BAHIR DAR UNIVERSITY

COLLAGE OF MEDICINE AND HEALTH SCINCES

DEPARTMENT OF ADULT HEALTH NURSING
Assignment on – Fluid and electrolyte management on critically ill patients
Submitted by- Berihun Bantie . ID 1207002PR
Submitted to -Mr Awol . S(Asst proffessor )

June ,2020
Bahirdar
7/10/2020 BY Berihun B. 1
 Content outlines
Objectives
Introduction to fluid therapy
 Evidence based fluid management for critically ill
patients
Evidence based electrolyte management for critically
ill patients
 ICU management status in Ethiopia
Summary
References
Acknowledgement

7/10/2020 BY Berihun B. 2
 Objectives of the lesson
Upon completion of this lesson , You the
students will able to
I. Mention the common fluid and electrolyte therapy for
critically ill patients
II. Analyze the cons and pros of different fluid and
electrolyte therapy for Critically ill patients Differentiate
staging and grading of cancers
III. Choose the recommended fluid therapy for the respective
patients in ICU.
IV. Improve their daily nursing practice on fluid and
electrolyte therapy by adopting evidence based findings .

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Introduction to fluid and electrolyte therapy
 Total volume of body fluids consists of 60% of
lean body weight in men 50% of lean body weight
in women.
 Distribution of fluid in the body is:
1. 1/3 extracellular fluid
Interstitial fluid- 75-80%
Plasma or intravascular fluid- 20-25%
Trans cellular fluid
2. 2/3 intracellular fluid
Fluid within a cell
Red blood cells
Other cells
7/10/2020 BY Berihun B. 4
 Conti--
• Intravenous fluids are similarly classified based
on their ability to pass through barriers
separating body fluid compartments, i.e
intravascular and extravascular (interstitial)
fluid compartments
• In 1861 Thomas Graham’s investigated and
classified substances or fluids as crystalloids
and colloids depending on their ability to diffuse
through a parchment membrane

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 Crystalloid fluids
• Crystalloid are electrolyte solutions with small molecules
that can diffuse freely from intravascular to interstitial fluid
compartments.
• Predominant effect of volume resuscitation with crystalloid
fluids is to expand the interstitial volume rather than the
plasma volume.
• Because of this, larger volumes of crystalloid than colloids
are required for fluid resuscitation and vascular expansion
( 3 l of NS needed for 1litter of vascular fluid loss )
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 Conti-
• Crystalloids can be either
1. Hypertonic – draws fluid into the intravascular
compartment from the cells and the interstitial
compartments, results cellular shrink. It includes
Hypertonic saline ,10%, 25% & 50% dextrose, D 1/2 NS
2. Hypotonic- shifts fluid out of the intravascular
compartment, hydrating the cells .Eg- 0.45% Sodium
Chloride(1/2 NS)
3. Isotonic- 0.9 N/s , Lactated Ringer’s and Hartman's
solution, stays in the intravascular space and expands the
intravascular compartment.
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 Common Crystalloids
Solution Uses Nursing considerations
Dextrose 5% in Fluid loss Use cautiously in renal and cardiac patients,
water(D5W) - Dehydration May cause hyperglycaemia or osmotic
Isotonic Hypernatremia diuresis, not used for shock
0.9% Sodium Shock ,Blood transfusions Can lead to overload, Use with caution in
Chloride Resuscitation and Preferred in patients with heart failure or oedema
(Normal saline case of brain injury, May produce a metabolic acidosis due to
( Isotonic) Fluid challenges, DKA/ initial/ hypercholermia ( 154meq/l)
Lactated Dehydration, Burns ,Lower GI Contains potassium, don’t use with renal
Ringer’s ( RL) fluid loss, pancreatitis failure patients, Don’t use with liver
( Isotonic) Acute blood loss, DKA disease/c they can’t metabolise lactate
Dextrose 10% Conditions where some Monitor blood sugar levels .
in water nutrition with glucose is uses for Water replacement
(hypertonic) required
Dextrose 5% in It is hypertonic solution used Use only when blood sugar falls below
½ NS Later in DKA 250mg/dl
0.45% (1/2) Water replacement, Na Excess Don’t use with liver disease, trauma or
NS ( DKA , Gastric fluid loss from burns, May cause cardiovascular collapse or
hypotonic NG or vomiting. increased intracranial pressure
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 Colloids
• Colloid fluid is a saline fluid with large solute
molecules/proteins/ that do not readily pass from
plasma to interstitial fluid.
• They remain in blood vessels longer time , hence
increase intravascular volume 3 times more than
crystalloid with equal volume administered
• They attract water from the cells into the blood vessels
and can lead to cellular dehydration

