Fluid Therapy in

GE Shock Vs. DSS(update 2016)

Dr. Aung Kyi WynnSenior consultant Pediatrician

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IntroductionHypovolemic shocksDifferent pathophysiologyDifferent management

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Scenario4 years old childBody weight 15 kg

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GE SHOCK OR CHOLERA SHOCK

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PathophysiologySecretory diarrheaExternal fluid loss

(water+electrolytes)-RapidFrom extravascular space ---

dehydration10% of body weight loss S/S

of shock

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Principle for GE shock treatment

Fluid out volume = Fluid in volume Rapid Refill

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Pre-illness BW estimation

Pre-illness BW = measured BW + 10% of BW 15kg = 13.5kg + 1.5kg

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Resuscitation Fluid loading doseR/L or N/S or 5% D/S25% glucose or 10% dextrose

(for hypoglycemia)

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Loading dose20 ml/kg within 15 min(300 ml)Second Loading dose if not

improved

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T0TAL FLUID PER DAYRMO/ 24 hour

Rehydration, Maintenance, Ongoing loss

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Rehydration-Plan C10% loss – 100 ml/kg100 ml * 15 kg = 1500 ml30 ml/kg in first ½ hr (450 ml)70 ml/kg in 2 ½ hr (1050 ml)Without loading dose in 30

ml/kg

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MaintenanceHolliday-Segar Method (15kg = 10 +

5 )

1st 10 kg 100ml/kg 1000ml2nd 10 - 20 kg 50ml/kg

250mlOver 20 kg 20ml/kg _ 1250 ml

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RateResuscitation loading 80ml/kg/hr

for15 minInitial 60ml/kg/hr for

30 min Later 30ml/kg/hr for

2 1/2hrs Maintenance 3ml/kg/hr for

24hrs

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Total RMORehydration 1500 mlMaintenance 1250 ml

2750 mlOngoing loss ?

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Ongoing lossFrom intake-output chart10ml/kg (150 ml) for one time of

loose motionORS(old formula) or IV line

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At least total 6 bottles of drip for 24 hr

Wide therapeutic indexLow risk for overloading

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DSS

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Pathophysiology

Immune reaction Increase vascular permeabilityPlasma leakage (directly from vascular

space)-moderate to slowThird space loss (serous cavity-internal

loss)-water+electrolytes+proteinNo dehydrationWill reenter into IVS and excreted by

kidneys in recovery phase (risk of overload)

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Loss in 4-6% of body weight (no actual weight loss) – S/S of shock

If coagulation defect +

GI bleeding

External loss

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Cause of death overload or bleeding

Death

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Principle of fluid therapy in DSS“ Just adequate “ the least fluid

volume to correct shock“ Fresh whole blood “ transfusion

is mandatory if indicated

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Loading dose (20ml/kg)-300ml within 15 minutes if BP zero (or)

20 ml/kg/hr if hypotension onlyR/L or N/S for loading , initial

replacement and maintenance Colloid - dextran 40, gelofusine

or ?Plasma 10ml/kg/hr for ongoing loss

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Type of fluidInitial stage

Isotonic fluid – R/L , N/S

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Later stageTo remain in IVS longer in later period

Osmolality and

Oncotic pressure must be above that of plasma

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OsmolalityR/L 273mosm/lNS 308mosm/l5%D/S 560mosm/l1/2strength D/S 406mosm/lDextran 40,70 310mosm/l

Gelofusine 274mosm/l Plasma 285-295mosm/l

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Indian J Anaesth. 2009 Oct; 53(5)

Characteristics of some available colloids.Product (Brand name) Conc. (%) Oncotic pressure (mmHg) Initial volume expansion (%) Albumin 25 100–120 200–400Dextran 70 (Macrodex) 6 56–68 120 Dextran 40 (Rheomacrodex) 10 168–191 200 Fluid gelatin (Geloplasma) 3 26–29 70 Plasma 28

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RateResuscitation loading 80ml/kg/hr

for15 min (or) 20ml/kg/hr for 1 hour Initial(compensated shock) 10ml/kg/hr for 1 hourLater 6ml/kg/hr for

1hourMaintenance 3ml/kg/hrAdjustment 1-2ml/kg/hr

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Replacement4% loss 5% loss 6 % loss

40 ml/kg 50 ml/kg 60 ml/kg

600 ml 750 ml 900 ml

Rate ---20ml/kg+10ml/kg+ 6ml/kg + 3ml/kg= 39ml/kg

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MaintenanceSame 1250mlwith crystalloid (N/S , ½ S D/S)

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1. Replacement 4% loss 5% loss 6% loss Crystalloid+colloid 600 ml 750 ml 900 ml 2. Maintenance Crystalloid 1250 ml 1250 ml 1250 ml

3. Ongoing loss

Colloid(or) ? ? ? Fresh whole blood ? ? ?

1850 ml 2000 ml 2150 ml 10ml/kg 10ml/kg

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Ongoing loss Plasma leakage colloid

10ml/kg/hr Dextran 40

Bleeding fresh whole blood 10ml/kg

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OPTIMUM VOLUME1 ½ of maintenance1250 * 1 ½ = 1875 mlLess than 2 times of

maintenance (<2500ml)

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BleedingShock not revived when close to

24 hr and more than 1850ml infused (OR)

Condition not improved in spite of stable PCV (OR)

Decreased PCV 20% suddenly

Fresh whole blood

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Counter checkRaised Hb G% = FWB ml/kg /6 = 10/6

=1.6 G

If raised PCV >5% wrong decision-risk of overload

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If not give FWB timely for bleeding Shock – hypoxia-----------death(or)

Overload

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CRITICAL POINT DECISION

(OVERLOAD or BLEEDING)

CAN SAVE LIFE

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Complicated casesA-acidosisB-bleedingC-calcium(hypocalcemia)S-sugar(hypoglycemia or

hyperglycemia)

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Narrow therapeutic indexType of fluid, rate, duration,

appropriate volume, timely

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Fluid Therapy in Cholera shock Vs. DSS

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CLOSE MONITORING

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ReferencesHandbook for clinical management of dengue –

WHO 2012The Harriet Lane Handbook – the Johns Hopkins

Hospital, twentieth edition,2015 Kalayanarooj Siripen and et al, clinical practice

guidelines of dengue/dengue hemorrhage fever management for Asian Economic Community, 2014

Paediatric Management Guideline – Myanmar Paediatric Society – 2nd edition - 2011

Paediatric Protocols for Malaysian hospitals – Malaysian Paediatric Association – 2nd edition – 2010

Sukanya Matra and Purva Khandelwal, Are all colloids same? How to select the right colloid?, Indian journal of anesthesia 2009 Oct 53(5)

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THANK YOU