dr. Iyan Darmawan

Parenteral Fluid TherapyUpdate

Case-based Approach

.

RESUSCITATION REPAIR MAINTENANCE PN

PERFUSION & OXYGENATION

CORRECTELECT & AB

HOMEOSTASIS/SUPPORTIVE

CORRECTNUTRITION ST

PARENTERAL FLUID THERAPY

Dehydration vs Hypovolemia

• Intracellular & Interstitial depletion

• Thirst, oliguria, dry mucous membrane

• Plasma Osmolarity ↑• BUN/creatinine ratio >20• FeNa* <1 %

• Intravascular depletion• Hemodynamic responses

in initial phase (compensated shock)

• Hypotension, MAP < 60 indicate advanced stage

Both types often coincides*FeNa = (U/P Na) : (U/P Creat) x 100

MAP (1S + 2D)3

Pulse Pressure (S-D)Heart RateCapilary refill timePeripheral VasoconstrictionOxygen saturation

MAP (mean arterial pressure) 70-105 mmHg HR (heart rate)

Neonates ( 0-30 days): 70 - 190 /minute Infants (1 - 11 months): 80-120 /minute Children 1 to 10 years: 70 - 130 /minute Children> 10 years and adults 60-100 minutes

Pulse Pressure (Systolic-Diastolic ) 30-40 mmHg CRT (capillary refill time) < 2 detik Partial Pressure of Arterial Oxygen (PaO2) 80-100

mmHg Arterial oxygen saturation(SaO2) 95-100% Mixed venous oxygen saturation (SvO2) 60-80%

Reference : http://www.lidco.com/docs/1462Educatioalcard7.pdf.

Guide

• Hemodynamics

• Electrolytes

• Metabolic

: MAP, HR, Pulse Pressure, CRT

Na+

K+

Cl-

HCO3-

: Glucose, BUN, creatinin, alb

Practical Guide1. Hemodynamics2. Urine Output3. Electrolyte/Metabolic Panel

Na+

K+

Cl-

HCO3-

BUNCr Glu

135-145

3.5-5

98-106

23-28

8-20

0.7-1.3

90-105 (fasting)

Resuscitation Fluid Therapy

Case 1

• A 12 year old patient with DHF. Nausea and vomiting (+)

• PE : restless;T 100/80 T 37.5 oC HR 120 x/min, RR 28 /min; cold extremities. Torniquet test(+). Height 120 cm Weight 50 kg

• Lab: Hct 48%; Platelet 70.000

How is the fluid regimen for this patient?

Answer: Grade 3 DHF requiring 5-10 ml/kg ideal BW /hour and monitor

Repair Fluid Therapy

A 15 kg postop patient with Na+ 97 mEq/L,. PE: Stuporous and convulsion.

How much is Na+ deficit in this patient, if we need to correct it until 125 mEq/L?How will you correct hyponatremia ini this? ; what is the administration rate of 3% NaCl?

Case 2

A 15 kg postop patient with Na+ 97 mEq/L,. PE: Stuporous and convulsion.

How much is Na+ deficit in this patient, if we need to correct it until 125 mEq/L?

How will you correct hyponatremia ini this? ; what is the administration rate of 3% NaCl?

Case 2

60% BB x (125-97) = 252 mEq

Infusate Na+– Serum Na+

Total body water + 1

(513-97) : (9+1) = 41.6mE/L

We will raise 1 mmol/L hourly for 5 hours

The amount of 3% NaCl 3% required= 5 : 41.6 = 0.120 L = 120 ml or 24 ml/hourObserve clinical condition and check serum Na+ after 5 hours.. Reduce rate if there is improvement, eg 0.5 mmol/L/hour until Na+ 115.

Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):1581-1589Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499.

Case 3

A 9 year old 20 kg patient with dehydration and shock (acute GE), has been resuscitated with Acetated Ringer’s ( Asering) for 5 hours along with separate line of 8.4% Meylon diluted in D5. Patient was then unconscious with seizures.

BP 110/75; HR 90/min ; RR 16/min; T 37oCNa+ 175 mmol/L; K+ 2.1 mmol/L

You wish to correct the hypernatremia and hypokalemia simultaneously with infusion solcontaining 30 mmol/L Na+ (KAEN 4A) plus 20 mmol KCl.

