Aspect to Consider in Fluid Therapy

Fluid Therapy

Resuscitation Maintenance fluid therapy Nutrition

Resuscitation
In Shock every stage of shock Dehydration Bleeding Burn Leakage syndrome hypovolemia

40

30

20

Third Space

10

Adolph H. Giesecke, Lawrence D. Egbert

IntraCellular Fluid

InterStitial Fluid

Plasma Volume

Class I Blood loss Blood loss ( % EBV) Pulse rate Blood pressure Pulse pressure Respiratory rate Urine output CNS/ mental status Up to 750 Up to 15% <100 Normal Normal or decrease 14-20 >30
Slightly anxious

Class II 750-1500 15-30% >100 Normal Decrease 20-30 20-30

Mildly anxious

Class III 1500-2000 30-40% >120 Decrease Decrease 30-35 5-15

Anxious and confused

Class IV >2000 >40% >140 Decrease Decrease >35 No UO

Confused and lethargic

Fluid replacement

crystalloid

crystalloid

Crystalloid/ colloid

Crystallloid/ colloid

Estimated Blood Volume

Age Neonate Premature Full-term Infant Adult Male Female Blood Volume
85-90/kgBW 85 ml/KgBW 80 ml/KgBW

75 ml/KgBW 65 ml/KgBW

DO2 = Cardiac Output x CaO2 ( arterial O2 content )

(Hb x SpO2 x1,34 )+ ( 0,003 x PaO2)

Stroke Vol x HR

Volume x contractility

Duration of fluid intravascular

Type of fluid Albumin 5% HES ( Hydroxy Ethyl Starch) Gelatin ( haemacel, gelofusin) Dextran Crystalloid Duration in intravascular 2-3 hour 4-5 hour 1.5 2 hour 1.5 2 hour 15 20 minute

Colloids are superior to cristalloids at attaining resuscitation hemodynamic endpoint,

What are the stakes?

Risks of inadequate resuscitation

Risks of excessive resuscitation
Life-threatening Nonfatal Life-threatening Nonfatal

Life-Threatening Consequences of Inadequate Resuscitation Lactic acidosis Acute renal failure Multisystem organ failure

Maintenance Fluid Support

- Patient fasting with normal body fluid composition - Critically ill patients with altered body fluid composition - Perioperative losses ( Preoperative, during the operation, postoperatively)

Basic Principles of Fluid Maintenance Therapy Replace

Abnormal loss: GIT, 3rd space, Ongoing loss, septic and Hypovolemic shock
IWL + urine Acid base, electrolyte imbalances

Maintenance

Repair

Normal Adult Water and Electrolyte Requirement

(electrolyte meq/kgBW/day and water cc/m2)

Component
Na

Minimal needs
0,3

Usual needs
0,7-3,6

K
Ca Mg

0,3 - 0,5
0,2 0,2 - 0,4

0,7 - 2,1
0,4 - 1,1 0,3 - 0,7

Cl
Water

0,3
870

0,7 - 3,6
1500

Substrat nutrisi

Jumlah

Maintenance fluid/electrolyte requirements

Air cc/kgBB/hari
Energi Kcal/kgBB/hari As.Amino/prot Gr/kgBB/hari Na meq/kgBB/hari K meq/kgBB/hari Glukosa : lemak

25 30 (kritis) 30 50
25 30 (kritis) 30 50 1 1,5 1 -2 1 3:1 - 1;1

Composition of Maintenance Fluid Type fluid

Tutofusin OPS

Na Cl
100 50 50 60 90 50 50 50

K
18 20 20 10

Ca
4 -

Mg lactate
6 38/acetate

Sugar
50/sorbitol 100 27 27

KaEn Mg3 KaEn 3B KaEn 3A

20 20 20

RL
KaEn 1B

131

112

4
-

4.5
-

28
-

37.5

38.5 38.5

Electro-neutrality
In aqueous solution the 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+ ) independent variable (SID, ATOT, PaCO2)

Plasma pH or [H+]

2 variable
Independent variable

Dependent variable

pCO2 SID - ATOT

H20 + CO2 H2CO3 H+ + HCO3ATOT A- + AH

pH, CO3-, H-, OH-, A-, AH, HCO3-

(Na++K++Ca+) ( Cl- + lactate )

Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.

STRONG ION DIFFERENCE

Gamblegram
Mg++ Ca++

K+ 4

HCO324
A- 42

SID

Na+ 140

Cl102

KATION

ANION

Weak acid imbalance ( albumin or phosphate )

HCO3

SID

HCO3

SID

K
HCO3 SID

Alb

Alb

Alb

Na

Na

Cl

Acidosis --. Na Hyperprotein / hyperalbumin Cl or phosphate

Alkalosis hypoalbumin/ Cl phosphate

Normal

Acidosis

Alkalosis

Rules of isolated abnormalities in strong ion difference (SID) and total concentration of Weak Acid SID/ATOT SID SID Isolated abnormalities Increase Decrease Result
Metabolic alkalosis Metabolic acidosis

ATOT ATOT

Increase Decrease

Metabolic acidosis Metabolic alkalosis

WATER DEFICIT
Diuretic

Diabetes Insipidus
Evaporasi

Plasma

Plasma

Na+ = 140 mEq/L Cl- = 102 mEq/L SID = 38 mEq/L

1 liter

140/1/2 = 280 mEq/L 102/1/2 = 204 mEq/L SID = 76 mEq/L

liter

SID : 38 76 = alkalosis

Contracted alkalosis

WATER EXCESS

Plasma
1 Liter H2O
140/2 = 70 mEq/L 102/2 = 51 mEq/L SID = 19 mEq/L

Na+ = 140 mEq/L Cl- = 102 mEq/L SID = 38 mEq/L

1 liter

2 liter

SID : 38 19 = Acidosis

Dilutional Acidosis

PLASMA + NaCl 0.9%

Plasma
Na+ = 140 mEq/L Cl- = 102 mEq/L SID = 38 mEq/L

NaCl 0.9%
Na+ = 154 mEq/L Cl- = 154 mEq/L SID = 0 mEq/L

1 liter

1 liter

SID : 38

Hyperchloremic acidosis after NaCl 0.9% infusion

Plasma

Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (102+ 154)/2 mEq/L= 128 mEq/L

SID = 19 mEq/L

2 liter

SID : 19 acidosis

PLASMA + Ringer Lactate solution

Plasma

Ringer laktat
Metabolized rapidly

Na+

= 140 mEq/L Cl- = 102 mEq/L SID= 38 mEq/L

1 liter

Cation+ = 137 mEq/L Cl- = 109 mEq/L Laktat- = 28 mEq/L SID = 0 mEq/L

1 liter

SID : 38

Normal pH after infusion of RINGER LACTATE Solution

Plasma

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

2 liter

SID : 34 more alkalis than after NaCl 0.9% infusion

Fima HES
colloids

HES not an acid

In Ringer Lactate solution
Na+ 138

Plasma

Cl- 125 SID = 13

ICF

ISF

Plasma

PLASMA + FIMA HES

Plasma
Na+ = 140 mEq/L Cl- = 102 mEq/L SID = 38 mEq/L

FIMA HES
Na+ = 138mEq/L Cl- = 125mEq/L SID = 13 mEq/L HES neutral

1 liter

1 liter

SID : (38+13)/2 = 26

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