Fluid replacement therapy

Doctor of Veterinary Medicine
Apr. 1, 2015

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Fluid replacement therapy

  1. Sakina Rubab 9th semester DVM Fluid Replacement Therapy
  2. Fluid Therapy is the administration of fluids to a patient as a treatment or preventative measure. It can be administered via an intravenous, intraperitoneal,oral and other routes.
  3. Indications Hypovolemia Hypotension Electrolyte, metabolic and acid base disorders Decreased oxygen delivery Geriatric patients at risk of organ failure
  4. Special considerations Shock Anaesthesia Hepatic diseases Central nervous system diseases Cardiac diseases
  5. Mechanism of shock  Changes in cardiac function  Sympathetic N.S  Compensatory changes
  6. To assess whether a patient is in shock the following signs may be seen:  Tachycardia  Pale mucous membranes (May be dark if distributive shock)  Prolonged/Absent capillary refill time  Reduced/Absent peripheral pulses  Hypotension
  7.  Hypovolemic is seen when there is reduced circulating blood volume and the most common form of shock.  Cardiogenic is seen in any condition when there is a failure for the heart to pump effectively.  Vascular can be sub-divided into -  Obstructive is seen when there is an obstruction to blood flow to a region of tissue.  Distributive is seen when there is inappropriate vasodilatation.
  8. Dehydration status  Semidry oral mucous membranes, normal skin turgor, and eyes maintaining normal moisture indicate 4%–5% dehydration.  Dry oral mucous membranes, mild loss of skin turgor, and eyes still moist indicate 6%–7% dehydration.  Dry mucous membranes, considerable loss of skin turgor, retracted eyes, acute weight loss, and weak rapid pulses indicate 8%–10% dehydration.  Very dry oral mucous membranes, complete loss of skin turgor, severe retraction of the eyes, dull eyes, possible alteration of consciousness, acute weight loss, slow and weak pulses indicate ≥12% dehydration.
  9. General indication  Loss of fluid from compartment  Severity(Dehydration status)  Compartment  Laboratory results  Symptoms
  10. Fluid Dynamics  3 compartments: intravascular, interstitial and intracellular (capillaries)  A capillary “membrane,” which consists of the endothelial cells and subendothelial cell matrix (separation)  This capillary “membrane” is freely permeable to water and small-molecular-weight particles such as electrolytes, glucose, acetate, lactate, gluconate, and bicarbonate
  11.  The interstitial compartment is the space between the capillaries and the cells.  The intracellular compartment is separated from the interstitial space by a cell membrane.  This membrane is freely permeable to water but not to small- or large-molecular-weight particles.  Interstitium and the cell :transport mechanism (eg, channel, ion pump, carrier mechanism).
  12. Types of fluids Crystalloids are able to enter all body compartments. Colloids are restricted to the plasma compartment. electrolyte imbalance
  13. Crystalloids  Ringer lactate  Normal saline 0.45%,0.9%,7%  Dextrose 2.5%,5%,10%,20%  Hartmann’s solution  Plasmalayte
  14. Colloids  Dextrans  Hydroxyethyl starch (HES)  Canine albumin  Stroma free haemoglobin
  15. Selection of fluids Fluids must be administered that will concentrate within the body fluid compartment where the volume deficit lies. Crystalloids are water-based solutions with small- molecular-weight particles, freely permeable to the capillary “membrane.” Colloids are water-based solutions with a molecular weight too large to freely pass across the capillary “membrane.”
  16. Colloids intravascular volume replacement solutions Crystalloids interstitial volume replacement solutions.
  17. Crystalloids  The small-molecular-weight particles in crystalloids are primarily electrolytes and buffers .Intravascular administration of isotonic crystalloids (e.g. lactated Ringer's, 0.9% saline) will result in interstitial volume replacement and minimal intracellular fluid accumulation.  Hypotonic fluids (e.g.5% dextrose in water, saline) will result in intracellular water accumulation and should not be used as resuscitation fluids.  Hypertonic solutions (e.g. 7% NaCl) contain higher concentrations of sodium and are best used when hydration is normal and concurrently with other fluids.
  18. Colloids  When colloids are to be administered, it must be decided whether a natural colloid (e.g., plasma, albumin, or whole blood) or a synthetic colloid(HES,dextran) is to be used.  When the animal requires RBCs, clotting factors, antithrombin III, or albumin, blood products are the colloids of choice.
  19. When to use which solution?  Hypotonic saline fluids such as 0.45% sodium chloride solution expand the intracellular compartment hypertonic dehydration, gastric fluid loss, and cellular dehydration from excessive diuresis.
  20.  Isotonic saline fluids 0.9% sodium chloride solution  expand the extracellular compartment  circulatory insufficiency, replenish sodium and chloride losses, treat diabetic ketoacidosis, replenish fluids in the early treatment of burns and adrenal insufficiency.  Because their osmolality is similar to that of blood, they're also the standard flush solutions used with blood transfusions.
