water balance, infusions

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KLINIKA ANESTÉZIOLÓGIE A INTENZÍVNEJ MEDICÍNY LF UPJŠ A FNLP KOŠICE. Water balance, infusions. MUDr. Štefan Trenkler, PhD. I. KAIM UPJS LF a UNLP Košice. Košice 2012. Distribution of body fluids and the Na & K concentrations in the body water compartments. - PowerPoint PPT Presentation

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  • MUDr. tefan Trenkler, PhD.I. KAIM UPJS LF a UNLP Koice

    Water balance, infusions Koice 2012

  • Distribution of body fluids and the Na & K concentrations in the body water compartmentsLobo DN: Physiological Aspects of Fluid and Electrolyte Balance, 2002 42 l = 28 + 14 (3,5 + 10,5) litres

  • Daily water balance in adults

    Water intake

    Water intake in form of fluids

    (volumes of drinks including soups)

    1000-1500 ml

    Water intake in form of semi-solid

    and solid foods

    700 ml

    Water of oxidation

    300 ml

    Total daily water intake

    2000-2500 ml

    Water output

    water loss in urine

    1000-1500 ml

    water loss through skin

    500 ml

    water loss through lungs

    400 ml

    water loss in stools

    100 ml

    Total daily output

    2000-2500 ml

  • Fluid balance

  • Additions to minimum water requirement,

    depending on clinical situation in adults

    (osmotic free water)

    - temperature elevation by 1 oC

    - moderate sweating

    - marked sweating, high fever

    - hyperventilation

    - hyperventilation in very dry surroundings

    - exposed wound surfaces and body cavities

    (operation lasting up to 5 hours)

    100-300 ml

    500 ml

    1000-1500 ml

    500 ml

    1000-1500 ml

    500-3000 ml

  • Water, electrolytes homeostasisAdequate volume of circulating plasma = normal tissue perfusionECF volume ~ total body Na+ contentKidney filtration, reabsorbtion of water, Na+Hormones renin, aldosteron, ADH; ANPPotassium

  • Na+: 1,5 mmol/kg/dK+: 1 mmol/kg/d

  • Homeostasis disturbancesWater hyper and dehydratationOsmolality (Na) hyper a hypoosmolalityOncotic disturbances Ions disturbancesABG disturbances

  • Osmotic pressureOsmotic pressure is force per area that prevents water from passing through membrane!

  • Osmotic pressure (e.g. erytrocyte)

  • Laboratory findings in disorders of water balance

    Disorder

    Na

    mmol/l

    MCHC

    g/l

    Protein

    g/l

    Hb

    mmol/l

    Hct

    %

    RCC

    T/l

    MCV

    fl

    Normal range

    135-145

    320-360M

    300-340F

    65-80

    8,7-11,2M

    7,4-9,9F

    40-48M

    36-42F

    4,5-6,1M

    4,1-5,3F

    82-93

    Hypotonic dehydration

    (

    (

    (

    (

    (

    (

    (

    Isotonic dehydration

    n

    n

    (

    (

    (

    (

    n

    Hypertonic dehydration

    (

    (

    (

    (

    (

    (

    (

    Hypotonic overhydration

    (

    (

    (

    (

    (

    (

    (

    Isotonic overhydration

    n

    n

    (

    (

    (

    (

    n

    Hypertonic overhydration

    (

    (

    (

    (

    (

    (

    (

    If isotonic dehydration is caused by blood loss, total protein, RCC, Hb and Hct are normal or low.

    If isotonic dehydration is caused by plasma loss, total protein is normal or low.

    MCHC = mean (erythrocyte) cellular haemoglobin concentration, Hb = haemoglobin,

    Hct = haematocrit, RCC = red cell count, MCV = mean (erythrocyte) cellular volume,

  • Fluid inputMaintaining the IC and EC fluid volume1. Basic requirements (30 ml/kg/d) (1000 ml NS 0.9%; 2000 ml free water (Glu); 60 mmol KCl)2. Pre-existing deficit (signs of dehydratation/hypovolemia - assessment)3. Additional losses

  • Hydratation status, intravascular volume assessmentHistoryPhysical examination (P, BP, RR, CR, MM, diuresis)Tests results (Na, K, osmolality, HTC, urea)Patient response to the fluid administration (physiological parameters) (10 20 ml NS 0.9%/kg)

  • Hypovolemia (fluid depletion)Hypotension MAP
  • Distribution of infused fluids in the body water compartments Lobo DN: Physiological Aspects of Fluid and Electrolyte Balance, 2002

  • Crystalloids composition

    A

    [mmol/l]KNaClCaHPO4HCO3MgkJkcalin

    F1/1154154

    F1/27777428103G 25 g

    Ringer41471562.3

    Ringer L5.41301121.8Lt 27

    Hartmann5.41301121.82.1Lt 30

    Darrow36120104Lt 52

    Plasmalyte414098

    G 5%855205G 50 g

    G 10%1710410G 100 g

    ArgininCl 21%1000

    NaHCO3 8,4%10001000

  • Colloids Natural

    Plasma 5 % (frozen)

    Albumin 4,5 %, 20 %

    Synthetic

    Gelatine Dextran 40, 70 Hydroxyetylstarch HAES, Voluven,

  • Crystalloids vs colloidsNo differences in clinical outcomeMore oedema with crystalloidsMore rapid replacement with colloids (permeability)Risk vs benefit; costNewer (better) HEAS?Mixture of C&C

  • Fluid replacementLoss of 1 liter of blood:

    Replacement: 1 l of blood or 1 l of colloid (IV)or 4 l of crystalloid (EC)or 12 l of glucose (IV + EC + IC)

    Distribution volumes of fluids!

    Speed of loosesReplace what is lostVolume vs haemoglobinOral/GI route has preference!!!

  • Guidelines for transfusion of red cellsAAGBI 2001Normally patients should not be not transfused if the haemoglobin concentration is >100 g/l.A strong indication for transfusion is a haemoglobin concentration
  • Transfusion trigger HB (g/L)Clinical situation 100Acute coronary syndrome 90Stabile heart failure 80Aged, vascular surgery, sepsis 70All other patients

  • Blood transfusionsIn the meantime complex decision; prudent and conservative management, based on: - awareness of risks - individual haemoglobin level (70-100 g/L) - clinical judgement based on the sound understanding of the normal and pathological physiology - normovolaemiaUnit-by-unit basis (1 u ~ 15 g/l), re-evaluationDepartmental/hospital guidelines; regular auditHaemovigilance system

  • Fluid regimePreoperative deficitsMaintenance fluidsBlood lossLosses to the third space

  • SituationBlood volume: 70 ml x 80 kg = 5600 mlBlood loss:20% ~ 25-30 g/l = 90 g/l

  • End

    **Normally patients sould be not transfused if the haemoglobin concetration is above 100 g/l.Strong indication for transfusion is a haemoglobinconcentration belo 70 g/l. Transfusion will become essentio when the haemoglobin concetration decrerase to 50 g/l. A haemoglobin concentration between 80 and 100 g/l is a safe level even for those patients with significant cardiorespiratory disease.Symptomatic patients should be transfused. *