The Role of Crystalloid, Colloid and Blood in

Fluid Therapy
Ike SR
FK UNPAD/RSHS
Bandung
Septic Shock
Kombinasi antara
Distributive
Kardiogenik
Hipovolemik
Bentuk syok yang sering terjadi di klinis
Merupakan kelanjutan dari proses SIRS dan sepsis
Terapi cairan
Preload
Contractility
Diperlukan volume
intravaskuler yang
cukup
Frank Starling
Afterload
Sistim vena
jantung
Sistim arteri/
kapiler
Kematian akut pada sindroma syok
30 - 54 25 - 35
Syok hemoragik
(trauma)
48 44
Syok kardiogenik
31 - 63
Syok septik
Hospital
death (%)
28 - 30 hari
(%)
dalam
2 - 3 jam (%)
N Eng J Med 2001; 344:699
JAMA 2002; 288: 862
JAMA 2005; 294:448
Circulation 2005; 112: 1992
N Engl J Med 1994; 331:1105
J Trauma 1998; 45:545
Crystallloid/
colloid
Crystalloid/
colloid
crystalloid crystalloid Fluid
replacement
Confused and
lethargic
Anxious and
confused
Mildly anxious Slightly
anxious
CNS/
mental status
No UO 5-15 20-30 >30 Urine
output
>35 30-35 20-30 14-20 Respiratory
rate
Decrease Decrease Decrease Normal or
decrease
Pulse
pressure
Decrease Decrease Normal Normal Blood
pressure
>140 >120 >100 <100 Pulse rate
>40% 30-40% 15-30% Up to 15% Blood loss
( % EBV)
>2000 1500-2000 750-1500 Up to 750 Blood loss
Class IV Class III Class II Class I
Prinsip dasar terapi cairan
Prinsip dasar terapi cairan
Resusitasi /
mengganti
defisit cairan
Maintenance
Repair
Kehilangan cairan abnormal
GIT
3
rd
space
Ongoing loss
septic
syok Hipovolemik
IWL + urine
Keseimbangan asam basa
keseimbangan elektrolit
Bbb
Bbbb
C
o
p
y
ri
g
ht
BOP
28 mmHg
IFHP
0 mmHg
Venous end
Arterial end
BOP
28 mmHg
IFHP
0 mmHg
7 mmHg
8 mmHg
BHP 30
mmHg
O2
Waste product
+CO2
O2 in
blood
Cells
Interstitial
space
Lymphatic
system
Delivery O2
(DO2)
VO2
Cellular
metabolisme
DO2 = Cardiac Output x CaO2 ( arterial O2 content )
Mikrosirkulasi harus dimonitor oleh karena makrosirkulasi yang baik tidak
menjamin mikrsirkulasi yang baik
MIKROSIRKULASI
Figure 27.5
The Integration of Fluid Volume Regulation and Sodium
Ion Concentrations in Body Fluids
Volume Replacement Therapy
with
Volume Replacement Therapy
with
Colloids
Albumin
PPS
Albumin
PPS
Dextran
solutions
Dextran
solutions
HES
Solutions
HES
Solutions
Gelatin
solutions
Gelatin
solutions
Crystalloids
Crystalloids
Lactated Ringer's
(Normal) Saline
Lactated Ringer's
(Normal) Saline
Natural -------------Synthetic--------------
+
But not every colloid for every indication!
Kapan menggunakan kristaloid ?
Di Emergensi mudah didapat dan murah
Dehidrasi
Mengisi volume intravaskuler sementara,
interstisial, dan volume intraselular
Rekomendasi ATLS 2000 cc pertama
kristaloid
> mahal Murah Harga
Dpt dipertahankan
menurun Plasma COP
+ - Risiko anafilaksis
> baik tidak sempurna Perfusi sistim kapiler
Kurang + Risiko edema jaringan
> sedikit > Banyak Kebutuhan cairan
Bertahan lebih lama Transient Stabilisasi hemodinamik
Bertahan > lama Singkat Intravascular persistance
Koloid Kristaloid
Kristaloid vs Koloid
Colloids fluid loading leads to greater increase in
preload recruit table LVSWI due to higher COP
caused by greater plasma volume ( PV ) expansion
Volume effect is >>>
Colloid loading gives higher CI, PV, and GEDVI
Kejadian histopatologis iskemik ( pemeriksaan PA)
pada kematian karena syok
4 3 6 Otak
3 6 7 Pankreas
16 26 9 Intestine
56 30 46 Hati
11 18 25 Jantung
10 65 55 Paru-paru
100 17 37 Jantung
Kardiogenik
n = 197 (%)
Sepsis
n = 93 (%)
