TERAPI CAIRAN

PADA ANAK
dr. Nurcahaya Sinaga SpAK
OUTLINE

◦ Fisiologi dan komposisi cairan dan elektrolit

pada anak
◦ Homeostasis cairan dan elektrolit
◦ Tatalaksana gangguan cairan dan elektrolit
 pendahuluan
Anak perlu cairan dan elektrolit lebih banyak dibanding dewasa
Anak Rentan untuk mengalami dehidrasi ol karena :
- Kecepatan metabolic lebih tinggi
- High insensible loss : minute ventilation, surface are,
immature epidermis pada premature
- Rendah kemampuan konsentrasi urine, walaupun
- Sedikit mampu mengeksresi a water load ( renal immaturity< 1
tahun dan tendency level ADH yang tinggi
Fungsi cairan tubuh dan elektrolit
Body Water
◦ Medium for biological activities Electrolytes
 transport of nutrients, O2 etc. ◦ Neuromuscular functions
 excretion of waste products ◦ Regulate acid-base
 cellular communication ◦ Maintain body fluid and regulate
acid-base balance etc.
 food digestion
 etc.
◦ Regulates body temperature
◦ Joint lubricants
 REGULATION OF BODY FLUID AND
ELECTROLYTE DISTRIBUTION
Distribution of fluid and electrolyte
Intracellular (33-40% Body Weight)
 Extracellular (20-45% Body Weight) :
◦ Plasma (25%)
◦ Interstisial (75%)

• Osmoreceptor EXTRACELLUL
• Baroreceptor
Normal water intake ER
• Renin-angio-aldo
• ADH
• Autonomic nerv syst
Water of cellular
metabolism Intracellular Extracellular
compartment Compartment

Filtrated
Stool+ 10% Pulmonary+ 1/3
Skin + 2/3

Total insensible losses Total urine Differences in composition of intracellular and

+ 30% output
+ 60% extracellular fluids
Body Fluid Composition mEq per liter
Kation Plasma Intersisial Intraseluler
Na+ 142 145.1 12
K+ 4.3 1.4 150
Ca2+ 5 2.4 4
Mg2+ 3 1.5 34
Total 154 153 200

Anion
Cl- 104 117.4 4
HCO3- 24 27.1 12
P 2 2.3 40
Protein 14 0 54
Other 5.9 6.2 90
Total 149.9 153 200
 Pathways of water balance
Increased plasma osmolality Decreased plasma osmolality
or or
Decreased arterial circulating volume Increased arterial circulating volume

Increased Increased Decreased Decreased

thirst ADH release thirst ADH release

Increased Decreased Decreased Increased

Water intake Water excretion Water intake Water excretion

Water retention Water excretion

Decreased plasma osmolality Increased plasma osmolality

or or
Increased arterial circulating volume Decreased arterial circulating volume

Decreased ADH release and thirst Increased ADH release and thirst

Conservation Excretion 7
Body Fluid Distribution Related Age
Fluid Requirements

The computed line was derived from the following equations:

• 0-10 kg :100cal/kg
1 cal ~ 1 mL
• 10-20 kg : 1000 cal + 50 cal/kg for each kg
• over 10 kg 20kg and up :1500cal+20cal/kg for each kg over 20kg
Holliday MA, Segar WE. Pediatrics 1957
Factors that Influence Fluid requirement
Factors that decrease requirement : Factors that increase requirement :
Humidified gases x 0,75 Full activity and oral feeds x 1,5 / free fluids
Paralysed x 0,7 Fever + 12% peroC core temp is > 37oC
High ADH (e.g. IPPV or coma) x 0,7 Room temp over 31oC + 30% peroC
Hypothermia. - 12% peroC core temp is < 37oC Hyperventilation x 1,2
High ambient humidify x 0,7 Preterm neonate (< 1,5 kg) x 1,2
Renal failure x 0,3 (+ urine output) Radiant heater x 1,5
Phototherapy x 1,5
Burns day 1 + 4% per 1% of body surface area affected
Burns day 2+. + 2% per 1% of body surface area affected
Electrolyte requirements

◦ Sodium = 2 - 3 mEq/100 ml H2O/day.

