Fluid Therapy

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Fluid And

Electrolytes

CME
Contents
1. Total body water and body water compartment
2. Principle of intravenous fluid therapy
3. Clinical assessment + fluid therapy concept
4. Types of fluid
a. Crystalloid: Normal saline,Hypotonic, Hypertonic, Dextrose solution, Ringer’s Lactate,
Hartmann’s
b. Colloid

5. Hydroxyethyl Starch (HES), Gelofusine-nik

6. Perioperative fluid

7. Blood products
Indication of Intravenous Fluid Therapy

According to NICE guidelines, hospitalized patients need IV fluid and


electrolytes for one or more of the following reason (the 4Rs).

● Resuscitation
● Routine maintainance
● Replacement
● Redistribution
1) Fluid Resuscitation

Usually urgent, aims to restore circulation to vital organs following loss of volume
either by bleeding, plasma loss, GI loss of external fluid and electrolyte loss or
severe internal loss eg. fluid redistribution in sepsis

2) Routine maintanence

Required for patient whoever cannot meet their normal fluid or electrolyte via
enteral fluid, otherwise well in term of fluid and electrolyte balance. Eg. they
are usually euvolaemic with no significant deficit or ongoing blood or fluid
loss.
3) Replacement

For patients with ongoing GI/urinary tract loss, fever or burns (plassma loss) as
well as insensible fluid loss in which daily fluid requirement cannot be met
without IV fluid.

4) Redistribution

It is particularly seen in sepsis, septic shock, post major surgery, co-morbidities


(cardiac, renal, liver) and critically ill. Many of these patients develop oedema
from sodium and water excess. Despite the inevitable fluid balance, massive fluid
resuscitation still required to restore circulation in order to prevent multi-organ
dysfunction.
Initial
assessment
Hypovolaemic? Indicators:

● systolic blood pressure is less than 100 mmHg

● heart rate is more than 90 beats per minute

● capillary refill time is more than 2 seconds or peripheries are cold to


touch

● respiratory rate is more than 20 breaths per minute


Clinically:

Hx: limited intake, thirst, the quantity and composition of abnormal losses

Clinical examination :

● Pulse, blood pressure, capillary refill and jugular venous pressure


● presence of pulmonary or peripheral oedema
● presence of postural hypotension.

Clinical monitoring: Fluid balance charts, weight

Laboratory investigations: Full blood count, Hematocrit, urea, creatinine and


electrolytes.
Resuscitation

● Crystalloids -Na+ (130–154 mmol/l), in bolus of 500 ml over 15 minutes.


● Assess ABC again and further fluid bluses up to 2000ml
● Paediatric age group: 20ml/kg
● Human albumin solution 4–5% for fluid resuscitation in severe sepsis.

Routine Maintenance

● 25–30 ml/kg/day of water


● Approximately 1 mmol/kg/day of potassium & sodium & chloride
● For patients who are obese, adjust the IV fluid prescription to their ideal
body weight.
Replacement and Redistribution
TYPES OF FLUID
Crystalloid
Colloid
Crystalloids
Solutions that contain small molecules that flow easily across the cell
membranes, allowing for transfer from the bloodstream into the cells and
body tissues.

This will increase fluid volume in both the interstitial and intravascular

spaces It is subdivided into:

* Isotonic

* Hypotonic

* Hypertonic
Types of isotonic solutions include:

● 0.9% sodium chloride (0.9%


NaCl)
● 5% dextrose in water (D5W)
● Ringer's lolution
Normal Saline When to be
given?
It’s the fluid of choice
0.9% - Simply salt water that contains for resuscitation
only water, sodium (150 mEq/L), efforts. It's the only
and chloride (150 mEq/L). fluid used with
- It's called "normal saline solution" administration of blood
products.
because the % of NaCl in the
1- to treat low
solution is similar to NaCl in
extracellular fluid, as in
intravascular space. fluid volume deficit
TAKE CARE: Because 0.9% sodium chloride from
replaces extracellular fluid, it should be used - Hemorrhage -
cautiously in :
Severe vomiting or
- CCF diarrhea - 2- Shock
- Renal failure 3 Mild hyponatremia
4 Diabetic
for fear of fluid volume overload!!
ketoacidosis
Ringer’s Lactate / Lactated
Ringer’s
/ Hartmann’s solution
- deemed the most “physiologic” fluid : closest to
normal body fluid composition
- Used in fluid resuscitation after blood loss due to
trauma, surgery, or burn injury
- To replace GI fluid losses (diarrhea or vomiting)
- LR maintains a more stable blood pH than normal
saline, so useful in metabolic acidosis (lactate >
bicarbonate in liver) but not for lactic acidosis
Dextrose 5%
● Considered isotonic, but when metabolized, the solution become
hypotonic - fluid shift into cells
● Basically provide free water that pass through membrane pores
both ICF and ECF space
● Correct dehydratiom and supplies calories
● Dextrose: to maintain tonicity, or prevent ketosis and hypoglycemia
due to fasting.

