Discuss some cases of fluid therapy commonly found in daily practice

1. dr. Iyan Darmawan
Parenteral Fluid Therapy
Update
Case-based Approach

2. .
RESUSCITATION REPAIR MAINTENANCE PN
PERFUSION &
OXYGENATION
CORRECT
ELECT & AB
HOMEOSTASIS/
SUPPORTIVE
CORRECT
NUTRITION ST
PARENTERAL FLUID THERAPY

3. Dehydration vs Hypovolemia
• Intracellular & Interstitial
depletion
• Thirst, oliguria, dry
mucous membrane
• Plasma Osmolarity ↑
• BUN/creatinine ratio >20
• FeNa* <1 %
• Intravascular depletion
• Hemodynamic responses
in initial phase
(compensated shock)
• Hypotension, MAP < 60
indicate advanced stage
Both types often coincides
*FeNa = (U/P Na) : (U/P Creat) x 100

4. MAP (1S + 2D)
3
Pulse Pressure (S-D)
Heart Rate
Capilary refill time
Peripheral Vasoconstriction
Oxygen saturation

5.  MAP (mean arterial pressure) 70-105 mmHg
 HR (heart rate)
 Neonates ( 0-30 days): 70 - 190 /minute
 Infants (1 - 11 months): 80-120 /minute
 Children 1 to 10 years: 70 - 130 /minute
 Children> 10 years and adults 60-100 minutes
 Pulse Pressure (Systolic-Diastolic ) 30-40 mmHg
 CRT (capillary refill time) < 2 detik
 Partial Pressure of Arterial Oxygen (PaO2) 80-100
mmHg
 Arterial oxygen saturation(SaO2) 95-100%
 Mixed venous oxygen saturation (SvO2) 60-80%
Reference : http://www.lidco.com/docs/1462Educatioalcard7.pdf.

6. Guide
• Hemodynamics
• Electrolytes
• Metabolic
: MAP, HR, Pulse Pressure, CRT
Na+
K+
Cl-
HCO3-
: Glucose, BUN, creatinin, alb

7. Practical Guide
1. Hemodynamics
2. Urine Output
3. Electrolyte/Metabolic Panel
Na+
K+
Cl-
HCO3-
BUN
Cr
Glu
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
90-105 (fasting)

8. Resuscitation Fluid Therapy

9. Case 1
• A 12 year old patient with DHF. Nausea and
vomiting (+)
• PE : restless;T 100/80 T 37.5 oC HR 120 x/min,
RR 28 /min; cold extremities. Torniquet test(+).
Height 120 cm Weight 50 kg
• Lab: Hct 48%; Platelet 70.000
How is the fluid regimen for this patient?
Answer: Grade 3 DHF requiring 5-10 ml/kg ideal BW /hour and monitor

11. Repair Fluid Therapy

12. A 15 kg postop patient with Na+ 97 mEq/L,. PE:
Stuporous and convulsion.
How much is Na+ deficit in this patient, if we need to correct it
until 125 mEq/L?
How will you correct hyponatremia ini this? ; what is the
administration rate of 3% NaCl?
Case 2

13. A 15 kg postop patient with Na+ 97 mEq/L,. PE:
Stuporous and convulsion.
How much is Na+ deficit in this patient, if we need to correct it
until 125 mEq/L?
How will you correct hyponatremia ini this? ; what is the
administration rate of 3% NaCl?
Case 2
60% BB x (125-97) = 252 mEq
Infusate Na+– Serum Na+
Total body water + 1
(513-97) : (9+1) = 41.6mE/L
We will raise 1 mmol/L hourly for
5 hours
The amount of 3% NaCl 3% required= 5 : 41.6 = 0.120 L = 120 ml or 24 ml/hour
Observe clinical condition and check serum Na+ after 5 hours.. Reduce rate if there is
improvement, eg 0.5 mmol/L/hour until Na+ 115.
Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):1581-1589
Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499.

