Ringer’s Acetate Solution

Ringer’s Acetate Solution

In Clinical PracticeIn Clinical Practice

Dr Iyan DarmawanMedical Department, PT Otsuka Indonesia

BackgroundBackground

• IV therapy is one of most crucial aspects of patient care

• NS -----------> hypovolemia w/ concomitant hyponatremia, hypochloremia or metabolic alkalosis

• N2/D5---------> maintenance to replace IWL

• RA -------------> best approximates ECF

RESUSITASIRESUSITASI RUMATANRUMATAN

NUTRISINUTRISIKristaloidKristaloid

Mengganti kehilangan akut (hemorrhage, GI loss, rongga ke3)

Mengganti kehilangan akut (hemorrhage, GI loss, rongga ke3)

1. Kebutuhan normal (IWL + urin+ feses)2. Dukungan nutrisi

1. Kebutuhan normal (IWL + urin+ feses)2. Dukungan nutrisi

KoloidElektrolitElektrolit

Repair

.

AseringRL/NS

DextranGelatin KAEN

RL

Asr

KAEN

D-NS

Dextr

NS

AA

Other

Survey Pemakaian infus di Ruang Perawatan

Interna Maret 2003 *

* Data : Survey NCE*) Widi Astuti, dkk.Data Survey NCE 2003

Total 35 RS, 56 ruangan (int)Total 28 RS,29 ruangan (ped)

.

.

Ringer AsetatRinger Asetat

ASERING®ASERING®

USAEROPA,UKJEPANGTHAILAND

USAEROPA,UKJEPANGTHAILAND

Ringer’s Aeetate Plasma

Na + 130 135-145K+ 4 3.5- 5Cl- 109 95-105 Ca++ 2,7 1.1-1.15Asetat- 28 22-26

COMPOSITION(in mmol/L)COMPOSITION(in mmol/L)

Na LactateNa Lactate BicarbonateBicarbonate

LACTATE VS. ACETATELACTATE VS. ACETATE

Na AcetateNa Acetate BicarbonateBicarbonate

100 mEq/hr

250-400 mEq/hr

C2H3O2- + 2O2 CO2 + H2O + HCO3

- ( Acetate )

C3H5O3- + 3O2 2CO2 + 2H2O + HCO3

-

( Lactate )

LACTATE VS. ACETATELACTATE VS. ACETATE

METABOLISME

1. SODIUM LAKTAT ( HATI )

CH3CH(OH)COONa + CO2 +H2O NaHCO3 + CH3CH(OH)COOH ( Laktat )

CH3CH(OH)COOH + 3 O2 3 CO2 + 3 H2O : TCA Cycle

2. SODIUM ASETAT ( OTOT )

CH3COONa + CO2 +H2O

CH3COOH + 2 O2 2 CO2 + 2 H2O : TCA Cycle

NaHCO3 + CH3COOH ( Asetat )

GLUkOSA

GLIKOGENG - 6 - PL- LAKTAT

PIRUVAT

LDH

Asetil KoAsintetase

ASETAT Asetil - KoA

2 CO2 TCA Cycle H2O

SHOCK SYNDROMESSHOCK SYNDROMES

• In shock states such as septic shock, tissue hypoxia and impaired hepatic gluconeogenesis and oxidation elevate plasma lactate by approx. 600% AR may be better alternative to LR

Wolfe RR, Miller HI: cardiovascular and metabolic responsesduring burn shock in the guinea pig. Am J Physiol 1976;231:892-897

HEPATIC INSUFFICIENCYHEPATIC INSUFFICIENCY• AR vs LR during induced hepatic insufficiency in

rabbits. • Hepatic artery, portal vein and bile duct were ligated and vessels were clamp for 20 minutes.• AR or LR administered within that 20 minutes. • In LR group: 75% reduction in ATP and a 7-fold

increase in AMP• Conclusion: in hepatic insufficiency, gluconeogenesis

is inhibited and the liver fails to metabolize lactate

Nakatani T, et al. Effects of Ringer’s acetate solutions during transienthepatic inflow occlusion in rabbits. transplantation 1995;59(7):952-57

SURGICAL PROCEDURESSURGICAL PROCEDURES

• Current clinical practice adopts the use of LR or isotonic solution during major operations.

