Advanced Neuro Critical Care Support ANCCS KESEIMBANGAN CAIRAN DAN ELEKTROLIT Advanced Neuro Critical Care Support ANCCS Electrical Neutrality Mg++ Ca++ Na+ lactate K+ H+ alb- PO4- CO2 SO4- -, OH -, others Cl- Advanced Neuro Critical Care Support ANCCS PENDAHULUAN • Elektrolit darah, jaringan, sel tubuh. konsentrasi dalam cairan tubuh bervariasi Kation utama : Na+, K+ Anion utama : Cl multifungsi Na+ mengendalikan volume cairan tubuh total K+, mengendalikan volume sel • Hukum Netralitas listrik : jumlah muatan-muatan negatip harus sama dengan jumlah muatan-muatan positip dalam setiap bagian. • Gangguan elektrolit yang sering mengancam nyawa : gangguan Na+, K+, Ca2+, Mg2+, PO42- Advanced Neuro Critical Care Support ANCCS Percentage of total body weight 100 50 0 Newborn infant (75%80%) Adult (60%) Adult over age 65 (45%-50%) Advanced Neuro Critical Care Support ANCCS o Bayi memiliki lemak tubuh rendah, massa tulang yang rendah dan lebih banyak air o Jumlah konten air menurun sepanjang hidup o Laki-laki normal sekitar 60% air; wanita normal sekitar 50% Perbedaan ini mencerminkan perempuan : Tinggi lemak tubuh Lebih kecil otot rangka o Pada usia tua, hanya sekitar 45% dari berat badan adalah air Advanced Neuro Critical Care Support ANCCS Fluid Compartments Terdapat dua kompartemen cairan utama Cairan intraseluler (ICF) - sekitar dua pertiga volume, yang terkandung dalam sel Cairan ekstraseluler (ECF) - terdiri dari dua subdivisi utama Plasma (IV) - bagian cairan dari darah Interstitial cairan (IF) -cairan di ruang antar sel Lain ECF - getah bening, cairan serebrospinal, humor mata, cairan sinovial, cairan serosa, dan sekresi gastrointestinal Advanced Neuro Critical Care Support ANCCS Body Compartements and water distribution endothel Cell Membrane ICF water I Na N Na-K T ATP ase R K A V water A water S water C U L A R 40% TBW ICF ICF ISF ECF ECF = ISF+IV TBW = 60% X BW (M) 50% X BW (F) ICF : 2/3 TBW ECF: 1/3 TBW ISF:2/3 ECF IV:1/3 ECF Advanced Neuro Critical Care Support ANCCS Electrolyte Composition of Body Fluid Compartments Advanced Neuro Critical Care Support ANCCS Setiap kompartemen cairan tubuh memiliki pola khas dari elektrolit Cairan intraseluler (rendah sodium dan klorida) Kalium adalah kation utama Fosfat adalah anion utama Cairan ekstraseluler mirip (kecuali plasma kandungan protein tinggi) Natrium adalah kation utama Klorida adalah anion utama Advanced Neuro Critical Care Support ANCCS KOMPOSISI ELEKTROLIT EKSTRASEL DAN INTRASEL Advanced Neuro Critical Care Support ANCCS Keseimbangan Air OSMOLARITAS • Ditentukan oleh jumlah partikel di dalam larutan • Normal (300 ± 10 mOsm/liter). • Rumus perkiraan Osmolaritas: 2(Na+K) + GD/18 + BUN/2,8 atau 2(Na+K) + GD/18 + Ureum/6,4 Advanced Neuro Critical Care Support ANCCS Hormone – Keseimbangan cairan dan elektrolit • ADH • Aldosterone • Atrial Natriuretic Peptide Penting !!!! Non hormonal: aktivasi simpatis Advanced Neuro Critical Care Support ANCCS Pathways of water balance (conservation) Increased plasma osmolality or decreased arterial circulating volume Increased thirst Increased ADH release Increased water intake Decreased water excretion Water retention Decreased plasma osmolality or increased arterial circulating volume A Decreased ADH release and thirst Advanced Neuro Critical Care Support ANCCS Pathways of water balance (excretion ) Decreased plasma osmolality or increased arterial circulating blood volume Decreased thirst Decreased ADH