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Principles of fluid therapy

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Principles of fluid therapy

  1. 1. FLUID THERAPY DR MUKESH SHUKLA , MD SENIOR RESIDENT MEDICINE, KGMU LUCKNOW
  2. 2. Body Water Compartments • Intracellular water: 2/ 3 (40%)of TBW • Extracellular water: 1/3 (20%)of TBW - Extravascular water[interstitial]: 3/4 (15%)of extracellular water - Intravascular water[plasma]: 1/4 (5%)of extracellular water
  3. 3. Why patients need intravenous fluid therapy ? Patient needs IV fluid therapy for Maintenance ( to supply daily needs ) , Replacement ( to replace deficit and on-going losses ) Resuscitation ( to correct an IV or extracellular deficit )
  4. 4. Practical Fluid Balance H2 O H2 O H2 O Rule 1 Water without Na expands the TBW (enter both ICF & ECF in proportion to their initial volume) ECFICF
  5. 5. Practical Fluid Balance Na + Na + Na + Na + Na + Na + Rule 2 All infused Na+ can not gain access to the ICF Because of the Sodium Pump ECFICF Isotonic = NO Water Exchange
  6. 6. Total body water ECF=1 liter ICF=0 Intravascular =1/4 ECF=250 ml 1 Liter 0.9% saline Interstitial=3/4 of ECF=750ml
  7. 7. Hypotonic = Water Exchange a. Hypotonic saline (¼ NS) H2 O Rule 3 Change in tonicity of Na solutions (relative to Plasma) causes water exchange Practical Fluid Balance
  8. 8. 1 liter 5% Dextose Total body water=1 liter ECF=1/3 = 300ml ICF=2/3 = 700ml Intravascular =1/4 of ECF~75ml
  9. 9. Hypertonic = water exchange b. Hypertonic solution H2 O
  10. 10. 1 liter 5% Albumin Intravascular=1 liter
  11. 11. Clinical characteristic of iv fluids  Ringer lactate is the most physiological iv fluid  Isotonic saline and DNS have maximum sodium  Isotonic saline ,DNS and ISO-G have maximum chloride  ISO – E,P,M directly correct acidosis  ISO-G only iv fluid which directly correct metabolic alkalosis.  ISO-M,P,G,E and Ringer lactate are usually avoided in renal failure.  ISO-G and Ringer lactate are avoided in patients with liver failure.
  12. 12. • Isotonic saline and Ringer Lactate do not contain glucose so preferred fluid for diabetic patients. • 5,10 and 20 D are only fluids which do not contain Na and Cl. Iso-M and P have low Na and Cl. • NS , DNS and dextrose containing fluids do not contain potassium and they do not correct metabolic acidosis and alkalosis directly.
  13. 13. Clinical characteristic of iv fluids DEXT Na k Cl ACE LACT NH4 CL CA MG HPO 4 CITR ATE mOs m/l 5D 50 NS 154 154 278 DNS 50 154 154 432 RL 130 4 109 28 3 586 ISO- G 50 63 17 150 70 274 ISO- M 50 40 35 40 20 15 580 ISO-P 50 25 20 22 23 3 3 410 ISO-E 50 140 10 103 47 5 3 8 368
  14. 14. Characteristics of intravenous fluids Characteristic Intravenous fluids Characteristic Intravenous fluids Most physiological RL Glucose free Saline, RL Rich in sodium NS,DNS,RL Sodium free Dextrose solutions Rich in chloride NS,DNS,Iso-G Potassium free NS/DNS,dextrose solution Rich in potassium Iso-M,P and G Avoid in liver failure RL, Iso-G, 5% D Corrects acidosis RL, all isolyte Except Iso-G Avoid in renal failure NS, RL, all isolyte Corrects alkalosis Isolyte-G, NS Provides phosphorous Isolyte-M
  15. 15. SUMMARY CHARACTERISTIC TYPE OF FLUID Most physiological Ringers lactate (RL) Rich in sodium NS, DNS Rich in Chloride NS, DNS,ISO - G Rich in potassium Isolyte - M, P, G Correct Acidosis Ringers Lactate, Iso-E,P,M Correct alkalosis Isolyte-G Caution in renal failure Ringer lactate , Isolyte-M,G,P and E Avoided in liver failure Ringer lactate , Isolyte-G Glucose free NS, Ringers lactate Sodium free 5,10,20 and 25 D Potassium free NS, DNS and Dextrose fluids
