INITIAL FLUID THERAPY OF

EMERGENCY CONDITION
IN PRIMARY CARE.
Dr Joko Murdiyanto SpAn
SMF Anesthesi dan Terapi Intensif RSPKU Muh Jogjakarta
Bagian Anestesi dan Terapi Intensif FKIK UMY

Pengalaman Kasus I
(Minggu I sbg Dr Puskesmas Th 1985)
Seorang laki-laki 45 tahun dengan Desentri
Cholera, datang dengan kondisi lemah, T = 80
mmHg palpasi, Laju nadi 120 x/menit, Laju
nafas 30 x/menit, Perabaan nadi lemah,
perabaan tangan dingin dan lembab.
Dikelola sebagai Desentri Cholera dengan syok
hipovolemik.
Airway Jaga tetap adekuat.
Breathing Nafas spontan.
Circulation Infus RL(2jalur) sampai 22 botol /24
jam.
Pantau VS, OUP .
Hari ke 5 pasien pulang.

Pengalaman II
(Sebagai DrSpAn di RSUD Pare-Pare Th 2000).

Seorang Perempuan 30 th, BB 90 Kg, dengan amenorhoe

16 minggu mendadak perut nyeri luar biasa pada saat
tugas lapangan, datang di RS tampak lemah, T = 70
mmHg palpasi, Laju Nadi 140x/menit, Laju Nafas
36x/menit, Peabaan nadi lemah, akral dingin lembab.
Dikelola sebagai KET akut, diputuskan segera lakukan
tindakan operasi dengan perbaikan keadaan umum.
Airway Jaga tetap adekuat.
Breathing O2 8 lt/m dengan NRM.
Circulation Segera kanulasi IV 4 jalur, kira-kira 1jam
masuk RL 16 botol, Dextran L 2 botol, evaluasi
perfusi ginjal OUP > 0,5 cc/kg, perfusi perifer akral
mulai hangat, T = 100/60 mmHg, Laju nadi 108/m.
Diputuskan segera operasi, hari ke 7 pasien pulang ke
Makasar.

Fluid imbalance
Electrolyte imbalance
Acid-base imbalance

The principle of fluid

maintain
tissue perfusion

therapy is to

Preload
Contractility
Afterload

HR
CO
SV

DO2

Hgb
PaO2
Sat O2

CaO2

Therapeutic endpoints
Goal
normal haemodynamic parameters
normal electrolyte concentration
Method
replace normal maintenance
requirements
ongoing losses and deficits
Studies suggest too little post op fluid
given

Fluid Therapy
Replacement
Maintenance
Repair deficit

BASIC PRINCIPLES
Replace

Maintain
Repair

rd space,
Abnormal loss: GIT, 3rd
Ongoing loss, septic and
Hypovolemic shock

IWL + urine
Acid base, electrolyte imbalances

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%

Terminology
mole: molecular weight of that substance in grams
mole eg: sodium chloride is 58 g (Na23, Cl35)

equivalent: chemical combining activity; atomic

weight expressed in grams divided by the valence
divalent ions (calcium or magnesium) 1 mmol
equals 2 mEq

osmole: used when the actual number of osmotically

active particles present in solution is considered
millimole of sodium chloride, which dissociates
nearly completely into sodium and chloride,
contributes 2 mOsm

Osmotic Pressure
physiologic and chemical activity of electrolytes
depend on three factors:
the number of particles present per unit
volume (moles or millimoles [mmol] per
liter)
the number of electric charges per unit
volume (equivalents or milliequivalents per
liter)
the number of osmotically active
particles or ions per unit volume
(osmoles or milliosmoles [mOsm] per liter)

Total Body Water

% of Body Weight % of Total Body
Water
Body Water
60
ICF
40
ECF
20
Intravascular
4
Interstitial
16

100
67
33
8
25

Intracellular Fluid
largest proportion in the skeletal
muscle
potassium and magnesium are the
principal cations
phosphates and proteins the
principal anions

Extracellular Fluid
interstitial fluid: two types
functional component (90%) - rapidly
equilibrating
nonfunctioning components (10%) slowly equilibrating
connective tissue water and transcellular
water
called a third space or distributional
change

sodium is the principal cation

chloride and bicarb the principal

Electrolyte composition
mEq/L
Na+
K+
Ca2+
Mg2+

15
150
150
2
27

ECF
Plasma
142
142
4
5
3

ClHCO3HPO42-

1
10
100
20
63

103
27
2
1
5
16

SO42Organic acid

Protein

ICF

Interstitial
144
144
4
2.5
1.5
114
30
2
1
5
6

Kinds of IV Fluid solutions

Hypotonic - 1/2NS
Isotonic- NS, LR, albumen
Hypertonic Hypertonic saline.
Crystalloid
Colloid
Others

