terapi cairan perioperatif

Perioperatif Fluid Management

dr. Isngadi, M.Kes., SpAn

Dept. Anesthesiology

dr. Saiful Anwar Hospital / Brawijaya University, School of Medicine

Malang

Fisiologi Cairan Tubuh

 

         ICF                ISF                 IVF

          40 %             15%                 5%

            Total Cairan tubuh : 60% BB

Tujuan Penatalaksanaan Cairan Perioperatif

Mempertahankan volume intravascular

Menjaga Transport Oksigen

Memenuhi Kebutuhan Basal Cairan

indikasi terapi cairan

Tidak dapat minum cukup pengganti urine, keringat, nafas

Koreksi ketidak-seimbangan cairan (jumlah & komposisi)

Koreksi kehilangan abnormal

Perlu nutrisi intravena (usus tidak berfungsi)

Cairan Maintenance

Cairan Replacement

Cairan Nutrisi

Bilamana pasien perlu mendapat infus ?

Tidak dapat minum cukup cairan pengganti kehilangan

Perlu koreksi ketidak-seimbangan cairan  (jumlah dan komposisi elektrolit)

Perlu nutrisi intravena karena usus tidak berfungsi

Perlu jalan masuk vena untuk obat   (keep vein open)_

Cairan Maintenance

Mengganti kehilangan cairan rutin           (turn over ECF)

keluar urine (25 ml/kg/hari)                       

keringat + uap air nafas (700 ml/m2/hari)

Pasien 50 kg = 1.5m2 mengeluarkan cairan         (50 kg x 25 ml) + (1.5 x 700 ml) = 2250 ml

Jumlah ini harus diganti agar               keseimbangan cairan terjaga baik

Kebutuhan sehari
Volume  :  2000 ml (40 - 50 cc/kg)
 Natrium : 100-200 mEq (2-4 mEq/kg)
Kalium   :   50-150 mEq ( 1-3 mEq/kg)
Kalori     :   1500 kcal  ( 25-30 kcal/kg)

RD 1000 + D5 1000 ml Natrium   147       Kalium         4         Kalori       400

KaEnMg 2000 ml Natrium    100 Kalium       40 Kalori       800

Pedoman terapi cairan
cairan keluar = cairan masuk

Cairan Intravena

Terapi cairan intravena terdiri dari infus kristaloid, koloid, atau kombinasi keduanya.

1.Cairan kristaloid :

  Merupakan cairan encer yg   terdiri dari ion-ion (garam) dg BM rendah, dg atau tanpa glukosa. Cairan ini cepat setimbang dan didistribusi seluruhnya ke ruang cairan ekstrasel.

2. Cairan koloid terdiri dari substansi dg BM tinggi spt protein atau polimer glukosa besar, yang berfungsi menjaga tekanan onkotik koloid plasma dan sebagian besar tetap berada intravaskuler

Cairan Kristaloid

Pemilihan cairan berdasarkan jenis kehilangan cairan.

üKehilangan air diganti dg cairan hipotonik (cairan maintenance-type)

üKehilangan air disertai defisit elektrolit diganti dg cairan elektrolit isotonik (cairan replacement-type)

üKehilangan cairan intra operasi kebanyakan adl isotonik, umumnya digunakan cairan replacement-type, umumnya digunakan Ringer Laktat 

•Waktu paruh intravaskuler : 20-30 menit

...con’t cairan kristaloid

Ringer Laktat

  hipotonik ringan, td. 100mL H2O dan Na 130 meq/L, plg fisiologis u/penggantian ciran dlm jml besar.

Normal salin

  cairan pilihan u/asidosis metabolik hiperkloremik dan u/mencairkan packed RBC sebelum transfusi

D5W

  u/mengganti defisit air murni dan sbg cairan maintenance bagi pasien dg pembatasan natrium

Cairan Koloid

Waktu paruh intravaskuler : 3-6 jam

Indikasi penggunaan koloid :

1.Resusitasi cairan pd pasien dg defisit cairan intravaskuler berat (contohnya syok hemoragik) sblm tersedia darah u/transfusi

2.Resusitasi cairan pd pasien yg mengalami hipoalbuminemia berat

3.Digunakan setelah resusitasi dg kristaloid saat EBL >20%, sebelum transfusi.   

