This document discusses fluid therapy concepts including: - Common terms used in fluid therapy like %, mmol, mEq, and mOsm. - Guidelines for fluid resuscitation in conditions like dehydration, hypovolemia, and hemorrhagic shock. - Types of intravenous fluids including isotonic, hypotonic, colloids, and their effects on fluid compartments. - Factors to consider in choosing maintenance versus replacement fluids.

1. dr Iyan Darmawan

2. 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

3.  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

4.  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 o
C 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 ?

6.  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 o
C 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 ?

7. Syok/Gangguan
Hemodinamik ?
Ada Gangguan
Elektrolit ?
Metabolik/
Nutrisi?
Komorbiditas/insufisi
ensi, gagal organ?

8. Shock grades

9.  MAP
 Pulse Pressure
 Tachycardia
 Capilary refill time
 Peripheral Vasoconstriction
 Oxygen saturation

10.  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

12. .
.
RESUSCITATION REPAIR MAINTENANCE PN
CORRECT
NUTRITION ST
PERFUSION &
OXYGENATION
HOMEOSTASIS/
SUPPORTIVE
CORRECT
ELECT & AB
PARENTERAL FLUID THERAPY

13. Plasma Osmolarity
• 2 x [Na+
] + Glu (mg/dl) + BUN (mg/dl)
18 2.8
• Range 280-290 mOsm/L
• > 296 mOsml/L  dehydration

14. Replacement vs Maintenance fluid
PlasmaPlasma ReplacementReplacement MaintenanceMaintenance
Normal
saline
AR/ LR Typical
maintenance
290 308 273
NaCl 0.45%-D5
290
154
+
278
140
+
150
432
ISOTONIC HYPOTONIC

15. 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)

16. 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

17. Replace acute/
abnormal
loss
Isotonic infusion
800 ml 200 ml
• ASERING
• Lactated Ringer’s
• Normal saline
1 L of
increases ECF
ICF ISF Plasma

18. increases ICF > ECF
ICF ISF Plasma
Replace Normal
loss (IWL + urine)
Hypotonic infusion
5% dextrose/ Maintenance sol
85 ml255 ml660 ml
1 L of

19. increases intravascular
ICF ISF Plasma
Hemorrhagic shock
Burn
Reserved for patients
in whom ISF expanded
but intravascular and
albumin is severely
depleted
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

20. increases intravascular
ICF ISF Plasma
Hemorrhagic shock
DSS
Loading 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

21. Fluid kinetics may be modified in
conditions with increased permeability
Even albumin leaks into the interstitial space in sepsis.

22. U
U U
U U U
20%3.5%U U
- + + - + + -
Transvascular Exchange and Organ Perfusion
6% Dextran 70 HES Gelatin Albumin Mannitol Urea Hypertonic
sa
Fluid permeability
Albumin permeability
Muscle volume
Rebound filtration
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

23. 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

24. HCF
Free Radicals
(NO + O2* =
Peroxynitrite)
TNF-α
IL-8
IL-1
IFN-γ
IL-2
TNF-β
IL-4
IL-5
IL-6
IL-10
IL-13
Cell apoptosis
(Mast cells,
Basophil, etc)
Histamine Increased
Vascular
Permeability
DF
DHF
VEGF-A
1) Chaturvedi UC, et al . Cytokine cascade in dengue hemorrhagic fever: implications
for pathogenesis FEMS Immunology and Medical Microbiology 28(2000) 183-188
2) JOURNAL OF VIROLOGY, Feb. 2007, p. 1592–1600
CD4+ T Cells
Th1 Th2
Macrophage
Pro-
infllamm
atoric
Anti-
infllamat
oric

25. 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

26. 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 increasesof lung capillary permeability
• antiinflammatory effect of HES, including
inhibition of NF-κBactivation
Anesth Analg 2004;98:768-774

27. Which product and correct timing ?

28. www. moh.gov.my : Management of Dengue Infection in Adults.2 edition 2008.
DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL. New Edition 2009
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 sec
Narrowing pulse pressure
Tachycardia
Tachypnoea
Cold extremities
Maintenance ONLY ISOTONIC INFUSION

29. * Ganong WF. Cardiovascular homeostasis in health and disease. In: Review of
*
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 patient
Capillary refill time↑ ( >2 sec)
Cool extremities
Weak peripheral pulses
Tachycardia
Normal syst pressure , raised
diastolic; postural hypotension
Narrowing 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 shock
Narrowed 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

32. Complete Main-
tenance solution
Aminofluid®
RL,RA,
Normal Saline
KAEN 3B, NaCl 0.45%/D5
Colloid
Dehydration Hypovolemia/Shock

33. Na+
77
Larutan Rumatan
Generasi 1 Generasi 2 Generasi 3
KAEN 3B
AMINOFLUID

34. 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

35. FATIGUE
An underestimated and undertreated symptom (1)
1. Michael Sharpe BMJ 2002;325:480-483
2. 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)

36. 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

37. 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

38. Administration of Amino Acids andAdministration of Amino Acids and
GlucoseGlucose
Amino acidsAmino 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

39. When the gut works, use it!
When it doesn’t work, use

40.  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 o
C 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 ?

41.  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 o
C 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 ?

42. 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

43. Terima Kasih