Fluid Resuscitation in

Trauma / Perioperative Pt

S. Sunatrio

Dept of Anesthesiology, Faculty of Medicine

University of Indonesia-Jakarta

S. Sunatrio 1
 TUJUAN RESUSITASI CAIRAN

RESTORASI PERFUSI JARINGAN

& PENGIRIMAN O2 KE SEL

MENGURANGI : ISKEMIA JARINGAN

KEGAGALAN ORGAN
S. Sunatrio 2
 LR NS
LR
Two wide bore iv cannulae 11LL Fast 1L

Raise the legs

O2 via a mask

Monitor BP&Pulse

Catheterise & measure

Urine output
S. Sunatrio 3
 TOTAL BODY WEIGHT ( 70 Kg )

TOTAL BODY WATER ( 42 L )

ICV ( 28 L ) ECV ( 14 L )

RBC PV
(3L)

Blood Volume (5 L)

IF = ECV- PV

S. Sunatrio 4
 Separation of Total Body Water
Osmotic and Colloid-Osmotic Pressure ( COP )
(Starling 1896)

TBW
ICS ECS
280 mOsm/l 280 mosm/l
K-ions Na-ions

Intravascular space Interstitial

COP ~25 mm Hg space
TP - 80% Albumin COP~ 5mmHg

Edema threshold : COP 20-15 mmHg - Albumin 2.5 g/dl - TP 5.0 g/dl (??)
Normal values : Albumin 3.5 - 5.5 g/dl, TP 6.0 - 8.0 g/dl
S. Sunatrio 5
 Blood volume distribution
Blood volume of ~ 5 - 6 l =100% ( ~ 7% of Bw)

Blood Volume
5 - 6 l = 100%

High Pressure system Low Pressure system

15% 75 - 80%

Capillary system
5 - 10%

Cardiac work increases

with Hct and viscosity
S. Sunatrio 6 and vice versa!
 Volume Replacement Therapy

Crystalloids Colloids
Lactated Ringer's
Normal Saline

Albumin Gelatin Dextran HES

PPL solutions solutions solutions

S. Sunatrio 7
 KOMPOSISI CAIRAN IV
CAIRAN GLUKOSA Na+ Cl- laktat Osmolaritas
(g/L ) (mEq/L) (mEq/L) (mEq/L) (mOsm/kg)

D5W 50 0 0 0 252
LRS 0 130 109 28 273
D5W / LRS 50 130 109 28 525
0,9 % Saline (NS) 0 154 154 0 308
6 % HES 0 154 154 0 310
5 % Albumin/NS 0 154 154 0 310
25 % Albumin 0 154 154 0 310
(rata2) ( rata2)

S. Sunatrio 8
 Sifat-sifat cairan koloid
Tekanan
Kadar~ BM Persen Osmotik Masa Paruh
Koloid
(%) (kisaran dalam d) Intravaskular Koloid Intravaskular
(mm Hg) (jam)
Albumin 5 69.000 80 20 >24

Dekstran 70 6 70.000 100 40# 6-12

(20.000 - 175.000)

Dekstran 40 10 40.000 100 2-3

Kanjiheta@ 6 450.000 100 30 >24

(10.000 - 1.000.000)

Kanjipenta 10 264.000 100 40@ 10$

(150.000 - 350.000)

* Dimodifikasikan dari Davies MJ. The role of colloids in blood conservation. Int Anesthesiol Clin 1990; 28:205
~ Dalam formulasi yang biasa dipakai di AS
# Data dari Carlson RW, Rattan S, Haupt MT. Fluid resuscitation in conditions of increased permeability. Anesthesiol Rev

1990; 17:14
@Kanjiheta dan kanjipenta tersusun dari molekul kanji hidroksietil dengan berbagai BM
$ Data dari Rackow EC, Astiz ME, et al. Effects of pentastarch and albumin infusion on cardiorespiratory function and

S.coagulation
Sunatrio 9 in patients with severe sepsis and systemic hypoperfusion. Crit Care Med 1989; 17:394
 PV EXPANSION WITH ADMINISTRATION OF
250 mL OF SELECTED FLUIDS

FLUID PV IFV ICV

(mL) (mL) (mL)

D5W 18 70 162
LRS 50 200 0
5 % Albumin 250 0 0
25 % Albumin 1000 -750 0

PV = change in plasma volume ; IFV = interstitial fluid volume ;

ICV = intracellular volume ; D5W = 5 % dextrose in water ;
LRS = Lactated Ringers Solution.

S. Sunatrio 10
 EFEK INFUS 1 L CAIRAN PADA KOMPONEN TUBUH

Intrasel Total Interstisial Plasma

Cairan Volume Ekstrasel Volume Volume

0,9 % NaCL - 100 1100 825 275

5 % Dextrose 660 340 255 85
5 % NaCL - 2950 3950 2690 990
5 % Albumin 0 1000 > 500 > 500
Darah Lengkap 0 1000 0 1000

S. Sunatrio 11
 Lamke et al. Plasma volume changes after infusion of various plasma
expanders. Resuscitation. 1976;5:93-102.

Plasma volume effect 90 minutes after fluid administration

Volume, mL
700

600

500

400

300

200

100

0
6% Hetastarch 5% Albumin Gelatin Saline

S. Sunatrio 12
 Average initial volume effect of synthetic
colloids in % of infused volume
Volume Effect Duration
3.5 % Polygeline
~70% ~2-3h
3-4% Modified Fluid Gelatin
6% HES 200/0.5
6% HES 130/0.4 ~ 100% ~3-4h
6% Dextran 70
6% HES 200/0.62 and 450/0.7
10% HES 200/0.45 and 0.5
~ 145% ~3-9h

10% Dextran 40 ~ 170% ~3-4h

0 50 100 150 200 (%)

S. Sunatrio 13
 PV = Volume cairan infus (PV / Vd)

PV = Perubahan PV yang diharapkan

Vd = Volume distribusi cairan infus

Tidak ada : Syok, Sepsis, Hipoksemia lama !

