update on fluid therapy in dhf
TRANSCRIPT
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dr Iyan Darmawan
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Basic Terms
• %
• mmol
• mEq
• mOsm
= g/dl
= mg/MW
MW = molecular weight
= mmol x valence
= Σ mmols of solutes
e.g NaCl 0.9% = 0.9 g/dl = 9 g/L 5% dextrose = 5 g/dl = 50 g/L
e.g. NaCl 9 g/L = 9 x 1000 23 + 35.5= 154 mmol/L
e.g. 1.75 mmol Ca++ = 3,5 mEq
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Pedoman berbeda-beda Deteksi gangguan hemodinamik Evaluasi Hemokonsentrasi Nilai normal HR tergantung usia (perhatikan
obat/zat yang dikonsumsi) Oliguria perlu ditelusuri Pemilihan cairan harus tailor-made Monitoring seksama esensial Obesitas
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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 (+). TB 120 cm BB 50 kg
Lab: Hct 48%; Trombosit 70.000 D/ DBD
Pemeriksaan fisik tambahan & Cairan apa yang dipilih dan berapa laju tetesan ?
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Wanita usia 35 th masuk RS dengan keluhan utama demam sejak 2 hari yl dan tidak mau makan. Mual & muntah (+), kembung dan tidak bisa minum walaupun haus
PF : CM;T 110/70 S 39 oC Nadi 100 x/menit, napas 16 kali/menit; Tes turniket (+).
Lab: Hct 40%; Trombosit 70.000; glukosa 72 mmol/L BUN 25 mg/dl, kreatinin 1.1 mg/dl D/ DBD
Cairan apa yang dipilih dan berapa laju tetesan ?
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Syok/Gangguan Hemodinamik ?
Ada Gangguan Elektrolit ?
Metabolik/Nutrisi?
Komorbiditas/insufisiensi, gagal organ?
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Shock grades
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MAP Pulse Pressure Tachycardia Capilary refill time Peripheral Vasoconstriction Oxygen saturation
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MAP (mean arterial pressure) 70-105 mmHg HR (heart rate)
Neonatus (usia 0-30 hari): 70 - 190 detak/menit Bayi (usia 1 - 11 bulan): 80-120 detak/menit Anak 1 sampai 10 tahun: 70 - 130 detak per menit Anak usia > 10 th dan dewasa 60-100 detak/menit
Pulse Pressure (TD sistolik-Diastolik) 30-40 mmHg CRT (capillary refill time) < 2 detik Partial Pressure of Arterial Oxygen (PaO2) 80-100
mmHg Saturasi oksigen darah arteri (SaO2) 95-100% Saturasi vena campur (SvO2) 60-80%
Referensi : http://www.lidco.com/docs/1462Educatioalcard7.pdf. Diunduh 30 Januari 2012
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.
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RESUSCITATION REPAIR MAINTENANCE PN
CORRECTNUTRITION ST
PERFUSION & OXYGENATION
HOMEOSTASIS/SUPPORTIVE
CORRECTELECT & AB
PARENTERAL FLUID THERAPY
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Plasma Osmolarity
• 2 x [Na+] + Glu (mg/dl) + BUN (mg/dl)
18 2.8
• Range 280-290 mOsm/L
• > 296 mOsml/L dehydration
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Replacement vs Maintenance fluid
PlasmaPlasma ReplacementReplacement MaintenanceMaintenance
Normalsaline
AR/ LR Typicalmaintenance
290 308 273
NaCl 0.45%-D5
290
154+278
140+150
432
ISOTONIC HYPOTONIC
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Dehydration vs Hypovolemia
• Intracellular & Interstitial depletion
• Thirst, oliguria, dry mucous membrane
• Plasma Osmolarity ↑• BUN/creatinine ratio >20
• FeNa* <1 %
• Intravascular depletion• Hemodynamic responses
in initial phase (compensated shock)
• Hypotension, MAP < 60 indicate advanced stage
Both types often coincides
*FeNa = (U/P Na) : (U/P Creat)
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RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE
Resuscitation vs Maintenance
Elect of High sodium > 100 mmol/L or synthetic colloid Low or no K+ ~ 10-20 ml/kg/hr (DSS, diarrhea) 2-3 L/10-15 min (hemorrhagic shock)
• Moderate sodium 35-70 mmol/L• K+ based on daily req • 20 drops/min 500 ml/6 hr
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Replace acute/abnormalloss
Isotonic infusion
800 ml 200 ml
• ASERING• Lactated Ringer’s• Normal saline
1 L of
increases ECF
ICF ISF Plasma
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increases ICF > ECF
ICF ISF Plasma
Replace Normal loss (IWL + urine)
Hypotonic infusion
5% dextrose/ Maintenance sol
85 ml255 ml660 ml
1 L of
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increases intravascular
ICF ISF Plasma
Hemorrhagic shockBurnReserved for patientsin whom ISF expandedbut intravascular andalbumin is severelydepleted
Albumin infusion
Albumin 25%
300-600 ml over 30-60 min
100 ml L of
Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 221
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increases intravascular
ICF ISF Plasma
Hemorrhagic shockDSSLoading reg anes
Plasma Expander infusion
Dextran Gelatin HES
500 m L of
750 ml at 1 hour; 1050 ml at 2 hr
Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 225
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Fluid kinetics may be modified in conditions with increased permeability
Even albumin leaks into the interstitial space in sepsis.
