6.rational fluid in dhf patients.ppt
TRANSCRIPT
SHORT CURICULUM VITAE
1.Name : Budhi Santoso2.Place/date of birth : Jakarta, 17 Mei 19674.Marial status : Married with 4 children5.Alumny : Medical Faculty of Brawijaya University Malang East Java:1993
6.Working Experienced : 6.1. Cipete Clinic, Jakarta (1993-1994)6.2. Puskesmas Moro Seneng-Kepri, Riau (1994-1997)6.3. Schering AG (Med Advisor: 1998-2000)6.4. Otsuka Indonesia (Med-Consultant: 2001-)
7.Training Experienced : 7.1. European GCP Advance Course, Schering AG-Berlin, 1998
7.2. Communication on Family Planning, Leiras-Sweden, 19997.3. ACOG Congress, Philadelphia-USA, 1999
7.4. Schering Internal Leadership Course, Dusit-Thailand, 20007.5. Critical Care Annual & Pensa Meeting, Bali: 2001, 2002, 20037.6. ATLS advanced, RSCM 20037.7. Indonesian GCP, RSCM 2004 7.8. Critically Ill in Children Course, Malang, 20057.9. Critical Care Workshop, Surabaya: 2006, 2007, 20087.10. Aminofluid Workshop,Tokushima, Japan, 2009
7.11. Compounding Infusion Course, Toho University, Tokyo, Japan 2012 7.12. Regulatory and Pharmacovigillence Meeting, Tokushima, Japan 2012
7.13. European Soc of Par and Enteral Conggess, Barcelona, Spain Sept 2012 7.14. Indonesian-Japan Symposia on Ensuring Safety and Efficacy, Jkt Feb 2013
Pendahuluan
• CFR DBD (2004=2%, 2006=1,6%, 2009=3,5%)• Apa virus tambah ganas ?• Apa penyebab kematian ?? (perdarahan massif,
DIC, syok tidak teratasi atau fluid overload, edema paru, dll)
• Pasien yang meninggal tidak diautopsi ???• Awareness kita ???? Misal: Simposium/Kursus DBD diadakan hanya
ketika ada KLB
Tata Laksana
Prof. Soegeng, Tatalaksana DBD terkini, RSUD Dr Soetomo/FKUnair, 2006
Divisi Tropik Infeksi FK Unair/RS Dr Sutomo
• Cairan pengganti pada SSD penatalaksanaan utama, memperbaiki kekurangan plasma
• Cairan kristaloid prioritas pertama• Pilihan cairan kristaloid: ringer asetat, ringer
laktat, NaCl 0.9%• Ringer asetat pilihan yang perlu didahulukan• Asetat di dalam tubuh diubah menjadi
bikarbonat oleh sel otot, laktat oleh sel hati• Sel hati kebanyakan terganggu pada infeksi
dengue pengaruh sitokin proinflamasi
Nasronudin, 2007
Hypovolemic shock
RESUSITASI RUMATAN
DESIGN TERAPI CAIRAN IV
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, trace Element dan as. amino 4:2:1 (misal 25 kg: 4 x10+2x10+1 x5 65ml/jam 500 ml/6 jam
Yuichi Imai: Practice of Clinical Training, 2004; 1 (5): 6-13.
