الدقافFluid therapy (1).pptxddhjdrrjjjrjjjr

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1. بسم الله الرحمن الرحيم

2. Fluid therapy Presented by Dr. Mohammed Aldakaf Surgical Oncologist Taiz University

3. Introduction Water Water is the body's primary fluid and is essential for proper organ system functioning and survival . Food versus water ??

4. Water has many functions in the body! Essential for Cell life . Regulate the Body temperature . Interfere in the Chemical and metabolic reactions . Nutrient absorption and transport . Elimination of waste products through urine .

5. How much of u is wate r? Body muscle mass is rich in water, while Adipose Tissue has a lower percentage of water content. That’s why : Overweight or obese people compared to someone who's lean and muscular have a lower percentage of water compared to someone who's lean and muscular. Women Older people Children

6. 15oo mL: Water drink 800 mL: Water content in food 3oo mL : Water from oxidation TOTAL: 2600mL 1500 mL: Urine 5oo mL: Skin 4oo mL: Respiratory tract 2oo mL: Stool TOTAL: 26oo mL Minimal Obligatory Daily input (ml/day): Minimal Obligatory Daily water output ( ml/day):

7. ( On average, an adult input and output is 30- 35mL/kg/day (about 2. 4L/day) Water requirements increase with: Fever, Sweating and tachypnea. Burns . Surgical drains. Urinary losses. Gastrointestinal losses through vomiting and diarrhea.

8. Intense thirst and weakness. Decrease tissue turgor. Oliguria and increase specific gravity of urine. Increase urine volume and body weight. Decrease serum Na concentration and hematocrit. GIT CNS Water depletion ( dehydration) Water excess ( intoxication )

9. Replaces the deficient by equal volume of sodium free water ( by assuming that each 3 m Eq elevation of serum Na concentration above normal range = ?? ). Deficient can be replace by glucose 5% for that glucose make the solution isotonic to ECF Mild : only restrict water in take. Sever : ?? Renal failure: ??

10. What are solute A substance dissolved in another substance ( a  solvent ), and together they form a  solution. There are three types of solutions that can occur in your body based on solute concentration ( isotonic , hypotonic, and hypertonic ) . An isotonic solution is : A hypotonic solution is : A hypertonic solution is :

11. Types of fluid – Blood component therapy The fluids used in clinical practice are usefully classified into: Crystalloids. Colloids . Blood products.

12. Fluid therapy Importance ! Loss of body water, whether acute or chronic, can cause a range of problems from mild headache to convulsions, coma, and in some cases, death Can be life-saving in certain conditions. Though fluid therapy can be a lifesaver, it's never always safe , and can be very harmful .

13. I. Crystalloids Solutions Solutions that contain small molecules that flow easily across the cell membranes, allowing for transfer from the bloodstream into the cells and body tissues. This will increase fluid volume in both the interstitial and intravascular spaces ( Extracellular ). It is subdivided into: Isotonic. Hypotonic. Hypertonic.

14. Sodium is the principle component of crystalloid solutions, and the most abundant solute in the extracellular fluid . Three types: 1-Hypotonic solutions . 2. Isotonic solutions. 3. Hypertonic solutions.

15. Hypertonic Isotonic Hypotonic Include: (7.5% NaCl ; 1283 mEq Na, 1283 mEq Cl ). Include: Normal saline (0.9% NaCl ; 154 mEq Na and 154 mEq Cl ) lactated Ringers (130meq Na, 109 mEq Cl , 4 mEq K, 3 mEq Ca , lactate as a buffer). Include: 0.45% Normal saline. 0.25% Normal saline. Used to: Treat symptomatic hyponatremia. Replacement must be done slowly to prevent central pontine myelinolysis. Used as: Maintenance fluids in adults (0.45% NS) and infants (0.25% NS).

16. Criteria of the ideal post operative fluid: NIC When to consider a solution isotonic ?

17. Types of isotonic solutions 0.9 % sodium chloride (0.9% NaCI ). lactated Ringer's solution. Ringer's solution. 5% dextrose in water (D5W).

18. A. 0,9 sodium chloride (Normal Saline) Simply salt water that contain only water, sodium (154mEq/L) and chloride ( 154mEq/L). Why called “Normal Saline Solution” ?

19. When to be given? 1. Treat low extracellular fluid , as in fluid volume deficit from: Hemorrhage and shock. Severe vomiting or diarrhea. (Heavy drainage from Gl suction and Fistulas ). RL?? 2. It is the fluid of choice for resuscitation efforts . 3. Mild hyponatremia. 4. Metabolic acidosis (such as diabetic ketoacidosis ). 5. It is the only fluid used with administration of blood products.

