Textbook Reading

Disorders of Electrolytes
(in surgical patients)
TAV/ARZ
Pendahuluan
13/

Penatalaksanaan cairan dan elektrolit sangat

esensial dalam perawatan kasus bedah
(perioperative care)
Gangguan keseimbangan tersebut dapat terjadi
pre,intra&post (operasi)
Sering menyertai pada kasus2 critical ill
(trauma & sepsis)
Topik ini dikhususkan hanya pada gangguan
keseimbangan elektrolit
Na dan K merupakan elektrolit utama yang
perlu pembahasan
Komposisi Cairan Tubuh

TOTAL BODY WEIGHT 100%

TOTAL BODY WATER 60%

ICF 40% ECF 20%

IVF
5%
Kompartemen cairan tubuh
Komposisi elektrolit dalam cairan
Natrium

Fungsi Natrium
Regulasi osmolalitas plasma

Mengatur permeabilitas membran sel

Berperan dalam konduksi impuls dan saraf

Kadar normal : 135 -145 mEq/L
Kebutuhan per hari: 2-4 mEq/kgBB/hari
Hyponatremia
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Manifestasi klinis

Sistem organ Hyponatremia

Central nervous system Nyeri kepala, confusion, hyper-or hypoactive deep tendon
reflexes, kejang, koma, peningkatan TIK
Musculoskeletal Kelemahan, kelelahan otot, muscle cramps/twitching
Gastrointestinal Anorexia, nausea, vomiting, diare
Cardiovascular Hypertension and bradycardia
Tissue Lacrimation, salivation
Renal Oliguria
Diagnostic
Approach
Terapi Hiponatremia (basic principles)

Volume expansion dg 0,9%

ECF
saline
Osmolalitas
ECF N

Restriksi cairan dg diuretik

ECF

Osmolalitas
N

No spesific therapy

Osmolalitas
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Treatment

Urea(antinatriuretic&osmotic diuresis):40mg in 150cc normal

saline IV every 8h
Hypertonic saline

Loop diuretik

Vasopressin antagonis(aquaresis than diuresis):conivaptan

20-40 mg daily

Severe hiponatremi (Na<120meq/l): correction!

Total Na required: Na desired-Na measured X TBW
TBW : male 0,6 X weight(kg); female 0,5 X weight(kg)
*maximum correction is 8-12 meq/day or 130 meq after correction
*Asymptomatic : increase the sodium level by no more than 0.5-1
meq/L/h

*Symptomatic: (Na<120 meq/L) Increase the sodium level by no

more than 1meq/L per hour until the serum Na level reaches 130
meq/L or neurologic symptoms are improved
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Rapid correction of
hyponatremia

central Pontine myelinolysis

Seizures, weakness/paresis,
akinetic movements,
unresponsiveness

Permanent brain damage

Death
Hypernatremia

Iatrogenic

Selalu hiperosmoler

Respon tubuh: haus dan release ADH

Etiologi

Hiperglikemia, manitol, diet

Renal tinggi protein (produksi urea),
diabetes incipidus
Free water
loss
Diare
Non
Insensible losses (fever &
Renal
burn)

Sodium
intake
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Manifestasi klinis

Body system hypernatremia

Central nervous system Restlessness, lethargy, ataxia,

irritability, tonic spasms,delirium,
seizures, coma
Musculoskeletal weakness
Cardiovascular Tachycardia, hypotension,
syncope
Tissue Dry sticky mucous membranes,
red swollen tongue,decreased
saliva and tears
Renal Oliguria
Metabolic Fever
Diagnostic
Approach
Terapi Hipernatremia

D5% atau NaCl 0,45% iv/oral

Water defisit = [left (serum sodium-140)/140] x
Free water TBW (liters)
loss Or:
Change in serum Na+ = (infusate Na+ - serum
Na+) (TBW + 1)

Diuretik (furosemide)
Sodium
intake
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The rate of fluid administration:

1. Acute hypernatremia: a decrease in

serum sodium of no more than 1meq/h and
12meq/d

1. Chronic hypernatremia: a decrease in

serum sodium of no more than 0.7meq/L/h
Kalium

Kation terbanyak di tubuh(98% intraseluler)

Keseimbangannya diatur oleh Na-K ATPase

pump

Ekskresi terbanyak melalui ginjal

Uptake-nya di intraseluler dipengaruhi oleh

insulin dan beta2 reseptor

Fungsi Kalium: eksitabilitas membran dan

fungsi sel

Kadar normal kalium: 3,5 5 mEq/L

Kebutuhan per hari : 1 mEq/kgBB/hr

Kalium

Rata-rata kebutuhan K per hari: 50-100meq/d

Rata-rata ekskresi melalui ginjal: 10-700meq/d

Kadar K dipengaruhi oleh:

Surgical stress
Injury
Acidosis
Tissue catabolism
Penyebab hipokalemia

Intake yg inadekuat:
Diet yang kurang
Pemberian cairan infus yg tdk mengandung K
Pemberian TPN yg tdk mengandung K
Ekskresi K yang berlebihan:
Hyperaldosteronism
obat2an
GI / renal losses:
Direct loss (diarrhea)
Renal loss (gastric fluid, either as vomiting or high nasogastric output)
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Gejala klinis hipokalemia

System hypokalemia

Gastrointestinal Ileus, constipation

Neuromuscular Decreased reflexes, fatigue, weakness,
paralysis
Cardiovascular Arrest
ECG changes U-waves
T-wave flattening
ST-segment changes
Arrhythmias
Department of Surgical Education, Orlando Regional
Medical Center/adult electrlyt replacement protocols
2008
Department of Surgical Education, Orlando Regional
Medical Center/adult electrlyt replacement protocols
2008
Penyebab hiperkalemia

Peningkatan intake:
Potassium supplementation
Blood transfusions
Endogenous load/destruction:
Hemolysis atau rhabdomyolysis
Crush injury
Gastrointestinal hemorrhage
peningkatan release:
Acidosis
Rapid rise of extracellular osmolality (hyperglycemia or mannitol)
Impaired excretion:
Potassium-sparing diuretics
Renal insufficiency/failure
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Gejala klinis hiperkalemia

System hyperkalemia
Gastrointestinal Nausea/vomiting ,colic, diarrhea
Neuromuscular weakness, paralysis, respiratory failure
Cardiovascular Arrhythmia, arrest

ECG changes Peaked T waves (early change)

Flattened P wave
Prolonged PR interval (first-degree block)
Widened QRS complex
Sine wave formation
Ventricular fibrillation
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Treatment of symptomatic hyperkalemia

Potassium removal
Kayexalate
Oral administration is 15-30 g in 50-100 mLof 20% sorbitol
Rectal administration is 50 g in 200 mL 20% sorbitol
Dialysis

Shift potassium
Glucose 1 vial of D50% and regular insulin 5-10 units intravenous
Bicarbonate 1 vial intravenous

Counteract cardiac effects

Calcium gluconate 5-10 mL of 10% solution
 Calcium

Fungsi utama:

Transmisi impuls saraf

Kontraksi otot jantung

Faktor pembekuan darah

Pembentukan gigi dan tulang

Kontraksi otot

29
http://lpi.oregonstate.edu/infocenter/minerals/calcium/capth.html
30
 Kalsium
Kebutuhan harian: 1-3g

Asidosis meningkatkan fraksi kalsium yang terionisasi oleh karena menurunkan

ikatan dengan protein

Hiperkalsemia

Penyebab : Hiperparatiroidism dan malignansi

Gejala: Gangguan neurologis, kelemahan otot dan nyeri, disfungsi renal, mual,
muntah, nyeri perut, hipertensi, aritmia, peningkatan toksisitas terhadap obat2an
digitalis

EKG : pemendekan QT interval, pemanjangan PR&QRS interval, peningkatan QRS

voltage, T wave flattening & widening, AV block->arrest
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Hipokalsemia

penyebab: pancreatitis, infeksi soft tissue yang luas, gagal

ginjal,fistula enteral, hypoparathyroidism, tumor lysis syndrome,
massive blood transfusion with citrate binding