S. Sunatrio 14
 BB 70 Kg PV= Vd= 3 L

Berapa banyak koloid isoonkotik ( albumin 5 % )

yang harus diinfuskan untuk meningkatkan PV
sebesar 2 L ?

2 L = Volume infus ( 3 L / 3 L )

Jadi volume koloid isoonkotik ( albumin 5 % ) yang

harus diinfuskan = 2 L

S. Sunatrio 15
 BB 70 Kg PV = 3 L
Vd = 14 L

Berapa banyak RL / NS yang harus diinfuskan untuk

meningkatkan PV sebesar 2 L ?

2 L = volume infus ( 3 L / 14 L )

Jadi volume RL / NS yang harus diinfuskan = 9,5 L

S. Sunatrio 16
 BB 70 Kg PV = 3 L
Vd = 42 L

Berapa banyak D5W yang harus diinfuskan untuk

meningkatkan PV sebesar 2 L ?

2 L = volume infus ( 3 L / 42 L )

Jadi volume D5W yang harus diinfuskan = 28 L

S. Sunatrio 17
 Crystalloid Solutions are
distributed over the entire
Extracellular Space.
And therefore crystalloids are
indicated and most effective
when this space is depleted.

S. Sunatrio 18
 Colloids
They remain largely within
the Intravascular Space.
Therefore, colloids are
most effective
in hypovolemic patients.

S. Sunatrio 19
 ADAKAH PENGARUH
MACAM CAIRAN RESUSITASI
TERHADAP
HASIL AKHIR ?

S. Sunatrio 20
 Volume replacement Therapy Three
distinct situations:

Blood loss during surgery

Blood loss with delayed resuscitation
(trauma)
Late shock or shock complicated by sepsis

S. Sunatrio 21
 Blood loss during surgery
In most cases of surgery blood loss
is witnessed,
can be measured and
replaced immediately by
appropriate solutions.
Crystalloids and Colloids help to
prevent major interstitial fluid shifts and
hypovolemia

S. Sunatrio 22
 Trauma and delayed resuscitation:
Blood loss is associated with interstitial fluid
loss:
colloid infusion until hemoglobin
decreases to about 8-10 g/dl.
Crystalloids in a dose of 5-15ml/kg/h
if the renal function is maintained and the
patient has
no brain or lung trauma.
Otherwise limitation of crystalloids.

S. Sunatrio 23
 Late hemorrhagic shock and sepsis:

Moderate hemodilution with synthetic colloids

if the patient has no contraindications,
crystalloids sparingly!
In patients with sepsis syndrome and capillary
leakage: Observation of the colloid osmotic
pressure (COP) under colloid therapy.

S. Sunatrio 24
 Colloid Infusion and COP in Sepsis and
Late Hemorrhagic Shock
Co-factors: clinical aspect, intake and output
Measurement of COP and Hct,
Colloid infusion and wait for 1-2 hours

Increase of COP: Unchanged COP: Decrease of COP:

Capillaries"intact! Differentiation ! "Capillary leak!
Colloid infusion. Control of Hct. Crystalloid infusion.

Unchanged Hct: Decrease of Hct:

Loss of colloids ! Influx of fluid !
Infusion of crystalloids. Infusion of colloids.

Normal COP: 25-28 mmHg, edema threshold : 15-20 mmHg,

target COP: 15-20 mmHg . [ Adams 1993 ]
S. Sunatrio 25
 Replacement of blood losses
Step by step
Volume loss (%)
100
90
80
70
60
50
40
30
20
10
0
Cryst.+colloids
Colloids + crystalloids
+ PRC +FFP +platelets
Target controlled replacement of
volume - oxygen carriers - plasmatic coagulation - cellular coagulation
Adapted from Adams, H.A. 1996

S. Sunatrio 26
 Effects of Synthetic Colloids
Retaining of fluid Oncotic
in the IVS pressure

increased IV
Hemodilution
volume

Venous flowback Improved

Hematocrit
(preload) rheology

Cardiac Flow Arterial oxygen

output resistance concentration

CO DO ca O2
2

S. Sunatrio 27
 Perdarahan hebat:

deplesi cadangan energi

gangguan fungsi membran selular
edema selular

S. Sunatrio 28
S. Sunatrio 29
 Pengamatan Sunatrio :

Transfusi yang kurang rasional

1. Transfusi dgn alasan sayang

2. Transfusi utk mencapai Hb > 10 g% spy
penyembuhan luka tdk terhambat
3. Transfusi untuk mencapai Hb > 10 g% (Hb
10 g% = minimal)

S. Sunatrio 30
 Pengamatan Sunatrio :

Transfusi yang kurang rasional

4. Relatif masih banyak diberikan darah lengkap,
seharusnya dpt digantikan dgn transfusi eritrosit
+ NS/RL
5. FFP / Albumin diberikan sbg bahan makanan.
FFP diberikan tanpa bukti adanya gangguan
koagulasi atau sbg substitusi plasma

S. Sunatrio 31
 Ditunjang data:
Meningkatkan kapasitas pembawa O2 dan transport
O2 ke jaringan

Tidak terbukti :
1. Mengurangi risiko infeksi
2. Promosi penyembuhan luka
3. Meningkatkan general well being
S. Sunatrio 32
 Perdarahan akut

Kehilangan darah 50% dapat

ditoleransikan (HB 15 gr% menjadi 7
gr%)
Hipovolemia dapat ditoleransikan maks
30%

S. Sunatrio 33
 BB 70 kg Hb 15 g %
Normal basal Kebutuhan O2 = 280 mL

Oksigen transport = CO x (sat O2 x Hb x 1,34 + pO2 x 0,003)

= 5 L/mnt x 20 mL O2/100mL
= 1 L O2/mnt
Hb 10 g% = 5 L/mnt x 14 mL O2/100mL
= 700 ml O2/mnt
Hb 5 g% = 15 L/mnt x 6,6 mL O2/100mL
= 1 L O2/mnt
S. Sunatrio 34
 DARAH

TRANSFUSI :
~ Bila Hb < 7 mg/dL (Ht < 21%)
~ Jarang bila Hb > 10 mg/dL (Ht 30%)
~ 7 < Hb < 10 mg/L : manfaat tdk jelas!!
RISIKO TRANSMISI VIRAL & BAKTERIAL
MODULASI IMUN SEKUNDER

S. Sunatrio 35
 RCT:
Hb 7-9 mg% atau 10-12 mg% tidak ber
beda dalam morbiditas dan mortalitas
Russell JA. Fluid Strategy in ARDS: The concept of maintaining peripheral
perfusion. In H Burchardi G, GJ Dobb, J Bion, RP Delinger (eds) WB
Saunders. London 1997p; 17-42.

