c:\documents and settings\administrator\桌面\11 fluid therapy
DESCRIPTION
TRANSCRIPT
Fluid Therapy The first affiliated hospital SUN YAT-SEN university
Prof. Wang Huishen
王慧深
Last lesson Emphasis
Etiology(in/ex/no)
Pathogenesis(4+ex/b/v/no)
Clinical manifestation
Diagnosis DifferentialDiagnosis
(p/d/n)Treatment
Predisposing(4)
Diagnosis Not difficultAccording to clinical manifestation,
laboratory tests and character of stool.
+ +Infectious OrNoninfectious
Dehydration Degree and quality
Electrolyte disturbances
AndDisturbance of
acid-base balance
Severity clinical signs of dehydration
mild moderate severeWater loss
By weight
Spirit
SkinMocous
Anterior fontanel and eye ball
Tear
Urine output
Peripheral circulation
< 50ml/kg
< 5%
Slightly dispirited
slightly agitated
Slightly drySlightly dry
Slightlydepressed
Normal
Slightly reduced
normal
50 ~ 100ml/kg
5% ~ 10%
DispiritedAgitated
Dry, paleVery dry
depressed
Reduced
Little or No
Little cool
100 ~ 120ml/kg
> 10%
Extremely dispiritedapathy, hypnody,
coma
Gray mottledParched
depressed greatly
No
No urine output
Cool, weak
pulse,shock
Dehydration
Dehydration
Same proportion loss
P IF CP IF
C
Electrolyte lossmore
P hypotonic,IF+C hypertonic
Cell expansionSevere
Easy to shock
P: plasma, IF: interstitial fluid, C: cell
Isotonic
P IF C
Water lossmore
P hypertonicIF+C hypotonic
Cell hydrationMild
Thirsty
Acute diarrheaafter
vomiting greatly
Hypotonic Hypertonic
Na+ :130 ~150mmol/L
Na+: < 130mmol/L Na+: > 150mmol/L
Electrolyte disturbance
Diarrhea complicated
hyponatremia & hypernatremia
hypokalemia
hypocalcemia
hypomagnesemia
K+ (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L)
causes :
Excessive losses: vomit, diarrhea.
Inadequate intake.
Renal function of keeping kalium ,it continues
excluding kalium when with hypokalemia.
Clinical manifestation: electrolyte disorder
Hypokalemia
depressed
Tension of skeletal muscle , tendon reflex , even respiratory muscle weakness
Tension of smooth muscl , abdominal extension, intestinal sound or disappear
Myocardium excitability , arrhythmia, ECG: T-wave is low or inversion, U-wave occurs, prolonged P-R interval and Q-T interval, ST section descending.
Baseosis
hypokalemia K+ (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L)
Clinical manifestation: nerve and muscular excitability
Ca2+ 1.75mmol/L (7mg/dl) ; ﹤ Mg2+ 0.6mmol/L (1.5mg/dl).﹤
Symptoms usually occur after dehydration and acidosis resolved, or fluid replacement.
Clinical manifestation: thrill, tetany, convulsion.
If convulsion hasn’t relieved after supplement
calcium, pay attention to hypomagnesemia.
hypocalcemia & hypomagnesemia
Case example
An 8 – month boy had diarrhea and vomited for 3 days, urine
stream reduced, irritability. PE: Pulse rate 150/min, weight
loss was 10%, blood pressure 65/40mmHg, skin color showed
grey and skin turgor looked like tents. Mucous membranes
were very dry; eye ball was sunken greatly, anterior fontanel
depressed greatly. Abdomen distended, bowel sound
diminished.
Questions:
1.What is the diagnosis? 2.How to administer the fluid therapy?
