Fluid Therapy Related terms: Resuscitation, Glucose, ‘Anesthesia, Dehydration, 1, Electrolyte, Sodium Chloride, Drinking Water, Fluid therapy must be carefully balanced to correct the electrolyte and acid base imbalance and to keep the urine output adequate. From: Clinical Cases in Tropical Medicine, 2015 View all Topics > ww, Download as PDF JX Set alert @ About this p: Body Fluid Compartments in the Fetus and Newborn Infant with Growth Aberration Karl Bauer MD, in Nephrology and FluidjElectrolyte Physiology: Neonatology Questions and Controversies, 2008 FLUID THERAPY IN SGA PRETERM NEONATES IN THE IMMEDIATE POSTNATAL PERIOD Fluid therapy in the immediate neonatal period in AGA preterm neonates has the following objectives: iit allows for the physiologic postnatal contraction of the extracellular volume to occur, i itaims at a postnatal weight loss of about 10% of body weight, (ji) it aims at a negative fluid and sodium balance on days 1-3 of life, and (iv)it minimizes transepidermal water loss (47), This can be achieved with a restricted water intake, which reduces the risk of PDA, NEC and death (48) There is also suggestive evidence that sodium restriction during the first week of life, to producea negative sodium balance, can achieve the same goals as fluid restriction (49,50). Unfortunately there are no systematic clinical trials about fluid therapy for SGA neonates. From the body water measurements we know that despite their ‘wrinkled’ appearance, SGA neonates are not dehydrated at birth. Severely growth restricted neonates rather have an expanded extracellular volume. The only study providing data on fluid therapy in the immediate neonatal period reports an attenuated postnatal weight loss in SGA preterm infants receiving the same amount of fluid intake as weight-matched AGA preterm infants (44). This study suggests that SGA preterm neonates do not need extra fluid intake in the immediate neonatal period but rather a cautious approach to fluid prescription. The need to provide a continuous infusion of glucose to treat and prevent hypoglycemia is the only condition necessitating earlier or additional fluid intake in SGA neonates (51). Clinical Techniques used for Nonhuman PrimatesRoman F. Wolf, Gary L. White, in Nonhuman Primates in Biomedical Research (Second Edition), 2012 Fluid and Electrolyte Administration Fluid therapy is indicated in nonhuman primates with 27% or greater dehydration. The common routes of| administration include: intravenous, subcutaneous, intraperitoneal, and oral. Intravenous administration of fluids is typically the method of choice for fluid therapy. Venepuncture is described above. One can either utilizea hypodermic needle or a vascular catheter for access to the vein. The needle or catheter is then attached to the fluid administration set for administration of fluids. The amount of fluid needed for replacement depends on the patient's status. Of primary concern is the status of the blood volume and later concern is directed to restoration of total body water and electrolytes. Subcutaneous fluids are given for mild dehydration and typically utilized when the intravenous route is not an option. When administrating fluids subcutaneously, isotonic fluids should be used and no more than 5-10 mifkg should be given at each injection site. The rate of subcutaneous fluid flow is governed by patient comfort. These fluids are aseptically administered and multiple sites are required to provide adequate fluid volume. Generally, all subcutaneous fluids are reabsorbed within 6-8 hours. If fluids are still noted subcutaneously after this time, the use of intravenous fluids to reestablish peripheral perfusion should be considered. Intraperitoneal administration of fluids is quick, easy and the fluids will generally be absorbed quickly, increasing the circulating volume. The potential of bacterial peritonitis, perforating viscera and decreasing ventilation from impeding diaphragmatic excursion are concerns that must be considered. The size of hypodermic needle is selected in relation to the size of the nonhuman primate. Oral administration of fluids is often utilized by placing either a nasogastric tube or gastric tube in the stomach of the nonhuman primate (described previously in this chapter). Factors to consider for oral administration of fluids include: the clinical condition of the nonhuman primate, the time required to administer the oral fluids, and the available technical assistance. oc | eee Cholera Infections Myron M. Levine, .. Samba O. Sow, in Tropical Infectious Diseases (Third Edition), 2011 Fluid Therapy Fluid therapy is divided into two phases: (1) rapid replacement of water and electrolyte deficits, known as rehydration phase; and (2) maintenance phase to infuse fluids to replace ongoing losses. Fluid