Multi center study:

Tidak ada perbaikan morbiditas &
mortalitas ps yg menerima transfusi dg
Hb 8 mg% - 10 mg%
Carson JL et al. Perioperative blood transfusion and postoperative
mortality. JAMA. 1998; 279:199-205.

S. Sunatrio 36
 HEMATOKRIT
%
40 NORMAL
OPTIMAL
35
TOLERABEL
30
25
20
15
10
5
0

S. Sunatrio 37
 Tidak ada Hb optimal universal
Pada psn normal biarkan Ht rendah
dan beri terapi besi & diet tinggi
protein bukannya darah
Transfusi ditentukan kasus per
kasus

S. Sunatrio 38
 Muda sehat 20%
Gagal ginjal kronik 18-22%
Syok septik 30%
Sesudah syok berat 30-40%
PJK 35%
Penyakit paru kronik berat > 40-50%
S. Sunatrio 39
S. Sunatrio 40
 FDA, USA :

Eritrosit jangan diberikan hanya utk ekspansi vol,

perbaiki KU, percepat penyembuhan atau sebagai
hematinik.
Trombosit jangan diberikan utk profilaksis.
FFP jangan digunakan utk ekspansi volume,
nutrisi atau profilaksis

S. Sunatrio 41
S. Sunatrio 42
 Healy et al. Lactated Ringers is superior to normal saline in a model of massive hemorrhage
and resuscitation. J Trauma. 1998;45:894-899.

HASIL
Resusitasi cairan dgn RL survival rate >>

Tournadre JP et al.Metabolic acidosis and respiratory acidosis impair

gastro-pyloric motility in anesthetized pigs. Anesth Analg. 2000;90:74-
79.

HASIL
Asidosis mengganggu motilitas
gastro-pilorus
S. Sunatrio 43
 Dexter et al : berdampak negatif
pd RBF & GFR

Peningkatan terjadinya
asidosis metabolik hiperClemia
yg selama ini dianggap tdk
berdampak negatif & akan hilang dgn
sendirinya ternyata dpt mengganggu
perfusi organ akhir &
mekanisme pertukaran sel.

S. Sunatrio 44
 Asidosis metabolik
hiperkloremik
Tdk selalu dikenali klinikus
Asidosis metab intraop yg menetap,
walau telah diberi cairan mungkin
diinterpretasikan sbg hipovolemia yg
belum teratasi dgn baik
NaCl 0,9% abnormalitas & asidosis
metab hiperkloremik mungkin ditangani
secara tdk tepat

S. Sunatrio 45
 Solution Balanced-Fluid Group Saline Group
Colloid Hextend Hespan
Hetastarch 60 g/L (6%) Hetastarch 60 g/L (6%)
+ +
Na 143 mmol/L Na 154 mmol/L
Cl - 124 mmol/L Cl - 154 mmol/L
Ca + 2.5 mmol/L
+
K 3 mmol/L
Magnesium 0.45 mmol/L
Glucose 0.99 g/L
Lactate 28 mmol/L

Crystalloid Hartmann's solution 0.9% Sodium chloride solution

+ +
Na 131 mmol/L Na 154 mmol/L
Cl - 111 mmol/L Cl - 154 mmol/L
+
Ca 2 mmol/L
+
K 5 mmol/L
Lactate 29 mmol/L

RCT BALANCED-FLUID VS SALINE

Mythen MG et al. Electrolyte Composition,Acid Base Balance, and Outcome in Geriatric
Surgical Patients. Symposium on Intraoperative Plasma Volume Optimization and
Postoperative Outcome, 12th World Congress of Anaesthesiologists Montral, Canada.
June 7, 2000.

S. Sunatrio 46
 HASIL
2/3 ps yg diberi Hespan + 0,9% NaCl
asidosis metabolik hiperClemia pd
akhir pembedahan.
Pasien yang diberi Hextend + RL
tidak menunjukkan asidosis
metabolik hiperClemia.

Mythen MG et al. Electrolyte Composition,Acid Base Balance, and Outcome in

Geriatric Surgical Patients. Symposium on Intraoperative Plasma Volume
Optimization and Postoperative Outcome, 12th World Congress of Anaesthesiologists
Montral, Canada. June 7, 2000.

S. Sunatrio 47
 ANDA DAPAT MENCEGAH
ASIDOSIS HIPERKLOREMIK
DENGAN MEMBERIKAN
KOMBINASI
KOLOID & RL

S. Sunatrio 48
 EFEK PRO-KOAGULAN KRISTALOID
In vitro:
Ruttmann TG, James MF, Viljoen JF. Haemodilution induces a
hypercoagulable state. Br J Anaesth. 1996;76:412-414.

Egli GA, Zollinger A, Seifert B, et al. Effect of progressive

haemodilution with hydroxyethyl starch, gelatin and albumin on
blood coagulation. Br J Anaesth. 1997;78:684-689.

In vivo:
Ng KF, Lo JW. The development of hypercoagulability state, as
measured by thrombelastography, associated with intraoperative
surgical blood loss. Anaesth Intensive Care. 1996;24:20-25.