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UU U
U U U
20%3.5%U U
- + + - + + -
Transvascular Exchange and Organ Perfusion
6% Dextran 70 HES Gelatin Albumin Mannitol Urea Hypertonic sal ine
Fluid permeabil i ty
Albumin permeabil i ty
Muscle volume
Rebound fi l tration
u = unchanged
Holbeck S, Grände PO: Effects on capillary fluid permeability and fluid exchange of albumin, dextran, gelatin, and hydroxyethyl starch in cat skeletal muscle. Crit Care Med 2000, 28:1089-1095
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Colloid in increased Capillary permeability?
• In some studies, the use of dextrans and hetastarch was shown to attenuate macromolecular leakage by presumably occluding some of the endothelial “gaps” associated with some conditions (e.g., ischemia, sepsis).
• However, there are concerns over the use of heterogeneous colloid solutions in states of increased permeability because the smaller colloid particles will extravasate into the interstitium and potentially promote edema.
1. Webb AR, Moss RF, Tighe D, et al: A narrow range, medium molecular weight pentastarch reduces structural organ damage in a hyperdynamic porcine model of sepsis. Intensive Care Med 18:348–355, 1992.
2. Zikria BA, King TC, Stanford J, Freeman HP: A biophysical approach to capillary permeability. Surgery 105(5):625–631, 1989.3. Oz MC, FitzPatrick MF, Zikria BA, et al: Attenuation of microvascular permeability dysfunction in postischemic striated muscle by
hydroxyethyl starch. Microvasc Res 50(1):71–79, 1995.4. McGrath AM, Conhaim RL, Myers GA, Harms BA: Pulmonary vascular filtration of starch-based macromolecules: Effects onlung fluid
balance. J Surg Res 65(2):128–134, 1996
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HCF
Free Radicals(NO + O2* =Peroxynitrite)
TNF-αIL-8IL-1
IFN-γIL-2TNF-β
IL-4IL-5IL-6IL-10IL-13
Cell apoptosis(Mast cells, Basophil, etc)
Histamine IncreasedVascularPermeability
DF
DHF
VEGF-A
1) Chaturvedi UC, et al . Cytokine cascade in dengue hemorrhagic fever: implicationsfor pathogenesis FEMS Immunology and Medical Microbiology 28(2000) 183-1882) JOURNAL OF VIROLOGY, Feb. 2007, p. 1592–1600
CD4+ T Cells
Th1 Th2
Macrophage
Pro-infllamm
atoric
Anti-infllamat
oric
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Vascular endothelial growth factor A (VEGF-A), the most potent permeability-enhancing cytokine, in DHF*
J Virol. 2007 February; 81(4): 1592–1600.
Capillary leakage
vasculitis, reperfusion injury
SIRS, ARDS, pneumonia, sepsis
Pancreatitis, and anaphylaxis.
DHF
Envenomation
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What is “sealing effect”?
• Effects of Hydroxyethyl Starch on Lung Capillary Permeability in Endotoxic Rats
• 3.75 and 7.5 mL/kg significantly reduced LPS-induced increases of lung capillary permeability
• antiinflammatory effect of HES, including inhibition of NF-κB activation
Anesth Analg 2004;98:768-774
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Which product and correct timing ?
