Parenteral fluids

Parenteral Fluids. During the past ten years interest has been renewed in the total alimentation of the infant by vein (2). The motivation for this is the fact that neonates may suffer from some congenital malformation of the intestinal tract which would require surgical resection. If this is done, then one needs some outside way for alimentation, bypassing the intestine, until the intestine is able to heal and recover its normal function. This may take many weeks. A second source of motivation is the small premature infant weighing less than a kilogram, whose immature central nervous system and gastrointestinal tract make it difficult to establish nutrition by oral intake soon after birth. These also require total intravenous nutrition for a substantial period of time. 

To support the institutional pharmacist in preparing IV admixtures (which typically involves adding one or more drugs to large-volume parenteral fluids), equipment manufacturers have designed laminar flow units, electromechanical compounding units, transfer devices, and filters specifically adaptable to a variety of hospital programs. 

Diet clear liquids as tolerated, supplemented with parenteral fluids... 

Diet NPO with parenteral fluids for resuscitation and maintenance... 

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 The appropriate volume is then withdrawn for proper dilution.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. 

VIII.b.1.3. Extensive disease. Rectal therapies are insufficient, and patients should receive, if outpatients, oral corticosteroids, and if in-patients oral or parenteral corticosteroids with full supportive treatment including parenteral fluids and blood transfusion. The need for intensive in-patient treatment is indicated by the presence of severe diarrhoea, anaemia, fever and tachycardia with radiographic evidence of colonic mucosal oedema on plain X-ray, or of toxic megacolon. 

The problems that can result from the administration in total parenteral fluid infusions of D-fructose or sorbitol have been reviewed (427). Either of these can cause life-... 

Determine Al concentrations in parenteral fluids that are safe for infants and children and enforce these standards. 

Oil of wintergreen in the form of candy flavoring was ingested by a 21-month-old boy who developed vomiting, lethargy, and hyperpnea but recovered rapidly with parenteral fluids and sodium bicarbonate (8). 

The problems that can result from the administration in total parenteral fluid infusions of D-fructose or sorbitol have been reviewed (4). Either of these can cause life-threatening hypoglycemia, unless glucose is administered concurrently, in patients who have underlying hereditary fructose intolerance. Unless there is a clear clinical history of the condition, it may not be readily identified. In some countries, fructose and D-glucitol (sorbitol) have been eliminated from the pharmacopoeia for this reason. 

Supportive measures, including administration of blood products, parenteral fluid, and electrolytes, are recommended. Removal of the seeds from the gastrointestinal tract can be done with charcoal. Whole bowel irrigation may also be considered after a dose of charcoal for patients with voluminous ingestions. Alkalinization of the urine with sodium bicarbonate has been recommended for the prevention of hemoglobin precipitates in the renal tubules. 

Respiratory and cardiovascular function should be supported with oxygen, assisted ventilation, and parenteral fluids. If eyes or skin are contaminated, they should be washed immediately. Gastrointestinal decontamination procedures should be used appropriately depending on the patient s level of consciousness and the amount of rotenone ingested. Oils or fats should not be administered because they can promote rotenone absorption. Activated charcoal should be used to block absorption with oral exposure. In animals, 10 mg of menadione (intravenously) reversed rotenone s blocking of mitochondrial... 

Chronic parenteral fluid therapy Osmotic diuresis... 

Excessive urinary losses of magnesium from the kidneys are important causes of magnesium deficiency. Clinically important causes include alcohol, diabetes meUitus (osmotic diuresis), loop diuretics (furosemide), and aminoglycoside antibiotics. Increased sodium excretion (parenteral fluid therapy) and increased calcium excretion (hypercalcemic states) also result in renal magnesium wasting. 

Most casualties of mustard exposure wiU, however, require some form of medical care— from a few days to many weeks. Eye care and airway care will promote healing within weeks skin lesions take the longest to heal and may necessitate hospitalization for months (Wdlems, 1989). Casualties with mUd to moderate mustard damage will need supportive care. Pain control is extremely important. Fluids and electrolytes should be carefully monitored. Although there is not as great a fluid loss from mustard bums (compared with thermal bums), a casualty will probably be dehydrated when he enters the MTF. Parenteral fluid supplements and vitamins will be of benefit. Casualties who have lost their eyesight because of mustard exposure should be reassured that they will recover their vision. 

