FLUID MANAGEMENT AND ACIDOSIS IN CRTICALLY PATIENT.pptx

fluid management

1. FLUID MANAGEMENT AND ACIDOSIS( METABOLIC) PRESENTER MD FAIRULNIZAN NUR YUNALISS EMILIA NUR NAZURAH NUR AZIERA

2. LEARNING OUTCOME Body Fluid Compartments Fluid Requirements Maintenance and Insensible Losses Fluid Deficit Third Space Blood Loss Types of Fluid and Resuscitation Crystalloids Colloids

3. LEARNING OUTCOME Intravenous Access Sites for Line Insertion Advantages and Disadvantages Complication Risks Insertion Techniques

4. The Human Body Water composition 1 – Males 55-60% 2 – Females 50-55% 3 – Infants 75-80%

5. Fluid Requirements for Surgery Calculated per hour during OR: Fluid deficit (NPO for 6+ hours): 4/2/1 Ongoing fluid requirements: 4/2/1 Replacement of blood loss -Crystalloid 3:1, Colloid 1:1 “Third-space” loss 4/6/8 rule: 4 ml/kg/h for minor surgery (hernias, wrist ORIF, breast) 6 for moderate surgery (gyne, ortho, thoracics) 8 for major procedures (major bowel, vascular, trauma)

6. What is osmolarity? What is normal serum osmolarity? 285 mOsm /L

7. Osmolarity Hypertonic: more concentrated than plasma Hypotonic: less concentrated than plasma Isotonic: the same concentration as plasma If you give too much hypotonic fluid, cells can swell and burst If you give too much hypertonic fluid, cells can shrink

8. Types of Fluids Classification: based on their behaviour once given Mostly go to ICF: free water Stay in ECF: crystalloid Stay in plasma: colloid

9. Free Water Dextrose 5% or D5W 10 % or D10W 50% or D50W (low volume packages)

10. CONT.... D5W: most commonly used D10W and D50W usually used for low blood glucose levels, not free water deficit Stats: Dextrose 5gm/dL pH 5.0 Osmolarity 253 IV infusion: little stays intravascular Dextrose is actively transported into cells and water follows it (equilibrium)

11. CONT... Pros: Treats hypoglycemia Often used preop for diabetic patients who are NPO Body needs sugar for long-term NPO Cons: No good for resuscitation Can cause hypo-osmolarity and water intoxication May worsen brain trauma

12. Crystalloids Used for fluid deficit, third space losses, maintenance Equilibrates in ECF (plasma/interstitial) When infused: about 1/3 stays in intravascular space, and after ~ 10 minutes, the other 2/3 has diffused out of the plasma When administering for blood loss, must use 3-5L for every 1L of blood Ex: 3L blood loss = 9-15L of RL!!

13. CONT... Normal Saline Hyperosmolar 308 mosm/l Sodium 154 Chloride 154 Acidic relative to the plasma pH 5.0 Excessive administration results in: Hyperchloremic metabolic acidosis 1000 ml NS – redistributed along [Na] Extracellular - ISF 750 ml, only 250 ml stays intravascular

14. CONT Pros: Good for initial resuscitation Cheap Readily available, multiple sizes Widely used for OR maintenance fluid Compatible with all drugs and blood products Cons: Hyperchloremic, hypernatremic metabolic acidosis (Use 3L or less) Large sodium load Use care with heart failure, renal failure, brain injury, old age

15. CONT... Ringer’s Lactate Osmolality 279 mOsm/L Na+ 130 mmol/L Cl- 110 mmol/L Lactate 27 mmol/L K+ 4 mmol/L Ca++ 3 mmol/L pH 6.5 Closer to physiologic pH and Osmo

16. CONT.... Pros: Good for resuscitation More “physiologic” Contains K Less hyperosmolar than saline No hyperchloremia Cons: More expensive Not compatible with some drugs or blood May worsen brain swelling (not as bad as NS) Use caution with elevated K, renal failure

17. Colloids CC COLLOIDS NS based fluids Contain osmotically active particles Large molecules unable to cross endothelium Provide colloid oncotic pressure Theoretically replenish intravascular volume and stay in this compartment much longer than crystalloids

18. CONT... Pentaspan Normal Saline plus 10 g/100ml pentastarch 250 kDa Protein pH 5.0 High Na load just as with NS Renal excretion 70% cleared in 24 hours in patients with normal GFR Max dose 28 mL/kg over 24 hours (2 L) Voluven Normal Saline plus 6g/100mL hydroxyethyl starch 130 kDa Protein pH 5.0 High Na load just as with NS Renal excretion 70% cleared in 72 hours in patients with normal GFR Max dose 50 mL/kg over 24 hours (3.5L)

19. CONT... Pros: Smaller infused volume Replace blood loss 1:1 Prolonged ↑ Intravasc vol Less edema -Pulmonary, peripheral Cons: No O 2 carrying capacity Expensive Dilutional coagulopathy Leaky capillaries = interstitial edema Increased anaphylactoid reactions

20. CONT... Albumin Human blood product -Purified protein from human blood -Large osmotically active protein increases oncotic pressure -Available as 5% and 25% solutions -Similar risks to other blood products Half-life -1.6 hours in plasma = 8 hours plasma elimination 20 days in the body Increased morbidity compared to other colloids

21. Hypertonic solutions Hypertonic Saline Available as 1.8%, 3%, 7.5%, 10% solutions Increases extracellular osmolality Promotes fluid shift from ICF to ECF Rare indications: Trauma Symptomatic acute hyponatremia (TURP syndrome) Unclear benefits – risk acute hypernatremia