• Kashimoto compared the effects of LR and AR on core body and peripheral temperature during isoflurane or sevoflurane anesthesia the use of AR during early period of Isoflurane anesthesia was associated with maintained central temp.

Kashimoto S. Comparative effects of Ringer’s acetate and lactate solutions on intraoperative central and peripheral temperatures. J Clin Anesth1998;10(1):23-27

Pendekatan rasional dalam resusitasi cairan Pendekatan rasional dalam resusitasi cairan

Na+ 130 mEq K+ 4 mEq Cl- 109 mEq Ca++ 3 mEq Acetate- 28 mEq

1. Gastroenteritis w/ dehydration2. Hemorrhage3. DSS4. BURNS

Ringer’s AcetateRinger’s Acetate

TERAPI CAIRANTERAPI CAIRAN

(Na+ > 100 mEq)- RA (Asering)- RL- NaCl 0,9%

RESUSITASIRESUSITASI RUMATANRUMATAN

KRISTALOIDKRISTALOID KOLOIDKOLOID ELEKTROLITELEKTROLIT NUTRISINUTRISI

Mengganti kehilangan akut

Dextran- 40

Memelihara keseimbangan

Na+ 50-60mEq;K+ 10-20 mEq (KAEN group)

AA 10% (AMIPAREN)

AA 5% (MINOVEL- 600)

AA 3%( PAN- AMIN G

D 10 % (KA-EN MG 3)

Maltosa 10% (MARTOS )

Terima Kasih

Iyan Darmawan

Penggunaan di Bagian Ilmu Kesehatan Anak

Ringer AsetatRinger Asetat

Pendahuluan

• RA bisa digunakan pada anak dan bayi

• Diindikasikan untuk resusitasi cairan

Ref: 1. Neonatal Hypernatremic Dehydration Secondary to Lactation Failure J Am Board Fam Pract 14(2):159-161, 2001. © 2001 American Board of Family Practice 2. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938. 3. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996 4. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva : World Health Organization. 1997 5. Communicable Disease Epidemiology Office of Epidemiology Washington State Department of Health.

1. Loren A et al. Oxidation of lactate and acetate in rat skeletal muscle. Journal of Applied Physiology 1997 ; 83 ( 1 ) : p. 32 - 39.

2. Heimberger DC,M.Roland RW. Handbook of Clinical Nutrition.Mosby 19973. Anderud T, Lund T. Intensive Care of Patients with Burns. Tidskr Nor Laegenforen 1989; p.3197 - 3199.4. Ringer acetate solution in clinical practice. Medimedia.1999

1. Metabolisme asetat terutama di otot, tidak terganggu pada kelainan hati(1)

2. Komposisi mirip dengan plasma, tepat untuk menggantikan

kehilangan akut cairan ekstraseluler. ( 2 )

3. Kecepatan metabolisme asetat 250-400 mEq/jam , sedangkan

laktat 100mEq/jam, dengan demikian asetat lebih cepat mengkoreksi asidosis. ( 3)

4. Metabolisme asetat memerlukan sedikit O2 , dan melepaskan sedikit CO2.( 4 )

Ringer Asetat

KOMPOSISI

Tek.Osmotik

Na+

K +

Cl - Ca2+ Asetat Laktat ( mOsm /L )

ASERING® ( RA ) 130 4 109 3 28 - 274

RINGER LAKTAT ( RL ) 130 4 109 3 - 28 274

Elektrolit ( mEq )

Setiap 1 L mengandung :