  16. 16. Daily Electrolyte Requirements • - Sodium: 100-250meq (western diet) – mostly excreted in urine • - Potassium: 50-100meq – mostly excreted in urine, 5% in feces • - Chloride: 60-150meq – Example: 1/2NS @ 100cc/hr provides ~180mEq of sodium and chloride/day! - this is why NS should not be used for maintenance fluid in patients with normal renal function- risk of hyperchloremic metabolic acidosis • - Bicarb: 1 meq/kg/day
  17. 17. Crystalloids  Combination of water and electrolytes Balanced salt solution: electrolyte composition and osmolality similar to plasma; example: lactated Ringer’s, Plasmlyte, Normosol. - Hypotonic salt solution: electrolyte composition lower than that of plasma; example: D5W.  True solution, No particulate  Expands IVC adequately (less than colloids), however Small increase in plasma volume  Replenishes interstitial compartment  It leaves IVC faster ( t/2 20-30 minutes)  Cheap  Increase GFR  No risk of allergic reaction
  18. 18.  Suspension of particle rather than a solution  High Molecular Weight: Unable to pass through semi permeable membrane  Remains confined to intra-vascular compartment (at least initially)  Do not correct water and electrolyte deficiencies  Examples: hetastarch (Hespan), albumin, dextran Colloids
  19. 19.  Antigenicity & Anaphylactic Reaction  Blood typing  Coagulopathy  Never exceed 1 – 1.5 liter/day (20 ml/kg/day) Colloids
  20. 20. colloids Colloids  Most logical choice for intravascular expansion  Since greater portion remains in IVC & for longer time ( t/2 3-6 hours)  Less volume is required& initial resuscitation is rapid  500 ml of colloids expands plasma by 500ml
  21. 21.  Blood-derived: Albumin 5%( Heated, Antigenic)  Dextran: Dextran 70, Dextran 40  Gelfusine (Anaphylaxis)  Hydroxy ethyl ether Hetastarch 6% MW = 450 000 Effective Plasma Expander Least Antigenicity &Effect on Coagulation Colloids (Types)
  22. 22. colloid • Advantages : Smaller infused volume. Prolonged increase in plasma volume. Less cerebral edema. • Disadvantages :Greater cost Coagulopathy(dextran>HES). Pulmonary edema (capillary leak states). Decreased GFR. Osmotic diuresis (low molecular weight dextran) crystalloid • Advantages : Lower cost. Greater urinary flow. Replaces interstitial fluid. • Disadvantages :Transient hemodynamic improvement. Peripheral edema(protein dilution). Pulmonary edema (protein dilution plus high PAOP)
  23. 23. CRYSTALOID CLASSIFICATION 1. Maintenance fluid 2. Replacement fluid 3. Special fluid 5% DEXTROSE NORMAL SALINE 25% DEXTROSE DEXTROSE WITH .45% NORMAL SALINE DNS SODIUM BICARBONATE RINGER LACTATE POTASSIUM CHLORIDE ISOLYTE – M,P,G
  24. 24. 5% DEXTROSE COMPOSITION –  One litre of fluid contains 50 gram of glucose .  PHARMACOLOGICAL BASIS –  Correct dehydration and supplies energy  Best agent to correct intracellular dehydration  Used where there is need of water but not electrolytes  INDICATIONS –  Dehydration due to inadequate water intake or excessive water loss  Pre and post operative fluid management  IV administration of various drugs  Prevention of ketosis in starvation , diarrhea , vomiting and high grade fever  Correction of hyperntremia due to pure water loss  Hypernatremia due to salt poisoning or excessive use of electrolyte solution
  25. 25. CONTRAINDICATIONS – Cerebral oedema Neurosurgical procedures Acute ischemic stroke Hypovolemic shock Hyponatremia and water intoxication Hypernatremia Blood transfusion Uncontrolled diabetes and severe hyperglycemia
  26. 26.  PRECAUTIONS –  May cause local pain , irritation and thrombophlebitis.  Can cause hypokalemia, hypomagnesaemia and hypophosphatemia RATE OF ADMINISTRATION –  Can be given .5gm/kg body weight/hour without causing glycosuria .
