20. Intake and output must be balanced.
Intake---N fluid ingested—2100 +from
metabolism(200)=2300ml
output—urine-1400+feces(100)
-sweat-100
- insensible loses—skin-
350+lungs350ml
Subject to variation environmental condition and
disease states
21. Weight Water requirement
0-10 kg 4mL/kg/hr
10-20 kg 40mL/hr +2ml/kg/hr for each kg>10kg
>20kg 60ml/hr +1ml/kg/hr for each
kg>20kg
for 60kg man this = 100ml/hr or 2400 ml/24 hrs
for normal people!!
24. Crystalloids
relatively large volume
for resus
Ideal for repleshing
third space loss
Less fear of allergic
reaction
Used as diluent for
ionotropic
adminstration
Colloids
Lesser volume better
expander more
duration
Allergic reaction seen
as well interfearance
with blood
crossmatch
25. R.L hartmen “solution,
balanced salt solution
Isotonic -isobaric- iso-
osmolar- crystalloid
solution.
Concentrations of ions—
Na-131mEq/l
calcium-2mEq/l
bicarbonate-29mEQ/L AS
LACTATE
K+ 5MeQ/L, CL- 110mEq/l
Ph-6.5,osmolarity-279
mosm/L
Normal saline Isotonic
isobaric 0.9% w/vsolution
Na+/cl- =154mEq/l Ph-5.0
0smolarity -308mosm/L
--common maintainence
fluid till other are made
available
---in treatment of diabetic
ketoacidosis—2 litres
--upper intestinal
obstruction and
hypochloremia
26. RL-Solutions provides
electrolytes with lactate.
Lactate is rapidly metabolized
in liver to bicarbonate helps in
correction of acidosis
Mild to moderate hypovolemia
due to any cause
As a maintainence fluid
Preloading before spinal
anaesthesia
Risk—Lactic acidosis
hyperkalemia
NS-Only fluid compatible with
blood.
Flushing of dialysis set with
saline Surgeons use for –
washing crush injuries
peritoneal lavage
under water seal bottle
Can be used as diluent for
medication
NS-RISK-Hyperchloraemic
metabolic acidosis more likely
with renal insufficiency
27. FULFILLS INDICATIONS OF BOTH 5% DEX
AND .9% SALINE
Useful particularly in pediatric patient
Safely be used as maintainence fluid.
Avoid for surgical procedures as dex best media
for bacterial growth
Can be used along with blood
28. It provides calories –each gm of glucose 4 kcal.
--used to correct water deficit
--used to correct hypoglycemia
--used as carrier for giving drugs
dopamine,
aminophylline,noradrenaline,insulin,SNP
29. Higher concentration is irritant to vien.
Avoid extravasation
Water intoxication,odema states
Should not be given along with blood transfusion
Avoid in known hyperglycemic as maintainence
fluid
30. Hemaccel 3.5% poly gelatin
Na 145/cl 145 k-5.1, ca++-6.25mEq/l
Mol wt 30,000 pH 7.3
Half life 4-6hr
Use in mod to severe shock.
Priming solution
31. Citrated blood should not be mixed.
Produces histamine release/anaphylactic
Dose should not increase 1000ml in 24 hrs.
Careful in digitalized patient
Avoid in hepatic renal and CCF
However unlike other colloids does not cause
agglutination and Rolex formation
32. 6% SOLUTION mol wt-2,00,000da
Dose 20ml/kg in 24 h
These are hyperoncotic and cause intravascular
volume expansion
Duration 12-24 hrs
The incidence of anphylactoid reaction is low
33. IT interferes PL Aggregation and coagulation.
Thermo osmalarity-308mosm/l
Ability to with draw fluid from interstital space in to
intravascular compartment
It should be cautiously used in presence of renal
failure
34. Dextran 40/ rheomacrodex
--IT decreases viscosity of blood.
--it improves micro circulation.