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 Common colloids
Types Action/use Nursing considerations

Albumin Emergency treatment of May cause anaphylaxis (a severe, often

(Plasma protein) shock if due to plasma loss. rapidly progressive allergic reaction that is
4% , 5%, 20% potentially life threatening)
Fluid resuscitation in
intensive care if for long time May cause fluid overload and pulmonary
edema
Clinical situations of Contraindicated in severs anemia and
hypo-Albuminemia cardiac failure
Dextran Shifts fluids into vessels Increased risk of bleeding
(Polysaccharide comparable to Albumin Contraindicated in bleeding disorders,
40 %or 70% Vascular expansion in burn, chronic heart failure and renal failure
Synthetic surgery , prophylaxis for
DVT
Hydroxethyl May cause fluid overload and Increased risk
starch (HES), Shifts fluids into vessels of bleeding
(synthetic Vascular expansion Contraindicated in bleeding disorders,
starch) chronic heart failure and renal failure
6% or 10% has anti-inflammatory effect
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 Evidence based Fluid management for
critically ill patients

• Critically ill patients are at risk of developing acute

cardiovascular insufficiency or shock from any cause,
defined as the imbalance between oxygen delivery and
tissue oxygen consumption.
• This state is characterized by cellular dysoxia that,
maintained over time, might progress to multi-organ
failure and death
• In order to prevent these consequences, hemodynamic
resuscitation has to be started early and aimed at
correcting tissue hypo perfusion (Antonio Artigas , 2013
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 Conti--
• Intravenous fluid therapy is one of the most common
interventions in critically ill patients.
• Each day , over 20% of patients in intensive care units
(ICUs) receive intravenous fluid resuscitation, and
more than 30% receive fluid resuscitation during their
first day in the ICU (Liu et al., 2018)
• Since disease processes are dynamic and their
response to fluid may change over time, The optimal
dose and types of intravenous (IV) fluid for
resuscitation in all situation remain undetermined
(Myburgh and Mythen, 2013, Semler et al., 2018).
• Evidence based management of fluid is mandatory
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 Crystalloids for ICU patients
• Crystalloid solutions are the most commonly
administered intravenous fluid and “ first line” for fluid
resuscitation in such common critical illnesses as
sepsis, hemorrhagic shock, and cardiac arrest. ((Casey
et al., 2018)
• Even though colloid solutions are thought to be more
efficient than crystalloids to meet Hemodynamic goals
of resuscitation such as CVP, MAP, and urine output
HR ,but Other criteria's like cost , availability and side
effects made them not to the first.
• Switching crystalloid to colloid is urgently
recommended for large volume replacement like sepsis
.( Martin and Bassett, 2019
7/10/2020
), Vincent, 2019
BY Berihun B. 13
 Crystalloid –conti--
• Two basic classes of crystalloid are available
1. Saline (0.9% sodium chloride)-typically contain high
concentrations of sodium-chloride than plasma and
have a pH that is lower than 6.0
2. Balanced crystalloids (e.g., lactated Ringer’s, Plasma-
Lyte and Isofundine ) are buffered by anions such as
NaCHO3 other than chloride
 The chloride concentrations of balanced solutions
therefore more closely approximate plasma but their
osmolality is lower

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 Conti--
• Currently, normal saline is the most commonly used
resuscitation fluid. How ever, can lead to a
hyperchloremic metabolic acidosis which has been
associated with complications in some studies.(Yunos
NM, 2012., , Shaw AD, et al.2014 )
• These “balanced” solutions are not universally
available and can be significantly more costly than
0.9% normal saline solution which are major criteria's
for choosing fluid
• Hence choosing the better is controversial overtime.