Janvrin SB, Davies G, Greenhalgh RM. Postoperative deep vein

thrombosis caused by intravenous fluids during surgery. Br J Surg.
1980;67:690-693.

S. Sunatrio 49
 Gan TJ et al. Hextend, a physiologically balanced plasma expander for large volume
use in major surgery: a randomized phase III clinical trial. Hextend Study Group. Anesth
Analg. 1999;88:992-998.,

A : koloid + cairan seimbang ( Ca+)

vs
B : koloid + garam fisiologis

HASIL
Sama efektif utk hipovolemia.
A : ~ profil koagulasi > baik (TEG)
~ perdarahan <
B : Kanjiheta 6% dlm NS hipokoagulasi
S. Sunatrio 50
 Ringer laktat

EFEK PRO-KOAGULAN
EFEK SAMPING
(TROMBOSIS VENA DLM,
EMBOLISME PARU)

S. Sunatrio 51
 KRISTALOID vs KOLOID:
area persetujuan
Resusitasi dgn cairan selain dari darah secara praktis
sangat bermanfaat
Anemia ternyata ditoleransikan lebih baik drpd
hipovolemia. Pd perdarahan akut pd orang sehat
anemia dpt ditoleransikan sampai 50%, sedangkan
hipovolemia hanya 30%
Kelebihan cairan dgn kedua macam lar merupakan
peristiwa yg tdk diinginkan
Mempertahankan TOK plasma dipostulasikan sbg
tujuan th/ cairan yg diinginkan; lar koloid lebih
efektif dlm mempertahankan tekanan osmotik koloid

S. Sunatrio 52
 KRISTALOID vs KOLOID:
area persetujuan
LAR. KOLOID MERUPAKAN BENTUK PENGGANTIAN
VOL DARAH YG LEBIH EFISIEN DRPD LAR KRISTALOID.
UTK MENCAPAI TITIK AKHIR TERTENTU DIPERLUKAN
LEBIH SEDIKIT LAR KOLOID DRPD LAR KRISTALOID
LAR KOLOID LEBIH MAHAL DARI KRISTALOID, LAR
KRISTALOID TDK MENYEBABKAN Rx ANAKFILAKTOID
YG DPT TERJADI DGN KOLOID, MESKIPUN Rx SPT INI
JARANG TERJADI PADA SYOK
HEMODILUSI SEBELUM TRANSFUSI DGN KRISTALOID
ATAU KOLOID BERMANFAAT PADA RESTORASI VOL
DARAH

S. Sunatrio 53
 KOLOID vs KRISTALOID
utk ekspansi ruang intravaskular
Pro koloid :
Koloid mempertahankan TOK &
meminimalkan akumulasi cairan
interstisial
Kristaloid mekan TOK
edema paru
Pe an TOK laju mortalitas

S. Sunatrio 54
 KOLOID vs KRISTALOID
ukt ekspansi ruang intravaskular

Pro kristaloid :
Mencela beaya & risiko th/koloid
Koloid keluar ke interstisium &
terperangkap edema

S. Sunatrio 55
 Hauser CJ, Shoemaker WC, Turpin I, Goldberg SJ. Oxygen
transport responses to colloid and crystalloids in critically ill surgical
patients. Surgery 1980; 150:811-6.

Kel koloid mengalami perbaikan yg lebih

baik pd variabel hemodinamik tanpa ada
bukti air paru atau terperangkapnya
albumin.
Kel kristaloid pertukaran gas paru lebih
buruk, VO2 & perbaikan variabel
hemodinamik sedang saja.

S. Sunatrio 56
 Appel PL, Shoemaker WC. Evaluation of fluid therapy in
adult respiratory failure. Crit Care Med 1981; 9:862-9.

Koloid menyebabkan perbaikan nyata

pd semua variabel hemodinamik & DO2
Kristaloid hanya sedikit perbaikan
Ruang interstisial sangat membesar &
tdk ada mekanisme kompensasi utk
mobilisasi & ekskresi cairan.

S. Sunatrio 57
 Pasien sakit kritis
Mekanisme kompensasi terhadap
kelebihan cairan
Edema interstisial gagal organ
Utk penanganan hipovolemia koloid >
baik

S. Sunatrio 58
 Scheinkestel CD, Tuxen DV, Cade JF et al. 1989
Rady M. 1994
Resusitasi cairan pd ps dng syok

Koloid sendiri mungkin lebih superior dari

kristaloid (vol plasma, CO, kinerja ventrikel
kiri, penyediaan O2 global & mikrosirkulasi)
Kristaloid berpengaruh tdk baik pd
mikrosirkulasi, DO2 & VO2 (ssd resusitasi,
hipoksia regional & global masih terus
berlanjut)

S. Sunatrio 59
 MORTALITAS
KOLOID vs KRISTALOID

Setiati (ps Dengue, 2000): mortalitas dng

HES 6% (BM 200 kD) < RL
Meta-an Velanovich (96 ps non trauma,
1989) : mortalitas dng koloid < kristaloid
Meta-an Schierhout (191 ps sakit kritis &
kombustio, 1998) : koloid risiko
mortalitas4%

S. Sunatrio 60
 KOMENTAR terhadap
META-AN SCHIERHOUT
Intervensi & karakteristik ps tdk
sebanding kesimpulan?
Regimen resusitasi berbeda-beda
Tipe koloid atau kristaloid, konsentrasi
& protokol utk menentukan jumlah
cairan yg diperlukan: bervariasi

S. Sunatrio 61
 Kritikan Webb (2000)
thd 3 meta-an yg melaporkan mortalitas dng koloid > drpd
kristaloid meski tdk bermakna

Lebih dari separo RCT yg diikutkan

dilaporkan sebelum th 1990
Perbedaan-perbedaan pd keparahan
penyakit, th/ yg diberikan bersamaan &
tatalaksana cairan tdk diperhitungkan
Sangat sedikit blinded RCT

S. Sunatrio 62
 Webb AR. The appropriate role of colloids in managing fluid imbalance: a
critical review of recent meta-analytic findings. Crit Care 2000; 4 Suppl 2: S26-
32.