Contraindications:

● Renal or cardiac problems - fluid overload


● High ICP - cerebral edema
● Not for resus : Poor expansion of intracellular volume
● Not for coadministration with blood - hemolyzed due to
hypotonicity
● Not to be used alone in fluid volume deficit - dilute
Precautions in using isotonic
solutions
- Patients being treated for hypovolemia can quickly develop hypervolemia
(fluid volume overload) following rapid or overinfusion of isotonic fluids.
- Frequently assess the patient's response to I.V. therapy, monitoring for
signs and symptoms of hypervolemia
- Monitor intake and output

SSX of hypervolemia: SSX of continued


hypovolemia:
- HPT
- Urine output <
- Bounding pulse
0.5ml/kg/h
- Pulmonary crackles - Poor skin turgor
- Peripheral edema - Tachycardia
- SOB
- Weak thready
pulse
- hypotension
Hypotonic Solution
(eg: 0.45% NaCl, 0.33%NaCl, 2.5%D5 in
H2O)
0.45% Normal saline

● Lower concentration of solute, osmolality less than 250 mOsm/L


● Lower the serum osmolality in vascular space, shifts fluid to intracellular
and interstitial space.
● Treat patient with intracellular dehydration such as hypernatremia,
DKA, hyperosmolar hyperglycemic state
● These solution hydrates cells but deplete fluid in circulatory system

CI

● PT with increased ICP - exacerbate cerebral edema!


● Don’t use in liver disease, trauma and burn patient - high risk for IV
fluid depletion!
Hypertonic
solution
● Higher solute concentration, osmolality more than 375 mOsm/L
● Draws water out of intracellular space, increasing extracellular fluid
volume (volume expander)
● Examples - S3, D10W, NSD5, NSD10, HSD5
● NSD5 - provide extra calories
● 3% NaCl - used in severe hyponatremia with neurological sequelae,
cerebral edema
● Caution: may cause intravascular fluid volume overload and pulmonary
edema
COLLOIDS

● A colloid (eg, hydroxyethyl starch, albumin, dextrans) is defined as a high


molecular weight (MW) substance that largely remains in the
intravascular compartment, thereby generating an oncotic pressure.

● Colloids are typically used for severe hypovolemia

● Colloids are of two types:


○ Natural, i.e., human albumin
○ Artificial, i.e., gelatin and dextran solutions, hydroxyethyl starches (HES).
Albumin
Albumin is a transport protein that is responsible for 75% of the oncotic pressure of plasma.

Heat-treated preparations of human serum albumin are commercially available in a 5% solution (50 g/L)
and a 25% solution (250 g/L) in an isotonic saline diluent.

Features

5% albumin - Initial volume expansion: 70-100%

Approximately half of the infused volume of 5% albumin stays in the vascular space. last 12 to 24 hours.

Disadvantages

1. Cost effectiveness: Albumin is expensive as compared to synthetic colloids.


2. Volume overload: In septic shock the release of inflammatory mediators has been implicated in
increasing the ‘leakiness’ of the vascular endothelium. The administration of exogenous albumin
may compound the problem by adding to the interstitial oedema.
Indications of Albumin
- Emergency treatment of shock due to loss of plasma
- Acute management of burns
- Fluid resuscitation in intensive care
- Clinical situations of hypo-albuminemia
- SBP
- Acute lung injury
- Correction of diuretic resistant nephrotic syndrome
- Following paracentesis
- Liver cirrhosis
- After liver transplant
- In therapeutic plasmapheresis, albumin is used as an exchange fluid to
replace removed plasma
Hydro yethyl Starch (HES)