Type of Fluid
Colloid
Albumin

Natural

Dextran
Gelatin

Syntetis

HES
(Hydroxyethyl
starch)

consist of :

electrolytes
&

macro
molecule

Crystalloi
d
NaCl 0.9%/
0,45%

RL

Other
Glucose 5%
Mannitol
Electrolyte
concentrates

Ringerfundin

etc.

consist of :

consist of :
high
concentration
of electrolytes

electrolyte
s.

Crystalloid vs Colloid
Type of particles (large or small)
Fluids with small crystalizable particles
like NaCl are called crystalloids
Fluids with large particles like albumin are
called colloids, these dont (quickly) fit
through vascular pores, so they stay in the
circulation and much smaller amounts can
be used for same volume expansion.
(250ml Albumin = 4 L NS)
Edema resulting from these also tends to stick
around longer for same reason.
Albumin can also trigger anaphylaxis.
(Dan Belz, 2008)

colloid has protein like

mass

A crystalloid is just an
ionic solution

Crystalloids and colloids

Crystalloid

Colloid

Intravascular
persistance

Poor

Good

Haemodynamic
stabilisation

Transient

Prolonged

Required infusion
volume

Large

Moderate

Risk of tissue oedema

Obvious

Insignificant

Enhancement of
capillary perfusion

Poor

Good

Risk of anaphylaxis

Nil

Low to
moderate

Plasma colloid
osmotic pressure

Reduced

Maintained

VOLUME EFFECT OF
CRYSTALLOIDS

FLUID THERAPY
RESUSCITATION

Crystalloid

Colloid

1.
1. Replace
Replace acute
acute loss
loss
(hemorrhage,
(hemorrhage, GI
GI loss,
loss,
rd
3
3rd space
space etc)
etc)

MAINTENANCE

ELECTROLYTES

NUTRITION

1.
1. Replace
Replace normal
normal loss
loss
(IWL
(IWL +
+ urine+
urine+ faecal)
faecal)
2.
2. Nutrition
Nutrition support
support

Fluids can be described as

being from three categories

sotonic
sotonic -- Fluid
Fluid has
has the
the same
same osmolarity
osmolarity as
as plasma
plasma
Normal
Normal Saline
Saline (N/S
(N/S or
or 0.9%
0.9% NaCl),
NaCl),
Ringers
Ringers Acetate(RA),
Acetate(RA), Ringers
Ringers lactate
lactate (RL)
(RL)

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

Hypertonic-Fluid
Hypertonic-Fluid has
has more
more solutes
solutes than
than plasma
plasma
5
5%
% Dextrose
Dextrose in
in Normal
Normal Saline
Saline (D5
(D5 N/S),
N/S),
3%
3% saline
saline solution,
solution, D5
D5 in
in RL.
RL.

Isotonic Dehydration
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

Hypertonic Dehydration
Second most common type
type of
of dehydration.
dehydration.
Occurs
Occurs when
when water
water loss
loss from
from ECF
ECF is
is greater
greater than
than solute
solute loss
loss
hyperventilation,
hyperventilation, pure
pure water
water loss
loss with
with high
high fevers,
fevers, and
and watery
watery
diarrhea.
diarrhea.
Diabetic
Diabetic Ketoacidosis
Ketoacidosis and
and Diabetes
Diabetes Insipidus
Insipidus
Iatrogenic
Iatrogenic Causes
Causes
prolonged
prolonged NPO,
NPO, excessive
excessive hypertonic
hypertonic fluids,
fluids, sodium
sodium bicarbonate,
bicarbonate, or
or
tube
tube feedings
feedings with
with inadequate
inadequate water
water

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

Hypotonic
Hypotonic Dehydration
Dehydration causes
causes fluid
fluid to
to shift
shift from
from the
the
blood
blood stream
stream into
into the
the cells,
cells, leading
leading to
to decreased
decreased
vascular
vascular volume
volume and
and eventual
eventual shock
shock
Seen
Seen in
in Heat
Heat Exhaustion
Exhaustion
Increased
Increased cellular
cellular swelling
swelling -causes
-causes increased
increased
intracrainial
intracrainial pressure
pressure -- H/A
H/A and
and Confusion.
Confusion.
Seen
Seen in
in Heat
Heat Stroke
Stroke

Why Fluid ?

