.

correct timing
correct indications, dosage
correct product (composition,
concentration)
tailored to patients fluid and electrolyte
status, not diagnosis
good monitoring
cost-effective
Rational Fluid regimen
History of Infusion Therapy
Goose quill
Bag made of pigs bladder
2003p4
1832 Treatment of cholera (Latta)
0.5% Sodium chloride and 0.2% sodium bicarbonate
1915 Treatment of pediatric diarrhea
Mortality decreased from 90% to 10%
1616 Discovery of blood circulation (William Harvey)
1658 Intravascular administration (Sir Christopher Wren)
mEq/L
CES
CIS
Plasma
Interstitial
fluid
K
a
t
i
o
n

Na
+
142
144 15
K
+
4 4 150
Ca
2+
5 2.5 2
Mg
2+
3 1.5 27
Total 154 152 194
A
n
i
o
n

Cl
-
103 114 1
HCO
3
-
27 30 10
HPO
4
-
2 2 100
SO
4
2-
1 1 20
Organic
acids
5 5
Proteins 16 0 63
Total 154 152 194
Normal
Saline
154 Na
+
154 Cl
-
Plasma Osmolality




Effective osmolality (Osmotic pressure)=
2 x [Na
+
] + [Glu]/18
285 + 5 mOsm/kg
Osmolality= 2 x [Na
+
] + [glucose] + [BUN]
18 2,8
Maintenance
Parenteral
Nutrition
Resuscitation
Fluid
Therapy
Repair/
correction
Enteral Nutrition
Nutrition
Therapy
Hospitalized Patients
Prevalence of distressing symptoms in the palliative patient
subgroup (N = 43 ) and the non-palliative group (N = 117)
Sigurdardottir and Haugen BMC Palliative Care 2008 7:16
Lack of wellbeing
Depression
Anxiety
Anorexia
Dry mouth
Dyspnea
Nausea
Fatigue
Pain on movement
Pain at rest
Osmolality Hypovolemia
Water loss >>
Na
+
loss > water
loss
Thirst,dry mouth
Oliguria
Anxiety/ excitation
Headache
Nausea/vomiting
Dizziness ipon standing
Hypotension
Dehydration Hypovolemia
Editorship: Yasuhiko Iino, Professor of Renal Internal Medicine, Nippon Medical School
Maintenance Solution Replacement Solution
BUN:Cr ratio
(mg/dl)
Location of renal disorder Mechanism
> 20 : 1 Pre-renal Reduced flow causes elevated
creatinine and BUN due to
decreased GFR. Additionally,
BUN reabsorption is increased
because of the lower flow; BUN
is disproportionately elevated
relative to creatinine
10-20 Normal or Post-renal
Disease
Normal range. In some
instances, can be Post-Renal, as
backflow from obstruction causes
elevated BUN reabsorption within
kidney; Cr is not reabsorbed,
therefore BUN:Cr ratio increases
<10 Intrarenal disease Renal damage causes reduced
BUN re-absorption, therefore
lowering BUN:Cr ratio
BUN:Cr ratio > 20 dehydration
FeNa < 1% renal blood flow
FeNa = fractional excretion of sodium
FeNa = (U/P Na) : (U/P Creat)
Additional Lab finding in dehydration
Effect of infusion solution to AVP
NaCl 0.9
increases vasopressin


Glucose
decreases vasopressin


Na
+
130 Cl
-
109 K
+
4 Ca
++
3 laktat
-
28
Na
+
154 Cl
-
154
Na
+
130 Cl
-
109 K
+
4 Ca
++
3 asetat
-
28
Syok + asidosis
Syok + alkalosis
Hiponatremia
Larutan Pengganti (Isotonik kristaloid)
Resuscitation
Na
+
154
Na
+
130
Maintenance
Na
+
77
Na
+
50 K
+
20, glu 27 g
Maintenance Solution
Na
+
50 Cl-50 K
+
20 Laktat- 20 Glu 27 gr
Na
+
50 Cl-50 K
+
20 Laktat- 20 Glu 100 gr
Maintenance Solution
Inpatient Problems
Dehydration
Anorexia
Fatigue
FATIGUE
Role of serotonin in central fatigue has been explored
1. Ryan JL, Carroll JK, Ryan EP et al. Mechanisms of cancer-related fatigue. The Oncologist
2007;12(suppl 1):2234
2. Castell LM, Yamamoto T, Phoenix J, Newsholme EA. The role of tryptophan in fatigue in
different conditions of stress. Adv Exp Med Biol. 1999;467:697-704.
3. Yamamoto T, Castell LM, Botella J, Powell H, Hall GM, Young A, Newsholme EA. Changes
in the albumin binding of tryptophan during postoperative recovery: a possible link with
central fatigue?Brain Res Bull. 1997;43(1):43-6. Erratum in: Brain Res Bull 1997;44(6):735
4. McGuire J et al. Biochemical markers for post-operative fatigue after major surgery Brain
Research Bulletin 60 (2003) 125130. Elsevier Science Inc
5. GJ Rubin, M Hotopf. Systematic review and meta-analysis of interventions for postoperative
letih. British Journal of Surgery 2002 89: 971-984.
6. DeCherney AH, Bachmann G, Isaacson K, Gall S.Postoperative fatigue negatively impacts
the daily lives of patients recovering from hysterectomy. Obstet Gynecol. 2002 Jan;99(1):51-
57

How do
BCAAs
improves
appetite ?

POMC
NPY
AgRP

Neuron
Food
Intake
Energy
Expenditure
Melanocortin (anorexigenic)
NeuroPeptideY/
Agouti-related
paptide (prophagic)
POMC

NPY
AgRP
Neuron
Diseases

Cytokines
(TNF,IL-1,IL-6)
5-HT

+
Anorexia

Tryp

BCAA
POMC

NPY
AgRP

Neuron
Diseases
Cytokines
(TNF,IL-1,IL-6)
5-HT
+
Appetite
Tryp

BCAA
Na
+
77
MAINTENANCE SOLUTIONS
1
st
generation 2
nd
generation 3
rd
generation
KAEN 3B
AMINOFLUID
No 1 Infusion solution in Japan

1 million softbag / month

2007 :First import into Indonesia &
launched (1000 ml)

End 2009 : Manufactured locally (500 ml)

KOMPOSISI
Recommended Indications?
Febrile illnesses. Fever increased IWL.
dehydration/dry mouth

Gastrointestinal disorders: Chronic diarrhea ,
malabsorption

Acute infection: Pneumonia, Hepatitis A, DHF (grade 1 &
2), etc

Hyperemesis gravidarum, postoperative nutrition support

Precaution: Renal failure, heart failure, young children
Safety Issue
Phlebitis

Hyperglycemia

Comorbidity
Grades 1 & 2 DHF
Aminofluid
Maintain electrolyte (potassium) homeostasis
Correct intracelullar dehydration
Prevent worsening of nutritional state in times of
insufficient oral food intake
Keep normal blood sugar level, and other serum
biochemistry
Increase appetite by reducing central 5HT

Combat fatigue
Facilitate enzymatic process and protein synthesis
Facilitate recovery
Take-Home Messages

Maintenance fluid therapy should be considered as an
important integral part of disease management.

It has evolved from simply giving water and electrolyte in
simple container to practical and complete composition
in advanced dual-chamber formulation

Most important goal of maintenance therapy is to correct
homeostasis, improve sense of well-being, combat
fatigue, increase appetite and finally faster recovery