Fluid Management

efinition
· Severe dengue:
1. F grade 3 and 4
2. engue with severe organ impairment:
÷ engue with fulminant hepatitis
÷ engue with myocarditis
÷ engue with encephalitis
÷ engue with respiratory distress
CIInIcaI course oI DHF
linical assessment for severe
dengue and F Grade 3 & 4
· uring critical phase:
÷ Plasma leakage around defervescence phase:
· Evidence of plasma leakage includes:
1. raised % (early marker),
2. haemodynamic instability,
· Skin- cool and pallor, delayed capillary refilled time
· Reduced pulse pressure to < 20 mmg
· %achycardia
· ypotension SBP< 90 mmg
3. fluid accumulation in extravascular space (rathe late marker)
· Pleural effusion
· Ascitis
4. hypoproteinemia.
F Grade 3 & 4-clinical assessment
· Ìntense thirst,
· Abdominal pain, epigastric pain,
· Vomiting,
· Restlessness,
· Reduced urine output
· Altered conscious level,
· Shortness of breath and tachypnoea,
· Sudden change from fever to subnormal
temperature
Fluid management · When to initiate
!v fluid replacement?
- Not taking orally
- Dehydration and rising haematocrit level
- Diarrhoea
- vomiting
- Decreased sensorium
- Compensated shock
- Decompensated shock
Fluid management - maintenance
· CaIcuIations for normaI maintenance of intravenous
fIuid infusion per hour:
(EquivaIent to HaIIiday-Segar formuIa)
4 mL/kg/h for first 10kg body weight
+ 2 mL/kg/h for next 10kg body weight
+ 1 mL/kg/h for subsequent kg body weight
*For overweight/obese patients calculate normal maintenance fluid
based on ideal body weight
Ideal bodyweight can be estimated based on the following formula
Female: 45.5 kg + 0.91(height -152.4) cm
Male: 50.0 kg + 0.91(height -152.4) cm
Exercise
· Body Weight 65kg
· 1
st
10kg --- 40ml/
· Next 10kg --- 20ml/
· Balance --- 45ml/
· 40+20+45 = 105ml/
· 105 x 24 = 2520ml/day
Fluid management - general rules
· Frequent adjustment of maintenance fluid
regime,
· 1.2-1.5 X Maintenance in critical phase,
· Ìf > 1X Maintenance required, regime need
to be reviewed 4-6 ly.
· Rising %- increase infusion rate
· SS ÷ fluid resuscitation algorithm
· Stop fluid therapy once after critical phase
and patient is stable (post defevercence).
engue Shock Syndrome ÷
F Grade 3 and 4 (SS)
· Medical emergency
· Early and prompt management lead to better
outcome,
· Should be nursed in igh dependency unit or
Ì&
· Fluid resuscitation should be prompt,
· Following initial resuscitation there maybe
recurrent episodes of shock because capillary
leakage can continue for 24-48 hours
Fluid management ÷ type of fluid
· no clear advantage of using colloids over
crystalloids in terms of the overall
outcome.
· colloid may be preferable in patients with
intractable shock in the initial resuscitation.
· %he choice of colloids includes gelatin
solution (e.g. Gelafusine) and starch
solution (e.g. Voluven)
SS ÷ Fluid resuscitation
· IV Iines (Iargest branuIa possibIe),
18G, 16G, 14G
· LabeI IV drip bottIe
· Time to compIete written cIearIy
DHF GRADE 3 & 4 (DSS)
FIuId ResuscItatIon AIgorItbm
After fluid resuscitation ÷
assessment for improvement
linical parameters
· Ìmprovement of general well being/ mental state
· Warm peripheries
· apillary refill time < 2sec
· BP stable
· Ìmproving pulse pressure
· Less tachycardia
· Ìncrease in urine output
· Less tachypnoea
Laboratory parameters
· ecrease in %
· Ìmprovement in metabolic acidosis
I no Improvement aIter tbe 1
st
boIus
I no Improvement aIter tbe 2
nd
boIus
NO response to 2
nd
bolus
< Blood transfusion ASAP
< Fresh whole blood
< Ìf not available, packed cell
< Ìf patient is given bolus, arrange for GS/GXM
If im¡rovcmcni aficr iIc lolus(cs}
After 1
st
bolus fluid ÷ ÌMPROVE
ES
CIinicaI parameters must be monitored
every 15-30 minutes during shock!
**FIuid regime must be reviewed and
readjusted every 30 -60 minutes.
Recurrent episodes of shock can occur
after initiaI resuscitation (due to
continuing pIasma Ieakage) - for
nd
boIus fIuid resuscitation
Exercise 1
· 35 years old gentlemen
· Fever for 4 days
· Vomiting for 2 days
· Epigastric pain
Exercise 1
· BP 104/85
· R 108/min
· %emp 37
· Weight 60kg
· iagnosis
Exercise 1
· F Grade 3 ompensated Shock
(engue Shock Syndrome) day 4 with
warning signs in critical phase day 1
defervescense.
Exercise 1
· 2 large bore branula
· Run 10ml/kg bolus (600ml) over 30 min
· FB, VBG stat and post bolus
· GS/GXM
Exercise 1
· Post bolus
· Mild epigastric pain
· BP 110/80
· R 100/min
· ct 48 46
· Plt 85 80
· O3 19 20
Exercise 1
· Run another bolus 20ml/kg (1200cc) over
30 min
· Repeat FB, VBG post bolus
Exercise 1
· Post 2
nd
bolus
· No complaints
· BP 120/80
· R 88/min
· ct 48 46 44
· Plt 85 80 76
· O3 19 20 22
Exercise 1
· Put on ÌV drip 5cc/kg/ ( 300ml/) for 2
hours
· %o cut down further if patient improves
· Admit ward
· Ìnform ward
Exercise 2
· 28 years old gentlemen
· Fever 3 days
· Lethargy
· Body aches
· Poor urine output
· Epigastric pain
Exercise 2
· BP 95/60
· R 114/min
· %emp 37.5
· Weight 100kg
· eight 160cm
Exercise 2
· Ìdeal body weight
· Male: 50.0 kg + 0.91(height -152.4) cm
· 50 + 0.91(160 ÷ 152.4) = 56.9kg
· Actual weight 100kg
Exercise 2
· F Grade 4 (ecompensated Shock)
day 3 with warning signs in critical phase
day 1 defervescence.
Exercise 2
· 2 large bore branula
· Run 20ml/kg bolus (1140ml) fast bolus
· FB, VBG stat and post bolus
· GS/GXM
Exercise 2
· Post bolus
· omplains of giddiness
· Epigastric pain
· BP 98/60
· R 110/min
· ct 50 49
· Plt 82 50
· O3 19 18
Exercise 2
· Run another bolus 20ml/kg (1200cc) rapid
bolus
· Repeat FB, VBG post bolus
· onfirm GXM
Exercise 2
· Post 2
nd
bolus
· Still has epigastric pain
· BP 100/60
· R 114/min
· ct 50 49 42
· Plt 82 50 44
· O3 19 18 17
Exercise 2
· %ranfuse 1 pint whole blood stat
· Vital signs monitoring every 15 min
Exercise 2
· Post blood transfusion
· BP 110/70
· R 90/min
· ct 50 49 42 46
· Plt 82 50 44 50
· O3 19 18 17 20

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