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Water balance, infusions

KLINIKA ANESTÉZIOLÓGIE A INTENZÍVNEJ MEDICÍNY LF UPJŠ A FNLP KOŠICE. Water balance, infusions. MUDr. Štefan Trenkler, PhD. I. KAIM UPJS LF a UNLP Košice. Košice 2012. Distribution of body fluids and the Na & K concentrations in the body water compartments.

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Water balance, infusions

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  1. KLINIKA ANESTÉZIOLÓGIE A INTENZÍVNEJ MEDICÍNY LF UPJŠ A FNLP KOŠICE Water balance, infusions MUDr. Štefan Trenkler, PhD. I. KAIM UPJS LF a UNLP Košice Košice 2012

  2. Distribution of body fluids and the Na & K concentrations in the body watercompartments 42 l = 28 + 14 (3,5 + 10,5) litres Lobo DN: Physiological Aspects of Fluid and Electrolyte Balance, 2002

  3. Fluid balance

  4. Water, electrolytes homeostasis • Adequate volume of circulating plasma = normal tissue perfusion • ECF volume ~ total body Na+ content • Kidney – filtration, reabsorbtion of water, Na+ • Hormones – renin, aldosteron, ADH; ANP • Potassium

  5. Na+: 1,5 mmol/kg/d K+: 1 mmol/kg/d

  6. Homeostasis disturbances • Water – hyper and dehydratation • Osmolality (Na) – hyper a hypoosmolality • Oncotic disturbances • Ions disturbances • ABG disturbances

  7. Osmotic pressure Osmotic pressure is force per area that prevents water from passing through membrane!

  8. Osmotic pressure (e.g. erytrocyte)

  9. Fluid inputMaintaining the IC and EC fluid volume 1. Basic requirements (30 ml/kg/d)(1000 ml NS 0.9%; 2000 ml free water (Glu); 60 mmol KCl) 2. Pre-existing deficit (signs of dehydratation/hypovolemia - assessment) 3. Additional losses

  10. Hydratation status, intravascular volume assessment • History • Physical examination (P, BP, RR, CR, MM, diuresis) • Tests results (Na, K, osmolality, HTC, urea) • Patient response to the fluid administration (physiological parameters)(10 – 20 ml NS 0.9%/kg)

  11. Hypovolemia (fluid depletion) • Hypotension MAP<65 mm Hg, tachykardia • Diuresis •  body weight • MAC (MLAC) • CVP • PAWP • LVEDP (TEE)

  12. Distribution of infused fluids in the body water compartments Lobo DN: Physiological Aspects of Fluid and Electrolyte Balance, 2002

  13. Crystalloids composition

  14. Natural Plasma 5 % (frozen) Albumin 4,5 %, 20 % Synthetic Gelatine Dextran 40, 70 Hydroxyetylstarch – HAES, Voluven, Colloids

  15. Crystalloids vs colloids • No differences in clinical outcome • More oedema with crystalloids • More rapid replacement with colloids (permeability) • Risk vs benefit; cost • Newer (better) HEAS? • Mixture of C&C

  16. Fluid replacement Loss of 1 liter of blood: Replacement: 1 l of blood or 1 l of colloid (IV) or4 l of crystalloid (EC) or12 l of glucose (IV + EC + IC) Distribution volumes of fluids! Speed of looses Replace what is lost Volume vs haemoglobin Oral/GI route has preference!!!

  17. Guidelines for transfusion of red cellsAAGBI 2001 • Normally patients should not be not transfused if the haemoglobin concentration is >100 g/l. • A strong indication for transfusion is a haemoglobin concentration <70 g/l. • Transfusion will become essential when the haemoglobin concentration decreases to 50 g/l. • A haemoglobin concentration between 80 and 100 g/l is a safe level even for those patients with significant cardiorespiratory disease. • Symptomatic patients should be transfused

  18. Transfusion trigger • HB (g/L) Clinical situation • 100 Acute coronary syndrome • 90 Stabile heart failure • 80 Aged, vascular surgery, sepsis • 70 All other patients

  19. Blood transfusions • In the meantime –complex decision; prudent and conservative management, based on: - awareness of risks - individual haemoglobin level (70-100 g/L) - clinical judgement based on the sound understanding of the normaland pathological physiology - normovolaemia • Unit-by-unit basis (1 u ~15 g/l), re-evaluation • Departmental/hospital guidelines; regular audit • Haemovigilance system

  20. Fluid regime • Preoperative deficits • Maintenance fluids • Blood loss • Losses to the third space

  21. Situation • Blood volume: • 70 ml x 80 kg = 5600 ml • Blood loss: • 20% ~ 25-30 g/l = 90 g/l

  22. End

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