Terapi Cairan pada Anak

Rational Fluid
. Regimen

• Correct timing
• Correct indications, dosage
• Correct product (composition,concentration)
• Tailored to patient’s fluid and electrolyte
status, not diagnosis
• Good monitoring
• Cost-effective
DN Lobo et al. (UK)*
PEMBERIAN CAIRAN  4 J

1. Jenis
2. Jumlah
3. Jalur
4. Jam
 TERAPI CAIRAN

RESUSITASI RUMATAN
Repair
KCl, Bicnat

KRISTALOID KOLOID ELEKTROLIT NUTRISI

KA-EN 1B® AMIPAREN®
ASERING® KA-EN 3A® AMINOVEL- 600®
OTSUTRAN - L®
Otsu-RL® KA-EN 3B® PAN- AMIN G®
Otsu- NS® KA-EN 4A® KA-EN MG 3®
KA-EN 4B® MARTOS 10®

Menggantikan Memelihara
kehilangan akut keseimbangan
cairan tubuh cairan tubuh
dan nutrisi
 TERAPI CAIRAN IV

RESUSITASI RUMATAN

 Natrium rendah
 Infus Natrium > 100 mEq/L
 4:2:1
 atau koloid
(misal 25 kg:
 20-30 ml/kg/jam 4 x10+2x10+1 x5 65ml/jam
 2-3 L/10-15 menit  500 ml/6 jam
AGE-RELATED BODY PROPORTION

Embryo (97%) Adults 55-60%

Newborn (70-80%) Elderly (45-55%)

 Water Composition
(% of body wright)

Intrauterine Extrauterine
Month Born Month Yr
3 5 0 0-1 1-12 1-12 >12
94% 80% 78% 75% 70% 65% 60%

Intrauterine Extrauterine
Compartment 5 month Born Month Yr
0-1 1-12 1-12
Intracellular 25% 33% 45% 45% 45%
Extracellular 60% 45% 30% 25% 20%
RL, Asering & NS INDIKASI

1L

Syok hipovolemik
Diare dengan dehidrasi berat
Muntah-muntah hebat
DSS
Perdarahan
800 ml Luka Bakar

200 ml Kedaruratan bedah

Intraoperatif
ASERING
® First Line
Ringer’s
acetate Fluid Resuscitation Therapy

Ringer’s acetate
 Average pH

• Ringer’s lactate 6.75

•Asering® 7
• Normal saline 6.25
 LR compare to ASERING®

 LACTATE: Primarily in the liver, and to lesser degree the

kidney, lactate is metabolized to pyruvate, which is then
converted to CO2 and H2O (80%) or glucose (20%), and
regeneration of bicarbonate1
 ACETATE: metabolized mainly in muscles and to a lesser
extent in tissues such as kidney, heart and liver2
Coenzyme A
Acetate + H+-------- Acetyl-CoA Kreb’s cycle
hydrogen source

Carbonic acid -------- bicarbonate

Ref. 1.Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4th ed 1994 p 554
2. Maxwell MH, Kleeman CR, Narins RG. Clinical Disorders of Fluid and Electrolyte Metabolism.
MacGraw-Hill 1987 4th edition p 1063
 LACTATE VS ASERING®

Na Lactate Bicarbonate
100 mEq/hr

Na Acetate Bicarbonate
250-400 mEq/hr
 LACTATE VS ASERING®

C3H5O3- + 3O2 2CO2 + 2H2O + HCO3-

( Lactate ) (bicarbonate)

(Liver)

C2H3O2- + 2O2 CO2 + H2O + HCO3-

( Acetate ) (bicarbonate)

(muscle)
 Indications of AR

• Replacement fluid for resuscitation

gastroenteritis, burn,hemorrhagic shock, DSS
• Intraoperative
• Priming solution for cardiopulmonary
bypass (CPB)
• Replacement fluid for children
Ringer Asetat
 Pendahuluan
• RA bisa digunakan pada anak dan bayi
• Diindikasikan untuk resusitasi cairan