Cholera Guidelines

Patients in shock should be given rapid IV rehydration with a balanced multielectrolyte solution containing approximately 130mEq/L of Na+, 25-48 mEq/L of bicarbonate, acetate or lactateions, and 10-15 mEq/L of K+. Useful solutions include Ringer'slactate or WHO “diarrhea treatment solution” (4 g NaCl, 1 gKCl, 6.5 g sodium acetate and 8 g glucose/L)

Ref: Communicable Disease Epidemiology Office of Epidemiology Washington State Department of Health.2002

RA pada Ketoasidosis Diabetik

Resusitasi cepat NaCl 0,9% 12.5 ml/kg/jam selama 0-2 jam sampai sirkulasi tepi pulih

Fase rehidrasi lambat selama 48 jam dengan Ringer Asetat (Rumatan + 5% BB/24 jam)

Rumatan

Ref. Ragnar Hanas. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996

DBD III & IVO2 2-4 L/menitRA 20 ml/kg bolus dalam 30 menit

Syok teratasiSyok teratasi Syok tidak teratasiSyok tidak teratasi

RA 10 ml/kg/jam

Stabil dalam 24 jamStabil dalam 24 jam

RA 5 ml/kg/jam 3 ml/kg/jamStop < 48 jam

Dextran 40 10-20 ml/kgTeratasiTeratasi

Tidak TeratasiTidak Teratasi

Ht turun Ht tetap/naik

FFP 10 ml/kg Dextran 20 ml/kg

Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999

SYOK

HIPOVOLEMIK

LUKA BAKAR

DBD

RESUSITASI ASERING®

PERDARAHAN TRAUMA

GASTROENTERITIS

AKUT DISERTAI

DEHIDRASI

ASERING ®ASERING ®

Ringer’s acetate

Terima KasihTerima Kasih

(Additional usage)(Additional usage)Acetated Ringer’s SolutionAcetated Ringer’s Solution

Iyan DarmawanIyan Darmawan

Medical Director, PT Otsuka IndonesiaMedical Director, PT Otsuka Indonesia

Grand Melia Hotel, 5 April 2003Grand Melia Hotel, 5 April 2003

Scientific MeetingScientific Meeting

1

TERAPI CAIRANTERAPI CAIRAN

(Na+ > 100 mEq)- RA (Asering)- RL- NaCl 0,9%

(Na+ > 100 mEq)- RA (Asering)- RL- NaCl 0,9%

RESUSITASIRESUSITASI RUMATANRUMATAN

KRISTALOIDKRISTALOID KOLOIDKOLOID ELEKTROLITELEKTROLIT NUTRISINUTRISI

Mengganti kehilangan akutMengganti kehilangan akut

Dextran- 40Dextran- 40

Memelihara keseimbanganMemelihara keseimbangan

Na+ 50-60mEq;K+ 10-20 mEq (KAEN group)

Na+ 50-60mEq;K+ 10-20 mEq (KAEN group)

AA 10% (AMIPAREN)

AA 5% (MINOVEL- 600)

AA 3%( PAN- AMIN G

D 10 % (KA-EN MG 3)

Maltosa 10% (MARTOS )

AA 10% (AMIPAREN)

AA 5% (MINOVEL- 600)

AA 3%( PAN- AMIN G

D 10 % (KA-EN MG 3)

Maltosa 10% (MARTOS )

NS, RL, RA,Colloids

RD5,RLD5,RAD5,DGAA

KAEN3BKAENMG3

NaCl3%NaHCO3

Glu 20%,40%Mannitol

Acute replacement (rehydrate, restore perfusion)

Acute replacement (rehydrate, restore perfusion)

Maintenance Maintenance

Repair correct extreme/ symptomatic elect derangement

Repair correct extreme/ symptomatic elect derangement

Fluid TherapyFluid Therapy

• Plasmalyte/Baxter

• Normosol-R/Abbott

• Veen-D/Hoechst

• Acetar/Thai Otsuka

• Asering/PTOI

• Plasmalyte/Baxter

• Normosol-R/Abbott

• Veen-D/Hoechst

• Acetar/Thai Otsuka

• Asering/PTOI

Acetated Ringer’s (or modified)Acetated Ringer’s (or modified)

