Fluid management

1. FLUID MANAGEMENT
/ DEHYDRATION /
HYPOVOLEMIA
Prepared By: Dr IMRAN ORUCOV

2. WATER
• Water is extremely important for the human body.
About half of the human body weight is water, and
without exaggeration it can be said that almost all
processes in the body take place in the water
environment. 65-75 % of a man's body, 60-65 % of a
child's body, and 50-55%of a woman's body consist of
water. Of course, these are average numbers.

3. DEHYDRATION AND
HYPOVOLEMIA
• Total body water is further divided into the intracellular
fluid (ICF), which comprises 55% to 75%, and the
extracellular fluid (ECF), which comprises around 25-45%.
The ECF is further divided into the intravascular and
extravascular (interstitial) spaces. ECF is the more readily
measured component as it can be estimated by arterial
blood pressure.
• Loss of body fluid is known by the term’s Dehydration and
Hypovolemia:

4. RECOMMENDED FLUID INTAKE/DAY WITH
NORMAL AMBIENT LOSSES

5. DEHYDRATION
AND
HYPOVOLEMIA
Hypovolemia refers to a state of intravascular volume
depletion, while dehydration describes a state of
reduced total body water volume, mostly affecting the
intracellular fluid compartment. In clinical practice,
however, these terms are often used interchangeably, as
they are often encountered simultaneously. Body fluid
loss (dehydration and/or hypovolemia) occurs when fluid
excretion exceeds fluid intake, e.g., due to inadequate
fluid intake, vomiting, and/or diarrhea.
Young children and the elderly are at an increased risk
of clinical dehydration because of differences in body
water distribution, the potential inability to
communicate needs to caregivers, and increased
diuretic use in elderly patients.

6. DEHYDRATION
•Sometimes dehydration occurs for simple reasons:
You don't drink enough because you're sick or busy,
or because you lack access to safe drinking water
when you're traveling, hiking or camping.
•Other dehydration causes include:
Diarrhea, vomiting.
Fever.
Excessive sweating
Increased urination
Etiology

7. Hypovolemia
• Renal
Diuretic excess
Mineralocorticoid
deficiency
Ketonuria
Osmotic diuresis(
mannitol, HBG)
Cerebral salt wasting
syndrome
Salt-wasting
nephropathies
The causes of hypovolemia are broadly divided into renal
and extrarenal etiologies.
• Extrarenal
Vomiting
 Diarrhea
Third spacing of fluid
Burns
Pancreatitis
Trauma
Bleeding

8. DEHYDRATION
AND
HYPOVOLEMIA
Patients may present with :
Increased thirst
Lethargy
Prolonged capillary refill
Abnormal vital signs(hypotension,tachycardia)
Decreased skin turgor

9. HYPOVOLEMIA
Patients can also develop hypovolemic shock
if hypovolemia is so severe that the body is
unable to compensate, resulting in end-organ
damage due to hypoperfusion.
Hypovolemia and dehydration are clinical
diagnoses and laboratory tests are only
indicated in patients with suspected
associated metabolic disturbances or severe
enough fluid loss to cause end-organ damage.

10. Clinical features: Symptoms

11. Clinical
features:
Physical
Findings

12. Diagnostics
• Diagnosing dehydration and/or hypovolemia relies on clinical
assessment
• Laboratory studies can help support the clinical diagnosis but
are not routinely required.
• Obtain laboratory studies for:
 Severe fluid loss requiring IV fluids
 Moderate fluid loss following unsuccessful enteral (e.g.,
PO/NG) fluid replacement
 Evaluation of the underlying cause, e.g., diabetes insipidus,
hyperglycemic crises
NB : Dehydration and hypovolemia are clinical diagnoses.