14. Case 3
A 9 year old 20 kg patient with dehydration and shock (acute GE),
has been resuscitated with Acetated Ringer’s ( Asering) for 5 hours
along with separate line of 8.4% Meylon diluted in D5. Patient was
then unconscious with seizures.
BP 110/75; HR 90/min ; RR 16/min; T 37oC
Na+ 175 mmol/L; K+ 2.1 mmol/L
You wish to correct the hypernatremia and hypokalemia simultaneously with infusion sol
containing 30 mmol/L Na+ (KAEN 4A) plus 20 mmol KCl.
You set a target of Na+ decrease to 165 mmol/L over 10 hours. What is the rate of infusion
you will set up?
Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):1581-1589
Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499.

15. A 9 year old 20 kg patient with dehydration and
shock (acute GE), has been resuscitated with
Acetated Ringer’s ( Asering) for 5 hours along with
separate line of 8.4% Meylon diluted in D5. Patient
was then unconscious with seizures.
BP 110/75; HR 90/min ; RR 16/min; T 37oC
Na+ 175 mmol/L; K+ 2.1 mmol/L
You wish to correct the hypernatremia and hypokalemia
simultaneously with infusion sol
containing 30 mmol/L Na+ (KAEN 4A) plus 20 mmol KCl.
You set a target of Na+ decrease to 165
mmol/L over 10 hours. What is the rate of
infusion you will set up?
(Infusate Na+ + K+ ) – serum Na+
Total body water + 1
= (30 + 20) – 175
(60% x 20) + 1
= -125
13
= - 9.6 mmol/L
This means 1 L infusion will decrease the
serum Na+ serum by 9.6 mmol/L
Reuired amount of infusion = 5: 9.61 =
0.520 L = 520 ml
over 10 hr give 520 ml, at the rate of 52
ml/hr.
Correction rate can be repeated for
subsequent 10-14 hours

16. A 62 year old patient was admitted because of malaise and fatigue after
nausea and vomiting for 5 days. Lack of eating and drinking due to anorexia.
History of hypertension and taking medication: Tenormin 50 mg, Aspirin 75
mg HCT 25 mg, Lisinopril 40 mg per day
PE : Alert, pale, moderate dehydration, BP 170/105.
Cor: extrasystole +, lung NA, hepatomegaly –
Lab:
Chest X-ray : LVH.
ECG : u wave & flattened T
Case 4
145
2.6 NA
25
1.0
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
98
How will you correct the hypokalemia in this patient

17. Hypokalemia( > 2.5 - <3.5 mEq/L )
Heart /cardiovascular disease?
No Yes
Give K+ according to
maintenance requirement
40 mmol
Correction K+ 40 mmol +
Maintenance 40 mmol

18. Hypokalemia ( > 2.5-3.4 mEq/L )
Without cardiovascular disease
* In case of fluid restrition : admix 10 mmol KCL into
1 bag of KAEN 3B, to get final conc of 20 mmol/500 ml.
40 mmol K+ per day
With cardiovascular disease (digitalis, diuretics)
80 mmol K+ per day

19. Hypokalemia( 2 - > 2.5 mEq/L )
80 mmol K+ per day

20. How about life-threatening Hypokalemia?
Serum K+ < 2 mmol/L
– Alkalosis
– Arrhythmia
– Respiratory paralysis
– rhabdomyolisis

21. Hypokalemia( < 2 mEq/L )
OTSU
NS
20 20 20
KCl 40 ml
+
20
over 1 hour
via central
vein

22. A 62 year old patient was admitted because of malaise and fatigue after
nausea and vomiting for 5 days. Lack of eating and drinking due to anorexia.
History of hypertension and taking medication: Tenormin 50 mg, Aspirin 75
mg HCT 25 mg, Lisinopril 40 mg per day
PE : Alert, pale, moderate dehydration, BP 170/105.
Cor: extrasystole +, lung NA, hepatomegaly –
Lab:
Chest X-ray : LVH.
ECG : u wave & flattened T
Case 4
145
2.6 NA
25
1.0
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
98
How will you correct the hypokalemia in this patient

23. Maintenance Fluid Therapy

24. Case 5. (Typhoid Fever)
• Stable hemodynamics, Temperature 390C
• Urine Output 1000 cc
• Electrolyte/Metabolic Panel
145
3.2 NA
22
0.7
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
102
1. Any signs of dehydration?
2. Can we prescribe Glucose containing solution ( Aminofluid ) now and how much?
Plasma Osmolarity & BUN/creat ratio
Hyperglycemia & renal function?
*FeNa = (U/P Na) : (U/P Creat)

