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13 Fluid Therapy

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  • 1. Fluid Therapy Mbbs.weebly.com
  • 2. Last lesson Emphasis Etiology (in/ex/no) Pathogenesis (4+ex/b/v/no) Clinical manifestation Diagnosis Differential Diagnosis (p/d/n) Treatment Predisposing (4)
  • 3.
    • Not difficult
    • According to clinical manifestation, laboratory tests and character of stool.
    Diagnosis + + Infectious Or Noninfectious Dehydration Degree and quality Electrolyte disturbances And Disturbance of acid-base balance
  • 4. Case example An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. PE: Pulse rate 150/min, weight loss was 10%, blood pressure 65/40mmHg, skin color showed grey and skin turgor looked like tents. Mucous membranes were very dry; eye ball was sunken greatly, anterior fontanel depressed greatly. Abdomen distended, bowel sound diminished. Questions: 1.What is the diagnosis? 2.How to administer the fluid therapy?
  • 5. Answer diagnosis
    • Acute diarrhea
    • severe dehydration
    • hypokalemia
  • 6. Neonate …………… ... 80% Older children ……… ..65% Adult ………………… ..60% features of body fluid balance in children The younger The larger proportion of body water Total body water (by body mass) ----amount of body fluid
  • 7. features of body fluid balance in children The younger The larger proportion of extracellular water Intracellular Body fluid Extracellular Interstitial fluid Plasma Lymph fluid Secretory juice ----distribution of body fluid
  • 8. P 6% IF 37% IC 35% IF 20% IF 10% ~ 15% IF 25% IC 40% P 5% P 5% P 5% IC 40% IC 40%~45% Neonate 78% ~1y 70% 2y~14y 65% Adult 55%~60% features of body fluid balance in children P: plasma IF: interstitial fluid IC: intracellular ----distribution of body fluid in different ages (by BW)
  • 9. features of body fluid balance in children ----water requirement
    • Requiring more water
    • Regulating function poorly
    • Easy water metabolism disturbance
  • 10.
    • Due to grow quickly, need 0.5%~3% water for growth.
    • Insensible water loss : 2 times more than adult.
    • Fluid exchange of digestive tract quicker.
    • Water metabolism higher: infant 1/2 by total fluid
    • adult 1/7 by total fluid.
    • Regulating function of water metabolism poorly:
    • kidney, lung.
    features of body fluid balance in children ----water requirement
  • 11.
    • Similar with adult
    Extracellular: Na + , Cl - , Hco 3 - Intracellular: K + , Mg  , Hpo 4 = , protein
    • Features of neonate ( Several days after birth ) :
    Composition of body fluid
    • Particularly in preterm infant
    K + , Cl - , P, lactic acid Na + , Ca ++ , Hco 3 - Function of excluding H + Acidosis
  • 12. Acid-base balance and adjust ----two concept
    • Acid-base balance
    • Acidity and alkalinity
    • Anion-cation balance
    • Anion and cation
  • 13.
    • Compensation of adjust has limit
    Acid-base balance and adjust ----body liquid
    • Buffer system
    • lung : exhale of store CO 2 (respiratory)
    • kidney: exclude H + and store Na + (metabolic)
    NaHCO 3 /H 2 CO 3 Na 2 HPO 4 /NaH 2 PO 4 Buffer system of plasma protein Adjust HCO 3 - NaHCO 3 /H 2 CO 3 =20:1
  • 14.
    • PH : 7.4 (7.35 ~7.45)
    • PaCO 2 : 40 (34 ~45) mmHg
    • SB : 24 (22 ~27) mmol/L
    • BE : -3 ~ +3 mmol/L
    • CO 2 CP : 22 (18 ~27) mmol/L
    Acid-base index Blood gas analysis ( normal )
  • 15.
    • Compensation & decompensation
    Acid-base balance disorder
    • respiratory acidosis
    • respiratory alkalosis
    • metabolic acidosis
    • metabolic alkalosis
  • 16. Electrolyte disturbance Diarrhea complicated
    • hyponatremia & hypernatremia
    • hypokalemia
    • hypocalcemia
    • hypomagnesemia
  • 17. Severity clinical signs of dehydration Dehydration mild moderate severe Water loss By weight Spirit Skin Mocous Anterior fontanel and eye ball Tear Urine output Peripheral circulation < 50ml/kg < 5% Slightly dispirited slightly agitated Slightly dry Slightly dry Slightly depressed Normal Slightly reduced normal 50 ~ 100ml/kg 5% ~ 10% Dispirited Agitated Dry, pale Very dry depressed Reduced Little or No Little cool 100 ~ 120ml/kg > 10% Extremely dispirited apathy, hypnody, coma Gray mottled Parched depressed greatly No No urine output Cool, weak pulse,shock
  • 18. Dehydration Same proportion loss P IF C P IF C Electrolyte loss more P hypotonic, IF+C hypertonic Cell expansion Severe Easy to shock P: plasma, IF: interstitial fluid, C: cell Isotonic P IF C Water loss more P hypertonic IF+C hypotonic Cell hydration Mild Thirsty Acute diarrhea after vomiting greatly Hypotonic Hypertonic Na+ : 130 ~ 150mmol/L Na+: < 130mmol/L Na+: > 150mmol/L
  • 19.
