Fluid Management

efinition
Severe dengue:
1. F grade 3 and 4
2. engue with severe organ impairment:
engue with fulminant hepatitis
engue with myocarditis
engue with encephalitis
engue with respiratory distress
CIInIcaI course oI DHF
linical assessment for severe
dengue and F Grade 3 & 4
uring critical phase:
Plasma leakage around defervescence phase:
Evidence of plasma leakage includes:
1. raised % (early marker),
2. haemodynamic instability,
Skin- cool and pallor, delayed capillary refilled time
Reduced pulse pressure to < 20 mmg
%achycardia
ypotension SBP< 90 mmg
3. fluid accumulation in extravascular space (rathe late marker)
Pleural effusion
Ascitis
4. hypoproteinemia.
F Grade 3 & 4-clinical assessment
ntense thirst,
Abdominal pain, epigastric pain,
Vomiting,
Restlessness,
Reduced urine output
Altered conscious level,
Shortness of breath and tachypnoea,
Sudden change from fever to subnormal
temperature
Fluid management When to initiate
!v fluid replacement?
- Not taking orally
- Dehydration and rising haematocrit level
- Diarrhoea
- vomiting
- Decreased sensorium
- Compensated shock
- Decompensated shock
Fluid management - maintenance
CaIcuIations for normaI maintenance of intravenous
fIuid infusion per hour:
(EquivaIent to HaIIiday-Segar formuIa)
4 mL/kg/h for first 10kg body weight
+ 2 mL/kg/h for next 10kg body weight
+ 1 mL/kg/h for subsequent kg body weight
*For overweight/obese patients calculate normal maintenance fluid
based on ideal body weight
Ideal bodyweight can be estimated based on the following formula
Female: 45.5 kg + 0.91(height -152.4) cm
Male: 50.0 kg + 0.91(height -152.4) cm
Exercise
Body Weight 65kg
1
st
10kg --- 40ml/
Next 10kg --- 20ml/
Balance --- 45ml/
40+20+45 = 105ml/
105 x 24 = 2520ml/day
Fluid management - general rules
Frequent adjustment of maintenance fluid
regime,
1.2-1.5 X Maintenance in critical phase,
f > 1X Maintenance required, regime need
to be reviewed 4-6 ly.
Rising %- increase infusion rate
SS fluid resuscitation algorithm
Stop fluid therapy once after critical phase
and patient is stable (post defevercence).
engue Shock Syndrome
F Grade 3 and 4 (SS)
Medical emergency
Early and prompt management lead to better
outcome,
Should be nursed in igh dependency unit or
&
Fluid resuscitation should be prompt,
Following initial resuscitation there maybe
recurrent episodes of shock because capillary
leakage can continue for 24-48 hours
Fluid management type of fluid
no clear advantage of using colloids over
crystalloids in terms of the overall
outcome.
colloid may be preferable in patients with
intractable shock in the initial resuscitation.
%he choice of colloids includes gelatin
solution (e.g. Gelafusine) and starch
solution (e.g. Voluven)
SS Fluid resuscitation
IV Iines (Iargest branuIa possibIe),
18G, 16G, 14G
LabeI IV drip bottIe
Time to compIete written cIearIy
DHF GRADE 3 & 4 (DSS)
FIuId ResuscItatIon AIgorItbm
After fluid resuscitation
assessment for improvement
linical parameters
mprovement of general well being/ mental state
Warm peripheries
apillary refill time < 2sec
BP stable
mproving pulse pressure
Less tachycardia
ncrease in urine output
Less tachypnoea
Laboratory parameters
ecrease in %
mprovement in metabolic acidosis
I no Improvement aIter tbe 1
st
boIus
I no Improvement aIter tbe 2
nd
boIus
NO response to 2
nd
bolus
< Blood transfusion ASAP
< Fresh whole blood
< f not available, packed cell
< f patient is given bolus, arrange for GS/GXM
If imrovcmcni aficr iIc lolus(cs}
After 1
st
bolus fluid MPROVE
ES
CIinicaI parameters must be monitored
every 15-30 minutes during shock!
**FIuid regime must be reviewed and
readjusted every 30 -60 minutes.
Recurrent episodes of shock can occur
after initiaI resuscitation (due to
continuing pIasma Ieakage) - for
nd
boIus fIuid resuscitation
Exercise 1
35 years old gentlemen
Fever for 4 days
Vomiting for 2 days
Epigastric pain
Exercise 1
BP 104/85
R 108/min
%emp 37
Weight 60kg
iagnosis
Exercise 1
F Grade 3 ompensated Shock
(engue Shock Syndrome) day 4 with
warning signs in critical phase day 1
defervescense.
Exercise 1
2 large bore branula
Run 10ml/kg bolus (600ml) over 30 min
FB, VBG stat and post bolus
GS/GXM
Exercise 1
Post bolus
Mild epigastric pain
BP 110/80
R 100/min
ct 48 46
Plt 85 80
O3 19 20
Exercise 1
Run another bolus 20ml/kg (1200cc) over
30 min
Repeat FB, VBG post bolus
Exercise 1
Post 2
nd
bolus
No complaints
BP 120/80
R 88/min
ct 48 46 44
Plt 85 80 76
O3 19 20 22
Exercise 1
Put on V drip 5cc/kg/ ( 300ml/) for 2
hours
%o cut down further if patient improves
Admit ward
nform ward
Exercise 2
28 years old gentlemen
Fever 3 days
Lethargy
Body aches
Poor urine output
Epigastric pain
Exercise 2
BP 95/60
R 114/min
%emp 37.5
Weight 100kg
eight 160cm
Exercise 2
deal body weight
Male: 50.0 kg + 0.91(height -152.4) cm
50 + 0.91(160 152.4) = 56.9kg
Actual weight 100kg
Exercise 2
F Grade 4 (ecompensated Shock)
day 3 with warning signs in critical phase
day 1 defervescence.
Exercise 2
2 large bore branula
Run 20ml/kg bolus (1140ml) fast bolus
FB, VBG stat and post bolus
GS/GXM
Exercise 2
Post bolus
omplains of giddiness
Epigastric pain
BP 98/60
R 110/min
ct 50 49
Plt 82 50
O3 19 18
Exercise 2
Run another bolus 20ml/kg (1200cc) rapid
bolus
Repeat FB, VBG post bolus
onfirm GXM
Exercise 2
Post 2
nd
bolus
Still has epigastric pain
BP 100/60
R 114/min
ct 50 49 42
Plt 82 50 44
O3 19 18 17
Exercise 2
%ranfuse 1 pint whole blood stat
Vital signs monitoring every 15 min
Exercise 2
Post blood transfusion
BP 110/70
R 90/min
ct 50 49 42 46
Plt 82 50 44 50
O3 19 18 17 20