I. FLUID THERAPY
Introduction
By eating and drinking our body gets the water, electrolytes, carbohydrates, fats, vitamins and other substances. Within 24 hours the amount of water and electrolytes into and out through urine, feces, perspiration and breathing in adults steam about the same as in the table below.
Input (ml per 24 hours)
Output (ml per 24 hours)
Drink 800 - 1700 Urine 600 - 1600
Eating 500 -1000 Faeces 50-200
Oxidation 200-300 IWL 850-1200
Total 1500 - 3000 of 1500 - 3000
Fluid therapy is required if the body can not enter the water, electrolytes, and nutrients orally, for example on the state of the patient should be fasting a long time (for example because of surgery GI), bleeding a lot, hypovolemic shock, severe anorexia, nausea, vomiting continuously, etc. . With fluid therapy, water and electrolyte needs can be met. In addition, under certain circumstances, fluid therapy can be used as additional substances to include drugs and food regularly or can also be used to maintain acid-base balance.
Composition of Body Fluids
Water content at birth is around 75% BB and at the age of 1 month approximately 65% BB. The composition of body fluids in adult men is approximately 60% of body weight, while in adult women 50% BB. The rest are solid substances such as proteins, fats, carbohydrates, etc..
Water in the body are in several rooms, which amounted to 40% intracellular and extracellular by 20%. Extracellular fluid is a liquid contained in antarsel space (interstitial) equal to 15% and 5% plasma. Special antarsel fluid called cerebrospinal fluid, the liquid transeluler eg, joint fluid, peritoneal fluid, etc..
Intra-and extracellular fluid composition described in the table below:
CIS
CES
Plasma
Interstitial
Sodium
15
142
144
Potassium
150
4
4
Calcium
2
5
2.5
Magnesium
27
3
1.5
Clorida
1
103
114
HCO3
10
27
30
HPO4
100
2
2
SO4
20
1
1
Organic Acids
-
5
5
Water across the cell membrane easily, but other substances pass through it is difficult or requires a special process in order to cross it; therefore outside and electrolyte composition in different cells. Intracellular fluid contains many ions K, Mg and phosphate, whereas the extracellular fluid contains Na and Cl ions.
Plasma is blood minus blood cells such as erythrocytes, leukocytes and platelets. Serum is blood plasma minus clotting factors such as fibrinogen and protrombin. Hematocrit is a percentage of the volume of erythrocytes in the blood.
Water movement
Osmotic pressure is the pressure required to prevent leakage (diffusion) of fluid through a semipermeable membrane into another liquid that concentration is higher. Semipermeable membrane is a membrane that can pass water (solvent) but can not pass solutes such as proteins.
Plasma osmotic pressure was 285 ± 5 mOsm / L. Solution which has the same osmotic pressure is called an isotonic solution (eg 0.96% NaCl, dextran 5%, Ringer-Lactate), the solution has a lower osmotic pressure is called hypotonic solution (eg distilled water) and solutions that have a higher osmotic pressure is called condensation hypertonic.
Water Needs and Elekrolit
Basal fluid requirements (routine maintenance) is 30-40 ml / kg / day in adults. To determine the fluid requirements in children can use the following guidelines:
à 4 ml / kg / hour for the first weight 10 kg
à 2 ml / kg / hr added for the second weight 10 kg
à 1 ml / kg / hour for the remaining add further weight
Example
Patients with body weight 23 kg, hence the need basalnya fluid is:
(4 x 10) + (2 x 10) + (1 x 3) = 63 ml / hr
FLUID THERAPY
Definition
Fluid therapy is to maintain the action, replace the interior milieu within physiological limits.
Indication, among others:
- Acute loss of body fluids
- Loss of blood
- Anorexia
- Gastrointestinal disorders
Goal
The aim of fluid therapy described in the chart below.
Giving Techniques
The main priority in replacing the lost fluid volume is via the enteral route / physiology eg drinking or via NGT. For fluid therapy can be used in a short time the veins on the back of the hand, wrist area, forearm or cubital region. In small children and infants are often used areas of your foot, feet in front of the eyes or heads. Provision of fluid therapy in newborns can be done through the umbilical vein.