Ref: 1. Neonatal Hypernatremic Dehydration Secondary to Lactation Failure

J Am Board Fam Pract 14(2):159-161, 2001. © 2001 American Board of Family Practice
2. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938.
3. Guidelines for btreatment of DKA, Swedish Pdiatric Association 1996
4. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva :
World Health Organization. 1997
5. Communicable Disease Epidemiology Office of Epidemiology Washington State Department
of Health.
 KOMPOSISI

Setiap 1 L mengandung :

Elektrolit ( mEq ) Tek.Osmotik

+ + -
Na K Cl Ca2+ Asetat Laktat ( mOsm /L )

ASERING® ( RA ) 130 4 109 3 28 - 274

RINGER LAKTAT ( RL ) 130 4 109 3 - 28 274

 Ringer Asetat

1. Metabolisme asetat terutama di otot, tidak terganggu pada kelainan hati(1)

2. Komposisi mirip dengan plasma, tepat untuk menggantikan
kehilangan akut cairan ekstraseluler. ( 2 )
3. Kecepatan metabolisme asetat 250-400 mEq/jam , sedangkan
laktat 100mEq/jam, dengan demikian asetat lebih cepat mengkoreksi asidosis.( 3)
4. Metabolisme asetat memerlukan sedikit O2 , dan melepaskan sedikit CO2.( 4 )

1. Loren A et al. Oxidation of lactate and acetate in rat skeletal muscle. Journal of Applied
Physiology 1997 ; 83 ( 1 ) : p. 32 - 39.
2. Heimberger DC,M.Roland RW. Handbook of Clinical Nutrition.Mosby 1997
3. Anderud T, Lund T. Intensive Care of Patients with Burns. Tidskr Nor Laegenforen 1989;
p.3197 - 3199.
4. Ringer acetate solution in clinical practice. Medimedia.1999
 SECONDARY DENGUE INFECTION

VIRUS REPLICATION ANAMNESTIC ANTIBODY RESPONSE

VIRUS ANTIBODY COMPLEX

MACROPHAG COMPLEMENT ACTIVATION

CYTOKINES:
Anafilatoksin C3a, C5a
Il-1, Il-6, Il-12, INF, TNF, LIF

VASCULAR PERMEABILITY 

LEAKAGE OF PLASMA

HYPOVOLEMIA

SHOCK
JENIS CAIRAN (WHO-1998)

Kristaloid:
ringer laktat (RL)
dekstrose 5% + RL (D5/RL)
ringer asetat (RA)
dekstrose 5% + RA (D5/RA)
NaCL 0,9%
dekstrose 5% + NaCl 0,9%

Koloid:
Dekstran 40 dalam RL
Plasma
Terapi cairan A (WHO)
Terapi cairan B (WHO)
DBD III & IV
O2 2-4 L/menit
RA/RL 20 ml/kg bolus dalam 30 menit

Syok teratasi Syok tidak teratasi

RA/RL 10 ml/kg/jam Teratasi Dextran 40 10-20 ml/kg

Tidak Teratasi
Stabil dalam 24 jam
RA/RL 5 ml/kg/jam Ht turun Ht tetap/naik
3 ml/kg/jam FFP 10 ml/kg Dextran 20 ml/kg
Stop < 48 jam
Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999
 Diagram 9. Alur tatalaksana Pemberian cairan Derajat IV
Prof. Soegeng, Tatalaksana DBD terkini, RSUD Dr Soetomo/FKUnair, 2006
 1. Aman digunakan pada anak & bayi.

2. Diindikasikan untuk resusitasi ( misal:

kasus dehidrasi berat, Syok DBD, burn, dll)

3. Indikasi yang lain:

3.a. Maintenance DKA pada anak
3.b. Mencegah risiko bayi post sectio dari
asidosis laktat
3.c. Maintain suhu sentral lebih baik
3.d. Dibanding NaCl hiperkloremia asidosis
3.e. Dibanding koloid tidak ada risiko perdarahan
dan lebih cost effective

