluid for children


ASERING
Ringers acetate

First Line
Fluid Resuscitation Therapy

Direkomendasikan oleh W.H.O. untuk


pasien Demam Berdarah Dengue
(DBD).
W.H.O. SEA Dept. of Communicable Disease. Regional Guidelines
on Dengue / DHF Prevention and Controll. Regional Publ. 29. 1999.

Pada stroke akut, pemberian ASERING


sesuai dengan konsep menghindari LAKTAT.
Pencampuran ASERING dengan 20%
MgSO4 sebanyak 10 cc, akan meningkatkan
tonisitas infus menjadi ISOTONIK.
Hardi Pranata. Clinical Experience of Ringers acetate with Magnesium sulphate adminstration in
Acute Ischemic Stroke. Proceeding of PIT PERDOSSI. 2001.
Darmawan I. Parenteral Fluid Therapy in Stroke Patients. Proceeding of PIT PERDOSSI. 2001.

Asering Benefit:
1. Komposisi mirip dengan plasma, tepat untuk menggantikan
kehilangan akut cairan ekstraseluler. ( 2 )
2. Kecepatan metabolisme asetat 250-400 mEq/jam , sedangkan
laktat 100mEq/jam, asetat lebih cepat mengkoreksi asidosis.( 3)
3. Asetat memerlukan sedikit O2 dan melepaskan sedikit CO2.( 4 )
4. Metabolisme asetat terutama di otot, tidak terganggu pada kelainan hati (1)

1. Loren A et al. Oxidation of lactate and acetate in rat skeletal muscle. Journal of Applied
Physiology 1997 ; 83 ( 1 ) : p. 32 - 39.
2. Heimberger DC,M.Roland RW. Handbook of Clinical Nutrition.Mosby 1997
3. Anderud T, Lund T. Intensive Care of Patients with Burns. Tidskr Nor Laegenforen 1989;
p.3197 - 3199.
4. Ringer acetate solution in clinical practice. Medimedia.1999

General Benefit

Average pH
Ringers lactate

6.75

ASERING

Normal saline

6.25

AR as priming solution in CPB


Anesthesiology 2000 Nov;93(5):1170-3
Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M

Role of pump prime in the etiology and pathogenesis of


cardiopulmonary
bypass-associated acidosis.
Plasmalyte 148 vs Polygeline+ Ringer in 22 patients

With the Haemaccel-Ringer's prime, the metabolic acidosis was


hyperchloremic ( Cl-, +9.50 mEq/l; CI, 7.00-11.50).
With Plasmalyte, the acidosis was induced by an increase in unmeasured
anions, most probably acetate and gluconate. 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 = -1.60
for Haemaccel-Ringer's vs. +1.15 for Plasmalyte; P = 0.0062).

N Engl J Med 2012; 367:124-134July 12, 2012DOI: 10.1056/NEJMoa1204242

Hydroxyethyl Starch 130/0.42 versus Ringer's Acetate in Severe


Sepsis
Anders Perner, M.D., Ph.D., Nicolai Haase, M.D., Anne B. Guttormsen, M.D., Ph.D., Jyrki Tenhunen, M.D., Ph.D., Gudmundur
Klemenzson, M.D., Anders neman, M.D., Ph.D., Kristian R. Madsen, M.D., Morten H. Mller, M.D., Ph.D., Jeanie M. Elkjr, M.D.,
Lone M. Poulsen, M.D., Asger Bendtsen, M.D., M.P.H., Robert Winding, M.D., Morten Steensen, M.D., Pawel Berezowicz, M.D., Ph.D.,
Peter Se-Jensen, M.D., Morten Bestle, M.D., Ph.D., Kristian Strand, M.D., Ph.D., Jrgen Wiis, M.D., Jonathan O. White, M.D., Klaus J.
Thornberg, M.D., Lars Quist, M.D., Jonas Nielsen, M.D., Ph.D., Lasse H. Andersen, M.D., Lars B. Holst, M.D., Katrin Thormar, M.D.,
Anne-Lene Kjldgaard, M.D., Maria L. Fabritius, M.D., Frederik Mondrup, M.D., Frank C. Pott, M.D., D.M.Sci., Thea P. Mller, M.D.,
Per Winkel, M.D., D.M.Sci., and Jrn Wetterslev, M.D., Ph.D. for the 6S Trial Group and the Scandinavian Critical Care Trials Group

In conclusion,
patients with severe sepsis who received fluid resuscitation with HES 130/0.42, as
compared with those who received Ringer's acetate, had a higher risk of death at 90
days, were more likely to receive renal-replacement therapy, and had fewer days
alive without renal-replacement therapy and fewer days alive out of the hospital.