FAKTOR-FAKTOR YANG DIEPERHATIKAN  DALAM PEMBERIAN TERAPI CAIRAN

Perbandingan komposisi
pada berbagai cairan infus

Seorang Dewasa BB 60 kg akan dilaksanakan operasi herniotomy. Pasien puasa 8 jam prabedah, lama operasi lebih kurang 1 Jam.

Berapa volume cairan yang diperlukan ?

Apa cairan yang dipilih ??

Jenis-Jenis larutan elektrolit
berdasarkan tonisitasnya

pengukuran dan monitoring tekanan intra kranial

MEASUREMENT AND MONITORING
PRESSURE INTRA cranial


Sectional HEAD
§ Intra Cranial Pressure
• ICT is the pressure caused by the addition of volume within the cranium

• The contents of the cranium are:

               86% of brain tissue,

               CSF of 10%

               4% of blood

In other words

 Total blood volume = Volume + Volume + Volume of brain CSF

• Hypothesis Monro kelly:
If there is an addition to the other component parts of the brain will adjust so that the brain volume remains constant.
• If the compensation limit exceeded slight increase in volume will result in an increase in ICT

In other words
Total blood volume = Volume + SCF + Volume Volume Volume + brain tumor

• The normal value of ICT is 1-15 mmHg


§ ICP NORMAL VALUE
Newborn § 0.7 to 1.5 mmHg
Infant § 1.5 to 6 mm Hg
§ Children 3 to 7.5 mmHg
§ Adult 1-15 mm Hg
§ Relationship Between Compliance and ICT
§ meninges (membranes surrounding the brain)

  A layer of the meninges (connective tissue) that covers the brain and spinal marrow.

   ☺ Piamater

   ☺ arachnoid

   ☺ dural
§
§ Brain blood flow (CBF)
§ The brain receives ± 15% of cardiac output

    ± 800 ml of blood flow to the brain

  CBF ± 50 cc / 100gr brain / min.

§ The brain blood flow and function to bring 02 glucose for energy.

CBF is governed by:
§ cerebral autoregulation.

      A. Stress / pressure

      2. Chemistry (PCO2 and PO2)
§
§ Maintained normal CBF at MAP 50-150 mmHg.
§
§ MAP <50 mmHg → cerebral ischemia, cerebral infarction
§
§ MAP> 150 mmHg

    → Damage to the defense of the brain, brain hemorrhage, brain edema
§
§
Pressure autoregulation.
§ pressure autoregulation serves to maintain blood flow to the brain and the CPP in the range of certain MAP
§ The ability of the brain to maintain CBF at MAP between 50-150 mmHg, this process because of the contraction of smooth muscle walls of blood vessels of the brain in response to pressure changes.
§ If MAP <50 mmHg cerebral ischemia occur
§ If MAP> 150 mmHg kontriksi power damage blood vessels and CBF will rise suddenly, there is damage to the blood brain barrier and cerebral edema occurs and bleeding of the brain
§ In certain circumstances this autoregulation is lost in the event of pathological conditions such as head trauma, trepanation, bleeding, chronic hypertension, cerebral ischemia, cerebral infarct, edema surrounding brain tumors
§ In the conditions of loss of autoregulation in case of hypertension will increase CBF and hypotension will occur ischemia.kedua this resulted in an increase in ICT
§
§

§ CBF ↔ PaCO2
§ CBF change at any time in the event of changes in PaCO2
§ CBF doubled in PaCO2 80 mmHg. means when the PaCO2 rises will occur vasodilatation
§ Decreased CBF when PaCO2 20 mmHg half. mean PaCO2 down will occur when vasoconstriction
§
§ CBF ↔ PaO2
§ Changing the state of low PaO2 and little change in the high PaO2.
§ When PaO2 <50 mmHg causes cerebral vasodilation occurs to increase CBF.
§ Circulation css
§ physiology
 Spinal fluid cerebrovascular (CSS)
§ Factors that influence CBF
§ sympathetic and parasympathetic, sympathetic and parasympathetic vasodilatation resulting in vasoconstriction resulting
§ increased blood viscosity so that CBF decreased
§ The temperature dropped causing cerebral metabolism decreased mean CBF fell
§ Age: the older the blood flow will increasingly fall
§ Causes of increased ICP
§ Edema of the brain
§ Surgery of the brain
§ Hidrocepalus
§ Mass in the brain
§ Bleeding in the brain
§ SIGNS AND SYMPTOMS INCREASING intracranial pressure
§ Dizziness
§ Vomiting
§ Decrease in consciousness
§ Trias chusing