• Replacement fluid for resuscitation gastroenteritis, burn,hemorrhagic shock, DSS

• Intraoperative

• Preloading anestesi regional

• Priming solution for cardiopulmonary bypass (CPB)

• Replacement during acute stroke

• Replacement fluid for resuscitation gastroenteritis, burn,hemorrhagic shock, DSS

• Intraoperative

• Preloading anestesi regional

• Priming solution for cardiopulmonary bypass (CPB)

• Replacement during acute stroke

Indications of ARIndications of AR

LACTATE: Primarily in the liver, and to lesser degree the kidney, lactate is metabolized to pyruvate, which is then converted to CO2 and H2O (80%) or glucose (20%), and regeneration of bicarbonate1

ACETATE: metabolized mainly in muscles and to a lesser extent in tissues such as kidney, heart and liver2

LACTATE: Primarily in the liver, and to lesser degree the kidney, lactate is metabolized to pyruvate, which is then converted to CO2 and H2O (80%) or glucose (20%), and regeneration of bicarbonate1

ACETATE: metabolized mainly in muscles and to a lesser extent in tissues such as kidney, heart and liver2

Acetate + H+-------- Acetyl-CoAAcetate + H+-------- Acetyl-CoA

Coenzyme ACoenzyme A

Carbonic acid -------- bicarbonateCarbonic acid -------- bicarbonate

hydrogen sourcehydrogen sourceKreb’s cycleKreb’s cycle

Ref. 1.Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4 th ed 1994 p 554 2. Maxwell MH, Kleeman CR, Narins RG. Clinical Disorders of Fluid and Electrolyte Metabolism. MacGraw-Hill 1987 4th edition p 1063

Ref. 1.Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4 th ed 1994 p 554 2. Maxwell MH, Kleeman CR, Narins RG. Clinical Disorders of Fluid and Electrolyte Metabolism. MacGraw-Hill 1987 4th edition p 1063

AR & LRAR & LR

1. SODIUM LAKTAT ( HATI )

CH3CH(OH)COONa + CO2 +H2O NaHCO3 + CH3CH(OH)COOH ( Laktat )

CH3CH(OH)COOH + 3 O2 3 CO2 + 3 H2O : TCA Cycle

2. SODIUM ASETAT ( OTOT )

CH3COONa + CO2 +H2O

CH3COOH + 2 O2 2 CO2 + 2 H2O : TCA Cycle

NaHCO3 + CH3COOH ( Asetat )

GLUkOSA

GLIKOGENG - 6 - PL- LAKTAT

PIRUVAT

LDH

Asetil KoAsintetase

ASETAT Asetil - KoA

2 CO2 TCA Cycle H2O

METABOLISMEMETABOLISME

• Ringer’s lactate 6.75

• Ringer’s acetate 7

• Normal saline 6.25

• Ringer’s lactate 6.75

• Ringer’s acetate 7

• Normal saline 6.25

Average pHAverage pH

Nonaka A, Tamaki F, Sugawara T, Oguchi T, Kashimoto S, Kumazawa T: [Premixing of 5% dextrose in Ringer's acetate solution with propofol reduces incidence and severity of pain on propofol injection]. Masui 1999 Aug;48(8):862-7

Nonaka A, Tamaki F, Sugawara T, Oguchi T, Kashimoto S, Kumazawa T: [Premixing of 5% dextrose in Ringer's acetate solution with propofol reduces incidence and severity of pain on propofol injection]. Masui 1999 Aug;48(8):862-7

AR is suitable as vehicle of maintenance propofolAR is suitable as vehicle of maintenance propofol

