LAMPIRAN

Lampiran 1

INTRAVENOUS FLUID MANAGEMENT PROTOCOL FOR NEUROSURGERY PATIENTS (non-trauma):

Mischer Neuroscience Institute and the University of Texas General Principle 1: maintain EUVOLEMIA for all patients, AT ALL TIMES, with no free water 1. For all patients, start NS with 20 meq/L KCl at 100 cc/hr 2. remove KCl if serum potassium is high 3. there is NO patient for whom hypervolemia is indicated, not even a patient getting treatment for vasospasm 4. free water should be given only when specifically ordered by the team; make sure none of the medications or drips are given with free water. General Principle 2: LIMIT total fluid intake to 3 Liters per day 1. we must follow input and output daily and accurately 2. 3 liter limit includes all medications, drips, colloid and blood administration 3. if the patient is on drips, getting medications, blood or colloids, then baseline IVF rate must be reduced or turned off so that total fluid does not exceed 125 cc/hour (on average) 4. tube feeds and oral intake should be counted towards the 3 liter limit 5. if necessary to stay within the limit, we must concentrate medications and drips 6. exceptions to 3 liter limit only when specifically ordered by the team for specific situations (eg, hypotension, poor urine output, DI) General Principle 3: patients returning from OR or procedures may have been given large volumes of fluid 1. we need to allow the patient to equilibrate this additional fluid 2. following procedures under general anesthesia, hold IVF post-procedure until patients urine output is less than 100 cc/hr for 2 hours 3. then start NS with 20 meq KCl/L at 75cc/hr General Principle 4: CVP is often an inaccurate measure of volume status 1. be very careful is using CVP to make management decisions; highly dependent on respiratory status, ventilator settings, other factors not related to volume status 2. never use or target the absolute CVP value; may be useful for trending data 3. if a central line and a PA catheter is in place; use the wedge pressure only and disregard CVP