  (Hypertension, bradicardia, impaired breathing pattern)
§ herniation of the brain
§ Management of ICT increases
§ Intubation
§ Control of ventilation by maintaining a PO 2 <35 mmHg
§ Volume resusitation
§ Normal blood pressure
§ normal CPP
§ Normalised ICP
§ Provide sedation
§ bolus of mannitol
§ Prophylactic anti seizure: Penitoin
§ Monitoring
§ Monitor the ICP
§ Monitor CVP
§ Monitor the CPP
§ Monitor Pulse oximetry
§
§ ICP MONITORING
§ icp monitoring objective is to determine directly the value of Seara intra cranial pressure (ICP) that can be calculated CPPnya value, because the CPP is essential for cerebral blood flow indicator.
§ Monitorning ICP can be through sub aracnoid, epidural, or intraventricular brain intraparenkim
§ masnig Each location has its advantages and disadvantages.
§ Advantages and disadvantages
§ Ventrikulostomy
§ Installation of ventricular catheter into the lateral ventricle.
§ Indications:
1.COB with GCS <7 or less with unstable hemodynamics with CT scans could not be examined
2.COB with normal CT scan with age> 40 years there are signs of SBP <90 mmHg with abnormal posture changes
3.COB difusse injury with damage
4.Secondary cerebral injury
5.Untuk monitor the effects of therapy to lower intracranial pressure sepoerti: Hyperventilation, diuresis, in patients with high ICT
§
§
§ Contra Indications:
§ Thrombocytopenia (<50,000)
§ the freezing extends
§ There is an open wound near the site of insertion
§ imunosupressi

§ Installation Destination
§ To drain excess CSS
§ For external mendrainage
§ Monitor the intra cranial pressure.
§ Old installation
5-10 days, should be replaced every 5 days
Criteria for the release of ICP monitor
ICP-normal with no other therapy after 24 hours
-Increase in GCS> 9
§ Insertion Locations ICP
§ Point Kocher

    Intersection:

    Mid pupillary line perpendicular to the

    3-4 cm lateral sagittal suture and 1 cm in the anterior sutura coronaria
§ ventriculostomy
§ How pegukuran ICP
§ Using the transducer and monitor
§ Passive
§
§ ventricle Drainage and ICP Monitoring
§
§ HOW TO MEASUREMENT ICP
1.Atur position of the patient as comfortable as possible.
2.Petugas wash hands
3.Pasang manometer on the IV pole
4.Ukur by using a water fitting to the zero point on the manometer (ventricles) are the temples of patients / acusticus external meatus
5.Titik equate to zero in patients with a zero point in using a water manometer fitting
6.Buka three way from the ventricle into the manometer while in view undulasinya.
7.Tunggu until the flow stops
8.Setelah stop the flow of reading on the manometer.
9.Kemudian three way back to its original position towards the reservoir
10.Petugas wash their hands and blame the results of measurements
11.Alat device cleared
§
§
§
§ Conversion of Measurement ICP / CVP
§ 1 mmHg = 13.6 mmH20 = 1.36 CmH2O
§ 1 cm H2O = 0.74 mmHg
§ How to calculate the conversion from cmH2O mmHg

          5 CmH2O = 5 CmH2O

                          1.36

           = 3.7 mmHg
Another way:

  CmH20 5CmH2O = 5 X 0.74 mm Hg = 3.7 mmHg
RISKS AND COMPLICATIONS OF INSTALLATION § ICP
§ Intracerebral Hemorrhage with ivh
§ ICT> 20 mmHg
§ Installation of> 5 days
§ irrigation system at the catheter is not smooth or clogged
§ Infection
§ Complications ventriculostomy
§
§ Care Objectives:
§ Preventing the ICT ↑ caused by body position, changing the physical state and the disease process
§ Treatment:
§ Neurological Examination
§ GCS, pupils, light reflexes, vital sign observation.
§ Setting the position of Head Up heads 150-300 and straight neck position
§ Maintain periodic aseptic measures in wound care
§ Maintain a closed system.

