PRINCIPLES OF FLUID THERAPY ON THE BASIS OF SEVERITY OF LOSS OF BODY FLUID AND NUTRITIONAL STATUS:

RECOMMENDED TYPES OF IV FLUIDS AND ORAL FLUIDS

(ORS, RESOMAL).
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Hendry Robert, MD Group 7 Facilitator: Dr Ntogwisangu

Introduction
Fluid therapy is therapy whose basic objective is to restore the volume and composition of the body fluids to normal with respect to water-electrolyte balance. Volume and composition derangement may be as a result of inadequate fluid intake or abnormally rapid losses of body fluids (example in haemorrhage, diarrhoea, vomiting, burn etc). Fluids may be administered intravenously or orally.

Intravenous fluid therapy

Is the giving of substances(IV fluids) directly into a vein (May also be give intraosseous). Types of IV Fluids 1. Isotonic fluids 2. Hypotonic fluids 3. Hypertonic fluids

Isotonic fluids
Osmolarity is similar to that of serum. These fluids remain intravascularly mommentarily, thus expanding the volume. Helpful with patients who are hypotensive or hypovolemic. Risk of fluid overloading exists. Therefore, be careful in patients with left ventricular dysfunction, history of CHF or hypertension. Avoid volume hyperexpansion in patients with intracranial pathology or space occupying lesions. Example: 0.9% Normal Saline Basically Salt and Water

Hypotonic fluids
Less osmolarity than serum (meaning: in general less sodium ion concentration than serum) These fluids DILUTE serum thus decreasing osmolarity. Water moves from the vascular compartment into the interstitial fluid compartment interstitial fluid becomes diluted osmolarity descreases water is drawn into adjacent cells. These are helpful when cells are dehydrated from conditions or treatments such as dialysis or diuretics or patients with DKA (high serum glucose causes fluid to move out of the cells into the vascular and interstitial compartments). Caution with use because sudden fluid shifts from the intravascular space to cells can cause cardiovascular collapse and increased ICP in certain patients. Example:0.45% Normal saline = Half Normal Saline hypotonic saline

Hypertonic fluids
These have a higher osmolarity than serum. These fluids pull fluid and sometimes electrolytes from the intracellular/interstitial compartments into the intravascular compartments. Useful for stabilizing blood pressure, increasing urine output, correcting hypotonic hyponatremia and decreasing edema. These can be dangerous in the setting of cell dehydration Example:1.8, 3.0, 7.0, 7.5 and 10% Saline = hypertonic saline

Main Groups of IV Fluids

Crystalloids Colloids Crystalloids Clear solutions fluids- made up of water & electrolyte solutions; small molecules. These fluids are good for volume expansion. However, both water & electrolytes will cross a semi-permeable membrane into the interstitial space and achieve equilibrium in 2-3 hours. Remember: 3mL of isotonic crystalloid solution are needed to replace 1mL of patient blood. This is because approximately 2/3rds of the solution will leave the vascular space in approx. 1 hour. In the management of hemorrhage, initial replacement should not exceed 3L before you start using whole blood because of risk of edema, especially pulmonary edema Some of the advantages of crystalloids are that they are inexpensive, easy to store with long shelf life, readily available with a very low incidence of adverse reactions, and there are a variety of formulations that are available that are effective for use as replacement fluids or maintenance fluids. A major disadvantage is that it takes approximately 2-3 x volume of a crystalloid to cause the same intravascular expansion as a single volume of colloid.

Composition of commonly used crystalloids

Colloids Colloids are large molecular weight solutions (nominally MW > 30,000 daltons)> These solutes are macormolecular substances made of gelatinous solutions which have particles suspended in solution and do NOT readily cross semi-permeable membranes or form sediments. Because of their high osmolarities, these are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries. These work well in reducing edema because they draw fluid from the interstitial and intracellular compartments into the vascular compartments. Initially these fluids stay almost entirely in the intravascular space for a prolonged period of time compared to crystalloids. These will leak out of the intravascular space when the capillary permeability is deranged or leaky. Albumin solutions are available for use as colloids for volume expansion in the setting of CHF however albumin is in short supply right now. There are other solutions containing artificial colloids available.

Principles of fluid therapy

Hypovolemia
True volume depletion, or hypovolemia, usually refers to a state of combined salt and water loss exceeding intake which leads to ECF volume contraction. The loss of sodium may be renal or extrarenal. ECF volume contraction is manifested as a decreased plasma volume and hypotension. Signs of intravascular volume contraction include decreased jugular venous pressure, postural hypotension, and postural tachycardia. Larger and more acute fluid losses lead to hypovolemic shock and manifest as hypotension, tachycardia, peripheral vasoconstriction, & hypoperfusion

Hypovolemia Etiologies With ECF Volume Contraction

Extrarenal Na+ Losses: GI: vomiting, NG suction, drainage, fistual, diarrhea Skin/Respiratory: insensible losses, sweat, burns Hemorrhage Renal Na+ and H2O Losses: Diuretics Osmotic Diuresis Hypoaldosteronism Salt-wasting Nephropathies Renal Water Loss Diabetes Insipidus (central or nephrogenic)