DBD III & IV

O2 2-4 L/menit
RA/RL 20 ml/kg bolus dalam 30 menit

Syok teratasi

RA/RL 10 ml/kg/jam

Syok tidak teratasi


Teratasi

Dextran 40 10-20 ml/kg


Tidak Teratasi

Stabil dalam 24 jam


RA 5 ml/kg/jam
Stop < 48 jam

3 ml/kg/jam

Ht turun
Ht tetap/naik
FFP 10 ml/kg Dextran 20 ml/kg

Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999

Asering /

Diagram 9. Alur tatalaksana Pemberian cairan Derajat IV


Prof. Soegeng, Tatalaksana DBD terkini, RSUD Dr Soetomo/FKUnair, 2006

ASERING & KAEN 3B

kompatibel dengan obat dibawah ini:


Nicholin
Trental
Sermion
Tagamet
Primperan

* Internal Laboratory Data (QA OI Factory)

MgSO4
Syntocinon
Aminophylline
Adonna

JAN 2012

TERAPI CAIRAN

RESUSITASI

Kristaloid

Koloid

RUMATAN

Elektrolit

NUTRISI

Aminofluid
Seri KA-EN

Mengganti kehilangan
1. Menjaga homeostasis haria
akut (hemorrhage,
2. Terapi suportif
GI loss, rongga ke3)
Memepercepat penyembuhan

Facts:
RL
5% Dextrose
5% Dextr. in Ringers
are still widely used
for maintenance therapy *****

What are the impacts ?

Bisa bisanya Otsuka


aja, tuh......
saya pakai RL 20tts/i
maintenance tidak
hipernatremi, tidak
hipokalemi ??

iya tanpa cek


serum Na
atau K nya,
kan ?

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 65 mEq

8 mEq

40 mEq

Infus RL bukan
Untuk Terapi Rumatan

Anak BB = 20 kg
Kebutuhan

Air 1.5 L

RL 1.5 L

KA-EN 3B, 1.5 L

Natrium

60 100 mEq

195 mEq

75 mEq

Kalium

20 - 50 mEq

6 mEq

30 mEq

Ref. :
1. Rice H. Fluid Therapy for the Pediatric
Surgical Patient. Emedicine. 2003 July.
www.emedicine.com/ped/topic2954.htm
2. Piwko, J.G. and Michael G.C. Neonatology Considerations
for the Pediatric Surgeon. Emedicine. 2004.
www.emedicine.com/ped/topic2982.htm

Infus RL bukan
Untuk Terapi Rumatan

Prevalences of
Hypokalemia
Chief Investigator

Centre

No of
% hypokalemia
patients on admission

% hypokalemia
on Discharge

Untung Sudomo

RSPAD

100

28

45

Djoko Widodo

RSCM

105

22.9

52.4

Nasronudin

RS Sutomo 110

36.36

50.91

1.
2.
3.

Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy vol.5. Ed: Dec 2004. Page: 115-120
Widodo D, Setiawan B, Khie Chen. The prevalence of hypokalemia in hospitalized patients with infectious diseases problems at
Ciptomangun-kusumo Hospital Jakarta. Acta Med Indones, 2006;38(4):202-5
Nasronudin et al. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients. Medika 2006 Vol
XXXII,No 12, p 732-734

How does maintenance


fluid therapy evolve?

Na+ 35 K+ 20

Na+ 50 K+ 20, glu 27 g

Na+ 77

Pasien Rawat-Inap (di Jepang)


Dehydrated
Previously well-nourished
Good appetite

Dehydrated
Previously well-nourished
Or slightly undernourished
Metabolically Non-stressed
Anorexia
Fatigue

Fluid & basic


electrolyte
maintenance

Complete
Electrolyte, 3% AA,
5-10% glucose
maintenance

KAEN3B

AMINOFLUID

Previously malnourished
Or undernourished or
Metabolically stressed
Hypoalbuminemia
Debilitated
If EN entirely impossible

