Maintenance fluid

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Maintenance fluid

  1. 1. Fluid TherapyCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  2. 2. FLUID THERAPY RESUSCITATION MAINTENANCE Crystalloid Colloid ELECTROLYTES NUTRITION 1. Replace acute loss 1. Replace normal loss (hemorrhage, GI loss, (IWL + urine+ faecal) 3rd space etc) 2. Nutrition supportCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  3. 3. Volume of Distribution of Water Solids ///////////////////// 60%-Males H2O 50%-FemalesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  4. 4. Solids 40% of Wt Intracellular Extracellular (2/3) (1/3) H2O H2O NaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  5. 5. E.C.F. COMPARTMENTS Interstitial 3/4 Intra- vascular 1/4 H2O H2O Na Na Colloids & RBCCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  6. 6. “Third Space” • Acute sequestration in a body compartment that is not in equilibrium with ECF • Examples: – Intestinal obstruction – Severe pancreatitis – Peritonitis – Major venous obstruction – Capillary leak syndrome – BurnsCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  7. 7. Daily Fluid Balance Intake: 1-1.5L Insensible Loss -Lungs 0.3L -Sweat 0.1 L Urine: 1.0 to 1.5LCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  8. 8. Body Water and Fluid Compartments TBW = 0.6 or 0.5 x kg TBW = ECF + ICF (1/3) (2/3) ECF = extracellular, ICF = intracellular ECF = Interstitial + Plasma (3/4) (1/4) Fluid spaces are iso-osmolar due to water movementCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  9. 9. 70 kg male Total body water=60% body wt =0.6X70=42 liters ECF=1/3 ICF=2/3 0.3X42=13 liters 0.6 X42=25 liters Blood=1/4 (ECF) 0.25X13=3. 3 litersCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  10. 10. • Monitoring Fluid Therapy • Serial exams: vascular fullness, skin turgor, auscultation,, pulse quality, HR, RR • Urine: specific gravity, volume • Blood pressure • Body weight • Labs: electrolytes, BUN, Creatinine, lactate (tissue perfusion) • CVPCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  11. 11. Why give fluids? • Replace intravascular volume • Improve tissue perfusion • Replace fluid deficits (dehydration) • Meet maintenance in NPO patient • Replace ongoing losses (burns, etc.) • Fluid diuresis to eliminate toxins • Anesthetic and surgical support • Replacement of specific components (blood, plasma) • Nutritional support (TPN, PPN)Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  12. 12. Clinical Diagnosis • Intravascular depletion MAP= CO x SVR Hemodynamic effects • BP HR JVP • Cool extremities • Reduced sweating • Dry mucus membranes • E.C.F. depletion – Skin turgor, sunken eyeballs •Water Depletion – Weight – Hemodynamic effects Thirst HypernatremiaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  13. 13. Electrolyte composition mEq/L ICF ECF Plasma Interstitial Na+ 15 142 142 144 144 K+ 150 150 4 4 Ca2+ 2 5 2.5 Mg2+ 27 3 1.5 - 1 103 114 Cl HCO3- 10 27 30 HPO42- 100 2 2 SO42- 20 1 1 Organic acid - 5 5 Protein 63 16 6Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  14. 14. . Ion Distribution COMPARTMENT CATION ANION Suitable solution ICF K+ Mg++ HPO4-, Prot containing K+ Mg+ and HPO4- ECF PLASMA Na+ Cl-, HCO3- Prot. High Na+ and Cl- ISF Na+ Cl- HCO3-Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  15. 15. Volume Deficit-Clinical Types • Total body water: – Water loss (diabetes insipidus, osmotic diarrhea) • Extracellular: – Salt and water loss (secretory diarrhea, ascites, edema) – Third spacing • Intravascular: – Acute hemorrhageCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  16. 16. Deficit . Dehydration Hypovolemia * thirst • headache * urine output  • nausea • syncope hypotonic isotonic electrolytes electrolytes 5% Dextrose Ringer’s acetate Ringer’s lactate Normal salineCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  17. 17. The IV Fluid Supermarket • Crystalloids • Colloids – Dextrose in water – Albumin • D5W • 5% in NS • D10W • D50W • 20% (Salt Poor) – Saline – Dextrans • Isotonic (0.9% or “normal”) – Hetastarch • Hypotonic (0.45%, 0.25%) • Hypertonic • Blood – Combo • D51/2NS • D5NS • D10NS – Ringer’s lactate “physiologic”. (K, HCO3, Mg, Ca)Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  18. 18. COMPOSITION OF PARENTERAL FLUIDS • Parenteral fluids are generally classified based on molecular weight and oncotic pressure. • Colloids have a molecular weight of >8000 and have high oncotic pressure. • Crystalloids have a molecular weight of <8000 and have low oncotic pressure.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  19. 19. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  20. 20. Nacl 5% Na 850 mmol/L CL 850 mmol/L 1700 mosm/LCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  21. 21. Kcl 15% K 2000mmol/L Cl 2000mmol/L 2000 mosm/LCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  22. 22. NaHco3 7.5% Na 1000mmol/L Hco3 1000mmol/L 2000mos/L NaHco3 HCL H2co3 Nacl H2co3 co2 H20Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  23. 23. Dextrose Hyper Tonic D25% 1180 mos/L D50% 2770 mos/LCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  24. 24. Colloids • Dextran solutions (dextran 40 and dextran 70): Similar osmotic pressure to plasma. Dextrans interfere with normal coagulation partly by hemodilution of clotting factors and partly by “coating” platelets and the vascular endothelium. May promote renal failure. • 20% Human serum albumin: Protein based solution, falling out of favor in some circles secondary to reports of increased mortality in the critically ill adult population, and some debate still lays in its use outside of the neonatal arena.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  25. 25. Colloids • Colloid refers to a liquid that exerts osmotic pressure due to large MW (greater than 30,000) particles in solution. A variety of colloid solutions are seen for in hospital use: • Hydroxyethyl starch (Hespan): hetastarch can cause a coagulopathy, through hemodilution of clotting factors, inhibition of platelet function and reduction of the activity of factor VIII • Pentastarch (Pentaspan):Pentastarch differs from hetastarch in that it has a lower mean MW. Preliminary studies also suggest that pentastarch may have fewer adverse effects on coagulation than hetastarch.25. No clear pediatric value yet.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  26. 26. Fluids can be described as being . from three categories Isotonic - Fluid has the same osmolarity as plasma Normal Saline (N/S or 0.9% NaCl), Ringers Acetate(RA), Ringer’s lactate (RL) Hypotonic -Fluid has fewer solutes than plasma Water, 1/2 N/S (0.45% NaCl), and D5W (5% dextrose in water) after the sugar is used up Hypertonic-Fluid has more solutes than plasma 7.5% Hco3Na/ 15% kcl 3% saline solution, 5%salin solutionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  27. 27. Isotonic Dehydration Most Common form of Dehydration Occurs when fluids and electrolytes are lost in even amounts There are no intercellular fluid shifts in isotonic dehydration Common Causes diuretic therapy excessive vomiting excessive urine loss hemorrhage decreased fluid intakeCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  28. 28. Hypertonic Dehydration Second most common type of dehydration. Occurs when water loss from ECF is greater than solute loss hyperventilation, pure water loss with high fevers, and watery diarrhea. Diabetic Ketoacidosis and Diabetes Insipidus Iatrogenic Causes prolonged NPO, excessive hypertonic fluids, sodium bicarbonate,Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  29. 29. Hypotonic Dehydration Relatively Uncommon - Loss of more solute (usually sodium) than water. Hypotonic Dehydration causes fluid to shift from the blood stream into the cells, leading to decreased vascular volume and eventual shock Seen in Heat Exhaustion Increased cellular swelling -causes increased intracrainial pressure - Confusion. Seen in Heat StrokeCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  30. 30. Isotonic infusion • Ringer’s acetate • Ringer’s lactate • Normal saline Replace acute/ increases ECF abnormal loss ICF ISF Plasma 700 ml 300 mlCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  31. 31. Hypotonic infusion • 5% dextrose Replace Normal increases ICF > ECF loss (IWL + urine) ICF ISF Plasma 660 ml 270 ml 70 mlCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  32. 32. Fluid Therapy • Replacement • Maintenance • Repair deficitCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  33. 33. BACIC PRINCIPLES Replace Abnormal loss: GIT, 3rd space, Ongoing loss, septic and Hypovolemic shock Maintain IWL + urine Repair Acid base, electrolyte imbalancesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  34. 34. FLUID SELECTION • Replace : RA, RL, NS • Maintain: N/2 + D (adult) • Repair : NaHCO3 8,4% KCl 15% NaCl 3%Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  35. 35. Maintenance • IWL + urine • Adults/children : 4:2:1 eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 = 100ml/hrCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  36. 36. Requirements • Fever • Restless/delirium • Warm ambient temperature • HyperventilationCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  37. 