FIGURE 36-1. Recommendations for treating acute diarrhea. Foiiow these steps (1) Perform a compiete history and physicai examination. (2) is the diarrhea acute or chronic if chronic diarrhea, go to Fig. 36-2. (3) if acute diarrhea, check for fever and/or systemic signs and symptoms (i.e., toxic patient), if systemic illness (fever, anorexia, or volume depletion), check for an infectious source. If positive for infectious diarrhea, use appropriate antibiotic/anthelmintic drug and symptomatic therapy. If negative for infectious cause, use only symptomatic treatment. (4) If no systemic findings, then use symptomatic therapy based on severity of volume depletion, oral or parenteral fluid/electrolytes, an-tidiarrheal agents (see Table 36-4), and diet. 

During diarrhea, the small intestine retains its ability to actively transport monosaccharides such as glucose. Glucose actively carries sodium with water and other electrolytes. Because the WHO-ORS has a high sodium concentration, U.S. physicians have been reluctant to use it in well-nourished children. Yet controlled comparative studies describe more favorable results with the WHO-ORS than with parenteral fluids. Amino acids promote sodium transport and act as... 

Protein-calorie malnutrition Total parenteral nutrition without magnesium Prolonged parenteral fluid administration without magnesium Alcoholism Reduced absorption... 

Appropriate follow-up care of patients with acute diarrhea is based on successful restoration of fluid losses. The clinical signs and symptoms (see Table 111-1) that led to the diagnosis also can indicate adequate rehydration and should be assessed frequently. Because oral rehydration therapy is now preferred, routine laboratory testing often is unnecessary. Electrolytes should be measured in those receiving parenteral fluids, when oral replacement fails, or when signs of hypernatremia or hypokalemia are present. Follow-up stool samples to ensure complete evacuation of the infecting pathogen may be necessary only... 

Parenteral fluids and nutritional support are an important part of the early management of most extreme preterm infants in the UK, and it is essential that iodine intake from these sources is sufficient to support brain growth and development. 

All infants, on admission to the neonatal intensive care unit, were established on parenteral fluids within the first hour of day 1 at 80 ml/kg/day with a solution of electrolytes, dextrose 10%, amino acids (Vaminolact, Fresenius Kabi, Cheshire, UK) and a phosphate supplement (Addiphos, Fresenius Kabi, Cheshire, UK). Fluid intakes were thereafter managed on the basis of clinical requirements. On day 2 of life, and thereafter, the solution was further supplemented with water-soluble vitamins (Solvito N, Fresenius Kabi, Cheshire, UK) and trace elements (Peditrace, Fresenius Kabi, Cheshire, UK), to the levels recommended by the manufacmrer. In tandem, a fat emulsion solution (Intralipid 20%, Fresenius Kabi, Cheshire, UK) with added fat-soluble vitamins (Vitfipid, Fresenius Kabi, Cheshire, UK) was infused, initially at 8ml/kg/ day, increasing maximally to 18 ml/kg/day by posma-tal day 5. Enteral feeds were started, when the condition of the infant was stable, as hourly boluses of 0.5—1 ml/h. Thereafter enteral feed volumes were gradually increased as determined by the infants clinical condition, with reciprocal reductions in the volume of parenteral nutrition infused. No infant progressed beyond hourly bolus feeds for the duration of the study. 

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

Review patient records to determine what parenteral fluids were administered for patients who are hospitalized. 

As a measure of the tonicity of blood one can calculate with the osmotic value because active substances and additives cannot pass the membrane of the erythrocyte (see Sect. 18.5.2). The osmotic value of blood is around 290 mOsm/kg. Some parenteral fluids however contain substances that can pass the membrane fast ethanol, glycerol, urea. Hyperosmotic solutions of these substances may cause haemolysis so they are hypotonic. The iso-osmotic concentration of ethanol is for example 1.39 % m/m. Ethanol 5 % v/v infusion fluid is therefore hyperosmotic but appears to be practically isotonic. 

The use of body surface area to gauge the needs of patients for parenteral fluids and electrolytes in clinical medicine has been an accepted practice for years. It is particularly pertinent to pediatric practice. The normal water... 

Other non-renal factors modifying the water requirement and tolerance of the ill patient must spring to the clinicians mind if his prescription of parenteral fluids is to maintain the patient in the safe zone where the automatic mechanisms for retention and... 

Medicine seems never to allow for complacency. As illustrated in Figure 6, we have been trapped in the Charybodian vortex through failure to recognize that the unusually safe rates of parenteral fluid administration may become quite inappropriate for the surgical patient as a result of operation itself, anesthesia, and the use of opiates for pain. 

Yet another factor which must enter consideration as to what constitutes safe parenteral fluid and electrolyte administration is adaptation time. Figure 7 shows the accumulation and disposal of water in a small child in whom the rate of delivery of intravenous fluids was increased abruptly to 30 ml per minute for half an hour, then slowed to 10 ml per minute for 90 minutes before being reduced to a bare maintenance level. 

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