Hypovolemia Etiologies With ECF Volume Normal or Expanded

Decreased Cardiac Output Myocardial, Valvular or Pericardial Disease Redistribution Hypoalbuminemia: hepatic, cirrhosis, nephrotic syndrome Capillary Leak: acute pancreatitis, ischemic bowl, rhabdomyolysis Increased Venous Capacitance Sepsis

Principles of Treatment of Hypovolemia

The goals of treatment is to restore normovolemia with fluid similar in composition to that lost and replace ongoing losses. Mild volume losses can be corrected via oral rout. More severe hypovolemia requires IV therapy. Isotonic or Normal Saline (0.9%NaCl) is the solution of choice in normonatremic and mildly hyponatremic patients and should be administered initially in patients with hypotension or shock. Severe hyponatremia may require Hypertonic Saline (3.0% NaCl) In the Hypernatremic patient, there is a proportionately greater deficit of water than sodium, therefore to correct this patient you will use a Hypotonic solution like NS (0.45% NaCl) of D5W. Patients with significant hemorrhage, anemia, or intravascular volume depletion may require blood transfusions or colloids (albumin/dextran). Hypokalemia can be simultaneously corrected by adding appropriate amounts of KCl to replacement solutions.

Example of severe body fluid loss BURN

Burn injury results in loss of the cholesterol-filled cornified layer of the skin, which provides a barrier against excessive loss by diffusion (the average water loss by diffusion through the skin is about 300 to 400 ml/day), When the cornified layer becomes denuded, as occurs with a result of extensive burns, the rate of evaporation can increase as much as 10-fold, to 3 to 5 L/day

 Burn also results in the activation of the compliment system and the release of large number of inflammatory mediators such as histamine, prostaglandins and leukotrienes. These mediators increase the permeability of the local and systemic vasculature, resulting in extravastion of intracellular fluids and proteins in into the interstitial space, contributing to fluid depletion and soft tissue oedema. The leakage of plasma proteins during the first 3 to 5 hours reduces the intravascular oncotic pressure and increases the interstitial oncotic pressure, which leads to an increase in oedema formation.

 Therapeutics must therefore be based on know ledge of these changes in time. It is important to realize that many of the problems are predictable and can and should be prevented before they happen. One of the many aspects of the care of the burn patient that must be monitored is the electrolyte balance. The correct approach will be considered with regard to three periods of time in relation to the main changes in each period

 The correct approach will be considered with regard to three periods of time in relation to the main changes in each period: the initial resuscitation period (between 0 and 36 h). characterized by hyponatraernia and hyperkalaemia; the early post-resuscitation period (between days and 6). in which we consider hypernatraemia. hypokalaemia, hypocalcaemia, hypomagnesaemia. and hypophosphataetnia: the inflammation-infection period (also known as the hypermetabolic period). which is most evident after the first week. when several imbalances may coexist, depending whether correction was performed. and. if so, how.

 First period
In major burns. intravascular volume is lost in burned and unburned tissues: this process is due to an increase in vascular permeability, increased interstitial osmotic pressure in burn tissue. and cellular oedema. with the most significant shifts occurring in the first hours. Hyponatraemia is frequent, and the restoration of sodium losses in the burn tissue is therefore essential hyperkalaemia is also characteristic of this period because of the massive tissue necrosis. Hyponatraemia (Na) (< 135 mEq/L) is due to extracellular sodium depletion following changes in cellular permeability

 It is fundamental that sodium replacement should be performed xvith resuscitation fluids (lactated Ringer's. normal saline); sometimes two ampoules of sodium lactate are added to each 1000 ml of normal saline in order to increase osmolaritv;' volume replacement with blood and the reduction ofJ additional sodium losses are other important factors If a hypertonic solution is used to restore serum sodium. it should not be allowed to increase above 160 mEq/1 and the rate of increase should not exceed 1.5 mEq/h. Hyperkalaemia (K+) (> 5.5 mEq/1) is mainly caused by- cell lvsis and tissue necrosis

Second period
The early post-resuscitation phase is a period of transition from the shock phase to the hypermetabolic phase, and fluid strategies should change radically with a view to restoring losses due to water evaporation.The main changes in this period are: A. Hypernatraemia (Na+) (> 115 mEq/1). This is caused by several mechanisms: intracellular sodium mobilization. reabsotption of cellular oedema, urinary retention of sodium (because of the increase in renin, angiotensin. and ADH), and the use of iso/hypertonic fluids in the resuscitation phase.Hypernatraemia presents in various forms, depending on the amount of water retained: peripheral oedema, ascites, pleural effusion, and interstitial/a1-eolar oedema (with possible impaired ventilation) may dominate, or alternatively manifestations of dehydration may be more significant. Therapeutics is performed with hypotonic~fluids (low sodium content, with or without glucose): NaCl 0.45% or DSc NaCI 0.-15%: in some cases it may be necessary to add diuretics. The amount of water necessary to bring Na+ back to normal is given by the formula: 0.6Jx weight (kg) x (Na+ initial/NaT desired -1). Correction should be performed in such a way that the decrease in Na` does not exceed 1.5 mEq/h (there is a danger of cerebral oedema if correction is too quick). B. Hypcoalaemia. This is most prevalent in the period following the first -18 h postburn and is characterized by K+ < 3.5 mEq/l. It may be due to increased potassium losses (urinary-, gastric. faecal) and the intracellular shift of potassium because of the administration of carbohydrates; this imbalance is also increased by coexistinff hypomagnesaemia.