Ringer’s Acetate : Intraoperative Use

Masui 1999 Aug;48(8):862-7

Nonaka A, Tamaki F, Sugawara T, Oguchi T, Kashimoto S, Kumazawa T: [Premixing of 5% dextrose in Ringer's acetate solution with propofol reduces incidence and severity of pain on propofol injection].prospective, randomized, double-blinded trial. 96 patients:1% propofol 20 ml; Group C, normal saline 2 ml, 70% Group L, 2% lidocaine 2 ml 33% Group A, 5% dextrose in Ringer's acetate solution 2 ml. 25%

AR is suitable as vehicle of maintenancepropofol

pain

Intraoperative Use

Masui 1999 Sep;48(9):977-80 Onizuka S, Kawano T, Takasaki M, Sameshima H, Ikenoue T

Comparison of the effect of rapid infusion of lactated and that of acetated Ringer's solutions on maternal and fetal metabolism and acid-base balance].

20 patients; combined spinal and epidural 25 ml/kg/hr Acetated Ringer's solution is better than lactated Ringer's solution in rapid infusion before cesarean section because of the correction of neonatal lactic acidosis.

Obstetric UseObstetric Use

Masui 1995 Dec;44(12):1654-60

Nakayama M, Kawana S, Yamauchi M, Tsuchida H,Iwasaki H, Namiki A[Utility of acetated Ringer solution as intraoperative fluids during hepatectomy].

Hemodynamics, metabolism, blood gas and renal & liver functions. Twenty patients15 ml/kg/hr with the first 500 ml and thereafter reduced to 10 ml/kg/hr.

Intraoperative Fluid during HepatectomyIntraoperative Fluid during Hepatectomy

0

5

10

15

20

25

30

35

40

45

50

Ringer's lactateRinger's acetate

Nakayama M, Kawana S, Yamauchi M, Tsuchida H, Iwasaki H, Namiki A[Utility of acetated Ringer solution as intraoperative fluids during hepatectomy], Masui 1995 Dec;44(12):1654-60

Lactate Level(mg/dl)

(Lactate level at the end of operation)

48.6 + 16.4

29.1 + 14.3

n = 20

AR as intraoperative fluid in hepatectomyAR as intraoperative fluid in hepatectomy

J Clin Anesth 1998 Feb;10(1):23-7

Kashimoto S, et alComparative effects of Ringer's acetate and lactate solutions onintraoperative central and peripheral temperatures.

PATIENTS: 60 ASA physical status I and II patients undergoinggeneral surgery.

INTERVENTIONS: Following induction with 5 mg/kg of thiamylal and 0.1 mg/kg of vecuronium, patients were randomly assigned to one of four groups (15 patients per group). They received inhalation anesthetics (66% nitrous oxide [N2O] and 1.0% to 2.0% isoflurane or 1.3% to 2.6% sevoflurane) and LR or AR

Effect on Core TemperatureEffect on Core Temperature

Tympanic Membrane Temperature

p<0.05

Effect on Core TemperatureEffect on Core Temperature

(temperature of tympanic membrane)

Anaesthesia 1994 Sep;49(9):779-81

McFarlane C, Lee A

A comparison of AR and 0.9% saline for intra-operative fluid replacement.

The exclusive use of 0.9% saline intra-operatively can produce a temporary hyperchloraemic acidosis which could be given false pathological significance. In addition it may exacerbate an acidosis resulting from an actual pathological state. The use of a balanced salt solution such as AR may avoid these complications.

AR more suitable as intraoperative fluid vs NS

Anesthesiology 2000 Nov;93(5):1170-3 Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M

Role of pump prime in the etiology and pathogenesis of cardiopulmonarybypass-associated acidosis.

Plasmalyte 148 vs Polygeline+ Ringer in 22 patients

With the Haemaccel-Ringer's prime, the metabolic acidosis was hyperchloremic ( Cl-, +9.50 mEq/l; CI, 7.00-11.50). With Plasmalyte, the acidosis was induced by an increase in unmeasured anions, most probably acetate and gluconate. The resolution of these two processes was different because the excretion of chloride was slower than that of the unmeasured anions ( base excess from t1 to t3 = -1.60 for Haemaccel-Ringer's vs. +1.15 for Plasmalyte; P = 0.0062).