Meta an-meta an tsb tdk menyokong kesimpulan

bahwa pilihan cairan resusitasi merupakan
penentu mortalitas yg penting pd ps sakit kritis
Meta-an tdk pula menyokong adanya perubahan
praktek tatalaksana cairan
Karenanya, pilihan cairan resusitasi hendaknya
berdasarkan pd apakah cairan tsb memungkinkan
ICU utk memberikan penanganan ps yg lebih
baik

S. Sunatrio 63
 Shih FJ. Colloids versus crystalloids for
emergency patients. Accid Emerg Nurs 1998; 6(3): 130-2.

Tatalaksana vol cairan yg tdk tepat pean

kinerja organ vital & potensial fatal
Ps sakit kritis dan/atau darurat sering mendpt
pula th/ lain & monitoring dng dampak pd
survival rate & end-point yg sama atau lebih
besar drpd dampak tipe cairan itu sendiri
Variabel-variabel tsb perbandingan-
perbandingan historis antara resusitasi koloid
vs kristaloid menjadi sulit !!!

S. Sunatrio 64
 Cochrane Injuries Group Albumin Reviewers. Human albumin administration in
critically-ill patients: systemic review of randomized controlled trials. BMJ 1998; 317:235-240. (META-
ANALISIS)

Albumin vs kristaloid
Risiko kematian pd albumin > tinggi dari
kristaloid
Limitasi bias pd seleksi penelitian
De Backer D. Which colloids in critically-ill patients?. The proceeding book of
Refresher Course Lectures 10th ESA Aniversary Meeting and 24th EAA Annual
Meeting Euroanaesthesia 2002; p: 171-75. (META-ANALISIS)

Kriteria seleksi berbeda dng di atas

Risiko kematian albumin kristaloid

S. Sunatrio 65
S. Sunatrio 66
 Study on the extra-vascular diffusion of hydroxyethyl
starch in a case of increased capillary permeability
Guidet B et al. Clinical Intensive Care 1994; 5: 93-94

MW HES is able to restore colloid osmotic

gradient between vascular / interstitial spaces and
thus act as a more effective plasma substitute in
capillary leak situations than human albumin
solution by reducing water diffusion through the
capillaries.

S. Sunatrio 67
 The influence of volume therapy and pentoxifylline
infusion on circulating adhesion molecules in trauma
patients
Boldt J et al. Anaesthesia 1996; 52: 529-535

HES is better than human albumin as it lowers the

soluble adhesion molecules level that are
considered to play a pivotal role in tissue damage
secondary to inflammatory process.

S. Sunatrio 68
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S. Sunatrio 76
 There was overall no beneficial effect of albumin on
mortality in this 55 studies including 3500 pts

S. Sunatrio 77
S. Sunatrio 78
 SAFE Study
New England J Med 2004;350:2247-56

Prospective Randomized Study

Conducted in Australia New Zeland
Critically ill pts including 3 subgroups:
Trauma/Sepsis/ARDS
Albumin 4% (n=3474) vs Normal Saline
(n=3460)

S. Sunatrio 79
 SAFE Study
New England J Med 2004;350:2247-56

Mortality Alb group : n = 726 (20.9%)

Mortality Normal Saline group : n = 729 (21.1%)
Subgr head trauma pts NS < alb
Subgr septic pts alb < NS

Indications of colloid/crystalloids
should not be evaluated globally
but indication by indication
S. Sunatrio 80
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S. Sunatrio 86
S. Sunatrio 87
 Albumin
Mahal
Makin tdk popular
Hipoproteinemia sendiri tdk
menyebabkan edema paru
Tdk ada bukti lebih baik drpd kristaloid
dlm mortalitas
Kurang efektif drpd koloid sintetik
Keuntungan tidak ada, jadi jangan dipakai

S. Sunatrio 88
S. Sunatrio 89
 CRYSTALLOID vs COLLOID
End point mortality
Assuming mortality 20%
(risk ratio 1.02)
Need to study 159,000 patients in each
group

Avie LR Shapiro
S. Sunatrio 90
 Prof. J. Boldt in:
Volume Therapy
Springer Verlag Berlin Heidelberg
New York Hong Kong London
2000, p76

It needs to be questioned whether meta-analyses are

helpful to examine the effects of crystalloid or colloid
fluid resuscitation on mortality, because mortality was
never the endpoint of any of the rystalloid/colloid
studies.

When comparing these two volume replacement

strategies, endpoints should be organ function,
perfusion or inflammation rather than outcome.

S. Sunatrio 91
S. Sunatrio 92
 The Crystalloid versus Colloid Controversy:
A Colloid versus Colloid Debate?

S. Sunatrio 93
 Without controversy
there is no progression.

--William Blake (1757-1827)

(Especially not in medical science!)

S. Sunatrio 94
 There was overall no beneficial effect of albumin on
mortality in this 55 studies including 3500 pts

S. Sunatrio 95
 Meta-analysis : Colloid vs Crystalloids

What is a statistician?

S. Sunatrio 96
 Crystalloid vs Colloid : Analysis on Mortality
Power Analysis
Critically ill Pts
assuming a 15% baseline MR

To demonstrate a 10% difference in treatment

effect between crystalloid & colloid
resuscitation
a two-tailed a of 0.05 & b of 0.20,
a randomized clinical trial involving 5748 pts
would be required

S. Sunatrio 97
 Crystalloid vs Colloid : Analysis on Mortality

Power Analysis
Critically ill Pts
assuming a 1% baseline MR

In this setting, is mortality

the right outcome to study?

a randomized clinical trial involving 299,496 pts would be required

S. Sunatrio 98
 CRYSTALLOID vs COLLOID

End point mortality

Assuming mortality 20%
(risk ratio 1.02)
Need to study 159,000 pts in each group

Avie LR Shapiro
S. Sunatrio 99
 The Crystalloid versus
Colloid controversy:

Unnecessary and illogical!