    • Dispirited, dysphoria, drowsiness, coma
    • Hypernea (Kussmauls breathing) , exhalation cool
    • Expiratory gas smells ketone
    • Cherry lips
    • Nausea, vomit
    Metabolic acidosis--clinical manifestation Mild: breath frequency slightly Severe: occur:
  • 20.
    • K + (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L)
    • causes :
    • Excessive losses: vomit, diarrhea.
    • Inadequate intake.
    • Renal function of keeping kalium ,it continues excluding kalium when with hypokalemia.
    Clinical manifestation-3: electrolyte disorder Hypokalemia
  • 21.
    • depressed
    • Tension of skeletal muscle , tendon reflex ,
    • even respiratory muscle weakness
    • Tension of smooth muscl , abdominal extension,
    • intestinal sound or disappear
    • Myocardium excitability , arrhythmia, ECG: T-wave
    • is low or inversion, U-wave occurs, prolonged P-R
    • interval and Q-T interval, ST section descending.
    • Baseosis
    hypokalemia K+ (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L) Clinical manifestation: nerve and muscular excitability
  • 22.
    • Ca 2+ ﹤1.75mmol/L (7mg/dl) ;
    • Mg 2+ ﹤0.6mmol/L (1.5mg/dl).
    • Symptoms usually occur after dehydration and
    • acidosis resolved, or fluid replacement.
    • Clinical manifestation: thrill, tetany, convulsion.
    • If convulsion hasn ’ t relieved after supplement
    • calcium, pay attention to hypomagnesemia.
    hypocalcemia & hypomagnesemia
  • 23. Fluid Therapy
  • 24. To cure water and electrolyte disturbance Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte Normal physiological function Purpose
  • 25. oral intravenous Method
    • prevention dehydration: Rice soup add salt solute ( 1/3 )
    • Mild dehydeation: ORS 。
    • Mild/moderate dehydeation : ORS
    • —— mild: ORS : 50 ~ 80ml/kg
    • —— moderate: ORS : 80 ~ 100ml/kg
    • Severe dehydration or vomiting and diarrhea
    • —— intravenous
  • 26.
    • NaCl : 3.5g
    • NaHCO 3 (Sodium citrate) : 2.5g (2.9g)
    • KCl : 1.5g
    • GS : 20g
    oral rehydration salts ( ORS ) Na+ 90mmol /L,K +20mmol /L, Cl - 80mmol /L, HCO3 - 30mmol /L Add water to 1000ml 2 / 3 isotonic , Total osmotic pressure: 220mmol /L Can be diluted in Children
  • 27. 口服补液盐 Oral rehydration salt (ORS)
    • WHO2002 年推荐的低渗透压 ORS 配方
    • 成分 含量 ( 克 )
    • NaCl 2.6
    • 枸橼酸钠 2.9
    • KCl 1.5
    • 葡萄糖 13.5
    • 水 1000ml
    • 该配方中各种电解质浓度为: Na + 75mmol/L , K + 20
    • mmol/L , C1 - 65 mmol/L ,枸橼酸根 10mmol/L ,葡萄糖 75m
    • mol/L 。总渗透压为 245 mOsm/L
    sodium citrate could instead by NaHCO3
  • 28.
    • Na + -- GS transport of Small intestine
    Na + – GS carrier enterocyte Brush border intracellular  intercellular  blood Na + GS Na + GS transport promote Na + 、 H 2 O absorb  Na + (pump)  intercellular space(Cl - )  OP   H 2 O into blood Mechanisms of ORS
  • 29. Characteristics of ORS ---Advantages
    • Osmotic pressure similar with plasma( 2/3 tonicity)
    • Correct losses by proper concentration of Na + 、 K + 、 Cl -
    • Children easily accept the tastes
    • Correct metabolic acidosis by sodium citrate
    • Promote Na + and H 2 O absorption by 2% GS
  • 30. Characteristics of ORS ---disadvantages
    • Liquid tonicity higher (2 / 3)
    • Can not be used as the maintenance media
    • Na + concentration is relatively higher to neonates
    • and infants (proper diluted) .