Anesthesiology 2000 Nov;93(5):1170-3 Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M

Role of pump prime in the etiology and pathogenesis of cardiopulmonarybypass-associated acidosis.

Plasmalyte 148 vs Polygeline+ Ringer in 22 patients

With the Haemaccel-Ringer's prime, the metabolic acidosis was hyperchloremic ( Cl-, +9.50 mEq/l; CI, 7.00-11.50). With Plasmalyte, the acidosis was induced by an increase in unmeasured anions, most probably acetate and gluconate. The resolution of these two processes was different because the excretion of chloride was slower than that of the unmeasured anions ( base excess from t1 to t3 = -1.60 for Haemaccel-Ringer's vs. +1.15 for Plasmalyte; P = 0.0062).

AR as priming solution in CPB

Acta Anaesthesiol Scand 1993 Oct;37(7):652-8 Kuitunen A, et al. Hydroxyethyl starch as a prime for cardiopulmonary bypass: effects of two different solutions on haemostasis.

Forty-five patients undergoing coronary bypass grafting were prospectively randomised to three groups and received in a double-blind manner as their CPB prime either 20 ml.kg-1 LMW-HES (Mw 120,000), 20 ml.kg-1 HMW-HES (Mw 400,000) or Ringer's acetate 2000 ml. The final volume of the prime was completed to 2000 ml with Ringer's acetate in the HES groups. Anaesthesia and CPB management were standardised. Plasma levels of von Willebrand factor antigen and factor VIII procoagulant activity were significantly more depressed after CPB in both HES-groups as compared with the crystalloid prime group. In addition, APTT was more prolonged and the maximal amplitude of thromboelastographic tracing was more decreased in the HES-groups.

It is concluded that it may be advisable to avoid HES solutions in the CPB prime, especially in patients with an increased risk for bleeding after cardiac operations.`

AR superior to HES as CPB Prime

Acta Anaesthesiol Scand 1995 Jul;39(5):671-7 Tollofsrud S, et al. Fluid balance and pulmonary functions during and after coronary artery bypass surgery: Ringer's acetate compared with dextran, polygeline, or albumin. The most expensive colloid fluid regimen (albumin) cost about 230 US$ more per patient than the RAc fluid regimen. We conclude that Ringer's acetate for volume replacement to stabilize haemodynamics during and after CAB surgery is associated with increased fluid retention only during the intraoperative period, compared with dextran 70 or polygeline, and with a lower serum colloid osmotic pressure and net lung capillary filtration pressure postoperatively, compared with all three colloid groups. This does not affect pulmonary functions adversely.

AR more cost-effective than colloidsAR more cost-effective than colloids

AR for acute stroke patientsAR for acute stroke patients

• Avoid hypotonic infusion

• No Lactate --- Ringer solution/NS

• No glucose

• Had specific effect to combat acidosis

• Ideally neuroprotective

• Avoid hypotonic infusion

• No Lactate --- Ringer solution/NS

• No glucose

• Had specific effect to combat acidosis

• Ideally neuroprotective

Fluid Therapy for Acute Stroke

Osm Intracell

distribution

Risk of Hyperchloremic acidosis

Lactate

NS 308 - +(Cl- 154 mEq/L)

-

RL 273 - - +

RA 273 - - -

D5 278 + - -

RS 310 - + (Cl- 155.5 mEq/L)

-

NS & RS can cause hyperchloremic acidosisNS & RS can cause hyperchloremic acidosis

(measured osmolarity 273.4 mOsm/L)

