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(ORS, RESOMAL).
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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.
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
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.
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.
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.
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?