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Maintenance Fluid Therapy

Maintenance Fluid Therapy. Iyan Darmawan, MD Medical Department Otsuka, Indonesia. FLUID THERAPY. RESUSCITATION. MAINTENANCE. Colloid . Crystalloid. ELECTROLYTES. NUTRITION. 1. Replace acute loss (hemorrhage, GI loss, 3 rd space etc). 1. Replace normal loss

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Maintenance Fluid Therapy

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  1. Maintenance Fluid Therapy Iyan Darmawan, MD Medical Department Otsuka, Indonesia

  2. FLUID THERAPY RESUSCITATION MAINTENANCE Colloid Crystalloid ELECTROLYTES NUTRITION 1. Replace acute loss (hemorrhage, GI loss, 3rd space etc) 1. Replace normal loss (IWL + urine+ faecal) 2. Nutrition support

  3. Electrolyte composition 144 142 Na+ 150 K+ Ca2+ Mg2+ Cl- HCO3- HPO42- SO42- Organic acid Protein

  4. . Ion Distribution 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-

  5. Deficit . Dehydration Hypovolemia • headache • nausea • syncope * thirst * urine output  hypotonic electrolytes isotonic electrolytes 5% Dextrose N/2-D5 Ringer’s acetate Ringer’s lactate Normal saline

  6. Fluids can be described as being from three categories . 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 is used up Hypertonic-Fluid has more solutes than plasma 5 % Dextrose in Normal Saline (D5 N/S), 3% saline solution, D5 in RL.

  7. Isotonic Dehydration 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

  8. 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, or tube feedings with inadequate water

  9. Hypotonic Dehydration Relatively Uncommon - Loss of more solute (usually sodium) than water. Hypotonic Dehydration causes fluid to shift from the blood stream into the cells, leading to decreased vascular volume and eventual shock Seen in Heat Exhaustion Increased cellular swelling -causes increased intracrainial pressure - H/A and Confusion. Seen in Heat Stroke

  10. Isotonic infusion • Ringer’s acetate • Ringer’s lactate • Normal saline Replace acute/ abnormal loss increases ECF ICF ISF Plasma 800 ml 200 ml

  11. Hypotonic infusion • 5% dextrose Replace Normal loss (IWL + urine) increases ICF > ECF ICF ISF Plasma 660 ml 255 ml 85 ml

  12. Fluid Therapy • Replacement • Maintenance • Repair deficit

  13. BACIC PRINCIPLES Abnormal loss: GIT, 3rd space, Ongoing loss, septic and Hypovolemic shock Replace Maintain IWL + urine Acid base, electrolyte imbalances Repair

  14. FLUID SELECTION • Replace : RA, RL, NS • Maintain: N/2 + D (adult) + K+ 20 mEq N/4 + D (chlldren) + K+ 20 mEq • Repair : NaHCO3 8,4% KCl 25 mEq/25 ml NaCl 3%

  15. Maintenance • IWL + urine • Adults/children : 4:2:1 eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 = 100ml/hr

  16. Requirements • Fever • Restless/delirium • Warm ambient temperature • Hyperventilation

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

  18. Rationale of maintenance solutions • Fluid redistribution • Basal requirement of potassium & sodium • electrolyte concentration in infusion solutions • ‘Ready for use’ solutions minimizes risk of contamination

  19. Electrolyte solutions Isotonic solutions Hypotonic solutions Plasma 308 273 278 290 290 278 D5 Normal saline Ringer’s acetate/ lactate KAEN 3B* * KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol Cl-, 20 mmol lactate, 27 g dextrose per L.

  20. 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

  21. 10 - - 8 - - 6 - - 4 - - 2 - - - serum K+ (meq/L) -900 -600 -300 0 +300 K+ deficit (meq) K+ excess (meq) Relationship between serum K+ serum and TBK at various levels of deficit and excess

  22. 5 - - 4 - - 3 - - 2 - - 1 - - - serum K+ (meq/L) 05 10 15 20 25 K+ deficit (%) Decreased serum K+ and deficit of TBK (%) total body K+ = 50 mEq/kg body weight

  23. A c i d o s i s + + 3 K 3 K + + 3 K 3 K + + H H + + H H + + 2 Na 2 Na + + 2 Na 2 Na + H  Urine Alkali + H  acid urine + K  + K  low urine K+ K+ and acid-base status K+ depletion Blood pH 7.2 7.3 7.4 7.5 7.6 5.0 4.5 4.0 3.5 3.0 0 mEq Serum K+ 4.5 4.0 3.5 3.0 2.5 100 mEq 4.0 3.5 3.0 2.5 2.0 200 mEq 3.2 3.0 2.5 2.0 1.5 400 mEq A l k a l o s i s Cell cell ECF ECF Tubulus distal DCC + H + K + K + H Urine Urin K+ urin tinggi

  24. Standard K+ concentration in i.v. solutions Cnc: <40 mEq/L 1 < 40mEq/L Rate of adm: <20 mEq/hr 2 KCl daily dosage : <100 mEq/day 3 Monitor ECG and serum K+ 4 U r i n e output: >0.5 ml/kg/hr 5 × KCl bolus

  25. Rate of administration of Electrolyte & glucose Na+ 100 mEq/hr K+ 20 mEq/hr Ca++ 20 mEq/hr Mg++ 20 mEq/hr HCO3-100mEq/hr Glucosa 0,5 gr/kg/hr ( 4 mg/kg/min)* * Neonates 6-8 mg/kg/min

  26. 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

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