Fluid therapy

From the above, derives the fundamental concept that the newborn infant must be maintained in an adequate degree of hydration and in electrolyte balance in order for the infant to thrive. In some cases, where for one reason or other, the infant is not able to take fluids by mouth in the normal manner, one may need to resort to supplementary fluid therapy by vein. For a rational approach to this problem one needs to have available from the clinical chemical laboratory> rapid response in order to continuously monitor changes in electrolyte levels so that fluids can be modified so as to correct these abnormal-ities. 

In addition to these two applications, intravenous nutrition and fluid therapy has been given for many years to newborns with chronic diarrhea, malabsorption for various reasons, and other problems associated with disease. 

During the administration of fluids, the newborn infant requires that one periodically assay for the various conq>onents discussed above, so as to see whether the fluids being administered are serving their purpose or need to be changed. The newborn infant does not have the reserve capacity that the adult has in being able to buffer and adjust for various problems which may arise during fluid therapy. For this reason, the newborn infant during acute treatment may require repetitive analyses, at relatively short intervals. Even when the condition is stabilized it is customary for the pediatrician to require analyses for electrolytes at periodic intervals for the security of the patient. 

What initial pharmacologic/fluid therapy is required at this time ... 

Is the systolic blood pressure less than 90 mm Hg (MAP less than 60 mm Hg) If yes, start aggressive fluid therapy beginning with 1000 to 2000 mL lactated Ringer s over... 

Has the goal arterial blood pressure been achieved If not, give additional fluid therapy hourly blending crystalloids and isooncotic colloids based on inadequate blood pressure response. 

Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004 8 R204-R212. 

The clinical scenario and the severity of the volume abnormality dictate monitoring parameters during fluid replacement therapy. These may include a subjective sense of thirst, mental status, skin turgor, orthostatic vital signs, pulse rate, weight changes, blood chemistries, fluid input and output, central venous pressure, pulmonary capillary wedge pressure, and cardiac output. Fluid replacement requires particular caution in patient populations at risk of fluid overload, such as those with renal failure, cardiac failure, hepatic failure, or the elderly. Other complications of IV fluid therapy include infiltration, infection, phlebitis, thrombophlebitis, and extravasation. 

In patients with peritonitis, hypovolemia is often accompanied by acidosis, so large volumes of a solution such as lac-tated Ringers may be required initially to restore intravascular volume. Maintenance fluids should be instituted (after intravascular volume is restored) with 0.9% sodium chloride and potassium chloride (20 mEq/L) or 5% dextrose and 0.45% sodium chloride with potassium chloride (20 mEq/L). The administration rate should be based on estimated daily fluid loss through urine and nasogastric suction, including 0.5 to 1.0 L for insensible fluid loss. Potassium would not be included routinely if the patient is hyperkalemic or has renal insufficiency. Aggressive fluid therapy often must be continued in the postoperative period because fluid will continue to sequester in the peritoneal cavity, bowel wall, and lumen. 

Inotropic agents and vasopressors are generally not indicated in the initial treatment of hypovolemic shock (assuming that fluid therapy is adequate),... 

Patients with acute chest syndrome should receive incentive spirometry appropriate fluid therapy broad-spectrum antibiotics including a mac-rolide or quinolone and, for hypoxia or acute distress, oxygen therapy. Steroids and nitric oxide are being evaluated. 

Concentrated sodium chioride- As an additive in parenteral fluid therapy for use in patients who have special problems of sodium electrolyte intake or excretion. It is intended to meet the specific requirements of the patient with unusual fluid and electrolyte needs. After available clinical and laboratory information is considered and correlated, determine the appropriate number of milliequivalents of concentrated sodium chloride injection, USP and dilute for use. 

The dosage as an additive in parenteral fluid therapy is predicated on specific requirements of the patient. The appropriate volume is then withdrawn for proper dilution. Having determined the mEq of sodium chloride to be added, divide by 4 to calculate the number of mL to be used. Withdraw this volume and transfer into appropriate IV solutions, such as 5% dextrose injection. The properly diluted solution may be given IV. 

The fundamental treatment for DKA includes aggressive intravenous hydration and insulin therapy and maintenance of potassium and other electrolyte levels. Fluid and insulin therapy is based on the patient s individual needs and requires frequent reevaluation and modification. Close attention has to be given to hydration and renal status, the sodium and potassium levels, and the rate of correction of plasma glucose and plasma osmolality. Fluid therapy generally begins with normal saline. Regular human insulin should be used for intravenous therapy with a usual starting dose of about 0.1 IU/kg/h. 

There has been one report of acute pulmonary edema during octreotide and intravenous fluid therapy for var-iceal bleeding (8). 

Takada K, Komori M, Notoya A, Tomizawa Y, Ozaki M. Effect of ulinastatin on microcirculation during excessive hemorrhage using fluid therapy. In Vivo 2003 17 129-136. 

When administering 10 mL fluid boluses it is recommended that the 0.9% NaCl be warmed to insure that the fluid therapy does not affect the animals temperature. 

Correct answer = D. It is important to increase the cardiac output to improve oxygen delivery and thus minimize anaerobic metabolism and improve CNS and renal perfusion. Since this patient apparently does not have a heart condition, such as congestive heart failure, she could benefit from fluid therapy. An inotropic agent, such as dopamine, would lead to an increased cardiac output and dilation of the renal vasculature. [Note At high doses, however, it may constrict the renal beds due to interaction on a receptors.] Antibiotic administration is also important but will not improve the patient s hemodynamics. 

Sodium When patients present with hypernatremia and elevated serum osmolality, they are suffering from severe fluid deficits. Depending on the patient s hemodynamic stability, fluid therapy should generally be instituted as a moderate-to-slow intravenous infusion of 0.9% normal saline over a period of 48-72 h to avoid cerebral edema. Patients with evidence of circulatory compromise will require more aggressive fluid resuscitation. Estimated plasma osmolality and corrected serum sodium concentrations are calculated using the following formulas ... 

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