c:\documents and settings\administrator\桌面\11 fluid therapy
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Fluid Therapy The first affiliated hospital SUN YAT-SEN university
Prof. Wang Huishen
王慧深
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Last lesson Emphasis
Etiology(in/ex/no)
Pathogenesis(4+ex/b/v/no)
Clinical manifestation
Diagnosis DifferentialDiagnosis
(p/d/n)Treatment
Predisposing(4)
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Diagnosis Not difficultAccording to clinical manifestation,
laboratory tests and character of stool.
+ +Infectious OrNoninfectious
Dehydration Degree and quality
Electrolyte disturbances
AndDisturbance of
acid-base balance
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Severity clinical signs of dehydration
mild moderate severeWater loss
By weight
Spirit
SkinMocous
Anterior fontanel and eye ball
Tear
Urine output
Peripheral circulation
< 50ml/kg
< 5%
Slightly dispirited
slightly agitated
Slightly drySlightly dry
Slightlydepressed
Normal
Slightly reduced
normal
50 ~ 100ml/kg
5% ~ 10%
DispiritedAgitated
Dry, paleVery dry
depressed
Reduced
Little or No
Little cool
100 ~ 120ml/kg
> 10%
Extremely dispiritedapathy, hypnody,
coma
Gray mottledParched
depressed greatly
No
No urine output
Cool, weak
pulse,shock
Dehydration
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Dehydration
Same proportion loss
P IF CP IF
C
Electrolyte lossmore
P hypotonic,IF+C hypertonic
Cell expansionSevere
Easy to shock
P: plasma, IF: interstitial fluid, C: cell
Isotonic
P IF C
Water lossmore
P hypertonicIF+C hypotonic
Cell hydrationMild
Thirsty
Acute diarrheaafter
vomiting greatly
Hypotonic Hypertonic
Na+ :130 ~150mmol/L
Na+: < 130mmol/L Na+: > 150mmol/L
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Electrolyte disturbance
Diarrhea complicated
hyponatremia & hypernatremia
hypokalemia
hypocalcemia
hypomagnesemia
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K+ (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L)
causes :
Excessive losses: vomit, diarrhea.
Inadequate intake.
Renal function of keeping kalium ,it continues
excluding kalium when with hypokalemia.
Clinical manifestation: electrolyte disorder
Hypokalemia
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depressed
Tension of skeletal muscle , tendon reflex , even respiratory muscle weakness
Tension of smooth muscl , abdominal extension, intestinal sound or disappear
Myocardium excitability , arrhythmia, ECG: T-wave is low or inversion, U-wave occurs, prolonged P-R interval and Q-T interval, ST section descending.
Baseosis
hypokalemia K+ (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L)
Clinical manifestation: nerve and muscular excitability
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Ca2+ 1.75mmol/L (7mg/dl) ; ﹤ Mg2+ 0.6mmol/L (1.5mg/dl).﹤
Symptoms usually occur after dehydration and acidosis resolved, or fluid replacement.
Clinical manifestation: thrill, tetany, convulsion.
If convulsion hasn’t relieved after supplement
calcium, pay attention to hypomagnesemia.
hypocalcemia & hypomagnesemia
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Case example
An 8 – month boy had diarrhea and vomited for 3 days, urine
stream reduced, irritability. PE: Pulse rate 150/min, weight
loss was 10%, blood pressure 65/40mmHg, skin color showed
grey and skin turgor looked like tents. Mucous membranes
were very dry; eye ball was sunken greatly, anterior fontanel
depressed greatly. Abdomen distended, bowel sound
diminished.
Questions:
1.What is the diagnosis? 2.How to administer the fluid therapy?