§
Care
§ Peimmeriksaan kepatenan airway
§ Maintain a supine patient position monitor function accurately sewhingga
§ Do not manipulate the drainage system
§ Avoid excessive stimulation in patients
§ Maintenance drainage continuously
- Note the periodic undulations of the following pulse.
-Place the container in accordance with the principles of sterile normal.hankan ICT
-Maintain the principle of sterile



§

Inhaled anesthetics

Inhaled anesthetics

FACTORS AFFECTING D GAS uptake ANAESTHESIAThe solubility of anesthetic gases in the blood.Alveolar blood flow.Partial pressure difference between alveolar air and venous blood.FACTORS DETERMINING THE CONCENTRATION D GAS INSPIRASI/F1Fresh Gas Flow speed.Volume breathing circuit.Absorption circuit anesthesia.
MINIMUM Alveolar ConcentrationMAC: The concentration of inhaled anesthetics which

                prevent 50% of patient movement

                to the standard stimuli

                (Surgical incision).





Nitrous OXIDE/N2ORespiratory system:

         - Cause tachypnea.

         - Reduce the tidal volume.

         - Hypoxic drive.Cardiovascular system:

         - Stimulate the sympathetic nervous system.

         - Increased resistance vasculer.

           blood vessels of the lungs.Nitrous OxideSSP:

         - Increase cerebral blood flow

            And cerebral blood volume.

         - Causes an increase in intra

            cranial pressure is light.

         - Increase CMRO ₂Renal:

         - Reduce RBF.

         - Decrease in GFR.


                                                                                          HalothaneRespiratory system:

        - Reduce the tidal volume.

        - Increased respiratory rate.

        - Increased PaCO2.

        - A potent bronchodilator.Cardiovascular system:

        - Depressed myocardial contractility.

        - Reduce the frequency of the heart.

        - Reduce coronary blood flow.

HalothaneCardiovascular system

        - Decrease in arterial blood pressure

           is dose dependent, occurring

           direct effect on depression

           myokardium.

        - At a concentration of 2 MAC, crossed the

           causes decreased cardiac output

           And blood pressure by 50%.Halothane

Central nervous system:

       - Pemb vasodilator. Cerebral blood.

       - Increase CBF.

       - Degrade CMR.

 Renal:

       - Reduce RBF and GFR.Hepatic:

       - Reduce the hepatic blood flow.
EnfluraneRespiratory system:

        - Increase the frequency of breath.

        - Reduce the minute ventilation.

        - Increased PaCO2.Cardiovascular system:

        - Depressed myocardial contractility.

        - Lower the SVR.

        - Increase the frequency of heart.EnfluraneCentral Nervous System:

        - Increase CBF and ICP.

        - Degrade CMR.

        - Increase seizure activity.Renal:

        - Reduce RBF and GFR.Hepatic:

        - Reduce the hepatic blood flow.IsofluraneThe respiratory system;

        - Reduce the minute ventilation.

        - Rarely cause tachypnea.Cardiovascular system:

        - Lower the SVR.

        - Dilatation of coronary arteries.

        - Lowering blood pressure.

      Isoflurane* Central nervous system:

       - At concentrations> 1 MAC, increased

         katkan CBF and ICP.

       - Decrease CMR O2.

 * Renal:

       - Reduce RBF and GFR.

 * Hepatic:

       - Reduce the hepatic blood flow.

       - Maintain hepatic perfusion.
SevofluraneCentral Nervous System:

       - A slight increase CBF and ICP.

       - Decrease CMR O2.Renal:

       - Slightly lower RBF.Hepatic:

       - Improve artery blood flow.

       - Decrease portal vein blood flow.SevofluraneRespiratory system:

       - Depression of respiration.

       - Increase the frequency of breath.Cardiovascular system:

       - Depressed myocardial contractility.

       - Prolong the QT interval.

       - A smaller decrease SVR

          of isoflurane and halothan.