Fluid Management in DHF
Grade 1
Grade 2
Grade 3
Grade 4
Isotonic crystalloids (RA,RL,NS);hypotonic crystalloid (NaCl 0.45%-D5)
Isotonic crystalloid/colloid/blood(component)
Prevention and Control of Dengue and Dengue Haemorrhagic Fever. WHO Regional Publication, SEARO No 29
Terapi Cairan DBD grade III dan IV(disertai Syok)
Isotonic Crystalloid• Asering/RL/NS• Umumnya dianjurkan jika Ht >
20%• NS berpotensi menyebabkan asidosis
hiperkloremik*• Kombinasi dg dekstrosa 5% (misal RA-
D5 (Asering5), RL-D5, NS-D5) diberikan jika kecepatan infus < 10 ml/kg/jam
Clinical Science (2003) 104, (17–24) (Printed in Great Britain)
Ringer’s acetate
®
®
Ringer’s acetate
First Line Fluid Resuscitation Therapy
ASERING
KOMPOSISI
Tek.Osmotik
Na+ K + Cl - Ca2+ Asetat Laktat ( mOsm /L )
ASERING® ( RA ) 130 4 109 3 28 - 274
RINGER LAKTAT ( RL ) 130 4 109 3 - 28 274
Elektrolit ( mEq )
Setiap 1 L mengandung :
• Ringer’s lactate 6.75
• Asering® 7• Normal saline 6.25
Average pH
LACTATE: Primarily in the liver, and to lesser degree the kidney, lactate is metabolized to pyruvate, which is then converted to CO2 and H2O (80%) or glucose (20%), and regeneration of bicarbonate1
ACETATE: metabolized mainly in muscles and to a lesser extent in tissues such as kidney, heart and liver2
Acetate + H+-------- Acetyl-CoA
Coenzyme A
Carbonic acid -------- bicarbonate
hydrogen sourceKreb’s cycle
Ref. 1.Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4 th ed 1994 p 554 2. Maxwell MH, Kleeman CR, Narins RG. Clinical Disorders of Fluid and Electrolyte Metabolism. MacGraw-Hill 1987 4th edition p 1063
ASERING® & LR
1. SODIUM LAKTAT ( HATI )
CH3CH(OH)COONa + CO2 +H2O NaHCO3 + CH3CH(OH)COOH ( Laktat )
CH3CH(OH)COOH + 3 O2 3 CO2 + 3 H2O : TCA Cycle
2. SODIUM ASETAT ( OTOT )
CH3COONa + CO2 +H2O
CH3COOH + 2 O2 2 CO2 + 2 H2O : TCA Cycle
NaHCO3 + CH3COOH ( Asetat )
GLUkOSA
GLIKOGENG - 6 - PL- LAKTAT
PIRUVAT
LDH
Asetil KoAsintetase
ASETAT Asetil - KoA
2 CO2 TCA Cycle H2O
METABOLISME ASERING®
Na Lactate Bicarbonate
LACTATE VS ASERING®
Na Acetate Bicarbonate
100 mEq/hr
250-400 mEq/hr
DBD III & IVO2 2-4 L/menitRA/RL 20 ml/kg bolus dalam 30 menit
Syok teratasi Syok tidak teratasi
RA/RL 10 ml/kg/jam
Stabil dalam 24 jam
RA 5 ml/kg/jam 3 ml/kg/jamStop < 48 jam
Dextran 40 10-20 ml/kgTeratasi
Tidak Teratasi
Ht turun Ht tetap/naikFFP 10 ml/kg Dextran 20 ml/kg
Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999
Dextran-40
• Koloid Standard untuk DSS• Efek volume dipertahankan 3,5-4,5 jam• Dosis maksimal 30 ml/kg/hari
Terapi Cairan DBD grade I dan II(Tanpa Syok)
Hypotonic Crystalloid
• Larutan rumatan diberikan pada pasien DBD stadium I tanpa peningkatan Ht jika asupan oral tidak memungkinkan (misal muntah-muntah)
• Memasok air dan suplemen kalori;serta elektrolit sesuai kebutuhan harian
• Contoh: KAEN 3B/ Aminofluid
Makalah simposium DBD SubTropik Infeksi Bag Peny. Dalam FKUI/RSCM 2010
Pasien Rawat Inap:Interna, Pediatric, Pulmonologi, Cardiology, Obgyn, Neurologi (Stroke)
Post Operative:Surgery pts, Obgyn pts,
Dextrosa & KAEN
1 L
225 ml
85 ml
INDIKASI
660 ml
MAINTENANCE
Kebutuhan harian:
Air : 30-50 mL/kgBBNa+ : 2 meq/kgBBK+ : 1 meq/kgBB
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 bukanUntuk Terapi Rumatan
Ilustrasi BB Dewasa (Org Indonesia) : ± 50 kg
Prevalences of HypokalemiaChief Investigator Centre No of
patients% hypokalemia 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. Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy vol.5. Ed: Dec 2004. Page: 115-120 2. 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 3. Nasronudin et al. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients. Medika 2006 Vol
XXXII,No 12, p 732-734
RSCM 23%
表 2．入退院時の血清内ｶﾘｳﾑﾚﾍﾞﾙ
How does maintenance fluid therapy evolve?