ORAL REHYDRATION THERAPY (ORT)

Is a simple treatment for dehydration associated with diarrhea, particularly gastroenteritis or gastroenteropathy, such as that caused by cholera or rotavirus. ORT consists of a solution of salts and sugars which is taken by mouth. It is used around the world, but is most important in the developing world, where it saves millions of children a year from death due to diarrhea . Oral fluid therapy is effective, safe, convenient, and inexpensive compared with IV therapy. It should be used for children with mild to moderate dehydration who are accepting fluids orally unless prohibited by copious vomiting or underlying disorders (eg, surgical abdomen, intestinal obstruction).

ORS Composition

ReSoMal
Diarrhoea is a serious and often fatal event in children with severe malnutrition. Although treatment and prevention of dehydration are essential, care of these children must also focus on careful management of their malnutrition and treatment of other infection Full-strength ORS solution should not be used for oral or NG rehydration. It provides too much sodium and too little potassium. Two approaches to develop a suitable oral solution are possible. (i) When using the previous standard ORS solution containing 90 mEq/l of sodium: dissolve one ORS packet into two litres of clean water (to make two litres instead of one litre); add 45 ml of potassium chloride solution (from stock solution containing 100g KCl/l); and add and dissolve 50g sucrose. (ii) When using the new reduced (low) osmolarity ORS solution containing 75 mEq/l of sodium: Dissolve one ORS packet into 1.5 litre of clean water (to make one and a half litres instead of one litre) add 33 ml of potassium chloride solution (from stock solution containing 100g KCl/l); and add and dissolve 38g sucrose.

EXAMPLE: Severe Diarrhea

During diarrhoea there is an increased loss of water and electrolytes (sodium, chloride, potassium, and bicarbonate) in the liquid stool. Water and electrolytes are also lost through vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops.

 The volume of fluid lost through the stools in 24 hours can vary from 5 ml/kg (near normal) to 200 ml/kg, or more. The concentrations and amounts of electrolytes lost also vary. The total body sodium deficit in young children with severe dehydration due to diarrhoea is usually about 70-110 millimoles per litre of water deficit. Potassium and chloride losses are in a similar range

Electrolyte disturbances
Hypernatraemia Some children with diarrhoea develop hypernatraemic dehydration, especially when given drinks that are hypertonic owing to their content of sugar (e.g. soft drinks, commercial fruit drinks) or salt. These draw water from the child's tissues and blood into the bowel, causing the concentration of sodium in extra-cellular fluid to rise. If the solute in the drink is not fully absorbed, the water remains in the bowel, causing osmotic diarrhoea. Children with hypernatraemic dehydration (serum Na >150 mmol/l) have thirst that is out of proportion to other signs of dehydration. Their most serious problem is convulsions, which usually occur when the serum sodium concentration exceeds 165 mmol/l, and especially when IV therapy is given. Seizures are much less likely when hypernatraemia is treated with ORS solution, which usually causes the serum sodium concentration to become normal within 24 hours.

 Hyponatraemia Children with diarrhoea who drink mostly water, or watery drinks that contain little salt, may develop hyponatraemia (serum Na <130 mmol/l). Hyponatraemia is especially common in children with shigellosis and in severely malnourished children with oedema. Hyponatraemia is occasionally associated with lethargy and, less often, seizures. ORS solution is safe and effective therapy for nearly all children with hyponatraemia. An exception is children with oedema (see section 8), for whom ORS solution provides too much sodium.

 Hypokalaemia Inadequate replacement of potassium losses during diarrhoea can lead to potassium depletion and hypokalaemia (serum K+ <3 mmol/l), especially in children with malnutrition. This can cause muscle weakness, paralytic ileus, impaired kidney function and cardiac arrhythmia. Hypokalaemia is worsened when base (bicarbonate or lactate) is given to treat acidosis without simultaneously providing potassium. Hypokalaemia can be prevented, and the potassium deficit corrected, by using ORS solution for rehydration therapy and by giving foods rich in potassium during diarrhoea and after it has stopped (see Section 4.2).

Conclusion
In Determining the administration of fluid therapy clinically one has always got to know What is the volume status of my patient(Hypovolemic, Hypervolemic, NPO Patient, surgical patient, euvolemic, Eating/drinking normally)? Do they have ongoing losses? Can my patient take PO safely? Are the NPO for a reason?