Gejala: parestesia wajah dan ekstremitas, kram otot, stridor,

tetani, kejang, hyperreflexia, Trousseaus sign, Chvosteks sign,
penurunan kontraktilitas jantung, gagal jantung

EKG : prolonged QT interval, T wave inversion, heart block, V-

fib
Koreksi hipokalsemia

Normalized calcium level <4.0 mg/dL:

With gastric access and tolerating enteral
nutrition:
Calcium carbonate suspension 1250 mg/5 mL q6h
per gastric access;
Recheck ionized calcium level in 3 d
Without gastric access or not tolerating enteral
nutrition:
Calcium gluconate 2 g IV over 1 h x 1 dose;
Recheck ionized calcium level in 3 d
IVF Composition

Solution Na CL K HCO
3 Ca Mg mOsm

Extracellular 142 103 4 27 5 3 280310

fluid
Lactated 130 109 4 28 3 273
Ringer's
0.9% Sodium 154 154 308
chloride
D50.45% 77 77 407
Sodium chloride

D5W 253

3% Sodium
chloride 513 513 1026
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Kebutuhan harian

Sodium: 1-2 mEq/kg/d

Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/d
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Lets do some exercise..

 13

Laki2 40 tahun dengan crush injury extremitas

inferior D, perawatan hari ke 3 post amputasi above
knee..sepsis teratasi.. cardiac arrest..

What do you think? What do you do?

 13

Pre-Arrest Rhythm Strip

 13
Diagnosis?
HYPERKALEMIA
Treatment
CaGluk. 10% - 1 ampule (10cc)
Sodium Bicarbonate - 1 ampule
D40 & Insulin 10 U
Kayexalate
 13

Perempuan 42 tahun dengan papillary ca throid post

op.total thyroidectomy hari ke-o.Dia mengeluh
kesemutan dan tebal di sekitar bibir. ECG QT
interval memanjang.

What do you think? What do you do?

HYPOCALCEMIA
13

Chvosteks sign -
facial muscle spasm
Trousseaus sign - carpal spasm

Treatment
monitor ECG
IV calcium (ca gluk. 10cc)
follow up labs
oral calcium supplements
normal is 1 gram/day
(800-1200mg/d)
 13

Laki2 56 th (70kg) dgn post op TURP hari ke-0,

penurunan kesadaran, T 170/100;N 64; prod.urine
50cc/4 jam

What do you think? What do you do?

Na 115 mEq/L 13
HIPONATREMIA dilutional(hiper
volemi)
Terapi:
1. 0,6 x 70kg x (125-115)= 420 meq (kebutuhan total)
2. kecepatan pemberian perjam tidak boleh lebih dari 0.5 meq/L/jam
: 0.6 x 70kg x 0.5 meq/l/jam = 21 meq/jam (maksimal)
3. 3% Nacl mengandung Na 513 meq/Liter
[ rate/jam ]/513 x 1000= # ml/hr

Maka : 21 meq/jam x 1000 ml = 40,93 ml/jam

513 meq/L
Lama pemberian = 420 meq : 21 meq/jam = 20 jam
Order: infuse Nacl 3% 40 ml/jam selama 20 jam. (800ml/20jam)
4. selesai koreksi lanjutkan dengan restriksi cairan
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wanita 41th (70kg) dgn combustio gr IIAB 58%,

lethargy, N 120; Na 165meq/l; K 3,0 meq/l

What do you think? What do you do?

 HIPERNATREMIA (Insensibl
e loss)

TBW: (0.5 x 70) = 35 L

D5 %
(0 meq/l Na 165meq/l) (35 + 1) = - 4.6 meq/l
The goal is to reduce his serum sodium by no more than 10 mmol/L in a 24-hour period.
Thus, (10 4.6) = 2.17 L of solution is required.
About 1-1.5 L will be added for obligatory water loss to make a total of up to 3.67 L of D5
W over 24 hours, or 153 cc/h.