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Fluid therapy
 

Fluid therapy

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    Fluid therapy Fluid therapy Presentation Transcript

    • Fluid & Electrolyte TherapyFluid & Electrolyte Therapy • C.S.N.VittalC.S.N.Vittal
    • Components of Body Water  ECF  Intravascular fluid: within blood vessels (5%)  Interstitial fluid: between cells - blood vessels (15%)  Transcellular fluid: cerebrospinal, pericardial, synovial  ICF  Inside cell  Most of body fluid here - 40% weight  Decreased in elderly
    • Body Fluid Composition Electrolyte : …is a substance capable of conducting electric current in solution. They exist in ions > Cations : Na+ , K+ , Ca++ etc. > Anions : Cl- , HCO3 - Conc. of electrolytes – expressed in mEq/L Equivalent weight: wt. of the substance in grams that can combine with or displace 1 gram of hydrogen. = atomic weight / valance For monovalent ions, 1 equivalent = 1 mole For divalent ions, 1 Eq = 0.5 mol For trivalent ions, 1 Eq = 0.333 mol
    • Body Fluid Composition Osmolality : …is a count of the total number of osmotically active particles in a solution and is equal to the sum of the molalities of all the solutes present in that solution. Normal = 290 mOsm/Kg Molarity is the number of particles of a particular substance in a volume of fluid (mmol / L) & Molality is the number of particles disolved in a mass weight of fluid (mmol / kg)
    • ELECTROLYTE BALANCE  The exchange of interstitial and intracellular fluid is controlled mainly by the presence of the electrolytes sodium and potassium NaNa++ KK++ NaNa++ KK++ NaNa++ KK++ NaNa++ KK++
    • Body Fluid Compartments Plasma Interstitial Fluid Intracellular Fluid Na+ 142 K+ 5 Ca++ 5 Mg++ 3 HCO3 – 24 Cl – 105 Protein 15 SO4 – 4 R – 2 HPO4 – 5 Na+ 144 K+ 5 Ca++ 5 Mg++ 3 HCO3 – 27 Cl – 118 SO4 – 4 R – 2 HPO4 – 5 Na+ 6 K+ 154 Mg++ 3 HCO3 – 24 Protein 15 R – 4 HPO4 – 106 SO4 – 17
    • ELECTROLYTE BALANCE  Potassium is the chief intracellular cation and sodium the chief extracellular cation  Because the osmotic pressure of the interstitial space and the ICF are generally equal, water typically does not enter or leave the cell KK++ NaNa++
    • Water is …  At Birth  75% of body wt.  By 2 years  60 % of body wt.  40% ICF  20% ECF  5% Intravascular (plasma)  15% Interstitial  Adult  55% - Males  51% - Females
    • Regulation of Body Water & Electrolytes  For every 100 Cal metabolized, body .. Loses Gains  65 ml water in urine  40 ml by sweating  15 ml from lungs  5 ml in feces  15 ml from metabolism Net loss of water = 110 ml per 100 Cal metabolized
    • Fluid Loss  Absolute deficit of ECF  Diarrhoea  Vomiting  Polyuria  Decreased intake  Decrease in effective circulation  Nephrotic syndrome  Cirrhosis of liver  Portal hypertension
    • Fluid Regulation  Antidiuretic hormone  Aldosterone (Renin – Angiotensin)  Atrial natruretic peptide  Thirst mechanism  Hypothalamus
    • Fluid Regulation ANP ADH Aldosterone (Renin – AT) Hypo thelamus Thirst KK++ NaNa++
    • ELECTROLYTE BALANCE  A change in the concentration of either electrolyte will cause water to move into or out of the cell via osmosis  A drop in potassium will cause fluid to leave the cell whilst a drop in sodium will cause fluid to enter the cell KK++ H2O H2O H2O H2O H2O H2O H2O H2O KK++ KK++ KK++ NaNa++ NaNa++ NaNa++ NaNa++
    • Why Infants are more vulnerable to water loss  Physiological inability of their renal tubules to concentrate  Higher metabolic rate  Larger body surface area  Poorly developed thirst mechanism  Larger turnover water exchange (50% of ECF every day)
