Fluid Therapy Mbbs.weebly.com
Last  lesson Emphasis  Etiology (in/ex/no)   Pathogenesis (4+ex/b/v/no)  Clinical  manifestation Diagnosis   Differential ...
<ul><li>Not difficult </li></ul><ul><li>According to clinical manifestation, laboratory tests and character of stool.  </l...
Case example  An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. PE: Pulse rate 150...
Answer  diagnosis <ul><li>Acute diarrhea  </li></ul><ul><li>severe dehydration </li></ul><ul><li>hypokalemia </li></ul>
Neonate …………… ...  80%  Older children ……… ..65%  Adult ………………… ..60% features of body fluid balance in children   The you...
features of body fluid balance in children The younger The larger proportion  of  extracellular water Intracellular  Body ...
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% A...
features of body fluid balance in children ----water requirement <ul><li>Requiring more water </li></ul><ul><li>Regulating...
<ul><li>Due to grow quickly, need 0.5%~3% water for growth. </li></ul><ul><li>Insensible water loss  : 2 times more than a...
<ul><li>Similar with adult </li></ul>Extracellular: Na + , Cl - , Hco 3 - Intracellular: K + , Mg  , Hpo 4 = , protein <...
Acid-base balance and adjust ----two concept <ul><li>Acid-base balance </li></ul><ul><li>Acidity and alkalinity </li></ul>...
<ul><li>Compensation of adjust has limit </li></ul>Acid-base balance and adjust ----body liquid <ul><li>Buffer system </li...
<ul><li>PH : 7.4 (7.35 ~7.45) </li></ul><ul><li>PaCO 2 : 40 (34 ~45) mmHg </li></ul><ul><li>SB : 24 (22 ~27) mmol/L </li><...
<ul><li>Compensation  &  decompensation </li></ul>Acid-base balance disorder <ul><li>respiratory acidosis </li></ul><ul><l...
Electrolyte disturbance Diarrhea complicated <ul><li>hyponatremia & hypernatremia </li></ul><ul><li>hypokalemia </li></ul>...
Severity clinical signs of dehydration Dehydration  mild moderate severe Water loss By weight Spirit  Skin Mocous  Anterio...
Dehydration   Same proportion  loss P IF C P IF C Electrolyte loss more P  hypotonic, IF+C  hypertonic Cell expansion Seve...
<ul><li>Dispirited, dysphoria, drowsiness, coma </li></ul><ul><li>Hypernea  (Kussmauls  breathing) , exhalation cool </li>...
<ul><li>K +  (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L) </li></ul><ul><li>causes :   </li></ul><ul><li>Excessive los...
<ul><li>depressed </li></ul><ul><li>Tension of skeletal muscle  , tendon reflex , </li></ul><ul><li>even respiratory muscl...
<ul><li>Ca 2+ ﹤1.75mmol/L (7mg/dl) ;  </li></ul><ul><li>Mg 2+ ﹤0.6mmol/L (1.5mg/dl). </li></ul><ul><li>Symptoms usually oc...
Fluid Therapy
To cure water and  electrolyte disturbance Recover and maintain  blood volume , osmotic pressure ,  Acidity , alkalinity a...
oral intravenous Method  <ul><li>prevention dehydration:  Rice soup add salt solute ( 1/3 ) </li></ul><ul><li>Mild dehydea...
<ul><li>NaCl : 3.5g </li></ul><ul><li>NaHCO 3  (Sodium citrate) : 2.5g (2.9g) </li></ul><ul><li>KCl : 1.5g  </li></ul><ul>...
口服补液盐  Oral rehydration salt (ORS)  <ul><li>WHO2002 年推荐的低渗透压 ORS 配方   </li></ul><ul><li>成分  含量  ( 克 ) </li></ul><ul><li>Na...
<ul><li>Na  +  -- GS transport of Small intestine </li></ul>Na + – GS carrier enterocyte Brush border intracellular  inte...
