Maintenance fluid

Fluid TherapyFluid Therapy

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RESUSCITATION MAINTENANCE

NUTRITIONCrystalloid

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

1. Replace normal loss(IWL + urine+ faecal)

2. Nutrition support

ELECTROLYTES

FLUID THERAPYFLUID THERAPY

Colloid




Volume of Distribution of Water

60%-Males

50%-Females

Solids

/////////////////////

H2O




Solids 40% of Wt

H2O H2O

Na

Intracellular

(2/3)

Extracellular

(1/3)




E.C.F. COMPARTMENTS

H2O

NaColloids & RBC

Intra-vascular1/4

Interstitial 3/4

H2O

Na




“Third Space”• Acute sequestration in a body compartment

that is not in equilibrium with ECF• Examples:

– Intestinal obstruction– Severe pancreatitis– Peritonitis– Major venous obstruction– Capillary leak syndrome– Burns




Daily Fluid Balance

Urine: 1.0 to 1.5L

Insensible Loss-Lungs 0.3L-Sweat 0.1 L

Intake:1-1.5L




Body Water and Fluid Body Water and Fluid CompartmentsCompartmentsTBW = 0.6 or 0.5 x kg

TBW = ECF + ICF(1/3) (2/3)

ECF = extracellular, ICF = intracellularECF = Interstitial + Plasma

(3/4) (1/4)Fluid spaces are iso-osmolar due to water

movement




70 kg male

Total body water=60% body wt

=0.6X70=42 liters

ICF=2/3

0.6 X42=25 liters

ECF=1/3

0.3X42=13 liters

Blood=1/4 (ECF)

0.25X13=3. 3 liters




• Monitoring Fluid Therapy

• Serial exams: vascular fullness, skin turgor, auscultation,, pulse quality, HR, RR

• Urine: specific gravity, volume• Blood pressure• Body weight• Labs: electrolytes, BUN, Creatinine, lactate

(tissue perfusion)• CVP




Why give fluids?Why give fluids?• Replace intravascular volume• Improve tissue perfusion• Replace fluid deficits (dehydration)• Meet maintenance in NPO patient• Replace ongoing losses (burns, etc.)• Fluid diuresis to eliminate toxins• Anesthetic and surgical support• Replacement of specific components (blood,

plasma)• Nutritional support (TPN, PPN)




Clinical Diagnosis

• Intravascular depletionMAP= CO x SVRHemodynamic effects

• BP HR JVP• Cool extremities• Reduced sweating• Dry mucus membranes

• E.C.F. depletion– Skin turgor, sunken eyeballs – Weight – Hemodynamic effects

•Water Depletion

ThirstHypernatremia




Electrolyte compositionElectrolyte compositionmEq/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-

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




Volume Deficit-Clinical Types

• Total body water:– Water loss (diabetes insipidus, osmotic diarrhea)

• Extracellular:– Salt and water loss (secretory diarrhea, ascites, edema)– Third spacing

• Intravascular: – Acute hemorrhage




DehydrationDehydration HypovolemiaHypovolemia

* thirst* urine output

• headache• nausea • syncope

hypotonic electrolytes

isotonic electrolytes

5% Dextrose5% Dextrose Ringer’s acetateRinger’s lactateNormal saline

Ringer’s acetateRinger’s lactateNormal saline

..DeficitDeficit




The IV Fluid Supermarket

• Colloids– Albumin

• 5% in NS• 20% (Salt Poor)

– Dextrans– Hetastarch

• Blood

• Crystalloids– Dextrose in water

• D5W• D10W• D50W

– Saline• Isotonic (0.9% or “normal”)• Hypotonic (0.45%, 0.25%)• Hypertonic

– Combo• D51/2NS• D5NS• D10NS

– Ringer’s lactate “physiologic”.(K, HCO3, Mg, Ca)




COMPOSITION OF PARENTERAL FLUIDS

• Parenteral fluids are generally classified based on molecular weight and oncotic pressure.

• Colloids have a molecular weight of >8000 and have high oncotic pressure.

• Crystalloids have a molecular weight of <8000 and have low oncotic pressure.