and electrolyte deficits should be replenished as rapidly as possible (within 2~4 hours of initiation), Patients suffering from severe dehydration with or without overt shock usually lose 10% of their body weight and must be rapidly rehydrated with intravenous fluids. The time recommended for rehydration in adult and pediatric populations is 3 and 6 hours respectively. In adults 30% of the total required fluid is administered in the first halfan hour, while in children it is 1 hour. Patients with cholera gravis generally require several liters of intravenous fluids to stabilize them to the point where oral rehydration can begin. In adults with cholera gravis, 8-12 liters of intravenous fluids may be required before oral hydration alone can keep up with losses. Cholera patients with mild or moderate dehydration and moderate purge rates (<500 ml/h) can usually be managed with oral rehydration alone. QI [re rcnase bookBody Composition in the Fetus and Newborn William Oh MD, in Nephrology and Fluidjelectrolyte Physiology (Third Edition), 2019 Clinical Implications of Transitional Body Water Changes in Preterm Very Low Birth Weight Infants Fluid therapy in the immediate neonatal period in preterm and low birth weight neonates has the following objectives: It (1) allows for the physiologic postnatal contraction of the extracellular volume to occur, (2) aims ata postnatal weight loss of approximately 109% of body weight, (3) aims ata negative fluid and sodium balance on days 1 0 3 oflfe, and (4) minimizes transepidermal water loss.'° These objectives can be achieved with restricted water intake and sequentially monitoring water and electrolyte balance by using the daily intake, output, weight changes, and serum electrolyte concentrations (particularly sodium) data in adjusting the appropriate amount of intake to achieve these goals. Failure to do so will resultin either dehydration ifinadequate amount of fluid is given or increased risk of patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), and perhaps chronic lung disease ifexcess fluid is given.‘°-** Thereis also suggestive evidence that sodium restriction during the first week of life to produce negative sodium balance can achieve the same goals as fluid restriction.45 The physiologic rationale behind the later is that if sodium intake exceeds the requirement, the sodium retention will resultin water excess producing the same result as in excess water intake with positive water balance. Maintaining negative water and sodium balance during the first week i the key to successful fluid and electrolyte ‘management of VLBW infants and even more so for ELBW infants because the latter are at much higher risk for various clinical morbidities The following case presentation illustrates how a clinician can balance the fluid and electrolyte status of an ELBW infant by paying close attention to daily body weight changes in the process of prescribing the daily fluid and electrolyte. Let us take the case ofa 1.0-kg AGA infant admitted to the neonatal intensive care unit with respiratory distress who was being cared for in a hybrid-humidified incubator (Giraffe OmniBed, GE Healthcare, Pittsburgh, Pennsylvania). The latter is a new high-technology incubator that has been shown to be very effective in maintaining body temperature and fluid balance in VLBW infants.*? The initial fluid order consisted of 70 mL kg of 10% glucose without electrolytes. Although some clinicians may add sodium and potassium during the first 24 hours of ife, ‘most would begin sodium and potassium at 1 to 2 mEq/kg per day on the second day and increase to 3 mEq/kg per day at the end of first week. The initial fluid volume is based on the estimated insensible water loss for this infant of, 50 mLkgand an additional 20 mL kg for estimated water required to excrete approximately 5 mOsm/kg of ‘endogenous solute load. Recent evidence suggests beneficial effects of early initiation of amino acid.## Most clinicians add the protein as early as the first day of life. Soy-based fat emulsion is usually added during the second day of life to provide essential fatty acid and energy, the latter taking advantage of ts high caloric density.4? Table 2.3 illustrates the potential scenario in body weight changes, intake, output data, and estimated insensible water loss, as well as the rationale for the prescribed fluid, electrolyte, and nutrition intake for this infant. The scenario shows that systematic data collection, interpretation, and forward calculation of intake are needed to ensure negative fluid and sodium balance in this infant during the first 72 hours. Note that the ECW contraction generally ceases at day 4 to 6 of life; thus the weight should be unchanged. By day 6 of life, the body weight should begin to increase at 20 to 30 g/kg, which reflects anabolic or the beginning of the growth phase. A useful way of ensuring the appropriate fluid balance is achieved is to plot the weight changes on a daily basis using a standard growth chart, such as the one shown in Fig. 2.3Table 2.3. 