Stroke volume

Preload dependent

Right atrial pressure

Why Fluid ?
Replacement of fluid deficit
increase oxygen delivery
augments tissue perfusion
stops anaerobic metabolism

32

33

Blood pressure is not a reliable sign

to rull-out shock !!!!

34

Pulse rate
Tachicardia

is more

sensitive

than low
blood pressure
False positive : Pain, anxiety
False negative: Drugs,
Cardiac
problems
35

Signs of hypoperfusion

Oliguria
Encephalopathy
Cool, pale skin
Cyanosis
High Lactate (>4mm/L)
Base deficite
Metabolic acidosis
36

Which Patient?
In the event of hypotension and/or
lactate > 4 mmol/L (36 mg/dL)
deliver an initial minimum of 20
mL/kg of crystalloid (or colloid
equivalent).
Surviving Sepsis Campaign: International guidelines
for
management of severe sepsis and septic shock: 2008*
R. Phillip Dellinger, MD; Mitchell M. Levy, MD; Jean M. Carlet, MD; Julian Bion,
MD; Margaret M. Parker, MD; Roman Jaeschke, MD;et a

Crit Care
Med 2008

37

Which fluid ?
In the event of hypotension and/or
lactate > 4 mmol/L (36 mg/dL)
deliver an initial minimum of 20
mL/kg of crystalloid (or colloid
equivalent).
Surviving Sepsis Campaign: International guidelines
for
management of severe sepsis and septic shock: 2008*
R. Phillip Dellinger, MD; Mitchell M. Levy, MD; Jean M. Carlet, MD; Julian Bion,
MD; Margaret M. Parker, MD; Roman Jaeschke, MD;et a

Crit Care
Med 2008

38

Practical differences
Roberts I, Alderson P, Bunn F,
PChinnock, KKer and Schierhout G.
Colloids versus crystalloids for
fluid resuscitation in critically ill
patients (Cochrane Review).
The Cochrane Library, Issue 4, August 24th, 2004

There is no evidence
from randomised controlled
trials
that
resuscitation
with colloids reduces the
risk of death compared to
crystalloids in patients with
trauma,
burns
and
following surgery.

Which Fluid ?
As colloids are not associated
with an improvement in
survival, and further, colloids are
considerably more expensive
than crystalloids, it is hard to see
how their continued use outside the
context of RCTs
The Cochrane Library 2011,
41

Persistence of fluids in
circulation

Assessment of intravascular
depletion
5%
thirst, dry mucous
membranes,
UO 1-2 ml/kg/hr
10%

tachycardia, oliguria,

UO 0.5-1 ml/kg/hr
15%-20%

tachycardia, hypotension,

severe oliguria,
UO < 0.5 ml/kg/hr

(1-2 L deficit)

Assessment of Stages of
Shock

% Blood
Volume
loss

< 15%

15 30%

30 40%

>40%

HR

<100

>100

>120

>140

SBP

N, DBP,
postural drop

Pulse
Pressure

N or

Cap Refill

< 3 sec

> 3 sec

>3 sec or
absent

absent

Resp

14 - 20

20 - 30

30 - 40

>35

CNS

anxious

v. anxious

confused

lethargic

Treatment

12L
crystalloid,
+
maintenanc
e

2L
crystalloid,
re-evaluate

2 L crystalloid, reevaluate, replace blood

loss 1:3 crystalloid, 1:1
colloid or blood products.
Urine output >0.5
mL/kg/hr

Clinical and laboratory assessment of

the severity of dehydration in
children
Signs and
Symptoms

Mild
Moderate
Dehydration Dehydration

Severe
Dehydration

Wt loss (%)

10

15

Fluid deficit
(ml/kg)
Vital Signs

50

100

150

Pulse

Normal

weak

greatly feeble

BP

Normal

Normal to low

, orthostatic

Respiration

Normal

Deep

Deep & rapid

Clinical and laboratory

assessment of the severity of
dehydration in children
Signs and
Symptoms

Mild
Dehydration

Moderate
Dehydration

Severe
Dehydration

Behavior

Normal

Irritable

Hyperirritable
to lethargic

Thirst

Slight

Moderate

Intense

Skin turgor

Normal

Decreased

Greatly

Ant. fontanelle Normal

Sunken

Markedly
depressed

Urine flow
(ml/kg/hr)