The use of needles anti-rust or anti trombogenik plastic catheters on peripheral veins usually need to be replaced every 1-3 days to avoid infection and jam drops. Giving intravenous fluids for more than three days should use big and long catheters inserted in the femoral vein, cubital vein, vena subclavia, external or internal jugular vein that ends as close as possible to the right atrium or the inferior or superior vena cava.
Nature-Substitute an Ideal Plasma Properties
The properties of the plasma is an ideal substitute:
* PH, pressure and viscosity comparable onkotik blood plasma
* Securities sufficient volume for a certain time period without the risk of overload on the cardiovascular system or edema
* Improving microcirculation and improve diuresis
* Do not disturb homeostasis
* Does not interfere with blood grouping and cross matching
* Accumulated a minimum of reticuloendothelial system
* Length of long-storage products
* Economical
Characteristics of Various Plasma Substitute
Criteria
Whole blood
Electrolyte solution
Albumin 20%
Dextran
40 +10
6% HES
Haemaccel
pH
7.3 to 7.4
5.5 to 6.5
6.47 to 7.2
4.5 to 5.7
5.0 to 7.0
7.0 to 7.6
The average BM
-
-
66 000
40 000
200 000 / 450,000
35 000
Physiological osmotic pressure of the Non-Iso-osmotic osmotic osmotic hyper-hyper-osmotic Iso-osmotic
Intravascular-interstitial fluid balance maintained edema Risk Dehydration Dehydration Repair Repair
Effective half-week A few days A few minutes A few days 12 hours 6-8 hours 4-6 hours
Disturbances in blood typing is usually not Pseudoaglu tinasi No No No No
There is the possibility of disruption of homeostasis (activation factor) Only pengence-bed-bed pengence Only Lowers Platelet function and coagulopathy Lowers Platelet function and coagulopathy Only dilution
Renal function
?
Recovery may be improved disturbed not found literature data Recovery
Overload cardiovascular Maybe Not Maybe Maybe Not likely No way
Possible side effects Anaphylaxis / incompatibility reaction kutis pulmonary edema, fever, hypotension while the need premedication Anaphylaxis Anaphylaxis or anaphylactic reaction to local skin reactions, hypotension while
Risk of transmission of viral diseases such as HIV, HBV, HCV No No No No No
Storage time 21 days 3 years 3-5 years 5 years 3 years 5 years
4-6 ° C storage temperature 2-25 ° C room temperature <25 ° C Room Temp Room Temp
Accumulation in RES No No No No Several weeks Several months
Advantages and Disadvantages of Plasma Substitute Various Preparations
1. 1. Whole blood
Excess
* The capacity of oxygen transport
* Capacity hemostatic
Shortage
* The provision of long
* Short storage time
* Minor to severe anaphylactic reactions
* Alloimunisasi
* Reaction hemolysis
* Reaction infection
* The viscosity increases
* Overload volume
* Hiperkalium, hiperkalsium, acidosis
Price * expensive
1. Electrolyte solution
Excess
* More easily available and cheap
* The composition similar to plasma (Ringer Acetate / Ringer Lactate)
* Can be stored in room temperature
* Free of anaphylactic reactions
* Complications of minimal
Shortage
* Edema can reduce chest wall ekspansibilitas
* Disturbed tissue oxygenation due to increased capillary and cell spacing
* Requires four times more volume
1. 3. Solution of human albumin
Excess
* The expansion of plasma volume without interstitial volume expansion
* Expansion of a larger volume
* A longer duration
* Better tissue oxygenation
* O2 alveolar-arterial gradient less
* The incidence of pulmonary edema or edema and lower systemic
Shortage
* Anaphylactic reaction
* Coagulopathy
* Albumin may aggravate myocardial depression shock patients
1. Dextran
Excess
* Securities or the volume of long length
* Anti-thrombotic effects
Shortage
* Expansion and dehydration ekstravaskuler interstitial compartment
* Impaired hemostasis
* Restrictions dose
* Fatal anaphylactic reactions
* Impaired renal function
* Accumulation in reticuloendothelial system
* Disturbances in blood grouping and cross matching
1. HES
Excess
* Securities or the volume of long length
* Anti-thrombotic effects
Shortage
* Expansion and dehydration ekstravaskuler interstitial compartment
* Impaired hemostasis
* Restrictions dose
* Fatal anaphylactic reactions
* Accumulation in reticuloendothelial system
1. Haemaccel
Excess
* Iso-osmotic
* Maintain fluid balance
* Securities optimal volume
* Improvement of renal function
* Does not interfere with hemostasis
* Does not interfere with blood grouping
* There was no accumulation in the RES
* Economical
Shortage
* Reaction anafilaktoid
Fluid Therapy Success
Fluid therapy which successfully described with the increase in cardiac index, oxygen transport and oxygen consumption as well as decreased pulmonary vascular resistance and systemic vascular resistance.
