FLUID THERAPY

Oleh:

Rahel Novianti (1915028)

Silvia Laveda P. (1915108)
Yenny Frida S. (1915133)
 TOTAL BODY WATER

● Water → approximately 60% of the

body weight of an average adult.
● The percentage is lower in :
○ Obesity, adipose tissue contains
less water than lean tissue.
○ Women than in males because of
the relatively greater amount of
adipose tissue in women.
BODY FLUID COMPARTMENTS
THE COMPOSITION OF FLUID COMPARTMENTS
WATER BALANCE
 PHYSICOCHEMICAL LAWS GOVERNING
FLUID AND ELECTROLYTE MOVEMENT
1. Diffusion, or the process of “being widely spread,” is the random
movement of molecules from an area of higher concentration to an area
of lower concentration.
 PHYSICOCHEMICAL LAWS GOVERNING
FLUID AND ELECTROLYTE MOVEMENT
2. Osmosis equalizes the concentrations of nondiffusible solutes within the
body. Thus, osmosis is the diffusion of a pure solvent, such as water, across a
semipermeable membrane in response to a concentration gradient, in
situations where the molecules of a higher concentration are nondiffusible.
 PHYSICOCHEMICAL LAWS GOVERNING
FLUID AND ELECTROLYTE MOVEMENT
An osmole is the
3. Osmolality is measure of osmoles of solute per number of moles
kilogram of solvent (Osm/kg). that a solute
"contributes to
the osmotic
4. Osmolarity is measure of osmoles of solute per pressure of a
liter of solution (Osm/L). solution."

Measuring the osmolality of a patient using an osmometer.

Then calculate the osmolarity.

Calculation of serum osmolarity.

Calculation of total body osmolality.

 PHYSICOCHEMICAL LAWS GOVERNING
FLUID AND ELECTROLYTE MOVEMENT
5. Tonicity is the effective osmolality of a solution throught a semipermeable
membrane. Tonicity describes a solution and how that solution affects the cell
volume when that cell is placed in the solution.
 PHYSICOCHEMICAL LAWS GOVERNING
FLUID AND ELECTROLYTE MOVEMENT

6. Oncotic Pressure ; colloid osmotic

pressure, is a form of osmotic pressure
exerted by proteins, notably albumin, in
a blood vessel's plasma (blood/liquid)
that usually tends to pull water into the
circulatory system.
 FLUID
REGULATION
CYCLE
Principle of Fluid Therapy
 3 Major Indications for IV Fluid Administration

a. Resuscitation → to correct an intravascular volume deficit

or acute hypovolemia.
b. Replacement → to correct existing developing deficits
that cannot be compensated by oral intake alone.
c. Maintenance → indicated in hemodynamically stable
patients that are not able/allowed to drink water in order
to cover their daily requirements of water and electrolytes.
 4Ds of Fluid Management
● Drug
○ Resuscitation → focus on rapid restoration of circulating
volume
○ Replacement → must mimic the fluid that has been lost
○ Maintenance → must deliver basic electrolytes and
glucose for metabolic needs
● Dosing
○ There’s no standard therapeutic dose for fluids.
○ Timing and administration rate
 4Ds of Fluid Management
● Duration
○ Crucial
○ “Starting triggers” and “stopping triggers”
● De-escalation → to withhold/withdraw fluids when they
are no longer required, thus reducing the risk of fluid
overload and related deleterious effects.
Dehydration
 Dehydration

● A decrease in total body water content due to fluid

loss, diminished fluid intake, or both.
● a physiologic disturbance caused by the reduction
or translocation of body fluids, leading to
hypovolemia.
 Dehydration

● Etiology:
○ ↓ intake
○ ↑ output
○ Renal losses: osmotic, non-osmotic, Na losing
○ GIT losses: diarrhea, vomiting
○ Translocation of fluids: burns, ascites, intestinal
 Dehydration

● Based on Severity:
○ Mild → fluid loss <5% BW
○ Moderate → fluid loss 5-10% BW
○ Severe → fluid loss >10% BW
● Based on Osmolarity:
○ Isotonic/isonatremic
○ Hypotonic/hyponatremic
○ Hypertonic/hypernatremic
 Dehydration Severity Index
Severity Index
Symptoms
Mild Moderate Severe
Normal, weak,
Apathy, lethargy,
Mental status Normal restlessness,
unconscious
irritability
Can’t/refusing to
Thirst Normal Normal, ↑
drink
Heart Rate Normal Normal-↑ ↑, ↓
Pulse Rate Normal Normal, weak Weak, not palpable
Respiratory Rate Normal Normal, ↑ Deep breathing
 Dehydration Severity Index
Severity Index
Symptoms
Mild Moderate Severe
Eyes Normal < Sunken > Sunken