Plasma osmolarity 285 + 5 mOsm/L

Ringer’s acetate is slightly hypotonic

Current Osmolarity of DesiredAsering (Ringer’s acetate) osmolarity

273.4 285 7.25

273.4 290 10.375

273.4 295 13.5

273.4 300 16.625

Current Osmolarity of DesiredAsering (Ringer’s acetate) osmolarity

273.4 285 7.25

273.4 290 10.375

273.4 295 13.5

273.4 300 16.625

ml of 20% MgSO4

to be added to 1L

ml of 20% MgSO4

to be added to 1L

12 mEq

17 mEq

22.41 mEq

27.5 mEq

12 mEq

17 mEq

22.41 mEq

27.5 mEq

Mg Mg

1 ml MgSO4 20% ~ 1.66 mEq1 ml MgSO4 20% ~ 1.66 mEq

Vol of MgSO4 added into 1L Asering

• AR is an alternative to LR/NS as resuscitation fluid

• Other indications include: intraoperative fluid therapy in various surgical settings , initiating parenteral fluid in acute phase of stroke

• Priming solution in CPB

• AR is an alternative to LR/NS as resuscitation fluid

• Other indications include: intraoperative fluid therapy in various surgical settings , initiating parenteral fluid in acute phase of stroke

• Priming solution in CPB

Conclusion

SYOK

HIPOVOLEMIK

LUKA BAKAR

DBD

RESUSITASI ASERING®

PERDARAHAN TRAUMA

GASTROENTERITIS

AKUT DISERTAI

DEHIDRASI

ASERING ®ASERING ®

Ringer’s acetate

Terima KasihTerima Kasih

Maintenance Fluid Therapy

Maintenance Fluid Therapy

Iyan Darmawan, Medical Department

Otsuka, Indonesia

iyan@ho.otsuka.co.id

Iyan Darmawan, Medical Department

Otsuka, Indonesia

iyan@ho.otsuka.co.id

..

• correct timing

• correct indications, dosage

• correct product (composition, concentration)

• tailored to patient’s fluid and electrolyte status, not diagnosis

• good monitoring

• cost-effective

• correct timing

• correct indications, dosage

• correct product (composition, concentration)

• tailored to patient’s fluid and electrolyte status, not diagnosis

• good monitoring

• cost-effective

Rational Fluid regimenRational Fluid regimen

..

• The most recent UK National Confidence Enquiry into Perioperative Deaths report has documented that a number of surgical patients die because of inappropriate fluid management by inadequately trained staff.

• Questionnaires to 200 doctors (100 Group A; 50 Group B; and 50 Group C)

• Group A: preregistration house officers questioned within 10 days of starting their job; Group B 6-8 weeks; Group C surgical senior house officers.

• The most recent UK National Confidence Enquiry into Perioperative Deaths report has documented that a number of surgical patients die because of inappropriate fluid management by inadequately trained staff.

• Questionnaires to 200 doctors (100 Group A; 50 Group B; and 50 Group C)

• Group A: preregistration house officers questioned within 10 days of starting their job; Group B 6-8 weeks; Group C surgical senior house officers.

DN Lobo et al. (UK)*DN Lobo et al. (UK)*

..

mmol/day Group A (%) Group B (%) Group C (%)

<60 - 2 2

60-100 18 10 36

101-150 26 60 38

151-180 18 4 4

>180 1 4 2

Don’t know 37 20 18

Daily Sodium requirement for a healthy 70 kg man (desired answer highlighted)Daily Sodium requirement for a healthy 70 kg man (desired answer highlighted)

..

mmol/day GroupA (%) Group B(%) Group C (%)

<60 38 22 20

60-80 47 70 70

>80 1 - 2

Don’t know 14 8 8

Daily potassium requirement for a healthy 70 kg man (desired answer highlighted)Daily potassium requirement for a healthy 70 kg man (desired answer highlighted)

..

• Only 50% prescribed the desired amount of potassium• About 26% prescribed > 2 L 0.9% saline/day.• Less than 40% of respondents were given formal or informal

guidelines on fluid and electrolyte prescribing on surgical firms

• Knowledge relevant to fluid and electrolyte prescribing among surgical junior doctors is inadequate

• Teaching on the subject at both undergraduate and postgraduate levels does not prepare junior doctors for the task.