22. Fluid Therapy Objectives Intravenous Access Sites for Line Insertion Advantages and Disadvantages Complication Risks Insertion Techniques

23. Sites for Line Insertion Peripheral Intravenous Access Central Intravenous Access Internal Jugular (IJ) Subclavian Femoral

24. PERIPHERAL LINE Advantages Easy to place Many points of access If unsuccessful, compressible site Fewer complications than central access Large bore access allows rapid infusion of large volumes Disadvantages Vein may be difficult to access Not used for prolonged administration of vasoactive drugs Cannot be placed distal to site of surgery or injury

25. CENTRAL VENOUS Advantages Reliable IV access when peripheral sites not available Long term IV and vasopressor therapy Large volume resuscitation Disadvantages Special equipment required Longer time to place Higher complication rate Need for special skill

26. Complications Mechanical Arterial puncture (femoral > IJ > subclavian) Hematoma (femoral > SC > IJ) Hemothorax (only seen in SC) Pneumothorax (SC >> IJ) Cardiac Tamponade (SC = IJ) Infectious Embolic Wire/catheter embolism

27. Blood Therapy Blood Therapy Objectives Blood Components Blood Transfusion Pros and Cons of Blood Products Indications for Transfusion Acceptable Blood Loss Factors Related to Blood Administration Complications Related to Transfusion Lab and Point of Care Testing Administration Techniques

28. CONT.... Blood Components Blood Transfusion Pros and Cons of Blood Products Indications for Transfusion Acceptable Blood Loss Factors Related to Blood Administration Complications Related to Transfusion Administration Techniques

29. Blood Components Cells: Red blood cells: carry oxygen Platelets: imperative for clotting White blood cells: removed Fluid: Plasma: Fluid with proteins (albumin), clotting factors Proteins: Clotting factors II-XII

30. Blood Transfusion Autologous blood Recovered blood Pooled blood products No “whole blood” anymore RBCs platelets Plasma Cryoprecipitate, factor VII

31. Autologous Blood Pros: Person’s own blood-low risk of transfusion reactions Can donate up to 4 units Whole blood: coagulation factors, etc. Cons: Anemic, heart disease, transmissible diseases not eligible Whole blood only Anemia from donation Expensive

32. Recovered Blood (Cell Saver) Pros: Person’s own RBCs, washed No transfusion reaction Can be used for some Jehovah’s Witnesses Cons: Expensive Surgical contamination Bone Infection Cancer? Not 100% recovery

33. CONT..... When Used? Major vascular procedures Major ortho procedures Major trauma Sometimes used in neurosurgery/backs Scoliosis surgery

34. Packed RBCs Pros: 1 unit =  Hb by 10 g/l Best replacement for excessive blood loss Stays in vascular compartment Mix with saline for faster infusion Cons: Transfusion reactions Expensive Freshness Risk/benefit ratio Cold

35. Frozen Plasma Pros: Contains all coagulation factors (V and VIII unstable) Use for high volume/ongoing transfusion or bleeding with coagulopathy used to be given for elevated INR Cons: Can contain infectious particles Fluid overload

36. Platelets Indications: Acute thrombocytopenia (platelet deficiency) Large volume transfusion + bleeding One unit = increase platelet count by 5-10 Complications: Stored at room temperature High risk of bacterial contamination/sepsis

37. Cryoprecipitate Contains Factor VIII Factor XIII Von Willebrand’s Factor Fibrinogen (Factor II) Indications Coagulopathy in massive bleeding and transfusion Actively bleeding patients with Fibrinogen < 0.8-1.0 g/L VWD or Hemophilia A (Factor 8 deficiency) Only in the absence of specific factor concentrates

38. Indication for Transfusion Blood products administered for dangerous levels of blood loss Normal Hgb 120-150g/L Healthy patients tolerate >70g/L With systemic disease >90g/L Start with PRBCs Historically, transfuse Plts, FP, cryo only when “indicated” low plts, surgical oozing, etc

39. Factors Related to Blood Administration Consent Discuss options early therefore alternatives can be considered Ensure all questions answered Type and scree Witnesses Most will not accept allogenic products Must verify what they will/won’t accept DOCUMENT IT IN THE CHART!

40. Complications of Blood Transfusion Transfusion reactions Clerical error: most common reason Transmission of infectious particles: Viruses Bacteria Volume overload heart failure, pulmonary edema Temperature hypothermia from large amounts of cold blood/fluid Air if given under pressure, risk of air entering circulation (air trapping in lung, heart, brain) Immune suppression non-specific suppression with blood product administration

41. Symptoms of Blood Reactions Pain, rash, hives, edema Fever, chills, nausea, vomiting, SOB BP, HR, O2 sat, mental status changes Pink or brown urine Circulatory collapse Any change in clinical condition after blood transfusion is suspect!! Stop transfusion and treat aggressively!!

42. Complications: What to Do STOP blood product IMMEDIATELY! Notify other OR staff, blood bank. Send blood and samples from patient to lab. O2, drugs as necessary to support vital signs. Fluids, drugs to flush kidneys. Monitor for coagulation problems, treat as necessary.

43. Administering Fluids and Blood Products Ensure at least one functional IV Normal Procedure IV infusion set up Fluid warmer - not necessary, often if >2hr procedure or possibility of blood transfusion Procedure with anticipated transfusion IV Blood set Fluid warmer essential

44. Compatibility Packed RBC Frozen Plasma Cryoprecipitate Platelets

45. ANY QUESTION