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    Maintenance Fluid

    Therapy

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    RESUSCITATION MAINTENANCE

    NUTRITIONCrystalloid

    1. Replace acute loss(hemorrhage, GI loss,

    3rd

    space etc)

    1. Replace normal loss(IWL + urine+ faecal)

    2. Nutrition support

    ELECTROLYTES

    FLUID THERAPY

    Colloid

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    Electrolyte compositionmEq/L ICF ECF

    Plasma Interstitial

    15 142 144

    150 4 4

    2 5 2.5

    27 3 1.5

    1 103 114

    10 27 30

    100 2 220 1 1

    - 5 5

    63 16 6

    Na+

    K+

    Ca2+

    Mg2+

    Cl-

    HCO3-

    HPO42-

    SO4

    2-

    Organic acid

    Protein

    142

    150

    144

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    .

    COMPARTMENT CATION ANION Suitable solution

    ICF K+

    Mg++

    HPO4-

    , Prot containing K+

    Mg+

    and HPO4-

    ECF PLASMA Na+ Cl-, HCO3- Prot. High Na+ and Cl-

    ISF Na+ Cl- HCO3-

    Ion Distribution

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    Dehydration Hypovolemia

    * thirst* urine output

    headache nausea

    syncope

    hypotonicelectrolytes

    isotonicelectrolytes

    5% DextroseN/2-D5

    Ringers acetateRingers lactateNormal saline

    .

    Deficit

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    Fluids can be described as being

    from three categories

    .Isotonic - Fluid has the same osmolarity as plasma

    Normal Saline (N/S or 0.9% NaCl),Ringers Acetate(RA), Ringers lactate (RL)

    Hypotonic -Fluid has fewer solutes than plasmaWater, 1/2 N/S (0.45% NaCl), and D5W(5% dextrose in water) after the sugar isused up

    Hypertonic-Fluid has more solutes than plasma5 % Dextrose in Normal Saline (D5 N/S),3% saline solution, D5 in RL.

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    Most Common form of Dehydration

    Occurs when fluids and electrolytes are lost ineven amounts

    There are no intercellular fluid shifts inisotonic dehydration

    Common Causes

    diuretic therapyexcessive vomitingexcessive urine losshemorrhagedecreased fluid intake

    Isotonic Dehydration

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    Hypertonic Dehydration

    Second most common type of dehydration.

    Occurs when water loss from ECF is greater thansolute loss

    hyperventilation, pure water loss with high fevers,and watery diarrhea.

    Diabetic Ketoacidosis and Diabetes Insipidus

    Iatrogenic Causesprolonged NPO, excessive hypertonic fluids, sodium

    bicarbonate, or tube feedings with inadequate water

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    Hypotonic Dehydration

    Relatively Uncommon - Loss of more solute(usually sodium) than water.

    Hypotonic Dehydration causes fluid to shift from theblood stream into the cells, leading to decreasedvascular volume and eventual shock

    Seen in Heat Exhaustion

    Increased cellular swelling -causes increasedintracrainial pressure - H/A and Confusion.

    Seen in Heat Stroke

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    increases ECF

    ICF ISF Plasma

    Replace acute/abnormalloss

    Isotonic infusion

    800 ml 200 ml

    Ringers acetateRingers lactate Normal saline

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    increases ICF > ECF

    ICF ISF Plasma

    Replace Normalloss (IWL + urine)

    Hypotonic infusion

    5% dextrose

    85 ml255 ml660 ml

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    Replacement

    Maintenance Repair deficit

    Fluid Therapy

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    BACIC PRINCIPLES

    Replace

    Maintain

    Repair

    Abnormal loss: GIT, 3rd space,Ongoing loss, septic andHypovolemic shock

    IWL + urine

    Acid base, electrolyte imbalances

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    FLUID SELECTION

    Replace : RA, RL, NS

    Maintain: N/2 + D (adult) + K+ 20 mEqN/4 + D (chlldren) + K+ 20 mEq

    Repair : NaHCO3 8,4%

    KCl 25 mEq/25 ml

    NaCl 3%

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    Maintenance

    IWL + urine

    Adults/children : 4:2:1

    eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 =100ml/hr

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    Requirements

    Fever

    Restless/delirium Warm ambient temperature

    Hyperventilation

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    Requirements

    Hypothermia

    High humidity

    Oliguria/anuria

    Reduced consciousness

    Retention/oedema Increased intracranial pressure

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    Rationale of maintenance

    solutions Fluid redistribution

    Basal requirement of potassium &

    sodium

    electrolyte concentration ininfusion solutions

    Ready for use solutionsminimizes risk of contamination

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    Electrolyte solutions

    Plasma Isotonicsolutions

    Hypotonic solutions

    Normalsaline

    Ringersacetate/ lactate

    KAEN 3B*

    290 308 273

    278

    D5

    290278

    * KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol

    Cl-, 20 mmol lactate, 27 g dextrose per L.

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    Basal requirement of

    Potassium

    K+ intake ranges from 40-150 mEq daily

    Homeostasis (minimum req) 20-30 mEq/day

    Increased requirement in heart failure and

    hypertension

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    -900 -600 -300 0 +300

    K+ deficit (meq) K+ excess (meq)

    10 -

    -

    8 -

    -

    6 --

    4 -

    -

    2 -

    -

    -

    serum K+

    (meq/L)

    Relationship between serum K+ serum andTBK at various levels of deficit and excess

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    05 10 15 20 25 K+ deficit (%)

    5 -

    -

    4 -

    -

    3 --

    2 -

    -

    1 -

    -

    -

    serum K+

    (meq/L)

    Decreased serum K+and deficit of TBK (%)

    total body K+ = 50 mEq/kg body weight

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    A c i d o s i s A l k a l o s i s

    Blood pH 7.2 7.3 7.4 7.5 7.6

    5.0 4.5 4.0 3.5 3.0 0 mEq4.5 4.0 3.5 3.0 2.5 100 mEq

    4.0 3.5 3.0 2.5 2.0 200 mEq

    3.2 3.0 2.5 2.0 1.5 400 mEq

    cell DCCECF

    3 K+

    H+

    2 Na+

    3 K+

    H+

    2 Na+

    K+

    H+

    Urine

    K+ low urine K+H+ acid urine

    3 K+

    H+

    2 Na+

    3 K+

    H+

    2 Na+

    K+

    H+ Urine Alkali

    K+

    H+

    Urin

    Cell Tubulus distalECF

    K+ and acid-base status

    Serum K+

    K+ depletion

    K+

    urin tinggi

    St d d K+ t ti i i

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    Cnc:

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    Rate of administration of

    Electrolyte & glucoseNa+ 100 mEq/hr

    K+ 20 mEq/hr

    Ca++ 20 mEq/hr

    Mg++ 20 mEq/hr

    HCO3

    -100mEq/hr

    Glucosa 0,5 gr/kg/hr ( 4 mg/kg/min)*

    * Neonates 6-8 mg/kg/min

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    Conclusion

    Maintenance fluid therapy : normal loss

    (IWL + Urine)

    Suitable in hypertonic dehydration Minimized risk of potassium depletion in cases

    of prolonged inadequate oral intake

    Ready for use product associated with lessrisk of contamination

    Can be combined with amino acids