1. II. Electrolyte THERAPY
2. a. Hyponatremia
1. SODIUM
Definition: serum Na + levels below normal (<135 mEq / L)
Hyponatremia is divided into:
1) hyponatremia à artifactual false
Reported laboratory error caused by:
* Hyperglycemic
Correction value of sodium (any increase in blood glucose of 100 mg / dl to reduce the sodium by 1.7 mEq / L)
* Hiperlipidemi
The measured serum osmolality will be normal or greater than the calculated osmolality (OSM = [2 x Na] + [Glukosa/18] + [BUN / 2.8])
Second) à hipervolemia dilutional hyponatremia with total body water expansion
Hyponatremia is caused by impaired excretion of water, it appears as edema; eg CHF, renal impairment and nephrotic syndrome.
3) hypovolemic hyponatremia à exceeds sodium depletion, water depletion, eg in renal failure, hypothyroidism and Addison's disease.
4) à euvolemik hyponatremia sodium and water depletion in the number of comparable
This happened to lose water and sodium through the digestive tract (in vomit, suction nasogastrik, diarrhea), loss to third cavity (on burns, surgery), excessive sweating, kidney and adrenal diseases (in uncontrolled diabetes mellitus, hipoaldosteron, Addison's disease , the recovery phase of renal disease).
Clinical picture
* Clinical features and severity of hyponatremia depends on the initial speed.
* Symptoms are more pronounced in rapidly developing hyponatremia.
• If the plasma Na decreased 10 mEq / L within several hours, patients may be nausea, vomiting, headaches and muscle cramps.
* If the plasma Na decreased 10 mEq / L in one hour can lead to severe headaches, lethargy, seizures, disorientation and coma.
* Perhaps the patient has signs of basic diseases (such as heart failure, Addison's disease).
* If hyponatremia occurs secondary to loss of fluids, there may be signs of shock such as hypotension and tachycardia.
Management of hyponatremia
* Overcome the basic disease
* Stop any drugs that contributed to the hyponatremia
* Correction of the long-standing hyponatremia gradually, whereas the more aggressive acute hyponatremia. Avoid excessive correction because it can cause central pontine myelinolysis
* Do not raise the serum Na is faster than 12 mEq / L in 24 hours in asymptomatic patients. If the patient is symptomatic, could increase by 1 to 1.5 mEq / L / hour until symptoms subside. To increase the amount of sodium required to raise serum sodium to 125 mEq / L used the formula:
Total Na (mEq) = [125 mEq / L - actual serum Na (mEq / L)] x TBW (in liters)
TBW (Total Body Water) = 0.6 x body weight (in kg)
* Solution can be a substitute for NaCl 3% or 5% (each containing 0.51 mEq / ml and 0.86 mEq / ml)
* In patients with expansion of extracellular fluid, diuretics may dperlukan
* Hyponatremia can be corrected with hypertonic NaCl (3%) with a speed of approximately 1 mL / kg per hour.