Nacl 5%

Na 850 mmol/L

CL 850 mmol/L

1700 mosm/L




Kcl 15%

K 2000mmol/L

Cl 2000mmol/L

2000 mosm/L




NaHco3 7.5%

Na 1000mmol/LHco3 1000mmol/L

2000mos/L

NaHco3 HCL H2co3 Nacl

H2co3 co2 H20




Dextrose Hyper Tonic

D25% 1180 mos/L

D50% 2770 mos/L




• Dextran solutions (dextran 40 and dextran70): Similar osmotic pressure to plasma. Dextransinterfere with normal coagulation partly by hemodilution of clotting factors and partly by “coating” platelets and the vascular endothelium. May promote renal failure.

• 20% Human serum albumin: Protein based solution, falling out of favor in some circles secondary to reports of increased mortality in the critically ill adult population, and some debate still lays in its use outside of the neonatal arena.

Colloids




• Colloid refers to a liquid that exerts osmotic pressure due to large MW (greater than 30,000) particles in solution. A variety of colloid solutions are seen for in hospital use:

• Hydroxyethyl starch (Hespan): hetastarch can cause a coagulopathy, through hemodilution of clotting factors, inhibition of platelet function and reduction of the activity of factor VIII

• Pentastarch (Pentaspan):Pentastarch differs from hetastarch in that it has a lower mean MW. Preliminary studies also suggest that pentastarch may have fewer adverse effects on coagulation than hetastarch.25. No clear pediatric value yet.

Colloids




Fluids can be described as being from three categories

Fluids can be described as being from three categories.

Isotonic - Fluid has the same osmolarity as plasmaNormal Saline (N/S or 0.9% NaCl),Ringers Acetate(RA), Ringer’s lactate (RL)

Hypotonic -Fluid has fewer solutes than plasma Water, 1/2 N/S (0.45% NaCl), and D5W(5% dextrose in water) after the sugar isused up

Hypertonic-Fluid has more solutes than plasma7.5% Hco3Na/ 15% kcl3% saline solution, 5%salin solution

. Isotonic - Fluid has the same osmolarity as plasma

Normal Saline (N/S or 0.9% NaCl),Ringers Acetate(RA), Ringer’s lactate (RL)

Hypotonic -Fluid has fewer solutes than plasma Water, 1/2 N/S (0.45% NaCl), and D5W(5% dextrose in water) after the sugar isused up

Hypertonic-Fluid has more solutes than plasma7.5% Hco3Na/ 15% kcl3% saline solution, 5%salin solution




Most Common form of Dehydration

Occurs when fluids and electrolytes are lost in even amounts

There are no intercellular fluid shifts in isotonic dehydration

Common Causes diuretic therapy excessive vomiting excessive urine loss hemorrhage decreased fluid intake

Most Common form of Dehydration

Occurs when fluids and electrolytes are lost in even amounts

There are no intercellular fluid shifts in isotonic dehydration

Common Causes diuretic therapy excessive vomiting excessive urine loss hemorrhage decreased fluid intake

Isotonic Dehydration




Hypertonic Dehydration

Second most common type of dehydration.

Occurs when water loss from ECF is greater than solute loss

hyperventilation, pure water loss with high fevers, and watery diarrhea.

Diabetic Ketoacidosis and Diabetes Insipidus

Iatrogenic Causes prolonged NPO, excessive hypertonic fluids, sodium bicarbonate,

Second most common type of dehydration.

Occurs when water loss from ECF is greater than solute loss

hyperventilation, pure water loss with high fevers, and watery diarrhea.

Diabetic Ketoacidosis and Diabetes Insipidus

Iatrogenic Causes prolonged NPO, excessive hypertonic fluids, sodium bicarbonate,




Hypotonic Dehydration

Relatively Uncommon - Loss of more solute (usually sodium) than water.

Hypotonic Dehydration causes fluid to shift from theblood stream into the cells, leading to decreased vascular volume and eventual shock

Seen in Heat Exhaustion

Increased cellular swelling -causes increased intracrainial pressure - Confusion.

Seen in Heat Stroke

Relatively Uncommon - Loss of more solute (usually sodium) than water.

Hypotonic Dehydration causes fluid to shift from theblood stream into the cells, leading to decreased vascular volume and eventual shock

Seen in Heat Exhaustion

Increased cellular swelling -causes increased intracrainial pressure - Confusion.