    • Dehydration  Water isn’t replaced in body  Fluid shifts from cells to EC space  Cells lose water  Happens in confused, comatose, bedridden persons along with infants & elderly
    • Degrees of Dehydration  Mild 3 – 5 %  Moderate 7 – 10 %  Severe 10 – 15 %
    • Symptoms of Dehydration  Restlessness  Excessive Thirst  Oliguria  Fever ± Mild:
    • Signs of Dehydration  Tachycardia  Oliguria  Irritable / lethargic  Sunken eyes and fontanel  Decreased tears  Dry mucus membranes  Mile tenting of skin  Delay in CFT  Cool & pale Moderate:
    • Signs of Dehydration  Rapid & weak pulse  Decreased BP  No urine output  Very sunken eyes & fontanel  No tears  Tenting of skin  CFT – very delayed  Cold & mottled skin  Parched mucus membranes Severe:
    • Degrees of Dehydration From treatment point of view, dehydration is usually classified as :  No dehydration,  Some dehydration and  Severe dehydration. Some Dehydration When symptoms and/or signs of dehydration are present. Severe Dehydration In the presence of shock and lethargy it is referred to as severe IMNCI System
    • Diarrhoea Treatment Instructions
    • Oral Rehydration Therapy  ORT is the cheap, simple and effective way to treat dehydration caused by diarrhoea.  Many of the millions of children who die every year in developing countries from diarrhoea could be saved if they were given ORT promptly.  This includes giving extra fluids at home such as tea, soups, rice water and fruit juices to prevent dehydration, and the use of Oral Rehydration salts (ORS) solutions to treat dehydration
    • Physiologic Basis For ORS  Sodium passes into these outermost cells by co-transport facilitated diffusion via the SGLT1 protein.  The co-transport of sodium into the epithelial cells via the SGLT1 protein requires glucose.  Two sodium ions and one molecule of glucose/galactose are transported together across the cell membrane through the SGLT1 protein.
    • WHO ORS Formulae - comparison Standard ORS (g/L) --- (mEq/L) Reduced osmolarity ORS (2003) Sodium Chloride 2.6 90 75 Chloride 80 65 Potassium chloride 1.5 20 20 Trisodium Citrate 2.9 10 10 Anhydrous Glucose 13.5 111 75 Total Osmolarity 311 245 (All values in mmol / litre)
    • Advantages of Low Osmolar ORS • Reduces stool output by about 25% when compared to the standard WHO ORS. • Reduces vomiting by almost 30% • Reduces the need for IV therapy by > 30%. • Results in reduced hospitalization
    • Super ORS … are the special types of ORS which instead of mono-sugars contain more complex sugars. They may be Food- based ( as rice-based ) or otherwise be starch-free (Glycine / alanine based or Glucose polymer based Advantages of Super-ORS  Provides rehydration.  Helps in reducing the stool output, frequency of stools and duration of diarrhea.  Furnishes increased amount of calories (180 kcal/ litre)  Contributes to weight gain, as it provides additional nutrition (thus is especially useful for those who are malnourished).  With gradual release of glucose, prevents secondary disaccharide intolerance. Disadvantages  Short shelf-life (not exceeding 10 hours)
    • Resomal  An oral rehydration salt (ORS) adapted to the needs of the severely malnourished patients. Ingredient Amount Water (boiled & cooled) 2 litres WHO-ORS One 1 litre-packet Sugar 50 g Electrolyte/mineral solution 40 ml (K, Mg and Zn) ReSoMal contains approximately 45 mmol Na, 40 mmol K and 3 mmol Mg/litre ReSoMal solution must only be given orally in small sips / by NG tube.
