Fluids: Presenter: Atwebembere Raymond Faciliitator: Dr. Kibengo

FLUIDS
P R E S E N T E R : AT W E B E M B E R E R AY M O N D
FA C I L I I TAT O R : D R . K I B E N G O
COMPOSITIONS OF BODY FLUIDS
• Water is the most abundant constituent in the body, comprising

of 50% of the body weight in women and 60% in men.
• 55-75% being ICF, 25-45% ECF; ECF is further divided in a
ratio of 1:3 into intravascular and extravascular spaces.
• Starlings forces aid movement of fluid across cappillary walls
between interstitial and intravascular spaces.
ION COMPOSITIONS (IN MOSM/L)
EXTRAVASCULAR
INTRACELLULA INTRAVASCULA INTERSTITIAL
R R
CATIONS
Na+ 10 142 145
K+ 157 4 4
Ca2+ 0.5 2.5 2.5
Mg2+ 20 0.8 0.7
ANIONS
Cl- 10 103 117
HCO-3 7 25 27
HPO2-4/HPO-4 11 2 2
SO2-4 1 0.5 0.5
ORGANIC ACIDS - 6 6
PROTEIN 4 1.2 0.2
FLUID IMPORTANCE IN THE BODY
• Homeostasis
• Water distribution
• pH maintenance
• Maintain electrolyte concentration
• Set of fluid balance
• Depletion
• over hydration
FLUID REGULATORS
• Renal sympathetic nerves

• Renin-angiotensin-aldosterone system.
• Atrial natriuretic peptide (ANP)
FLUID REQUIREMENTS
SOURCES LOSSES
WATER 1500ML URINE 1500ML
FOOD 800ML STOOL 200ML
OXIDATION 300ML SKIN(12ml/kg/day) 500ML
RESP. TRACT 400ML
TOTAL 2600ML TOTAL 2600ML
FLUID MANAGEMENT
• In fluid management, maintenance volume(60%), along with

deficit(20%) and ongoing loss(20%) must balance.
• Input of fluids may be from; Oral intake, NG tube, IV
crystalloids or colloids.
• Out put; Urine, stool, NG tube, Fistula, drains and vomiting
• Through insensible loss from skin, respiration which maybe
around 500ml to 1l and can exceed 2 liters a day in a pyrexial
patient with open wounds.
MAINTENANCE FLUID
• Water required:
• 100-50-20 (60kg=2300ml/day)
• 100ml/kg/day (1st 10kgs) + 50ml/kg/day (for 2nd 10kg) + 20ml/kg/day
(per added 1kg)
• Per hour:
• 4-2-1(60kg=100ml/hr = 2400ml/day)
• 4ml/kg/hr + 2ml/kg/hr + 1ml/kg/hr
• Equivalent to 1.5ml/kg/hr, in a 60kg man = 90ml/hr equivalent to
2160ml/day
• Electrolyte:
• Na+ 2-3 mmol/kg/day
• K+ 1-2 mmol/kg/day
• Considering that electrolyte exchange from the gut into cells is
an active process, glucose must me considered as well to aid
the process successfully take please on top of metabolism and
other energy requiring processes; 100-150g of dextrose per
day
PARENTERAL FLUID MANAGEMENT
IV FLUIDS
Blood and Non blood and IV

products fluids
Crystalloids Colloids
Glucose containing electrolyte

Proteinous Non proteinous
solutions
Gelatines:
Albumin 20% and
Haemaccel and Starch Dextrans
5%
Gelofusion
HES, Pentastarch,
Tetrastarch
COMMON PARENTERAL COLLOID
FLUIDS
Soluti Vol Na+ K+ Ca2+ Mg2+ Cl- HCO- Dex mOs
on 3 m/l
ECF 142 4 5 103 27 280-
310
6% 500 154 154 310
hetasta
rch
5% 250,50 130- <2.5 130- 330
Album 0 160 160
in
25% 20,50, 130- <2.5 130- 330
Album 100 160 160
in
PARENTERAL FLUID THERAPY FOR
CRYSTALLOIDS
Soln Vol Na+ K+ Ca2+ Mg2+ Cl- HCO-3 Dex mOsm/
l
ECF 142 4 5 103 27 280-
310
Ring. L 500 130 4 5 109 28 273
0.9% 500 154 154 308
NaCl
0.45% 500 77 77 154
NaCl
D5W/D 50/100
10W
D2.5/0. 500 77 77 25 406
45%
NaCl
3% 513 513 1026
NaCl
HYPOVOLEMIA
• A condition defined by decrease in volume of circulating plasma.