Seen in Heat Stroke




increases ECFincreases ECF

ICF ISF PlasmaICF ISF Plasma

Replace acute/abnormalloss

Replace acute/abnormalloss

Isotonic infusionIsotonic infusion

700 ml 300 ml

• Ringer’s acetate• Ringer’s lactate• Normal saline

• Ringer’s acetate• Ringer’s lactate• Normal saline




increases ICF > ECFincreases ICF > ECF

ICF ISF PlasmaICF ISF Plasma

Replace Normal loss (IWL + urine)Replace Normal loss (IWL + urine)

Hypotonic infusionHypotonic infusion• 5% dextrose• 5% dextrose

70 ml70 ml270 ml270 ml660 ml660 ml




• Replacement• Maintenance• Repair deficit

• Replacement• Maintenance• Repair deficit

Fluid TherapyFluid Therapy




BACIC PRINCIPLESBACIC PRINCIPLES

Replace Replace

MaintainMaintain

Repair Repair

Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock

Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock

IWL + urine IWL + urine

Acid base, electrolyte imbalancesAcid base, electrolyte imbalances




FLUID SELECTIONFLUID SELECTION• Replace : RA, RL, NS

• Maintain: N/2 + D (adult)

• Repair : NaHCO3 8,4%KCl 15%NaCl 3%

• Replace : RA, RL, NS

• Maintain: N/2 + D (adult)

• Repair : NaHCO3 8,4%KCl 15%NaCl 3%




MaintenanceMaintenance

• IWL + urine• Adults/children : 4:2:1

eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 = 100ml/hr

• IWL + urine• Adults/children : 4:2:1

eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 = 100ml/hr




Requirements Requirements

• Fever• Restless/delirium• Warm ambient temperature• Hyperventilation

• Fever• Restless/delirium• Warm ambient temperature• Hyperventilation




Requirements Requirements

• Hypothermia• High humidity• Oliguria/anuria• Reduced consciousness• Retention/oedema• Increased intracranial pressure

• Hypothermia• High humidity• Oliguria/anuria• Reduced consciousness• Retention/oedema• Increased intracranial pressure




Rationale of maintenance solutions

Rationale of maintenance solutions

• Fluid redistribution• Basal requirement of potassium &

sodium• electrolyte concentration in

infusion solutions

• Fluid redistribution• Basal requirement of potassium &

sodium• electrolyte concentration in

infusion solutions




Electrolyte solutionsElectrolyte solutions

Plasma Isotonicsolutions

Hypotonic solutions

Normalsaline

Ringer’sacetate/ lactate

KAEN 3B*

290 308 273

278

D5

290278

* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmolCl-, 20 mmol lactate, 27 g dextrose per L.




Electrolyte Requirements:70-kg adult

• Sodium (as NaCl): 80-150 mEq (mmol)/d (Pediatric patients, 3-4 mEq/kg/ 24 h [mmol/kg/24 h])

• Chloride: 80-150 mEq (mmol)/d, as NaCl• Potassium: 50-100 mEq/d (mmol/d)

(Pediatric patients, 2-3 mEq/kg/24 h [mmol/kg/24 h]).

• Calcium: 1-3 gr/d, • Magnesium: 20 mEq/d (mmol/d).




Sodium Physiology

1. Sodium and its anions make up about 90% of the total extracellular osmotically active solute.

2. Serum osmolality (mOsm/kg H20) = 2 X [Na+] + [glucose]/18 + [BUN]/2.8

3. For practical purposes, twice the Na+ concentration equals serum osmolalitybecause urea and glucose ordinarily are responsible for less than 5% of the osmotic pressure.




Hyponatremia(Na+ <136 mEq/L

[mmol/L])• Low osmolality. Further classified based on clinical assessment of

extracellular volume status• Isovolemic.