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Answer 1 (diagnosis)
Acute diarrhea severe dehydration hypokalemia
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Neonate……………... 80%
Older children………..65%
Adult…………………..60%
features of body fluid balance in children
The younger The larger proportion of body water
Total body water
(by body mass)
----amount of body fluid
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features of body fluid balance in children
The youngerThe larger proportion
of extracellular water
Intracellular
Body fluid
Extracellular
Interstitial fluid
Plasma
Lymph fluid
Secretory juice
----distribution of body fluid
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P6%
IF37%
IC35%
IF20%
IF10%
~15%
IF25%
IC40%
P5%
P5%
P5%
IC40%
IC40%~45%
Neonate 78% ~1y 70%
2y~14y 65% Adult 55%~60%
features of body fluid balance in children
P: plasma
IF: interstitial fluid
IC: intracellular
----distribution of body fluid in different ages (by BW)
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features of body fluid balance in children
----water requirement
Requiring more water
Regulating function poorly
Easy water metabolism disturbance
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Due to grow quickly, need 0.5%~3% water for growth.
Insensible water loss : 2 times more than adult.
Fluid exchange of digestive tract quicker.
Water metabolism higher: infant 1/2 by total fluid
adult 1/7 by total fluid.
Regulating function of water metabolism poorly:
kidney, lung.
features of body fluid balance in children
----water requirement
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◆Similar with adultExtracellular:
Na+, Cl-, Hco3-
Intracellular:
K+, Mg, Hpo4=, protein
◆Features of neonate (Several days after birth) :
Composition of body fluid
Particularly in preterm infantK+, Cl-, P, lactic acid
Na+, Ca++, Hco3-
Function of excluding H+ Acidosis
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Acid-base balance and adjust
----two concept
Acid-base balance
Acidity and alkalinity
Anion-cation balance
Anion and cation
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Compensation of adjust has limit
Acid-base balance and adjust
----body liquid
Buffer system
lung : exhale of store CO2 (respiratory)
kidney: exclude H+ and store Na+ (metabolic)
NaHCO3/H2CO3
Na2HPO4/NaH2PO4
Buffer system of plasma protein
Adjust HCO3- NaHCO3/H2CO3=20:1
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PH : 7.4 (7.35~7.45)
PaCO2 : 40 (34~45) mmHg
SB : 24 (22~27) mmol/L
BE : -3 ~ +3 mmol/L
CO2CP : 22 (18~27) mmol/L
Acid-base index
Blood gas analysis ( normal )
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Compensation & decompensation
Acid-base balance disorder
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
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Dispirited, dysphoria, drowsiness, coma
Hypernea (Kussmauls breathing) , exhalation cool
Expiratory gas smells ketone
Cherry lips
Nausea, vomit
Metabolic acidosis--clinical manifestation
Mild: breath frequency slightly
Severe: occur:
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To cure water and electrolyte disturbance
Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte
Normal physiological function
Fluid therapy Purpose
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oral intravenous
Fluid therapy Method
prevention dehydration: Rice soup add salt solute ( 1/3 )Mild dehydration: ORS 。Mild/moderate dehydration : ORS ——mild: ORS : 50 ~ 80ml/kg ——moderate: ORS : 80 ~ 100ml/kgSevere dehydration or vomiting and diarrhea —— intravenous
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NaCl : 3.5g
NaHCO3 (Sodium citrate) : 2.5g (2.9g)
KCl : 1.5g
GS : 20g
oral rehydration salts ( ORS )
Na+ 90mmol /L,K +20mmol /L,Cl - 80mmol /L, HCO3 - 30mmol /L
Add water to 1000ml 2 / 3 isotonic , Total osmotic pressure: 220mmol /LCan be diluted in Children
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口服补液盐 Oral rehydration salt (ORS)
WHO2002 年推荐的低渗透压 ORS 配方 成分 含量 ( 克 )
NaCl 2.6枸橼酸钠 2.9KCl 1.5葡萄糖 13.5水 1000ml
该配方中各种电解质浓度为: Na+ 75mmol/L , K+ 20
mmol/L , C1- 65 mmol/L ,枸橼酸根 10mmol/L ,葡萄糖 75m
mol/L 。总渗透压为 245 mOsm/Lsodium citrate could instead by NaHCO3
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Na + -- GS transport in Small intestine
Na+–GScarrier
enterocyteBrush border intracellularintercellularblood
Na+
GS
Na+
GS
transport
promoteNa+ 、 H2O absorb
Na+(pump) intercellular space(Cl- )OP H2O into blood
Mechanisms of ORSMechanisms of ORS
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Characteristics of ORS
---Advantages
Osmotic pressure similar with plasma(2/3 tonicity)2/3 tonicity)
Correct losses by proper concentration of
Na+ 、 K+ 、 Cl-
Children easily accept the tastes
Correct metabolic acidosis by sodium citrate
Promote Na+ and H2O absorption by 2% GS
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Characteristics of ORS ---disadvantages
Liquid tonicity higher (2 / 3)
Can not be used as the maintenance media
Na+ concentration is relatively higher to neonates
and infants (proper diluted) .