  27. 27. ISOTONIC SALINE COMPOSITION – One litre of normal saline contains 154 meq sodium and 154 meq chloride PHARMACOLOGICAL BASIS –  Used to provide major extracellular electrolytes Very useful to correct fluid and electrolyte deficit Very useful to raise blood pressure in patient with hupovolemic shock
  28. 28. INDICATIONS –  Water and salt depletion as in diarrhoea, vomiting,excessive diuresis or excessive persppiration  Treatment of hypovolemic shock  Treatment of alkalosis with dehydration  Severe salt depletion and hyponatremia  Inicial fluid therapy in DKA  Treatment of hypercalcemia  Fluid challenge in prerenal ARF  Irrigation for washing of body fluids  Vehicle for certain drugs
  29. 29.  Can be given safely with blood  Hypertonic saline(3% nacl) is used in treatment of hyponatremia due to SIADH or water intoxication along with diuretic .
  30. 30. Contraindications :  Hypertensive or preeclampsia patients  Patient with edema due to CHF , renal disease and cirrhosis  Very young and elderly patients  Dehydration with severe hypokalemia
  31. 31. DEXTROSE SALINE (DNS) COMPOSITION –  One litre fluid contains 50gm glucose,154meq sodium and 154 meq chloride. Pharmacological basis –  useful to supply major extracellular electrolytes and energy along with fluid to correct dehydration .  Unlike 5D it is not hypotonic (due to Nacl) and hence it is compatible with blood transfusion.
  32. 32. INDICATIONS –  Correction of salt depletion and hypovolemia with supply of energy  Correction of vomiting and nasogastric aspiration induced alkalosis and hypochlremia along with supply of energy  Fluid compatible with blood transfusion CONTRAINDICATIONS –  Anasarca of cardiac, hepatic and renal disease  Hypovolemic shock
  33. 33. RINGER LACTATE  Most physiological fluid  Rapidly expands intravascular volume so very effective in severe hypovolemia  Provide bicarbonate so useful in correction of metabolic acidisis  INDICATIONS-  Correction of severe hypovolemia  Postoperative patients ,burns ,fracture and peritoneal irrigation  Diarrhoea induced hypovolemia with hupokalemic metabolic acidosis  Diabetic ketoacidosis  For maintaing normal ECF fluid and elecrolyte balance during and after surgery
  34. 34.  Contraindications –  Liver disease , severe hypoxia and shock  CHF  Addison's disease  Severe metabolic acidosis  Vomiting and continuous nasogastric aspiration  Infusion of RL and blood product in one IV line contraindicated  Calcium in RL binds with certain drugs like amphotercin and reduces their bioavailability and efficiency
  35. 35. ISOLYTE -M • ISO-M is the richest source of potassium. • Also correct acidosis and supplies energy so ideal fluid for maintenance fluid therapy  INDICATIONS-  For parenteral fluid therapy, it is the ideal maintenance fluid.  To correct hypokalemia  CONTRAINDICATIONS –  Renal failure  Hyponatremia and water intoxication  Adrenocortical deficiency  Burns
  36. 36. OTHER’s ISOLYTE-G- only fluid to correct metabolic alkalosis.Used to replace fluid loss due to vomiting or continuous nasogastri aspiration . ISOLYTE- P- Provide less electrolytes(half of isolyte –M) and more water .Useful in pediatric patients. ISOLYTE – E – Correct all ecf electrolytes, acidosis and supplies glucose .