Answer 1 (diagnosis)
Acute diarrhea severe dehydration hypokalemia
Neonate……………... 80%
Older children………..65%
Adult…………………..60%
features of body fluid balance in children
The younger The larger proportion of body water
Total body water
(by body mass)
----amount of body fluid
features of body fluid balance in children
The youngerThe larger proportion
of extracellular water
Intracellular
Body fluid
Extracellular
Interstitial fluid
Plasma
Lymph fluid
Secretory juice
----distribution of body fluid
P6%
IF37%
IC35%
IF20%
IF10%
~15%
IF25%
IC40%
P5%
P5%
P5%
IC40%
IC40%~45%
Neonate 78% ~1y 70%
2y~14y 65% Adult 55%~60%
features of body fluid balance in children
P: plasma
IF: interstitial fluid
IC: intracellular
----distribution of body fluid in different ages (by BW)
features of body fluid balance in children
----water requirement
Requiring more water
Regulating function poorly
Easy water metabolism disturbance
Due to grow quickly, need 0.5%~3% water for growth.
Insensible water loss : 2 times more than adult.
Fluid exchange of digestive tract quicker.
Water metabolism higher: infant 1/2 by total fluid
adult 1/7 by total fluid.
Regulating function of water metabolism poorly:
kidney, lung.
features of body fluid balance in children
----water requirement
◆Similar with adultExtracellular:
Na+, Cl-, Hco3-
Intracellular:
K+, Mg, Hpo4=, protein
◆Features of neonate (Several days after birth) :
Composition of body fluid
Particularly in preterm infantK+, Cl-, P, lactic acid
Na+, Ca++, Hco3-
Function of excluding H+ Acidosis
Acid-base balance and adjust
----two concept
Acid-base balance
Acidity and alkalinity
Anion-cation balance
Anion and cation
Compensation of adjust has limit
Acid-base balance and adjust
----body liquid
Buffer system
lung : exhale of store CO2 (respiratory)
kidney: exclude H+ and store Na+ (metabolic)
NaHCO3/H2CO3
Na2HPO4/NaH2PO4
Buffer system of plasma protein
Adjust HCO3- NaHCO3/H2CO3=20:1
PH : 7.4 (7.35~7.45)
PaCO2 : 40 (34~45) mmHg
SB : 24 (22~27) mmol/L
BE : -3 ~ +3 mmol/L
CO2CP : 22 (18~27) mmol/L
Acid-base index
Blood gas analysis ( normal )
Compensation & decompensation
Acid-base balance disorder
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
Dispirited, dysphoria, drowsiness, coma
Hypernea (Kussmauls breathing) , exhalation cool
Expiratory gas smells ketone
Cherry lips
Nausea, vomit
Metabolic acidosis--clinical manifestation
Mild: breath frequency slightly
Severe: occur:
To cure water and electrolyte disturbance
Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte
Normal physiological function
Fluid therapy Purpose
oral intravenous
Fluid therapy Method
prevention dehydration: Rice soup add salt solute ( 1/3 )Mild dehydration: ORS 。Mild/moderate dehydration : ORS ——mild: ORS : 50 ~ 80ml/kg ——moderate: ORS : 80 ~ 100ml/kgSevere dehydration or vomiting and diarrhea —— intravenous
NaCl : 3.5g
NaHCO3 (Sodium citrate) : 2.5g (2.9g)
KCl : 1.5g
GS : 20g
oral rehydration salts ( ORS )
Na+ 90mmol /L,K +20mmol /L,Cl - 80mmol /L, HCO3 - 30mmol /L
Add water to 1000ml 2 / 3 isotonic , Total osmotic pressure: 220mmol /LCan be diluted in Children
口服补液盐 Oral rehydration salt (ORS)
WHO2002 年推荐的低渗透压 ORS 配方 成分 含量 ( 克 )
NaCl 2.6枸橼酸钠 2.9KCl 1.5葡萄糖 13.5水 1000ml
该配方中各种电解质浓度为: Na+ 75mmol/L , K+ 20
mmol/L , C1- 65 mmol/L ,枸橼酸根 10mmol/L ,葡萄糖 75m
mol/L 。总渗透压为 245 mOsm/Lsodium citrate could instead by NaHCO3
Na + -- GS transport in Small intestine
Na+–GScarrier
enterocyteBrush border intracellularintercellularblood
Na+
GS
Na+
GS
transport
promoteNa+ 、 H2O absorb
Na+(pump) intercellular space(Cl- )OP H2O into blood
Mechanisms of ORSMechanisms of ORS
Characteristics of ORS
---Advantages
Osmotic pressure similar with plasma(2/3 tonicity)2/3 tonicity)
Correct losses by proper concentration of
Na+ 、 K+ 、 Cl-
Children easily accept the tastes
Correct metabolic acidosis by sodium citrate
Promote Na+ and H2O absorption by 2% GS
Characteristics of ORS ---disadvantages
Liquid tonicity higher (2 / 3)
Can not be used as the maintenance media
Na+ concentration is relatively higher to neonates
and infants (proper diluted) .