0DY WEIGHT CHANGES, INTAKE, OUTPUT, ESTIMATED INSENSIBLE WATER LOSS, AND CALCULATED INTAKE THE NEXT 2¢ Weight Intake Urine Serum(Na Estimated “Fluid Next Sodium Age) (rlfig)——(elfkg)——_m ft) wt 24h (nEqykg) Birth 1,000 _ = _ 50 70° oO 2h 970 70 20 Mo ao 1008 1 48h 950 100 43, 140 72 120% 1 Tah 930 © 120 6 Mo 72 140 2 Td 9808 140 60 140 50 140° 2 IWL, Insensible water loss. Estimated insensible water loss = Intake ~ Urine output - Weight changes = 70 - 20+ 30 = 80. 10% glucose. Amino acid added Fat emulsion added. [Again of 20 g from the previous 24 hours IWL¢ Urine + Stool + Weight gain = 50.4 60 +10 + 20= 140. Theres essentially no clinical trial about fluid therapy for LGA, as well as SGA, neonates. From the body water measurements, we know that despite their “wrinkled” appearance, SGA neonates are not dehydrated at birth. Rather, severely growth-restricted neonates have an expanded extracellular volume. The only study providing data on fluid therapy in the immediate neonatal period reports an attenuated postnatal weight loss in SGA preterm infants receiving the same amount of fluid intake as weight-matched AGA preterm infants.*® This study suggests that SGA preterm neonates do not need extra luid intake in the immediate neonatal period, but rather a cautious approach to fluid prescription. Itis probably fair to state that the description of fluid therapy above is appropriate for VLBW infants of various growth categories. However, future clinical trials to confirm this statement are desirable. Anesthesia and Analgesia Patrick A. Lester, Daniel D. Myers, in The Laboratory Rabi Fluid Therapy Guinea Pig, Hamster, and Other Rodents, 2012Fluid therapy will depend on the patient (.c. hydration and daily fluid requirements), presence of underlying diseases, and duration and invasiveness of the procedure. Crystalloid solutions (e.g, Lactated Ringer's, 0.9% sodium chloride, Normosol-R) are isotonic and can be used to replace fluid losses that occur during surgical procedures. Such fluid will quickly equilibrate between the intravascular and interstitial fluid compartments so that only 25% of the administered amount will remain in the intravascular space. Therefore, three times the volume needed must be administered in order to appropriately replace any intravascular losses (Thurmon et a., 1996). Colloid solutions (eg. Hetastarch, Dextran, plasma, whole blood) are suspensions of large particles. The administration of these solutions leads to an increase in osmotic pressure within the vasculature which prevents fluid loss as well as draws water from the interstitial to the intravascular space. These types of solutions can be useful in cases of acute blood or protein loss during surgery. It should be noted that Hetastarch and Dextran are not replacements for blood products as they have no oxygen-carrying ability (Thurmon etal., 1996). Rodent vessels are not usually amenable to intravenous fluid administration unless a vascular cut-down procedure is performed, so warmed fluids are usually administered via intraperitoneal or subcutaneous routes. Rodents and rabbits require higher maintenance fluid rates than larger species (100 mikg every 24 hours) (McKelvey and Hollingshead, 2003) The marginal auricular or cephalic veins are easily catheterized in rabbits, which allows administration of IV fluids. A rate of at least 10 mil/kgjh is reported to be adequate for procedures of shortto ‘moderate duration (Lipman et al, 2008). Administration of fluids at this high of arate(10 ml/kgih) for longer procedures (>2 hours) may lead to hemodilution and excessive accumulation of fluid within the interstitial space, so lower rates (5-8 ml/kg/h) should be used if longer procedures are planned (Thurmon et al, 1996). BEE [rennin Components of Fluid Balance and Monitoring Josée Bouchard, ... Ravindra L. Mehta, in Critical Care Nephrology (Third Edition), 2019 Practical Issues and Conclusion Fluid therapy is a dynamic process. Over the last years, the concept of phases of fluid therapy has been introduced given that intravenous fluid therapy can be lifesaving or harmful depending on the clinical situation, timing, and amount of fluid administered.’ Some experts have suggested that the initial resuscitation of patients with septic shock should include boluses of $00 mL or less of crystalloid (Ringer's lactate) up to a maximum of 20 mL/kg? Septic patients who require urgent surgery for intraabdominal catastrophe may require more aggressive fluid resuscitation, However, because aggressive fluid resuscitation also can increas worsen morbidity and mortality rates, intraabdominal pressure monitoring is required in these patients.7? In general populations, because fluid boluses of 20 to 30 mL/kg are associated with volume overload, the mini-fluid raabdominal hypertension and bolus approach to fluid therapy (200 to 500 mL) has been recommended by some experts.”4 Importantly, even when fluid is administered for urgent resuscitation, about half of patients respond to fluid, and even a lower proportion of septic patients. Therefore initial fluid resuscitation and fluid optimization should be guided by an assessment of fluid responsiveness whenever feasible. Unfortunately, a large majority of patients do not benefit from a proper assessment of fluid responsiveness after a fluid challenge."? Early bedside echocardiographic assessment of cardiac function is a useful tool to guide hemodynamic management. Ifa patient responds to fluid by a 10% to 15% increase in SV or CO, further fluids can be given as long as there is a positive response. This approach avoids fluid overload, because the only excess fluids are equivalent to one fluid challenge(250 mL}. Moreover, hemodynamic changes in fluid responders are usually short lived’> and may even decrease systemic resistance.*?7© In septic patients who are fluid nonresponders, vasopressors (norepinephrine) should be initiated in patients with persistent hypotension. Because fluid overload is associated with worse outcomes, in the stabilization and de-escalation phases, clinicians should target a neutral and then a negative fluid balance if fluid overload is present. Diuretics can be used as an adjunctive therapy in critically ill patients, including those with AKI, to treat fluid overload and possibly to prevent it. However, diuretics should not be pursued if they do not provide the expected response. AKI patients with significant fluid accumulation who are unresponsive to diuretics should be considered for early initiation of dialysis to correct fluid overload In conclusion, fluid therapy in critically ill patients or those undergoing major surgery is a dynamic process. Individual assessment of fluid requirements and timing of fluid administration are needed, as well as frequent reassessment of response and ongoing needs. Further studies are required to assess the benefits of conservative, hemodynamically guided fluid resuscitation strategy and early use of vasopressors, as well as to optimize techniques to manage fluid overload. Intravascular Volume Replacement Therapy Christer Svensen, Peter Rodhe, in Pharmacology and Physiology for Anesthesia (Second Edition), 2019 Gastrointestinal Surgery Most recent fluid therapy outcome studies are focused on gastrointestinal surgery. Optimal fluid therapy for open abdominal surgery has been a matter of controversy for decades. The study by Brandstrup and colleagues sparked the debate regarding liberal versus restrictive fluid therapy that continues today.* Restrictive fluid therapy aimed for a net balance in water intake and output as measured by body weight before and after surgery, Numerous studies have shown a lower rate of perioperative complications when more restrictive fluid therapy regimens are used The more liberal fluid therapies might be associated with more complications in part because evaporative fluid loss is often grossly overestimated (and replaced) as are losses to the presumed third space that might not exist?9-1*? The following guidelines are gaining acceptance: + Thecurrent practice in many parts of Europes to apply an enhanced recover after surgery (ERAS) concept to perioperative fluid management of patients undergoing gastrointestinal surgery. + Perioperative fluid management in this setting is guided by using semi-invasive devices such as the esophageal Doppler where small incremental boluses (150-200 mL) of colloids are given in addition to a low maintenance rate of erystalloids (2-3 mL kg per hour). The concept is to incrementally give fluids to a deflection point on the Frank Starling curve. Purchase bookDisorders of the Gastrointestinal System L Chris Sanchez, in Equine Internal Medicine (Fourth Edition), 2018 Fluid Therapy and Cardiovascular Support Fluid therapy is a mainstay of therapy of most endotoxemic patients suffering from the cardiovascular effects of systemic inflammation. Many endotoxemic equine patients require fluid therapy for treatment of the underlying disease process and correction of dehydration and electrolyte and acid-base abnormalities. Principles of fluid therapy are discussed in Chapter 4 of this text. Patients with severe hypovolemia and shock present management challenges, especially because increased vascular permeability in endotoxemic patients requires careful consideration of fluid therapy plans. A rapid increase in total