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Fluid Therapy

Fluid Therapy. 鐘國慶 醫師. Introduction. Total body fluid 1/3 2/3 Extracellular fluid Intracellular fluid 1/3 2/3 plasma interstitial fluid. 體液約佔人體體重的60-75%，其中分成： 細胞外液及細胞內液

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Fluid Therapy

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  1. FluidTherapy 鐘國慶 醫師

  2. Introduction Total body fluid 1/3 2/3 Extracellular fluid Intracellular fluid 1/3 2/3 plasma interstitial fluid

  3. 體液約佔人體體重的60-75%，其中分成： 細胞外液及細胞內液 細胞內液（ICF）：約佔體重的50%（2/3）細胞外液（ICF）：約佔體重的25%（1/3） ，其中5%為血漿，15%為間質液。

  4. Total body water = 80% of body weight 32 weeks gestation Total body water = 78% of body weight Term Total body water = 67% of body weight 3 months

  5. Fluid therapy • Maintenance • Deficit replacement ( Dehydration) • Supplement replacement of ongoing loss • Special hydration

  6. 輸液治療計算原則 • 輸液補充可分為三部份: • 1.維持生理需求液量. • 2.補充已經發生的缺失. • 3.補充繼續留失量.

  7. 體液需要量計算 • 臨床上最常用的是依體重計算: ＜10kg 每公斤每天給100ml水份 10-20kg 超過10 kg部份，每公 斤每天加50ml水份 ＞20kg 超過20 kg部份，每公斤每 天加20ml水份

  8. 輸液治療原則和緊急輸液治療 • 1.先測量病患體重 • 2.一般狀況下在患者沒有尿量時，切勿 在輸液中加鉀離子. • 3.若輸液治療有效，可見有適當尿液量 、正常的血液循環和體重恢復. • 4.晶質溶液如N/S、L/R可暫時擴充血管 內容量 .

  9. 輸液治療原則和緊急輸液治療 • 5.膠質溶液如Albumin、FFP可以把細胞 內及組織內的水分帶至血管內，使容 量增加. • 6.低容性休克時，選擇晶質溶液20ml/Kg 快速輸注. • 7.評估病人的膚色、體溫、脈搏、意識 狀態及尿量決定治療的反應.

  10. Maintenance Therapy Including water loss from • Feces: negligible • Insensible losses ( 1/3) : 400 cc/m2 BSA -- pulmonary loss ( 1/3) -- cutaneous loss ( 2/3) • Urine loss (2/3)

  11. Increased insensible loss • Activity • Fever ( 1 C -->  12 % ) •  vapor tension in the environment • Hyperventilation ( asthma, DKA) • Low or very low birth weight infant (by cutaneous) • Phototherapy ( 15-20% by one direction)

  12. Urine water requirement • Concentration ability • ADH deficiency -- CNS trauma, neoplasm • Solute load -- DM, mannitol, radiocontrast, electrolyte

  13. If urinary water loss is abnormal, maintenance fluid therapy should be adjusted according to insensible water loss + urinary output

  14. Maintenance therapy • Holliday-Segar method first 10 kg 100 ml/kg second 10 kg 50 ml/kg each additional kg 20 ml/kg Na 3 meq/kg/day K 2 meq/kg/day Cl 2 meq/kg/day

  15. Deficit therapy • Fluid deficit(L)=pre-illness weight(kg)-illness weight(kg) • % dehydration= Fluid deficit(L)/ pre-illness weight(kg) x 100%

  16. Q1: 8 y/o children with BW 25 kg

  17. Q1: 8 y/o children with BW 25 kg Ans: 10 x 100 + 10 x 50 + 5 x 20 = 1600 ( ml)

  18. Clinical observation of Dehydration dehydration skin turgor skin touch buccal musoca eyes crying , tears fontanelle CNS Pulse Urine out put 6-10% moderate tenting dry dry deep set reduced soft irritable slightly  decreased 3-5% mild normal normal moist normal present flat consolable regular normal 11-15% severe none clammy parched sunken none sunken lethargic increased anuric

  19. Lab findings of dehydration • Hemoconcentration • Electrolyte: Na depends on types K: acidosis, renal function  K: alkalosis, pyloric stenosis • HCO3-: acidosis: severe diarrhea alkalosis: vomiting, NG drainage • BUN increased • U/R: specific gravity> 1.020 hyaline and granular cast, WBC, RBC, proteinuria 30-100 mg/dl

  20. 低體液量休克 • 1) 臨床症狀: • 因體液流失而造成全身灌流量不足, 血壓降低, 心跳加快, 體表溫度降低, 意識改變, 尿量減少, 多重器官衰竭. • 2) 處理原則: • 矯正體液不足的情形, 視情況給予低張, 等張或高張電解質液.