You set a target of Na+ decrease to 165 mmol/L over 10 hours. What is the rate of infusionyou will set up?

Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):1581-1589Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499.

A 9 year old 20 kg patient with dehydration and shock (acute GE), has been resuscitated with Acetated Ringer’s ( Asering) for 5 hours along with separate line of 8.4% Meylon diluted in D5. Patient was then unconscious with seizures.

BP 110/75; HR 90/min ; RR 16/min; T 37oCNa+ 175 mmol/L; K+ 2.1 mmol/L

You wish to correct the hypernatremia and hypokalemia simultaneously with infusion solcontaining 30 mmol/L Na+ (KAEN 4A) plus 20 mmol KCl.

You set a target of Na+ decrease to 165 mmol/L over 10 hours. What is the rate of infusion you will set up?

(Infusate Na+ + K+ ) – serum Na+

Total body water + 1

= (30 + 20) – 175(60% x 20) + 1

= -12513

= - 9.6 mmol/LThis means 1 L infusion will decrease the serum Na+ serum by 9.6 mmol/L

Reuired amount of infusion = 5: 9.61 = 0.520 L = 520 ml

over 10 hr give 520 ml, at the rate of 52 ml/hr.Correction rate can be repeated for subsequent 10-14 hours

A 62 year old patient was admitted because of malaise and fatigue after nausea and vomiting for 5 days. Lack of eating and drinking due to anorexia.History of hypertension and taking medication: Tenormin 50 mg, Aspirin 75 mg HCT 25 mg, Lisinopril 40 mg per day

PE : Alert, pale, moderate dehydration, BP 170/105.Cor: extrasystole +, lung NA, hepatomegaly –

Lab:Chest X-ray : LVH.ECG : u wave & flattened T

Case 4

145

2.6 NA

25

1.0 70

135-145

3.5-5

98-106

23-28

8-20

0.7-1.3

70-105 (fasting)

98

How will you correct the hypokalemia in this patient

Hypokalemia( > 2.5 - <3.5 mEq/L )

Heart /cardiovascular disease?

No Yes

Give K+ according to maintenance requirement 40 mmol

Correction K+ 40 mmol +Maintenance 40 mmol

Hypokalemia ( > 2.5-3.4 mEq/L )Without cardiovascular disease

* In case of fluid restrition : admix 10 mmol KCL into 1 bag of KAEN 3B, to get final conc of 20 mmol/500 ml.

40 mmol K+ per day

With cardiovascular disease (digitalis, diuretics)

80 mmol K+ per day

Hypokalemia( 2 - > 2.5 mEq/L )

80 mmol K+ per day

How about life-threatening Hypokalemia?Serum K+ < 2 mmol/L

– Alkalosis– Arrhythmia– Respiratory paralysis– rhabdomyolisis

Hypokalemia( < 2 mEq/L )

OTSUNS

20 20 20

KCl 40 ml+

20over 1 hour

via central vein

A 62 year old patient was admitted because of malaise and fatigue after nausea and vomiting for 5 days. Lack of eating and drinking due to anorexia.History of hypertension and taking medication: Tenormin 50 mg, Aspirin 75 mg HCT 25 mg, Lisinopril 40 mg per day

PE : Alert, pale, moderate dehydration, BP 170/105.Cor: extrasystole +, lung NA, hepatomegaly –

Lab:Chest X-ray : LVH.ECG : u wave & flattened T

Case 4

145

2.6 NA

25

1.0 70

135-145

3.5-5

98-106

23-28

8-20

0.7-1.3

70-105 (fasting)

98

How will you correct the hypokalemia in this patient

Maintenance Fluid Therapy

Case 5. (Typhoid Fever)• Stable hemodynamics, Temperature 390C• Urine Output 1000 cc• Electrolyte/Metabolic Panel

145

3.2 NA

22

0.7 70

135-145

3.5-5

98-106

23-28

8-20

0.7-1.3

70-105 (fasting)

102

1. Any signs of dehydration?2. Can we prescribe Glucose containing solution ( Aminofluid ) now and how much?

Plasma Osmolarity & BUN/creat ratio

Hyperglycemia & renal function?