20. Take care: Because 0.9% Sodium-chloride replaces extracellular fluid , it should be used cautiously in certain patients (those with cardiac or renal disease) for fear of fluid volume overload ).

21. B. Ringer’s lactate or Hartmann solution Is the most physiologically adaptable fluid ? Why? LR is metabolized in the liver, which converts the lactate to bicarbonate.

22. When to be used? Another choice for first-line fluid resuscitation for certain patients, such as those with burn injuries . To replace GI tract fluid losses ( Diarrhea or vomiting) and fistula drainage. Fluid losses due to burns and trauma. Patients experiencing acute blood loss or hypovolemia due to third-space fluid shifts . Notice . Both 0.9% sodium chloride and LR may be used in many clinical situations, but patients requiring electrolyte replacement (such as surgical or burn patients) will benefit more from an infusion of LR.

23. Take care : Don't give LR to patients with liver disease ? Why? Used cautiously in patients with sever renal impairment ? Why? LR is often administered to patients who have metabolic acidosis not patients with lactic acidosis. LR shouldn't be given to a patient whose pH is greater than 7.5.

24. C -Ringer's solution . Like.LR contains sodium , potassium, calcium and chloride in similar. But it doesn't contain lactate . Ringer's solution is used in a similar fashion as LR, but doesn't have the contraindications related to lactate.

25. D- Dextrose 5% . It is considered an isotonic solution, but when the dextrose is metabolized, the solution actually becomes hypotonic. It provides 170 calories per liter, but it doesn't replace electrolytes. The supplied calories doesn't provide enough nutrition for prolonged use. But still can be added to provide some calories while the patient is NPO.

26. Take Care ! Not used for resuscitation ? why? Never mix dextrose with blood ? Why? D5W shouldn't be used in isolation to treat fluid volume deficit ? why? Not used in the early postoperative period? Why?

27. D5W is not good for patients with renal failure or cardiac problems since it could cause fluid overload . Patients at risk for intracranial pressure should not receive D5W since it could increase cerebral edema. D5W shouldn't be used in isolation to treat fluid volume deficit because it dilutes plasma electrolyte concentrations.

28. Precautions in usage of lsotonic solutions Be aware that patients being treated for hypovolemia can quickly develop hypervolemia (fluid volume overload) following rapid or over infusion of isotonic fluid. Document base line vital signs, edema status, lung sounds, and heart sounds before beginning the infusion , and continue monitoring during and after the infusion.

29. Frequently assess the patient's response to I.V. therapy, monitoring for signs and symptoms of hypervolemia such as: Hypertension . Bounding pulse . Pulmonary crackles . Peripheral edema . Dyspnea ( shortness of breath). Jugular Venus distention. Monitor intake and output. Elevate the head of bed at 35 to 45 degrees, unless contraindicated . If edema is present, elevate the patient's legs.

30. Modes of administration. Peripheral lV: line placed into a peripheral vein. ( PlCC, peripheral inserted central catheter ): Central line that is placed via the peripheral vasculature . Its tip terminates in the superior vena cava. Hickman lines: Skin tunneled cuffed central catheter.

31. How to calculate IV flow rates ! Intravenous fluid must be given at a specific rate , neither too fast nor too slow. The specific rate may be measured as ml/hour, L/hour or drops/min . To control or adjust the flow rate only drops per minute are used.

32. What is a drop factor? Drop factor is the number of drops in one milliliter used in IV fluid administration ( also called drip factor ). A number of different drop factors are available but the Commonest are : 1-10 drops/ml (blood set) 2- 15 drops / ml (regular set) 3- 60 drops / ml (microdrop, burette)

33. II . Colloid solutions. Solutions that contain large molecules that don't pass the cell membranes . When infused, they remain in the intravascular compartment and expand the intravascular volume and they draw fluid from extravascular spaces via their high oncotic pressure ( colloid osmotic pressure ). Is indicated for volume expansion.

34. Three types: 1-Albumin (5% or 25 %). 2-Purified protein fraction (Plasmanate). 3-Hetastarch (Hespan).

35. Hetastarch ( Hespan ). Purified protein fraction ( Plasmanate ) Albumin Consists of synthetic colloid (6% hetastarch in saline). Maximum dose is 1500 cc per 24 hours, and may prolong the partial thromboplastin time. Consists of 83% albumin and 17% globulin. (5% or 25%) It is useful for volume expansion and raising osmotic pressure. It is indicated for volume expansion as an alternative to albumin. Is useful for hypovolemia or to induce diuresis with furosemide in hypervolemic , hypoproteinemic patients. Salt poor albumin is used in cirrhosis.

