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IV FLUID THERAPY. Dr. Ahmed Magdy MD General Surgery. Maintenance fluid requirements. The Holliday- Segard nomogram approximates daily fluid loss, and therefore the daily fluid requirements, as follows: 100 ml/kg for the 1st 10 kg of wt. 50 ml/kg for the 2nd 10 kg of wt.
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IV FLUID THERAPY Dr. Ahmed Magdy MD General Surgery
Maintenance fluid requirements The Holliday-Segard nomogram approximates daily fluid loss, and therefore the daily fluid requirements, as follows: • 100 ml/kg for the 1st 10 kg of wt. • 50 ml/kg for the 2nd 10 kg of wt. • 20 ml/kg for the remaining wt.
Maintenance fluid requirements It is correct to think about fluid requirements on a 24-hour basis, the delivery pumps used in hospitals are designed to be programmed for an hourly infusion rate. The 24-hour number is often divided into approximate hourly rates for convenience, leading to the "4-2-1" formula. • 100 ml/kg/24-hours = 4 ml/kg/hr for the 1st 10 kg • 50 ml/kg/24-hours = 2 ml/kg/hr for the 2nd 10 kg • 20 ml/kg/24-hours = 1 ml/kg/hr for the remainder So, for a 30 kg child, maintenance fluid rate would be: • 40 ml/hr + 20 ml/hr + 10 ml/hr = 70 ml/hr
IV FLUID THERAPY Intravenous ﬂuid therapy in critically ill patients aims to treat hypovolaemia and dehydration, replace lost electrolytes, and act as a vehicle for the excretion of wasteproductsandredundantmetabolites.Noneoftheexistingcrystalloid solutions perfectly suits all of these roles; It is a well-publicized fact that 0.9% saline solution produces a metabolic acidosis when administered in sufficiently large quantities; Alexis Hartmann added lactate to Ringer’s solution in the 1930s, these substances have remained unchanged.
Normal Saline It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration. It contains no antimicrobial agents. The nominal pH is 5.5 (4.5 to 7.0). 0.45% Sodium Chloride Injection, USP contains 4.5 g/L Sodium Chloride (sodium chloride (It contains 77 mEq/L sodium and 77 mEq/L chloride). 0.9% Sodium Chloride Injection, USP contains 9 g/L Sodium Chloride (It contains 154 mEq/L sodium and 154 mEq/L chloride).
Normal Saline DOSAGE AND ADMINISTRATION: Dosage is dependent upon the age, weight and clinical condition of the patient as well as laboratory determinations. SodiumChloride Injection, USP should be used with great care, if at all, in patients with congestive heart failure, severe renal insufficiency, and in clinical states in which there exists edema with sodium retention. Dilutional hyperchloraemic acidosis is a side effect, mainly observed after the administration of large volumes of isotonic saline as a crystalloid.
Lactated Ringer's Injection USP Lactated Ringer's Injection USP is sterile, nonpyrogenic and contains no bacteriostatic or antimicrobial agents. This product is intended for intravenous administration in a single dose container. The formulas of the active ingredients are: Ingredients Molecular Formula Molecular Weight Sodium Chloride USP NaCl 58.44 Sodium Lactate CH3CH(OH)COONa 112.06 Potassium Chloride USP KCl 74.55 Calcium Chloride Dihydrate USP CaCl2•2H2O 147.02
Lactated Ringer's Injection USP Sodium, the major cation of the extracellular fluid, functions primarily in the control of water distribution, fluid balance, and osmotic pressure of body fluids. Sodium is also associated with chloride and bicarbonate in the regulation of the acid-base equilibrium of body fluid. Potassium, the principal cation of intracellular fluid, participates in carbohydrate utilization and protein synthesis, and is critical in the regulation of nerve conduction and muscle contraction, particularly in the heart. Chloride, the major extracellular anion, closely follows the metabolism of sodium, and changes in the acid-base balance of the body are reflected by changes in the chloride concentration. Calcium, an important cation, provides the framework of bones and teeth in the form of calcium phosphate and calcium carbonate. In the ionized form, calcium is essential for the functional mechanism of the clotting of blood, normal cardiac function, and regulation of neuromuscular irritability. Sodium lactate is a racemic salt containing both the levo form, which is oxidized by the liver to bicarbonate, and the dextro form, which is converted to glycogen. Lactate is slowly metabolized to carbon dioxide and water, accepting one hydrogen ion and resulting in the formation of bicarbonate for the lactate consumed. These reactions depend on oxidative cellular activity.
Hartmann's IV Infusion Ingredients: Compound Sodium Lactate (Hartmann’s) contains sodium lactate (3.17g/L), sodium chloride (6.0g/L), potassium chloride (400 mg/L) and calcium chloride dihydrate (270mg/L) in water for injections.
What is the purpose of a saline IV solution containing dextrose? To add on, D5NS (Dextrose 5% in normal saline) is hypertonic, meaning it has a higher solute concentration than tissues, so it can be used to help draw fluids out of oedematous (fluid-swollen) tissues.Lactated Ringer's solution, on the other hand, is isotonic, meaning it will stay in the veins, not move into tissues, but will not draw fluid out of tissues either. It can be used when someone needs to replenish their blood volume really quickly, such as a person who has had a really bad bleed or burn and is headed for shock.Saline on its own is hypotonic (some will say it's isotonic, but actually it's hypo), meaning it has a lower solute concentration than the fluid inside cells. Through osmosis, water (the saline!) will move into the cells to try to equalize the concentration inside and outside body cells... This is great if someone is extremely dehydrated, but baaaad if they're already fluid overloaded (as with oedema)
Prehospital and ED Fluid Resuscitation in Trauma…to give or not to give…
What is the choice? • Crystalloids Colloids • Saline Albumin • Dextrose Gelatines • Hartmann’s Starches
Cell membrane Capillary wall Fluid distribution
“There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death compared to crystalloids in patients with trauma, burns and following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patient types can be justified outside the context of randomised controlled trials”
How much fluid • Trauma: • Restrictive fluid strategy until bleeding controlled. • Sepsis: • Early aggressive fluids to restore perfusion. • Restrict fluids late to avoid oedema.
Which fluid • It probably doesn’t matter! • Avoid dextrose (water) as large volumes will be required, worsening tissue oedema; • If using crystalloid, the patient will require 1.4 times the volume compared to colloid; • Crystalloid may be better in trauma; • Colloid (or possibly starches) may be better in critically ill / sepsis (Caution: anaphylaxis, coagulation disorders, Risk of renal impairment, and pruritis)