Post on 14-Apr-2018
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Maintenance Fluid
Therapy
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RESUSCITATION MAINTENANCE
NUTRITIONCrystalloid
1. Replace acute loss(hemorrhage, GI loss,
3rd
space etc)
1. Replace normal loss(IWL + urine+ faecal)
2. Nutrition support
ELECTROLYTES
FLUID THERAPY
Colloid
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Electrolyte compositionmEq/L ICF ECF
Plasma Interstitial
15 142 144
150 4 4
2 5 2.5
27 3 1.5
1 103 114
10 27 30
100 2 220 1 1
- 5 5
63 16 6
Na+
K+
Ca2+
Mg2+
Cl-
HCO3-
HPO42-
SO4
2-
Organic acid
Protein
142
150
144
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.
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-
Ion Distribution
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Dehydration Hypovolemia
* thirst* urine output
headache nausea
syncope
hypotonicelectrolytes
isotonicelectrolytes
5% DextroseN/2-D5
Ringers acetateRingers lactateNormal saline
.
Deficit
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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), Ringers lactate (RL)
Hypotonic -Fluid has fewer solutes than plasmaWater, 1/2 N/S (0.45% NaCl), and D5W(5% dextrose in water) after the sugar isused up
Hypertonic-Fluid has more solutes than plasma5 % Dextrose in Normal Saline (D5 N/S),3% saline solution, D5 in RL.
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Most Common form of Dehydration
Occurs when fluids and electrolytes are lost ineven amounts
There are no intercellular fluid shifts inisotonic dehydration
Common Causes
diuretic therapyexcessive vomitingexcessive urine losshemorrhagedecreased fluid intake
Isotonic Dehydration
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Hypertonic Dehydration
Second most common type of dehydration.
Occurs when water loss from ECF is greater thansolute loss
hyperventilation, pure water loss with high fevers,and watery diarrhea.
Diabetic Ketoacidosis and Diabetes Insipidus
Iatrogenic Causesprolonged NPO, excessive hypertonic fluids, sodium
bicarbonate, or tube feedings with inadequate water
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Hypotonic Dehydration
Relatively Uncommon - Loss of more solute(usually sodium) than water.
Hypotonic Dehydration causes fluid to shift from theblood stream into the cells, leading to decreasedvascular volume and eventual shock
Seen in Heat Exhaustion
Increased cellular swelling -causes increasedintracrainial pressure - H/A and Confusion.
Seen in Heat Stroke
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increases ECF
ICF ISF Plasma
Replace acute/abnormalloss
Isotonic infusion
800 ml 200 ml
Ringers acetateRingers lactate Normal saline
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increases ICF > ECF
ICF ISF Plasma
Replace Normalloss (IWL + urine)
Hypotonic infusion
5% dextrose
85 ml255 ml660 ml
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Replacement
Maintenance Repair deficit
Fluid Therapy
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BACIC PRINCIPLES
Replace
Maintain
Repair
Abnormal loss: GIT, 3rd space,Ongoing loss, septic andHypovolemic shock
IWL + urine
Acid base, electrolyte imbalances
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FLUID SELECTION
Replace : RA, RL, NS
Maintain: N/2 + D (adult) + K+ 20 mEqN/4 + D (chlldren) + K+ 20 mEq
Repair : NaHCO3 8,4%
KCl 25 mEq/25 ml
NaCl 3%
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Maintenance
IWL + urine
Adults/children : 4:2:1
eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 =100ml/hr
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Requirements
Fever
Restless/delirium Warm ambient temperature
Hyperventilation
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Requirements
Hypothermia
High humidity
Oliguria/anuria
Reduced consciousness
Retention/oedema Increased intracranial pressure
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Rationale of maintenance
solutions Fluid redistribution
Basal requirement of potassium &
sodium
electrolyte concentration ininfusion solutions
Ready for use solutionsminimizes risk of contamination
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Electrolyte solutions
Plasma Isotonicsolutions
Hypotonic solutions
Normalsaline
Ringersacetate/ lactate
KAEN 3B*
290 308 273
278
D5
290278
* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol
Cl-, 20 mmol lactate, 27 g dextrose per L.
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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
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-900 -600 -300 0 +300
K+ deficit (meq) K+ excess (meq)
10 -
-
8 -
-
6 --
4 -
-
2 -
-
-
serum K+
(meq/L)
Relationship between serum K+ serum andTBK at various levels of deficit and excess
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05 10 15 20 25 K+ deficit (%)
5 -
-
4 -
-
3 --
2 -
-
1 -
-
-
serum K+
(meq/L)
Decreased serum K+and deficit of TBK (%)
total body K+ = 50 mEq/kg body weight
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A c i d o s i s A l k a l o s i s
Blood pH 7.2 7.3 7.4 7.5 7.6
5.0 4.5 4.0 3.5 3.0 0 mEq4.5 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
cell DCCECF
3 K+
H+
2 Na+
3 K+
H+
2 Na+
K+
H+
Urine
K+ low urine K+H+ acid urine
3 K+
H+
2 Na+
3 K+
H+
2 Na+
K+
H+ Urine Alkali
K+
H+
Urin
Cell Tubulus distalECF
K+ and acid-base status
Serum K+
K+ depletion
K+
urin tinggi
St d d K+ t ti i i
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Cnc:
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Rate of administration of
Electrolyte & glucoseNa+ 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
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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 lessrisk of contamination
Can be combined with amino acids