1. b. Hypernatremia
Definition: serum Na + above normal (> 145 mEq / L)
Causa
* Happen if hypotonic fluids lost are not replaced adequately.
* If you are not losing fluids through the kidneys (lost through the gastrointestinal tract, sweat or hyperventilation), urine osmolality greater than serum, and urine sodium will be <20 mEq / L.
* Urine osmolality less than or equal to imply the loss of serum through the kidneys (eg, diuretic therapy, osmotic diuresis, diabetes insipidus, acute tubular sekrosis, uropati post-obstruction, nephropathy hiperkalsemik).
* Hypernatremia can occur with hyperalimentation or other hypertonic fluids.
Signs and Symptoms
Muscle irritability, confusion, ataxia, tremors, convulsions and coma secondary to hypernatremia. Additional common secondary manifestation of the basic abnormalities and volume status (tachycardia and orthostatic hypotension with volume depletion; edema when there is excess fluid).
Management of hypernatremia
* Hypernatremia with volume depletion must be overcome by giving normal saline until hemodynamic stability. Furthermore, water deficit can be corrected with 5% dextrose or hypotonic NaCl.
* Hypernatremia with excess volume treated with diuresis, or if necessary by dialysis. Dextrose 5% and then given to replace the water deficit.
* Body of water deficit was estimated as follows:
Deficit = body water (TBW) for the desired (liter) - the body of water current
Body of water required = (who measured serum Na) x (water body current / normal serum Na)
Water body now = 0.6 x BB now (kg)
* Half of the calculated water deficit should be administered within the first 24 hours, and the remaining deficit is corrected within one or two days to avoid cerebral edema.
1. Potassium
Total body potassium approximate 50 mEq / kg, 98% contained in the cell. Decrease in serum levels of 1 mEq K + compared with 10% to 20% total body potassium deficit.
1. a. Hypokalaemia
Definition: K + serum levels below normal (<3.5 mEq / L)
Etiology
* Loss of K + via GI tract (eg vomiting, nasogastrik suction, diarrhea, malabsorption syndrome, laxative abuse)
* Diuretics
* K + intake from the diet is not enough
* Excessive excretion through the kidneys
* Maldistribusi K +
* Hiperaldosteron
Clinical features
Weak (especially the proximal muscles), maybe arefleksia, orthostatic hypotension, decreased gastrointestinal motility that cause ileus. Hiperpolarisasi myokard occurs in hypokalemia and can cause ventricular ectopic beats, Reentry phenomena, and conduction abnormalities. ECG frequently showed flat T waves, U waves and ST segment depression. Hypokalaemia is also causing an increase in sensitivity of heart cells and can lead to digitalis toxicity at therapeutic levels.
Management of hypokalaemia
* Potassium deficit is difficult or impossible to be corrected if there hipomagnesia. This often happens on wasteful use of diuretics potassium. Magnesium should be replaced if low serum.
* Oral therapy. K + supplementation (20 mEq KCl) should be given at the beginning of diuretic therapy. Recheck K + concentration from 2 to 4 weeks after supplementation began.
* Intravenous therapy should be used for severe hypokalemia and in patients who can not stand with oral supplementation. With the speed of the following:
o If the levels of serum K +> 2.4 mEq / L and no ECG abnormalities, K + can be given with a speed of 0 to 20 mEq / h with a maximum of 200 mEq per day.
o In children 0.5 to 1 mEq / kg / dose in one hour. Doses should not exceed the maximum adult dose.
1. b. Hyperkalemia
Definition: K + serum levels above normal (> 5.5 mEq / L)
Etiology
* Inadequate renal excretion; eg in acute or chronic renal failure, potassium-saving diuretics, ACE inhibitors.
* Expenses of potassium from the cell necrosis caused massive trauma (crush injuries), major surgery, burns, acute arterial embolism, hemolysis, gastrointestinal bleeding or rhabdomyolisis. Exogenous sources include potassium supplementation and salt replacement, blood transfusions and high doses of penicillin should also be considered.