<2

<1

<0.5

Urine SG

1.020

1.020 1.030

>1.030

NORMAL EXCHANGE OF FLUID AND

ELECTROLYTES

Water Exchange
Salt Gain & Losses

Volume Changes
If isotonic salt solution is added to or lost
from the body fluids, only the volume of the
ECF is changed, ICF is relatively unaffected
If water is added to or lost from the ECF,
the conc. of osmotically active particles
changes
Water will pass into the intracellular
space until osmolarity is again equal in
the two compartments

Volume Changes
BUN level rises with an ECF deficit of sufficient
magnitude to reduce GFR
creatinine level may not incr. proportionally
in young people with healthy kidneys
hematocrit increases with an ECF deficit and
decreases with ECF excess
sodium is not reliably related to the volume
status of ECF
a severe volume deficit may exist with a
normal, low, or high serum level

Volume Deficit
ECF volume deficit is most common
fluid loss in surgical patients
most common causes of ECF volume
deficit are: GI losses from vomiting,
nasogastric suction,diarrhea, and
fistular drainage
other common causes: soft-tissue
injuries and infections, peritonitis,
obstruction,
and burns

Volume Deficit
signs and symptoms of volume
deficit:
CNS: sleepy, apathy stupor,
coma
GI: dec food consumption N/V
CVS: orthostatic, tachy,
collapsed veins - hypotension
Tissue: dec skin turgor, small
tongue sunken eyes, atonia

Volume Excess
Iatrogenic or Secondary to renal
insufficiency, cirrhosis, or CHF
signs & symptoms of volume excess:
CNS: none
GI: edema of bowel
CVS: elevated CVP, venous
distension pulmonary edema
Tissue: pitting edema anasarca

Concentration Changes
Na+ primarily responsible for ECF osmolarity
Hyponatremia and hypernatremia & often occur if
changes are severe or occur rapidly
The concentration of most ions within the ECF can
be altered without significant osmolality change,
thus producing only a compositional change
Example: rise of potassium from 4 to 8 mEq/L
would significantly effect the myocardium, but
not the effective osmotic pressure of the ECF

Hyponatremia
(water intoxication)
acute symptomatic hyponatremia (< 130)
hypertension can occur & is probably induced by
the rise in intracranial pressure
signs & symptoms:
CNS: twitching, hyperactive reflexes inc ICP,
convulsions, areflexia
CVS: HTN/brady due to inc ICP
Tissue: salivation, watery diarrhea
Renal: oliguria - anuria

Hyponatremia
(water intoxication)
Hyponatremia occurs when water is
given to replace losses of sodiumcontaining fluids or when water
administration consistently exceeds
water losses
Hyperglycemia: glucose exerts an
osmotic force in the ECF and causes
the transfer of cellular water into the
ECF, resulting in a dilutional

Hypernatremia
(water deficit)
The only state in which dry, sticky mucous
membranes are characteristic
sign does not occur with pure ECF deficit alone
signs & symptoms:
CNS: restless, weak - delirium
CVS: tachycardia - hypotension
Tissue: dry/sticky muc membranes swollen
tongue
Renal: oliguria
Metabolic: fever heat stroke

Composition Changes

Acid/Base Balance
Potassium Abnormalities
Calcium Abnormalities
Magnesium Abnormalities

Acid-Base Balance
large load of acid produced endogenously as a byproduct of body metabolism
acids are neutralized efficiently by several buffer
systems and subsequently excreted by the lungs
and kidneys
Buffers:
proteins and phosphates: primary role in
maintaining intracellular pH
bicarbonatecarbonic acid system: operates
principally in ECF

Acid-Base Balance
buffer systems consists of a weak acid or
base and the salt of that acid or base
Henderson-Hasselbalch equation, which
defines the pH in terms of the ratio of the
salt and acid:
pH = pK + log BHCO3 / H2CO3 = 27
mEq/L / 1.33 mEq/L = 20 / 1 = 7.4
As long as the 20:1 ratio is maintained,
regardless of the absolute values, the pH
will remain at 7.4

Acid-Base Balance
Four types of acid-base disturbances
combinations of respiratory and metabolic
changes may represent:
compensation for the initial acid-base
disturbance or,
two or more coexisting primary
disorders
10-mmHg PaCO2 change yields a 0.08 pH
change