❖ Synthetic colloid
❖ Starch molecules are derived from plants. Advantages:
-Less expensive compa
❖ Smaller starch molecules eliminated by kidney, large molecule -Nonantigenic, rare an
will be broken down by amylase first. reaction.
-No significant effect t
coagulation studies an
•Indication: time.
● Volume expander in treatment and prophylaxis of hypovolemia.
● Administer up to 50 mL/kg/day (equivalent to 3 g hydroxyethyl
starch and 7.7 mEq Na per kg of body weight).
Side effects:
• This dose is equivalent to 1. Pruritus
3500 mL for a 70 kg patient 2. Increased serum amylase
Give initial 10-20 mL by slow 3. Decreased coagulation factors
IV infusion n HCT
4. AKI
Gelofusine

● solution of succinylated gelatine, behaves like blood filled albumins. Thus,


it helps increase the blood volume, blood flow, cardiac output and oxygen
transportation.

Indication:

● Prophylaxis and treatment of hypovolemia and shock.


● Prophylaxis of hypotension eg during induction of epidural or
spinal anaesthesia.
● Procedures involving intracorporeal circulation eg heart-lung
machine
Gelofusine

Advantage: ● Side effects:


● Nausea, vomiting.
-cost-effective ● Vomiting, diarrhea,
-no limit to the amount ● Muscular twitching
that can be infused.
● Anaphylactic
-small-sized molecules
thus easily excreted reaction (itchiness,
renally, no effect on renal rashes)
impairment.
Dextran
Indications:
Contraindications:
- Improves - Severe oliguria and
microcirculatory flow
renal failure
in microsurgical - Severe CCF
re-implantations - Bleeding disorders
- Extra-corporal circulation - Severe dehydration
(ECMO): During - Known hypersensitivity
cardio-pilmonary bypass
to DExtran
- Correction of
hypovolemia: 100-150%
increase in
intravascular volume
Blood
Products
Packed Cells
Product Description

Packed red blood cells (PRBCs) are made from a


unit of whole blood by centrifugation and removal of
most of the plasma, leaving a unit with a hematocrit
of about 60%. One PRBC unit will raise the
hematocrit of a standard adult patient by 3% (or
about 1%/mL/kg in a child - 12%/25 kg with the
standard 300 mL PRBC unit). PRBCs are used to
replace red cell mass when tissue oxygenation is
impaired by acute or chronic anemia.
Fresh Frozen
Plasma

FFP contains all factors of the soluble coagulation


system, including the labile factors V and VIII.
FFP is indicated when a patient has MULTIPLE
factor deficiencies and is BLEEDING. Note that
FFP SHOULD NEVER be used as a plasma
expander.

1. Plasma component of blood


2. Expands volume and provide clotting
factors
3. NO RBC
4. Increase clotting factors by 2-3 %
Platelets
A single platelet unit is derived from one whole
blood unit collected. Platelets are stored at
room temperature and CANNOT be frozen.
They must be used in 5 days. Pooled platelets
from multiple donors from whole blood
collections are cheaper to produce but the
exposure to the recipient increases.

1. Increase platelet about


5000/mL
Cryoprecipitate

Cryoprecipitate (cryo) contains a concentrated


subset of FFP components including fibrinogen,
factor VIII coagulant, vonWillebrand factor, and factor
XIII. Cryoprecipitate is used for hypofibrinogenemia,
vonWillebrand disease, and in situations calling for a
"fibrin glue." Cryo IS NOT just a concentrate of FFP.
In fact, a unit of cryo contains only 40-50% of the
coag factors found in a unit of FFP, but those factors
are more concentrated in the cryo (less volume).
Indications for Blood Product Usage

There are situations identified in which blood products may be needed:


● Packed RBCs: generally indicated with a hemoglobin of 7 to 8 g/dL, a markedly decreased
oxygen saturation and/or orthostatic hypotension. There is indication that the patient needs
additional oxygen carrying capacity.
● Platelets: generally indicated for a platelet count of less than 50,000/microliter and there is active
bleeding, or if a procedure such as surgery is to be performed. Spontaneous bleeding is unlikely
until the platelet count drops below 10,000 to 20,000/microliter.
● FFP: generally indicated when a patient has multiple factor deficiencies and is bleeding, or for
thrombotic thrombocytopenic purpura (TTP). The PT and PTT will be prolonged, and the INR
generally should be greater than 1.6.
● Cryo: generally indicated for hypofibrinogenemia, vonWillebrand disease, and in situations
calling for a "fibrin glue”.

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