Na+ 77
Na+ 50 K+ 20, glu 27 g
Na+ 35 K+ 20
Aminofluid pada DBD
• Walaupun pasien merasa haus karena dehidrasi hipertonik, mungkin mereka tidak bisa mengkonsumsi air dan nutrien cukup akibat keluhan saluran cerna/ nyeri, hepatomegali
• Peningkatan kadar sitokin, seperti interferon (IFN), interleukin-2 (IL-2), IL-8, dan tumor necrosis factor alpha, telah dilaporkan pada DHF Salah satu efek pleiotropiknya adalah memperlambat pengososan lambung
• Pasien mungkin mengalami anoreksia karena mulut kering (dehidrasi), malaise dan fatigue di samping gejala-gejala sistemik lain
Aminofluid
Infeksi akut/
Demam
Penya-kit Gastro-
intestinal
Postoperatif
Hiper-emesis
Gravida-rum
Neurologi
Sepsis
DiabetesMellitus
DBD
Anon Srikiatkhachorn, Chuanpis Ajariyakhajorn, Timothy P. Endy, Siripen Kalayanarooj, Daniel H. Libraty, Sharone Green, Francis A. Ennis, and Alan L. Rothman Virus-Induced Decline in Soluble Vascular Endothelial Growth Receptor 2 Is Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. 2007 February; 81(4): 1592–1600.Othman N.Clinical profile of dengue infection in children versus adults.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page S435
FATIGUE An underestimated and undertreated symptom (1)
1. Michael Sharpe BMJ 2002;325:480-4832. Seet RCS, et al. Post-infectious fatigue syndrome in dengue infection. Journal of Clinical Virology Volume
38, Issue 1, January 2007, Pages 1-6
Post-infectious fatigue was observed in approximately 25% of hospitalized patients with dengue infection (2)
Tabel 1. Komposisi Aminofluid dibandingkan RL dan KAEN3B
-54 g150 g ¥Glukosa
0.8 g/kg/hari--AA 60 gAsam amino
2.5-5 g--10 µmolZn
20-40 mEq/hari--20P
10-15 mEq/hari--10Ca++
8-20 mEq/hari--10Mg++
sesuai kebutuhan21810070Cl-
1-2 mEq/kg*/hari84040K+
1-2 mEq/kg/hari26010070Na+
30-40 ml/kg/hari200020002000Air
ASPEN guideline(2)Ringer’s lactateKAEN3BAminofluidKomposisi
•kebutuhan basal untuk homeostasis K+ adalah 20-30 mEq/hari (10); • kebutuhan basal asam-aminopada pasien nonstressed; •¥ protein-sparing effect
E. Blomstrand A Role for Branched-Chain Amino Acids in Reducing Central Fatigue J. Nutr., February 1, 2006; 136(2): 544S - 547S
Tryptophan
(Serotonin)
BBB
Appetite
Fatigue
BCAA
(Serotonin)
80%
www. moh.gov.my : Management of Dengue Infection in Adults.2 edition 2008.DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL. New Edition 2009Yip WCL. Dengue Haemorrhagic Fever: Current Approaches to Management.Medical Progress October 1980
WARNING SIGNS
• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation (pleural effusion, ascites)• Mucosal bleed• Restlessness or lethargy• Liver enlargement > 2 cm• Laboratory : Increase in HCT concurrent with rapid decrease in platelet
COMPENSATED SHOCK ISOTONIC CRYS 10 ml/kg/hr
Capillary refill > 2 secNarrowing pulse pressureTachycardiaTachypnoeaCold extremities
Maintenance ONLY ISOTONIC INFUSION
Indikasi Aminofluid yang dianjurkan: • 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
JAN’ 2012
CONCLUSION1. When hemodynamic patients is not stable (DBD gr III and IV) Asering
for replacement therapy seems superior compare to LR or NS2. If hemodynamic still stable (DBD gr I and II) and patients could intake
adequate orally give hypotonic solution which meet daily requirement and It has evolved from simply giving water and electrolyte in simple container to practical and complete composition in advanced dual-chamber formulation.
3. Most important goal of maintenance therapy is to correct homeostasis, improve sense of well-being, combat fatigue, increase appetite and finally faster recovery.
4. Aminofluid already designed for advance maintenance fluid therapy today