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 Conti--
• Some observational studies, clinical trials and meta
analysis suggest the use balanced crystalloid use is
associated with lower risk patient outcomes such as
acute kidney injury/AKI/ and death in critically ill
patients.(Semler et al. 2019)(Liu et al., 2018)
• Current evidences from meta analysis studies shows
no clinically statistical significant difference
In the length of in hospital stay ,
Incidence acute kidney injury, or
organ-system dysfunction and rate of death
between 0.9% normal saline solution and balanced
crystalloid solutions(((Zhou et al., 2018,Liu et al., 2019,
Xu et al., 2020,Antequera Martín et al., 2019)
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 Conti– 5, 10 , 25,40 %Dextrose
Many disadvantages in critically ill pts. like
 increase lactate production due to impairment of cellular
glucose utilization leads to cellular dehydration
 Aggravate Ischemic brain injury and
 increase risk of infection,
• combined with a lack of documented benefit, the
recommendation is that the routine use of 5% and other
dextrose infusions be abandoned in critically ill patients,
especially for resuscitation .(Finney et al , 2003)

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 Colloids For ICU patients

 Colloid solutions remain in the intravascular space for

a longer period, making edema less likely

 Thus crystalloids and colloids should be used together,

especially in patients likely to require large fluid
volumes like sepsis and severe hemorrhagic shock.
.((Vincent, 2019)

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 Conti-- Albumin
• Albumin -is the only natural colloid used for intravascular
volume replacement in humans.
• Overall, albumin is equivalent to saline for fluid
resuscitation of critically ill patients ,but could have
beneficial effects in patients with sepsis and those with
spontaneous bacterial peritonitis etc (Finfer et al., 2018)
• Given the cost of human albumin, it should generally not be
considered the first choice for fluid replacement unless
there is a specific indication ( cirrhosis and liver
transplantation, SBP ) for its use ((Martin et al., 2018).
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 Cont---
• Albumin increases mortality in traumatic brain injury

• Semisynthetic colloids like Dextran‘s, HES and

Gelatin appear to increase the risk of acute kidney
injury, pruritus,coagulopathy/ bleeding/ and therefore
should not be used for fluid resuscitation of most
critically ill patients. ((Finfer et al., 2018,Casey et al.,
2018)

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Fluid Administration in Specific Disease Conditions

• As noted above, there is accumulating evidence that

specific disease states may require different fluid
therapy and no ideal fluid is present at all time .
• The cost, availability, disease condition
hemodynamic outcomes, lengthen the hospital stay
, risk for AKI and mortality are those factors
determine the fluid choice (Finfer et al., 2018)

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 Fluid for sepsis
• Aggressive volume resuscitation is the best initial
therapy for the cardiovascular instability of sepsis
• Even though intravenous administration of 0.9% saline
may cause hyperchlorema acidosis no significant
difference b/n balanced and NS crystalloids on rates
of mortality and AKI of sepsis patients ((Gottlieb et
al., 2020)
• Hence 0.9% saline remains the treatment of choice
for hemodynamic ally unstable septic patients .

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 Conti– protocol of management

 Start with at least 30ml/kg in the first 3hrs with 1-2Lin

30-60 minutes, then additional fluid bolus( 500 ml RL
 Start Norepinephrine if hemodynamic response is
poor with in a hour ( MAP < 65 mm Hg, UOP ).
 Continue fluid ( up to 5l/ 6hr) and 14L /72 hrs)
 Monitor signs of fluid overload ( JVD, Crackles,
pulmonary edema ) ((Brown and Semler, 2019)
• If acute hypovolemic is not responsive to crystalloids a
lone, the use of colloid (human albumin only ) can be
considered.
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 septic shock management on severe COVID 19

• Immediate aggressive volume expansion with isotonic

solution, preferably R/L or alternatively with N/S, is
the main stay of treatment during septic shock
• start with at least 30ml/kg in the first 3hrs, then
additional fluid boluses
• using norepinephrine as the first-line vasoactive but
Dopamine is not recommended
• Closely monitor for signs of fluid overload
• Fluid restriction is recommended due to ARDS
• Stop if there is sign of fluid overload ((Xu et al., 2020)