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ORS :
Rice soup 500ml+ salt 1.75g
Fried rice noodles 25g + salt 1.75g
+ water 500ml (Cooking 2 - 3min)
GNS:
White sugar 10g + salt 1.75g + water 500ml (boil)
Simple preparation at home
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Severe dehydration
intravenous
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Osmotic pressure of plasma (OPP)
OPP= (crystal + colloid) osmotic pressure
Na+ 142 Cation: K+ 5(mmol) Ca++ 2.5 Mg++ 1.5
HCO3- 27
Anion: Cl- 103 (mmol) HPO4
= 1 SO4
= 0.5 Organo-anion 19.5
151 mmol/L 151 mmol/L
OPP range : 280 - 320mOsm/L
Concentration of electrolyte and calculation
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Osmotic pressure, osmol ( OSM )
Dissolve 1mmol solute into 100ml water: 1mOsm.
100ml water
1mmol1mOsm
Concentration of electrolyte and calculation
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To non electrolyte
1mmolGS 1mOsm
2mOsm1mmolNacl
To electrolyte
1mmolCacl2
3mOsm
Concentration of electrolyte and calculation
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Na:Cl=3:2 ( in plasma )
Fluid isotonic
Isotonic liquid: osmotic pressure similar with plasma
Sodium isotonic:Isotonic: 150mmol sodium in 1000ml
½ tonicity: 75mmol sodium in 1000ml
2/3 tonicity: 100mmol sodium in 1000ml
1/3 tonicity: 50mmol sodium in 1000ml
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Liquid solution commonly used
5%GS
10%GS
0.9%NaCl
10%NaCl
Ringer
5% NaHCO3 11.2% NaL
10%KCl
Mixture
nonelectrolyte solution
electrolyte solution
glucose enter the body by oxidation change into water and CO2 for energy and water without tension
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Percentage concentration: 5%GS 、 10%NaCl
Molar (mol, gram molecular weight) , mmol 1 mol NaCl=23+35.5=58.5g
Molarity (mol/L)
calculation :
mol/L=
e.g. 0.9%NaCl= =0.154mol/L
Concentration of electrolyte and calculation
Percentage concentration of solute ( % ) 10
Molecular weight (atomic weight)
0.9×10
58.5=154mmol/L
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10%NaCl : 1ml=1.7mmol
5%NaHCO3 : 1ml=0.6mmol
11.2%NaL : 1ml=1mmol
10%KCl : 1ml=1.34mmol
Calculation
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The element and simple dispensing in the commonly mixed solution
Solution composition ratio dispensing (ml)
NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl
2:1 isotonic solution . 2 1 500 30 47
1:1 solution (1/2 tonicity) 1 1 500 20
2:3:1 solution (1/2tonicity)2 3 1 500 15 24
4:3:2 solution (2/3tonicity)4 3 2 500 20 33
1:2 solution (1/3 tonicity)1 2 500 15
1:4 solution (1/5 tonicity) 1 4 500 9
daily requirementrequirement (1/3tonic) 1 4 500 9 7.5
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常用溶液成分溶 液 每 100ml 含 Na∶Cl 电解质渗透压
血 浆 ( 142 : 103 ) 3 : 2 300mmol/L
①0.9% 氯化钠 0.9g 1∶1 等张
②5% 或 10% 葡萄糖 5 或 10g
③5% 碳酸氢钠 5g 3.5 张
④1.4% 碳酸氢钠 1.4g 等张
⑤10% 氯化钾 10g 8.9 张
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溶 液 每 100ml 含 Na∶Cl 电解质
1∶1 含钠液 ① 50ml,②50ml 1∶1 1/2 张
1∶2 含钠液 ① 35ml,②65ml 1∶1 1/3 张
1∶4 含钠液 ① 20ml,②80ml 1∶1 1/5 张
2∶1 含钠液 ① 65ml,④35ml 3∶2 等张
2∶3∶1 含钠液 ① 33ml,②50ml
④17ml 3∶2 1/2 张
4∶3∶2 含钠液 ① 45ml,②33ml 3∶2 2/3 张
④22ml
续 表
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Water supplement & correct acidosis
Accumulative losses ---losses from onset to pre-treatment
ongoing losses
---continuing losses during treatment
daily requirement ---to maintain basically physiological function
Amount , composition and time
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The first day fluid infusion :
Dehydration Fluid replacement=losses (Accumulation + ongoing + daily )
Accumulation ongoing daily total amount (ml/Kg)
mild 50 10~30 60~80 90~120
moderate 50~100 10~30 60~80 120~150
Severe 100~120 10~30 60~80 150~180