ORS :
Rice soup 500ml+ salt 1.75g
Fried rice noodles 25g + salt 1.75g
+ water 500ml (Cooking 2 - 3min)
GNS:
White sugar 10g + salt 1.75g + water 500ml (boil)
Simple preparation at home
Severe dehydration
intravenous
Osmotic pressure of plasma (OPP)
OPP= (crystal + colloid) osmotic pressure
Na+ 142 Cation: K+ 5(mmol) Ca++ 2.5 Mg++ 1.5
HCO3- 27
Anion: Cl- 103 (mmol) HPO4
= 1 SO4
= 0.5 Organo-anion 19.5
151 mmol/L 151 mmol/L
OPP range : 280 - 320mOsm/L
Concentration of electrolyte and calculation
Osmotic pressure, osmol ( OSM )
Dissolve 1mmol solute into 100ml water: 1mOsm.
100ml water
1mmol1mOsm
Concentration of electrolyte and calculation
To non electrolyte
1mmolGS 1mOsm
2mOsm1mmolNacl
To electrolyte
1mmolCacl2
3mOsm
Concentration of electrolyte and calculation
Na:Cl=3:2 ( in plasma )
Fluid isotonic
Isotonic liquid: osmotic pressure similar with plasma
Sodium isotonic:Isotonic: 150mmol sodium in 1000ml
½ tonicity: 75mmol sodium in 1000ml
2/3 tonicity: 100mmol sodium in 1000ml
1/3 tonicity: 50mmol sodium in 1000ml
Liquid solution commonly used
5%GS
10%GS
0.9%NaCl
10%NaCl
Ringer
5% NaHCO3 11.2% NaL
10%KCl
Mixture
nonelectrolyte solution
electrolyte solution
glucose enter the body by oxidation change into water and CO2 for energy and water without tension
Percentage concentration: 5%GS 、 10%NaCl
Molar (mol, gram molecular weight) , mmol 1 mol NaCl=23+35.5=58.5g
Molarity (mol/L)
calculation :
mol/L=
e.g. 0.9%NaCl= =0.154mol/L
Concentration of electrolyte and calculation
Percentage concentration of solute ( % ) 10
Molecular weight (atomic weight)
0.9×10
58.5=154mmol/L
10%NaCl : 1ml=1.7mmol
5%NaHCO3 : 1ml=0.6mmol
11.2%NaL : 1ml=1mmol
10%KCl : 1ml=1.34mmol
Calculation
The element and simple dispensing in the commonly mixed solution
Solution composition ratio dispensing (ml)
NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl
2:1 isotonic solution . 2 1 500 30 47
1:1 solution (1/2 tonicity) 1 1 500 20
2:3:1 solution (1/2tonicity)2 3 1 500 15 24
4:3:2 solution (2/3tonicity)4 3 2 500 20 33
1:2 solution (1/3 tonicity)1 2 500 15
1:4 solution (1/5 tonicity) 1 4 500 9
daily requirementrequirement (1/3tonic) 1 4 500 9 7.5
常用溶液成分溶 液 每 100ml 含 Na∶Cl 电解质渗透压
血 浆 ( 142 : 103 ) 3 : 2 300mmol/L
①0.9% 氯化钠 0.9g 1∶1 等张
②5% 或 10% 葡萄糖 5 或 10g
③5% 碳酸氢钠 5g 3.5 张
④1.4% 碳酸氢钠 1.4g 等张
⑤10% 氯化钾 10g 8.9 张
溶 液 每 100ml 含 Na∶Cl 电解质
1∶1 含钠液 ① 50ml,②50ml 1∶1 1/2 张
1∶2 含钠液 ① 35ml,②65ml 1∶1 1/3 张
1∶4 含钠液 ① 20ml,②80ml 1∶1 1/5 张
2∶1 含钠液 ① 65ml,④35ml 3∶2 等张
2∶3∶1 含钠液 ① 33ml,②50ml
④17ml 3∶2 1/2 张
4∶3∶2 含钠液 ① 45ml,②33ml 3∶2 2/3 张
④22ml
续 表
Water supplement & correct acidosis
Accumulative losses ---losses from onset to pre-treatment
ongoing losses
---continuing losses during treatment
daily requirement ---to maintain basically physiological function
Amount , composition and time
The first day fluid infusion :
Dehydration Fluid replacement=losses (Accumulation + ongoing + daily )
Accumulation ongoing daily total amount (ml/Kg)
mild 50 10~30 60~80 90~120
moderate 50~100 10~30 60~80 120~150
Severe 100~120 10~30 60~80 150~180
Accumulation: accumulation lossesOngoing: Ongoing lossesOngoing lossesdaily: Physiological requirementPhysiological requirement
