Maintenance Fluid Therapy

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Maintenance Fluid Therapy

• Iyan Darmawan, MD
• Medical Department
• Otsuka, Indonesia

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FLUID THERAPY
RESUSCITATION
MAINTENANCE
Colloid
NUTRITION
Crystalloid
ELECTROLYTES
1. Replace acute loss (hemorrhage, GI loss,
3rd space etc)
1. Replace normal loss (IWL urine
faecal) 2. Nutrition support
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Electrolyte composition
144
142
Na
150
K
Ca2
Mg2
Cl-
HCO3-
HPO42-
SO42-
Organic acid
Protein
4
.
Ion Distribution
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-
5
.
Deficit
Dehydration
Hypovolemia

• headache
• nausea
• syncope

thirst urine output ?
hypotonic electrolytes
isotonic electrolytes
5 Dextrose N/2-D5
Ringers acetate Ringers lactate Normal saline
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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 plasma
Water, 1/2 N/S (0.45 NaCl), and
D5W (5 dextrose in water) after
the sugar is used up
Hypertonic-Fluid has more solutes than plasma
5 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 in
even amounts There are no
intercellular fluid shifts in isotonic
dehydration Common Causes
diuretic therapy excessive vomiting
excessive urine loss
hemorrhage decreased fluid intake
Isotonic Dehydration
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Hypertonic Dehydration
Second most common type of dehydration.
Occurs when water loss from ECF is greater than
solute loss hyperventilation, pure water loss
with high fevers, and watery diarrhea. Diabetic
Ketoacidosis and Diabetes Insipidus Iatrogenic
Causes prolonged 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 the
blood stream into the cells, leading to decreased
vascular volume and eventual shock
Seen in Heat Exhaustion Increased
cellular swelling -causes increased
intracrainial pressure - H/A and Confusion.
Seen in Heat Stroke
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Isotonic infusion

• Ringers acetate
• Ringers lactate
• Normal saline

Replace acute/ abnormal loss
increases ECF
ICF ISF Plasma
800 ml 200 ml
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Hypotonic infusion

• 5 dextrose

Replace Normal loss (IWL urine)
increases ICF gt ECF
ICF ISF Plasma
85 ml
255 ml
660 ml
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Fluid Therapy

• Replacement
• Maintenance
• Repair deficit

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BACIC PRINCIPLES
Abnormal loss GIT, 3rd space, Ongoing loss,
septic and Hypovolemic shock
Replace
Maintain
IWL urine
Acid base, electrolyte imbalances
Repair
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FLUID SELECTION

• Replace RA, RL, NS
• Maintain N/2 D (adult) K 20 mEq
• N/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 421
• 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 in infusion solutions
• Ready for use solutions minimizes risk of
  contamination

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Electrolyte solutions
Isotonic solutions
Hypotonic solutions
Plasma
308
273
290
278
290
278
D5
Normal saline
Ringers acetate/ lactate
KAEN 3B
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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Relationship between serum K serum and TBK at
various levels of deficit and excess
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Decreased serum K and deficit of TBK ()
total body K 50 mEq/kg body weight
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K and acid-base status
K depletion
Blood pH 7.2 7.3 7.4 7.5
7.6
5.0 4.5 4.0 3.5 3.0
0 mEq
Serum K
4.5 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
A l k a l o s i s
Cell
cell
ECF
ECF
Tubulus distal
DCC
H

K

K

H

Urine
Urin
K urin tinggi
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Standard K concentration in i.v. solutions
Cnc lt40 mEq/L
1
lt 40mEq/L
Rate of adm lt20 mEq/hr
2
KCl
daily dosage lt100 mEq/day
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Monitor ECG and serum K
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U r i n e output gt0.5 ml/kg/hr
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KCl bolus
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Rate of administration of Electrolyte glucose
Na 100
mEq/hr K
20 mEq/hr Ca
20 mEq/hr Mg
20 mEq/hr HCO3-
100 mEq/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 less
  risk of contamination
• Can be combined with amino acids