Umur
Total cairan caira n tubuh (%) terhadap BB
Bayi BL
77
6 Bulan
72
2 Tahun ahun
60
16 Tahun ahun
60
20-39 Tahun: Pria/Wanita
60/50
40-59 Tahun: Pria/Wanita
55/47
Total body fluid is 60% of body weight Intracelluler 2/3 (40%)
Interstitial 15%
extracelluler 1/3 (20%)
Plasma 5%
Transcelluler 1-3%
Electrolyte
Plasma(mEq/L
Interstetiel (mEq/KgH2o)
Intracelluler (mEq/KgH2o)
Na+
142
145
10
K +
4
4
159
Ca2+
5
3
1
Mg2+
2
2
40
Total
153
154
210
Cl-
103
117
3
HCO3-
25
28
7
Protein
17
-
45
Others
8
9
155
Total
153
154
210
Cation:
Anion:
Intake (Range)
Output (range)
Air minum = 1400 – 1800 ml Urine = 1400 – 1.800 ml Makanan = 700 – 1000 ml
Faeces = 100 ml
Oksigenasi = 300 – 400 ml
Kulit = 300 – 500 ml Nafas = 600 – 800 ml
TOTAL
= 2400 - 3200 ml
TOTAL
= 2400 – 3200 ml
Intake (range)
Output (range) Urine = 65 (50-100)
Natrium (mEq) = 70 (50-100)
Faeces = 5 (2-20) Kalium (mEq) = 100 (50-120)
Urine
Magnesium (mEq) = 30 (5-60)
= 90 (50-120)
Faeces = 10 (2-40) Urine = 10 (2-20) Faeces = 20 (2-50)
Kalsium (mEq) = 15 (2-50)
Urine = 3(0-10) Faeces = 12 (2-30)
Protein (g) = 55 (30-80) Nitrogen (g) = 8 (4-12) Kalori = 1800-3000
o o o
(nilai 36,8 °C adalah konstanta) IWL + 200 (suhu tinggi - 36,8 .°C)
Input cairan: Air (makan+Minum) Cairan Infus Terapi injeksi Air Metabolisme
= = = =
......cc ......cc ......cc ......cc (Hitung AM= 5
cc/kgBB/hari) Output cairan: Urine = ......cc Feses = .....cc Muntah/perdarahan/cairan drainage luka/cairan NGT terbuka = .....cc IWL = .....cc
DEHIDRASI ( vol sirkulasi efektif ↓ )
Osmolality plasma ↑
Thirst ↑ Water ingesti ↑ exc ↓
ADH ↑ water
Water retensi Osmolaliti plasma ↓ Vol sirkulasi ↑
Tubuh kekurangan cairan Etiologi kekurangan cairan : ◦
Melalui sal cerna
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Melalui sal kencing
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Pemakaian diuretik Penyakit ginjal diabetes
Melalui kulit
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Muntah Diare perdarahan
Luka bakar Keringat ↑↑
Perpindahan keruang dalam badan
Peritonitis Pankreatitis
1. 2. 3.
Sistem skor ( dehidrasi akut, mis GE akut ) Pemasangan CUP Ukur kadar Na plasma defisit cairan = 0,6 X BB { Na plasma _ 1} 140
4.
Ukur hematokrit defisit cairan = 0,2 X BB {
Ht
_ 1} Ht N
5.
Ukur BJ plasma
Muntah Suara serak Kesadaran apatis Kesadaran somnolen, sopor sampai koma. Sistolik ≤ 90 mmHg Nadi ≥ 120/mnt Nafas kusmaul ( ˃ 30/mnt ) Turgor kulit kurang Facies Cholerica Extremitas dingin Jari tangan keriput (washer hand) Sianosis Umur ≥ 50 thn Umur ≥ 60 thn
skor x 10 % BB (kg) x 1 liter 15
1 2 1 2 2 1 1 1 2 1 1 2 -1 -2
Gejala dehidrasi : lesu tek darah ↓ nadi halus cepat urin ↓
akral dingin mukosa kering turgor ↓
Pengobatan : Sesuai penyakit dasar Pemberian cairan oral - parenteral
Patogenesis ↑ tekanan darah hidrostatik kapiler 1. 1. Payah jantung 2. Sirosis hati 3. Obstruksi vena lokal 2.
↓ tekanan koloid osmotik plasma ( alb↓ ) 1. Sind. Nefrotik 2. Sirosis hepatis 3. Malnutrisi
3.
Permeabilitas kapiler ↑ 1. 2. 3. 4.
4.
