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FLUID MANAGEMENT (GENERAL)

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FLUID MANAGEMENT (GENERAL)

Uploaded by

olivermugambim
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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FLUID MANAGEMENT

Assessment of water/electrolyte disorders

 History – clinical examination - laboratory

History

 Vomiting
 Diarrhea
 Polydipsia
 Exposure to heat
 Thirst
 Psychiatric illness
 Note severity of vomiting, diarrhea, drinking, etc

Examination

 Dehydration: Dry mucus membranes, dry shrunken


tongue, sunken eyes, flat veins, sunken fontanelles, low
blood pressure, high pulse rate, postural haemodynamic
changes
 Water/Salt Retention: oedema, neck vein distension,
ascitis, congestive heart failure, drowsiness, weakness,
convulsions

Laboratory

 Dehydration: low urine output, high urine osmolarlity and


specific gravity, raised urea/creatinine, elevated serum
osmolarlity, raised haematocrit, elevated protein level.
 Serial measurements more diagnostic and helpful during
management

Extend of Dehydration

 Upto
→ 5%
→ 5 – 10%
→ 10 – 15%
→ 15 – 20%
→ >20%

Fluid Management

Consider:

1. Pathophysiology of the Disease: What has been lost –


water alone, water with electrolytes, plasma, blood
(ketoacidosis, diarrhea/vomiting, intestinal obstruction,
burns, etc)
2. Quantify the amount of loss/deficit (from history, clinical,
laboratory, different formulae), weight
3. Determine the amount of fluid required in a given time
(say – 24 hr)
 Deficit/loss + on going losses + maintenance
 Roughly: Dehydration
a) 5% - 50ml/kg + maintenance
b) 10% - 100ml/kg + maintenance
c) 15% - 150ml/kg + maintenance
4. Select the most appropriate fluid(s) for replacement

Phases of fluid replacement

1. Resuscitation – 20 – 40min – upto 1 hr to restore


intravascular volume:
 Give upto 40% of half amount to be given in 24 hours
2. Repletion phase – 5 – 8 hrs – to replenish ECF (interstitial):
 60% of half of 24 hr period
3. Early recovery phase
 16 – 24 hrs
 To replenish intracellular volume
 Rest of half of 24 hrs to be given

 Warm Fluids to 37-38C to avoid hypothermia


 Monitor clinical + laboratory data for guidance

Water intoxication management


Elevated body water

 May be associated with reduced normal or increased


sodium
 Water excess + hyponatriemia – associated with reduced
ability to excrete free water (reduced delivery of fluid to
the diluting segment of the nephron, reduced GRF, CHF,
Cirrhosis + ascites, nephrotic syndrome, myxedema, etc)
 Loop diuretics (frusemide/thiazides), Bartters syndrome –
lead to decrease in solute resorption in the diluting
segment
 Increased water resorption in the collecting duct (ADH,
glucocorticoid deficiency): Primary polydypsia – leads to
hyponatriemia and fluid excess
 Water excess with normal sodium: Occurs mostly in heart
failure, liver and kidney failure
 Water excess with hypernatriemia may occur during
infusion of a patient with normal/hypertonic saline in renal
impairment

Treatment

Mild

 Restriction of intake (water)


 Inactivity (several days)

Severe

 Hypertonic saline (1, 8, 3, 5%) to induce diuresis


 ADH antagonists (demeclocycline ≥ 600mg – nephrogenic
diabetes insipitus)
 Dialysis (Renal Failure)

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