Characteristics of ORS   ---Advantages <ul><li>Osmotic pressure similar with plasma( 2/3 tonicity) </li></ul><ul><li>Corre...
Characteristics of ORS   ---disadvantages <ul><li>Liquid tonicity higher (2 / 3)  </li></ul><ul><li>Can not be used as the...
<ul><li>ORS : </li></ul><ul><li>Rice soup 500ml+ salt 1.75g </li></ul><ul><li>Fried rice noodles 25g + salt 1.75g  </li></...
Sever dehydration <ul><li>intravenous </li></ul>
<ul><li>Osmotic pressure of plasma (OPP) </li></ul><ul><li>OPP= (crystal + colloid) osmotic pressure </li></ul>Na +   142 ...
<ul><li>Na : Cl=3 :2  ( in plasma ) </li></ul>Fluid isotonic Isotonic liquid: osmotic pressure similar with plasma  Sodium...
Liquid solution commonly used 5%GS 10%GS 0.9%NaCl 10%NaCl Ringer 5% NaHCO3  11.2% NaL 10%KCl Mixture nonelectrolyte soluti...
<ul><li>10%NaCl :  1ml=1.7mmol </li></ul><ul><li>5%NaHCO 3 : 1ml=0.6mmol </li></ul><ul><li>11.2%NaL :  1ml=1mmol </li></ul...
The element and simple dispensing    in the commonly mixed solution <ul><li>Solution  composition ratio   dispensing   (ml...
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...
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...
Water supplement &  correct acidosis <ul><li>Accumulative losses </li></ul><ul><li>---losses from onset to pre-treatment <...
To master three principles <ul><li>The volum of rehydration </li></ul><ul><li>Deficit fluid </li></ul><ul><li>=(percentage...
four steps (for fluid and electrolyte deficits) <ul><li>Step 1. Expanding volume: </li></ul><ul><li>restoration of circula...
<ul><li>Step 3. maintenance rehydration: </li></ul><ul><li>- next 16 hours </li></ul><ul><li>5ml/(kg.h) </li></ul><ul><li>...
Accumulation losses amount mild :  50ml/kg moderate: 50 ~100ml/kg severe :  100 ~120ml/kg Water supplement-1:   accumulati...
composition isotonic  :  1/2 tonicity(1:1) hypotonic : 2/3 tonicity(4:3:1) Hypertonic:1/3~1/5 tonicity  ( 1/3 tonicity) sp...
Severity clinical signs of dehydration Dehydration  mild moderate severe Water loss By weight Spirit  Skin Mocous  Anterio...
Ongoing losses amount 1/2~1/3 tonicity(1:1) speed <ul><li>12~16h after stage-1  </li></ul><ul><li>In 24h, steady speed </l...
daily requirement amount 1/3~1/5 tonicity (Physical main medium) speed <ul><li>In 24h, steady speed </li></ul><ul><li>Acco...
<ul><li>Dehydration  </li></ul><ul><li>Fluid replacement=losses  </li></ul><ul><li>(Accumulation + ongoing + daily ) </li>...
<ul><li>mild : correct etiological factor </li></ul><ul><li>Moderat & severe : </li></ul><ul><li>Alkaline solution require...
<ul><li>Emergency : </li></ul><ul><li>Per-elevate 5mmol HCO 3 -  5mmol/L (10% CO 2 -CP) </li></ul><ul><li>need alkaline so...
Supplement  potassium: 10%KCL <ul><li>mild hypokalemia : 200~300mg/ ( kg·d )    2~3ml/ ( kg·d ) oral  </li></ul><ul><li>se...
<ul><li>Supplement after urine or urination </li></ul><ul><li>before coming diagnoses  </li></ul><ul><li>Intravenous conce...
Supplement   Calcium  and Magnesium <ul><li>Convulsion emerged  : </li></ul><ul><li>10% Calcium Gluconate 10ml+25% Glucose...
Principles of Therapy first fast then slow first thick then thin supplement potassium when having urine adjust any time  a...