Trauma Radang Luka bakar Alergi
↑ tekanan koloid osmotik intertitial 1. Sumbatan sal limfe
Pengobatan
Sesuai penyakit dasar
Simptomatis
1. Diet rendah garam 2. Diuretik
Pseudohyperkalaemia Haemolysis Leucocytosis (>50.000/ml) Thrombocytosis(>1.000.000/ml)
Impaired renal excretion Renal failure Drugs: ACE inhibitors K-sparing diuretics NSAIDS
Transcellular shifts Acidosis Beta-blockers Insulin deficiency Succinylcholine Rhabdomyolysis
Excess intake K-supplement Massive transfusion
MANIFESTASI KLINIK OTOT SKELET: PARALYSIS/FLACCID PARALYSIS ARREST PERNAFASAN ILEUS
DYS-RYTHMIA : TACHYCARDIA FIBRILLASI VENTRIKULER SINUS BRADYCARDIA SINUS ARREST RYTHME IDIO-VENTRICULAR LAMBAT
PENGOBATAN
Table 28-4. Treatment of Hyperkalemia 1 Antagonism of membrane action A. Calcium B. Hypertonic Na solution (if hyponatremic) 2. Increased K+ entry into cells A. Glucose and Insulin B. NaHCO3 C. β2-adrenergic agonist D. Hypertonic Na+ solution ( if hyponatremic) 3. Removal of the excess K+ A. Diuretics B. Cation exchange resin C. Hemodialysis or peritoneal dialysis Burton Davis Rose: Hyperkalemia, in: Clinical Physiology of Acid-Base Balance And Electolyte
Management of Hyperkalemia
K+ Meninggi ?
Ya
Tidak Berhenti
Apakah nyata? Ya Apakah > 6.0 mEq/L atau ada perubahan EKG
Tidak Berhenti
Ya Pasien perlu penurunan K+ darurat.
Tidak
EKG abnormal ? Ya
Tidak Beri insulin dengan glukosa dan/atau Ventolin dgn nebulizer Lanjutkan dengan evaluasi
Beri kalsium glukonat
Periksa K+ urine, osmolailty, kreatinin K < 6.0 mEq/L?
Tidak Ulangi insulin dan glukosa, pertimbangkan hemodialisis
Ya Beri cation exchange resin atau furosemide Evaluasi lanjutan dan
1. Direct membrane antagonism (cardiac toxicity): IV Ca-gluconas, CaCl2 10% 10 ml, over 2-5 minute 2. Transcellular shift of K: a. IV dextrose 50% 50ml + IV 5-10 unit Regular-Insulin b. IV Na.Bicarbonate 50-100mEq infused over 5-10 min 3. Enhanced clearance from body - diuretics: IV frusemide 10-20mg - haemodialysis/CRRT - ion exchange resins (Resonium A PO 15g q 8h or enema 30g q8h)
Etiologi : 1. Tanpa defisit K total tubuh
1. Alkalosis 2. Sekresi insulin yang menetap 2. Dengan defisit K total tubuh
1. Intake ↓, anoreksia 2. Hilang → sal cerna : GE, muntah ginjal : hiperaldosteron, loop diuretik
Gejala Klinis :
↓ resistensi perifer
↓
2. pH urin ↑ ↓ eksresi K ↓ 2. Gangguan toleransi glukosa ok sekresi insulin terhambat
Kalium serum < 3,5 mEq / L
K oral / parenteral
K parenteral (Replacement rate 10-30 mEq/h diluted in 100-200 NS/D5% ( central vein)) indikasinya : Hipokalemi barat Aritmia Gagal otot nafas
→ ekstrasel → sel dehidrasi → ADH ↑ (kompetensi tubuh) → haus → intake ↑
Hypernatraemia ([Na]>150mEq/L)
Assess ECF volume
Hypovolaemia
Renal losses Diuretic Osmotic diuresis Diabetes insipidus Extrarenal losses Vomiting, diarrhea Skin, respiratory
Euvolaemia
Renal losses Diabetes insipidus Extrarenal losses Vomiting, diarrhea Sweating, respiratory
Hypervolaemia
Iatrogenic Hypertonic saline or Na-Bic administration Cushing Syndrome Hyperaldosteronism
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Low ECFV : Isotonic saline, then hypotonic fluids IV (<300ml/h) or PO free water High ECFV: loop diuretics, Replace with hypotonic fluids if necessary Correction Na level should < 0.5mEq/L/h, or <1.0 mMeq /L/h for acute hyper Na Treat underlying condition e.g Diabetes Inspidus: Desmopressin When hypovolemia has been corrected: Current TBW x current [Na] = normal TBW x normal [Na] Current TBW = normal TBW x (140/current[Na]) TBW deficit = normal TBW – current TBW = 0.6 BW (kg) – current TBW = (0.6xBW)(1 – 140/current [Na
HIPONATREMI
Gejala oleh karena edem sel otak, yang timbul bila hipoosmolalitas dalam plasma terjadi dengan cepat Pada kadar Na 120 – 125 : nausea-vomit 110 – 120 : letargi-cephalgia < 110 : kejang-koma
TERAPI
asymptomatic: replace with isotonic saline symptomatic: replace with hypertonic saline
asymptomatic: frusemide diuresis + isotonic saline symptomatic : frusemide + hypertonic saline
asymptomatic : frusemide diuresis symptomatic: frusemide diuresis + hypertonic saline
Pertahankan Na > 120 mEq / L
Hiponatremi yang disertai hipokalemi (mis,GE) → koreksi kalium saja telah langsung mengoreksi Na
Larutan NaCl 3 % (~ 513 mEq/L) diberikan bila ada gejala edem serebri Bila gejala edem serebri hilang → cukup berikan NaCl isotonis
PTH: from parathyroid activate osteoclasts enhance intestinal absorption increase kidney reabsorption ◦
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most calcium in bones as calcium phosphate PO4- reabsorbed in proximal tubules regulated by PTH ◦
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