No evidence of edema, normal BP. Caused by water intoxication (urinary osmolality <80 mOsm), SIADH, hypothyroidism, hypoadrenalism, thiazide diuretics, beer potomania

• Hypovolemic. Evidence of decreased skin turgor and an increase in heart rate and

decrease in BP after going from lying to standing. Due to renal loss (urinary sodium >20 mEq/L) from diuretics, postobstructive diuresis, mineralocorticoid deficiency (Addison disease, hypoaldosteronism) or extrarenal losses (urinary sodium <10mEq/L) from sweating, vomiting, diarrhea, third spacing fluids (burns, pancreatitis, peritonitis, bowel obstruction, muscle trauma)

• Hypervolemic.Evidence of edema. urinary sodium <10 mEq/L). Seen with CHF,

nephrosis, renal failure, and liver disease




• severity of symptoms correlates with the rate of decrease in Na+.

• ?Lethargy, confusion, coma• ?Muscle twitches and irritability,

seizures• ?Nausea, vomiting• Signs: Hyporeflexia, mental status changes

Symptoms: Usually with Na+ <125 mEq/L (mmol/L)




Life-Threatening. (Seizures, coma) 3-5% NS can be given in the ICU setting. Attempt to raise the sodium to about 125 mEq/L with 3-5% NS.

Isovolemic Hyponatremia. (SIADH)• Restrict fluids (1000-1500 mL/d).• Demeclocycline can be used in chronic SIADH.Hypervolemic Hyponatremia• Restrict sodium and fluids (1000-1500 mL/d).• Treat underlying disorder. CHF may respond to a combination of

ACE inhibitor and furosemide.Hypovolemic Hyponatremia• Give D5NS or NS.

Treatment: Based on determination of volume status.




• Mechanisms: Most frequently, a deficit of total body water.

• (Hypovolemic hypernatremia). • (Isovolemic hypernatremia).• (Hypervolemic hypernatremia).

Hypernatremia (Na+ >144 mEq/L [mmol/L])






• Combined Sodium and Water Losses (Hypovolemic hypernatremia).

• Water loss in excess of sodium loss results in low total body sodium.

• Due to renal (diuretics, osmotic diuresisdue to glycosuria, mannitol, etc) or extrarenal (sweating, GI, respiratory) losses





• Excess Sodium (Hypervolemic hypernatremia).

• Total body sodium increased, caused by iatrogenic sodium administration (ie, hypertonic dialysis, sodium-containing medications) or adrenal hyperfunction (Cushing’s syndrome, hyperaldosteronism).





• Excess Water Loss (Isovolemic hypernatremia).

• Total body sodium remains normal, but total body water is decreased. Caused by diabetes insipidus ,excess skin losses, respiratory loss, others.






• Combined Sodium and Water Losses (Hypovolemic hypernatremia).

• Water loss in excess of sodium loss results in low total body sodium.

• Due to renal (diuretics, osmotic diuresisdue to glycosuria, mannitol, etc) or extrarenal (sweating, GI, respiratory) losses




Hypernatremia

• Symptoms:Depend on how rapidly the sodium level has changed

• Confusion, lethargy, stupor, coma• Muscle tremors, seizures• Signs: Hyperreflexia, mental status changes




Hypernatremia:Treatment:

• Euvolemic/Isovolemic. (No orthostatic hypotension) calculate the volume of free water needed to correct the Na+ to normal as follows:

• Body water deficit = Normal TBW - Current TBW

Where Normal TBW = 0.6 x Body weight in kg• And Current TBW =Normal serum sodium x

TBW / Measured serum sodium




Hypervolemic Hypernatremia

• Avoid medications that contain excessive sodium(carbenicillin, etc).

Use furosemide along with D5W.




Hypernatremia:Treatment:

• Hypovolemic Hypernatremia. Determine if the patient volume is depleted by determining if orthostatic hypotension is present;

• if volume is depleted, rehydrate with NS until hemodynamically stable,

• then administer hypotonic saline (1/2 NS).




Treatment of hypernatremia

• Hypotonic fluid loss is the most common form of hypernatremia.

• It is caused by gastroenteritis, osmotic diuresis.

