Resuscitation, fluid therapy

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 ... 

The use of colloids has recently been advocated for the resuscitation of hypovolemic horses and for the treatment of severe hypoproteinemia (McFarlane 1999). Colloids have two advantages over crystalloids that makes them attractive for fluid therapy. Firstly, because of their persistence in the circulation, a three to six times lower volume of a colloid solution is required to produce the same resuscitative effect as a crystalloid solution (Rackow et al 1987). This is particularly useful in acute resuscitation of severely dehydrated horses or in the field where large amounts of crystalloids may be difficult to transport. Secondly, the administration of colloids can increase colloidal oncotic pressure, in contrast to the administration of large volumes of crystalloids, which decreases the colloidal oncotic pressure (Jones et al 1997,2001). 

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 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. 

Septic patients have enormous fluid requirements as a result of peripheral vasodilation and capillary leakage. Rapid fluid resuscitation is the best initial therapeutic intervention for the treatment of hypotension in sepsis. The goal of fluid therapy is to maximize cardiac output by increasing the left ventricular preload, which ultimately will restore tissue perfusion. Fluid administration should be titrated to clinical end points such as heart rate, urine output, blood pressure, and mental status. An increased serum lactate level, a byproduct of cellular anaerobic metabolism, should normalize as the tissue perfusion improves. 

Observational studies In a 10-year prospective study of the effects of the timing of the introduction of amiodarone after corrective surgery for congenital heart defects, 71 of 2651 patients (2885 procedures, 2106 cardiopulmonary bypass procedures) received amiodarone for newly detected postoperative atrial tachydysrhythmias (n = 70) or ventricular tachydysrhythmias (n = 7) as early treatment (i.e. within 60 minutes from detection n = 29) or late treatment (i.e. after 60 minutes from detection n = 42) [21 ]. There were significant benefits of early treatment for time to rate and rhythm control, reduction in the dose needed to obtain rate control, and reduction of pediatric cardiac intensive care stay. No adverse events in either group required additional catecholamine therapy, additional fluids, or resuscitation. 

Assess patient for prerenal azotemia and hold diuretic therapy o Fluid resuscitate if evidence of volume depletion... 

Successful treatment of hypovolemic shock is measured by the restoration of blood pressure to baseline values and reversal of associated organ dysfunction. The likelihood of a successful fluid resuscitation will be directly related to the expediency of treatment. Therapy goals include ... 

Is there any evidence of adverse events from the resuscitation therapies employed such as fluid overload, electrolyte disturbances, transfusion reactions, and/or alterations in coagulation If yes, manage the particular adverse event accordingly. 

For peritonitis, early and aggressive intravenous fluid resuscitation and electrolyte replacement therapy are essential. A common cause of early death is hypovolemic shock caused by inadequate intravascular volume expansion and tissue perfusion. 

Evaluate early goal-directed resuscitation therapy. Understand what parameters define efficacy and failure of initial therapy. Recommend alternative resuscitation therapy if the patient does not respond to initial fluid challenge. 

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. 

Therapy with IL-2 can cause severe and life-threatening toxicides that include hypotension and capillary leak syndrome [54]. Approximately 50-75% of patients receiving high-dose IL-2 experience grade 5-A hypotension requiring fluid resuscitation and pressor support Capillary leak syndrome that can result in ascites, respiratory distress, and pleural effusions has been observed in 10-20% of treated patients. Due to the toxicity profile, studies have evaluated the comparative efficacy of low-dose and high-dose IL-2 for metastatic renal cell carcinoma. 

All were successfully treated with hyperinsulinemia/ euglycemia therapy. The authors described the mechanism of action of this form of therapy, which is mainly related to improvement in cardiac contractility and peripheral vascular resistance and reversal of acidosis. They proposed indications and dosing for this therapy consisting in most cases of intravenous glucose with an intravenous bolus dose of insulin 1 U/kg followed by an infusion of 0.5-1 U/kg/hour until the systolic blood pressure is over 100 mm/Hg and the heart rate over 50/minute. Hyperinsulinemia/euglycemia therapy is currently reserved as an adjunct to conventional therapy and is recommended only after an inadequate response to fluid resuscitation, high-dose calcium salts, and pressor agents. 

Early goal-directed therapy with aggressive fluid resuscitation in the emergency department within the first 6 hours of presentation improves survival in sepsis and septic shock. 

The primary therapy for hypovolemic shock is fluid replacement. The institutional cost of 1 L of most crystalloid solutions is less than 1. Assuming that such fluids are used, it is the associated costs of personnel and equipment that become the primary economic considerations in the resuscitation of patients with hypovolemic shock. However,... 

Primary peritonitis is treated with antimicrobials and rarely requires drainage. Secondary peritonitis requires surgical correction of the underlying pathology. The drainage of the purulent material is the critical component of management of an intraabdominal abscess. Without adequate drainage of the abscess, antimicrobial therapy and fluid resuscitation can be expected to fail. 

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