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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
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* Ganong WF. Cardiovascular homeostasis in health and disease. In: Review ofMedical Physiology. 22nd Edition. London: McGraw-Hill; 2005:p.630-46.
*
Clear consciousness
Brisk capillary refill time (<2 sec)
Warm and pink extremities
Good volume peripheral pulses
Normal heart rate for age
Normal pulse pressure for age
Normal respiratory rate for age
Normal urine output
Clear consc-shock can be missed if we don’t touch the patientCapillary refill time↑ ( >2 sec)Cool extremitiesWeak peripheral pulses
Tachycardia
Normal syst pressure , raised diastolic; postural hypotensionNarrowing pulse pressure
Tachypnea
Reduced l urine output
Restless or lethargy
Mottled skin, Cap refill time ↑↑
Cold,clammy extremities
Feeble or absent peripheral pulses
Severe tachycardia; bradycardia in late shockNarrowed pulse pressure(<20)
Hyperpnoea/Kussmaul
Oliguria/Anuria
Maintenance solution: 20 drops/min or 3 ml/kg/hr
Replacement solution: 5-10 ml/kg/hr
Replacement solution: Bolus 20 ml/kg (15 min) or colloid
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Complete Main-tenance solutionAminofluid
RL,RA,Normal SalineKAEN 3B, NaCl 0.45%/D5
Colloid
Dehydration Hypovolemia/Shock
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Na+ 77
Larutan Rumatan
Generasi 1 Generasi 2 Generasi 3
KAEN 3B
AMINOFLUID
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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, 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.
2. Othman N.Clinical profile of dengue infection in children versus adults.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page S435
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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)
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Out of 127 patients,
•fever (93.7%) •poor appetite (89.0%) •fatigue (80.3%) •headaches (74.8%) •nausea (69.3%) •chills (69.3%) •muscle pain (62.2%) •and rashes (50.4%)
Seet RCS, et al. Post-infectious fatigue syndrome in dengue infection. Journal of Clinical Virology Volume 38, Issue 1, January 2007, Pages 1-6
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E. Blomstrand A Role for Branched-Chain Amino Acids in Reducing Central Fatigue J. Nutr., February 1, 2006; 136(2): 544S - 547S
Serotonin
BBB
Anorexia
Fatigue
BCAA
Tryptophan
Cytokines released during acute infection , including DHF stmulate serotonin
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Administration of Amino Acids and Administration of Amino Acids and GlucoseGlucose
Amino acids Amino acids
With NPC
Without NPC
Utilized for protein synthesisUtilized for protein synthesis
Consumed as an expensive energy source
Changes in body weight
(%)0
-10
-20 *
*
Nitrogen balance
-3000
-2000
-1000
0(mgN/kg)
* *Mean ± S.D.Tukey’s group comparison test
*: p < 0.05 vs. the amino acid, glucose, and electrolyte solution group
Urabe H, et al. Yakuri To Chiryo 1994;22 (Supplement):S835
3% Amino acid solution group
Electrolyte solution with 10% glucose group
(n=10) (n=7) (n=10)
Amino acid, glucose, and electrolyte solution group
(n=10) (n=7) (n=10)
Amino acid, glucose, and electrolyte solution group
3% Amino acid solution group
Electrolyte solution with 10% glucose group
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When the gut works, use it!
When it doesn’t work, use
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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 ?
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Wanita usia 35 th masuk RS dengan keluhan utama demam sejak 2 hari yl dan tidak mau makan. Mual & muntah (+), kembung dan tidak bisa minum walaupun haus
PF : CM;T 110/70 S 39 oC Nadi 100 x/menit, napas 16 kali/menit; Tes turniket (+).
Lab: Hct 40%; Trombosit 70.000; glukosa 72 mmol/L BUN 25 mg/dl, kreatinin 1.1 mg/dl D/ DBD
Cairan apa yang dipilih dan berapa laju tetesan ?
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Take Home Messages
• DHF is dynamic disease, and fluid therapy should be adjusted and monitored
• Maintenance fluid should be encouraged during febrile phase when oral intake is severely compromised
• Recognition of early stage of shock (compensated shock) is mandatory where isotonic (replacement) solution MUST BE ADMINISTERED aggresively
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Terima Kasih