References:
1. Anesthesiology 2000 Nov;93(5):1170-3 Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M.
2. Communicable Disease Epidemiology Office of Epidemiology Washington State Department of Health.
3. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938.
4. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva :World Health Organization.1997
5. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996
6. McFarlane C, Lee AA comparison of AR and 0.9% saline for intra-operative fluid replacement.
7. Neonatal Hypernatremic, Dehydration Secondary to Lactation Failure, J Am Board Fam Pract 14(2):159-161, 2001. © 2001 American
Board of Family Practice.
8. Onizuka S, Kawano T, Takasaki M, Sameshima H, Ikenoue T[ Comparison of the effect of rapid infusion of lactated and that of acetated
Ringer's solutions on maternal and fetal metabolism and acid-base balance]. Masui 1999 Sep;48(9):977-80
9. Tollofsrud S, et al. Fluid balance and pulmonary functions during and after coronary artery bypass surgery: Ringer's acetate compared
with dextran, polygeline, or albumin. Acta Anaesthesiol Scand 1995 Jul;39(5):671-7
 TERAPI CAIRAN

RESUSITASI RUMATAN

Kristaloid Koloid Elektrolit NUTRISI

Seri KA-EN

Mengganti kehilangan 1. Kebutuhan normal

akut (hemorrhage, (IWL + urin+ feses)
GI loss, rongga ke3) 2. Dukungan nutrisi
 .
Rasionale of maintenance solutions

• Fluid redistribution
• Basal requirement of potassium &
sodium
• electrolyte concentration in
infusion solutions
• ‘Ready for use’ solutions
minimises risk of contamination

Lobo,DN. Et all
 Dextrosa & KAEN INDIKASI

1L

Pasien rawat inap

Interna, pediatric

225 ml Pulmonologi

660 ml Obgyn

85 ml Neurologi, stroke, dll

 KA-EN 3A®
Rational infusion solution for maintenance therapy (age > 3 years)
KA-EN 3B®

KA-EN 4B® Rational infusion solution for maintenance therapy (age < 3 years)

Kebutuhan air untuk bayi dan anak

Kebutuhan air dan elektrolit untuk bayi sampai anak 1 : menghitung kebutuhan cairan rumatan dari berat badan
(berdasarkan pada 100 mL untuk setiap 100 kcal yang digunakan)
Sampai dengan 10 kg 100 mL / kg
11 - 20 kg 1000 mL + 50 mL / kg (untuk tiap kg di atas 10 kg )
> 20 kg 1500 mL + 20 mL /kg (untuk tiap kg di atas 20 kg)

1. Viviana Martinez-Bianchi, M.R. Peterson, and M.A. Graber. Pediatrics : Vomiting, Diarrhea and Dehydration. Univ. of Iowa Family Practice Handbook 3rd Ed. Chapter 10.
 Asal Larutan Rumatan

Mixing
Larutan Normal Larutan
Saline (Na+ 154 mEq/L) Glukosa 5%

Larutan 1/2 NS Larutan 1/3 NS Larutan 1/4 NS Larutan 1/5 NS

Na+ 77 mEq/L Na+ 51mEq/L Na+ 38 mEq/L Na+ 31 mEq/L

Larutan KAEN 1 A Larutan KAEN 2 Larutan KAEN 3 Larutan KAEN 4

Suplementasi elektrolit Suplementasi air

• RL
• 5% Dextrose
• 5% Dextr. in Ringers

are still widely used

for maintenance therapy
 KA-EN 3A®
Rational infusion solution for maintenance therapy (age > 3 years)
KA-EN 3B®

KA-EN 4B® Rational infusion solution for maintenance therapy (age < 3 years)

Anak BB = 20 kg

Kebutuhan Air 1.5 L RL 1.5 L KA-EN 3B®, 1.5 L

Natrium 60 – 100 mEq 195 mEq 75 mEq
Kalium 20 - 50 mEq 6 mEq 30 mEq

Ref. :
1. Rice H. Fluid Therapy for the Pediatric
Surgical Patient. Emedicine. 2003 July.
Infus RL bukan
www.emedicine.com/ped/topic2954.htm
2. Piwko, J.G. and Michael G.C. Neonatology Considerations
Untuk Terapi Rumatan
for the Pediatric Surgeon. Emedicine. 2004.
www.emedicine.com/ped/topic2982.htm
 INDICATIONS
• KAEN 1B • Initiating > 3yr
(Na 38.5,Cl 38.5,Glu 37.5)
• KAEN 3B • Maintenance >3 yr
(Na 50 K 20, Glu 27)
• KAEN 3A • Maintenance > 3 yr
(Na 60 K 10, Glu 27)
• KAEN 4A
(Na 30)
• Initiating < 3 yr
• KAEN 4B
(Na 30,K 8) • Maintenance < 3 yr
 KAEN SOLUTIONS