Severity clinical signs of dehydration
mild moderate severeWater loss
By weight
Spirit
SkinMocous
Anterior fontanel and eye ball
Tear
Urine output
Peripheral circulation
< 50ml/kg
< 5%
Slightly dispirited
slightly agitated
Slightly drySlightly dry
Slightlydepressed
Normal
Slightly reduced
normal
50 ~ 100ml/kg
5% ~ 10%
DispiritedAgitated
Dry, paleVery dry
depressed
Reduced
Little or No
Little cool
100 ~ 120ml/kg
> 10%
Extremely dispiritedapathy, hypnody,
coma
Gray mottledParched
depressed greatly
No
No urine output
Cool, weak
pulse,shock
Dehydration
AccumulationAccumulationlosseslosses
amount
mild : 50ml/kg
moderate: 50~100ml/kgsevere : 100~120ml/kg
Water supplement-1: accumulation losses
Amount , composition and speed:
--- according to the degree and quality of dehydration
composition
isotonic : 1/2 tonicity(1:1)hypotonic : 2/3 tonicity(4:3:1)Hypertonic:1/3~1/5 tonicity (1/3 tonicity)
speed
Principle: fast slowsevere : bolus of isotonic fluid
2:1 isotonic : 20ml/kg(<300ml)
in 30’~1h(rapidly expand) others : 8~12h (8 ~ 10ml/ ( kg·h ) iv
Water supplement-1: accumulation losses
AccumulationAccumulationlosseslosses
Dehydration :
OngoingOngoinglosseslosses
amount
1/2~1/3 tonicity(1:1)
speed
12~16h after stage-1 In 24h, steady speed 5ml/ ( kg·h )
10~40ml/kg.d
composition
Water supplement-2: ongoing losses
dailydailyrequirementrequirement
amount
1/3~1/5 tonicity(Physical main medium)
speed
In 24h, steady speedAccompany with stage-2
60~80ml/kg.d( including oral )
composition
Water supplement-3: daily requirement
To master three principles
The volum of rehydration- AmountDeficit fluid
=(percentage of dehydration)×(body weight in Kg)
The type of fluid- CompositionIsotonic dehydration——1/2 tonicity solution
Hypotonic dehydration——2/3 tonicity solution
Hypertonic dehydration——1/3 tonicity solution
The speed of liquid-Time : four steps
four steps(for fluid and electrolyte deficits)
Step 1. Expanding volume: restoration of circulation –emergency,
within 30 min to 1 hour
20ml/kg, 2:1 (isotonic )sodium solution
Step 2. supplement lost body liquid: first 8~10 hours
8~10ml/h
half of total loss volume
2:3:1 solution(1/2 tonicity)
Step 3. maintenance rehydration: - another half loss
- next 16 hours
5ml/(kg.h)
physical demand : 60~80ml/kg
4:1 solution(1/3~1/2 tonicity)
Step 4. repair of potassium deficit
four steps
mild : correct etiological factor
Moderat & severe :Alkaline solution requirement (mmol)
(40 –CO2CP Vol%)
2.2
= (22 - CO2CP mmol/L) 0.7 kg
= BE 0.3 kg
0.7 kg
Usually use the dose halved first and than according to blood gas analyses
Correct acidosis
=
Emergency :
Per-elevate 5mmol HCO3- 5mmol/L(10% CO2-CP)
need alkaline solution: 3mmol/kg
5%NaHco3 5ml/kg or 1.4% NaHco320ml/kg
Correct acidosis
Supplement potassium: 10%KCL
mild hypokalemia : 200~300mg/ ( kg·
d ) 2~3ml/ ( kg·d ) oral
sever hypokalemia : 300~450mg/ ( kg·
d ) 3~4.5ml/kg.d 10% KCl ivdrip
Supplement after urine or urination before coming diagnoses
Intravenous concentration<0.3% in the solute
speed : >6~8h/d ( intravenous )Time : keep 4 ~ 6 day
interdiction : directly intravenous , because heart stop !