  • 31.
    • ORS :
    • Rice soup 500ml+ salt 1.75g
    • Fried rice noodles 25g + salt 1.75g
    • + water 500ml (Cooking 2 - 3min)
    • GNS:
    • White sugar 10g + salt 1.75g + water 500ml (boil)
    Simple preparation at home
  • 32. Sever dehydration
    • intravenous
  • 33.
    • Osmotic pressure of plasma (OPP)
    • OPP= (crystal + colloid) osmotic pressure
    Na + 142 Cation: K + 5 (mmol) Ca ++ 2.5 Mg ++ 1.5 HCO 3 - 27 Anion: Cl - 103 (mmol) HPO 4 = 1 SO 4 = 0.5 Organo-anion 19.5 151 mmol/L 151 mmol/L OPP range : 280 - 320mOsm/L Concentration of electrolyte and calculation
  • 34.
    • Na : Cl=3 :2 ( in plasma )
    Fluid isotonic Isotonic liquid: osmotic pressure similar with plasma Sodium isotonic:
    • Isotonic: 150mmol sodium in 1000ml
    • ½ tonicity: 75mmol sodium in 1000ml
    • 2/3 tonicity: 100mmol sodium in 1000ml
    • 1/3 tonicity: 50mmol sodium in 1000ml
  • 35. Liquid solution commonly used 5%GS 10%GS 0.9%NaCl 10%NaCl Ringer 5% NaHCO3 11.2% NaL 10%KCl Mixture nonelectrolyte solution electrolyte solution glucose enter the body by oxidation change into water and CO2 for energy and water without tension
  • 36.
    • 10%NaCl : 1ml=1.7mmol
    • 5%NaHCO 3 : 1ml=0.6mmol
    • 11.2%NaL : 1ml=1mmol
    • 10%KCl : 1ml=1.34mmol
    Calculation
  • 37. The element and simple dispensing in the commonly mixed solution
    • Solution composition ratio dispensing (ml)
    • NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl
    • 2:1 isotonic solution . 2 1 500 30 47
    • 1:1 solution (1/2 tonicity) 1 1 500 20
    • 2:3:1 solution (1/2tonicity)2 3 1 500 15 24  
    • 4:3:2 solution (2/3tonicity)4 3 2 500 20 33  
    • 1:2 solution (1/3 tonicity)1 2 500 15  
    • 1:4 solution (1/5 tonicity) 1 4 500 9  
    • daily requirement
    • (1/3tonic) 1 4 500 9 7.5
  • 38. 常用溶液成分 溶 液 每 100ml 含 Na∶Cl 电解质渗透压 血 浆 ( 142 : 103 ) 3 : 2 300mmol/L ① 0.9% 氯化钠 0.9g 1∶1 等张 ② 5% 或 10% 葡萄糖 5 或 10g ③ 5% 碳酸氢钠 5g 3.5 张 ④ 1.4% 碳酸氢钠 1.4g 等张 ⑤ 10% 氯化钾 10g 8.9 张
  • 39. 溶 液 每 100ml 含 Na∶Cl 电解质 1∶1 含钠液 ① 50ml,②50ml 1∶1 1/2 张 1∶2 含钠液 ① 35ml,②65ml 1∶1 1/3 张 1∶4 含钠液 ① 20ml,②80ml 1∶1 1/5 张 2∶1 含钠液 ① 65ml,④35ml 3∶2 等张 2∶3∶1 含钠液 ① 33ml,②50ml ④ 17ml 3∶2 1/2 张 4∶3∶2 含钠液 ① 45ml,②33ml 3∶2 2/3 张 ④ 22ml 续 表
  • 40. Water supplement & correct acidosis
    • Accumulative losses
    • ---losses from onset to pre-treatment
    • ongoing losses
    • ---continuing losses during treatment
    • daily requirement
    • ---to maintain basically physiological function
    Amount , composition and time
  • 41. To master three principles
    • The volum of rehydration
    • Deficit fluid
    • =(percentage of dehydration)×(body weight in Kg)
    • The type of fluid
    • Isotonic dehydration—— 1/2 tonicity solution
    • Hypotonic dehydration—— 2/3 tonicity solution
    • Hypertonic dehydration—— 1/3 tonicity solution
    • The speed of liquid : four steps
  • 42. four steps (for fluid and electrolyte deficits)
    • Step 1. Expanding volume:
    • restoration of circulation –emergency,
    • within 30 min to 1 hour
    • 20ml/kg, 2:1 (isotonic )sodium solution
    • Step 2. supplement lost body liquid:
    • first 8~10 hours
    • 8~10ml/h
    • half of total loss volume
    • 2:3:1 solution(1/2 tonicity)
  • 43.