37. Requirements • Hypothermia • High humidity • Oliguria/anuria • Reduced consciousness • Retention/oedema • Increased intracranial pressureCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  38. 38. Rationale of maintenance solutions • Fluid redistribution • Basal requirement of potassium & sodium • electrolyte concentration in infusion solutionsCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  39. 39. Electrolyte solutions Plasma Isotonic Hypotonic solutions solutions 290 308 273 278 290 278 Normal Ringer’s D5 KAEN 3B* saline acetate/ lactate * KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol Cl-, 20 mmol lactate, 27 g dextrose per L.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  40. 40. Electrolyte Requirements: 70-kg adult • Sodium (as NaCl): 80-150 mEq (mmol)/d (Pediatric patients, 3-4 mEq/kg/ 24 h [mmol/kg/24 h]) • Chloride: 80-150 mEq (mmol)/d, as NaCl • Potassium: 50-100 mEq/d (mmol/d) (Pediatric patients, 2-3 mEq/kg/24 h [mmol/kg/24 h]). • Calcium: 1-3 gr/d, • Magnesium: 20 mEq/d (mmol/d).Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  41. 41. Sodium Physiology 1. Sodium and its anions make up about 90% of the total extracellular osmotically active solute. 2. Serum osmolality (mOsm/kg H20) = 2 X [Na+] + [glucose]/18 + [BUN]/2.8 3. For practical purposes, twice the Na+ concentration equals serum osmolality because urea and glucose ordinarily are responsible for less than 5% of the osmotic pressure.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  42. 42. Hyponatremia (Na+ <136 mEq/L [mmol/L]) • Low osmolality. Further classified based on clinical assessment of extracellular volume status • Isovolemic. No evidence of edema, normal BP. Caused by water intoxication (urinary osmolality <80 mOsm), SIADH, hypothyroidism, hypoadrenalism, thiazide diuretics, beer potomania • Hypovolemic. Evidence of decreased skin turgor and an increase in heart rate and decrease in BP after going from lying to standing. Due to renal loss (urinary sodium >20 mEq/L) from diuretics, postobstructive diuresis, mineralocorticoid deficiency (Addison disease, hypoaldosteronism) or extrarenal losses (urinary sodium <10mEq/L) from sweating, vomiting, diarrhea, third spacing fluids (burns, pancreatitis, peritonitis, bowel obstruction, muscle trauma) • Hypervolemic. Evidence of edema. urinary sodium <10 mEq/L). Seen with CHF, nephrosis, renal failure, and liver diseaseCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  43. 43. Symptoms: Usually with Na+ <125 mEq/L (mmol/L) • severity of symptoms correlates with the rate of decrease in Na+. • ?Lethargy, confusion, coma • ?Muscle twitches and irritability, seizures • ?Nausea, vomiting • Signs: Hyporeflexia, mental status changesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  44. 44. Treatment: Based on determination of volume status. Life-Threatening. (Seizures, coma) 3-5% NS can be given in the ICU setting. Attempt to raise the sodium to about 125 mEq/L with 3-5% NS. Isovolemic Hyponatremia. (SIADH) • Restrict fluids (1000-1500 mL/d). • Demeclocycline can be used in chronic SIADH. Hypervolemic Hyponatremia • Restrict sodium and fluids (1000-1500 mL/d). • Treat underlying disorder. CHF may respond to a combination of ACE inhibitor and furosemide. Hypovolemic Hyponatremia • Give D5NS or NS.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  45. 45. Hypernatremia (Na+ >144 mEq/L [mmol/L]) • Mechanisms: Most frequently, a deficit of total body water. • (Hypovolemic hypernatremia). • (Isovolemic hypernatremia). • (Hypervolemic hypernatremia).Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  46. 46. Hypernatremia (Na+ >144 mEq/L [mmol/L]) • Mechanisms: Most frequently, a deficit of total body water. • Combined Sodium and Water Losses (Hypovolemic hypernatremia). • Water loss in excess of sodium loss results in low total body sodium. • Due to renal (diuretics, osmotic diuresis due to glycosuria, mannitol, etc) or extrarenal (sweating, GI, respiratory) lossesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  47. 47. Hypernatremia (Na+ >144 mEq/L [mmol/L]) • Excess Sodium (Hypervolemic hypernatremia). • Total body sodium increased, caused by iatrogenic sodium administration (ie, hypertonic dialysis, sodium-containing medications) or adrenal hyperfunction (Cushing’s syndrome, hyperaldosteronism).Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  48. 48. Hypernatremia (Na+ >144 mEq/L [mmol/L]) • Excess Water Loss (Isovolemic hypernatremia). • Total body sodium remains normal, but total body water is decreased. Caused by diabetes insipidus ,excess skin losses, respiratory loss, others.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  49. 