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 Fluid therapy for Adult Respiratory Distress
Syndrome/ARDS/
• ARDS was initially considered an inflammatory protein-
rich pulmonary edema accompanied by leakage of
protein-rich fluids into the interstitial space
• ARDS has both inflammatory edema and hydrostatic
components due to pulmonary hypertension
• Conservative( not liberal) fluid management decreases
hydrostatic pressure and increase serum oncotic pressure
,potentially limiting the development of pulmonary
edeoma leads better oxygenation and shorter periods of
mechanical ventilation ((Martin et al., 2018,((Silversides
et al., 2019))
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 Conti--
• Three main areas of conservative management
1. Restrictive use of fluid, together with earlier use of
vasopressor
2. De- resuscitation- defined as active fluid removal
using diuretics after resuscitation if CVP > 8 mmhg
or CVP 4-8 plus UOP >0.5ml/kghr
3. Taking into account the etiologies(burns, TBI,
infection) , patient conditions and hemodynamic
status to predict who will benefit and who .not

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 Fluid for Major Abdominal Surgery
• Fluid administration is part of the perioperative routine
in both elective and urgent major abdominal surgery .
• Adequate preoperative preparation for elective major
abdominal surgery should not induce a fluid deficit
exceeding 2.5% of body weight.((Martin et al., 2018)
• Intraoperative/postoperative rehydration of elective
cases should be performed with a balanced salt
solution
• The principles guiding fluid administration in sepsis
should also guide perioperative fluid administration in
patients undergoing urgent abdominal surgery.

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 Conti--
• The crystalloid chosen for patients after urgent
abdominal surgery should be determined individuals
status after arrival on Intensive care unit.((Martin et
al., 2018)
• Colloids may be administered in elective surgery
cases if required.

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 Fluid management for trauma patients
• In the hypotensive trauma patient, crystalloids should
be administered initially and the amount of fluids
administered should be restricted
• Balanced crystalloids are preferred over normal saline
for large volume resuscitation of trauma patients .
(Martin et al., 2018)
• Colloids and hypertonic solutions can not be used as
first line therapy even if they accelerate hemodynamic
goals .(Liu et al., 2019)
• Albumin and hypotonic saline should not be
administered to patients with TBI.
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 Fluid therapy for AKI patients
• Fluid administration is one of the cornerstones of
prevention of AKI.
• Regarding to the cause and/or mechanism of AKI ,
decrease tissue perfusion as in case of hemorrhagic
shock, endothelial dysfunction, local and systemic
inflammatory processes and oxidative stress in case of
sepsis are the major contributing factors

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 Conti– AKI
• If a large volume of fluid is likely to be required for
resuscitation, especially in septic patients, balanced
fluid solutions should be selected as these may
reduce the likelihood of AKI.
• Normal saline 0.9% remains useful for patients with
hypochloremic alkalosis
• Administration of HES increases the incidence of
AKI and RRT in critically ill patients ,the use of HES
is therefore no longer approved for these patients
regardless of cause of admission.((Finfer et al.,
2018)

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Electrolyte management for critically ill patient

• Electrolytes are involved in many metabolic and

homeostatic functions.
• Electrolyte imbalances are frequently encountered in
the Intensive Care Unit (ICU) and protocol-driven
interventions may facilitate more timely and uniform
care
• The major electrolyte disturbances in critically ill
patients are Hypocalcaemia, hypomagnesia , hypo/
hyperkalemia , hypo/ hypernatremia .

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 Hyponatremia management
• It has been observed in 14% of patients upon
admission to the ICU
• Occurs as a result relative water excess in
conjunction with impaired ability of the kidney to
excrete electrolyte-free water due to SIADH, disease
like Heart failure, sepsis and shock
• Symptoms of hyponatremia such as orthostatic
hypotension, poor mental status, dry oral mucos and
altered mental status, occur most commonly with a
rapid decrease in plasma [Na+] to < 125 mEq/L.

7/10/2020 BY Berihun B. 33
 Conti--

• Correction of plasma [Na+] should be undertaken

without delay in symptomatic patients, particularly
those experiencing seizures to prevent cerebral edema
• Hypertonic sodium chloride with or without a loop
diuretic is usually started at a rate of 1-2 mL/kg/hr to
raise sodium concentration by 1-2 mEq/L/hr.
• The overall correction of [Na+] should not exceed 8-12
mEq/L for 24 hours to prevent its complication

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 Hypernatremia management
• Patients in the ICU are at a high risk of developing
hypernatremia due to
1. Administration of sodium bicarbonate solutions to
correct metabolic acidosis;
2. Renal water loss through a concentrating defect from
renal disease
3. Gastrointestinal fluid losses through nasogastric
suction and lactulose administration
4. water losses through fever, drainages, and open
wounds