• Only 50% prescribed the desired amount of potassium• About 26% prescribed > 2 L 0.9% saline/day.• Less than 40% of respondents were given formal or informal

guidelines on fluid and electrolyte prescribing on surgical firms

• Knowledge relevant to fluid and electrolyte prescribing among surgical junior doctors is inadequate

• Teaching on the subject at both undergraduate and postgraduate levels does not prepare junior doctors for the task.

ResultsResults

RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE

NUTRITIONNUTRITIONCrystalloidCrystalloid

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support

1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support

ELECTROLYTESELECTROLYTES

FLUID THERAPYFLUID THERAPY

Colloid

RA/RL/NSRA/RL/NS KAEN3BKAEN3B

Repair

Electrolyte composition Electrolyte composition mEq/L ICF ECF

Plasma Interstitial15 142 144

150 4 42 5 2.527 3 1.5

1 103 11410 27 30

100 2 220 1 1- 5 5

63 16 6

Na+

K+

Ca2+

Mg2+

Cl-

HCO3-

HPO42-

SO42-

Organic acid

Protein

142150

144

..

COMPARTMENT CATION ANION Suitable solution

ICF K+ Mg++ HPO4-, Prot containing K+ Mg+

and HPO4-

ECF PLASMA Na+ Cl-, HCO3- Prot. High Na+ and Cl- ISF Na+ Cl- HCO3-

Ion DistributionIon Distribution

Perioperative IV Fluid Restrictions Helpful in Colorectal resection

Perioperative IV Fluid Restrictions Helpful in Colorectal resection

• Eliminate preoperative fluids and replacement for 3rd space loss

• Blood loss was replaced volume-for-volume with colloid

• 1000 ml Glucose 5% administered for the remainder of the day of operation

• On the surgical ward, any weight increase more than 1 kg was treated with furosemide

• All patients receive NGT 4 hours after surgery

Standard regimen500 ml colloid preloaded during epidural anes3rd space loss NSBlood loss < 500 1-1,5 L NS > 500 colloid + 1-2 L crystalloid

vs

Ann Surg.2003;238:641-648

Results (restricted vs standard)Results (restricted vs standard)

• Overall postop complications 33% vs 51% (p = 0.013)

• Cardiopulmonary comp 7% vs 24% (p=0.007)

• Tissue-healing complications 16% vs 31% (p =0.04)

• Deaths 0% vs 4.7% (p=0.12)

Ann Surg.2003;238:641-648

Fatal Postoperative Pulmonary Edema

Fatal Postoperative Pulmonary Edema

• A known postop complication, but the clinical manifestation and danger levels for fluid administration are not known

• Can occur within the initial 36 postoperative hours when net fluid retention exceeds 67 ml/kg/d

CHEST 1999;115:1371-1377

Hypoalbuminemia, ECF expansion and Picking the right infusion

Sequestration of fluid from ECW

35

30

25

20

15

10

5

% BODYWEIGHT

NORMAL ACUTE INJURY ELECT & IV Col PHASE OF RESOLUTION

ICW

IF

PL

I.V. fluids Diuresis

FormingSequestratedECF

SequestratedECF

ResolvingSequestratedECF

3rd space

Kokko & Tannen Fluids & Electrolytes. WB Saunders 3 ed.p738

Why give excessive fluid?

• Hypotension following induction of anesthesia

• Fluid sequestration during surgery

• Maintenance of BP after traumatic injury

• Excessive blood loss

• Postoperative fever

Type of dehydration5,8

Description Common cause Serum osmolarity

Isotonic Balanced loss of water and sodium

Vomiting, diarrhea

Normal (275-295 mOsm/kg)

Hypertonic Water losses exceed sodium losses

Fever Increased (>300 mOsm/kg)

Hypotonic Sodium losses exceed water losses

Overuse of diuretics

Decreased (<250 mOsm/kg)