<ul><li>Ongoing losses and  daily  requirement   </li></ul><ul><ul><li>daily  requirement   60~80ml/kg ( 1/3~1/5 tonicity)...
<ul><li>Neonate: to reduce the liquid and electrolytes properly. </li></ul><ul><li>Severe malnutrition : to reduce the wat...
<ul><li>operation day  2 ml/kg/h </li></ul><ul><li>the first day*  4 ml/kg/h  </li></ul><ul><li>—— (the first 10kg)  4 ml/...
heart  failure or heart post operation   <ul><li>Control the solution by intravascular injection </li></ul><ul><li>Volume ...
Fluid requirement  at post operation   <ul><li>Include potassium glucose and sodium  1/4~1/5 tonicity  </li></ul><ul><li>1...
<ul><li>An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability.  </li></ul><ul><li>PE: P...
Step 1 : Plan supplementary fluid. <ul><li>First body weight is calculated by  </li></ul><ul><li>formula of growth and dev...
Step 2 : Acute loss <ul><li>be always isotonic dehydration, so we choose  : </li></ul><ul><li>—— 2:3:1 (2:glucose , 3: sod...
Step 3. : 4:1  sodium <ul><li>●   be taken next 16 hours </li></ul><ul><li>5 ml/(kg·h) </li></ul><ul><li>●  80 ml/kg×8kg=6...
Step 4 : Potassium supplement <ul><li>8kg×0.4g=3.2g/d.  </li></ul><ul><li>That means about 10% potassium chloride solution...
 
 
Thanks!!!
<ul><li>Percentage concentration: 5%GS 、 10%NaCl </li></ul><ul><li>Molar (mol, gram molecular weight) , mmol </li></ul><ul...
<ul><li>Osmotic pressure, osmol ( OSM ) </li></ul><ul><li>Dissolve 1mmol solute into 100ml water: 1mOsm. </li></ul>100ml w...
<ul><li>To non electrolyte   </li></ul>1mmol GS 1mOsm 2mOsm 1mmol Nacl <ul><li>To electrolyte  </li></ul>1mmol Cacl 2 3mOs...
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13 Fluid Therapy

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  1. 1. Fluid Therapy Mbbs.weebly.com
  2. 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. 3. <ul><li>Not difficult </li></ul><ul><li>According to clinical manifestation, laboratory tests and character of stool. </li></ul>Diagnosis + + Infectious Or Noninfectious Dehydration Degree and quality Electrolyte disturbances And Disturbance of acid-base balance
  4. 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. 5. Answer diagnosis <ul><li>Acute diarrhea </li></ul><ul><li>severe dehydration </li></ul><ul><li>hypokalemia </li></ul>
  6. 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. 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. 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. 9. features of body fluid balance in children ----water requirement <ul><li>Requiring more water </li></ul><ul><li>Regulating function poorly </li></ul><ul><li>Easy water metabolism disturbance </li></ul>
  10. 10. <ul><li>Due to grow quickly, need 0.5%~3% water for growth. </li></ul><ul><li>Insensible water loss : 2 times more than adult. </li></ul><ul><li>Fluid exchange of digestive tract quicker. </li></ul><ul><li>Water metabolism higher: infant 1/2 by total fluid </li></ul><ul><li>adult 1/7 by total fluid. </li></ul><ul><li>Regulating function of water metabolism poorly: </li></ul><ul><li>kidney, lung. </li></ul>features of body fluid balance in children ----water requirement