• Causes include; vomiting, diarrhea and excessive bleeding which
could worsen into hypovolemic shock.
• Signs:
• Diminished skin turgor
• Dry oral mucous membrane
• Oliguria <500ml/day (normal is 0.5-1ml/kg/hr.)
• Tachycardia
• Orthostatic hypotension
• Hypo perfusion presenting as cyanosis
• Altered mental status
ORTHOSTATIC HYPOTENSION
• A decrease in systolic blood pressure of greater than 20mmhg

from supine to standing position. Indicates 6-8% body weight
of fluid deficit.
• As a result, heart rate should increase as a compensatory

mechanism. If it doesn’t, consider autonomic dysfunction or
use of antihypertensives.
C/F OF HYPOVOLEMIA
• Thorough History: poor intake, severe bleeding, moderate to

severe diarrhea, vomiting.
• Examination
• Investigations;
• BUN; Creatinine > 20:1
• BUN increase: hyperalimentation, glucocorticoid therapy, UGI bleeding
• Increased S.G
• Increased Hematocrit
• Electrolyte imbalance
• Acid Base disorder
HYPOVOLEMIC SHOCK
• 1L of NS is selected as the fluid of choice initially as it will

increase the intravascular volume by 300ml
1l fluids Intravascular Interstitial ICF
ECF ECF
NS 300ml 700ml nil
5% Dex 75-100ml 260ml 670
colloids 1000ml
• In unknown glycemic status; Dex

• Unknown renal status; RL can cause hyperkalemia or lactic
acidosis.
• RL is preferred after urine output is established, it’s the most
physiological fluid hence infusion with minimal worry of
electrolyte imbalance
• Colloids in Hypovolemic shock
• More effective plasma expanders as they are restricted in intravascular
compartment -> lesser risk of pulmonary edema
• Highly recommended into protein losing states like burns
• Blood
• In bleeding patients
• Severe anemia
• In transfusion, hematocrit shouldn't’t go above 35% as it may result to
increased viscosity and blood stasis.
SEPSIS
• Cardiovascular instability as a result of:

• Endothelial dysfunction
• Intravascular fluid loss
• Vasodilation with fluid maldistribution
• Sympathetic redistribution from peripheral organs and impairment in
cardiac function
• Fluid resuscitation with the goal of maintaining adequate end
organ perfusion is therefore a key part in the first 6 hours of
sepsis tx.
• Patients with sepsis + tissue hypo perfusion, defined by lactate
concentration > 4mmol/L or hypotension after initial IV fluid
challenge:
• CVP 8 to 12mmhg (12-15mmhg in patients on ventilation)
• MAP 65mmhg or greater
• Urine output 0.5mL/kg/hr or greater
• Scvo2 greater than 70%
RECOMMENDATIONS
• Guidelines on IV fluid therapy by National Institute for Health

and Care Excellence recommends: crystalloids with 130-154
mmol/l of sodium for IV resuscitation and recommended
against tetra starch use in this purpose
• Use 30ml/kg of crystalloids following protocol
• In patients requiring more fluid, albumin should be considered
along with vasopressors, inotropes and RBC transfusion to
attain goals.
FLUID CHALLENGE
• Considered goal standard for diagnosis of fluid

responsiveness.
• Volume infused must be sufficient to increase right ventricular
diastolic volume and stroke volume by 10-15% subsequently
as described as Frank starling law.
• Duration of fluid infusion has influence on responsiveness
• Success depends on; Xtics of fluid challenge technique,
intravascular filling, vascular tone or ventricular contractility
4 STEP PROCESS OF GIVING FLUID
CHALLENGE
• Type of fluid
• Rate of administration
• In whom to do these tests;
• Hypotension 20 to hypovolemia; clinically MAP< 65mmhg – 70mmhg
• Tachycardia 20 to hypovolemia
• Low urine output 20 to hypovolaemia
• Low cardiac output secondary to low filling pressures.
SAFETY LIMITS
• Monitor for signs of pulmonary edema due to fluid overload

• Monitor CVP in patients with no intrinsic heart or lung disease
• In patients with intrinsic heart or lung disease, a pulmonary
artery monitoring catheter may be used
CONGESTIVE HEART FAILURE
• Edema in CCF is as a result of water and salt retention; water

more than salts resulting into a dilutional hyponatremia
• Oral route is preferred to provide better salt restriction.
• DON’T
• Correct hyponatremia with salt supplementation
• Treat hyponatremia with sodium rich fluids
• Chase urine out- diuretic induced
• DO’S
• Give less fluids
• Restrict sodium
• Correct potassium deficit as a result of diuretic
ARF
• General principles:
• Fluid restriction in edematous and oliguric patients
• Fluid intake= urine output + 500ml/day
• Salt restriction to 2-3g/day
• Avoid hyperkalemia
• Acute Renal Failure, fluid management as per presentation
1. Prerenal azotemia;
1. In oliguric patients who are not volume overloaded and prerenal azotemia
is likely, do fluid challenge
2. 500-100ml of NS over 30-60min may result into increased urine flow
3. NS IV in hypotensive state
• Non Oliguric ARF
• Due to septicemia, aminoglycosides, acute interstitial nephritis; these
carry a risk of hyperkalemia and acidosis, K+ should be restricted.
• Oliguric ARF
• Due to acute tubular necrosis usually lasting for 1-3 weeks.
• Urine output <400ml/day or 05ml/kg/hr.
• Fluid, salt and K+ restricted
• 5% or 10% dex is recommended as fluid of choice.
• Diuretic phase of ARF
• Volume depletion and dehydration should be avoided
• Half strength saline 0.45% with K+ as per requirement
HEPATIC FAILURE
• Ascites in cirrhosis of liver