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instek VP SHUNT

Handling instrumen

Instek  pemasangan VP SHUNT

Ø  pengertian

     Suatu cara melakukan pengelolaan instrumen  

     selama operasi pemasangan VP SHUNT

Ø  Indikasi

§   Pasien dengan Hidrocephalus

1.        Persiapan alat

v  Set dasar

Handvat mess no 3,4

Handvat mess panjang

Pincet anatomis

Pincet  chirurgis

Arteri klem van pean

Arteri klem khocker

Nald voeder

Gunting

Doek klem

Desinfeksi klem

v  Set tambahan

Raspatorium

Desektor

Gelpy/ sprider

Bor set

Mess no11

Mandrin ventrikel katheter

Klem sepatu

Spaner VP SHUNT

2. Persiapan bahan

Larutan desinfektan

Kassa steril

Watches

Bon wax

Surgicel

Spuitt 10 cc

Ventrikel katheter

ST

Steril drape

Sufratul

Hypafic

Mess no 24, 10,11

Sterile  drapes

Larutan adrenalin 1: 200.000

3.  Persiapan benang

Side 2,0 :  untuk fiksasi v katheter

Side no 1 : u fiksasi spaner sbgpengantar VP SHUNT

Benang absorbable 2,0 : u jahit soft tissue

Benang non absorbable no 3,0 : u jahit kulit

4. linen steril

Doek kecil 4-5

Doek besar lubang 1

Gaun operasi

handuk

5.  Persiapan pasien

Posisi supine kepala diganjal dg bantal bulat(donat)

Posisi sedikit head up (15-30)

Pasang body strapping

Prosedur operasi

Tim operasi melakukan scrubbing, gowning and gloving

Desinfeksi area operasi

Drapping area operasi

Pasang sterile drapes (opsite)

Pasang couter bipolar, selang suction + canule suction

Injeksi dg adrenalin 1: 200000 pada lokasi incisi

Lanjutan…

Berikan mess 1 u incisi kulit- sub cutis

Berikan mess 2 u incisi fat – galea – otot- periosteum

Rawat perdarahan dengan couter bipolar, irigasi dg larutan NS saat c bipolar difungsikan, sambil dilakukan suction

Berikan raspatorium u menyisihkan periosteum

Tutup luka incisi kepala sementara dg kassa basah

Lanjutan…

Berikan mess 1 u incisi kulit abd bag atas

Perdalam incisi s/d fasia (sampai kelihatan fasia)

Berikan  spaner VP shunt u memasang Ventrkel VP shunt,dari kepala-leher-abdomen        keluar pada daerah incisi di abdomen.

Ujung mandrin VP shunt diikat dg side no 1

Tarik mandrin VP shunt ke atas ( bag incisi kepala )

Lanjutan…..

Berikan ventrikel VP shunt kmd diikat dg side no 1 yg sudah dimasukkan dalam soft tissue ( dibawah fat diatas fasia)

Side no 1 ditarik ke bag bawah ( incisi pd abdomen)       ventrikel VP shunt sudah masuk dan terhubung dari kepala ke abdomen

Pasang konector VP shunt kmd di spool dg NS     sampai lancar tidak ada hambatan

Berikan bor set u bor hole  kmd    rawat perdarahan

Berikan desector dan klem pean bengkok u ambil sisa tulang

Berikan couter bipolar u ces dura

Berikan speed mess u incisi dura

Lanjutan….

Berikan ventrikel katheter + mandrin dimasukkanke dalam intra cerebral sampai keluar cairan (hidrocephalus)

Sambung ventrikel katheter dg ventrikel VP shunt

Sambungan difiksasi

Tarik ventr VP shunt ke arah distal (abdomen)

Pastikan aliran cairan pada ventrkel lancar

Berikan pincet anatomis 2 buah + gunting metzenbaum u incisi peritoneum ± 1 cm

Masukkan ventrikel VP shunt kedalam peritoneum.

Lanjutan…

Tutup luka incisi

Berikan jahitan benang absorbable u jahit fasia, fat pada kepala dan abdomen

Berikan jahitan benang non absorbable u jahit kulit

Bersihkan luka dg kassa basah kmd keringkan

Beri sufratul – kassa – hipafic

Inventaris alat

Op selesai

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