  11. 11. <ul><li>Similar with adult </li></ul>Extracellular: Na + , Cl - , Hco 3 - Intracellular: K + , Mg  , Hpo 4 = , protein <ul><li>Features of neonate ( Several days after birth ) : </li></ul>Composition of body fluid <ul><li>Particularly in preterm infant </li></ul>K + , Cl - , P, lactic acid Na + , Ca ++ , Hco 3 - Function of excluding H + Acidosis
  12. 12. Acid-base balance and adjust ----two concept <ul><li>Acid-base balance </li></ul><ul><li>Acidity and alkalinity </li></ul><ul><li>Anion-cation balance </li></ul><ul><li>Anion and cation </li></ul>
  13. 13. <ul><li>Compensation of adjust has limit </li></ul>Acid-base balance and adjust ----body liquid <ul><li>Buffer system </li></ul><ul><li>lung : exhale of store CO 2 (respiratory) </li></ul><ul><li>kidney: exclude H + and store Na + (metabolic) </li></ul>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. 14. <ul><li>PH : 7.4 (7.35 ~7.45) </li></ul><ul><li>PaCO 2 : 40 (34 ~45) mmHg </li></ul><ul><li>SB : 24 (22 ~27) mmol/L </li></ul><ul><li>BE : -3 ~ +3 mmol/L </li></ul><ul><li>CO 2 CP : 22 (18 ~27) mmol/L </li></ul>Acid-base index Blood gas analysis ( normal )
  15. 15. <ul><li>Compensation & decompensation </li></ul>Acid-base balance disorder <ul><li>respiratory acidosis </li></ul><ul><li>respiratory alkalosis </li></ul><ul><li>metabolic acidosis </li></ul><ul><li>metabolic alkalosis </li></ul>
  16. 16. Electrolyte disturbance Diarrhea complicated <ul><li>hyponatremia & hypernatremia </li></ul><ul><li>hypokalemia </li></ul><ul><li>hypocalcemia </li></ul><ul><li>hypomagnesemia </li></ul>
  17. 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. 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. 19. <ul><li>Dispirited, dysphoria, drowsiness, coma </li></ul><ul><li>Hypernea (Kussmauls breathing) , exhalation cool </li></ul><ul><li>Expiratory gas smells ketone </li></ul><ul><li>Cherry lips </li></ul><ul><li>Nausea, vomit </li></ul>Metabolic acidosis--clinical manifestation Mild: breath frequency slightly Severe: occur:
  20. 20. <ul><li>K + (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L) </li></ul><ul><li>causes : </li></ul><ul><li>Excessive losses: vomit, diarrhea. </li></ul><ul><li>Inadequate intake. </li></ul><ul><li>Renal function of keeping kalium ,it continues excluding kalium when with hypokalemia. </li></ul>Clinical manifestation-3: electrolyte disorder Hypokalemia
  21. 21. <ul><li>depressed </li></ul><ul><li>Tension of skeletal muscle , tendon reflex , </li></ul><ul><li>even respiratory muscle weakness </li></ul><ul><li>Tension of smooth muscl , abdominal extension, </li></ul><ul><li>intestinal sound or disappear </li></ul><ul><li>Myocardium excitability , arrhythmia, ECG: T-wave </li></ul><ul><li>is low or inversion, U-wave occurs, prolonged P-R </li></ul><ul><li>interval and Q-T interval, ST section descending. </li></ul><ul><li>Baseosis </li></ul>hypokalemia K+ (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L) Clinical manifestation: nerve and muscular excitability
  22. 22. <ul><li>Ca 2+ ﹤1.75mmol/L (7mg/dl) ; </li></ul><ul><li>Mg 2+ ﹤0.6mmol/L (1.5mg/dl). </li></ul><ul><li>Symptoms usually occur after dehydration and </li></ul><ul><li>acidosis resolved, or fluid replacement. </li></ul><ul><li>Clinical manifestation: thrill, tetany, convulsion. </li></ul><ul><li>If convulsion hasn ’ t relieved after supplement </li></ul><ul><li>calcium, pay attention to hypomagnesemia. </li></ul>hypocalcemia & hypomagnesemia