body fluid volume may be detrimental in patients with compromised cardiac and peripheral vasomotor function and ‘may increase the severity of vascular pooling in peripheral organs. In these patients hypertonic solutions or colloids ‘may be more appropriate means of stabilization than large volumes of crystalloid solutions. Hypertonic saline solution (7.5% sodium chloride) is the most commonly used hypertonic solution in horses and has beneficial effects in endotoxemic patients."93 A dosage of 4 mL/kg is recommended, which should be given as a bolus infusion over 10 to 15 minutes, followed by administration of an isotonic solution to restore total body fluid volume. The clinician should use hypertonic saline with caution in patients with sodium or chloride derangements and should monitor serum electrolyte concentrations in the case of repeated administration. Failure of urination despite appropriate fluid resuscitation should result in critical evaluation of renal function. In one recent study small- volume resuscitation with hypertonic saline plus hydroxyethyl starch failed to alleviate hemodynamic responses in experimental endotoxin infusion in horses.434 Plasma is an ideal colloid and should be administered to maintain a serum total protein concentration above 4.2 gldl.?°? To raise plasma protein concentration and colloid osmotic pressure significantly, however, horses often require large volumes of plasma (7-10 L or more in a 450-kg horse), and alternative colloids should be considered. High-molecular-weight polymers are thought to provide superior oncotic effects in cases of sepsis and endotoxemia, when vascular permeability is increased. Hetastarch, or hydroxyethyl starch (Hespan), is commercially available as a 6% solution in 0.9% sodium chloride. Hetastarch molecules havea very high molecular weight, and degradation must occur before renal excretion."*5 These properties resultin a longer plasma half-life and prolonged oncotic effects compared with other colloids; persistence of the oncotic effect for 24 hours was observed in hypoproteinemic horses."°® A dosage of 5 to 15 ml,kg given by slow IV infusion along with an equal or greater volume of crystalloid fluids has been recommended.*35:*37 In human patients prolonged activated partial ‘thromboplastin time, decreased factor Vill activity, and decreased serum fibrinogen concentration have been described in association with hetastarch use.*?* In the limited number of equine studies, bleeding times were not affected*?940; however, patients treated with hetastarch should be monitored for coagulopathy. Metabolic acidosis in endotoxic shock is attributable to lactic acidemia and inadequate tissue perfusion. Acid- base balance often improves considerably after fluid resuscitation alone; however, additional sodium bicarbonate ‘may be required in cases in which serum bicarbonate concentration remains below 15 mEq/l. Foals with sepsis are frequently hypoglycemic, and 5% dextrose solutions are useful as initial resuscitation fluids. The clinician should reduce the glucose concentration of IV solutions according to the blood glucose concentration to avoid prolonged hyperglycemia, Administration of hyperimmune plasma (20~40 ml/kg body mass) is highly recommended in foals with evidence of partial or complete failure of passive transfer. One should consider positive inotropic and vasomotor agents in patients with persistently inadequate tissue perfusion. Lower dosages of dopamine (0.5-2 pg/kg/min) result in vasodilation of the renal, mesenteric, coronary, and intracerebral vasculature via dopaminergic effects, whereas higher dosages (up to 10 yig/kg/min) also exert stimulation of a-adrenergic receptors, resultingin increased myocardial contractility and heart rate.*#2Dobutamine is a direct o} adrenergic agonist and does not appear to have significant vasodilator properties. Dosages for dobutamine of 1 to 5 pgikg/min as a continuous IV infusion have been recommended for use in horses. Norepinephrine was evaluated in hypotensive critically ill foals that were refractory to the effects of dopamine and dobutamine.