aspect to consider in fluid therapy.ppt
TRANSCRIPT
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Aspect to Consider in Fluid Therapy
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Fluid Therapy
Resuscitation
Maintenance fluid therapy
Nutrition
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Resuscitation
In Shockevery stage of shock
Dehydration
Bleeding Burn
Leakage syndromehypovolemia
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30
20
10
0
ThirdSpace
Intra-Cellular
Fluid
Inter-StitialFluid
PlasmaVolume
dolph H. Giesecke,Lawrence D. Egbert
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Class I Class II Class III Class IV
Blood loss Up to 750 750-1500 1500-2000 >2000
Blood loss
( % EBV)
Up to 15% 15-30% 30-40% >40%
Pulse rate 100 >120 >140
Blood
pressure
Normal Normal Decrease Decrease
Pulse pressure Normal ordecrease
Decrease Decrease Decrease
Respiratory
rate
14-20 20-30 30-35 >35
Urine output >30 20-30 5-15 No UO
CNS/ mental
status
Slightly
anxious
Mildly anxious Anxious and
confused
Confused and
lethargic
Fluid
replacement
crystalloid crystalloid Crystalloid/
colloid
Crystallloid/
colloid
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Estimated Blood Volume
Age Blood Volume
Neonate
Premature 85-90/kgBWFull-term 85 ml/KgBW
Infant 80 ml/KgBW
AdultMale 75 ml/KgBW
Female 65 ml/KgBW
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DO2 = Cardiac Outputx CaO2 ( arterial O2 content )
(Hb xSpO2 x1,34 )+ ( 0,003 x PaO2)
Stroke Vol x HR
Volume x contractility
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What are the stakes?
Risks of inadequate resuscitation
Life-threatening
Nonfatal
Risks of excessive resuscitation
Life-threatening
Nonfatal
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Life-Threatening Consequences of
Inadequate Resuscitation
Lactic acidosis Acute renal failure
Multisystem organ failure
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Maintenance Fluid Support
-Patient fasting with normal body fluid
composition
- Critically ill patients with altered bodyfluid composition
- Perioperative losses ( Preoperative,
during the operation, postoperatively)
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Basic Principles of Fluid Maintenance
Therapy
Replace
Maintenance
Repair
Abnormal loss: GIT, 3rdspace,
Ongoing loss, septic and
Hypovolemic shock
IWL + urine
Acid base, electrolyte imbalances
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Normal Adult Water and Electrolyte
Requirement(electrolyte meq/kgBW/day and water cc/m2)
1500870Water
0,7 - 3,60,3Cl
0,3 - 0,70,2 - 0,4Mg
0,4 - 1,10,2Ca
0,7 - 2,10,3 - 0,5K
0,7-3,60,3Na
Usual needsMinimal needsComponent
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3 : 1 - 1 ; 1Glukosa : lemak1K meq/kgBB/hari
1 -2Na meq/kgBB/hari
1 1,5As.Amino/prot
Gr/kgBB/hari
25 30 (kritis)
30 50
Energi Kcal/kgBB/hari
25 30 (kritis)
30 50
Air cc/kgBB/hari
JumlahSubstrat nutrisi
Maintenance
fluid/electrolyterequirements
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Composition of Maintenance Fluid
Type fluid Na Cl K Ca Mg lactate SugarTutofusin OPS 100 90 18 4 6 38/acetate 50/sorbitol
KaEn Mg3 50 50 20 - - 20 100
KaEn 3B 50 50 20 - - 20 27
KaEn 3A 60 50 10 - - 20 27
RL 131 112 4 4.5 - 28 -
KaEn 1B 38.5 38.5 - - - - 37.5
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Electro-neutrality
In aqueous solutionthe sum of all negatively charge
ion must equal the sum of all positively charged ion
In pure water: the concentration of H+= HCO3-
In plasma: other charged ion present also have an
effect on the relative proportion of H+and HCO3-
These other charged molecule ( which affect the
dissociation of water to give H+)independentvariable (SID, ATOT, PaCO2)
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2 variable
Plasma pH or [H+]
Independent
variable
Stewart PA. Can J Physiol
Pharmacol 61:1444-1461,
1983.
Dependent
variableX
pCO2SID - ATOT pH, CO3-, H-, OH-, A-, AH, HCO3-
H20 + CO2 H2CO3 H++ HCO3-
ATOT
A-+ AH(Na++K++Ca+)
( Cl- + lactate )
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Gamblegram
Na+
140
K+ 4
Ca++
Mg++
Cl-
102
HCO3-
24
KATION ANION
SID
STRONG ION DIFFERENCE
A- 42
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Na Na Na
K K KHCO3
Cl Cl Cl
HCO3HCO3SID
Normal Acidosis Alkalosis
Weak acid imbalance
( albumin or phosphate )
AlbAlbAlb
SIDSID
Alkalosis
hypoalbumin/
phosphate
Acidosis --.
Hyperprotein /
hyperalbumin
or phosphate
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Rules of isolated abnormalities in strong ion
difference (SID) and total concentration of Weak
Acid
SID/ATOT Isolated
abnormalities
Result
SID Increase Metabolic alkalosis
SID Decrease Metabolic acidosis
ATOT
Increase Metabolic acidosis
ATOT Decrease Metabolic alkalosis
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Na+= 140 mEq/L
Cl-= 102 mEq/L
SID = 38 mEq/L 140/1/2= 280 mEq/L
102/1/2 = 204 mEq/L
SID = 76 mEq/L1 liter liter
WATER DEFICITDiuretic
Diabetes Insipidus
Evaporasi
SID : 38 76 = alkalosis
Contracted alkalosis
Plasma Plasma
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Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID = 38 mEq/L
140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L
1 liter 2 liter
WATER EXCESS
1 Liter
H2O
SID : 3819 = Acidosis
Dilutional Acidosis
Plasma
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Na+= 140 mEq/L
Cl-= 102 mEq/L
SID = 38 mEq/L
Na+= 154 mEq/L
Cl-= 154 mEq/L
SID = 0 mEq/L1 liter 1 liter
PLASMA + NaCl 0.9%
SID : 38
Plasma NaCl 0.9%
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2 liter
Hyperchloremic acidosis after NaCl 0.9%
infusion
=
SID : 19 acidosis
Na+= (140+154)/2 mEq/L= 147 mEq/L
Cl-= (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma
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Na+= 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
Cation+= 137 mEq/L
Cl-= 109 mEq/L
Laktat-= 28 mEq/L
SID = 0 mEq/L1 liter 1 liter
PLASMA + Ringer Lactate solution
SID : 38
Plasma Ringer laktat
Metabolizedrapidly
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2 liter
=
Normal pH after infusion of RINGER
LACTATESolution
SID : 34more alkalis than after NaCl 0.9% infusion
Na+= (140+137)/2 mEq/L= 139 mEq/L
Cl-= (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L
SID = 34 mEq/L
Plasma
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Plasma
ICF ISF Plasma
colloids
Fima HESHES not an acid
In RingerLactate solution
Na+
138Cl-125
SID = 13
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Na+= 140 mEq/L
Cl-= 102 mEq/L
SID = 38 mEq/L
Na+= 138mEq/L
Cl-= 125mEq/L
SID = 13 mEq/L
HESneutral1 liter 1 liter
PLASMA + FIMA HES
SID : (38+13)/2 = 26
Plasma FIMA HES
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Conclusion
Effect of fluid therapy :
volume effect
Maintenance
Electrolyte and acid base balance
Type of fluid
For volume effect
Maintenance All will influence acid base and electrolyte
balance
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