Introduction to fluid therapyPlenary lecture

Dr. Vizi Zsuzsanna

2018.

The beginning… 1832

1830-ies : Dr. Thomas Latta

1880-ies: Hartog Jacob Hamburger:

„physiological” saline

1880-ies Sidney Ringer

1930ies: Alexis Hartmann:→ Lactated Ringer Hartmann

Fluid balance

Fluid loss:-„ daily obligatory”:

-Sensible: urine, feaces-Insensible: panting, evaporation

- Pathologic: vomitus, salivation, diarrhea, polyuria

Fluid intake:

Eating/drinking40-60 ml/kg/day

Questions to answer…

What?

How much?

How fast?

Dehydration: lack of fluid

the intersticial and

intracellular space

Definitions

Hypovolemia: Lack of

fluid in the intravascular

space

Examination of the fluid homeostasis

Physical exam:

Dehydration and

perfusion parameters

Simple lab tests (PCV,

TP, USG)

Bodyweight

measurement

Blood pressure

Examination and estimation of dehydration

Grade of dehydration in the % of BW

• < 5% - can not be detected

• 5-6% - tachy MM

• 6-8% - decreased skin turgor, dry MM

• 8-10% - + enophtalmus

• 10-12% persistent skin tenting,

cloudy cornea, hypovolaemia

• >12% hypovolaemic shock and death

History: anorexia, hypodipsia, vomiting, diarrhea, etc.

Dryness of MM – BUT salivation, nausea

Skin turgor – BUT obese or old or cachectic animals

Position of the eyesESTIMATION!!

Examination of hypovolemia

• Perfusion parameters:

– Colour of MM

– CRT

– Heart rate

– Pulse quality

– (jugular vein distention)

Threshold values:→ Not pink (red or pale)→>2 sec→ D>140/min,

C <140 or >240/min→Weak/bounding, irregular

The types of the infusions

Classification of the infusion

CrystalloidsSmall molecular weight compounds

(electrolytes, glucose)

• Isotonic

– 0,9% NaCl (Salsol A), Ringer, Lactated Ringer, Sterofundin

• Hypotonic

– 5% Glucose, 0,45% NaCl(Salsol B), Balansol, Rindex

• Hypertonic

– NaCl 10 % inj.

ColloidsLarge molecular weight compounds

(starch, proteins)

• Syntetic

- Starch (HAES)

- Gelatine

• Natural

- Human albumin

- Blood products (plazma, blood)

Na+

Distribution of the infusions in the fluid compartments

IV IS ICHypotonic/

Glucose solutions 13 % 32% 55%

Isotonic solutions

20-30% 70-80%

Hypertonicsolutions >300 %

Colloids 70-100%

Hyperoncoticsolutions 100-140%

Dr. Joris Robben (Utrecht) nyomán

WHAT? HOW FAST?

Hypovolaemia Dehydration

Quickly! Minutes or hours (i.v., i.o.)

Slower (1-2 days) -mild: p.os, s.c.-Moderate to severe: i.v.

Isotonic crystalloids+

Colloid and/orHypertonic saline

Isotonic crystalloids

ACUTEFluid resuscitation

CHRONICrehydration, maintanance

ACUTE therapy – FLUID RESUSCITATION

The GOAL is not the administration of a certain amount of

fluid, but the normalisation of the vital signs!

• First choice: Isotonic crystalloids– (Dog: 60-90 ml/kg/h; Cat: 45-60 ml/kg/h )

– Recommendation: 10-20 ml/kg boluses in 15-20 min

• Colloids – eg. HAES – in combination with crystalloids– Dog: 10-20 ml/kg, Cat: 5-10 ml/kg

– 2-5 ml/kg boluses in 10-20 minutes

• Hypertonic saline 4-7 ml/kg (dog); 2-4 ml/kg (cat)

Re-evaluate! – and gear to the findings

General condition Dehydration or hypovolaemia

Signs of overhydrationBodyweight!!

PCV, lactate, electrolytes

„Chronic” fluid therapy

Rehydration

• Correct dehydration

Maintanace therapy

• Correction of obligatory fluid losses

• Not eating/not drinking

Correct ongoing losses

• Ongoing diarrhea/vomitus, polyuria

• Drained fluids

REHYDRATION• Depends on: condition of the patients, lab results

• Mainly isotonic crystalloids

• Lactated Ringer, Isolyte, Sterofundin G, Ringerfundin, Ringer, 0,9%NaCl

• Electrolyte components are similar to EC space

– Na(131-150 mmol/l), K: (4 mmol/l)

Deficit (ml) = kg x 10 x dehydration %Eg. 10 kg- dog with 8% dehydration: 10 x 10x 8 = 800 ml

• How fast? Rate of fluid loss Rehidráció sebessége

Acute deficit 2-4 hours→ fluid resuscitaion

In 12-24 hours 4-8 hours

Chronic deficit 12-24-48 hours

MAINTANANCE THERAPY

• Daily requirement (if noteating/drinking)

• Daily „obligatory fluid losses” (urine, feaces, panting) – usually

hypotonic, Na (65-78 mmol/l), K (18-25 mmol/l)

• Maintanace infusion: Hypotonic→ Distribution in everycompartment! Can NOT be applied in boluses

• EG. Sterofundin B, Sterovet, Balansol inf.

• „Home made” maintanance recipe

• 1 part 0,9 % NaCl + 1 part 5% Glucose

+ 20 mmol/l KCl• Rate: K+: max 0,5 mmol/kg/h

MAINTANANCE THERAPY – HOW MUCH?• RER (resting energy requirements) 1 kcal=1ml– RER = 97 x kg0,655 ?

– RER = 70 x kg0,75

AAHA/AAFP 2013:

C: 80 x kg0,75

D:132 x kg0,75

• 40-60 ml/kg/day

• 2-3 ml/kg/hour

0

500

1000

1500

2000

2500

3000

3500

4000

1 5 10 15 20 25 30 35 40 45 50

ml

Bodyweight (kg)

Maintanace needs

3ml/h

50 ml/kg

97xttkg^0,655

132xttkg^0,75

Complications of fluid therapy

• Overhydration➢ Weight gain➢ Serous nasal discharge➢ Chemosis➢ Restlessness➢ Gelly-like subcutis➢ Tremor➢ Tachycardia➢ Couging

➢ Tachypnoe / Dyspnoe➢ Ascites➢ Polyuria➢ Exophtalmus➢ Vomitus/diarrhea

• Venous catheter complicaitons: ✓ Paravenous infusion✓ Thrombophlebitis✓ Infection (septicaemia)

Discontinuation of fluid therapy• Gradually decrease 25-50% / day

• Medullary wash out → Decreased ability toproduce concentrate urine→dehydration/hypovolaemia

• Info for the owner: polydipsia for a few days(oral rehydration solutions)

3 things as „take home message”

If you don’t know what to give, Choose Lactated Ringer

Take care of iv catheters!

Monitor the effectand recalculate if necessary !