Update on Parenteral Fluid

Therapy in Infectious Diseases

Dr Iyan Darmawan
Medical Director PT Otsuka
 Points of Presentation
Body Composition
Classification of Parenteral Fluid Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
 Points of Presentation
Body Composition
Classification of Parenteral Fluid Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
 Classic Figures of Fluid
Compartments
Human body largely composed
Total Body Water of fluids
60% BW
Total body fluid ranges from 50
60%
smaller proportion in the elderly,
obesity,and female
ICF ECF
40 % BW 20 % BW

ISF
15% BW
Plasma
5% BW
 Komposisi elektrolit cairan tubuh
Cairan ekstrasel Caiarn
Ion terbanyak
mEq/L intrasel
Plasma Interstisial di ekstrasel
Na+ 142 144 15
K+ 4 4 150
Kation

Na+
Ca2+ 5 2.5 2 Cl-
Mg2+ 3 1.5 27
Total 154 152 194
Ion terbanyak
Cl- 103 114 1 di intrasel
HCO3- 27 30 10
Anion

HPO42- 2 2 100
K+ Mg2+
SO42- 1 1 20
Asam organik 5 5 - HPO42-
Protein 16 0 63
Total 154 152 194

Dinding kapiler Membran sel

 Points of Presentation
Body Composition
Classification of Parenteral Fluid
Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
 PARENTERAL FLUID THERAPY

RESUSCITATION REPAIR MAINTENANCE PN

PERFUSION & CORRECT HOMEOSTASIS/ CORRECT

OXYGENATION ELECT & AB SUPPORTIVE NUTRITION ST
 GANGGUAN HEMODINAMIK ?

MAP < 65 mmHg

Takikardia
Akral dingin
CRT > 2 detik

Ya Tidak

Ada gangguan elektrolit/Metabolik ?

RESUSITASI
RA/RL Tidak
NS
KOLOID Gizi Buruk ?
Koreksi
Ya
NaCl 3%
KCl 7.46%
Meylon Ya
Tidak
MgCl 20%
Glukosa 40% PPN
Rumatan
BCAA
 Points of Presentation
Body Composition
Classification of Parenteral Fluid Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
 Fever &
Dehydration
Gastro-
enteritis
Fluid, electro-
Acute Release of lyte and
Cytokines
Infection hemodynamic
disorders
Capillary
leakage
Hemorrhage/
sepsis Advising patients to increase fluid intake for treating acute
respiratory infections (Review)
Copyright 2011 The Cochrane Collaboration. Published by
JohnWiley & Sons, Ltd.
Michiel van der Flier Infect Immun. 2000 August; 68(8): 47924794.
 Vicious Cycle of Infection-
Malnutrition

Ghattas H. INFECTION Nutritional Interactions Encyclopedia of Human Nutrition, 2005, Pages 47-54
Normal Metabolic Rate 25-30 kcal/kg/day

Adequate oxygen available for energy production

Protein intake is used for protein synthesis and

maintaining lean mass

In the nonstressed, starved state where 90 percent of

calories come from fat stores and only five to eight
percent are derived from protein
Robert H. Demling. Wounds. 2000;12(1)
 Breakdown in the Body in Starvation
When there is no nutritional intake (energy, proteins, etc.)
Decrease in muscle mass
Decrease in visceral proteins
Store in the Body

Impairment of immunocompetence
Proteolysis
Delayed wound healing
Lipolysis Organopathy Biological
maladaptation
Glycerol
Free fatty acids Nitrogen death
(ketone bodies)
(70%)

Glycogenolysis

Duration of Starvation

Steffee W.P.: JAMA 1980;244(23): 26302635

CADANGAN KARBOHIDRAT TUBUH TERBATAS

Glikogen hati
100 g

Glikogen otot (250 g)

Protein tubuh 11 kg

Jika tdk makan, karbohidrat

tubuh akan habis dalam 1 hari

Hill G.L. Churchill Livingstone 1990

Imbalanced Excess Excess Inflammatory Response (Mediators)
Hormone Hepatic Catabolism (Local and Systemic)
Levels Gluconeo- Mediator Pyrogen
Maladaptive Hormone Response
genesis induced cell induced
Catechols damage fever

Cortisol

Glucagon - Metabolic rate:Energy demand

Body temp-CNS driven
Insulin
Liver glucose production

GH Catabolism-Net protein Loss

Anabolism- Net protein loss

Robert H. Demling. Wounds. 2000;12(1)

 Nitrogen Loss
Estimates of Nitrogen Loss Cumulative Nitrogen Loss (g)
Following Catabolic Illness (First 10
Days, Ad Lib Feedings) 1 g N ~ 6.25 g protein
Precipitating Factor
Injury
Major bum 170
Multiple injury 150
Peritonitis 136
Simple fracture 115
Major operation 50
Minor operation 24
Infection
Typhoid fever (untreated) 116
Pneumonia (untreated) 59
Tularemia (treated) 52
Q fever (treated) 40
Sandfly fever (untreated) 16

The Role of Protein and Amino Acids in Sustaining and Enhancing PerformanceNational Academy Press
Washington, D.C. 1999
 TIMING OF Catabolic response - altered production and utilization
CATABOLIC of metabolic fuel, glucocorticoid release

RESPONSE TO
INFECTION Onset of catabolic phenomena (neg
balance Nitrogen, K,Mg,PO4,Zn SO4)

Retention of salt and water through increased

secretion aldosteron and ADH

Anorexia
Diuresis (additional weight loss)
vomiting

Return to positive nitrogen

balance

Repletion of metabolic fuel

stores

Exposure to infecting Incubation Illness 3 to 7 days Convalescence

organism periode
18
Prof Suharto MANIFESTO 2, Makassar March 2012
No adaptive responses activated

