Fluid therapy maintenance

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. 

Supportive therapy Maintenance of blood pressure, artificial respiration, rehydration (fluid/electrolyte therapy) and control of convulsions. 

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. 

Maintenance fluid therapy, acute fluid resuscitation, edema Burn patients, edema... 

The fluid therapy plan should be divided into three stages initial resuscitation, rehydration and maintenance. The focus of resuscitation is the rapid reversal of hypovolemia. Rehydration aims to replace fluid losses. The maintenance phase aims to prevent the occurrence of further fluid deficits. In severely hypovolemic horses, a transition phase, in which fluid rates are higher than those calculated for the rehydration phase, may be necessary after initial resuscitation. The need for this should be assessed based on the clinical and laboratory responses to the initial resuscitation. Although plasma electrolyte imbalances may... 

The goal of the maintenance phase of fluid therapy is to supply the basal fluid requirement of the horse ("maintenance" rate) and replace ongoing fluid losses. The mean daily water intake (including the water content of feed) of normal... 

The volume to be infused and rate of delivery are only part of the therapeutic plan for fluid therapy, albeit the most important in acute resuscitation. The electrolyte and acid-base status of the horse should also be considered and fluids chosen to help to correct physiological imbalances. Unfortunately, it is not possible to predict electrolyte and acid-base disturbances accurately based on clinical signs. Seemingly similar clinical presentations may have a quite different pathophysiology (Brownlow Hutchins 1982, Svendsen et al 1979). The recent availability of relatively inexpensive, portable blood gas and electrolyte measuring equipment (Grosenbaugh et al 1998) has made determining the acid-base status possible in ambulatory equine practice and allows the field veterinarian to monitor and treat these disturbances. As stated earlier, in the absence of specific laboratory information, fluid therapy should probably be limited to isotonic polyionic crystalloid fluids, possibly with the addition of 10-20 mEq/1 potassium chloride in the maintenance phase. 

Crystalloids Crystalloids are replacement and maintenance fluid therapy. These include dextrose,... 

Crystalloids are IV fluids used for replacement and maintenance of fluid therapy. 

Drug delivery vehicles also may contain nutrients. Most intravenous therapies (maintenance intravenous fluids, drugs, and electrolyte replacements) are delivered using either dextrose (e.g., dextrose 5% in water) or sodium (e.g., 0.9% normal saline) in the admixture. Lipid emulsion (10%) is used as the vehicle for the anesthetic... 

Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957 19(5) 823-32. 

The expected outcomes for the patient may include an optimal response to therapy, management of common adverse reactions, an absence of diarrhea, maintenance of an adequate intake of fluids, maintenance of adequate nutrition, an understanding of the therapeutic regimen (hospitalized patients), and an understanding of and compliance with the prescribed therapeutic regimen (outpatients). 

Allopurinol is well absorbed with a short half-life of 2 to 3 hours. The half-life of oxypurinol approaches 24 hours, allowing allopurinol to be dosed once daily. Oxypurinol is cleared primarily renally and can accumulate in patients with reduced kidney function. Allopurinol should not be started during an acute gout attack because sudden shifts in serum uric acid levels may precipitate or exacerbate gouty arthritis. Rapid shifts in serum uric acid can change the concentration of monosodium urate crystals in synovial fluid, causing more crystals to precipitate. Thus some clinicians advocate a prophylactic dose of colchicine (0.6 mg/day) during initiation of antihyperuricemic therapy. Acute episodes should be treated appropriately before maintenance treatment is started. 

Most clinicians agree that crystalloids should be the initial therapy of circulatory insufficiency. Crystalloids are preferred over colloids as initial therapy for burn patients because they are less likely to cause interstitial fluid accumulation. If volume resuscitation is suboptimal following several liters of crystalloid, colloids should be considered. Some patients may require blood products to assure maintenance of 02-carrying capacity, as well as clotting factors and platelets for blood hemostasis. 

The indications for pulmonary artery catheterization are controversial. Because there is a lack of a well-defined outcome of data associated with this procedure, its use is presently best reserved for complicated cases of shock not responding to conventional fluid and medication therapies. Complications related to catheter insertion, maintenance, and removal include damage to vessels and organs during insertion, arrhythmias, infections, and thromboembolic damage. 

Hydration and analgesics are the mainstays of treatment for vasoocclusive (painful) crisis. Fluid replacement should be 1.5 times the maintenance requirement, can be administered IV or orally, and should be monitored to avoid volume overload. An infectious etiology should be considered if appropriate, empiric therapy should be initiated. 

Cirrhosis of the liver accompanied by edema or ascites - For maintenance therapy in conjunction with bed rest and the restriction of fluid and sodium. 

The most clinically significant adverse effect of foscarnet is renal impairment. Nephrotoxicity is most likely to occur during the second week of induction therapy but may occur at any time during induction or maintenance therapy. Serum creatinine levels may be elevated in up to 33 to 50% of patients this effect is usually reversible upon drug discontinuation. Dehydration, previous renal impairment, and concurrent administration of other nephrotoxic drugs increase the risk of renal toxicity. Infusion of fluids along with foscarnet decreases the likelihood of renal impairment to about 12%. Dosage adjustment is required for patients with renal insufficiency. 

Hemodjmamic and cardiac complications are the major limitations of high-dose aldesleukin and have been described in both adults (19,20) and children (21). Significant hypotension requiring meticulous maintenance therapy with intravenous fluids or low-dose vasopressors was observed in most patients (22). The clinical findings were very similar to the hemodynamic pattern seen in early septic shock. Aldesleukin-induced increases in plasma nitrate and nitrite concentrations correlated with the severity of hypotension (23). 

Case Conclusion In addition to having urate crystals present in the joint fluid aspirate, KM has met several criteria to support the diagnosis of gout. This acute gout attack is treated with high-dose ibuprofen, which is tapered over 7 days. Once the attack is resolved, maintenance therapy with allopurinol is initiated to lower uric acid levels and prevent future acute gout attacks. 

In the support of hematology patients, the therapy candidates for home care may be chemotherapy, IV antibiotics in febrile neutropenia, blood products, IV immunoglobulins, fluid/electrolyte replacement, central line maintenance, and specific treatments such as deferoxamine administration. 

Rehydration and maintenance of water and electrolytes are primary treatment goals until the diarrheal episode ends. If the patient is volume depleted, rehydration should be directed at replacing water and electrolytes to normal body composition. Then water and electrolyte composition are maintained by replacing losses. Many patients will not develop volume depletion and therefore will only require maintenance fluid and electrolyte therapy. Parenteral and enteral routes may be used for supplying water and electrolytes. If vomiting and dehydration are not severe, enteral feeding is the less costly and preferred method. In the United States, many commercial oral rehydration preparations are available (Table 36-3). 

Regardless of the serotypes, the primary goal of therapy is restoration of fluid and electrolyte losses caused by watery diarrhea. ORT is the preferred method of rehydration, and several studies showed reduction in fluid requirements by 32% to 35% when rice-based instead of glucose-based ORT solutions are used (50-80 g rice instead of 20 g glucose per liter). In patients who cannot tolerate ORT, IV Ringer s lactate solution can be used. Normal saline is not recommended because it does not correct metabolic acidosis. After rehydration, maintenance fluid is given based on accurate recording of intake and output volumes. 

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