  37. 37. SODIUM BICARBONATE • Commonaly available preparation contains 7.5% , 25ml ampoule • Each ampule contains 22.5 meq sodium and 22.5 meq bicarbonte  INDICATIONS –  Treatment of metabolic acidosis  For cardiopulmonary resuscitation and shock  Treatment of hyperkalemia  Alkaline forced diuresis in treatment of acute poisoning of barbiturate and salicylates
  38. 38.  When to use – In severe metabolic acidosis  How much to give –  Always under corrected  Amount in meq /l= .5xweight in kg x(desired bicarbonate – actual bicarbonate )  How to infuse –  50% corrected in 4 hours and rest gradually over 24 hours  To avoid irritation of vein and sudden sodium loading added to 5D  Special precations –  Should not be given in bolus except in emergency  Establish proper IV line for infusion as it is very irritant
  39. 39.  Avoid overdose and alkalosis  Never treat acidosis without treating etiology  In renal failure bicarb correction may cause tetany and pulmonary oedema so prefer dialysis if acidosis and renal failure are severe  Never correct acidosis without correcting assosiated hypokalemia  Never mix sodabicarb with injection calcium as combination can precipitate calcium carbonate as white crystals  Avoid mixing of sodabicarb with ionotropes
  40. 40.  Complications –  Overshoot , post treatment metabolic alkalosis  Hypokalemia  Volume overload  Hypocalcemia – tetany  Contraindications –  Respiratory alkalosis , metabolic alakalosis and hypokalemia  Correct dehydration, hypokalemia and hypocalcemia prior to bicarb treatment  Cautious use in congestive heart failure , chronic renal failure ,cirrhosis of liver or hypertension
  41. 41. POTASSIUM CHLORIDE  One amp of 10ml contains 1.5 gm or 20 meq potassium .  INDICATION-  Prevention and treatment of hypokalemia  Added in potassium free peritoneal dialysis  During cardiac bypass surgery  PRECAUTIONS-  Never give direct iv injection  Never add more than 40 mEq potassium/litre  Never infuse more than 10mEq potassim /hour  Never add potassium chloride in ISO-M  Monitor potassium level closely and if possible also monitor by ECG
  42. 42.  CONTRAINDICATIONS-  Cautious use in renal failure  Never use injection Kcl without knowing potassium status
  43. 43. 25D • 100 ml of 25D contains 25gm of glucose. • Dextrose supplies energy and prevents , used when faster replacement of glucose is needed like in hypoglycemic coma. • In fluid restricted state like CHF provides larger glucose in smaller volume. INDICATIONS-  Rapid correction of hypoglycemia  Provide nutrition to the patient  For treatment of hyperkalemia
  44. 44. CONTAINDICATIONS-  Dehydrated patient with anuria  Intracranial and intraspinal hemorrhage  Delerium tremens  Avoided in diabetic patients CAUTION –  Rapid infusion of 25D can cause glycosuria secondary to hyperglycemia ,should be infused slowly
  45. 45. ALBUMIN  Physiologic plasma protein  Maintain plasma oncotic pressure  Binding and transport of low molecular weight substances  25% albumin expands the plasma volume by 4-5 times the volume infused  Plasma volume expansion occurs at the expense of interstitial volume  Oncotic pressure lasts for 12 to 18 hrs  Preferred in case of hypoproteinemia with anasarca with oedema
  46. 46.  INDICATIONS –  Plasma volume expansion  Correction of hypoproteinemia  As an exchange fluid in therapeutic plasmapheresis  Adverse effects –  Nausea  Vomiting  Febrile reaction  Allergic reaction including anaphylactic shock
  47. 47. Precautions and contraindications –  Fast infusion may cause vascular overload and pulmonary oedema  Severe anemia and CHF  Low cardiac reserve and cardiac insfficiency  Dehydrated patients  Should not be used for parenteral nutrition  How much to give-  Infusion of 25 gm of albumin is suggested at 1-2 ml /minute (5% alba )and 1 ml /minute (25 % albumin)  High rates may be needed in treatment of shock
  48. 48. HEMACCEL • Sterile,pyrogen free,colloid plasma volume substitute contain a polymer degraded gelatin and elecro electrolytes INDICATIONS- Rapid expansion of intravascular volume Prophylactic use in major surgery Primig of heart lung machine
  49. 49. PRECAUTIONS –  Contain no preservative so ensure clear solution before infusion  Contains calcium so should not be mixed with citrated blood  Monitor for adverse reactions SIDE EFFECTS-  Hypersensitivity reaction  Bronchospasm and fall in blood pressure
  50. 50. MONITORING  Weight  Skin and tongue  Sensorium  Urine out put  Pulse rate  Blood pressure  Hematocrit  Metabolic acidosis  CVP and PAWP
  51. 51. Calculation Of Fluid Infusion For routine IV set –  15 drops = 1 ml  Rule of ten for fluid calculation for 24 hours : iv fluid in litre/24 hrsx10=Drop rate / minute Drop rate per minute /10= IV fluid in litre in24 hrs  Rule of Four for fluid calculation for one hour: Volume in ml per hr/4= Drop rate per minute Drop rate per min x4 = Volume in ml per hour
  52. 52. • Drop rate calculation by any parameter : Volume to be infused in ml Drop rate Duration of infusion in hours minute For micro Drip set :  For micro drip set 1 ml = 60 drops  Number of micro drops /minute = volume in ml per hr

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