release Decreased water intake Increased water excretion Water excretion Increased plasma osmolality and decreased arterial circulating volume B Increased ADH release and thirst Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS Influence and Regulation of ADH Air reabsorpsi di saluran pengumpul sebanding dengan pelepasan ADH Kadar ADH rendah menghasilkan urin encer dan banyak akibatnya volume cairan tubuh berkurang Kadar ADH tinggi menghasilkan urin terkonsentrasi Osmoreseptor hipotalamus memicu atau menghambat ADH pelepasan Advanced Neuro Critical Care Support ANCCS Mechanisms and Consequences of ADH Release Advanced Neuro Critical Care Support ANCCS Osmoreceptors stimulated ADH release thirst HOMEOSTASIS DISTURBED [Na] in ECF HOMEOSTASIS [Na] in ECF normal Homeostasis restored Homeostasis restored HOMEOSTASIS DISTURBED [Na] in ECF Osmoreceptors inhibited ADH release thirst Urinary water loss water gain Additional water dilutes ECF, volume Water loss Concentrates ECF volume Urinary water loss Water gain The Homeostatic Regulation of normal [Na] in Body Fluids Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS Cardiovascular System Baroreceptors Baroreseptor memberitahu otak peningkatan volume darah (tekanan darah meningkat) impuls sistem saraf simpatik ke ginjal menurun Melebarkan arteriol aferen Laju filtrasi glomerulus meningkat output Natrium dan air meningkat Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS Atrial Natriuretic Peptide (ANP) Dilepaskan dari atrium jantung sebagai respon terhadap peregangan (tekanan darah tinggi) Mengurangi tekanan darah dan volume darah dengan : • menghambat vasokonstriksi • menghambat retensi air dan Na •memiliki efek diuretik kuat dan natriuretik •meningkatkan ekskresi natrium dan air •menghambat produksi angiotensin II Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS Mechanisms and Consequences of ANP Release The Integration of Fluid Volume Regulation and [Na] in Body Fluid Blood volume and atrial distension ANP release ADH release HOMEOSTASIS DISTURBED ECF volume thirst Water loss (by fluid or Fluid and salt gain) HOMEOSTASIS RESTORED HOMEOSTASIS Normal ECF volume HOMEOSTASIS DISTURBED ECF volume Na loss HOMEOSTASIS RESTORED thirst Water loss (by fluid or fluid and salt loss) Blood volume and blood pressure Aldosteron release Na retention Renin secretion angiotensin II activation Aldosterone release ADH release Advanced Neuro Critical Care Support ANCCS Regulation of Water Intake: Thirst Mechanism Maintenance of Blood Pressure Homeostasis Advanced Neuro Critical Care Support ANCCS Pathogenesis of dysnatremias Plasma osmolality 300 mOsm/kg H2O Decrease Suppression of thirst Suppression of ADH release Increased Stimulation of thirst Stimulation of ADH release Dilute urine Concentrated urine Disorder involving urine dilution with H2O intake Disorder involving urine concentration with inadequate H2O intake Hyponatremia Hypernatremia Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS TERMINOLOGI % : g/dl D5% : 5 g / 100 ml = 50 gr/L Mmol : mg/Berat molekul, berat atom NaCl 0,9% 9g = 9000 mg Na 154 Mmol, Cl 154 Mmol Meq : Mmol x valensi 1,75 Ca ( valensi2) = 3,5 Meq M osm : Jumlah Mmol dalam zat terlarut (liter) mEq/L = mg% X 10 X k Berat molekul Advanced Neuro Critical Care Support ANCCS • mEq/L = mg% X 10 X k Berat molekul • NaCl 3% = 3000 X 10 X 1 = 517 mEq/L 58 • NaCl 0,9% = 900 X 10 X 1 = 155 mEq/L 58 Advanced Neuro Critical Care Support