◦ Potassium = 1 - 2 mEq/100 ml H2O/day.
◦ Chloride = 2 - 3 mEq/100 ml H2O/day.

Oliguric patients require less electrolyte replacement to maintain balance

Patients who lose excess electrolytes in large volumes of urine require very
high levels of electrolyte suplementation

Patients with unusual losses will require careful monitoring and adjustment
to their electrolyte replacement regimen
Equations for fluid and electrolyte ”maintenance” are based on a
series of ASSUMPTIONS, including :
• Average insensible losses
• Average energy expenditure and metabolism
• Average urinary losses
• No additional losses from other sites
• Normal renal function

Hospitalized patients frequently have abnormalities that go

counter to the above assumptions.

Fluid and electrolyte therapy must be adjusted based on the

clinical circumstances
 Estimating the fluid deficit
1. Check the weight
Rapid changes in weight likely represent changes in TBW
2. History
◦ Losses : - diarrhea, vomiting, bleeding, burns, drainage
- how much, how often
◦ Replacement : what fluids, how much, how successful
◦ Urine output
3. Physical exam findings
Mental status, pulse, HR, BP, mucous membranes, skin
turgor, skin color, periferal perfusion, capillary refill
4. Laboratory evaluation
Serum chemistries, hematocrit, urine studies
Rehydration and Resuscitation
Fluid
Intra
Intrasel Interstisiel Vaskuler

Rehydration:to replace the Dehydration Bleeding/

body fluid Combustio

Hypovolemia Resuscitation fluid: to

replace the effective
circulation volume 
koloid , kristaloid
Fluid Distribution Scheme in Intravascular
Dextrose 5%

RL, NaCl 0.9%, Asering, Ringer Asetate Malate

40% 15% 5%
Koloid:
-Blood - Gelatin
Intra -Plasma - Dextran
Intrasel Interstisiel Vaskuler -Plasma expander

24 9 3

+ 4 L Kristaloid + 4 L Koloid

+ 4 L Dekstrose

24 12 4 24 9 7

26,67 10 3,33
3. How should I continue iv fluids ?
Continue iv fluids in situations where oral rehydration will be difficult, consider :

~ Remaining deficit (water & electrolyte)

Volume : - check current weight & desired baseline
- consider volume given in resuscitation
Sodium : if hyponatremic, calculate the sodium deficit
Water : if hypernatremic, calculate free water deficit

~ Daily requirements for water & electrolytes

Adjust based on the clinical situation (e.g. fever, ventilator, etc)

~ Ongoing losses (volume & electrolyte composition)

Consider replacing these as needed

Provide therapy :
~ Add up water & electrolyte from deficits & daily requirements
 Mortalitas Renjatan/Gangguan Sirkulasi

Mortalitas renjatan
Mortalitas renjatan

Tanpa terapi adekuat

8% 38%

Terapi adekuat

0% 10% 20% 30% 40%

1 (Haraiani N dkk, 2012; Larsen GY, Mecham N, 2011 )

7
Komponen sistem sirkulasi dan target sistem
sirkulasi
Sistem Sirkulasi

Oksigen Nutrien

Sel

(Wheeler DS, Basu RK, 2013; Silverman AM, Godambe

S, Lloyd VJ, 2015; McKiernan CA, Lieberman SA,
1 2005; Arikan AA, Citak A, 2008)
8
Fisiologi Hemodinamik
DO2

CO CaO2

SV HR Hb SaO2

Preload Kontraktilitas Afterload

Preload
CO

SV HR

Preload Kontraktilitas Afterload

Preload adalah volume darah pada akhir fase diastolik

Hubungan preload dan stroke
volume

(Monnet X, Teboul J-L, 2013)