    • Management of Diarrhoea Plan A: Treat Diarrhoea at Home Plan B: Treat Some Dehydration with ORS Plan C: Treat Severe Dehydration Quickly
    • ORT to prevent Dehydration – Plan A Counsel the mother 4 rules of Home Treatment 1. Give Extra fluid (as much as the child takes) 2. Give Zinc supplements 3. Continue Feeding 4. When to Return
    • ORT to prevent Dehydration – Plan A 1. Give Extra fluid (as much as the child takes) 1. Tell mother to breast feed, give ORS, food based fluids (soup, rice water, yoghurt drinks), or clean water 2. Teach mother how to mix and give ORS 3. Show how much extra fluid to give in addition to usual fluid intake 1. Upto 2 yrs : 50 – 100 ml after each loose stool 2. 2 yrs or more : 100 – 200 ml
    • ORT to prevent Dehydration – Plan A 2. Give Zinc Supplements 1. Tell mother how much zinc to give 1. Up to 6 mo : ½ tab per day for 14 days 2. 6 mo and > : 1 tab per day for 14 days 2. Show mother how to give zinc supplements 3. Remind mother to give zinc for full 14 days
    • ORT to prevent Dehydration – Plan A 3. Continue Feeding 4. When to Return 1. Immediately : 1. Child is not able to drink or breastfeed 2. Child becomes sicker 3. if blood per stool or 4. drinking poorly 2. After 5 days : if diarrhoea persists
    • Prevention of dehydration – Plan A Age Amt of ORS after each stool < 24mo 50 - 100ml 2yr -10yr 100 - 200ml > 10yrs As much as wanted How much ORS ?
    • ORT to prevent Dehydration – Plan B for Patients with physical signs of Dehydration a) Correction of existing water and electrolyte deficit as indicated by the presence of signs of dehydration b) Replacement of ongoing losses due to continuing diarrhoea to prevent recurrence of dehydration c) Provision of normal daily fluid requirement
    • Weight Wt 6 kg 6 – 10 kg 10 – 12 lg 12 – 19 kg Use child’s age only when you do not know the weight. Approx amt of ORS required (ml) = Child’s Wt. in Kg. X 75
    • SOME DEHYDRATION: PLAN B  ORS: 75ml/kg plus for ongoing losses (50ml/stool)  one liter of potable water + one full sachet of ORS to be dissolved & kept in a container with lid.
    • When is ORT ineffective ?  High stool purge rate ( > 5 ml/kg/hr)  Persistent vomitings ( > 3 / hr)  Incorrect preparation of ORS  Abdominal distension  Glucose malabsorption
    • Children with Severe Dehydration – Plan C  Start IV fluids immediately  While drip is being set up give ORS of child can drink
    • Parenteral Fluid Therapy 1. Deficit 2. Maintenance 3. Ongoing losses replacement
    • Principles Of Rehydration 1. Step I • Restore intravascular volume • Normal saline (20ml/kg) over 20 minutes (Repeat until intravascular volume restored) 2. Step II • Calculate 24 hour water needs (maintenance & deficit) • Calculate 24 hour electrolyte needs • Both maintenance & Deficit sodium and potassium • Subtract the fluid volume/ electrolyte concentration used in resuscitation phase. 3. Step III • Replace ongoing losses
    • Electrolyte Deficit  Rapid Dehydration (< 2 days)  Ratio of ECF to ICF deficit is 75 : 25 %  Moderately Rapid Dehydration (2-7 days)  Ratio of ECF / ICF is 60 : 40 %  Slow Dehydration (>7days)  Ratio of ECF / ICF is 50 : 50 %