Accumulation: accumulation lossesOngoing: Ongoing lossesOngoing lossesdaily: Physiological requirementPhysiological requirement
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Severity clinical signs of dehydration
mild moderate severeWater loss
By weight
Spirit
SkinMocous
Anterior fontanel and eye ball
Tear
Urine output
Peripheral circulation
< 50ml/kg
< 5%
Slightly dispirited
slightly agitated
Slightly drySlightly dry
Slightlydepressed
Normal
Slightly reduced
normal
50 ~ 100ml/kg
5% ~ 10%
DispiritedAgitated
Dry, paleVery dry
depressed
Reduced
Little or No
Little cool
100 ~ 120ml/kg
> 10%
Extremely dispiritedapathy, hypnody,
coma
Gray mottledParched
depressed greatly
No
No urine output
Cool, weak
pulse,shock
Dehydration
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AccumulationAccumulationlosseslosses
amount
mild : 50ml/kg
moderate: 50~100ml/kgsevere : 100~120ml/kg
Water supplement-1: accumulation losses
Amount , composition and speed:
--- according to the degree and quality of dehydration
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composition
isotonic : 1/2 tonicity(1:1)hypotonic : 2/3 tonicity(4:3:1)Hypertonic:1/3~1/5 tonicity (1/3 tonicity)
speed
Principle: fast slowsevere : bolus of isotonic fluid
2:1 isotonic : 20ml/kg(<300ml)
in 30’~1h(rapidly expand) others : 8~12h (8 ~ 10ml/ ( kg·h ) iv
Water supplement-1: accumulation losses
AccumulationAccumulationlosseslosses
Dehydration :
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OngoingOngoinglosseslosses
amount
1/2~1/3 tonicity(1:1)
speed
12~16h after stage-1 In 24h, steady speed 5ml/ ( kg·h )
10~40ml/kg.d
composition
Water supplement-2: ongoing losses
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dailydailyrequirementrequirement
amount
1/3~1/5 tonicity(Physical main medium)
speed
In 24h, steady speedAccompany with stage-2
60~80ml/kg.d( including oral )
composition
Water supplement-3: daily requirement
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To master three principles
The volum of rehydration- AmountDeficit fluid
=(percentage of dehydration)×(body weight in Kg)
The type of fluid- CompositionIsotonic dehydration——1/2 tonicity solution
Hypotonic dehydration——2/3 tonicity solution
Hypertonic dehydration——1/3 tonicity solution
The speed of liquid-Time : four steps
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four steps(for fluid and electrolyte deficits)
Step 1. Expanding volume: restoration of circulation –emergency,
within 30 min to 1 hour
20ml/kg, 2:1 (isotonic )sodium solution
Step 2. supplement lost body liquid: first 8~10 hours
8~10ml/h
half of total loss volume
2:3:1 solution(1/2 tonicity)
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Step 3. maintenance rehydration: - another half loss
- next 16 hours
5ml/(kg.h)
physical demand : 60~80ml/kg
4:1 solution(1/3~1/2 tonicity)
Step 4. repair of potassium deficit
four steps
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mild : correct etiological factor
Moderat & severe :Alkaline solution requirement (mmol)
(40 –CO2CP Vol%)
2.2
= (22 - CO2CP mmol/L) 0.7 kg
= BE 0.3 kg
0.7 kg
Usually use the dose halved first and than according to blood gas analyses
Correct acidosis
=
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Emergency :
Per-elevate 5mmol HCO3- 5mmol/L(10% CO2-CP)
need alkaline solution: 3mmol/kg
5%NaHco3 5ml/kg or 1.4% NaHco320ml/kg
Correct acidosis
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Supplement potassium: 10%KCL
mild hypokalemia : 200~300mg/ ( kg·
d ) 2~3ml/ ( kg·d ) oral
sever hypokalemia : 300~450mg/ ( kg·
d ) 3~4.5ml/kg.d 10% KCl ivdrip
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Supplement after urine or urination before coming diagnoses
Intravenous concentration<0.3% in the solute
speed : >6~8h/d ( intravenous )Time : keep 4 ~ 6 day
interdiction : directly intravenous , because heart stop !