S. Sunatrio 100
S. Sunatrio 101
 KRISTALOID >>
edema interstisial
OTAK EDEMA, DST
JANTUNG KINERJA
PARU OKSIGENASI
PENCERNAAN TRANSLOKASI
BAKTERIAL
PERIFERAL PENYEMBUHAN
LUKA

S. Sunatrio 102
 Gan TJ. Impact of Resuscitation Fluid Choice on Quality of Surgical Recovery.
Symposium intra-operative Plasma Volume Optimization and Postoperative Outcome,12 th World Congress
of Anaesthesiologists Montral, Canada. June, 2000.

Percentage of patients exhibiting

postoperative morbidity

80
RL
P = .03
70 Hextend
Hespan
60 P = .01
Patients,
50
%
40 P = .08
30 P = .02
P = .01
20
10
0
nausea rescue postop pain double vision periorbital
antiemetic edema

S. Sunatrio 103
S. Sunatrio 104
 KOLOID vs KRISTALOID
Pemberian koloid selama pembedahan
berhubungan dgn perbaikan profil
penyembuhan & kenyamanan pasien yg lebih
baik, dibanding dgn pemberian kristaloid.
Perbedaan ini mengakibatkan :
memperpendek masa rawat RS

beaya lebih kecil

S. Sunatrio 105
S. Sunatrio 106
 TRAUMA BERAT
ICV < NORMAL
ECV >>> NORMAL
RASIO KRISTALOID : KOLOID
=68:1
(NORMAL = 3 - 4 : 1)

S. Sunatrio 107
 Sinha HA, Baron BJ, Buckley MC, et al. Fluid
restriction versus early resuscitation in hemorrhagic
shock. J Trauma 1994; 37:1015

Sustained hypotension produces a

more injurious shock insult than
do multiple episodes of shock and
resuscitation.

S. Sunatrio 108
 Efek koloid yg menguntungkan
mekan TOK
mekan volume darah
sealing effect (HES 100-300 kD)
Mengembalikan aliran darah regional pd
hipovolemia
mekan viskositas, mengganggu formasi
Rouleau, mekan daya adesif leukosit

S. Sunatrio 109
 Efek koloid yg merugikan

Gelatin Kanji HES Dekstran

Reaksi anafilaktik tidak biasa tidak biasa biasa dan parah

Efek pada koagulasi tidak ya (bgt dosis) ya
Keracunan ginjal tidak ya tidak biasa
(dosis tinggi)
Keracunan hati tidak mungkin tidak
Akumulasi jaringan tidak ya tidak
Pembatasan penggunaan
pada gagal ginjal tidak ya tidak

S. Sunatrio 110
 Terapi cairan rasional
Perkiraan defisit air tiap kompartemen cairan
fisiologis
Krsitaloid / koloid yg tepat utk resusitasi
kompartemen yg memerlukan
Pengurangan ruang intravaskular :
- laju jantung
- TD , TVS
- Urin

S. Sunatrio 111
 Pemilihan
Kristaloid vs Koloid
Ikuti prinsip dasar fisiologis yg telah
mapan
Bukan oleh karena resusitator pemakai
kristaloid atau koloid
Ditentukan oleh ps
Pertahankan kadar Hb & faktor koagulasi

S. Sunatrio 112
 Terapi cairan
Pertimbangan kuantitatif & kualitatif
Optimasi prabeban dengan volume
intravaskular
Bolus dititrasi
Menilai efek pada prabeban & keluaran
ventrikular
Sifat masing-masing cairan
dipertimbangkan

S. Sunatrio 113
 PERTIMBANGAN KUALITATIF

Dilema : darah
(CaO2 - CvO2 ) ( C.O.x 10 ) > VO2
Elektrolit , faktor asam-basa
Kontroversi koloid vs kristaloid

S. Sunatrio 114
 RESUSITASI CAIRAN
Disesuaikan untuk setiap pasien
Penilaian kontinyu respons terhadap terapi
Cairan >> Morbiditas
Cairan << Kegagalan organ
Kehadiran dokter

S. Sunatrio 115
 DEFEKT PILIHAN
primer cairan

DEHIDRASI ECV IFV RL/RA

DEHIDRASI ICV ICV D5W

PERDARAHAN BARU IVV KOLOID

PERDARAHAN LAMA IVV + IFV KOLOID+RL

S. Sunatrio 116
S. Sunatrio 117
S. Sunatrio 118
S. Sunatrio 119
S. Sunatrio 120
S. Sunatrio 121
 Pilihan koloid

Perdrhan tanpa indikasi transfusi BM

sedang tinggi (dekstran 70, HES 100-300
kD)
Indikasi transfusi menunggu cocok
silang BM rendah (HES 40.000, gelatin
mod, dekstran 40, poligelin)
Reologi & anti trombosis dekstran

S. Sunatrio 122
 Pilihan koloid
Syok berat krn dehidrasi poligelin
Perdrhan baru syok ringan isoonkotik
Syok berat hiperonkotik
Kebocoran kapiler HES 100-300 kD

S. Sunatrio 123
 Ruang interstisial otak Sawar darah otak

Lumen kapiler

Sel darah merah

Partikel dg BM tinggi
(misal albumin, dekstran)
Jaringan
Partikel dg BM rendah
(msal Na+, Cl-, glukosa)
Plasma

Dalam kapiler serebral, adanya BBB mencegah perpindahan partikel

yang sangat kecil di antara lumen kapiler dan ruang interstisial otak. Meningkatkan
osmolalitas plasma dengan infus iv manitol/NaCl hipertonik dapat menciptakan
gradien osmotik di antara otak dan ruang intravaskular yang menyebabkan
perpindahan air dari otak ke dalam kapiler.