  21.  Hypertonic saline fluids 5% dextrose in 0.9% sodium chloride solution  are used cautiously to treat severe hyponatremia.
  22.  Precautions: Closely monitor the patient for complications, such as electrolyte imbalances, calorie depletion, and increased intracranial pressure (ICP).  Because hypertonic fluids pull water from the intracellular space into the extracellular space, fluid volume and ICP can increase. Watch for fluid overload in patients with a history of heart failure or hypertension.
  23.  Dextrose fluids, which contain dextrose and free water(2.5%, 5%, 10%, 20%, and 50%)  Dextrose fluids also are available in combination with other solutions, such as sodium chloride or Ringer's solution.  Dextrose fluids provide calories for energy, sparing body protein and preventing ketosis, which occurs when the body burns fat.  They also make it easier for potassium to move from the extracellular to the intracellular compartment. Dextrose fluids flush the kidneys with water, helping them excrete solutes, and improve liver function (glucose is stored in the liver as glycogen).
  24.  Precautions: Never mix dextrose with blood ,it causes blood to haemolyze. Prolonged therapy with dextrose in water can cause hypokalemia, hyponatremia, and water intoxication by diluting the body's normal level of electrolytes.  Severe hyponatremia can lead to encephalopathy, brain damage, and death; young women are at highest risk. (confusion, change in mental status)  Hypertonic dextrose solutions can cause hyperglycemia, leading to osmotic diuresis and hyperosmolar coma.(serum glucose levels, urine specific gravity, and fluid intake and output,polyuria, polydipsia, weight loss, and weakness)  Dextrose can be given to diabetic patients in acute illness as long as the patient's blood glucose is closely monitored so the balance of blood glucose and insulin is maintained.
  25.  Electrolyte replacement fluids, Ringer's solution:isotonic fluids containing electrolytes in the same concentrations found in plasma.  However, these solutions don't contain magnesium and phosphorus, which shouldn't be routinely given.  The exact electrolyte content depends on the fluid manufacturer. Ringer's injection and lactated Ringer's solution, the two most common electrolyte fluids, contain potassium, sodium, chloride, and calcium. Lactate, added as a buffer to produce bicarbonate, is contraindicated in patients with liver disease because they can't metabolize it.
  26.  Electrolyte fluids provide hydration and electrolytes for patients who can't take in food or fluid orally and for those who've experienced abnormally high fluid losses from severe vomiting, diarrhoea or diuresis.  Lactated Ringer's solution is also used for volume replacement in patients with third- spacing.  5% dextrose may be mixed with the electrolyte fluid to provide energy, keep in mind that the resulting solution is hypertonic.
  27.  Precautions:These fluids generally aren't given for more than 48 hours (unless the patient's condition is unchanged) because of the risk of overhydration, hypernatremia, hyperkalemia, metabolic alkalosis, and calorie depletion if the fluid isn't mixed with dextrose.
  28. Standard shock rate  For crystalloid solution is 80 to 90 ml/kg for a dog and 40 to 60 ml/kg for a cat, and it is normally given in increments (e.g. one-third, one-half) of the calculated amount over a period of 10 to 30 minutes.  For colloid solution is 10 to 20 ml/kg for dogs and 5 to 10 ml/kg for cats.
  29. Fluid rate calculation Maintenance Replacement Ongoing Losses
  30. Replacement  Replacements are calculated based on the level of dehydration. To calculate the amount required for replacement within a 24 hour period, the percentage dehydration is used in the following calculation. Replacement = % Dehydration x Bodyweight (kg) x 10
  31. Maintenance  Maintenance is the basic rate which a patient requires during a 24 hour period. 50ml/kg/24hr, or 2ml/kg/hr.
  32. Ongoing Losses  Ongoing losses are calculated based on a predicted fluid amount lost by a patient within a 24 hour period.  To calculate the fluid requirement, the following calculation is used. Ongoing losses = Amount per loss (ml/kg) xbody weight No. of losses Ongoing losses amount+ replacement amount
  33. Example  Fluid replacement in a dog weighing 25kg.  Replacement= %dehydration*body weight*10 =5% * 25kg* 10 =12.5ml  Maintenance= 2ml/kg/hr For 25kg: 50ml/hr or 1200ml/24hrs  Ongoing losses= fluid lost ml/kg*body weight*no.of losses =100ml/25kg(vomition)*25kg*1 =100ml  100ml+12.5ml+1200ml=1312.5ml/24hrs
  34.  Requirement per hour (ml/hr) = Requirement per day (ml/24hr) ÷ 24  Requirement per minute (ml/min) = Requirement per hour (ml/hr) ÷ 60  Requirement per second (ml/s)= Requirement per minute(ml/min) ÷ 60  Drops per second = Requirement per second (ml/s)x Giving Set Factor
  35. Monitoring fluid therapy urine output Packed Cell Volume (PVC) Total Solids mucous membrane color Total Protein blood pressure oedema Skin turgor
  36. Clinical aspect  Drips  Syringes  Rough estimation of dehydration status  Quick administration
  37. References  edicine_and_critical_care/fluid_therapy/the_fluid_ resuscitation_plan.html  erapy.pdf   calculating-rate-and-choosing-correct-solution
  38. Thank you