ANCCS Total ECF Na ECFV ECFV overload signs of edematous state Total ECF Na ECFV ECFV depletion signs of “dehydration” ECFV : defisit air dan Na, tetapi kehilangan Na > air ECFV : kelebihan air dan Na, tetapi jumlah air daripada total body Na ECFV normal : TBW tanpa perubahan pada total body Na Advanced Neuro Critical Care Support ANCCS [Na] serum tidak memberitahu tentang jumlah total Na di kompartemen ECF atau ukuran ECFV. [Na] serum hanya memberitahu tentang jumlah relatif natrium terhadap jumlah air. ANLS OKTOBER 2009 Advanced Neuro Critical Care Support ANCCS Hypernatremia Gangguan keseimbangan air mempengaruhi kadar Na,yaitu dapat menyebabkan hipernatremi atau hiponatremi Hipernatremi adalah kenaikan kadar Natrium di dalam darah > 145 mmol/L Advanced Neuro Critical Care Support ANCCS [Na +]> 145mEq / L Serum osmolalitas> 300 mOsm / kg (selalu dikaitkan dengan hipertonisitas) defisit air Tanda dan gejala: tidak spesifik; perubahan status mental, gangguan pemikiran, koma, kejang. Seringkali iatrogenik pada pasien rawat inap Beberapa komplikasi yang serius (edema serebral) hasil dari pengobatan Advanced Neuro Critical Care Support ANCCS penyebab Hipernatremia • Net water loss: Pure water • Net water loss: Hypotonic fluid – Renal: diuretics, osmotic diuresis, postobstructuve diuresis – Insensible loss, GI losses, burns, excessive sweating – Acquired diabetes insipidus (neurogenic, renal, hypercalcemia, drugs – lithium, amphotericin B) Advanced Neuro Critical Care Support ANCCS • Hipertonik sodium gain – iatrogenik – – – – Sodium bicarbonate Hipertonik feeding Sodium chloride rich emetics or enemas Hipertonik dialysis • Ingestions – Sodium chloride • Other – Primary hyperaldosteronism – Cushing’s Disease Advanced Neuro Critical Care Support ANCCS Hypernatraemia([Na]>145mEq/L) Assess ECF volume Hypovolaemia Euvolaemia Hypervolaemia Renal losses Renal losses Iatrogenic Diuretics Osmotic diuresis Diab.Insipidus Diab.Inspidus Hypertonic saline or Na-bic, admintr. Cushing syndr. Hyperaldosteronism Extrarenal losses Vomiting, diarrhea Skin,Respiratory Extrarenal losses vomiting, diarrhea , sweating, respiratory Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS Efek hipernatremi pada otak dan respon adaptasi Advanced Neuro Critical Care Support ANCCS Penatalaksanaan • Pengobatan hipernatremia membutuhkan 2 pendekatan, yaitu : - Mengatasi penyakit yang mendasari, mis. : menghentikan kehilangan cairan dari gastro intestinal, menghentikan pemberian laktulosa dan diuretik, mengatasi hiperkalsemia dan hipokalemi - Koreksi hipertonisitas Advanced Neuro Critical Care Support ANCCS Terapi hipernatraemia • Low ECFV : Isotonik saline, dilanjutkan cairan hipotonik fluids IV (<300ml/h) atau air per oral • High ECFV: loop diuretics, ganti dengan cairan hipotonik jika perlu koreksi Na < 0.5mEq/L/j (kronik) <1.0 mMeq/L/j (akut) • Terapi penyebab Diabetes Inspidus: Desmopressin Advanced Neuro Critical Care Support ANCCS Rumus: 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]) ANLS OKTOBER 2009 Advanced Neuro Critical Care Support ANCCS Rumus pemberian cairan untuk mengatasi hipernatremi ANLS OKTOBER 2009 Manajemen pilihan untuk pasien dengan hipernatremia Hypovolemic hipernatremia Euvolemic hipernatremia Koreksi defisit volume Koreksi defisit air Berikan salin isotonik sampai hipovolemia teratasi Mengobati penyebab kehilangan cairan (insulin, menghilangkan obstruksi saluran kemih, diuretik osmotik Hitung