Supplement potassium principle :
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Supplement Calcium and Magnesium
Convulsion emerged : 10% Calcium Gluconate 10ml+25% Glucose 10ml IV
If convulsion hasn’t relieved after supplement calcium, ——give 25% Mg.Sulfas 0.2~0.4ml/kg deeply IM Q6h
be careful ( Calcium ) : HR<80 time /minute , stop ! Don’t leak out vessel Interval of the Digitalis Don’t injection with subcutaneous and intramuscular
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first fast then slow
Principles of TherapyPrinciples of Therapy
first thick then thin
supplement potassium when having urine
adjust any time and monitor
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Ongoing losses and Ongoing losses and daily requirementrequirement
daily requirementrequirement 60~80ml/kg (1/3~1/5 tonicity)
Ongoing losses follow the how much of the lostOngoing losses follow the how much of the lost in the any time ( in the any time ( 1/2~1/3 tonicity)
12~24H equal the speed iv drip
To continue the supplement potassium and correct acidosis
The second day fluid infusion :
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Neonate: to reduce the liquid and electrolytes
properly.
Severe malnutrition : to reduce the water
amount properly, with low speed, 2/3~1/2 tonic
supplement 10% GS and / or plasma
Notes
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An 8 – month boy had diarrhea and vomited for 3 days,
urine stream reduced, irritability.
PE: Pulse rate 150/min, weight loss was 10%, blood
pressure 65/40mmHg, skin color showed grey and skin
turgor looked like tents. Mucous membranes were very
dry; eye ball was sunken greatly, anterior fontanel
depressed greatly. Abdomen extended, bowel sound
diminished.
Answer question 2How to administer the fluid therapy?
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The first day fluid infusion :
Dehydration Fluid replacement=losses (Accumulation + ongoing + daily )
Accumulation ongoing daily total amount (ml/Kg)
mild 50 10~30 60~80 90~120
moderate 50~100 10~30 60~80 120~150
Severe 100~120 10~30 60~80 150~180
Accumulation: accumulation lossesOngoing: Ongoing lossesOngoing lossesdaily: Physiological requirementPhysiological requirement
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Step 1 : Plan supplementary fluid.
First body weight is calculated by
formula of growth and development section.
——(6+8×0.25=8kg)
——2:1 sodium :20ml×8=160ml
——finished intravenously within 30min.
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Step 2 : Acute loss
be always isotonic dehydration, so we choose :
——2:3:1 (2:glucose , 3: sodium, 1: 1.4% bicarbonate )
——that belong to 1/2 tonicity.
——Repair of water and sodium deficits
● first 8-10 hours 8-10 ml/(kg·h)
● half of total loss volume
(160×8)ml/2=640 ml.
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Step 3. : 4:1 sodium
● be taken next 16 hours
5 ml/(kg·h)
● 80 ml/kg×8kg=640 ml (another half)
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Step 4 : Potassium supplement
8kg×0.4g=3.2g/d. That means about 10% potassium chloride solution
32ml will be used by intravenous infusion. Notice supplement potassium
——when urine stream must be seen;
——meanwhile, be aware of concentration(<0.3%)
——speed and time of it.
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