    • Step 3. maintenance rehydration:
    • - next 16 hours
    • 5ml/(kg.h)
    • - another half loss
    • physical demand : 60~80ml/kg
    • 4:1 solution(1/3~1/2 tonicity)
    • Step 4. repair of potassium deficit
    four steps
  • 44. Accumulation losses amount mild : 50ml/kg moderate: 50 ~100ml/kg severe : 100 ~120ml/kg Water supplement-1: accumulation losses Amount , composition and speed: --- according to the degree and quality of dehydration
  • 45. composition isotonic : 1/2 tonicity(1:1) hypotonic : 2/3 tonicity(4:3:1) Hypertonic:1/3~1/5 tonicity ( 1/3 tonicity) speed Principle: fast slow severe : bolus of isotonic fluid 2:1 tonicity : 20ml/kg (<300ml ) in 30’~1h(rapidly expand) others : 8~12h ( 8 ~ 10ml/ ( kg·h ) iv Water supplement-1 : accumulation losses Accumulation losses Dehydration :
  • 46. Severity clinical signs of dehydration Dehydration mild moderate severe Water loss By weight Spirit Skin Mocous Anterior fontanel and eye ball Tear Urine output Peripheral circulation < 50ml/kg < 5% Slightly dispirited slightly agitated Slightly dry Slightly dry Slightly depressed Normal Slightly reduced normal 50 ~ 100ml/kg 5% ~ 10% Dispirited Agitated Dry, pale Very dry depressed Reduced Little or No Little cool 100 ~ 120ml/kg > 10% Extremely dispirited apathy, hypnody, coma Gray mottled Parched depressed greatly No No urine output Cool, weak pulse,shock
  • 47. Ongoing losses amount 1/2~1/3 tonicity(1:1) speed
    • 12~16h after stage-1
    • In 24h, steady speed
    • 5ml/ ( kg·h )
    10~40ml/kg.d composition Water supplement-2: ongoing losses
  • 48. daily requirement amount 1/3~1/5 tonicity (Physical main medium) speed
    • In 24h, steady speed
    • Accompany with stage-2
    60~80ml/kg.d ( including oral ) composition Water supplement-3: daily requirement
  • 49.
    • Dehydration
    • Fluid replacement=losses
    • (Accumulation + ongoing + daily )
    • Accumulation ongoing daily total amount
    • (ml/Kg)
    • mild 50 10 ~ 30 60 ~ 80 90 ~ 120
    • moderate 50 ~ 100 10 ~ 30 60 ~ 80 120 ~ 150
    • Severe 100 ~ 120 10 ~ 30 60 ~ 80 150 ~ 180
    The first day fluid infusion : Accumulation: accumulation losses Ongoing: Ongoing losses daily: Physiological requirement
  • 50.
    • mild : correct etiological factor
    • Moderat & severe :
    • Alkaline solution requirement (mmol)
    • (40 –CO 2 CP Vol%)
    •     2.2
    • = (22 - CO 2 CP mmol/L)  0.7  kg
    • =   BE  0.3  kg
     0.7  kg
            • Usually use the dose halved first and
            • than according to blood gas analyses
    Correct acidosis =
  • 51.
    • Emergency :
    • Per-elevate 5mmol HCO 3 - 5mmol/L (10% CO 2 -CP)
    • need alkaline solution: 3mmol/kg
    • 5%NaHco 3 5ml/kg or 1.4% NaHco 3 20ml/kg
    Correct acidosis
  • 52. Supplement potassium: 10%KCL
    • mild hypokalemia : 200~300mg/ ( kg·d ) 2~3ml/ ( kg·d ) oral
    • sever hypokalemia : 300~450mg/ ( kg·d ) 3~4.5ml/kg.d 10% KCl ivdrip
  • 53.
    • Supplement after urine or urination
    • before coming diagnoses
    • Intravenous concentration <0.3% in the solute
    • speed : >6~8 h/d ( intravenous )
    • Time : keep 4 ~ 6 day
    • interdiction : directly intravenous ,
    • because heart stop !
    Supplement potassium principle :
  • 54. Supplement Calcium and Magnesium
    • Convulsion emerged :
    • 10% Calcium Gluconate 10ml+25% Glucose 10ml IV
    • If convulsion hasn’t relieved
    • after supplement calcium,
    • —— give 25% Mg.Sulfas 0.2~0.4ml/kg deeply IM Q6h
    • be careful ( Calcium ) :
      • HR<80 time /minute , stop !
