NurseReview.Org - Third Spacing: Where has all the fluids gone?

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  • 1. Third-Spacing: Where Has All the Fluid Gone? By Marcia Bixby, RN, CS, CCRN, MS Nursing made Incredibly Easy! September/October 2006 2.5 ANCC/AACN contact hours Online: http://www. nursingcenter .com © 2006 by Lippincott Williams & Wilkins. All world rights reserved.
  • 2. Fluids 101
    • Fluids bring nutrition and oxygen into the cells and remove wastes
    • Fluid is divided into two compartments: intracellular and extracellular
    • Extracellular is divided into interstitial and
    • intravascular
  • 3. Fluids 101
    • The body’s fluid should be in balance; volume entering the body = volume leaving the body
    • Fluid loss occurs via urine, sweat, stool, and incidental losses from respiratory effort
  • 4. On the Move
    • Diffusion: Passive movement of fluid from an area of higher concentration to an area of lower concentration
    • Osmosis: Water movement through a selectively permeable membrane from an area of lower concentration to an area of higher concentration
  • 5. On the Move
    • Active transport: Movement of molecules against a concentration as they move from an area of lower concentration to an area of higher concentration; this movement requires energy
    • Third spacing occurs when the fluid is “trapped” in the interstitial spaces
  • 6. How Fluids Affect Cells: Isotonic Solutions
  • 7. How Fluids Affect Cells: Hypertonic Solutions
  • 8. How Fluids Affect Cells: Hypotonic Solutions
  • 9. Decreased Oncotic Pressure
    • Loss of albumin or protein leads to decreased oncotic pressure, causing fluid to “leak” from the intravascular space to the interstitial space
    • Due to the loss in circulating fluid volume, cardiac output decreases
  • 10. Causes of Fluid Shifts
    • Albumin losses can occur in liver failure, liver dysfunction, and malnutrition
    • Albumin losses can lead to fluid shifting into the peritoneum, causing ascites
    • Destruction of endothelial cells, such as in bowel surgery, can cause fluid to move and be trapped in the interstitial spaces
    • Fluid trapped in the lungs can lead to pulmonary edema
  • 11. Inside the Cells
    • Interstitial fluid trapping can cause compression of the microvasculature, resulting in hypoperfusion and ischemia
    • Inflammatory “mediators” are released into the bloodstream, which can lead to systemic inflammatory response syndrome (SIRS)
    • Multiple organ dysfunction syndrome (MODS) occurs, leading to organ failure and death
  • 12. Mediators of SIRS and MODS
  • 13. What Happens When Fluids Shift?
    • With decreased circulating volume, baroreceptors in the aorta are activated
    • Sympathetic nervous system releases epinephrine and norepinephrine, causing vasoconstriction and an increased heart rate
    • Kidneys launch the renin-angiotensin-aldosterone system in response to a lower glomerular filtration rate
    • All this happens with the goal of increasing circulating volume, blood pressure, and cardiac output
  • 14. Fluid Shift in the Bowel
    • Causes abdominal distention
    • Measure bladder pressure and abdominal girth at least every 4 to 8 hours while signs are abnormal
  • 15. Making the Grade
    • A patient’s intra-abdominal pressure (IAP) determines if he has intra-abdominal hypertension.
    • According to the World Society of Abdominal Compartment Syndrome, there are four grades of intra-abdominal hypertension:
      • Grade I: IAP of 12 to 15 mm Hg
      • Grade II: IAP of 16 to 20 mm Hg
      • Grade III: IAP of 21 to 25 mm Hg
      • Grade IV: IAP of > 25 mm Hg
  • 16. Complications of Abdominal Swelling
    • Decreased cardiac output leads to decreased blood pressure, which causes:
      • increased pressure on the aorta and the iliac and femoral arteries, leading to decreased cardiac output and decreased blood pressure
      • impaired kidney function
      • impaired blood flow to the bowel, liver, and spleen
  • 17. Monitoring the Patient
    • Fluid shift will either resolve over the next several hours (up to 48 hours) or the patient will continue to develop bowel edema and, eventually, ischemia
    • Closely monitor vital signs, urine output, peripheral perfusion, mental status, ventilation/perfusion status, hematocrit/hemoglobin, serum electrolytes (elevated lactate may indicate bowel ischemia)
  • 18. Fluid Resuscitation
    • Administer maintenance I.V. isotonic fluid plus intermittent colloids (i.e., albumin); pulls fluid from the interstitial spaces into the intravascular space
    • Small dose of a loop diuretic, such as furosemide (Lasix) may be ordered if kidneys can’t get rid of the excess fluid
    • If hemoglobin is low, infuse blood products, such as packed red blood cells, as ordered to help increase oxygen and pull fluid from the interstitial space
  • 19. If Bowel Ischemia Occurs
    • A kidney-ureter-bladder X-ray (KUB) may be done; it will show bowel edema and any “free air,” which may indicate bowel perforation
    • A CT scan can detect worsening bowel edema, inadequate perfusion, and hematomas
    • Patient may need further surgery to repair a perforated bowel or to decrease edema