Lacrimal fluid (+) ↓ (-)

Mouth Normal Dry Cracks
Skin turgor Normal <2 s >2 s
CRT <2 s >2 s >2 s, min
Extremities Warm Cold Cold
Urinary output Normal-↓ ↓ ↓↓
Hemorrhage (Hemorrhagic Shock)
 Hemorrhage

● Hemorrhage → acute loss of circulating blood

volume.
● Hemorrhage is the most common cause of shock in
trauma patients.
● Recognition of shock: any injured patient who is
cool to the touch & is tachycardic should be
considered to be in shock until proven otherwise.
Hemorrhage
 Hemorrhage
● Basic management principle → to stop the bleeding &
replace the volume loss
● A & B: supplementary O2 to maintain O2 saturation >95%
● C: adequate IV access, assessing tissue perfusion
○ Bleeding from external wounds → direct pressure to
bleeding site/tourniquet/pelvic binder (pelvic fractures)
○ Internal hemorrhage → surgical or angioembolization
● D: neurological examination; E: complete examination
● Gastric dilation → decompression; urinary catheterization
 Hemorrhage Management: Vascular Access
● Obtain access to vascular system promptly → inserting 2
large-caliber (min. of 18-gauge in an adult) peripheral IV
catheters.
● Sites: forearms & antecubital veins
● Peripheral access cannot be obtained → consider
intraosseous needle (temporary access); large-caliber
central venous access
● Draw blood samples: type, crossmatch, lab analyses,
toxicology, pregnancy testing (all ♀️of childbearing age)
 Hemorrhage Management: Initial Fluid Therapy
● Initial, warmed fluid bolus of isotonic fluid
○ 1 L for adults
○ 20 mL/kg for pediatric patients (BW<40 kg)
○ Absolute volumes should be based on patient
response to fluid administration.
● Persistent infusion of large volumes of fluid & blood in an
attempt to achieve a normal blood pressure is not a
substitute for definitive control of bleeding.
● Goal: restore organ perfusion & tissue oxygenation
 Hemorrhage Management: Initial Fluid Therapy
● Balancing the goal with the avoidance of rebleeding by
accepting a lower-than-normal blood pressure →
“controlled/balanced/hypotensive/resuscitation”,
“permissive hypotension”
● Early resuscitation with blood & blood products must be
considered in patients with evidence of class III & IV
hemorrhage.
Hemorrhage Management: Patient’s Response
NICE Algorithms For IV Fluid Therapy
In Adults
Holliday-Segar Formula
Blood and Products
Intravenous Fluid
Crystalloid Solutions
○Crystalloid solutions contain
low-molecular-weight, which
dissolve in water and freely
pass between the
intravascular space and the
interstitial and intracellular
spaces

○Crystalloids solutions include:

■ 0.9% sodium chloride
■ Ringer’s Lactate
■ 5% dextrose
■Ringer’s solution
A. 0,9% sodium chloride (normal saline)
● Simply salt water that contains only water, sodium (154 mEq/L),
and chloride (154 mEq/L) It’s called “normal saline solution”
because the percentage of sodium chloride in the solution is
simillar to the concentration of sodium and chloride in the
intravascular space

● Indication : low extracellular fluid (fluid deficit from hemorrhage,

severe vomiting or diarrhea), shock, mild hyponatremia, metabolic
asidosis (such as diabetic ketocidosis), fluid of choice for
resuscitation efforts,
B. Ringer’s lactate or Hartmann solution
● The most physiologically adaptable fluid because its electrolyte
content is most closely related to the composition of the body’s
blood serum and plasma
● Another choice for first-line fluid resuscitation for certain
patients, such as those with burn injuries

● Indication :
○ To replace GI tract fluid losses (diarrhea or vomiting)
○ Fluid losses due to trauma and burns
C. Dextrose 5%
● Provides free water that pass through membrane pores to both
intracellular and extracellular spaces. Its smaller size allows the
molecules to pass more freely between compartments
● The supplied calories doesnt provide enough nutrition for
prolonged use. But still can be added to provide some calories
while the patient is NPO (medical instruction to withhold food
and fluids)
Indications :
● Prevention and treatment of intracellular dehydration
● Cheapest fluid to provide adequate callories to body
● For pre and post operative fluid management
● Adequate glucose infusion protects liver against toxic
substances
D. Ringer’s solution
Like LR, contains sodium, potassium, calcium and chloride in
similar. But it doesn’t contain lactate. Ringer’s solution is used in a
similar fashion as LR, but doesn’t have the contraindications
related to lactate
Intravenous Fluid
Colloid Solutions

○Colloids contain larger

molecules than crystalloids.
These molecules are
unable to cross capillary
membranes, so colloid
solutions largely remain in
the intravascular space.