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Introduction
Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively, and postoperatively, as well as in response to trauma and sepsis.
Understanding the physiologic mechanisms that regulate the composition and volume of the body fluids and the principles of fluid and electrolyte therapy is essential for optimal patient management such for nutrient, apply medicine and maintaining acid base balance.
Definition
The body fluid is a liquid suspension of cells in the body of multicellular creatures such as humans or animals that have specific physiological functions.
Diffusion
movement of molecules through the pores.The solution will move from high concentration to the low concentration solution. Vascular hydrostatic pressure will push the water inlet diffuses through the pores. Thus, diffusion depends on the different concentration and hydrostatic pressure.
Volume Overload
Volume overload is a condition caused by iatrogenic (intravenous fluids such as saline which causes excess water and sodium chloride or glucose intravenous fluids that cause excess water) or be secondary to renal insufficiency (GFR interference), cirrhosis, or congestive heart failure.
Sodium Imbalance
Sodium Imbalance
Potassium Imbalance
Hipokalemia (levels of potassium <3 mEq / L), Signs and symptoms of hypokalemia can be disritmik heart, ECG changes (QRS widening segment, ST segment depression, postural hypotension, skeletal muscle weakness, polyuria, glucose intolerance. Therapy: infusion of potassium chloride to 10 mEq / hour (for mild hypokalemia;> 2 mEq / L) or intravenous potassium chloride and 40 mEq / h with monitoring by ECG (for severe hypokalemia; <2mEq / L with ECG changes, severe muscle weakness) . Counting Formula Potassium Deficit: K = K1 - K0 x 0.3 x BB
K = potassium needed K1 = the desired serum potassium K0 = measured serum potassium B = weight (kg)
Hiperkalemia (potassium levels> 5 mEq / L, Often due to renal insufficiency or drug that limits the excretion of potassium (NSAIDs, ACE-inhibitors, cyclosporin, diuretics). Signs and symptoms primarily involve the central nervous system (paresthesias, muscle weakness) and cardiovascular system (disritmik, ECG changes). Therapy for hyperkalemia may include intravenous calcium chloride 10% in 10 min, 50-100 mEq of sodium bicarbonate in 5-10 minutes, or diuretics, hemodialysis.
Respiratory Acidosis
(pH <3.75 and PaCO2> 45 mmHg) This condition is associated with CO2 retention secondary to decrease alveolar ventilation in surgical patients.
Acute events are the result of inadequate ventilation include airway obstruction, atelectasis, pneumonia, pleural effusion, upper abdominal pain from the incision, abdominal distension and excessive use of narcotics.
Management involves adequate correction of the defect pulmonary, endotracheal intubation and mechanical ventilation if necessary.
Respiratory Alkalosis
(pH> 7.45 and PaCO2 <35 mmHg) This condition is caused by fear, pain, hypoxia, CNS injury, and assisted ventilation. In the acute phase, normal serum bicarbonate concentration, and alkalosis occurs as a result of the rapid decrease in PaCO2. Therapy: sedation, analgesia, mechanical ventilators, and correction of potassium deficits that occur
Metabolic Acidosis
(pH <7.35 and bicarbonate <21 mEq / L This condition is caused by the retention or addition of acid or loss of bicarbonate. The most common causes include diarrhea, kidney failure, small bowel fistulas, diabetic ketoacidosis, and lactic acidosis, shock. Initial compensation that occurs is increased ventilation and PaCO2 depression.
Therapy should be directed toward correction of the underlying disorder. Bicarbonate therapy is only for handling severe acidosis and respiratory alkalosis only after compensation is used.
Metabolic Alkalosis
(pH> 7.45 and bicarbonate> 27 mEq / L) This disorder is a result of the loss or addition of acid and bicarbonate exacerbated by hypokalemia. A common problem in surgical patients is hipokloremik (hypokalaemic effect of extracellular volume deficit). The therapy used was isotonic sodium chloride and potassium deficiency replacement. Alkalosis should be gradual correction over during the period of 24 hours by measuring pH, PaCO2 and serum electrolytes often.
Fluid Theraphy
Fluid therapy is action to maintain, replace fluids within physiological limits with crystalloid fluids (electrolyte) or colloid (plasma expanders) intravenously
Fluid therapy serves to replace the fluid deficit during fasting before and after surgery, during surgery routine needs replacing, replace bleeding occurred, and replace fluids move into the third cavity.
Resuscitation fluid therapy can be performed with the infusion Normal Saline (NS), Ringer Acetate (RA), or Ringer's lactate (RL) of 20 ml / kg for 30-60 minutes. In hemorrhagic shock can be given 2-3 L in 10 minutes.
Maintenance Therapy
Objective: maintain the balance of body fluids and nutrients.
Average adult requires: liquid 40 ml / kg / day The main electrolyte: Na + = 1-2 mmol / kg / day K + = 1 mmol / kg / day.
The need for replacement fluid is lost due to the formation of urine, gastrointestinal secretion, sweating and expenditures through the lungs, known as Insensible Water Losses.
Strategies for rehydration should take into account: a deficit of fluids, fluid maintenance and ongoing fluid losses.