13. Laboratory studies
• BMP: (Basic Metabolic Panel)Serum Na used to guide treatment.
• CBC
• Lactate
• Uric acid
• POC glucose ( express BG measurement)
• Urinalysis
• Urine electrolytes: e.g., urine Na
Orders: to evaluate severe fluid loss

14. Laboratory findings in dehydration and
hypovolemia
AKI- acute kidney injury ;FENa-Fractional Excretion of Sodium

15. Urine Dipsticks
Specific Gravity of >1.030
Ketones (small with mild
dehydration and large more
significant dehydration)
Protein (can see with more
significant dehydration)
Blood (will see with more
significant dehydration)
Ketones, Protein and
Blood can also be seen
normally after a hard days
work or exercise and not
adequately hydrated
Ketones, Protein and
Blood they should all clear
up as the patient hydrates
over the hours and thus
should be monitored along
with the Specific gravity
for improvement of
hydration

16. Urine
Dipsticks
Prolonged presence of Ketones, Blood and Protein
past 24 hours may indicate more chronic pathology
such as chronic kidney disease, thus continual
monitoring may be indicated in some patients.
Ketones, Protein and Blood in the urine may also
indicate other pathology together or individually :
• Acute renal failure
• Kidney stones
• Diabetic ketoacidosis
• Sepsis

18. DEHYDRATION AND
HYPOVOLEMIA
The primary goals of treatment are to first address the hypovolemia, if
present, in order to quickly restore the circulatory volume, followed by the
management of dehydration through the gradual correction of any:
Remaining fluid deficit (including free water deficit)
Associated electrolyte abnormalities
Ongoing fluid losses
Maintenance fluid requirements.

19. Treatment
Initial fluids for dehydration and hypovolemia: Administer
isotonic fluid and choose route and rate based on estimated
fluid loss.
Severe fluid loss (hypovolemic shock): Begin immediate
hemodynamic support with aggressive IV fluid
resuscitation, e.g., 20-30 mL/kg bolus of isotonic crystalloid.
Moderate fluid loss (hypovolemia without shock)
Administer enteral OR parenteral fluids to correct
extracellular volume deficit.
If starting with IV fluids, transition to enteral fluids as soon
as possible.
Mild fluid loss:
Prioritize enteral replacement of fluids (i.e., oral
rehydration therapy).

20. Initial fluid
therapy for
dehydration
and
hypovolemia
Fluid administration in the first 2–4 hours of presentation is
typically more aggressive, depending on the degree of fluid loss.
Goal: to correct hypovolemia
Indications
Severe fluid loss
Mild fluid loss OR moderate fluid loss with:
Inability to tolerate oral fluids (due to e.g., intractable vomiting,
inability to swallow, pain)
Dehydration or hypovolemia refractory to a trial of enteral fluid
therapy

21. Oral
rehydration
therapy
Indications
• Children: first-line
therapy for mild fluid loss
or moderate fluid loss due
to gastroenteritis and/or
diarrhea
• Adults: mild fluid loss
and moderate fluid loss
due to acute watery
diarrhea (e.g. traveler's
diarrhea) and viral
gastroenteritis
Goal: to correct hypovolemia and dehydration using
oral rehydration solutions
Contraindications include:
• Hemodynamic instability
• Depressed mental status
• Refractory vomiting
• Diarrhea with LGIB
(Lower gastrointestinal
bleeding) or paralytic
ileus
• Disorders of sodium
balance
• Glucose malabsorption
NB! Total ORS volume required in the first 4 hours for adults and
children with mild fluid loss or moderate fluid loss can be
approximated to 75 mL/kg

22. Oral
rehydration
therapy
Oral Fluids (for isotonic fluid losses like gastroenteritis)
Rehidron (282 mOsm/L)
 Reneza (239 mOsm/L)
 Asidolit (225 mOsm/L)
Homemade
 One level teaspoon of table salt and eight level teaspoons
of sugar per liter of water provide 86 mM sodium to which
one cup of orange juice or two bananas can be added for
potassium.
NB! The normal serum osmolality should range from 285±
10 mOsm/L
Types of oral rehydration solution (ORS)