defisit air Berikan salin 0,45%, 5% dekstrosa atau air per oral untuk menggantikan defisit dan kehilangan yang sedang berlangsung Pada diabetes insipidus sentral yang berat vasopresin (pitressin) 5 U SC q 6 jam Pantau konsentrasi natrium serum hati-hati untuk menghindari air keracunan ) Koreksi defisit air Hitung defisit air Berikan salin 0,45%, 5% dekstrosa atau air per oral yang mengganti defisit dan kehilangan yang sedang berlangsung Terapi jangka panjang Diabetes Insipidus Sentral Diabetes Insipidus Nephrogenic Konsentrasi plasma kalium dan kalsium Hapus obat memepengaruhi Diet Rendah sodium thiazide diuretik Amiloride (untuk lithium-induced diabetes insipidus nefrogenik Hypervolemic hipernatremia Penghilangan natrium Hentikan zat penyebab Berikan furosemide hemodialisis Advanced Neuro Critical Care Support ANCCS Advanced Neuro Critical Care Support ANCCS Hiponatraemia (Na+ < 130 mEq/L) • Pseudohiponatraemia Plasma osmolality normal (hiperlipidemia, hiperproteinemia) Plasma osmolality meningkat (hiperglikemia, mannitol, glycerol, glycine) • Hipotonik / True hiponatraemia Advanced Neuro Critical Care Support ANCCS Hyponatraemia (Na < 135 mEq/L) nilai plasma osmolality normal atau meningkat Pseudohiponatraemia hipovolaemia non-renal losses diarrhea, vomiting skin losses third spacing renal losses diuretics, renal failure menurun ECF volume euvolaemia SIADH hypothyroidism adrenal insufficiency psychogenic polydipsia hipervolaemia Oedema states CCF renal failure nephrosis cirrhosis Advanced Neuro Critical Care Support ANCCS Pathogenesis of CNS symptoms Advanced Neuro Critical Care Support ANCCS Hyponatremia flow chart Advanced Neuro Critical Care Support ANCCS SIADH v.s. Cerebral Salt Wasting SIADH CSW Serum Na ↓ ↓ ECFv Normal ↓ UNa ↑ ↑↑ UOSM ↑ ↑ Urine volume N or ↓ ↑ Serum urate ↓ N or ↓ Urine urate ↑ N or ↑ Advanced Neuro Critical Care Support ANCCS Terapi hiponatraemia • Low ECF asymptomatik symptomatik : koreksi dengan isotonik saline : koreksi dengan hipertonik saline • Normal ECF asymptomatik symptomatik : furosemide + isotonik saline : furosemide + hipertonik saline • High ECF asymptomatik symptomatik : furosemide diuresis : furosemide diuresis + hipertonik saline Advanced Neuro Critical Care Support ANCCS Koreksi hiponatremia, euvolemik Hitung water excess BB X TBW X (1 - Na+) 125 Hitung waktu koreksi Selisih Na+ Kecepatan koreksi = 125 – [Na+] = 0,5 mEq L perjam Berikan Furosemide IV untuk menaikkan output urine (dewasa 40 mg IV, anak 1 mg/kg IV) Monitor output urine, kadar Na urine dan plasma tiap jam. Ganti kehilangan Na+ lewat urine (volume urine X kadar Na+urine) dengan NaCl 3% Urine output/jam selanjutnya harus ditambahkan dengan volume NaCl yang diberikan untuk menggantikan Na+. Bila urine out put berlebih dari target berikan D5W Bila urine output sangat kurang tambahkan furosemide. Advanced Neuro Critical Care Support ANCCS Rx Hyponatremia • Na deficit = TBW(kg) x (desired [Na] - actual [Na])(mmol) • Kapan koreksi cepat? – Acute (<24h) severe (< 120 mEq/L) Hyponatremia • Mencegah odem otak atau memperbaiki odem otak – Symptomatic Hyponatremia (Seizures, coma, etc.) • Terapi symptoms • “CEPAT”: 3% NS, 1-2 mEq/L/h sampai: • Symptoms membaik • Selama 3-4 jam atau Na serum mencapai 120 mEq/L • Koreksi lambat • 0.5 mEq/L/h with 0.9% NS , restriksi cairan dalam 24 jam koreksi < 10-12 mEq/L/d mencegah myelinolysis Advanced Neuro Critical Care Support ANCCS Severe hyponatremia Advanced Neuro