Potassium Abnormalities
normal daily dietary intake of K+ is approx. 50
to 100 mEq
majority of K+ is excreted in the urine
98% of the potassium in the body is located in
ICF @ 150 mEq/L and it is the major cation of
intracellular water
intracellular K+ is released into the extracellular
space in response to severe injury or surgical
stress, acidosis, and the catabolic state

Hyperkalemia
signs & symptoms:
CVS: peaked T waves, widened
QRS complex, and depressed ST
segments Disappearance of T
waves, heart block, and diastolic
cardiac arrest
GI: nausea, vomiting, diarrhea
(hyperfunctional bowel)

Hypokalemia
K+ has an important role in the
regulation of acid-base balance
alkalosis causes increased renal K+/H+
excretion

signs & symptoms:

CVS: flatten T waves, depressed ST
segments
GI: paralytic ileus
Muscular: weakness - flaccid paralysis,
diminished to absent tendon reflexes

Calcium Abnormalities
majority of the 1000 to 1200g of calcium
in the average-sized adult is found in the
bone
Normal daily intake of calcium is 1 to 3 gm
Most is excreted via the GI tract
half is non-ionized and bound to proteins
ionized portion is responsible for
neuromuscular stability

Hypocalcemia
signs & symptoms (serum level < 8):
numbness and tingling of the circumoral
region and the tips of the fingers and
toes
hyperactive tendon reflexes, positive
Chvostek's sign, muscle and abdominal
cramps, tetany with carpopedal spasm,
convulsions (with severe deficit), and
prolongation of the Q-T interval on the
ECG

Hypocalcemia
causes:
acute pancreatitis, massive softtissue infections (necrotizing
fasciitis), acute and chronic renal
failure, pancreatic and smallbowel fistulas, and
hypoparathyroidism

Hypercalcemia
signs & symptoms:
CNS: easy fatigue, weakness,
stupor, and coma
GI: anorexia, nausea, vomiting,
and weight loss, thirst, polydipsia,
and polyuria

Hypercalcemia
two major causes:
hyperparathyroidism and cancer
bone mets
PTH-like peptide in malignancies

Magnesium
Abnormalities
total body content of magnesium 2000
mEq
about half of which is incorporated in bone
distribution of Mg similar to K+, the major
portion being intracellular
normal daily dietary intake of magnesium
is approximately 240 mg
most is excreted in the feces and the
remainder in the urine

Magnesium Deficiency
causes:
starvation, malabsorption
syndromes, GI losses, prolonged IV
or TPN with magnesium-free
solutions
signs & symptoms:
similar to those of calcium
deficiency

Magnesium Excess
Symptomatic hypermagnesemia,
although rare, is most commonly
seen with severe renal insufficiency
signs & symptoms:
CNS: lethargy and weakness with
progressive loss of DTRs somnolence,
coma, death
CVS: increased P-R interval, widened
QRS complex, and elevated T waves
(resemble hyperkalemia) cardiac arrest

Secretions

Goals of Fluid Resuscitation

Easily measured

Mentation
Blood Pressure
Heart Rate
Jugular Venous Pressure
Urine Output

Goals of Fluid Resuscitation

A little less easily measured

Central Venous Pressure (CVP)

Left Atrial Pressure
Central Venous Oxygen
Saturation SCVO2

Goals of Fluid Resuscitation

A bit more of a pain to measure

Pulmonary Capillary Wedge

Pressure (PCWP)
Systemic Vascular Resistance
(SVR)
Cardiac Output / Cardiac Index

RESPONSES TO INITIAL FLUID RESCUSITATION

Rapid
response

Transient
response

No Response

Vital signs

Return to
normal

Transient
improvement;
recurrence of
BP
& HR

Remain
abnormal

Estimated
blood loss

Estimated
blood loss
Minimal (1020%)

Moderate and
ongoing (2040%)

Severe (>40%)

Need more
crystalloid

Low

High

High

Need for blood

Low

Moderate to
high

Immediate

Blood
preparation

Type and
crossmatch

Type-specific

Emergency
blood
release (O-neg)

Need for
operative

Possibly

Likely

Highly likely

Algorithma shock

Conclusion
1.Fluid imbalance Electrolite imbalance
Acid base imbalance.
2.The principle of fluid therapy maintain
tissue perfusion.
3.Basic principle of fluid therapy
replacement, maintain , repair deficit.
4.Kind of IV fluid solution hypotonic,
isotonic, hypertonic and colloids,
crystalloids.

Thank You For Attention

Wassalamualaikum WW