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NurseReview.Org - Third Spacing: Where has all the fluids gone?


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NurseReview.Org - Third Spacing: Where has all the fluids gone?

  1. 1. Third-Spacing: Where Has All the Fluid Gone? By Marcia Bixby, RN, CS, CCRN, MS Nursing made Incredibly Easy! September/October 2006 2.5 ANCC/AACN contact hours Online: http://www. nursingcenter .com © 2006 by Lippincott Williams & Wilkins. All world rights reserved.
  2. 2. Fluids 101 <ul><li>Fluids bring nutrition and oxygen into the cells and remove wastes </li></ul><ul><li>Fluid is divided into two compartments: intracellular and extracellular </li></ul><ul><li>Extracellular is divided into interstitial and </li></ul><ul><li>intravascular </li></ul>
  3. 3. Fluids 101 <ul><li>The body’s fluid should be in balance; volume entering the body = volume leaving the body </li></ul><ul><li>Fluid loss occurs via urine, sweat, stool, and incidental losses from respiratory effort </li></ul>
  4. 4. On the Move <ul><li>Diffusion: Passive movement of fluid from an area of higher concentration to an area of lower concentration </li></ul><ul><li>Osmosis: Water movement through a selectively permeable membrane from an area of lower concentration to an area of higher concentration </li></ul>
  5. 5. On the Move <ul><li>Active transport: Movement of molecules against a concentration as they move from an area of lower concentration to an area of higher concentration; this movement requires energy </li></ul><ul><li>Third spacing occurs when the fluid is “trapped” in the interstitial spaces </li></ul>
  6. 6. How Fluids Affect Cells: Isotonic Solutions
  7. 7. How Fluids Affect Cells: Hypertonic Solutions
  8. 8. How Fluids Affect Cells: Hypotonic Solutions
  9. 9. Decreased Oncotic Pressure <ul><li>Loss of albumin or protein leads to decreased oncotic pressure, causing fluid to “leak” from the intravascular space to the interstitial space </li></ul><ul><li>Due to the loss in circulating fluid volume, cardiac output decreases </li></ul>
  10. 10. Causes of Fluid Shifts <ul><li>Albumin losses can occur in liver failure, liver dysfunction, and malnutrition </li></ul><ul><li>Albumin losses can lead to fluid shifting into the peritoneum, causing ascites </li></ul><ul><li>Destruction of endothelial cells, such as in bowel surgery, can cause fluid to move and be trapped in the interstitial spaces </li></ul><ul><li>Fluid trapped in the lungs can lead to pulmonary edema </li></ul>
  11. 11. Inside the Cells <ul><li>Interstitial fluid trapping can cause compression of the microvasculature, resulting in hypoperfusion and ischemia </li></ul><ul><li>Inflammatory “mediators” are released into the bloodstream, which can lead to systemic inflammatory response syndrome (SIRS) </li></ul><ul><li>Multiple organ dysfunction syndrome (MODS) occurs, leading to organ failure and death </li></ul>
  12. 12. Mediators of SIRS and MODS
  13. 13. What Happens When Fluids Shift? <ul><li>With decreased circulating volume, baroreceptors in the aorta are activated </li></ul><ul><li>Sympathetic nervous system releases epinephrine and norepinephrine, causing vasoconstriction and an increased heart rate </li></ul><ul><li>Kidneys launch the renin-angiotensin-aldosterone system in response to a lower glomerular filtration rate </li></ul><ul><li>All this happens with the goal of increasing circulating volume, blood pressure, and cardiac output </li></ul>
  14. 14. Fluid Shift in the Bowel <ul><li>Causes abdominal distention </li></ul><ul><li>Measure bladder pressure and abdominal girth at least every 4 to 8 hours while signs are abnormal </li></ul>
  15. 15. Making the Grade <ul><li>A patient’s intra-abdominal pressure (IAP) determines if he has intra-abdominal hypertension. </li></ul><ul><li>According to the World Society of Abdominal Compartment Syndrome, there are four grades of intra-abdominal hypertension: </li></ul><ul><ul><li>Grade I: IAP of 12 to 15 mm Hg </li></ul></ul><ul><ul><li>Grade II: IAP of 16 to 20 mm Hg </li></ul></ul><ul><ul><li>Grade III: IAP of 21 to 25 mm Hg </li></ul></ul><ul><ul><li>Grade IV: IAP of > 25 mm Hg </li></ul></ul>
  16. 16. Complications of Abdominal Swelling <ul><li>Decreased cardiac output leads to decreased blood pressure, which causes: </li></ul><ul><ul><li>increased pressure on the aorta and the iliac and femoral arteries, leading to decreased cardiac output and decreased blood pressure </li></ul></ul><ul><ul><li>impaired kidney function </li></ul></ul><ul><ul><li>impaired blood flow to the bowel, liver, and spleen </li></ul></ul>
  17. 17. Monitoring the Patient <ul><li>Fluid shift will either resolve over the next several hours (up to 48 hours) or the patient will continue to develop bowel edema and, eventually, ischemia </li></ul><ul><li>Closely monitor vital signs, urine output, peripheral perfusion, mental status, ventilation/perfusion status, hematocrit/hemoglobin, serum electrolytes (elevated lactate may indicate bowel ischemia) </li></ul>
  18. 18. Fluid Resuscitation <ul><li>Administer maintenance I.V. isotonic fluid plus intermittent colloids (i.e., albumin); pulls fluid from the interstitial spaces into the intravascular space </li></ul><ul><li>Small dose of a loop diuretic, such as furosemide (Lasix) may be ordered if kidneys can’t get rid of the excess fluid </li></ul><ul><li>If hemoglobin is low, infuse blood products, such as packed red blood cells, as ordered to help increase oxygen and pull fluid from the interstitial space </li></ul>
  19. 19. If Bowel Ischemia Occurs <ul><li>A kidney-ureter-bladder X-ray (KUB) may be done; it will show bowel edema and any “free air,” which may indicate bowel perforation </li></ul><ul><li>A CT scan can detect worsening bowel edema, inadequate perfusion, and hematomas </li></ul><ul><li>Patient may need further surgery to repair a perforated bowel or to decrease edema </li></ul>