Na+ K+ Mg++ Cl- P Lactate Glucose pH mOsm/L

(mEq/L) (mEq/L) (mEq/L) (mEq/L) (mmol/L) (mmol/L) (gr/L)

KAEN 1B 38,5 - - 38,5 - - 37,5 4,8 285

KAEN 3A 60 10 - 50 - 20 27 5,4 290
KAEN 3B 50 20 - 50 - 20 27 5,4 290
KAEN 4A 30 - - 20 - 10 40 5,5 282
KAEN 4B 30 8 - 28 - 10 37,5 5,5 284
 COMMON ILLNESSES
• Ileus : RL/RA to replace 3rd space loss,
followed by KAEN
• Pneumonia/bronchopneumonia: KAEN
3A/3B (watch for SIADH--- NS)
• Meningitis/encephalitis : KAEN 4A/4B if
hypertonic dehydration
• Postoperative : Asering followed by
KAEN 3A (watch for hyponatremia)
KA-EN 4A® Paed Maintenance Infusion Solutions
KA-EN 4B® Paed for Paediatric Patients

KA-EN 4A® Paed/KA-EN 4B® Paed

Komposisi per Liter :
No Nama Elektrolit (mEq/L) Kalori Kemasan
Produk Na+ K+ Cl- Laktat- (kcal/L) (mL)

1 KA-EN 4A® paed 30 0 20 10 160 500

2 KA-EN 4B® paed 30 8 28 10 150 500
 PEMAKAIAN INFUS DI UGD
SYOK HIPOVOLEMIK

Ya TIDAK

< 3 tahun > 3 tahun

ASERING KAEN 4A KAEN 1B

20-30 ml/kg/jam Kecepatan: BB < 10 kg: 4 ml/kg/jam
11-20 kg : 2 ml/kg/jam
> 25 kg : 1 ml/kg.jam
Observasi/ Normo/
Normo/hipoK
monitor hipoK
Contoh : Anak 5 tahun BB 15 kg-
4 x 10 + 2 x 5 =
nadi teraba
50 ml/jam = 12 tetes/menit
akral hangat
urine output +
KAEN 4B KAEN 3B/MG3
kecepatan bisa
diturunkan 10 73 ml/kg/jam
KAEN 3B mengandung kalium 10 mEq/500 ml

Anjuran kecepatan: 10 mEq/jam*

(INGAT KECEPATAN  DOSIS HARIAN)

Dalam praktek:
Kecepatan Rumatan 500 ml/6 jam
~ 80 ml/jam; 20 tetes/menit
Dalam 500 mL = 10 mEq,
500 mL diberikan dalam 6 jam
Maka dalam 1 jam ~ 1,6 mEq K+/jam

Risiko Hiperkalemia minimal!

Berapa Banyak K+ diperoleh dari makanan?

(Note: 2000 mg ~ 60 mEq)

Sayuran
Kentang, buncis 500 gr
Kacang 5000 gr

Buah
Pisang 800 gr
Jeruk 1200 gr

Daging
Sapi atau ayam 600 gr
Halperin & Goldtstein. Fluid, Electrolyte and Acid Base Physiology.
WB Saunders Co. 2nd ed.p 358
 Conclusion
• Rasionale of fuid therapy becomes big issue toward
• Resuscitation fluid therapy : replace acut state
first line ASERING®
• Maintenance fluid therapy : normal loss (IWL + Urine)
• Different types of dehydration
• ‘Ready for use” product associated with less risk of
contamination (KAEN Series)
• Suitable in hypertonic dehydration
• KAEN 4B, 3B & 3A minimize risk of potassium depletion
• Beware of iatrogenic imbalances; monitoring
 KOMPOSISI
ALT ERNAT IF PENGGANT I