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 Conti- Management

 Replacement of the water deficit ( Half of it with 12-14

hrs. ) and the remaining ( with in 48 hrs) along with
monitoring of neurological status. .
• In hypovolemic hypernatremia as in DI , isotonic sodium
chloride should be given with underlying cause treatment.
• Hypervolemia hypernatremia is not uncommon and often
iatrogenic if it occurs removal of requires removal of
excess sodium from the body ((Muhsin and Mount, 2016)

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 Hypocalcaemia management

• Hypocalcaemia is ubiquitous in the ICU, affecting 80% to

90% of all patients, and when present, is associated with
longer ICU stays, increased mortality and higher rates of
bacteremia (edlacek M, Schoolwerth AC, 2014)
• Most common causes of hypocalcaemia include trauma,
acute and chronic renal failure, sepsis,
hyperparathyroidism, hypomagnesaemia
• The symptoms and signs of severe acute hypocalcaemia
include Numbness, tingling of fingers, toes, and positive
muscle tetany, papilledema, and seizure
7/10/2020 BY Berihun B. 37
 Conti-
• For acute correction of symptomatic hypocalcemia, IV
calcium gluconate((10 mL of a 10% solution) or
1000mg calcium chloride can be administered over 10
minutes ((Forsythe et al., 2008)
• Continuous infusion of calcium may be required, with
close monitoring of serum calcium levels at least every
six hours during the infusion
• The infusion rate should not exceed 0.8-1.5 mEq/min
because of the potential risk for cardiac arrhythmias

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 Hypomagnesaemia management
• Hypomagnesaemia is frequently observed in critically
ill patients, and its prevalence in the ICU is reported
to be as high as 50%.((Limaye et al., 2011)
• Excess gastrointestinal or renal losses, surgery,
trauma, infection or sepsis, burns,, alcoholism,
starvation or malnutrition and diuretics are the most
common causes
• Severe hypomagnesaemia can result in
electrocardiographic changes, arrhythmias , comma
and death

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 Conti--
• Goal of therapy to maintain serum Mg++ b/n 1.5- 2.4
mg/dl , resolve symptoms and avoid hypomagnesaemia
• Intravenous administration of magnesium sulfate is
preferred in critically ill patients with severe (plasma
[Mg2+] < 1 mg/dL) or symptomatic hypomagnesaemia
• Since it distributes slowly and renal excretion is low
,doses less than 6 g of magnesium sulfate are infused
over 8-12 hours, and higher doses are given over 24
hours ((Latcha , 2015)

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 Hyperkalemia management
• Renal failure, adrenal insufficiency, insulin deficiency
and resistance, medications ( B-blockers, RAAS
inhibitors, NSAID) predisposes to hyperkalemia
• Treatment strategy of hyperkalemia depends on the
presence of emergent signs like ventricular tachycardia
shown in ECG.
• Intravenous calcium gluconate is the first step of
management to antagonize the depolarizing effect of
hyperkalemia
• The next step should be to facilitate the shift of
potassium into intracellular compartment (Insulin with
50% glucose is most effective ) (Weisberg, 2008)
7/10/2020 BY Berihun B. 41
 Hypokalemia management
• Major causes of hypokalemia include
1. Medications like sympathomimetic, insulin,
methylxanthines, and dobutamine commonly
prescribed in the ICU are associated with
hypokalemia
2. Low dietary potassium intake and diuretics
The most dreaded complications related to
hypokalemia are cardiac arrhythmias, especially in
patients with hypertension, myocardial
infarction/ischemia, or heart failure.

7/10/2020 BY Berihun B.
 Conti-
• Except for emergent settings, oral administration of
potassium is always preferred
• Rapid infusion of potassium for emergent conditions
(i.e., > 10-20 mEq/hr) requires a central venous catheter,
as infusion via a peripheral line causes phlebitis and vein
injury.
• Amount of the initial dose should be in the range of 40-
80 mEq.
• Total amount of daily K+ replacement should be less than
240-400 mEq/day and it should be added dextrose free
solutions
7/10/2020 BY Berihun B. 43
 ICU management practice in Ethiopia
• ICU mortality rate was 50.4% and major causes included
trauma, cardiac disease, acute abdominal presentations,
septic shock (Smith et al., 2013)
• KAP of nurses on ICU management is poor
(Dereje.N , 2108)
• Prevalence of medication administration errors
predominantly fluid errors in the ICU of JUSH (51.8%).
- wrong timing administration (30.3%)
-omission due to unavailability (29.0%)
and missed doses (18.3%) among others occurs due to
lack of trained nurses and close supervision.((Agalu et al.,
2012)
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 Nursing diagnosis