Hipovolemik
n = 102 (%)
McGovern VJ, Pathol Annu 1984;19:15
Saline or colloids do not affect permeability
HES decrease permeability due to endothelial protections
LIS ( lung Injury Score ) may slightly increase in colloid
estimated by respiratory compliance caused by increase
ITBV which IV volume was included ( increased volume due
to increased COP )
ITBV
Proporti
on of
patients
without
ARF
Creatinin concentration over 28 days
Effects of Colloid solutions on
hemostasis and coagulation
Gelatins HES Dextrans
Factor VIII, vWF
Platelets
adhesion
aggregation
Thrombus
formation
Blood typing
No effect
No
effect
No clinical
effect
No effect
In emergency situations
blood typing before infusion !
The patients Hb level, although important, should not be the
sole deciding factor in starting transfusion. The decision to
transfuse should be supported by the need to relieve clinical
signs & symptoms & prevent significant morbidity &
mortality
The clinician should be aware of the risks of transfusion-
transmissible infection in the blood components that are
available for the individual pt**
** It should be noted that the rates of non-infective
complications are probably higher than those of infective
complication
WHO principles for the clinical use of blood
components [WHO (1998a)]
Transfusion should be prescribed only when the
benefits to the pt are likely to outweigh the risks
The clinician should record the reason for
transfusion clearly
A trained person should monitor the transfused pt
& respond immediately if any adverse effects
occur
WHO principles for the clinical use of blood
components [WHO (1998a)]
FDA guidelines
RBC should not be given for
volume expansion
for improvement of general sense of well being
to accelerate wound healing
as hematinic agent
Platelet should not be given for prophylaxis, either
after CPB or massive transfusion
FFP should not be used for
volume expansion
as nutritional supplement
for prophylaxis, either after CPB or massive
transfusion
Hb 7-14
Rekomendasi dari Transfusi Sel Darah Merah
Indikasi
Hb <7g/dL hampir selalu indikasi untuk
transfusi darah merah
Dapat ditunda bila tidak terdapat tanda2
klinis hipoksia yang jelas
Dapat ditunda bila pasien mendapat
terapi yang dapat meningkatkan Hb
seperti erythropoietin /EPO
Rekomendasi transfusi sel darah merah PRC
Indikasi
Bila Hb 7 10 g/dL :
Keuntungan pemberian transfusi PRC
tidak jelas
Transfusi PRC dapat dilakukan bila
terdapat hipoksia yang jelas
hypoxemia
Transfusi Sel Darah Merah PRC
Indikasi
Hb 10g/dL tidak perlu transfusi PRC
kecuali pasien2 yang memerlukan
kemampuan transport O2 yang lebih
tinggi
COPD yang berat
Iskemia jantung
Pemberian transfusi pada keadaan ini harus
dengan alasan yang jelas dan tertulis
DO2 = Cardiac Output x CaO2 ( arterial O2 content )
(Hb x SpO2 x1,34 )+ ( 0,003 x PaO2)
Stroke Vol x HR
Volume x contractility
}
Combine thoracic epidural and general anesthesia
elective colorectal resection ASA I III
Intra Cellular Space
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a
v
a
s
c
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a
r

S
p
a
c
e
RBC
C
a
p
i
l
l
a
r
y

m
e
m
b
r
a
n
e
Kesimpulan
15%
5%
40%
Na = 140 meq/l
K = 4 meq/l
N
a

=

1
4
0

m
e
q
/
l
K

=

4

m
e
q
/
l
Interstitial
Space
Colloid
crystalloids
Glucose solution
Na = 8 meq/l
K = 151 meq/l
Untuk memperbaiki DO2 Curah
Jantung dan O2 content transfusi