Aspect to Consider in Fluid Therapy.ppt

8/14/2019 Aspect to Consider in Fluid Therapy.ppt

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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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Aspect to Consider in Fluid Therapy.ppt

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