  23. 23. Fluid Therapy
  24. 24. To cure water and electrolyte disturbance Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte Normal physiological function Purpose
  25. 25. oral intravenous Method <ul><li>prevention dehydration: Rice soup add salt solute ( 1/3 ) </li></ul><ul><li>Mild dehydeation: ORS 。 </li></ul><ul><li>Mild/moderate dehydeation : ORS </li></ul><ul><li>—— mild: ORS : 50 ~ 80ml/kg </li></ul><ul><li>—— moderate: ORS : 80 ~ 100ml/kg </li></ul><ul><li>Severe dehydration or vomiting and diarrhea </li></ul><ul><li>—— intravenous </li></ul>
  26. 26. <ul><li>NaCl : 3.5g </li></ul><ul><li>NaHCO 3 (Sodium citrate) : 2.5g (2.9g) </li></ul><ul><li>KCl : 1.5g </li></ul><ul><li>GS : 20g </li></ul>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. 27. 口服补液盐 Oral rehydration salt (ORS) <ul><li>WHO2002 年推荐的低渗透压 ORS 配方 </li></ul><ul><li>成分 含量 ( 克 ) </li></ul><ul><li>NaCl 2.6 </li></ul><ul><li>枸橼酸钠 2.9 </li></ul><ul><li>KCl 1.5 </li></ul><ul><li>葡萄糖 13.5 </li></ul><ul><li>水 1000ml </li></ul><ul><li>该配方中各种电解质浓度为: Na + 75mmol/L , K + 20 </li></ul><ul><li>mmol/L , C1 - 65 mmol/L ,枸橼酸根 10mmol/L ,葡萄糖 75m </li></ul><ul><li>mol/L 。总渗透压为 245 mOsm/L </li></ul>sodium citrate could instead by NaHCO3
  28. 28. <ul><li>Na + -- GS transport of Small intestine </li></ul>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. 29. Characteristics of ORS ---Advantages <ul><li>Osmotic pressure similar with plasma( 2/3 tonicity) </li></ul><ul><li>Correct losses by proper concentration of Na + 、 K + 、 Cl - </li></ul><ul><li>Children easily accept the tastes </li></ul><ul><li>Correct metabolic acidosis by sodium citrate </li></ul><ul><li>Promote Na + and H 2 O absorption by 2% GS </li></ul>
  30. 30. Characteristics of ORS ---disadvantages <ul><li>Liquid tonicity higher (2 / 3) </li></ul><ul><li>Can not be used as the maintenance media </li></ul><ul><li>Na + concentration is relatively higher to neonates </li></ul><ul><li>and infants (proper diluted) . </li></ul>
  31. 31. <ul><li>ORS : </li></ul><ul><li>Rice soup 500ml+ salt 1.75g </li></ul><ul><li>Fried rice noodles 25g + salt 1.75g </li></ul><ul><li>+ water 500ml (Cooking 2 - 3min) </li></ul><ul><li>GNS: </li></ul><ul><li>White sugar 10g + salt 1.75g + water 500ml (boil) </li></ul>Simple preparation at home
  32. 32. Sever dehydration <ul><li>intravenous </li></ul>
  33. 33. <ul><li>Osmotic pressure of plasma (OPP) </li></ul><ul><li>OPP= (crystal + colloid) osmotic pressure </li></ul>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. 34. <ul><li>Na : Cl=3 :2 ( in plasma ) </li></ul>Fluid isotonic Isotonic liquid: osmotic pressure similar with plasma Sodium isotonic: <ul><li>Isotonic: 150mmol sodium in 1000ml </li></ul><ul><li>½ tonicity: 75mmol sodium in 1000ml </li></ul><ul><li>2/3 tonicity: 100mmol sodium in 1000ml </li></ul><ul><li>1/3 tonicity: 50mmol sodium in 1000ml </li></ul>
  35. 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. 36. <ul><li>10%NaCl : 1ml=1.7mmol </li></ul><ul><li>5%NaHCO 3 : 1ml=0.6mmol </li></ul><ul><li>11.2%NaL : 1ml=1mmol </li></ul><ul><li>10%KCl : 1ml=1.34mmol </li></ul>Calculation