23. Oral
rehydration
therapy
Consider a preemptive antiemetic in patients with a history of recent vomiting
Prescribe an initial volume and rate of ORS based on age and severity of fluid loss
Encourage frequent small-volume ingestion to reduce the risk of abdominal discomfort and
vomiting.
Perform regular clinical reassessment
Consider serial electrolytes and other hemodynamic monitoring parameters in at-risk patients.
Approach to fluid administration

24. Classification
of
antiemetics
CLass Drug Sit e of action Generic name
Dopamin receptor
antoganist
Metaclhlopramide
Domperidon
Prochlorperazine
D2 reseptors Serukal 5 mg/ml
5-10MG PO, IM or IV every 8
hrs- Motillium 10mg PO every
8hrs
Serotonin
antogonists
Ondansetron
Granisetron
Romosetron
Polonosetron
5HT-3 receptors Zofran 2mg/ ml
(4 mg to 8mg PO,IM or IV every
12 hrs )
Antimuscarin(
Anticholinergic)
Atropin
Hysocine
M1 receptors
Buskopan 20mg /ml PO , IM or
IV 3-5 times
Antihistaminics Hydroxizine H1 reseptorls
antogonists
Atarax 25mg PO 2-3 times

25. DOES
THE
PATIENT
NEED
IVF?
In mild to moderate dehydration or
hypovolemia, from vomiting and/ or diarrhea,
oral hydration SHOULD be attempted with
patience. Rehydration should be attempted by
drinking small amounts of fluids at a time, as
this will decrease the chance of vomiting. If
this fails, IVF may be necessary.
For moderate or severe dehydration, from
vomiting and diarrhea, hypovolemia from
bleeding, sepsis or poor PO intake should
receive IVF.
Some conditions require a patient be NPO.
These patients should receive IVF as well.

26. DOESTHE PATIENT NEED AN INTRAVENOUS
BOLUS?
Given that the decision has
been made to administer
IVF and the criteria used to
make that decision, most
patients will benefit from a
bolus.
A reasonable bolus in a
normal adult is 1 – 2 liters of
NS or LR.The patient should
be assessed frequently
during fluid administration to
determine if additional fluid
is needed.
Any patient with severe
dehydration, hypotension,
tachycardia, or in the case of
sepsis,, should receive a
bolus.
For most normal sized
adults with normal renal
and cardiac function, a 1-2 L
bolus may be given.After
the fist liter, the patient
should be monitored for the
response and using that
information the decision
should be made if they need
a second liter of IVF.
In general, for normal sized
adults with normal renal and
cardiac function, a bolus is
very unlikely to do any harm
and, in most cases, will
benefit the patient or at least
make them feel better.
The bolus for children is 20
mL / kg of NS.This may be
repeated x 1 if necessary.

27. Intravenous fluid therapy
(Parenteral fluid therapy)
• Intravenous fluid therapy involves the intravenous
administration of crystalloid solutions and, less
commonly, colloidal solutions.The type, amount, and
infusion rates of fluids are determined based on the
indication for fluid therapy and specific patient needs.
• Crystalloid solutions are used to resuscitate patients who
are hypovolemic or dehydrated, correct free water
deficits, replace ongoing fluid losses, and meet the fluid
requirements of patients who cannot take fluids enterally.
• The use of colloidal solutions is controversial and should
be reserved for special situations (e.g., severe cases of low
oncotic pressure).All patients should be closely monitored
using a combination of clinical parameters and laboratory
tests to determine therapeutic endpoints, and fluid
therapy should be appropriately de-escalated for patients
in recovery to avoid fluid overload.