      • Don’t leak out vessel
      • Interval of the Digitalis
      • Don’t injection with subcutaneous and intramuscular
  • 55. Principles of Therapy first fast then slow first thick then thin supplement potassium when having urine adjust any time and monitor
  • 56.
    • Ongoing losses and daily requirement
      • daily requirement 60~80ml/kg ( 1/3~1/5 tonicity)
      • Ongoing losses follow the how much of the lost
      • in the any time ( 1/2~ 1/3 tonicity)
    • 12~24H equal the speed iv drip
    • To continue the supplement potassium
    • and correct acidosis
    The second day fluid infusion :
  • 57.
    • Neonate: to reduce the liquid and electrolytes properly.
    • Severe malnutrition : to reduce the water amount properly, with low speed, 2/3 ~1/2 tonicity, supplement 10% GS and / or plasma
    Notes
  • 58.
    • operation day 2 ml/kg/h
    • the first day* 4 ml/kg/h
    • —— (the first 10kg) 4 ml/kg/h
    • —— (the second 10kg) 2 ml/kg/h
    • * heart failure / breathing machine utilization: 3ml/kg/h
    • put to open warm casing, the volume > 10%
    Fluid requirement at post operation or heart failure
  • 59. heart failure or heart post operation
    • Control the solution by intravascular injection
    • Volume include :
    • — maintenance fluid in vascular ;
    • — medicine and dilution ;
    • — rinse solution for the vascular tubule ;
    • — gastric tube or food-intake 。
  • 60. Fluid requirement at post operation
    • Include potassium glucose and sodium 1/4~1/5 tonicity
    • 10% GS 500ml
    • 10%NaCl 10ml
    • 10% KCl 15ml
    • ( 9.5%GS 、 0.19%NaCl 、 0.29%KCl )
  • 61.
    • An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability.
    • PE: Pulse rate 150/min, weight loss was 10%, blood pressure 65/40mmHg, skin color showed grey and skin turgor looked like tents. Mucous membranes were very dry; eye ball was sunken greatly, anterior fontanel depressed greatly. Abdomen extended, bowel sound diminished.
    Answer question 2 How to administer the fluid therapy?
  • 62. Step 1 : Plan supplementary fluid.
    • First body weight is calculated by
    • formula of growth and development section.
    • —— (6+8×0.25=8kg)
    • —— 2:1 sodium :20ml×8=160ml
    • —— finished intravenously within 30min.
  • 63. Step 2 : Acute loss
    • be always isotonic dehydration, so we choose :
    • —— 2:3:1 (2:glucose , 3: sodium, 1: 1.4% bicarbonate )
    • —— that belong to 1/2 tonicity.
    • —— Repair of water and sodium deficits
    • ● first 8-10 hours 8-10 ml/(kg·h)
    • ● half of total loss volume
    • (160×8)ml/2=640 ml.
  • 64. Step 3. : 4:1 sodium
    • ● be taken next 16 hours
    • 5 ml/(kg·h)
    • ● 80 ml/kg×8kg=640 ml
    • (another half)
  • 65. Step 4 : Potassium supplement
    • 8kg×0.4g=3.2g/d.
    • That means about 10% potassium chloride solution
    • 32ml will be used by intravenous infusion.
    • Notice supplement potassium
    • —— when urine stream must be seen;
    • —— meanwhile, be aware of concentration(<0.3%)
    • —— speed and time of it.
  • 66.  
  • 67.  
  • 68. Thanks!!!
  • 69.
    • Percentage concentration: 5%GS 、 10%NaCl
    • Molar (mol, gram molecular weight) , mmol
    • 1 mol NaCl=23+35.5=58.5g
    • Molarity (mol/L)
    • calculation :
    mol/L= e.g. 0.9%NaCl= = 0.154mol/L Concentration of electrolyte and calculation Percentage concentration of solute ( % )  10 Molecular weight (atomic weight) 0.9×10 58.5 =154mmol/L
  • 70.
    • Osmotic pressure, osmol ( OSM )
    • Dissolve 1mmol solute into 100ml water: 1mOsm.
    100ml water 1mmo l 1mOsm Concentration of electrolyte and calculation
  • 71.
    • To non electrolyte
    1mmol GS 1mOsm 2mOsm 1mmol Nacl
    • To electrolyte
    1mmol Cacl 2 3mOsm Concentration of electrolyte and calculation

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