    • Classification of Dehydration based on Tonicity  Isonatremic (Isotonic) Dehydration  Serum Na =135 to 145 mEq./L  Hyponatremic (Hypotonic) Dehydration  Serum Na < 130 mEq./L  Hypernatremic (Hypertonic) Dehydration  Serum Na >145 mEq./L
    • Concept of Maintenance Fluids Principles of Therapy -2. MAINTENANCE Calculation based on caloric expenditure
    • Concept of Maintenance Fluids Calculation based on caloric expenditure [ Holiday & Segar Formula ] Wt. Calories Expended Maintenance waterWt. Calories Expended Maintenance water Till 10 Kg 100 Cal / Kg 100 ml / Kg 10 – 20 Kg 1000 Cal + 50 Cal for 1000 ml + 50 ml for Every Kg > 10 / Kg Every Kg >10 / Kg 20 Kg 1500 Cal + 20 Cal for 1500 ml + 20 ml for every Kg above 20 Kg every Kg above 20 Kg
    • Concept of Maintenance Fluids Route Water Na K Evaporative  Lungs  Skin 15 40 0 0.1 0 0.2 Stool 5 0.1 0.2 Urine 65 3.0 2.0 TOTAL 125 3.2 2.4 Less Metabolic Water 10 – 15 110 - 115 Loss per 100 Cal. of metabolism per Day
    • Concept of Maintenance Fluids Calculation based on caloric expenditure [ Holiday & Segar Formula ] Wt Water (ml /day) Water ml / hr Electrolytes mEq / L of water 0 – 10 kg 100 ml / kg 4 / kg Na 30, K 20 10 – 20 kg 1000 + 50 ml /kg for each kg above 10 40 + 2 / kg for each kg above 10 Na 30, K 20 > 20 kg 1500 + 20 ml /kg for each kg above 20 60 + 1 / kg for each kg above 10 Na 30, K 20 Baseline estimates are affected by fever (increasing by 12% for each degree > 37.8° C), hypothermia, and activity (eg, increased for hyperthyroidism or status epilepticus, decreased for coma).
    • Concept of Maintenance Fluids Example : 22 kg child For the first 10 kg: 10 X 100 = 1000 ml For the second 10 kg 10 X 50 = 500 ml For every kg > 20 2 X 20 = 40 ml TOTAL = 1540 ml / 24 hrs i.e. = 64 ml / hr maintenance fluid
    • Concept of Maintenance Electrolytes  Insensible water losses contain no electrolytes  Na+ and K+ losses are those present in urine, feces and sweat. •3 mEq of Na in 100 ml of fluid •2 mEq of K in 100 ml of fluid
    • Maintenance Fluid and Glucose Maintenance fluid must contain glucose –  To prevent hypoglycemia  To prevent catabolism by providing calories • If 20 % of caloric requirement is met, tissue catabolism can be avoided • 5 g of glucose (provide 20 Cal. Is added to 100 ml of maintenance fluid)
    • Concept of Maintenance Fluids Composition  Differs from solutions used to replace deficits and ongoing losses.  Patients require  Na 3 mEq/100 kcal/24 h (3 mEq/100 mL/24 h) and  K 2 mEq/100 kcal/24 h (2 mEq/100 mL/24 h).  This need is met by using 0.2% to 0.3% saline with 20 mEq / L of K in a 5% dextrose solution.  Other electrolytes (eg, Mg, Ca) are not routinely added.
    • Maintenance Fluid and Glucose Maintenance fluid Choice – < 1 yr : 0.2% NaCl, 5% D/W plus 2 mEq KCl / 100 ml > 1 yr : 0.33% NaCl, 5% D/W plus 2 mEq KCl / 100 ml > 3 yr : 0.45% NaCl, 5% D/W plus 2 mEq KCl / 100 ml  Rate : at 64 ml / hr
    • Calculating Deficit, Maintenance and Total Electrolytes  Moderately Rapid (2-7 days)  Therefore ECF / ICF Ration is 60 / 40 %  Deficit Water is 1000 ml  ECF Component is 60% (600 ml) and  ICF component is 40% (400 ml)  Principle electrolyte in ECF is Na which is 140 mEq/L For 600 ml = 84 mEq.  Principle electrolyte in ICF is K which is 150 mEq/L For 400 ml = 60 mEq.