Increase metabolic rate 35-40 kcal/kg/day

Increase glucose production in excess of need

Increase use of protein for fuel (glucose)

Inefficient use of fat for energy

approximately 30 percent of calorie needs comes from the

endogenous protein mass and only 50 percent come from fat

Robert H. Demling. Wounds. 2000;12(1)

 Points of Presentation
Body Composition
Classification of Parenteral Fluid Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
 Effects of Undernutrition
Psychology
Ventilation - loss of depression & apathy
muscle & hypoxic
Immunity Increased risk
responses
of infection
liver fatty change,
functional decline Decreased Cardiac output
necrosis, fibrosis
Renal function - loss of
Impaired wound ability to excrete
healing Na & H2O

Hypothermia
Impaired gut
integrity and
immunity Loss of strength

Anorexia
? Micronutrient deficiency
 Points of Presentation
Body Composition
Classification of Parenteral Fluid Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
 Rationale of Maintenance Fluid Tx
Despite thirst due to hypertonic dehydration, many patients may not
be able to ingest enough water and nutrient owing to abdominal
discomfort/pain, hepatomegaly

Elevated levels of cytokines, such as interferons (IFNs), interleukin-2

(IL-2), IL-8, and tumor necrosis factor alpha, have been reported in
DHF(1) One of their pleiotrophic effects is delaying gastric emptying

Patients might experience loss of appetite because of dry mouth

(dehydration), malaise and fatigue besides other systemic
symptoms(2)

1. Anon Srikiatkhachorn et al, J Virol. 2007 February; 81(4): 15921600.

2. Othman.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page
S435
 Kepentingan suplementasi KH dan AA
Starvasi Stres
- KH menghambat katabolisme protein
- KH 100 g/hari menghambat katabolisme Kebutuhan energi meningkat dan
protein menjadi 50%. hiperkatabolisme protein
- Suplementasi suatu sumber energi sendiri tidak
bisa menghambat katabolisme protein100%.
Efek Protein-sparing glukosa
0
Perlu Pemberian energi (KH,
lemak)
100 + Pemberian Asam amino
Protein loss (g)

200 g
200 100 g

300 50 g
0g Perbaikan imbang N dan metabolisme
400 (Starvation) protein, serta penghambatan
katabolisme protein tubuh adalah
1 2 3 4 5 6 sangat penting
Lama puasa
JAMES L.GAMBLE 1957p134147
 Pentingnya suplementasi Asam Amino

Peran Asam amino Kehilangan nitrogen obligat(FAO/WHO)

Bahan utk sintesis mg N/kg/hari Total

protein
Perbaikan imbang nitrogen Urin 37
Perbaikan metabolisme 54 mg/kg/hari
protein Tinja 12 Konversi menjadi asam
amino
Kulit 3
(manusia berat 60 kg)
Lain 2 31 .6 g/hari
Pencegahan komplikasi
pasca bedah 0.054(g) 7.5* 60(kg) 1.3**=31.6 (g)
*Jml nitrogen dikonversi menjadi jml asam amino (6.25 1.2)
Perbaikan prognosis **: Mengingat variasi individu, ditambahkan ekstra 30% .
Perbaikan hasil terapi FAO: Food and Agriculture Organization

1989p4648
 AMINO ACID SHOULD BE ADMINISTERED
SIMULTANEOUSLY WITH GLUCOSE

AA CHO
 The significance of infusing amino acid
Starvation unavoidable nitrogen loss quantity
FAO/WHO
At least 100 g of glucose is 500mL x 2bags
necessary per day amino acid30g

(GAMBLE) mgN/kg/day TOTAL

Urine 37
54mg/kg/day
Protein loss (g)

100
Stool 12 When I convert it into
an amino acid
Skin 3
200g 50kg in weight
200 Others 2 26.3 g /day
100g
Glucose
300 0.054(g) 7.5*50(kg)1.3**26.3(g)
50g * convert nitrogen into quantity of amino acid 6.251.2
0g ** usually increase by 30% in consideration of
Starved individual difference
400
1 2 3 4 5 6
Period of starvation (days)
 Patients in medical wards
Majority already in mild to
Suppressed level moderate dehydration,
of consciousness Hemodynamics not
severely compromised Anxiety, depression
Anorexia, or fear
nausea, or
distress
Malaise or fatigue
Inflexible mealtimes

Insufficient oral intake Unfamiliarity or

(too weak to chew or dislike of hospital
bitter dry tongue) food

They need maintenance support

 Points of Presentation
Body Composition
Classification of Parenteral Fluid Therapy
Hypercatabolism in Acute Infection
Effects of Undernutrition
Rationale of maintenance fluid tx
Case illustration
Kasus 1
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

Cairan apa yang dipilih dan berapa laju tetesan ?

 Kasus 2

Pasien usia 12 th masuk RS dengan keluhan utama

demam sudah 4 hari dan tidak mau makan. Mual &
muntah (+)
PF : Gelisah;T 100/80 S 37.5 oC Nadi 120 x/menit,
napas 28 kali/menit dalam; akral dingin. Tes turniket (+).
Lab: Hct 48%; Trombosit 70.000
D/ DBD

Pemeriksaan fisik tambahan & Cairan apa yang dipilih dan berapa laju
tetesan ?
 Infection may result in fluid,electrolyte and
hemodynamic disorders
Maintenance fluid should be encouraged
during febrile phase when oral intake is
severely compromised
A practical and complete maintenance solution
helps facilitate recovery after infection
Recognition of early stage of shock
(compensated shock) is mandatory where
isotonic (replacement) solution MUST BE
ADMINISTERED aggresively
Terima Kasih