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Maintenance Fluid Therapy

Iyan Darmawan, MD Medical Department Otsuka, Indonesia

FLUID THERAPY
RESUSCITATION MAINTENANCE

Crystalloid

Colloid

ELECTROLYTES

NUTRITION

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace normal loss (IWL + urine+ faecal) 2. Nutrition support

Electrolyte composition
mEq/L
Na+ K+ Ca2+ Mg2+ ClHCO3HPO42SO42Organic acid

ICF 15 150 150 2 27 1 10 100 20 63

ECF Plasma 142 142 4 5 3 103 27 2 1 5 16

Interstitial 144 144 4 2.5 1.5 114 30 2 1 5 6

Protein

Ion Distribution
ANION Suitable solution

COMPARTMENT CATION ICF ECF PLASMA ISF K+ Na+ Na+

Mg++ HPO4-, Prot

containing K+ Mg+ and HPO4Cl-, HCO3- Prot. High Na+ and ClCl- HCO3-

Deficit .
Dehydration
* thirst * urine output hypotonic electrolytes

Hypovolemia
headache nausea syncope isotonic electrolytes

5% Dextrose N/2-D5

Ringers acetate Ringers lactate Normal saline

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 plasma Water, 1/2 N/S (0.45% NaCl), and D5W (5% dextrose in water) after the sugar is used up
Hypertonic-Fluid has more solutes than plasma 5 % Dextrose in Normal Saline (D5 N/S), 3% saline solution, D5 in RL.

Isotonic Dehydration
Most Common form of Dehydration

Occurs when fluids and electrolytes are lost in even amounts


There are no intercellular fluid shifts in isotonic dehydration Common Causes diuretic therapy excessive vomiting excessive urine loss hemorrhage decreased fluid intake

Hypertonic Dehydration
Second most common type of dehydration.
Occurs when water loss from ECF is greater than solute loss

hyperventilation, pure water loss with high fevers, and watery diarrhea.
Diabetic Ketoacidosis and Diabetes Insipidus Iatrogenic Causes prolonged NPO, excessive hypertonic fluids, sodium bicarbonate, or tube feedings with inadequate water

Hypotonic Dehydration
Relatively Uncommon - Loss of more solute
(usually sodium) than water. Hypotonic Dehydration causes fluid to shift from the blood stream into the cells, leading to decreased vascular volume and eventual shock

Seen in Heat Exhaustion

Increased cellular swelling -causes increased intracrainial pressure - H/A and Confusion.

Seen in Heat Stroke

Isotonic infusion
Ringers acetate Ringers lactate Normal saline
Replace acute/ abnormal loss

increases ECF

ICF

ISF 800 ml

Plasma 200 ml

Hypotonic infusion
5% dextrose

increases ICF > ECF

Replace Normal loss (IWL + urine)

ICF
660 ml

ISF
255 ml

Plasma
85 ml

Fluid Therapy
Replacement Maintenance Repair deficit

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

Maintain Repair

FLUID SELECTION
Replace : RA, RL, NS
Maintain: N/2 + D (adult) + K+ 20 mEq

N/4 + D (chlldren) + K+ 20 mEq


Repair : NaHCO3 8,4% KCl 25 mEq/25 ml NaCl 3%

Maintenance
IWL + urine Adults/children : 4:2:1 eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 = 100ml/hr

Requirements
Fever Restless/delirium Warm ambient temperature Hyperventilation

Requirements
Hypothermia High humidity Oliguria/anuria Reduced consciousness Retention/oedema Increased intracranial pressure

Rationale of maintenance solutions


Fluid redistribution Basal requirement of potassium & sodium electrolyte concentration in infusion solutions Ready for use solutions minimizes risk of contamination

Electrolyte solutions
Plasma
Isotonic solutions 308 273 Hypotonic solutions

290

278 278

290

Normal Ringers saline acetate/ lactate

D5

KAEN 3B*

* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol Cl-, 20 mmol lactate, 27 g dextrose per L.

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

Relationship between serum K+ serum and TBK at various levels of deficit and excess
10 86serum K+ (meq/L) 4 2-900 -600 -300 0 +300 K+ deficit (meq) K+ excess (meq)

Decreased serum K+ and deficit of TBK (%)


543serum K+ (meq/L) 2 1-

total body K+ = 50 mEq/kg body weight


05 10 15 20 25 K+ deficit (%)

K+ and acid-base status


Blood pH Serum K+ 7.2 5.0 7.3 4.5 7.4 4.0 7.5 3.5 7.6 3.0 K+ depletion 0 mEq

4.5
4.0

4.0
3.5

3.5
3.0

3.0
2.5

2.5
2.0

100 mEq
200 mEq

3.2
Acidosis
cell ECF

3.0

2.5

2.0

1.5

400 mEq Alkalosis

DCC

Cell

ECF

Tubulus distal

3 K+ H+ 2 Na +

3 K+ H+ 2 Na +

H+ K+

3 K+

3 K+

H+ 2 Na +

H+ 2 Na +

K+ H+ Urin

Urine

H +

acid urine

K + low urine K+

H + Urine Alkali K + K+ urin tinggi

Standard K+ concentration in i.v. solutions


1 Cnc: <40 mEq/L 2 Rate of adm: <20 mEq/hr 3 daily dosage : <100 mEq/day 4 Monitor ECG and serum K+ 5 U r i n e output: >0.5 ml/kg/hr
< 40mEq/L KCl

KCl bolus

Rate of administration of Electrolyte & glucose


Na+ K+ Ca++ Mg++ HCO3 Glucosa
100 mEq/hr 20 mEq/hr 20 mEq/hr 20 mEq/hr 100 mEq/hr

0,5 gr/kg/hr ( 4 mg/kg/min)*

* Neonates 6-8 mg/kg/min

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 less risk of contamination Can be combined with amino acids