compare and contrast between two hypovoluemic shocks in fluid therapy ( update 2016 )

1. Fluid Therapy
in
GE Shock Vs. DSS
(update 2016)
Dr. Aung Kyi
Wynn
Senior consultant
Pediatrician

2. Introduction
 Hypovolemic shocks
 Different pathophysiology
 Different management
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3. Scenario
 4 years old child
 Body weight 15 kg
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4. GE SHOCK OR
CHOLERA SHOCK
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5. Pathophysiology
 Secretory diarrhea
 External fluid loss (water+electrolytes)-
Rapid
 From extravascular space ---dehydration
 10% of body weight loss S/S of
shock
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6. Principle for GE shock treatment
Fluid out volume = Fluid in
volume
Rapid
Refill
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7. Pre-illness BW estimation
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Pre-illness BW = measured BW + 10% of
BW
15kg = 13.5kg + 1.5kg

8. Resuscitation
 Fluid loading dose
 R/L or N/S or 5% D/S
 25% glucose or 10% dextrose (for
hypoglycemia)
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9. Loading dose
 20 ml/kg within 15 min(300 ml)
 Second Loading dose if not improved
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10. T0TAL FLUID PER DAY
 RMO/ 24 hour
 Rehydration, Maintenance, Ongoing
loss
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11. Rehydration-Plan C
 10% loss – 100 ml/kg
 100 ml * 15 kg = 1500 ml
 30 ml/kg in first ½ hr (450 ml)
 70 ml/kg in 2 ½ hr (1050 ml)
 Without loading dose in 30 ml/kg
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12. Maintenance
 Holliday-Segar Method (15kg = 10 + 5
)
 1st 10 kg 100ml/kg
1000ml
 2nd 10 - 20 kg 50ml/kg
250ml
 Over 20 kg 20ml/kg _
1250 mlAKW9/6/2016 12

13. Rate
 Resuscitation loading 80ml/kg/hr for15
min
 Initial 60ml/kg/hr for 30
min
 Later 30ml/kg/hr for 2
1/2hrs
 Maintenance 3ml/kg/hr for 24hrs
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14. Total RMO
 Rehydration 1500 ml
 Maintenance 1250 ml
2750 ml
 Ongoing loss ?
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15. Ongoing loss
 From intake-output chart
 10ml/kg (150 ml) for one time of loose
motion
 ORS(old formula) or IV line
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16.  At least total 6 bottles of drip for 24 hr
 Wide therapeutic index
 Low risk for overloading
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17. DSS
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18. Pathophysiology
 Immune reaction
 Increase vascular permeability
 Plasma leakage (directly from vascular
space)-moderate to slow
 Third space loss (serous cavity-internal
loss)-water+electrolytes+protein
 No dehydration
 Will reenter into IVS and excreted by
kidneys in recovery phase (risk of
overload)
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19.  Loss in 4-6% of body weight (no
actual weight loss) – S/S of shock
 If coagulation defect +
GI bleeding
External loss
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20. Cause of death
overload or bleeding
Death
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21. Principle of fluid therapy in
DSS
 “ Just adequate “ the least fluid
volume to correct shock
 “ Fresh whole blood “ transfusion is
mandatory if indicated
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22.  Loading dose (20ml/kg)-300ml within
15 minutes if BP zero (or)
 20 ml/kg/hr if hypotension only
 R/L or N/S for loading , initial
replacement and maintenance
 Colloid - dextran 40, gelofusine or
?Plasma 10ml/kg/hr for ongoing loss
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23. Type of fluid
Initial stage
Isotonic fluid – R/L , N/S
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24. Later stage
To remain in IVS longer in later period
 Osmolality and
 Oncotic pressure must be above that
of plasma
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25. Osmolality
 R/L 273mosm/l
 NS 308mosm/l
 5%D/S 560mosm/l
 1/2strength D/S 406mosm/l
 Dextran 40,70 310mosm/l
 Gelofusine 274mosm/l
 Plasma 285-295mosm/l
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26. Indian J Anaesth. 2009 Oct; 53(5)
Characteristics of some available
colloids
.
Product (Brand name) Conc. (%) Oncotic pressure (mmHg) Initial volume
expansion (%)
Albumin 25 100–120 200–400
Dextran 70 (Macrodex) 6 56–68 120
Dextran 40 (Rheomacrodex) 10 168–191
200
Fluid gelatin (Geloplasma) 3 26–29 70
Plasma 28
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27. Rate
 Resuscitation loading 80ml/kg/hr for15
min
(or) 20ml/kg/hr for 1
hour
 Initial
(compensated shock) 10ml/kg/hr for 1
hour
 Later 6ml/kg/hr for
1hour
 Maintenance 3ml/kg/hr
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28. Replacement
4% loss 5% loss 6 % loss
40 ml/kg 50 ml/kg 60 ml/kg
600 ml 750 ml 900 ml
Rate ---20ml/kg+10ml/kg+ 6ml/kg + 3ml/kg= 39ml/kg
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29. Maintenance
 Same 1250ml
 with crystalloid (N/S , ½ S D/S)
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30. 1. Replacement 4% loss 5% loss 6% loss
Crystalloid+colloid 600 ml 750 ml 900 ml
2. Maintenance
Crystalloid 1250 ml 1250 ml 1250 ml
3. Ongoing loss
Colloid(or) ? ? ?
Fresh whole blood ? ? ?
1850 ml 2000 ml 2150 ml
10ml/kg 10ml/kg
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31. Ongoing loss
 Plasma leakage colloid
10ml/kg/hr
Dextran 40
 Bleeding fresh whole blood
10ml/kg
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32. OPTIMUM VOLUME
 1 ½ of maintenance
 1250 * 1 ½ = 1875 ml
 Less than 2 times of maintenance
(<2500ml)
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33. Bleeding
 Shock not revived when close to 24 hr
and more than 1850ml infused (OR)
 Condition not improved in spite of
stable PCV (OR)
 Decreased PCV 20% suddenly
Fresh whole blood
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34. Counter check
 Raised Hb G% = FWB ml/kg /6 = 10/6 =1.6
G
 If raised PCV >5% wrong
decision-risk of overload
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35. If not give FWB timely for
bleeding
 Shock – hypoxia-----------death(or)
 Overload
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36. CRITICAL POINT DECISION
(OVERLOAD or BLEEDING)
CAN SAVE LIFE
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37. Complicated cases
 A-acidosis
 B-bleeding
 C-calcium(hypocalcemia)
 S-sugar(hypoglycemia or
hyperglycemia)
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38.  Narrow therapeutic index
 Type of fluid, rate, duration,
appropriate volume, timely
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39. Fluid Therapy in Cholera shock Vs.
DSS
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40. CLOSE
MONITORING
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41. References
 Handbook for clinical management of dengue
–WHO 2012
 The Harriet Lane Handbook – the Johns
Hopkins Hospital, twentieth edition,2015
 Kalayanarooj Siripen and et al, clinical
practice guidelines of dengue/dengue
hemorrhage fever management for Asian
Economic Community, 2014
 Paediatric Management Guideline –
Myanmar Paediatric Society – 2nd edition -
2011
 Paediatric Protocols for Malaysian hospitals –
Malaysian Paediatric Association – 2nd edition
– 2010
 Sukanya Matra and Purva Khandelwal, Are
all colloids same? How to select the right
colloid?, Indian journal of anesthesia 2009
Oct 53(5) AKW9/6/2016 41

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