• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
C:\documents and settings\administrator\桌面\11 fluid therapy
 

C:\documents and settings\administrator\桌面\11 fluid therapy

on

  • 1,164 views

 

Statistics

Views

Total Views
1,164
Views on SlideShare
1,164
Embed Views
0

Actions

Likes
0
Downloads
47
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    C:\documents and settings\administrator\桌面\11 fluid therapy C:\documents and settings\administrator\桌面\11 fluid therapy Presentation Transcript

    • Fluid Therapy The first affiliated hospital SUN YAT-SEN university Prof. Wang Huishen 王慧深
    • Last lesson Emphasis Etiology (in/ex/no) Pathogenesis (4+ex/b/v/no) Clinical manifestation Diagnosis Differential Diagnosis (p/d/n) Treatment Predisposing (4)
      • 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
    • 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
    • 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
    • Electrolyte disturbance Diarrhea complicated
      • hyponatremia & hypernatremia
      • hypokalemia
      • hypocalcemia
      • hypomagnesemia
      • 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: electrolyte disorder Hypokalemia
      • 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
      • 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
    • 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?
    • Answer 1 (diagnosis)
      • Acute diarrhea
      • severe dehydration
      • hypokalemia
    • Fluid Therapy
    • 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
    • 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
    • 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)
    • features of body fluid balance in children ----water requirement
      • Requiring more water
      • Regulating function poorly
      • Easy water metabolism disturbance
      • 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
      • 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
    • Acid-base balance and adjust ----two concept
      • Acid-base balance
      • Acidity and alkalinity
      • Anion-cation balance
      • Anion and cation
      • 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
      • 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 )
      • Compensation & decompensation
      Acid-base balance disorder
      • respiratory acidosis
      • respiratory alkalosis
      • metabolic acidosis
      • metabolic alkalosis
      • 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:
    • To cure water and electrolyte disturbance Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte Normal physiological function Fluid therapy Purpose
    • oral intravenous Fluid therapy Method
      • prevention dehydration: Rice soup add salt solute ( 1/3 )
      • Mild dehydration: ORS 。
      • Mild/moderate dehydration : ORS
      • —— mild: ORS : 50 ~ 80ml/kg
      • —— moderate: ORS : 80 ~ 100ml/kg
      • Severe dehydration or vomiting and diarrhea
      • —— intravenous
      • 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
    • 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
      • Na + -- GS transport in 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
    • 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
    • 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) .
      • 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
    • Severe dehydration
      • intravenous
      • 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
      • Osmotic pressure, osmol ( OSM )
      • Dissolve 1mmol solute into 100ml water: 1mOsm.
      100ml water 1mmo l 1mOsm Concentration of electrolyte and calculation
      • To non electrolyte
      1mmol GS 1mOsm 2mOsm 1mmol Nacl
      • To electrolyte
      1mmol Cacl 2 3mOsm Concentration of electrolyte and calculation
      • 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
    • 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
      • 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
      • 10%NaCl : 1ml=1.7mmol
      • 5%NaHCO 3 : 1ml=0.6mmol
      • 11.2%NaL : 1ml=1mmol
      • 10%KCl : 1ml=1.34mmol
      Calculation
    • 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
    • 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
    • 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
    • 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
      • 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
    • 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
    • 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
    • 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 isotonic : 20ml/kg (<300ml ) in 30’~1h(rapidly expand) others : 8~12h ( 8 ~ 10ml/ ( kg·h ) iv Water supplement-1 : accumulation losses Accumulation losses Dehydration :
    • 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
    • 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
    • To master three principles
      • The volum of rehydration- Amount
      • Deficit fluid
      • =(percentage of dehydration)×(body weight in Kg)
      • The type of fluid- Composition
      • Isotonic dehydration—— 1/2 tonicity solution
      • Hypotonic dehydration—— 2/3 tonicity solution
      • Hypertonic dehydration—— 1/3 tonicity solution
      • The speed of liquid- Time : four steps
    • 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)
      • Step 3. maintenance rehydration:
      • - another half loss
      • - next 16 hours
      • 5ml/(kg.h)
      • physical demand : 60~80ml/kg
      • 4:1 solution(1/3~1/2 tonicity)
      • Step 4. repair of potassium deficit
      four steps
      • 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 =
      • 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
    • 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
      • 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 :
    • 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
    • Principles of Therapy first fast then slow first thick then thin supplement potassium when having urine adjust any time and monitor
      • 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 :
      • Neonate: to reduce the liquid and electrolytes properly.
      • Severe malnutrition : to reduce the water amount properly, with low speed, 2/3 ~1/2 tonic
      • supplement 10% GS and / or plasma
      Notes
      • 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?
      • 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
    • 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.
    • 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.
    • Step 3. : 4:1 sodium
      • ● be taken next 16 hours
      • 5 ml/(kg·h)
      • ● 80 ml/kg×8kg=640 ml
      • (another half)
    • 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.
    •  
    •  
    • Thanks!!!