Supplement potassium principle :
Supplement Calcium and Magnesium
Convulsion emerged : 10% Calcium Gluconate 10ml+25% Glucose 10ml IV
If convulsion hasn’t relieved after supplement calcium, ——give 25% Mg.Sulfas 0.2~0.4ml/kg deeply IM Q6h
be careful ( Calcium ) : HR<80 time /minute , stop ! Don’t leak out vessel Interval of the Digitalis Don’t injection with subcutaneous and intramuscular
first fast then slow
Principles of TherapyPrinciples of Therapy
first thick then thin
supplement potassium when having urine
adjust any time and monitor
Ongoing losses and Ongoing losses and daily requirementrequirement
daily requirementrequirement 60~80ml/kg (1/3~1/5 tonicity)
Ongoing losses follow the how much of the lostOngoing losses follow the how much of the lost in the any time ( in the any time ( 1/2~1/3 tonicity)
12~24H equal the speed iv drip
To continue the supplement potassium and correct acidosis
The second day fluid infusion :
Neonate: to reduce the liquid and electrolytes
properly.
Severe malnutrition : to reduce the water
amount properly, with low speed, 2/3~1/2 tonic
supplement 10% GS and / or plasma
Notes
An 8 – month boy had diarrhea and vomited for 3 days,
urine stream reduced, irritability.
PE: Pulse rate 150/min, weight loss was 10%, blood
pressure 65/40mmHg, skin color showed grey and skin
turgor looked like tents. Mucous membranes were very
dry; eye ball was sunken greatly, anterior fontanel
depressed greatly. Abdomen extended, bowel sound
diminished.
Answer question 2How to administer the fluid therapy?
The first day fluid infusion :
Dehydration Fluid replacement=losses (Accumulation + ongoing + daily )
Accumulation ongoing daily total amount (ml/Kg)
mild 50 10~30 60~80 90~120
moderate 50~100 10~30 60~80 120~150
Severe 100~120 10~30 60~80 150~180
Accumulation: accumulation lossesOngoing: Ongoing lossesOngoing lossesdaily: Physiological requirementPhysiological requirement
Step 1 : Plan supplementary fluid.
First body weight is calculated by
formula of growth and development section.
——(6+8×0.25=8kg)
——2:1 sodium :20ml×8=160ml
——finished intravenously within 30min.
Step 2 : Acute loss
be always isotonic dehydration, so we choose :
——2:3:1 (2:glucose , 3: sodium, 1: 1.4% bicarbonate )
——that belong to 1/2 tonicity.
——Repair of water and sodium deficits
● first 8-10 hours 8-10 ml/(kg·h)
● half of total loss volume
(160×8)ml/2=640 ml.
Step 3. : 4:1 sodium
● be taken next 16 hours
5 ml/(kg·h)
● 80 ml/kg×8kg=640 ml (another half)
Step 4 : Potassium supplement
8kg×0.4g=3.2g/d. That means about 10% potassium chloride solution
32ml will be used by intravenous infusion. Notice supplement potassium
——when urine stream must be seen;
——meanwhile, be aware of concentration(<0.3%)
——speed and time of it.