* The shift from intra-to extracellular; eg acidosis, digitalization, deficiency of insulin or a rapid increase in blood osmolality.
* Adrenal insufficiency
* Pseudohiperkalemia. Secondary to hemolysis of blood samples or installation is too long torniket
* Hipoaldosteron
Clinical features
The most important effect is the change of heart eksitabilitas. ECG shows sequential changes along with the elevation of serum potassium. In the beginning, looked sharp T wave (K +> 6.5 mEq / L). This was followed by a PR interval extends, the P wave amplitude decreases, widened QRS complex (K + = 7 to 8 mEq / L). QT interval lengthening and finally lead to a sine-wave pattern. Ventricular fibrillation and asistole tend to occur in K +> 10 mEq / L. Other findings include paresthesias, weakness, and paralysis ascending arefleksia.
Management of hyperkalemia
* Continuous ECG monitoring is recommended if any ECG abnormalities or if the serum potassium> 7 mEq / L
* Calcium gluconate can be given iv as a 10 ml solution of 10% over 10 minutes to stabilize the cardiac conduction system myocard
* Sodium bicarbonate makes the blood becomes alkaline and causes potassium to move from extra to intracellular. Bic nat as much as 40 to 150 mEq NaHCO3 iv for 30 minutes or as an iv bolus in the emergency
* Insulin causes the displacement of potassium from extracellular to intracellular fluid. 5 to 10 units of regular insulin with one ampoule should be given 50% glucose iv for 5 minutes
* Dialysis may be needed in severe and refractory cases of hyperkalemia
* Restrictions potassium is indicated at an advanced stage renal failure (GFR <15 ml / min)
1. III. Transfusion
Body response to hemorrhage depends on the volume, speed, and duration of bleeding. State of the patient before the bleeding will affect the responses given.
In healthy adults, bleeding 10% total blood volume did not cause changes in physical signs. Pulse rate, blood pressure, circulation, peripheral and central venous pressure remained unchanged. Receptors in the heart will detect this and cause a decrease in the volume of vasomotor centers to stimulate the sympathetic nervous system which in turn causes vasoconstriction.
Decrease in arterial blood pressure at the tip of the capillary causes the displacement of fluid into the interstitial space is reduced. Decrease in renal perfusion caused water retention and Na + ions. This causes the blood volume returns to normal within 12 hours. Plasma protein levels rapidly became normal within two weeks, there'll also be generating extra hemopoesis erythrocytes. This compensation process is very effective until the bleeding as much as 30%.
On the bleeding that occurred under 50% or the hematocrit is still above 20%, blood loss can still be replaced with a liquid colloid with colloid or crystalloid combinations are similar in composition to the blood of Ringer Lactate. However if blood loss> 50%, usually required a transfusion.
To replace the lost blood can be used in the basic formula of blood transfusion, namely:
V = (target Hb - Hb initials) x 80% x BB
Donor Hb
1. 1. Red blood cell transfusions
Indications of a red blood cell transfusions
* Acute blood loss
If blood is lost due to trauma or surgery, then either the replacement of red blood cells and blood volume needed. If more than half the blood volume hlang, the complete blood should be given, if less than half, then concentrate red blood cells or plasma expander is given.
* Blood transfusion prabedah
* Iron deficiency Anema
Patients with iron deficiency can not be transfused, unless it is required for immediate surgery or who fail to respond to treatment at full therapeutic doses of oral iron.
* Anemia associated with chronic disorders
* Kidney failure
Severe anemia associated with renal failure should be treated with transfusions of red blood cells as well as with the human recombinant eritropoetin.
* Failure of bone marrow
Patients with bone marrow failure due to leukemia, cytotoxic treatment, or infiltrating malignancy will require not only red blood cells, but also other blood components.
* Patients who are dependent trasnfusi
Patients with severe thalassemia syndrome, aplastic anemia, and anemia requiring transfusion sideroblastik regularly every four to six weeks, so they are able to live a normal life.
Patients with sickle cell month *
Some people with this disease requires trasnfusi regularly, especially after the stoke, for "chest syndrome" recurrent life-threatening, and during pregnancy.