• Signs of intravascular depletion are evident.• Treatment involves replacement volume with

normal saline, followed by correction of the free water deficit




Basal requirement of Potassium

Basal requirement of Potassium

• K+ intake ranges from 40-150 mEq daily• Homeostasis (minimum req) 20-30 mEq/day• Increased requirement in heart failure and

hypertension

• K+ intake ranges from 40-150 mEq daily• Homeostasis (minimum req) 20-30 mEq/day• Increased requirement in heart failure and

hypertension







-900 -600 -300 0 +300-900 -600 -300 0 +300K+ deficit (meq)K+ deficit (meq) K+ excess (meq)K+ excess (meq)

10 --

8 --

6 --

4 --

2 ---

10 --

8 --

6 --

4 --

2 ---

serum K+

(meq/L)serum K+

(meq/L)

Relationship between serum K+ serum and TBK at various levels of deficit and excessRelationship between serum K+ serum and TBK at various levels of deficit and excess




05 10 15 20 25 K+ deficit (%)05 10 15 20 25 K+ deficit (%)

5 --

4 --

3 --

2 --

1 ---

5 --

4 --

3 --

2 --

1 ---

serum K+

(meq/L)serum K+

(meq/L)

Decreased serum K+

and deficit of TBK (%)Decreased serum K+

and deficit of TBK (%)

total body K+ = 50 mEq/kg body weighttotal body K+ = 50 mEq/kg body weight




A c i d o s i sA c i d o s i s A l k a l o s i sA l k a l o s i s

Blood pH 7.2 7.3 7.4 7.5 7.6 5.0 4.5 4.0 3.5 3.0 0 mEq4.5 4.0 3.5 3.0 2.5 100 mEq4.0 3.5 3.0 2.5 2.0 200 mEq3.2 3.0 2.5 2.0 1.5 400 mEq

cell DCCECF

3 K+

H+

2 Na+

3 K +

H+

2 Na+

K+

H+

Urine

K+ low urine K+

H+ acid urine

3 K +

H+

2 Na+

3 K +

H+

2 Na+

K+H+ Urine Alkali

K+

H+

Urin

Cell Tubulus distalECF

K+ and acid-base statusK+ and acid-base status

Serum K+

K+ depletion

K+ urin tinggi




Cnc: <40 mEq/LCnc: <40 mEq/L11Rate of adm: <20 mEq/hrRate of adm: <20 mEq/hr22daily dosage : <100 mEq/daydaily dosage : <100 mEq/day33Monitor ECG and serum K+Monitor ECG and serum K+44U r i n e output: >0.5 ml/kg/hr U r i n e output: >0.5 ml/kg/hr 55

< 40mEq/L< 40mEq/LKClKCl

××

Standard K+ concentration in i.v.solutions

Standard K+ concentration in i.v.solutions

KCl bolusKCl bolus




Serum ElectrolytesSerum ElectrolytesMAGNESIUM

• common electrolyte abnormality hospitalized humans is hypomagnesimia

• Primarily intracellular• Low Mg may be clinically silent but makes

hypocalcemia and hypokalemia refractory to treatment

• Vitamin D controls Mg absorption• May see high Mg in renal failure




Serum ElectrolytesSerum ElectrolytesMAGNESIUM

• Normosol and Plasmalyte contain Mg• Very low Mg may require treatment with IV

MgSO4

• Cofactor for NaK ATPase




Rate of administration of Electrolyte & glucose

Rate of administration of Electrolyte & glucose

Na+ 100 mEq/hr

K+ 20 mEq/hr

Ca++ 20 mEq/hr

Mg++ 20 mEq/hr

HCO3-

100 mEq/hr

Glucosa 0,5 gr/kg/hr ( 4 mg/kg/min)*

Na+ 100 mEq/hr

K+ 20 mEq/hr

Ca++ 20 mEq/hr

Mg++ 20 mEq/hr

HCO3-

100 mEq/hr

Glucosa 0,5 gr/kg/hr ( 4 mg/kg/min)*

* Neonates 6-8 mg/kg/min* Neonates 6-8 mg/kg/min




Conclusion

• Maintenance fluid therapy : normal loss• (IWL + Urine)• Suitable in hypertonic dehydration• Minimized risk of potassium depletion in cases

of prolonged inadequate oral intake• ‘Ready for use” product associated with less

risk of contamination• Can be combined with amino acids

• Maintenance fluid therapy : normal loss• (IWL + Urine)• Suitable in hypertonic dehydration• Minimized risk of potassium depletion in cases

of prolonged inadequate oral intake• ‘Ready for use” product associated with less

risk of contamination• Can be combined with amino acids




Technology

Maintenance fluid