2
1
Tanda klinis
gangguan sirkulasi
Stadium Kompensata
◦ Takikardia

◦ Denyut nadi perifer lebih lemah dibandingkan nadi sentral

◦ Kulit pucat Mottled

◦ Akral dingin

◦ Pengisian kapiler >2 detik

◦ Tekanan nadi menyempit

◦ Penurunan kesadaran
Stadium Dekompensata
◦ Takikardia semakin nyata
◦ Takipneu
◦ Tekanan darah menurun (hipotensi)
◦ Oliguria/anuria
◦ Tingkat kesadaran semakin menurun
Stadium Irreversibel
◦ Nadi perifer tidak teraba
◦ Tekanan darah tidak terukur
◦ Gagal multiorgan
Target / Sasaran
terapi
Target / Sasaran Terapi
Secara Klinis
◦ Frekuensi denyut jantung/nadi menurun

◦ Kualitas nadi sentral dan perifer sama

◦ Akral hangat, pengisian kapiler <2 detik

◦ Diuresis >1 ml/kg/jam

◦ Kesadaran membaik

◦ Tekanan sistolik >P5

◦ Saturasi oksigen (SpO2) 92-100%

Target / Sasaran terapi
secara laboratorium
◦ Kadar laktat serum <2,0 mmol/L
◦ Saturasi vena sentral (vena cava superior) >70%
◦ Penurunan base deficit <3 (atau base excess >-3)
◦ Penurunan anion gap (AG) <16
◦ Kadar glukosa 80-150 g/dL
◦ Kadar kalsium ion >1,1 meq/L
Macam cairan
resusitasi
Cairan infus yang diberikan
menggantikan?

Dawet atau santan?

Plasma atau Eritrosit?

Kristaloid
Jenis cairan kristaloid terdiri dari:
• Kristaloid isotonis: NaCl 0,9%, Ringer Lactat, Ringer
Asetat, Ringer Asetat Malat
• Kristaloid Hipotonis: D5%, NaCl 0,45%, NaCl 0,33%, D5% +
NaCl 0,225%
• Kristaloid Hipertonis: NaCl 3%
Koloid
◦ Koloid alami : darah, albumin dan dextran
◦ Koloid sintetik berupa gelatin dan
Hidroxyethul starch
Memahami Fluid Replacement
36
(Carcillo JA, Han K, Lin J, Orr R, 2007)
Hyponatremia

◦ Define as : serum Na < 130 mEq/L

◦ Usually due to too much water for solute, rather than too little sodium
◦ Sodium deficit calculation :

[(normal Na (mEq/L)) – (measured Na (mEq/L)] x TBW (L)

Use 135 mEq/L as normal
◦ Need to determine the patient’s overall fluid status to help clarify cause of hyponatremia
Signs and symptoms of hyponatremi
Central Nervous System Gastrointestinal System
Mild Severe
- Anorexia
- Apathy - Stupor - Nausea
- Headache - Coma - Vomiting
- Lethargy - Pseudobulbar palsy
Musculoskeletal System
Moderate - Tentorial herniation - Cramps
- Agitation - Cheyne-Stokes respiration - Diminished deep tendon reflexes
- Ataxia - Death
- Confusion
- Disorientation

- Psychosis
 Treatment of Symptomatic hyponatremia
◦ Acute hyponatremia (duration < 48 hrs)
Hypertonic saline < 3 mEq/L/h ~ 5 mEq/L or symptoms resolve 
further correction more slowly
Coadministration of furosemide
Full correction probably safe but not necessary

◦ Chronic hyponatremia (duration > 48 hrs)