* Neonatal hemolytic disease
Neonatal hemolytic disease can also be an indication for transfusion substitute, if the neonate had severe hyperbilirubinemia or anemia.
Various components of red blood cells
Component
Packaging vol blood cells
Given volume
The main indication
A complete blood
0.35 to 0.45
510 ml
Acute massive blood loss
Fresh blood
0.35 to 0.45
510 ml
Can not be proven
Concentrated red blood cells
0.55 to 0.75
Approximately 200 ml
Chronic blood loss or anemia
Filtered blood
varies
varies
Non-hemolytic transfusion reactions and the prevention of HLA immunization prior to transplantation
Washed red blood cells
varies
varies
Non-hemolytic transfusion reaction to plasma proteins
Red blood cells frozen, thawed and washed
varies
vary, but usually <200ml
Patients with rare antibody
Criteria transfusion with RBC concentrates
* Hb <8 g%
* Hb 80-10 g%, accompanied by sign of disturbance normovolemia myocardial, cerebral, respiratory
Great * Bleeding> 10 ml / kg in the first 1 hour or 5 ml / kg in the first three hours
Problems associated with transfusion of red blood cells
1. Urgent problem
* Expenses teradi circulation if the blood transfused too quickly so that rapid replacement of fluid redistribution occurs, or if there is cardiac dysfunction. Central venous pressure increased, and in cases of severe left ventricular failure
* Leakage of potassium out of the red blood cells during storage. This hyperkalemia dieksaserbasikan for blood storage at room temperature for too long
* Massive transfusion may cause hypothermia, toxicity, citric acid load, and shrinkage Platelet and coagulation factors
* Hemolytic reaction may cause fever, tachycardia, insomnia, sore groin, rigor, vomiting, diarrhea, headache, hypotension, shock, and eventually acute renal failure and bleeding due to DIC
* Raksi non-hemolytic can cause urticaria, fever and severe anaphylactic reactions, although rare
1. Medium-term problem
* Local phlebitis can occur if the plastic kanula abandoned in the same place too long. Sometimes an infection by the Staphylococcus or corinebacterium
* Hypertension and / or spasm syndrome is sometimes found in patients with sickle cell and b thalassemia major who received regular transfusions
* Infection can be transmitted by transfusion
1. Long-term problem
Iron burden. Every unit of blood contains 250 mg of iron that can not be excreted body. Regular transfusions can often cause tertimbunnya iron in the body resulting in pigmentation, growth inhibition in young people, hepatic cirrhosis, diabetes, hipoparatiroid, heart failure, arrhythmias, and ultimately death. Treatment with iron chelation should be considered in these patients before serious organ damage occurs.
1. Platelets Transfusion and Granulocyt
Platelet and granulocyte transfusions are necessary for patients with life-threatening thrombocytopenia and netropenia caused by bone marrow failure. This situation is probably a direct result of disease sufferers, such as acute leukemia, anemia aplastika, or bone marrow transplant.
Platelet transfusion indication
* Failure of bone marrow by disease or treatment yangdisebabkan mielotoksik
* Abnormalities of thrombocyte function
* Thrombocytopenia due to dilution
* Shortcuts cardiopulmonary
* Autoimmune thrombocytopenia purpura
Adverse effects on Platelet transfusion
Adverse effects on Platelet transfusion is the emergence kerefrakteran platelets, aloimunisasi, transmission of the disease and sometimes graft versus host disease.
Indications of granulocyte transfusion
* Neutropenia persistent and severe infections - If the neutrophil count kept less than 0.2 x 109 / L and there is clear evidence of bacterial or fungal infections that can not be controlled with proper medication use antibotik within 48-72 hours.
* Abnormal neutrophil function and persistent infection
* Neonatal Sepsis
Granulocyte transfusion adverse effects
Detrimental effect on the incidence of transfusion of granulocytes is aloimunisasi, transmission of infection, lung infiltration, and a graft versus host disease.