*FeNa = (U/P Na) : (U/P Creat)

Case 5. (Typhoid Fever)• Stable hemodynamics, Temperature 390C• Urine Output 1000 cc• Electrolyte/Metabolic Panel

145

3.2 NA

22

0.7 70

135-145

3.5-5

98-106

23-28

8-20

0.7-1.3

70-105 (fasting)

102

1. Any signs of dehydration? yes

2. Can we prescribe Glucose containing solution ( Aminofluid ) now and how much?

Plasma Osmolarity & BUN/creat ratio

Hyperglycemia & renal function?

*FeNa = (U/P Na) : (U/P Creat)

2 x [Na+] + BUN/2.8 + Glu/18 = 2 x 145 + 22/2.8 + 70/18 = 301 mOsm/L

BUN/creat ratio = 31

yes, we can. Adult 30-40 ml/kg/day; pediatric 4:2:1 formula. Increease by 12% forevery centigrade over 37oC

Case 6 Patient admitted 24 hours ago. D/ Stroke iskemik akut.

PE : stupor, TD 180/110, 37oC, HR 112, RR 12 shortElectrolyte/Metabolic Panel

ABG : PCO2 60 , PO2 90, pH 7.2

148 87

3.2 32

22

0.8240

1. Any signs of dehydration? yes

2. What acid-base disorder(s) in this patient?Will you administer sodium bicarbonate ( Meylon)? Respiratory acidosis. Meylon is contraindicated.

3. How will you cope with hyperglycemia? Could you give parenteral glucose at this moment ? • Reduce plasma glucose until 150 mg/dl. (use Yale formula: 240/70 3 U bolus + 3 u eg insulin

drip/hour)• Calculate TDDI (0.3-0.5 u/kg)• Prandial insulin 1 u/10 g glucose

Plasma Osmolarity & BUN/creat ratio?

HBA1c 8 %

2 x [Na+] + BUN/2.8 + Glu/18 = 2 x 148 + 22/2.8 + 240/18 = 317.18 mOsm/L

BUN/creat ratio = 22/0.8

Case 7. Acute Nephritic Syndrome, 60 kg , Oliguria for 3 days• Good hemodynamics• Urine output 300 cc; urinary Na+ 40 mmol/L; urinary Cr 30

mg/dl

*FeNa = (U/P Na) : (U/P Creat) * 100

135

4 NA

15

2.3 70

135-145

3.5-5

98-106

23-28

8-20

0.7-1.3

70-105 (fasting)

102

40/13530/2.3 x 100 =2.27 %

Urine + IWL (15 cc/kg) -Metabolic Water (5 cc/kg)

300 + 900-300 = 900 cc per 24 hours

Fractional Sodium Excretion

Parenteral Nutrition Therapy

COPD Height 170 cm Weight 45 kg • What is the the total calories and protein

requirement?

Ideal BW = ( Hight – 100) x 90% = 63 kg

Adjusted body weight = (Actual BW – Ideal BW)2

+ Ideal BW

45 - 632

+ 63 = 54 kg

25 kcal/kg BW and 1 g protein/kg BW

Case 8

Sepsis Height 160 cm Weight 80 kg • What is the the total calories and protein

requirement?

Ideal BW= ( TB – 100) x 90% = 54 kg

Adjusted body weight = (Actual BW – Ideal BW)2

+ Ideal BW

80 - 542

+ 54 = 67 kg

25 kcal/kg BW and 1.5 g protein/kg BW

Case 9

60% 20% 20%

TOTAL CALORIES(25 kcal/kg/day)

GLUCOSE LIPID PROTEIN

Average Patient

60% 20% 20%

TOTAL CALORIES(1500 kcal)

GLUCOSE LIPID PROTEIN

900 kcal

30 g

300 kcal 300 kcal

225 g 75 g

Average Patient

40% 20%

TOTAL CALORIES(1500 kcal)

GLUCOSE LIPID PROTEIN

600 kcal

60 g

600 kcal 300 kcal

150 g 75 g

40%

COPD Patient

Thank you