**? At dosages up to 1.5 pg/kg/min administered concurrently with dobutamine, six of seven foals showed an increase in mean arterial pressure, and all foals had inereased urine output, Because of the risk of cardiac side effects, close monitoring of heart rate and rhythm should accompany infusion of inotropes. Indirect blood pressure measurements usinga tail cuff may be used to monitor the effects of treatment. Read full chapter View PDF Download book Kidney-Lung Interactions ‘Sean M. Bagshaw, Rinaldo Bellomo, in Mechanical Ventilation, 2008 EFFECT OF FLUID THERAPY ON LUNG AND KIDNEY FUNCTION Fluid therapy is considered a cornerstone of resuscitation of the critically ill patient. Similarly, fluid resuscitation is a primary strategy for preservation of kidney function in the patient with progressive increases in serum creatinine and urea or the development of oliguria. However, evidence suggests that there may be negative consequences to fluid therapy for both lung function and kidney function. Both the type of fluid and the quantity of fluid administered (or cumulative fluid balance) appear to have important implications for normal lung and kidney physiology in critical illness. Type of Fluid Therapy Synthetic colloid therapies (.e,, hydroxyethyl starches) have been associated with declines in kidney function after cadaveric kidney transplantation. Patients administered starches have been found to have higher postoperative serum creatinine values, greater need for RRT, and evidence of osmotic-nephrosis-like lesions on histologic evaluation.7®77 Similar findings have been shown in critically ill patients after resuscitation for severe sepsis in whom the use of starches was associated with higher rates of ARF compared with other colloids or erystalloids 787° ‘The exact mechanism remains uncertain, although the hydroxyethyl starches may influence intrarenal hemodynamics or the GER through alterations in vascular oncotic pressure. Ina small observational study of septic critically il patients, Van Biesen and associates*° compared the fluid intake of patients developing and not developing ARF. These authors found that patients with ARF had, on average, received a significantly higher volume of colloid resuscitation (2000 mL for ARF versus 1100 ml. for no ARF) in the first 72 hours, even though both groups were administered similar volumes of crystalloid. Further, patients with ARF had evidence of higher filling pressures and a lower urine output despite diuretic therapy in the majority. Additional fluid loading in these patients, in spite of apparently optimal hemodynamics and intravascular volume status, failed to improve kidney function, although it contributed to a notable deterioration in oxygenation. It remains unclear from this study whether the differences are attributable to the type of fluid (ie, colloid) orto the extra volume of fluid administered. Amount of Fluid Therapy An increasing body of evidence suggests that a positive curnulatve fluid balance can worsen the outcome in critically ill patients with lung injury21-®? The ARDS Clinical Trials Network completed the largest randomized trial assessing fluid therapy in patients with lung injury.** This trial compared restrictive and liberal strategies for fluid‘management in 1000 crticallill patients, mostly with pneumonia or sepsis, and evidence of acute lung injury. At 72 hours, patients receiving a restrictive fluid strategy had a nearly neutral fluid balance, whereas those in the liberal strategy were positive (>5 L). though the study failed to show a difference in mortality between the strategies, a restrictive strategy improved lung function, increased in ventilator-free days, reduced length of stay in the intensive care unit (ICU), and, most important, was associated with no difference in nonpulmonary organ failure, specifically ARF. In fact, although the restrictive group had nonsignificant increases in serum creatinine and urea, there was @ trend toward a reduced need for RRT. The indications for initiation of RRT were not provided, yet pulmonary complications likely contributed to the greater need for RRT in patients receiving a liberal fluid strategy (Box 17.3). A restrictive fluid strategy, such as described earlier, requires not only judicious use of fluids, but also an aggressive method for fluid removal. Short of hemofiltration, patients are commonly given diuretics to promote natriuresis, and diuresis that can translate into a reduction in extravascular lung water and improved lung function. The most common diuretic used is furosemide, a loop diuretic. Furosemide can also exert additional effects independent of its action on the kidney. In experimental studies, furosemide was shown to induce pulmonary vasodilation and to act as 85-87 1 reduction in total serum a weak bronchodilator, both of which can improve ventilation-perfusion matching. protein, and hence colloid oncotic pressure, was shown to be predictive of a positive fluid balance and a worse outcome for patients with ARDS.*® Experimental studies suggested that furosemide may also act to reduce extravascular lung water by causing.an increase colloid oncotic pressure? In a small, randomized trial, Martin and colleagues”? found that furosemide combined with albumin administration in hypoproteinemic patients with lung. injury resulted in greater improvements in oxygenation, net negative fluid balance, and hemodynamic stability compared with patients receiving furosemide alone. Purchase book