Parenteral Nutrition :
10 % AA, High NPC
(glucose , lipid)
NEOPAREN/MIXID

AMINOFLUID
Glucose
7.5

Amino acids

3%
Aminofluid

Electrolytes
(Na, K, Cl, Mg, Ca, P)

Zinc
By SS 2006-2007

36

Tabel 1. Komposisi Aminofluid dibandingkan RL dan KAEN3B


KAEN3B
Ringers lactate ASPEN guideline(2)
Komposisi
Aminofluid
Air

2000

2000

2000

30-40 ml/kg/hari

Na+

70

100

260

1-2 mEq/kg/hari

K+

40

40

1-2 mEq/kg*/hari

Cl-

70

100

218

sesuai kebutuhan

Mg++

10

8-20 mEq/hari

Ca++

10

10-15 mEq/hari

20

20-40 mEq/hari

Zn

10 mol

2.5-5 g

Asam amino

AA 60 g

0.8 g/kg/hari

Glukosa

150 g

54 g

kebutuhan basal untuk homeostasis K+ adalah 20-30 mEq/hari (10);


kebutuhan basal asam-aminopada pasien nonstressed; protein-sparing ef,
Recommended by ASPEN GUIDELINES 2008

BCAA

BBB
Appetite

Fatigue
(Serotonin)

Tryptophan
80%

(Serotonin)

E. Blomstrand A Role for Branched-Chain Amino Acids in Reducing Central Fatigue J. Nutr.,
February 1, 2006; 136(2): 544S - 547S

3 GOLDEN WAYS

Why Aminofluid is particularly helpful in infection,


trauma or for post operative pts

Infeksi/Trauma

Inflammation, fever,
hyperventilation

Dehydration,
dry tongue
& mouth
LOSS OF
APPETITE

Cytokines
(TNF,IL-1,IL-6)

serotonin

Melanocortin
2

Delayed gastric emptying

3
Tryptophan/BCAA ratio centrally
combat fatigue syndrome

Best Recommended in
Following Conditions:
Febrile illnesses
Dehydrated and anorexic, dyspeptic patients
Gastrointestinal diseases, post resuscitation of
severe diarrhea, colonoscopy, gastroparesis
Acute Infectious diseases
Early post operative maintenance (straightforward
surgery)
Hyperemesis gravidarum (after 0.9% NaCl)
Stroke (after metabolic and electrolyte correction)
Precautions:
Renal Failure associated with hyperkalemia
Heart Failure
Small children

Penyakit
Gastrointestinal

DBD
Infeksi akut/
Demam
Hiperemesis
gravidarum

Neurologi

Aminofluid
Diabetes
Mellitus

Postoperatif

Sepsis

POD1

+
ASERING-5
NPC
AA
Na+
K+

500 kcal
30 g
165 mEq
24 mEq

POD 2

NPC
AA
Na+
K+

600 kcal
60 g
70 mEq
40 mEq

POD 3

(stress metabolic sedang/berat)

NPC
AA
Na+
K+

300 kcal
80 g
35 mEq
20 mEq

Rekomendasi Cairan solumix DBD grade I d

Aminofluid 500 mL
pOsm: 816 mOsm/L
Na : 35 mEq
K : 20 mEq

Asering 500 mL
pOsm: 274 mOsm/L
Na : 130 mEq
K : 4 mEq

pOsmotik menjadi 545 mOsml/L


Na : 82,5 mEq

Hypovolemic shock

Stable
Hemodynamic

AMINOFLUID

JAN 2012

Take Home Message


1.
2.

3.
4.

Agar rasional memberikan infus pahami 4 hal: Indikasi,


Fisiologi, Patofisiologi dehidrasi dan hipovolemi, Sediaan infus
yang ada dipasaran.
Asering (AR) pilihan utama infus resusitasi dan memiliki
kelebihan dibanding RL atau NS, seperti: maintain suhu utama
perioperatif, DKA, CPB, mencegah asidosis laktat pada
neonatus saat SC
Kaen series di desain memenuhi kebutuhan maintenance
dasar, misal: KAEN 3B (Na+ 50 mEq, K+: 20mEq and glucose
27 gr)
Aminofluid didesain sebagai infus maintenace terkini yang
sekaligus bisa mengatasi dehidrasi, mencegah anorexia dan
mengatasi fatigue sehingga mempercepat penyembuhan
pasien rawat inap

Mencegah infus tidak adekuat, tidak


rasional

Have a nice
day

You might also like