  37. 37. The element and simple dispensing in the commonly mixed solution <ul><li>Solution composition ratio dispensing (ml) </li></ul><ul><li>NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl </li></ul><ul><li>2:1 isotonic solution . 2 1 500 30 47 </li></ul><ul><li>1:1 solution (1/2 tonicity) 1 1 500 20 </li></ul><ul><li>2:3:1 solution (1/2tonicity)2 3 1 500 15 24   </li></ul><ul><li>4:3:2 solution (2/3tonicity)4 3 2 500 20 33   </li></ul><ul><li>1:2 solution (1/3 tonicity)1 2 500 15   </li></ul><ul><li>1:4 solution (1/5 tonicity) 1 4 500 9   </li></ul><ul><li>daily requirement </li></ul><ul><li>(1/3tonic) 1 4 500 9 7.5 </li></ul>
  38. 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. 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. 40. Water supplement & correct acidosis <ul><li>Accumulative losses </li></ul><ul><li>---losses from onset to pre-treatment </li></ul><ul><li>ongoing losses </li></ul><ul><li>---continuing losses during treatment </li></ul><ul><li>daily requirement </li></ul><ul><li>---to maintain basically physiological function </li></ul>Amount , composition and time
  41. 41. To master three principles <ul><li>The volum of rehydration </li></ul><ul><li>Deficit fluid </li></ul><ul><li>=(percentage of dehydration)×(body weight in Kg) </li></ul><ul><li>The type of fluid </li></ul><ul><li>Isotonic dehydration—— 1/2 tonicity solution </li></ul><ul><li>Hypotonic dehydration—— 2/3 tonicity solution </li></ul><ul><li>Hypertonic dehydration—— 1/3 tonicity solution </li></ul><ul><li>The speed of liquid : four steps </li></ul>
  42. 42. four steps (for fluid and electrolyte deficits) <ul><li>Step 1. Expanding volume: </li></ul><ul><li>restoration of circulation –emergency, </li></ul><ul><li>within 30 min to 1 hour </li></ul><ul><li>20ml/kg, 2:1 (isotonic )sodium solution </li></ul><ul><li>Step 2. supplement lost body liquid: </li></ul><ul><li>first 8~10 hours </li></ul><ul><li>8~10ml/h </li></ul><ul><li>half of total loss volume </li></ul><ul><li>2:3:1 solution(1/2 tonicity) </li></ul>
  43. 43. <ul><li>Step 3. maintenance rehydration: </li></ul><ul><li>- next 16 hours </li></ul><ul><li>5ml/(kg.h) </li></ul><ul><li>- another half loss </li></ul><ul><li>physical demand : 60~80ml/kg </li></ul><ul><li>4:1 solution(1/3~1/2 tonicity) </li></ul><ul><li>Step 4. repair of potassium deficit </li></ul>four steps
  44. 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. 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. 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. 47. Ongoing losses amount 1/2~1/3 tonicity(1:1) speed <ul><li>12~16h after stage-1 </li></ul><ul><li>In 24h, steady speed </li></ul><ul><li>5ml/ ( kg·h ) </li></ul>10~40ml/kg.d composition Water supplement-2: ongoing losses
  48. 48. daily requirement amount 1/3~1/5 tonicity (Physical main medium) speed <ul><li>In 24h, steady speed </li></ul><ul><li>Accompany with stage-2 </li></ul>60~80ml/kg.d ( including oral ) composition Water supplement-3: daily requirement
