Lecture_Intravenous_fluid_therapy_ICU.pptx

Presentation for a lecture on Intravenous_fluid_therapy_in ICU

1. Intravenous fluid therapy Anesthesiology , Reanimatology & Intensive care Faculty with Ambulance/Paramed course. TSMU of RF Health ministry

2. History of Fluid Resuscitation The physiology of fluid balance in health Alexis  Frank Hartmann , Sr.   was an American  pediatrician  and  clinical biochemist . He is best known for adding  sodium lactate  to  Ringer's solution , creating what is now known as  Ringer's lactate solution  or  Hartmann's solution  for intravenous infusions. Sydney Ringer   FRS  (March 1835 – 14 October 1910) was a British clinician, physiologist and pharmacologist, best known for inventing  Ringer's solution asanguineous – not containing blood -

3. Body Fluids The physiology of fluid balance in health

4. Fluid therapy Tonicity

5. Fluid therapy Types of Tonicity in Solution

6. Body Fluids Diagrammatic representation of major body fluid volumes and relationships in a standard 70-kg human body. Total body water = 23 + 13.5 + 3 + 2 + 0.5 = 42 Liters. The physiology of fluid balance in health

7. Body Fluids Intracellular solutions extracellular fluid (ECF), intracellular fluid (ICF)

8. Body Fluids INTERSTITIAL SOLUTIONS (TISSUE FLUIDS)

9. Body Fluids Blood plasma blood volume = 5-7% of body weight, approx. 4 – 5L

10. Fluid Balance Flux of fluid across the gastrointestinal tract

11. Fluid Balance Intake Approximate daily water balance in health Average daily intake

12. Fluid Balance Fluid input and output

13. Fluid therapy Ongoing losses diagram

14. Body Fluids Transcapillary escape of albumin

15. Body Fluids Transcapillary escape of albumin

16. Fluid therapy The Physiology of Fluid Resuscitation

17. Fluid therapy The Physiology of Fluid Resuscitation The structure and function of the endothelial glycocalyx layer, a web of membrane-bound glycoproteins and proteoglycans on endothelial cells, are key determinants of membrane permeability in various vascular organ systems. Panel A shows a healthy endothelial glycocalyx layer. Panel B shows a damaged endothelial glycocalyx layer and resultant effect on permeability, including the development of interstitial edema in some patients, particularly those with inflammatory conditions (e.g., sepsis)

18. COLLOID & CRYSTALLOID RESUSCITATION Fluid therapy Illustration depicting the different tendencies of colloid and crystalloid fluids to expand the plasma volume and the interstitial fluid volume.

19. CRYSTALLOID FLUIDS Fluid therapy The predominant effect of crystalloid fluids is to expand the interstitial volume, not the plasma volume

20. Fluid therapy Comparison of Plasma and Crystalloid Resuscitation Fluids ξ Concentration of ionized calcium in mg/ dL . Normal Saline is Not Normal

21. Fluid therapy Isotonic Saline The effects of selected colloid and crystalloid fluids on the plasma volume and interstitial fluid volume. The infusion volume of each fluid is shown in parentheses .

22. Fluid therapy Ringer’s Fluids The principal advantage of Ringer’s lactate and Ringer’s acetate over isotonic saline (0.9% NaCL ) is the lack of a significant effect on acid-base balance. The principal disadvantage of Ringer’s solutions is the calcium content; i.e., the ionized calcium in Ringer’s solutions can bind to the citrated anticoagulant in stored RBCs and promote clot formation.

23. Fluid therapy Hypertonic Saline

24. Fluid therapy 5% DEXTROSE SOLUTIONS Volume Effects Enhanced Lactate Production Hyperglycemia Protein-Sparing Effect

25. Fluid therapy 5% DEXTROSE SOLUTIONS Volume Effects Enhanced Lactate Production Hyperglycemia Protein-Sparing Effect The effect of intravenous fluid therapy with and without dextrose on blood lactate levels in patients undergoing abdominal aortic aneurysm repair. Each point represents the mean lactate level in 10 study patients.

26. Fluid therapy 5% DEXTROSE SOLUTIONS Volume Effects Enhanced Lactate Production Hyperglycemia Protein-Sparing Effect

27. Fluid therapy COLLOID FLUIDS

28. Fluid therapy COLLOID FLUIDS

29. Fluid therapy COLLOID FLUIDS Characteristics of Individual Colloid Fluids

30. Fluid therapy Characteristics of Hydroxyethyl starch Preparations COLLOID FLUIDS

31. Fluid therapy COLLOID FLUIDS Altered Hemostasis Nephrotoxicity Hyperamylasemia

32. Fluid therapy The Ideal Resuscitation Fluid

33. Fluid therapy Colloid–Crystalloid conundrum

34. Fluid therapy Colloid–Crystalloid conundrum Volume of infusion required to expand the plasma volume by 1 L

35. Fluid therapy Prescription and Administration Does the patient need any prescription at all today? If so, does the patient need this for resuscitation, replacement of losses, or merely for maintenance?

36. Fluid therapy 3. What is the patient’s current fluid and electrolyte status and what is the best estimate of any current abnormality 4. Which is the simplest, safest, and most effective route of administration? 5. What is the most appropriate fluid to use and how is that fluid distributed in the body? Prescription and Administration

37. Fluid therapy The four D`s of fluid management Drug Dosing Duration De‑escalation

38. Fluid therapy

39. Fluid therapy The 4 phases of fluid therapy and the R.O.S.E. or S.O.S.D. concept

40. Fluid therapy R.O.S.E. or S.O.S.D. concept Resuscitation phase (R) or salvage phase (S)

41. Fluid therapy R.O.S.E. or S.O.S.D. concept Optimization phase (O) The TROL mnemonic of fluid challenge: considerations for administration of a fluid bolus in critically ill patients. CO cardiac output; CVP central venous pressure; EVLWI extra vascular lung water index; PVPI pulmonary vascular permeability index (Adapted from Vincent and Weil)

42. Fluid therapy R.O.S.E. or S.O.S.D. concept Stabilization phase (S)

43. Fluid therapy R.O.S.E. or S.O.S.D. concept Evacuation phase (E) or de‑escalation phase (D)

44. Fluid therapy Recommendations for Fluid Resuscitation in Acutely Ill Patients. Fluids should be administered with the same caution that is used with any intravenous drug. Fluid resuscitation is a component of a complex physiological process Consider the type, dose, indications, contraindications, potential for toxicity, and cost. Identify the fluid that is most likely to be lost and replace the fluid lost in equivalent volumes. Consider serum sodium, osmolarity , and acid–base status when selecting a resuscitation fluid. Consider cumulative fluid balance and actual body weight when selecting the dose of resuscitation fluid. Consider the early use of catecholamines as concomitant treatment of shock Fluid requirements change over time in critically ill patients. Specific considerations apply to different categories of patients. Bleeding patients require control of hemorrhage and transfusion with red cells and blood components as indicated. Isotonic, balanced salt solutions are a pragmatic initial resuscitation fluid for the majority of acutely ill patients. Consider saline in patients with hypovolemia and alkalosis. Consider albumin during the early resuscitation of patients with severe sepsis. Saline or isotonic crystalloids are indicated in patients with traumatic brain injury