S. Sunatrio 124
 KAPILER SEREBRAL
LUMEN VASKULAR RUANG INTERSTISIAL
7A

H2 O H2 O

Na+ Na+
ion-ion kecil ion-ion kecil

P P
BBB

Skema diagram kapiler serebral. BBB impermeabel terhadap ion-

ion kecil dan protein, tidak terhadap air.
S. Sunatrio 125
 Ruang interstisial otak

Kapiler

Sel darah merah

Partikel dg BM tinggi
(misal albumin, dekstran)
Partikel dg BM rendah
(misal Na+, Cl-,glukosa)
Sesudah berbagai cedera otak (misal iskemia, kontusio), mungkin terjadi
kerusakan BBB yang memungkinkan lolosnya partikel-partikel dengan BM rendah
dan tinggi dari lumen kapiler (yaitu kapiler menjadi bocor). Pada kasus berat bahkan
mungkin terjadi ekstravasasi sel darah merah ke dalam interstisial, pemberian larutan
baik hiperosmolar maupun hiperonkotik tidak bermanfaat untuk mengurangi
pembentukan edema pada area yang mengalami cedera. Larutan hiperosmolar masih
mungkin bermanfaatpada area yang jauh dari area cedera di mana BBB masih tetap utuh.

S. Sunatrio 126
 KAPILER PERIFERAL
LUMEN VASKULAR RUANG INTERSTISIAL
65 A

H2O H2O

Na+ Na+
ion-ion kecil ion-ion kecil

P P

Skema diagram kapiler periferal. Dinding pembuluh darah permeabel

untuk kedua cairan dan ion-ion kecil, tetapi tidak terhadap protein
S. Sunatrio 127
 BBB utuh,
osmolalitas plasma:kunci penentu perbedaan air
antara SSP & ruang iv.
COP 50% tdk menyebabkan air otak.
BBB tidak utuh,
tdk mungkin utk mempertahankan gradien
onkotik/osmotik antara darah & interstisium otak
tdk ada perubahan kandungan air otak meski terjadi
perubahan gradien.
BBB cedera sedang,
berfungsi spt kapiler di jaringan periferal.

S. Sunatrio 128
 PENGGANTIAN VOL/ TDK
EDEMA SEREBRI
EXPANSI VOL
BEREFEK

A OSMOLALITAS SERUM
S DIPERTAHANKAN
A TEK HIDROSTATIK SEREBRAL
TDK SECARA NYATA
L

KRISTALOID vs KOLOID ?
S. Sunatrio 129
 KRANIOTOMI

HINDARI CAIRAN YG MENGANDUNG

DEKSTROSA KECUALI NEONATUS,
DM, OPERASI LAMA.
HINDARI CAIRAN HIPOOSMOLAR

S. Sunatrio 130
 ICP AIR OTAK

NaCl 0,9% -
RL
NaCl HIPERTONIK
HES NaCl 0,9% - -

S. Sunatrio 131
 Hypertonic fluids
lesser amounts can provide rapid vol
expansion & improve haemodynamics
decreasing tissue edema, ICP & brain water
can be combined with colloid sol to
prolong their plasma vol expansion effects
combined with 6% HES improve
neurologic fc & CPP in pts with traumatic
brain injury

S. Sunatrio 132
 KRANIOTOMI
Th/CAIRAN:
PAKAI KRISTALOID ISOTONIK (RL &
NaCl 0,9%) UTK SEMUA KEADAAN
KECUALI RESUSITASI VOLUME UTK
SYOK & UTK PERTAHANKAN
OSMOLALITAS SERUM NORMAL
BATASI JUMLAH RL 1-3 L (TAMBAH NS
KP)

S. Sunatrio 133
 DEKSTRAN

TDK DIANJURKAN PD KELAINAN

PATOLOGI INTRAKRANIAL SELAIN
DARI UTK REOLOGI PD PENYAKIT
OTAK ISKEMIK.

S. Sunatrio 134
 Resusitasi cairan pd kombustio
24 jam pertama :
kehilangan integritas kap pd jar yg rusak
kehilangan cairan isotonik & albumin dari
kompartemen IV ke jar sekitar luka
Beri kristaloid vol > utk ekspansi cairan
ekstraselular
Sesudah 24 jam :
beri koloid vol >
beri kristaloid vol <
S. Sunatrio 135
 Current status of burn resuscitation
Yowler,C.J. et al., Case Western Reserve University, Cleveland, Ohio, USA
Clin Plast Surg 2000 Jan;27(1):1-10

The ideal burn resuscitation formula does not exist!

The goal is to maintain urine output in the range of

0.5 to 1 mL/kg/hr for adults and 1 to 1.5 mL/kg/hr
in children.

In fluid requirements of > than 150% of that

predicted
addition of colloid at 12 hours can reduce total fluid
requirements and burn edema.
S. Sunatrio 136
 University Hospital Ulm, Germany
Guidelines for Fluid Treatment of Major Burns

First Hour:
On the ambulance: 500-1000 ml Colloid (e.g. Gelatin)
Ad admission: 500 ml Colloid + 1000 ml LR

Second Phase (2-8th hr):

0.5ml/kg/% BSA Colloid (e.g. Gelatin)

1.0ml/kg/% BSA Lactated Ringer

Third Phase (9-24 hr):

0.5 ml/kg/% BSA Colloid ( 5% Human Albumin)

1.0 ml/kg/% BSA Lactated Ringer
S. Sunatrio 137
 Preoperative volume management

Crystalloid
vs
Colloid

S. Sunatrio 138
 Meta-analysis
Observation: Compensatory fluid administration for
preoperative dehydration improves outcome?
Medline search (1966-2001)
17 papers met inclusion criteria
Two groups:
< 1 litre (nine studies)
1 litre (eight studies)
Conclusion: Fluid to compensate preoperative dehydration
reduces postoperative drowsiness & dizziness
Holte K. Kehlet H. acta Anaesthesil Scand 2002;46(9):1089-93
S. Sunatrio 139
 System Review