  49. 49. <ul><li>Dehydration </li></ul><ul><li>Fluid replacement=losses </li></ul><ul><li>(Accumulation + ongoing + daily ) </li></ul><ul><li>Accumulation ongoing daily total amount </li></ul><ul><li>(ml/Kg) </li></ul><ul><li>mild 50 10 ~ 30 60 ~ 80 90 ~ 120 </li></ul><ul><li>moderate 50 ~ 100 10 ~ 30 60 ~ 80 120 ~ 150 </li></ul><ul><li>Severe 100 ~ 120 10 ~ 30 60 ~ 80 150 ~ 180 </li></ul>The first day fluid infusion : Accumulation: accumulation losses Ongoing: Ongoing losses daily: Physiological requirement
  50. 50. <ul><li>mild : correct etiological factor </li></ul><ul><li>Moderat & severe : </li></ul><ul><li>Alkaline solution requirement (mmol) </li></ul><ul><li>(40 –CO 2 CP Vol%) </li></ul><ul><li>    2.2 </li></ul><ul><li>= (22 - CO 2 CP mmol/L)  0.7  kg </li></ul><ul><li>=   BE  0.3  kg </li></ul> 0.7  kg <ul><ul><ul><ul><ul><li>Usually use the dose halved first and </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>than according to blood gas analyses </li></ul></ul></ul></ul></ul>Correct acidosis =
  51. 51. <ul><li>Emergency : </li></ul><ul><li>Per-elevate 5mmol HCO 3 - 5mmol/L (10% CO 2 -CP) </li></ul><ul><li>need alkaline solution: 3mmol/kg </li></ul><ul><li>5%NaHco 3 5ml/kg or 1.4% NaHco 3 20ml/kg </li></ul>Correct acidosis
  52. 52. Supplement potassium: 10%KCL <ul><li>mild hypokalemia : 200~300mg/ ( kg·d ) 2~3ml/ ( kg·d ) oral </li></ul><ul><li>sever hypokalemia : 300~450mg/ ( kg·d ) 3~4.5ml/kg.d 10% KCl ivdrip </li></ul>
  53. 53. <ul><li>Supplement after urine or urination </li></ul><ul><li>before coming diagnoses </li></ul><ul><li>Intravenous concentration <0.3% in the solute </li></ul><ul><li>speed : >6~8 h/d ( intravenous ) </li></ul><ul><li>Time : keep 4 ~ 6 day </li></ul><ul><li>interdiction : directly intravenous , </li></ul><ul><li>because heart stop ! </li></ul>Supplement potassium principle :
  54. 54. Supplement Calcium and Magnesium <ul><li>Convulsion emerged : </li></ul><ul><li>10% Calcium Gluconate 10ml+25% Glucose 10ml IV </li></ul><ul><li>If convulsion hasn’t relieved </li></ul><ul><li>after supplement calcium, </li></ul><ul><li>—— give 25% Mg.Sulfas 0.2~0.4ml/kg deeply IM Q6h </li></ul><ul><li>be careful ( Calcium ) : </li></ul><ul><ul><li>HR<80 time /minute , stop ! </li></ul></ul><ul><ul><li>Don’t leak out vessel </li></ul></ul><ul><ul><li>Interval of the Digitalis </li></ul></ul><ul><ul><li>Don’t injection with subcutaneous and intramuscular </li></ul></ul>
  55. 55. Principles of Therapy first fast then slow first thick then thin supplement potassium when having urine adjust any time and monitor
  56. 56. <ul><li>Ongoing losses and daily requirement </li></ul><ul><ul><li>daily requirement 60~80ml/kg ( 1/3~1/5 tonicity) </li></ul></ul><ul><ul><li>Ongoing losses follow the how much of the lost </li></ul></ul><ul><ul><li>in the any time ( 1/2~ 1/3 tonicity) </li></ul></ul><ul><li>12~24H equal the speed iv drip </li></ul><ul><li>To continue the supplement potassium </li></ul><ul><li>and correct acidosis </li></ul>The second day fluid infusion :
  57. 57. <ul><li>Neonate: to reduce the liquid and electrolytes properly. </li></ul><ul><li>Severe malnutrition : to reduce the water amount properly, with low speed, 2/3 ~1/2 tonicity, supplement 10% GS and / or plasma </li></ul>Notes