• Plasma volume expansion during paracentensis by colloids like albumin,
plasma, proteins, blood transfusion prevents hypotension and permits large
volume paracentesis
• 6-8gm of albumin per liter of ascetic fluid removed
• FFP for coagulation disorder and whole blood anemia
• Hepatic Encephalopathy
• 10%, 20% dex and DNS to prevent hypoglycemia
• Avoid :
• 5% dex; hypotonic fluid aggravate cerebral edema
• Isolyte G; Contains ammonium chloride which precipitate hepatic precoma
• RL; Contains lactate that’s converted into bicarbonate by the liver -> alkalosis. If
lactate metabolism is impaired -> lactic acidosis,
IN DIARRHEA
• Replacement of established losses; about 1-1.5l in moderate

disease of 6 to 10 stools per day.
• Replacement of ongoing losses: 200ml loss of isotonic fluid is

lost in every stool episode.
• Replacement of normal daily requirements: 1-2l of fluid orally

taken or by IV in patients that cant feed orally.
FLUID THERAPY IN VOMITING
• Hypovolemia
• Hypokalemia
• Loss in vomitus
• Loss Na+ in gastric juices -> increased aldosterone -> Na+ reabsorption
and K excretion.
• Metabolic Alkalosis
• Upper GI loss of H+
• Hypovolemia -> increased reabsorption of HCO3 in proximal tubules
• High aldosterone will secrete H+ -> aciduria -> metabolic alkalosis
• Hypochloremia -> loss in GIT -> increased renal absorption of
HCO3 -> alkalosis
• Isotonic saline
• Corrects fluid deficit -> increased ECF -> Decreased HCO3 absorption
-> correction M. Alkalosis
• Correction of volume and Na -> decreased aldosterone -> decreased
Potassium and H+ secretion -> hypokalemia and alkalosis correction.
• Corrects hypochloremia -> favors HCO3 secretion -> correction of M.
Alkalosis
• Isotonic saline corrects all biochemical abnormalities except K+ deficit
• Isolyte- G
• Is specific for replacement of upper GI loss correcting H+, Cl-, K+ and
Na+
HYPERVOLEMIA
• Signs of hypervolemia
• Hypertension
• Polyuria
• Peripheral edema
• Wet lung
• Jugular vein engorgement
• Management:
• Prevention being the best way
• Guide fluid therapy with CVP level or pulmonary wedge pressure
• Diuretics
• Increased oncotic pressure; FFP or albumin infusion
• Dialysis
REFERENCES
• DAVIDSONS PRINCIPLES AND PRACTICE OF

MEDICINE, 22ND EDITION
• GUYTON AND HALL TEXTBOOK OF MEDICINE
PHYSIOLOGY 13TH EDITION

Fluids: Presenter: Atwebembere Raymond Faciliitator: Dr. Kibengo

Uploaded by

Copyright:

Available Formats

Fluids: Presenter: Atwebembere Raymond Faciliitator: Dr. Kibengo

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fluids: Presenter: Atwebembere Raymond Faciliitator: Dr. Kibengo

Uploaded by

Copyright:

Available Formats

FLUIDS

• Water is the most abundant constituent in the body, comprising

• Renal sympathetic nerves

• In fluid management, maintenance volume(60%), along with

Blood and Non blood and IV

Glucose containing electrolyte

• A condition defined by decrease in volume of circulating plasma.

• A decrease in systolic blood pressure of greater than 20mmhg

• As a result, heart rate should increase as a compensatory

• Thorough History: poor intake, severe bleeding, moderate to

• 1L of NS is selected as the fluid of choice initially as it will

• In unknown glycemic status; Dex

• Cardiovascular instability as a result of:

• Guidelines on IV fluid therapy by National Institute for Health

• Considered goal standard for diagnosis of fluid

• Monitor for signs of pulmonary edema due to fluid overload

• Edema in CCF is as a result of water and salt retention; water

• Ascites in cirrhosis of liver

• Replacement of established losses; about 1-1.5l in moderate

• Replacement of ongoing losses: 200ml loss of isotonic fluid is

• Replacement of normal daily requirements: 1-2l of fluid orally

• DAVIDSONS PRINCIPLES AND PRACTICE OF

You might also like