--plasma half life 6-12hrs
--dose 20 cc/kg/24hrs
--it does not interfere with blood gp and
crossmatch
35. Accumulation and tissue storage
Effects on renal function
Coagulopathy and bleeding risk
Increase in amylase levels
Anaphylactic potentials
Cost factors
36. New generation colloids-0.4 Molar
substitution==degradation factor
hydroxyl ethyl group
No risk of accumulation even with dosages increased
from 20ml/kg---50ml/kg
No effects on renal and coagulopathy
Quest for the new colloid--
Balanced colloid solution like volulyte will end the debate
41. Fluid resuscitation in uncontrolled
bleeding is deleterious
Delayed resuscitation is valid in trauma
systems with short response times
(<20 minutes to hospital from injury)
Attempts to control bleed should be given
greater importance
42. Fluids (pre-op) 2.4 L 0.4 L (p<0.001)
Survival 62% 70% (p=0.04)
ARDS/ renal failure 30% 23% (p=0.08)
Sepsis/ infection
Hospital days 14+24 11+19 (p=0.006)
N Engl J Med 1994;
331:1105-1109.
598 patients; penetrating torso injury
Field systolic BP <90 mm Hg (58+35)
309 289
Immediate fluids Delayed until induction
46. PERIPHERIAL INTRACATH 16G
Same gauze central line
Hagen poiseuille equation rate @{radius} 4th
power
inversely proportional to length
:;; infusion through central catheter will be as
much as 75% less than infusion rate through
peripheral cathter of equal diameter
47. Fluid resuscitation may consist of natural or
artificial colloids or crystalloids
No evidenced-based support for one type
of fluid over another
•Crystalloids have a much larger volume of
distribution compared to colloids
•Crystalloid resuscitation requires more fluid to
achieve the same endpoints as colloid
•Crystalloids result in more edema
Choi PTL. Crit Care Med 1999;27:200-210.
Cook D. Ann Intern Med 2001;135:205-208.
Schierhout G. BMJ 1998;316:961-964.
Fluid Therapy: Choice of FluidFluid Therapy: Choice of Fluid
Grade C
Dellinger, et. al. Crit Care Med 2004, 32: 858-873.
48. Fluid challenge in patients with suspected
hypovolemia may be given
500 - 1000 mL of crystalloids over 30 mins
300 - 500 mL of colloids over 30 mins
Repeat based on response and tolerance
Input is typically greater than output due to
venodilation and capillary leak
Most patients require continuing aggressive
fluid resuscitation during the first 24 hours of
management
Fluid Therapy: Fluid ChallengeFluid Therapy: Fluid Challenge
Grade E
Dellinger, et. al. Crit Care Med 2004, 32: 858-873.
49. Central venous pressure (CVP) 8–12 mmHg
– Mean arterial pressure (MAP) 65 mmHg
– Urine output 0.5 ml/kg h1
– Central venous (superior vena cava) or mixed
venous oxygen saturation 70%.
Rationale. Early goal-directed therapy
(EGDT)
51. Blood Pressure—not a sensitive marker until
blood loss >30%
NIBP-spuriously low measurement in patient with
hypovolemia (vasoconstrictor response)
Direct IAP better ?
Cardiac filling pressures
CVP—limitation—Indirect measure
52. Change in CVP measured before
and 5 mins after bolus of fluid
◦0-3 mmHg: underfilled
◦3-5 mmHg: adequately filled
◦5-7 mmHg: overfilled
53. 1 a wave is due to atrial
contraction
2.c wave due to buldging
of tricuspid valve in rt
atrium
3 x descent depicts atrial
relaxation
4 v due to rise in atrial
pressure before the
tricuspid valve opens
5 y decent is due to atrial
emptying as blood enters
ventricles
No evidence-based support for one type of crystalloid over another No studies that are specific to sepsis population Note: since development of these guidelines the preliminary results of the SAFE (Fluid resuscitation with Albumin vs. Saline) study results have been reported at the Society of Critical Care Medicine National Scientific Meeting held in Feb. 2004. This randomized controlled trial of over 7,000 patients demonstrated that in the subset of severe sepsis patients there was a mortality benefit with albumin over saline (RR .087; CI 0.74-1.02). This data set was locked in late 2003; therefore, final manuscript publication is pending.
Fluid Challenge describes the initial volume expansion period in which the patient’s response is closely monitored. Fluid Challenge must be clearly separated from an increase in maintenance fluid administration Response may be measured by increase in blood pressure and urine output Tolerance may be measured by evidence of intravascular volume overload Input/output ratio is of no utility to judge fluid resuscitation during this time period