1. volume deficient related to impaired fluid and

electrolyte regulation mechanisms s as manifested by
hypotension, decrease urine output
2. Electrolyte disturbances related to impaired fluid
volume adjustments as manifested disturbance in
sodium, potassium and calcium levels .
3. Risk for fluid overload related to lack of intensive
monitoring of hemodynamic status.
4. Risk for infections related hospitalizations .

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 Summary
• Intravenous fluid therapy is one of the most common
interventions in acutely ill patients.
• Crystalloid commonly normal saline is the most
commonly used resuscitation solution with no
significant difference.
• Even if colloids achieve hemodynamic goals early , they
are not first line management for fluid therapy and
they may be added for sepsis and shock if unresponsive
for crystalloid
• Hypocalcaemia, hypomagnesia , hypo/ hyperkalemia ,
hypo/ hypernatrmia are common electrolyte disorders
occurred on ICU patients
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 References
1. Anders Perner, P.B.H., et.al , Focus ( 2019): On FluidTherapyInCritically ill
patients Springer, p. 1-3.
2. Antequera Martín, A.M., et al (2019)., Buffered solutions versus 0.9% saline
for resuscitation in critically ill adults and children. Cochrane Database Syst
Rev,. 7(7): p. Cd012247.
3. Casey, J.D., R.M. Brown et.al (2018), Resuscitation fluids. Curr Opin Crit
Care,. 24(6): p. 512-518.
4. Freeman, L., et al(2019:), Assessment of Electrolyte Replacement in Critically
Ill Patients During a Drug Shortage. Hospital Pharmacy:
p.0018578719893375
5. Gottlieb, M., V. et.al (2020). , Are Balanced Crystalloid Solutions Better Than
Normal Saline Solution for the Resuscitation of Children and Adult Patients?
Ann Emerg Med, 75(4): p. 532-534.
6. Keddissi, J.I., et al ( 2019) ., Fluid management in Acute Respiratory Distress
Syndrome: A narrative review. Canadian journal of respiratory therapy:
CJRT= Revue canadienne de la therapie respiratoire: RCTR, 55:
7. Atcha, S et atl (2014,) Electrolyte Disorders in Critically Ill Patients, in Critical
Care,., McGraw-Hill Education: New York, NY.

7/10/2020 BY Berihun B. 47
 Conti--
8. Martin, G.S. and P. Bassett, Crystalloids vs. colloids for fluid
resuscitation in the Intensive Care Unit: A systematic review and
meta-analysis. Journal of critical care, 2019. 50: p. 144-154.
9. Semler, M.W. and J.A. Kellum, Balanced Crystalloid Solutions. Am
J Respir Crit Care Med, 2019. 199(8): p. 952-960.
10. Shin, C.H., et al., Effects of intraoperative fluid management on
postoperative outcomes: a hospital registry study. Annals of
surgery, 2018. 267(6): p. 1084-1092.
11. Silversides, J.A., A. Perner, and M.L. Malbrain, Liberal versus
restrictive fluid therapy in critically ill patients. Intensive care
medicine, 2019. 45(10): p. 1440-1442.
12. vincent, J.-L., Fluid management in the critically ill. Kidney
international, 2019.
13. Wang, A.S., et al., The Impact of IV Electrolyte Replacement on
the Fluid Balance of Critically Ill Surgical Patients. Am Surg, 2019.
85(10): p. 1171-1174.

7/10/2020 BY Berihun B. 48
 Acknowledgment
• My deepest gratitude and appreciation goes to our
instructor Mr Awol.(Asst professor,) and Mr Yeshaneh
(Asst professor )for offering this assignment which
enforces me to explore different literature's related on
fluid and electrolyte management for critically ill patients
and to have better know how on it.
• Secondly I would like to express my heartfelt thanks to
Bahirdar University College of medicine and Health
science for Initiating and cascading virtual learning
during corona pandemic so that we will manage our time
properly.

7/10/2020 BY Berihun B. 49
 STAY SAFE !!!

7/10/2020 BY Berihun B. 50