principles of fluid therapy on the basis of-edited

8/3/2019 Principles of Fluid Therapy on the Basis of-edited

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PRINCIPLES OF FLUID THERAPY ON THEBASIS OF SEVERITY OF LOSS OF BODY

FLUID AND NUTRITIONAL STATUS:RECOMMENDED TYPES OF IV FLUIDS AND ORAL FLUIDSRECOMMENDED TYPES OF IV FLUIDS AND ORAL FLUIDS

(ORS, RESOMAL)(ORS, RESOMAL)..

KASONDA GEORGE

MMED STUDENT(PAEDIATRIC).

Facilitator: Dr Ntogwisangu

_________________________________________________________________


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Topic layout

Introduction

Types of Iv fluids

Principles of administering IV fluids

Oral Rehydration Therapy

oral fluids, example of rehydration

diarrhea

Conclusion


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Introduction Fluid therapy is therapy whose basic objective is

to restore the volume and composition of the bodyfluids to normal with respect to water-electrolytebalance.

OR is the administration of fluids to a patient as a

treatment or preventative measure.

Fluids may be administered intravenously, orally orintraoseous.


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Intravenous fluid therapy

Is the giving of substances directly into a

vein .

There are 3 types of IV fluid.

1. Isotonic fluids

2. Hypotonic fluids3. Hypertonic fluids


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Isotonic fluids

Osmolarity is similar to that of serum.

These fluids remain intravascular

momentarily, thus expanding the volume. Crucial for hypotensive or hypovolemic.

Risk of fluid overloading exists.

. Example: 0.9% Normal Saline Basically

Salt and Water


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Hypotonic fluids Less osmolarity than serum.

Water moves from the vascular compartment into theinterstitial fluid compartment.

These are helpful when cells are dehydrated from conditionsexample patients with DKA.

Caution with use because sudden fluid shifts from the

intravascular space to cells can cause cardiovascularcollapse

Example:0.45% Normal saline = Half Normal Salinehypotonic saline


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Hypertonic fluids

These have a higher osmolarity than serum. These fluids pull fluid and sometimes electrolytes

from the intracellular/interstitial compartments intothe intravascular compartments.

Useful for stabilizing blood pressure, increasingurine output, correcting hypotonic hyponatremiaand decreasing edema.

These can be dangerous in the setting of cell

dehydration

Example:1.8, 3.0, 7.0, 7.5 and 10% Saline =hypertonic saline


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Main Groups.

Crystalloids Colloids

Crystalloids Clear solutions fluids- made up of water & electrolyte

solutions

These fluids are good for volume expansion.

However, both water & electrolytes will cross a semi-permeable membrane into the interstitial space andachieve equilibrium in few hours.(3hr)


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Composition of commonly used

crystalloids


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Colloids are large molecular weight solutions(nominally MW > 30,000 daltons).

Made of gelatinous solutions and do NOT readilycross semi-permeable membranes or formsediments.

Because of their high osmolarities, these are

important in capillary fluid dynamics. (examplethey work well in reducing edema)

Example: Albumin solutions

Colloids


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Principle of IV fluid administration


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Consideration

When calculating the fluid requirements of

patient, there are 3 elements to consider

Replacement (based on the level of dehydration )

Maintainance (basic rate which a patient requiresduring a 24 hour period )

Ongoing Losses (based on a predicted fluidamount lost by a patient within a 24 hour period )


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Hypovolemia

Usually refers to a state of combined salt andwater loss exceeding intake which leads to

ECF volume contraction.

ECF volume contraction is manifested as a

decreased plasma volume and hypotension.

It manifest as decreased jugular venous

pressure, postural hypotension, and postural

tachycardia.


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Treatment of Hypovolemia

The goals of treatment is to restore normovolemia withfluid similar in composition to that lost and replaceongoing losses.

Mild volume losses can be corrected via oral rout.

More severe hypovolemia requires IV therapy.

Isotonic or Normal Saline (0.9%NaCl) is the solution ofchoice in normonatremic and mildly hyponatremicpatients and should be administered initially in patientswith hypotension or shock.


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Severe hyponatremia may require Hypertonic Saline

(3.0% NaCl)

In the Hypernatremic patient, there is a proportionatelygreater deficit of water than sodium, therefore to correctthis patient you will use a Hypotonic solution like NS(0.45% NaCl) of D5W.

Patients with significant hemorrhage, anemia, orintravascular volume depletion may require blood

transfusions or colloids (albumin/dextran).

Hypokalemia can be simultaneously corrected by addingappropriate amounts of KCl to replacement solutions.

Cont..


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Example of a cause of Hypovolemia

BURN

Burn injury results in loss of the cholesterol-filledcornified layer of the skin.

When the cornified layer becomes denuded, asoccurs with a result of extensive burns, the rate ofevaporation can increase as much as 10-fold, to 3to 5 L/day.

Burn also results in the activation of the complimentsystem and the release of large number ofinflammatory mediators such as histamine,

prostaglandins and leukotrienes.