How rehydration: Calculate the degree of dehydration (Dehydration = D) The degree of dehydration Adults Infants and Children Mild dehydration 5% 4% Medium 6% 10% Severe 8% 15%
The amount of fluid given = degree of dehydration (%) x BB x 1000 ml 2. Calculate maintenance fluid. (Maintenence = M) Infants and Children: formula 4, 2, 1 (Holliday Segar) Adults: 40 ml/kg/24 hours 3. Fluid (Guillot). First 6 hours = D + M Next 18 hours = D + M
With the induction of anesthesia, compensatory mechanisms are lost and hypotension will develop if volume deficits are not appropriately corrected Blood loss during surgery, open abdominal surgeries, Large soft tissue wounds, complex fractures with associated soft tissue injury, and burns all have additional third-space losses that must be considered in the operating room.
Before surgery patients will be fasted for 6 hours (adults) or 4 hours (infantsand children) Substances lost during fasting, every hour: Water 60 ml 2.6 g KH Na + 1.8 mEq Fat 5.6 g K + 2.4 mEq Protein 6.4 g Fluids ongoing operations: Substitute fasting 2 ml / kg / hour Maintenance of 2 ml / kg / hour Stress operation: Adults Minor surgery 4 ml / kg / hour Mild surgery 6 ml / kg / hour Major surgery 8 ml / kg / hour
The first 8 hours total requirement The next 16 hours remaining needs
Within 24 hours II Within 24 hours III the amount of liquid the first day the amount of fluid second day
Within 24 hours of II
Ringer lactate: x 4 x BB x% burn
Hemmorrhage
Variabel Systole (mmHg) HR (x/menit) RR (x/menit) Mental Blood Lost Theraphy Grade I > 110 < 100 16 Grade II > 100 >> 100 16-20 Grade III < 90 >>120 21-26 confused Grade IV << 90 >> 140 > 26 lethargy
anxious agitated
750ml 750-1500ml 1500-2000ml >2000ml < 15 % 15-30% 30-40 % > 40 % Crystaloid Crystaloid Crystaloid Crystaloid Blood Blood Surgery
WHOLE BLOOD transfusion may use or PACKED RED CELLS. For acute bleeding, use Whole Blood. Criteria for transfusion with Packed Red Cells: Hb <7 g / dL Hb 7-10 g / dL, normovolemik accompanied by signs myocardial disorders, cerebral and respiratory Bleeding great: 10 ml / kg in the first 1 hour or> 5 ml / kg in the first 3 hours To increase Hb, transfusion with: Whole blood: (HBX - Hb patients) x BB x 6 =. . . ml Packed red cells: (HBX - Hb patients) x B x 3 =. . . ml
Hipovolemic Shock
The body loses intravascular and interstitial fluid, there was extensive burns, severe vomiting and diarrhea, severe sepsis, diabetes, use of diuretics strong, ileus obstruction. The response of the body against bleeding depends on the volume, speed, and duration of bleeding. When intravascular volume is reduced, the body will always try to maintain perfusion of vital organs (heart and brain) at the expense of perfusion of other organs such as the kidneys, liver, and skin. The goal of therapy: normalize the intravascular and interstitial volume. Marked with the unstable vital signs and urine output is less. Returns plasma and interstitial volume is only possible when given a combination of colloidal fluids (blood, plasma, dextran, etc.) and saline balance.
When it is clear there is an increase in the content of the pulse and blood pressure, the infusion should be slowed. The danger of rapid infusion is pulmonary edema, especially elderly patients.
Crystalloid Group: is isotonic, so effective in filling a volume of fluid (volume expanders) into a blood vessel in a short time, and is useful in patients who need liqiud soon
1. Ringer's Lactate (RL) Most physiological fluids if necessary volumes. Widely used as a replacement fluid therapy (resuscitation or replacement therapy), for example: hypovolemic shock, diarrhea, trauma and burns.
Lactate in the RL will be metabolized by the liver to bicarbonate to improve the situation, such as metabolic acidosis. Potassium in RL is not enough for their daily needs, especially in the case of potassium deficit. Does not contain glucose, so that as fluid maintenance (maintenance) should be added glucose to prevent ketosis. Giving maximum 2000 ml per day.
2. NaCl 0.9% (normal saline) Used as fluid resuscitation (replacement therapy), especially in the case of: low levels of Na + if RL does not match (alkalosis, retention of K +) fluid selected for head trauma to dilute eritosit before transfusion Has shortcomings: does not contain HCO3 does not contain K + levels of Na + and Cl-are relatively high, so it can Hyperchloraemia acidosis, dilutional acidosis, and hypernatremia
3. Dextrose 5% Used as fluid maintenance (maintenance) in patients with limiting sodium intake or as a substitute for the pure liquid water deficit. Perioperative Use: ongoing metabolism provide for water prevent hypoglycemia maintaining existing protein; required at least 100 g of carbohydrate to prevent katabolism of body protein content reduce levels of free fatty acids and ketone prevent ketosis, it takes a minimum of 200 g carbohydrate
Dextrose 5% should not be given to patients with head trauma (neuro-trauma) as dextrose and water will move freely into the brain cells. In the brain cells (intracellular), dextrose will be metabolized which causes brain edema.
Colloids Group molecular size (typically a protein) is large enough so it will not come out of the capillary membrane, and remain in the blood vessels, the hypertonic nature, and can draw fluid from outside the blood vessels.
1. HES (Hydroxyethyl Starch) a. Solvent NaCl 0.9%: Wida HES, HES sterile b. Solvent Electrolyte balanced: FIMAHES 2. gelatin 3. dextran 4. albumin
Advantages HES: plug leaks (sealing effect) It has anti-inflammatory effects, by inhibiting the production of inflammatory mediators NF-kappa , so it can be used on cases of inflammation (sepsis)
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