28. Types of parenteral fluids
Crystalloids: solutions that contain small molecular weight solutes (e.g.,
minerals, dextrose)
Colloids: solutions that contain larger molecular weight solutes (e.g.,
albumin and starch)
Balanced IV fluid solutions: crystalloids or colloids that do not significantly
alter the homeostasis of the extracellular compartment

29. Crystalloid solutions
Aqueous solutions with
varying concentrations of
electrolytes
The most used fluids in a
hospital setting
Crystalloids increase
intravascular volume; the
extent to which they do
this depends on their
tonicity (effect on fluid
compartments).

30. Crystalloid
solutions
• Isotonic crystalloid
Best solutions for IV fluid resuscitation
 Normal saline (0.9% NaCl)
 Lactated Ringer's solution (LR)
Mixed isotonic solutions (i.e., containing glucose) are
preferred as maintenance fluids
 5% dextrose in 0.9% NaCl (D5NS); isotonic
 5% dextrose in 0.45% NaCl (D5½NS);

31. Crystalloid solutions

32. Crystalloid solutions
• Hypotonic crystalloids-Hypotonic crystalloids can be used to correct free
water deficits and as a maintenance fluid if there is free water loss
NB! Maintenance fluid therapy with hypotonic solutions can cause iatrogenic hyponatremia
and cerebral edema.

33. Crystalloid solutions
• Hypertonic crystalloids-Hypertonic saline solutions must be administered
with extreme caution because of the risk of rapid osmotic changes.
NB! When administering hypertonic saline, frequent serum sodium controls must be
conducted so that treatment can be adjusted accordingly. A rapid increase in serum sodium
can lead to osmotic demyelination syndrome.

34. Route of parenteral fluid therapy
Peripheral IV access:The intravenous route is most used for administering
fluids and/or medication.
Intraosseous access: In “difficult/collapsed” peripheral veins, IO (intraosseous)
access is preferred to central venous access for resuscitation.
Central venous access: typically, longer length than most peripheral IV and IO
access catheters
A wider lumen and a shorter catheter tube allow for a higher flow rate.
Rapid introduction of large volumes of fluid through multiple large-bore (16G or wider)
peripheral venous catheters is preferred to resuscitate patients with hypovolemic shock.

35. Initial fluid
therapy for
dehydration
and
hypovolemia
• Continue fluid
resuscitation and treat
as hypovolemic shock.
• Add replacement of
ongoing GI fluid loss in
patients with vomiting
and diarrhea.
Clinical deterioration Clinical improvement
• Start enteral fluids (e.g.,
ORS) if no aspiration risk
factors are present.
• Address remaining
continued fluid needs
(e.g, maintenance fluids,
free water deficit) and
metabolic disturbances.

36. Prescribing
parenteral
fluids
IV fluids should be prescribed as any other drug.
The phases of IV fluid treatment and the 4 Ds can be used as
guiding principles.
Drug: Prescribe the type of fluid.
Dosing: Indicate the number of fluids and the rate.
Duration: Monitor the response and determine the
minimum and maximum duration of therapy.
De-escalation:Taper and eventually discontinue the fluid.
Patients receiving IV fluids should be evaluated continuously
(at least daily).

37. Referance
• RMI RHCP Guidelines Last editionAugust 2017
• AMBOSS: medical knowledge platform for doctors and students
• Asim M, Alkadi MM,Asim H, GhaffarA. Dehydration and volume depletion: How to handle
the misconceptions.World J of Nephrol. 2019; 8(1): p.23-32. doi: 10.5527/wjn.v8.i1.23
• Bhave G, Neilson EG.Volume DepletionVersus Dehydration: How Understanding the
Difference CanGuideTherapy.Am J Kidney Dis. 2011; 58(2): p.302-309. doi:
10.1053/j.ajkd.2011.02.395
• Huang LJ. Dehydration. In: CordenTE Dehydration. NewYork, NY:
WebMD.http://emedicine.medscape.com/article/906999
• Ofei SY, Fuchs GJ. Principles and Practice of Oral Rehydration. Curr Gastroenterol Rep.
2019; 21(12). doi: 10.1007/s11894-019-0734-1
• ...