  58. 58. <ul><li>operation day 2 ml/kg/h </li></ul><ul><li>the first day* 4 ml/kg/h </li></ul><ul><li>—— (the first 10kg) 4 ml/kg/h </li></ul><ul><li>—— (the second 10kg) 2 ml/kg/h </li></ul><ul><li>* heart failure / breathing machine utilization: 3ml/kg/h </li></ul><ul><li>put to open warm casing, the volume > 10% </li></ul>Fluid requirement at post operation or heart failure
  59. 59. heart failure or heart post operation <ul><li>Control the solution by intravascular injection </li></ul><ul><li>Volume include : </li></ul><ul><li>— maintenance fluid in vascular ; </li></ul><ul><li>— medicine and dilution ; </li></ul><ul><li>— rinse solution for the vascular tubule ; </li></ul><ul><li>— gastric tube or food-intake 。 </li></ul>
  60. 60. Fluid requirement at post operation <ul><li>Include potassium glucose and sodium 1/4~1/5 tonicity </li></ul><ul><li>10% GS 500ml </li></ul><ul><li>10%NaCl 10ml </li></ul><ul><li>10% KCl 15ml </li></ul><ul><li>( 9.5%GS 、 0.19%NaCl 、 0.29%KCl ) </li></ul>
  61. 61. <ul><li>An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. </li></ul><ul><li>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. </li></ul>Answer question 2 How to administer the fluid therapy?
  62. 62. Step 1 : Plan supplementary fluid. <ul><li>First body weight is calculated by </li></ul><ul><li>formula of growth and development section. </li></ul><ul><li>—— (6+8×0.25=8kg) </li></ul><ul><li>—— 2:1 sodium :20ml×8=160ml </li></ul><ul><li>—— finished intravenously within 30min. </li></ul>
  63. 63. Step 2 : Acute loss <ul><li>be always isotonic dehydration, so we choose : </li></ul><ul><li>—— 2:3:1 (2:glucose , 3: sodium, 1: 1.4% bicarbonate ) </li></ul><ul><li>—— that belong to 1/2 tonicity. </li></ul><ul><li>—— Repair of water and sodium deficits </li></ul><ul><li>● first 8-10 hours 8-10 ml/(kg·h) </li></ul><ul><li>● half of total loss volume </li></ul><ul><li>(160×8)ml/2=640 ml. </li></ul>
  64. 64. Step 3. : 4:1 sodium <ul><li>● be taken next 16 hours </li></ul><ul><li>5 ml/(kg·h) </li></ul><ul><li>● 80 ml/kg×8kg=640 ml </li></ul><ul><li>(another half) </li></ul>
  65. 65. Step 4 : Potassium supplement <ul><li>8kg×0.4g=3.2g/d. </li></ul><ul><li>That means about 10% potassium chloride solution </li></ul><ul><li>32ml will be used by intravenous infusion. </li></ul><ul><li>Notice supplement potassium </li></ul><ul><li>—— when urine stream must be seen; </li></ul><ul><li>—— meanwhile, be aware of concentration(<0.3%) </li></ul><ul><li>—— speed and time of it. </li></ul>
  66. 68. Thanks!!!
  67. 69. <ul><li>Percentage concentration: 5%GS 、 10%NaCl </li></ul><ul><li>Molar (mol, gram molecular weight) , mmol </li></ul><ul><li>1 mol NaCl=23+35.5=58.5g </li></ul><ul><li>Molarity (mol/L) </li></ul><ul><li>calculation : </li></ul>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
  68. 70. <ul><li>Osmotic pressure, osmol ( OSM ) </li></ul><ul><li>Dissolve 1mmol solute into 100ml water: 1mOsm. </li></ul>100ml water 1mmo l 1mOsm Concentration of electrolyte and calculation
  69. 71. <ul><li>To non electrolyte </li></ul>1mmol GS 1mOsm 2mOsm 1mmol Nacl <ul><li>To electrolyte </li></ul>1mmol Cacl 2 3mOsm Concentration of electrolyte and calculation

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