PJ Morgan, SH Halpern, J Tarshis. The Effects

of an Increase of Central Blood Volume Before
Spinal Anesthesia for Cesarean Delivery: A
Qualitative Systematic Review. Anesth Analg
2001;92:997-1005

S. Sunatrio 140
 Data Collection

MEDLINE (1966 2000)

Embase (January 1988 April 2000)
Cochrane Library (Issue 1, 2000)
Hand searching of non-MEDLINE journals, &
abstracts of major anesthesia meetings (1995
2000)

S. Sunatrio 141
 Groups

Crystalloid preloading
Colloid vs crystalloid (preloading)

S. Sunatrio 142
 Results
91 papers from MEDLINE, 23 randomized
controlled trials (RCT)
23 RCT are divided into three categories
1. Comparison of large & small vol crystalloids
2. Colloid vs crystalloid or different colloid regimens
3. Mechanical or pt positioning as a means of increasing
preload

Total: 1504 cases, 16 160 cases in each RCT

S. Sunatrio 143
 The result of system review

The efficacy of crystalloid preload to prevent

hypotension is inconsistent
The dose of crystalloid
Use of Ephedrine
Colloid is better than crystalloid

S. Sunatrio 144
 Crystalloid vs Colloid

Effects of Crystalloid & Colloid Preload on Blood

Volume in the Parturient Undergoing Spinal
Anesthesia for Elective Cesarean
Section.Anesthesiology,1999,91(6):1571

S. Sunatrio 145
 Clinical Data

36 pts, 3 groups (n=12)

1.5 L Ringer`s
0.5 L 6% HES
1.0 L 6% HES
Monitoring (indocyanine)
Blood volume
Cardiac output

S. Sunatrio 146
 Intravascular remaining vol at 30 min
after fluid infusion

Groups IVRV(L) %

RL 0.430.20 28

0.5L HES 0.540.14 100

1.0L HES 1.030.21 100

S. Sunatrio 147 IVRV: Intravascular remaining vol

 Mojica JL, et al. The timing of intravenous crystalloid administration and incidence
of cardiovascular side effects during spinal anesthesia: the results from a
randomized controlled trial. Anesth Analg, 2002,94

Spinal anesthesia. Ringer`s for vol expansion

404 cases, three groups
Control (LR 2 mL/min)
20 min before anesthesia (LR 20 mL/kg)
At anesthetic induction (LR 20 mL/kg)

Cardiovascular side effects

9.9%, 9.2% and 2.3% respectively

Conclusion: fluid infusion at anesthetic

induction is most beneficial
S. Sunatrio 148
 Cipto Mangunkusumo Hospital
Sunatrio S et al. Anestesia & Critical Care

Preloading fluid for spinal anesthesia in

cesarean section
Gelatin was more effective than RL (n=60)
(2002)
HES 6% (MW 200kD) was better than RL
(n=60) (2002)
HES 6% (MW 40kD) was better than RL
(n=60) (2003)

S. Sunatrio 149
 Zhongshan Hospital
16 pts with hepatic carcinoma
hyper-vol hemodilution before anesthesia
hyper-vol hemodilution after anesthesia
General+epidural anesthesia
25mL/kg Ringers within 30 min
Conclusion:
Hyper-volume hemodilution is better

S. Sunatrio 150
 Ruijin Hospital
150 ASA I & II pts undergoing abd surgery
A: normal rate infusion of crystalloid
B: rapid infusion of crystalloid
C: rapid infusion of colloid
Protocol:
Group A, Ringers(15mL/kg/h) started on anesthetic induction
Group B, 7mL/kg & 13mL/kg Ringers within 20min before & after
induction respectively. And then 15mL/kg/h until 40mL/kg
Group C, 7mL/kg & 13mL/kg 6%HES within 20min before & after
induction respectively. 15mL/kg/h (1:1 Ringers/6%HES) until 40mL/kg

S. Sunatrio 151
 Ruijin Hospital-conclusion
Rapid infusion on induction has some
prophylaxis to hypotension. Crystalloid &
colloid at same infused vol have similar
prophylaxis
Although rapid infusion of crystalloid &
colloid at same rate & vol on induction, CVP
increase was greater in HES group, indicating
vol expanding effect of HES is better than
Ringers.

S. Sunatrio 152
 TERAPI CAIRAN
Pendekatan Seimbang

Terampil dalam terapi dengan
kedua macam larutan
(Kristaloid & Koloid)

S. Sunatrio 153
 Terapi Cairan

RESUSITASI RUMATAN

Kristaloid Koloid Elektrolit NUTRISI

Repair
Mengganti kehilangan 1. Kebutuhan normal
akut (hemorrhage, (IWL + urin+ feses)
GI loss, rongga ke3) 2. Dukungan nutrisi
S. Sunatrio 154
 RL atau Ringer Solution bukan untuk rumatan

RL RS KAEN 3B KAEN MG3 Kebutuhan*

Na+ 130 147 50 50 1-2 meq/kg

K+ 4 4 20 20 1 meq/kg

Glukosa - - 27 100

S. Sunatrio 155
 TERAPI CAIRAN

RESUSITASI RUMATAN

KRISTALOID KOLOID ELEKTROLIT NUTRISI

Dextran- 40 Na+ 50-60mEq; AA 10% (AMIPAREN)

(Na+ > 100 mEq) K+ 10-20 mEq AA 5% (MINOVEL- 600)
- RA (KAEN group) AA 3%( PAN- AMIN G
- RL D 10 % (KA-EN MG 3)
Maltosa 10% (MARTOS )
- NaCl 0,9%
Mengganti kehilangan akut Memelihara keseimbangan

S. Sunatrio 156
 APA YG KITA MILIKI PENTING
NAMUN
YG LEBIH PENTING LAGI :
APA YG BISA KITA PERBUAT
DGN APA YG KITA MILIKI

S. Sunatrio 157
S. Sunatrio 158