25. Case 5. (Typhoid Fever)
• Stable hemodynamics, Temperature 390C
• Urine Output 1000 cc
• Electrolyte/Metabolic Panel
145
3.2 NA
22
0.7
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
102
1. Any signs of dehydration? yes
2. Can we prescribe Glucose containing solution ( Aminofluid ) now and how much?
Plasma Osmolarity & BUN/creat ratio
Hyperglycemia & renal function?
*FeNa = (U/P Na) : (U/P Creat)
2 x [Na+] + BUN/2.8 + Glu/18 = 2 x 145 + 22/2.8 + 70/18 = 301 mOsm/L
BUN/creat ratio = 31
yes, we can. Adult 30-40 ml/kg/day; pediatric 4:2:1 formula. Increease by 12% for
every centigrade over 37oC

26. Case 6 Patient admitted 24 hours ago. D/
Stroke iskemik akut.
PE : stupor, TD 180/110, 37oC, HR 112, RR 12 short
Electrolyte/Metabolic Panel
ABG : PCO2 60 , PO2 90, pH 7.2
148 87
3.2 32
22
0.8
240
1. Any signs of dehydration? yes
2. What acid-base disorder(s) in this patient?Will you administer sodium bicarbonate ( Meylon)?
Respiratory acidosis. Meylon is contraindicated.
3. How will you cope with hyperglycemia? Could you give parenteral glucose at this moment ?
• Reduce plasma glucose until 150 mg/dl. (use Yale formula: 240/70 3 U bolus + 3 u eg insulin
drip/hour)
• Calculate TDDI (0.3-0.5 u/kg)
• Prandial insulin 1 u/10 g glucose
Plasma Osmolarity & BUN/creat ratio?
HBA1c 8 %
2 x [Na+] + BUN/2.8 + Glu/18 = 2 x 148 + 22/2.8 + 240/18 = 317.18 mOsm/L
BUN/creat ratio = 22/0.8

27. Case 7. Acute Nephritic Syndrome, 60 kg ,
Oliguria for 3 days
• Good hemodynamics
• Urine output 300 cc; urinary Na+ 40 mmol/L; urinary Cr 30
mg/dl
*FeNa = (U/P Na) : (U/P Creat) * 100
135
4 NA
15
2.3
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
102
40/135
30/2.3
x 100 =2.27 %
Urine + IWL (15 cc/kg) -Metabolic Water (5 cc/kg)
300 + 900-300 = 900 cc per 24 hours

28. Fractional Sodium Excretion

29. Parenteral Nutrition Therapy

30. COPD Height 170 cm Weight 45 kg
• What is the the total calories and protein
requirement?
Ideal BW = ( Hight – 100) x 90% = 63 kg
Adjusted body weight = (Actual BW – Ideal BW)
2
+ Ideal BW
45 - 63
2
+ 63 = 54 kg
25 kcal/kg BW and 1 g protein/kg BW
Case 8

31. Sepsis Height 160 cm Weight 80 kg
• What is the the total calories and protein
requirement?
Ideal BW= ( TB – 100) x 90% = 54 kg
Adjusted body weight = (Actual BW – Ideal BW)
2
+ Ideal BW
80 - 54
2
+ 54 = 67 kg
25 kcal/kg BW and 1.5 g protein/kg BW
Case 9

32. 60% 20% 20%
TOTAL CALORIES
(25 kcal/kg/day)
GLUCOSE LIPID PROTEIN
Average Patient

33. 60% 20% 20%
TOTAL CALORIES
(1500 kcal)
GLUCOSE LIPID PROTEIN
900 kcal
30 g
300 kcal 300 kcal
225 g 75 g
Average Patient

34. 40% 20%
TOTAL CALORIES
(1500 kcal)
GLUCOSE LIPID PROTEIN
600 kcal
60 g
600 kcal 300 kcal
150 g 75 g
40%
COPD Patient

35. Thank you