Product Name Osmolarity Electrolyte (mEq / L )

(mOsm/L) Na+ K+ Ca++ CI- Laktat - A setat -

DGAA 296 61 17.5 52 26.5

KA - EN 3B 290 50 20 50 20

N/2 - D2.5 (2A), 0.45% NaCl & D2.5% + KCl 10 mEq 308 77 10 77

KA - EN 3A 290 60 10 50 20

N/4 - D5 (4:1) 282 38.5 38.5

KA - EN 1B 285 38.5 38.5

N/4 - D5 (3:1), 0.225% NaCl & D5% 353 38.5 38.5

KA - EN 1B 285 38.5 38.5

N/5 - D4 353 30 30

KA - EN 4A 282 30 20 10

KA - EN 4B 284 30 8 28 10

Ringer Laktat (RL) 273 130 4 3 109 28

Ringer asetat (A SERING) 273 130 4 3 109 28

5% Dext in Ringer laktat (RLD5) 551 130 4 3 109 28

5% Dext in Ringer asetat (A sering 5) 551 130 4 3 109 28

Bagaimana menata kebutuhan harian Natrium?
 Potassium and Sodium
Homeostasis and Daily Requirement

Potassium Sodium
(mEq/kgBW/day) (mEq/kgBW/day)
Adult1 0.9 - 1.3 1.0 - 1.7
For infant to children2 : based on 100 ml of water for each 100 kcal expended.
Maintenance elect. requirement : 100 ml and 2-4 mEq of Na and K for every 100 kcal expended.
up to 10 kg 100 ml water / kg
11 - 20 kg 1000 ml + 50 ml / kg for each kg above 10 kg
> 20 kg 1500 ml + 20 ml /kg for each kg above 20 kg
Daily Body Fluid ± 20 - 30 ± 1.0
Homeostasis3 (minimum) (minimum)

1. Page C.P., Thomas C.H. and George M. Nutritional Assessment and Support. A primer 2nd Ed. P : 26. 1994.
2. Martinez-Bianchi, V., MD, Michelle, RP, MD., Mark A.G., MD. Pediatrics : Vomiting, Diarrhea, and Dehydration in Family
Practice Handbook 3rd Ed. USA.
3. Kokko and Tannen. Fluid and Electrolyte 3rd Ed. WB Saunders.
Air dan Na Tidak Bisa Dipisahkan

??

Air Na+

Pengaturan Jumlah Na = Pengaturan Vol Cairan Ekstraseluler

= Pengaturan Vol Cairan Tubuh
 •Edema paru bisa terjadi dalam 36 jam pasca bedah bila retensi cairan
melebihi 67 ml/kg/d sebaiknya intake air < 2000 ml

•Pemulihan Fungsi saluran cerna lebih cepat pada kelompok pasien reseksi
usus yang mendapat cairan postop < 2 L; 77 mEq Na dibandingkan
kelompok > 3 L; 154 mEq Na sebaiknya asupan Na+ pasca bedah <
60-100 mEq

•Pasien hipoalbuminemia mengalami ekspansi cairan ke interstisial,

pemberian natrium tinggi menyebabkan luka operasi sulit sembuh

•Ekskresi air dan natrium lebih lambat pada pasien postop yang mendapat
cairan dengan kandungan natrium yang lebih tinggi

•Kalori minimal 600 kcal memiliki efek menghemat protein (Protein-sparing

effect)

1. Arieff Allen L. Fatal Postoperative Pulmonary Edema. Pathogenesis & Literature Review. CHEST 1999;115:1371-1377
2. Lobo DN et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection.
Lancet 2002 May 25.359(5320):1792-3
3. Hill G.L. Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone 1990
4. Fiona REID, Dileep N. LOBO, Robert N. WILLIAMS, Brian J. ROWLAND Sand Simon P. ALLISON (Ab)normal saline and
physiological Hartmann's solution: a randomized double-blind crossover study Clinical Science (2003) 104, (17–24)
 IV Fluid Overload

• Decrease muscular oxygen tension

and delay recovery of gastrointestinal
function
• Cause general edema
• Impede tissue healing and
cardiopulmonary function
Terima kasih