    • Calculating Deficit, Maintenance and Total Electrolytes  Maintenance / d 1000 30 20  ECF Water Deficit 600 84 -  ICF Water Deficit 400 - 60  Total 2000 114 80 H2O Na K ml mEq mEq
    • Na+ K + Cl - Bicarb++ Ca ++ G/100 ml mOsml/L D5-W 5 252 D10-W 10 505 Normal Saline (0.9%) 154 154 308 0.45% Na Chloride 77 77 154 0.45% Na Cl + 5% Dex 77 77 5 400 0.33% Na Cl + 5% Dex 56 56 5 350 D5-Normal Saline 154 154 560 D5-0 45% Na Chloride 77 77 406 D5-0.2% Na Chloride 34 34 321 D5-Ringer's Lactate 130 4 109 28 2.7 525 Ringer's Lactate 130 4 109 28 2.7 273 3% Na Chloride 513 513 1027 Ready Mixed Solutions (Electrolyte Content is meq per Liter)
    • Fluid Therapy  Phase 1 : (Shock Therapy)  Restoration of volume - 1 to 2 hrs 20 ml / Kg N.Saline or R.L. rapid IV
    • Fluid Therapy  Phase 2 :  Replacement of ½ the calculated fluid loss (Deficit + Maintenance) in first 8 hrs.
    • Fluid Therapy  Phase 3 :  Replacement of ½ the calculated fluid loss (Deficit + Maintenance) in next 16 hrs  Replacement of K+ (after voiding with a max. of 40mEq/L)  Half the potassium deficit is replaced in 1st day
    • Calculating pre-illness weight: Eg. Infant with moderate isonatremic dehydration – weighing now 5.3 kg  Pre illness weight is say ‘X’  X / 5.3 = 100 / 90  X = 530 / 90 = 5.9 kg. Deficit is (10 % Dehydration) = 600 ml. Maintenance fluid = 600 ml (Holideay& Segar)
    • Eg. 10 Kg child  Phase 1 (1st hr)  20 ml / Kg of NS (200 ml of NS, 31 mEq. of Na)  Phase 2 (2-8 hrs)  Replace half the fluid loss in next 7 hrs  900 ml in 7 hrs That is 129 ml / hr  We like to add Na in a conc of 46 mEq. L (which is roughly in 1/3rd NS  We can use 1/3 NS in 5% D/W at 129 ml / hr.  Phase 3 (hrs. 9-24) [ patient voids ]  Replace remaining half of fluid loss and add K now  900 ml over 16 hrs of D5, 1/3 NS at 56ml/hr  (Pt has 25mEq/L of K loss. We are replacing 900 ml (roughly 1 L) of fluid we may chose 25mEq./L of KCl
    • Treating Hypotonic Dehydration (S. Na+ < 130 mEq/L)  First calculate the total fluids and electrolytes needed for isonatremic dehydration plus maintenance fluids.  Then use the following formula to raise the serum sodium: Wt (kg) x 0.6 x desired mEq increase in serum Na+  After correction of shock, prefer ½ N DNS rather than 1/3 N DNS  If child is convulsing : 3ml/Kg of 3% Nacl over 10-15 min  Raising the S.Na by 5 mEq/L is sufficient to control symptoms.
    • Treating Hypertonic Dehydration (S. Na+ > 150 mEq/L)  This type of dehydration is usually the most serious and correction should be done with caution. Rapid correction  May result in CNS problems.  Generally, elevated serum sodium should be lowered no faster than 15 mEq/L in 24 hours.  One simple way is to calculate the total maintenance and deficit fluid and electrolytes that would be used in isotonic dehydration but keep sodium at maintenance levels.  Give deficit fluid over 48 hrs rater than 24 hrs  Hydrating fluid must contain Na +
    • Treating Potassium Deficits  Regardless of the deficit, the usual maximum  concentration of K+ is 4 mEq per 100 ml of IV fluid (for peripheral infusion).  For most instances 2-3mEq per 100 ml will suffice.  In cases of hypokalemia higher levels can be used, but the heart should be monitored.  Before giving potassium be aware of the possible existence of renal failure.
    • Replacement of ongoing losses Average composition of diarrhoeal stools  Na+ 55 meq/l  K+ 25 meq/l  HCO3 15 meq/l  Fluid for replacement (ml/ml every 1-6 hourly)  D 5 with 1/4 NS + 15 meq /l bicarbonate + 25 meq/l of KCL.
    • Priniciples of Rehydration - Summary  Select an appropriate fluid (based on total water and electrolyte needs)  Administer half the calculated fluid during the first 8 hours  Administer the remainder over the next 16 hours  Don’t add KCL until the child voids urine.
    • - Vittal