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Therapeutics must therefore be based on

know ledge of these changes in time. It is important to realize that many of the

problems are predictable and can andshould be prevented before they happen.

One of the many aspects of the care of theburn patient that must be monitored is theelectrolyte balance.

The correct approach will be consideredwith regard to three phases of time inrelation to the main changes in eachphase

Cont


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:

1) The initial resuscitation period (between 0and 36 h). characterized by hyponatraernia andhyperkalaemia(shock phase).

2) The early post-resuscitation period (between

2 days and 6). in which we considerhypernatraemia. hypokalaemia,hypocalcaemia, hypomagnesaemia. andhypophosphataetnia.

3) The inflammation-infection period (also

known as the hypermetabolic period). which ismost evident after the first week. when severalimbalances may coexist, depending whethercorrection was performed. and. if so, how.

Cont...


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First part (shock phase)..

It is fundamental that sodium replacement

should be performed with resuscitation

fluids (lactated Ringer's. normal saline);

If a hypertonic solution is used to restoreserum sodium. it should not be allowed to

increase above 160 mEq/1 and the rate of

increase should not exceed 1.5 mEq/h. Hyperkalaemia (K+) (> 5.5 mEq/1) is

mainly caused by- cell lysis and tissue

necrosis

Cont


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Second and third phase

These ar early post-resuscitation phase(hypermetabolic phases)

The main changes in this period are:

A.Hypernatraemia caused by several mechanisms:Therapeutics is performed with hypotonic~fluids (low

sodium content, with or without glucose): NaCl 0.45%

or DSc NaCI 0.-15).

B. Hypokalaemia. It may be due to increased potassiumlosses and the intracellular shift of potassium because ofthe administration of carbohydrates.


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ORAL REHYDRATION THERAPY

(ORT) Is a simple treatment for dehydration associated

with diarrhea, particularly gastroenteritis orgastroenteropathy, such as that caused bycholera or rotavirus.

ORT consists of a solution of salts and sugarswhich is taken by mouth. It is used around theworld, but is most important in the developing

world, where it saves millions of children a yearfrom death due to diarrhea .

Examples ORS and ReSoMal


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ORS Composition


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ReSoMal

Rehydration Salt for Malnutrion, this is amodified ORS with low sodium.

Full-strength ORSprovides too much sodiumand too little potassium.

ReSoMal contains approximately 37.5 mmolNa, 40 mmol K, and 3 mmol Mg per litre


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EXAMPLE: Severe Diarrhea

During diarrhoea there is an increased

loss of water and electrolytes (sodium,

chloride, potassium, and bicarbonate) in

the liquid stool.

Dehydration occurs when these losses are

not replaced adequately and a deficit of

water and electrolytes develops.


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The volume of fluid lost through the stools in 24

hours can vary from 5 ml/kg (near normal) to200 ml/kg, or more. The concentrations and

amounts of electrolytes lost also vary.

The total body sodium deficit(Hyponatremia) in

with severe dehydration due to diarrhoea isusually about 70-110 millimoles per litre of water

deficit(this is especially evident in children).

Potassium(Hypokalemia) and

chloride(hypochloremia) losses are in a similar

range

Cont..


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Fluid therapy in Diarrhea

(Particularly in children)

The 3 essential elements in the

management of all children with diarrhoea

are

i) Rehydration therapy

ii) Zinc supplementation(play a role in

cell immune mechanism.

iii) Continued feeding.


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Cont..

The rehydration regimen is selected according to the degree ofdehydration.

No dehydration and some dehydration-ORS vs ReSoMal

Severe Dehydration:The best IV fluid solution is Ringer's lactateSolution (also called Hartmanns Solution for Injection).

If Ringer's lactate is not available, normal saline solution (0.9%NaCl) can be used.

5% glucose (dextrose) solution on its own is not effective andshould not be used.


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Conclusion

Fluid therapy is indicated either when there is aloss of fluid from any part of body compartmentsor there is a risk of loss of fluid.

The severity of the fluid loss, and thecompartment which has been lost from willinfluence the choice of fluid and the speed atwhich it needs to be administered.

If fluid therapy is performed as a treatment thenit is necessary to diagnose and treat theunderlying condition.


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References

Terry, J. (ed): Intravenous Therapy: Clinical Principlesand Practice. Philadelphia, L.: "Back to Basics. WouldYou Haug These I.B. Solutions Co., 1995.

Clinical Physiology by E.J. Moran Campbell, C.J. Dickson,

J.D. Slater, C.R.W. Edwards and K. Sikora. Publ.Blackwell Scientific publications, Oxford.

Vonfrolio, L.: "Back to Basics. Would You Hang These I.V.Solutions?" AJN. 95(6):37-39, June 1995

Textbook of Medical Physiology by Arthur Guyton andJohn Hall. Publ. WB Saunders, Philadelphia, London,New York.

WHO A manual for physicians and other senior healthworkers

principles of fluid therapy on the basis of-edited

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