Fluid therapy principles

When intravenous fluid therapy has been decided upon, certain general principles determine which lluid to be used (Fig. I). 

Prophylactic measures with regard to the hepatorenal syndrome are of decisive and vital importance. It must be borne in mind that the water balance is extremely sensitive in cirrhotic patients. The cause can almost always be found in an enormous iatrogenic intervention in the volumetric balance (aggressive diuresis, imbalance in the tapping of ascitic fluid, excessive restriction of fluid). For this reason, it is important to avoid all substances which could worsen renal function (e.g. nonsteroidal antirheumatics, aminoglycoside antibiotics) and all measures which could lead to a reduction in the effective plasma volume. Furthermore, care should be taken to apply the principles of prophylaxis and therapy... 

When diuretics are administered at the same time, it is not absolutely necessary to adhere to strict salt restriction. We followed the recommended 6-8 g/day. Indeed, such a moderate restriction is usually observed more reliably by the patient. Reducing water intake to 1.5-2.0 1/day is also sufficient. Only a hyponatraemic condition of <130 mmol/1 requires a reduction in fluid intake to <1,000 ml/day. Determination of fractional sodium elimination (FEnJ may point to potential success even before treatment has begun with a value of >0.5%, treatment steps 1 and 2 (see above) will achieve a probable success rate of about 95%. This favourable initial situation is supported by a still sufficient spontaneous sodium excretion of >40 mmol/day. Therapy resistance must be anticipated when fractional sodium elimination is <0.1% and sodium excretion is <10 mmol/day. If treatment steps 1—4 are unsuccessful or renal function is clearly impaired initially and FENa is <0.1%, the insertion of a peritovenous shunt (PVS) should be considered. This procedure is designed to make use of the principle of ascites reinfusion for as long as possible, (s. tabs. 16.14—16.18) (s. p. 311) TIPS may also prove to be an alternative to PVS, especially when using a polytetrafluoroethylene-covered stent to prevent occlusion. (Ill) (s. fig. 16.15) (s. pp 259, 314, 362)... 

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