49. Hypernatremia (Na+ >144 mEq/L [mmol/L]) • Mechanisms: Most frequently, a deficit of total body water. • Combined Sodium and Water Losses (Hypovolemic hypernatremia). • Water loss in excess of sodium loss results in low total body sodium. • Due to renal (diuretics, osmotic diuresis due to glycosuria, mannitol, etc) or extrarenal (sweating, GI, respiratory) lossesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  50. 50. Hypernatremia • Symptoms: Depend on how rapidly the sodium level has changed • Confusion, lethargy, stupor, coma • Muscle tremors, seizures • Signs: Hyperreflexia, mental status changesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  51. 51. Hypernatremia: Treatment: • Euvolemic/Isovolemic. (No orthostatic hypotension) calculate the volume of free water needed to correct the Na+ to normal as follows: • Body water deficit = Normal TBW - Current TBW Where Normal TBW = 0.6 x Body weight in kg • And Current TBW =Normal serum sodium x TBW / Measured serum sodiumCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  52. 52. Hypervolemic Hypernatremia • Avoid medications that contain excessive sodium (carbenicillin, etc). Use furosemide along with D5W.Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  53. 53. Hypernatremia: Treatment: • Hypovolemic Hypernatremia. Determine if the patient volume is depleted by determining if orthostatic hypotension is present; • if volume is depleted, rehydrate with NS until hemodynamically stable, • then administer hypotonic saline (1/2 NS).Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  54. 54. Treatment of hypernatremia • Hypotonic fluid loss is the most common form of hypernatremia. • It is caused by gastroenteritis, osmotic diuresis. • Signs of intravascular depletion are evident. • Treatment involves replacement volume with normal saline, followed by correction of the free water deficitCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  55. 55. Basal requirement of Potassium • K+ intake ranges from 40-150 mEq daily • Homeostasis (minimum req) 20-30 mEq/day • Increased requirement in heart failure and hypertensionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
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  57. 57. Relationship between serum K+ serum and TBK at various levels of deficit and excess 10 - - 8 - - 6 - serum K+ - (meq/L) 4 - - 2 - - - -900 -600 -300 0 +300 K+ deficit (meq) K+ excess (meq)Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  58. 58. Decreased serum K+ and deficit of TBK (%) 5 - - 4 - - 3 - serum K+ - (meq/L) 2 - - 1 - - total body K+ = 50 mEq/kg body weight - 05 10 15 20 25 K+ deficit (%)Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  59. 59. K+ and acid-base status Blood pH 7.2 7.3 7.4 7.5 7.6 K+ depletion 5.0 4.5 4.0 3.5 3.0 0 mEq Serum K+ 4.5 4.0 3.5 3.0 2.5 100 mEq 4.0 3.5 3.0 2.5 2.0 200 mEq 3.2 3.0 2.5 2.0 1.5 400 mEq Acidosis Alkalosis cell ECF DCC Cell ECF Tubulus distal 3 K+ 3 K+ H+ 3 K+ 3 K+ K+ K+ H+ H+ H+ H+ H+ 2 Na + 2 Na + 2 Na + 2 Na + Urine Urin H + acid urine H+ Urine Alkali K + low urine K+ K + K+ urin tinggiCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  60. 60. Standard K+ concentration in i.v. solutions 1 Cnc: <40 mEq/L < 40mEq/L 2 Rate of adm: <20 mEq/hr KCl 3 daily dosage : <100 mEq/day 4 Monitor ECG and serum K+ 5 U r i n e output: >0.5 ml/kg/hr KCl bolusCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  61. 61. Serum Electrolytes MAGNESIUM • common electrolyte abnormality hospitalized humans is hypomagnesimia • Primarily intracellular • Low Mg may be clinically silent but makes hypocalcemia and hypokalemia refractory to treatment • Vitamin D controls Mg absorption • May see high Mg in renal failureCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  62. 62. Serum Electrolytes MAGNESIUM • Normosol and Plasmalyte contain Mg • Very low Mg may require treatment with IV MgSO4 • Cofactor for NaK ATPaseCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  63. 63. Rate of administration of Electrolyte & glucose Na+ 100 mEq/hr K+ 20 mEq/hr Ca++ 20 mEq/hr Mg++ 20 mEq/hr - HCO3 100 mEq/hr Glucosa 0,5 gr/kg/hr ( 4 mg/kg/min)* * Neonates 6-8 mg/kg/minCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)
  64. 64. Conclusion • Maintenance fluid therapy : normal loss • (IWL + Urine) • Suitable in hypertonic dehydration • Minimized risk of potassium depletion in cases of prolonged inadequate oral intake • ‘Ready for use” product associated with less risk of contamination • Can be combined with amino acidsCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

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