Hypertonic saline < 1.5 mEq/L/h ~ 5 mEq/L or symptoms resolve
 rate may be reduced and change to water restriction (total < 15
mEq/d)
Coadministration of furosemide
Frequent measurement of serum and urine electrolytes
◦ The sum of urinary cations (UNa + UK) should be < infused [Na],
◦ to ensure excretion of electrolyte-free water
Hypernatremia
Define as : serum Na > 150 mEq/L
◦ Neurological effects usually seen with Na > 160 mEq/L
◦ Usually due to a relative deficiency of water for normal extracellular solut
◦ Free water deficit calculation :

measured Na (mEq/L)
x TBW (L) - TBW (L)
desired Na (mEq/L)
Use 145 mEq/L as desired Na
◦ Need to determine the patient’s overall fluid status to help clarify cause of
hypernatremia
Signs and symptoms of hypernatremi
Central Nervous System Respiratory system
- Labored respiration
◦ Mild
- Restlessness Gastrointestinal System
- Lethargy - Intense thirst
- Altered mental status
- Irritability - Nausea
- Vomiting
◦ Moderate
- Disorientation Musculoskeletal System
- Confusion - Muscle twitching
- Spasticity
◦ Severe - Hyperreflexia
- Stupor
- Coma
- Seizures
- Death
Treatment of Symptomatic
hypernatremia
◦ Plasma osmolality should not be decreased > 2 mOsm/h (serum Na  <10-15
mEq/L/d)
◦ Sodium levels > 165 for > 48 hrs, correction rate < 1 mOsm/h
◦ Replace half of the water defisit over the first 12-24 hr
◦ Replace the remaining defisit over the next 24-36 hrs
◦ Serial neurologic examinations (prescribed rate of correction can be decreased
as symptoms improve)
◦ Frequent measurement of serum and urine electrolytes
Hypokalemia
◦ Serum K+<3.5 mEq/L Etiology
◦ Shift: metabolic alkalosis, insulin (DKA treatment)
◦ Loss: vomiting, diarrhea, diuretics, sweat, aldosteronism, decreased intake
Pathophysiology:
◦ K+ shift into cells as ECF pH rises →↑0.1 causes ↓serum K+ 0.5 mEq/L
◦ ↑Aldosterone →Na+ & HCO3- retention in exchange for K+
Symptoms : muscle weakness and fatigue, confusion, arrhythmia, ileus paralytic,
ECG change (ST depression)
Treatment Hypokalemia
◦ Oral or IV supplementation  urgency of symptoms
◦ Oral :
◦ Asymptomatic hypokalemia (no ECG changes) or mild hypokalemia
◦ Ability to tolerate
◦ Increase diet intake
◦ 1-3 mEq/kg/day in three or four divided doses
◦ Safest
A conservative protocol for IV replacement :
3.0-3.5 mEq/L  0,25 mEq/kg of IV KCl over 1 hour
2.5-3.0 mEq/L  0.5 mEq/kg of IV KCl over 2 hours
less than 2.5 mEq/L  0.75 mEq/kg of IV KCl over 3 hours.
A potassium level should be checked halfway through this infusion.
====>>>> SYMPTOMATIC HYPOKALEMIA
Hyperkalemia
◦ Serum K+>5.5 mEq/L Etiology
◦ Decreased excretion: renal failure, aldosterone deficiency
K+ load: hemolysis, excessive tissue breakdown, K+ supplements
◦ Shifts: acidosis, insulin deficiency, β-blokade
◦ Symptoms : muscle cramps, muscle twist, paraesthesia, irritability, ECG change
(tall-T), dysrhythmia (Ventricular Fibrilation), cardiac arrest
 Treatment of Hyperkalemia
Administer one or more of the drug therapies :
1. Calcium gluconate, 100 mg/kg over 3 min (1mL/kg of 10% solution) IV
2. Sodium bicarbonate, 1-2 mEq/kg given IV over 10-15 min
3. Insulin, 0.1 U/kg/hr, mixed with Dextrose solution 0.5 g/kg/hr
4. An exchange resin, such as sodium polystyrene resin (Kayexalate)
Summary
◦ Water, sodium and potassium are strongly regulated by the kidney, renin-
angiotensin- aldosterone and ADH systems
◦ Understanding water and electrolytes homeostasis is important for diagnosis and
management of water and electrolytes imbalance
◦ Fluid and electrolyte therapy must be adjusted based on the clinical
circumstances
Thank