Post on 10-Mar-2020
Introduction to fluid therapyPlenary lecture
Dr. Vizi Zsuzsanna
2018.
The beginning… 1832
1830-ies : Dr. Thomas Latta
1880-ies: Hartog Jacob Hamburger:
„physiological” saline
1880-ies Sidney Ringer
1930ies: Alexis Hartmann:→ Lactated Ringer Hartmann
Fluid balance
Fluid loss:-„ daily obligatory”:
-Sensible: urine, feaces-Insensible: panting, evaporation
- Pathologic: vomitus, salivation, diarrhea, polyuria
Fluid intake:
Eating/drinking40-60 ml/kg/day
Questions to answer…
What?
How much?
How fast?
Dehydration: lack of fluid
the intersticial and
intracellular space
Definitions
Hypovolemia: Lack of
fluid in the intravascular
space
Examination of the fluid homeostasis
Physical exam:
Dehydration and
perfusion parameters
Simple lab tests (PCV,
TP, USG)
Bodyweight
measurement
Blood pressure
Examination and estimation of dehydration
Grade of dehydration in the % of BW
• < 5% - can not be detected
• 5-6% - tachy MM
• 6-8% - decreased skin turgor, dry MM
• 8-10% - + enophtalmus
• 10-12% persistent skin tenting,
cloudy cornea, hypovolaemia
• >12% hypovolaemic shock and death
History: anorexia, hypodipsia, vomiting, diarrhea, etc.
Dryness of MM – BUT salivation, nausea
Skin turgor – BUT obese or old or cachectic animals
Position of the eyesESTIMATION!!
Examination of hypovolemia
• Perfusion parameters:
– Colour of MM
– CRT
– Heart rate
– Pulse quality
– (jugular vein distention)
Threshold values:→ Not pink (red or pale)→>2 sec→ D>140/min,
C <140 or >240/min→Weak/bounding, irregular
The types of the infusions
Classification of the infusion
CrystalloidsSmall molecular weight compounds
(electrolytes, glucose)
• Isotonic
– 0,9% NaCl (Salsol A), Ringer, Lactated Ringer, Sterofundin
• Hypotonic
– 5% Glucose, 0,45% NaCl(Salsol B), Balansol, Rindex
• Hypertonic
– NaCl 10 % inj.
ColloidsLarge molecular weight compounds
(starch, proteins)
• Syntetic
- Starch (HAES)
- Gelatine
• Natural
- Human albumin
- Blood products (plazma, blood)
Na+
Distribution of the infusions in the fluid compartments
IV IS ICHypotonic/
Glucose solutions 13 % 32% 55%
Isotonic solutions
20-30% 70-80%
Hypertonicsolutions >300 %
Colloids 70-100%
Hyperoncoticsolutions 100-140%
Dr. Joris Robben (Utrecht) nyomán
WHAT? HOW FAST?
Hypovolaemia Dehydration
Quickly! Minutes or hours (i.v., i.o.)
Slower (1-2 days) -mild: p.os, s.c.-Moderate to severe: i.v.
Isotonic crystalloids+
Colloid and/orHypertonic saline
Isotonic crystalloids
ACUTEFluid resuscitation
CHRONICrehydration, maintanance
ACUTE therapy – FLUID RESUSCITATION
The GOAL is not the administration of a certain amount of
fluid, but the normalisation of the vital signs!
• First choice: Isotonic crystalloids– (Dog: 60-90 ml/kg/h; Cat: 45-60 ml/kg/h )
– Recommendation: 10-20 ml/kg boluses in 15-20 min
• Colloids – eg. HAES – in combination with crystalloids– Dog: 10-20 ml/kg, Cat: 5-10 ml/kg
– 2-5 ml/kg boluses in 10-20 minutes
• Hypertonic saline 4-7 ml/kg (dog); 2-4 ml/kg (cat)
Re-evaluate! – and gear to the findings
General condition Dehydration or hypovolaemia
Signs of overhydrationBodyweight!!
PCV, lactate, electrolytes
„Chronic” fluid therapy
Rehydration
• Correct dehydration
Maintanace therapy
• Correction of obligatory fluid losses
• Not eating/not drinking
Correct ongoing losses
• Ongoing diarrhea/vomitus, polyuria
• Drained fluids
REHYDRATION• Depends on: condition of the patients, lab results
• Mainly isotonic crystalloids
• Lactated Ringer, Isolyte, Sterofundin G, Ringerfundin, Ringer, 0,9%NaCl
• Electrolyte components are similar to EC space
– Na(131-150 mmol/l), K: (4 mmol/l)
Deficit (ml) = kg x 10 x dehydration %Eg. 10 kg- dog with 8% dehydration: 10 x 10x 8 = 800 ml
• How fast? Rate of fluid loss Rehidráció sebessége
Acute deficit 2-4 hours→ fluid resuscitaion
In 12-24 hours 4-8 hours
Chronic deficit 12-24-48 hours
MAINTANANCE THERAPY
• Daily requirement (if noteating/drinking)
• Daily „obligatory fluid losses” (urine, feaces, panting) – usually
hypotonic, Na (65-78 mmol/l), K (18-25 mmol/l)
• Maintanace infusion: Hypotonic→ Distribution in everycompartment! Can NOT be applied in boluses
• EG. Sterofundin B, Sterovet, Balansol inf.
• „Home made” maintanance recipe
• 1 part 0,9 % NaCl + 1 part 5% Glucose
+ 20 mmol/l KCl• Rate: K+: max 0,5 mmol/kg/h
MAINTANANCE THERAPY – HOW MUCH?• RER (resting energy requirements) 1 kcal=1ml– RER = 97 x kg0,655 ?
– RER = 70 x kg0,75
AAHA/AAFP 2013:
C: 80 x kg0,75
D:132 x kg0,75
• 40-60 ml/kg/day
• 2-3 ml/kg/hour
0
500
1000
1500
2000
2500
3000
3500
4000
1 5 10 15 20 25 30 35 40 45 50
ml
Bodyweight (kg)
Maintanace needs
3ml/h
50 ml/kg
97xttkg^0,655
132xttkg^0,75
Complications of fluid therapy
• Overhydration➢ Weight gain➢ Serous nasal discharge➢ Chemosis➢ Restlessness➢ Gelly-like subcutis➢ Tremor➢ Tachycardia➢ Couging
➢ Tachypnoe / Dyspnoe➢ Ascites➢ Polyuria➢ Exophtalmus➢ Vomitus/diarrhea
• Venous catheter complicaitons: ✓ Paravenous infusion✓ Thrombophlebitis✓ Infection (septicaemia)
Discontinuation of fluid therapy• Gradually decrease 25-50% / day
• Medullary wash out → Decreased ability toproduce concentrate urine→dehydration/hypovolaemia
• Info for the owner: polydipsia for a few days(oral rehydration solutions)
3 things as „take home message”
If you don’t know what to give, Choose Lactated Ringer
Take care of iv catheters!
Monitor the effectand recalculate if necessary !