36. III. Blood component products. 1-Packed red blood cells (PRBCs). Each unit provides 400 cc of volume, and each unit should raise hemoglobin by 1 gm./ dL and hematocrit by 3%. 2- Autologous blood. The patient donates blood within 35 days of surgery; frozen blood can be stored for up to 2 years. Autologous blood is useful in elective orthopedic, cardiac, and peripheral vascular procedures.

37. 3-Platelets. Indicated for bleeding due to thrombocytopenia or thrombopathy. ABO typing is not necessary before platelets are given. Platelets are usually transfused 8-10 units at a time, and each unit should raise the platelet count by 5,000-10,000 cells/ mul . Dilutional thrombocytopenia occurs after massive blood transfusions. Therefore, platelet transfusion should be considered after 8-10 units of blood replacement .

38. 4-Fr esh frozen plasma (FFP). Is indicated for bleeding secondary to liver disease , coagulation factor deficiencies dilutional coagulopathy (from multiple blood transfusions ). ABO typing is required before administration of FFP, but cross matching is not required. Improvement of INR/PTT usually requires 2-3 units. One unit of FFP should be administered for every 4-6 units of PRBCs . FFP contains all clotting factors except factors V and VII .

39. 5-Cryoprecipitate. Contains factor VIII, and fibrinogen, necessary for massive transfusions. It is given 8-10 units at a time.

40. Indication of blood therapy Major surgical procedure. Hb less than ? gm % ( normal ? %). Acute blood loose less than 40% . Anticipation of ongoing blood loos more than 100 ml / min. Medical status ( if the patient has symptoms of anemia, such as chest pain, dyspnea, mental status).

41. Classical fluid management Maintenance. Deficits. 3 rd Space. Blood loss.

42. Principle of fluid therapy Principle of fluid therapy in any patient, (the standard principles of fluid balance in the postoperative patient are ): T o correct any pre-existing deficit ( dehydration or electrolyte imbalance). To supply basal needs ( requirement ). To replace unusual losses (e.g. from the pre- existing surgical problem, fistula, vomiting, surgical drains, pyrexia or third space like peritonitis). To use the oral route where possible ( there is often an unnecessary delay in commencing oral intake after surgery).

43. I. Maintenance fluid guidelines. Insensible losses such as evaporation of water from respiratory tract, sweat, feces, urinary excretion. Occurs continually. Adults : approximately 1.5 ml/kg/hr. “4-2-1 Rule” - 4 ml/kg/hr. for the first 10 kg of body weight - 2 ml/kg/hr. for the second 10 kg body weight - 1 ml/kg/hr. subsequent kg body weight - Extra fluid for fever, tracheotomy, denuded surfaces. A 70 Kg patient has a maintenance fluid requirement of approximately 125 mL/hr.

44. Basal requirement in the post operative patients ( The basal requirements for young adults are approximately): 30 ml/kg/ day of water. 1.0-1.4 mmol/kg/ day of sodium. 0.7-0.9 mmol/kg/ day of potassium.

45. Specific replacement fluids of specific losses: Gastric fluid (nasogastric tube, emesis). D5 1/2 NS with 20 mEq/liter KCL; replace equal volume of lost fluid q6h. Diarrhea . D5LR with 15 mEq/liter KCL. Provide 1 liter replacement for each 1 kg or 2.2 lb of lost body weight; bicarbonate 45 mEq (1/2 amp) per liter may be added. Bile . D5LR with 25 mEq/liter (1/2 amp) of bicarbonate. Pancreatic . D5LR with 50 mEq /liter (1 amp) bicarbonate.

46. II. Nothing per oral and other deficit. Nothing per oral deficit ( NPO) = number of hours nothing per oral x maintenance fluid requirement . Bowel preparation. may result in up to 1 L fluid loss . ? cc of fluid for each 1c rise in temperature.

47. III. Third space losses. Surgery d epends on :- 1- Location and duration of surgical procedure. 2- Amount of tissue trauma. 3- Ambient temperature and room ventilation . Superficial Surgical Trauma : 1-2 ml/kg/hr. Minimal Surgical Trauma: 3-4 ml/kg/hr. Moderate Surgical Trauma: 5-6 ml/kg/hr . Severe Surgical Trauma : 8-10 ml/kg/hr. (or more ).

48. -: Other Factors Other factors. Ongoing fluid losses from other sites: Gastric drainage. stoma output. Diarrhea. Vomiting. Replace volume per volume with crystalloid solutions.

49. IV. Blood loose Replace 3 cc of crystalloid solution per cc of blood loss (crystalloid solutions leave the intravascular space ). When using blood products or colloids replace blood loss volume per volume.