Critical Care Support ANCCS Central Pontine Myelinolysis • Dalam jam sampai hari setelah koreksi • Berhubungan dengan koreksi cepat > 12 meq/24 jam • Tremor, incontinence, hyperreflexia, dysarthria, dysphagia, quadriparesis, quadriplegia, mutism/locked-in syndrome Advanced Neuro Critical Care Support ANCCS Hiperkalemia Pseudohiperkalemia: hemolysis, leucocytosis(>50.000), thrombocytosis (>1000000/ml) Gangguan ekskresi renal: renal failure, drugs (ACE inhib, K sparing diuretics, NSAIDs) Intake >>: K supplements, massive transfusion Perpindahan Transcellular : acidosis, b-blockers, insulin deficiency, succinylicholine, rhabdomyolysis Advanced Neuro Critical Care Support ANCCS Clinical approach Hyperkalemia Hyperkalaemia 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 Advanced Neuro Critical Care Support ANCCS Hiperkalemia Jantung tall peak T waves, prolonged PR interval, loss of P waves, widened QRS, VT, VF, cardiac arrest. Neuromuscular weakness, areflexia, paralysis, paraesthesia Advanced Neuro Critical Care Support ANCCS HYPERKALEMIA ECG karakteristik • Peaking T •Shortening QT interval • Rhythm : atrial & ventricular rhythm regular • Rate : normal • P wave : low amplitude (mild), wide & flattened p wave (moderate), posible indiscernible (severe) • PR interval : normal or prolonged • QRS complex: widened • Segmen ST : may be elevated (severe) • T wave : tall T • QT interval : shortened Advanced Neuro Critical Care Support ANCCS Hyperkalemia Tall T Shortening QT interval Prolonged PR interval Wide QRS complex Advanced Neuro Critical Care Support ANCCS PenangananHiperkalemia 1.Direct membrane antagonism (cardiac toxicity) : IV Ca-gluconas, CaCl2 10% 10 ml 2.Transcellular shift o: IV dextrose 40% 50ml + IV 10 unit Insulin 3.Enhanced clearance from body - diuretik: IV furosemide - haemodialysis/CRRT - ion exchange resins Advanced Neuro Critical Care Support ANCCS Hipokalemia • Transcellular shifts: insulin, glucose, beta-agonist, alkalosis • Renal K saving ( urine K<30mEq/L) G-I losses: diarrhea, nasogastric • Renal K wasting ( urine K >30mEq/L) diuretics, Mg depletion, dehydration, Mineralocorticoid excess, Alkalosis, Amphotericin-B Advanced Neuro Critical Care Support ANCCS Flat T wave U wave appearance HIPOKALEMIA Rhythm : atrial & ventricular rhythm regular Rate : normal limit P wave : normal size and configuration, tall P (severe hypokalemia) PR interval : may be prolonged QRS complex : normal or possibly widened (prolonged in severe hypocalemia) ST segment : depressed T wave : decreased amplitude, flat or inverted, fusion T wave with prominent U wave (severe) QT interval : indiscernible as the T wave flattens U wave : prominent U wave, fusion with T wave Advanced Neuro Critical Care Support ANCCS Hipokalaemia Hypokalaemia urine K+ Transcellular shifts Insulin administr. Glucosa administr. Alkalosis -agonist renal-K+ saving (Urine-K<30mEq/L/d) renal-K+ wasting (Urine-K>30mEq/L/d) GI losses diarrhea nasogastric Renal losses Diuretics Mg depletion Dehydration Mineralocorticoid excess Alkalosis Amphotericin-B Advanced Neuro Critical Care Support ANCCS Hipokalemia Jantung flattened or inverted T Waves, U waves, Arrhytmia Neuromuscular muscle weakness, ileus, paralysis Ginjal Nephrogenic Diabetes Insipidus. TREATMENT: koreksi 10-30 mEq/j dalam 100-200 NS/D5% ( central vein) Advanced Neuro Critical Care Support ANCCS ANLS OKTOBER 2009 Advanced Neuro Critical Care Support ANCCS NEXT LECTURE 68