  21. 低體液量休克 • 3) 輸液治療方針: • (i)在5-20 分鐘內, 給予20cc/kg crystalloid (0.9% NaCl, lactated Ringer's solution or D5NS), 視情況, 可多次給予 ( 最高可到 80cc/kg ) . • (ii)對新生兒而言, O型全血 ( 提供血量, 氧氣 攜帶能力, colloid ) 為首選, 其次依序為FFP, 5% albumin, 0.9% NaCl 可在5-10分鐘內給予 10cc/kg, 若無改善可再重複.

  22. 低體液量休克 • (iii) 在情況穩定後, 視脫水性質而給予 適當濃度電解質液: 低張性脫水(Na<130mEq/L): 在休 克症狀控制後, 算出實際體液及電 解質缺損量, 在前八小時補充一半 量, 後十六小時補充另一半量. • (iv) 低張, 等張或高張電解質液的補充則 同前所述之”脫水”部份

  23. 出血性休克 • (1) 臨床症狀: • 因出血而造成全身灌流量不足, 血壓降低, 心 跳加快, 體表溫度降低, 意識改變, 尿量減少, 多重器官衰竭. • (2) 處理原則: (i)矯正血量不足的情形, 先給予等張電解 質液治療. (ii)輸血以補足流失之血量. (iii)補充凝血因子及血小板缺損.

  24. 出血性休克 • (3) 輸液治療方針: (I)在5-20 分鐘內, 20cc/kg crystalloid (0.9% NS or lactated Ringer‘s solution),可多次 給予( 最高可到 80cc/kg ). (ii)對新生兒而言, O型全血 ( 提供血量, 氧氣 攜帶能力, colloid ) 為首選, 其次依序為 FFP, 5% albumin, 0.9% NaCl可在5-10分鐘 內給予10cc/kg, 若無改善可再重複. 若大量 失血造成凝血因子及血小板缺損, 則給予血 漿(10cc/kg, 如果必要可q6-8hr給)及血小板 (0.3unit/kg).

  25. 出血性休克 (iii) 給予適當血型或O型之全血 ( 最高可 到 80cc/kg ), 濃厚紅血球液. (iv) 補充凝血因子及血小板缺損, 給予血 漿(10cc/kg, 如果必要可q6-8hr給)及 血小板(0.3unit/kg).

  26. 敗血性休克 • (1) 臨床症狀: 因感染而造成瀰散性血管內出 血, 使血流分佈異常, 造成全身 灌流量不足, 血壓降低, 心跳加 快, 體表溫度降低, 意識改變, 尿量減少, 多重器官衰竭。

  27. 敗血性休克 • (2) 處理原則: (I)矯正preload 不足情況, 先給予等張 溶液治療. (ii)給予升壓劑, 治療敗血症本身. (iii)補充凝血因子及血小板缺損, 給予血 漿, 血小板.

  28. 敗血性休克 • (3) 輸液治療方針: (I)在5-20 分鐘內, 20cc/kg crystalloid (0.9% NaCl or lactated Ringer‘s solution), 可多次給予( 最高可到 80cc/kg ). (ii)補充凝血因子及血小板缺損, 給予血漿(10cc/kg, 如 果必要可q6-8hr給)及血小板(0.3unit/kg). (iii)新生兒而言, O型全血 ( 提供血量, 氧氣攜帶能力, colloid ) 在5-10分鐘內徐緩給予10cc/kg 若無改善可 再重複至20cc/kg, 給予血漿(10cc/kg, 如果必要可q6- 8hr給)及血小板(0.3unit/kg), 以補充凝血因子及血小板 缺損. (iv)Dopamine (5-20ug/kg/min), Dobutamine (5-20ug/kg/min), Epinephrine (0.1-1ug/kg/min)

  29. Types of dehydration • Hypotonic ( Na < 130 meq/L) • excess Na loss, water ECF--> ICF • (135-Na) x kg x 0.6 (mEq Na+) • Isotonic ( Na 130-150 meq/L) • No shift • Hypertonic ( Na > 150 meq/L) • Free water loss, water ICF --> ECF • ( Na-145) x 4 cc/kg x kg (free water loss)

  30. Types of dehydration from ECF and ICF compartments • Duration Deficit form ECFDeficit from ICF • < 3 days 80% 20% • > 3 days 60% 40% Na 145 meq K 150 meq

  31. 3 % NaCl 10% Ca gluconate 0.22 % GS 0.33 % GS 0.45 % GS 0.90 % GS 7% NaHCO3 15% KCl 0.5 meq/cc Na 0.45 meq/cc Ca 38 meq /L Na 56 meq /L 77 meq /L 154 meq /L 0.85 meq/ cc OH- 2 meq/c.c K How to choose fluid

  32. Q.A : 7 kg infant with 10% dehydration, 4 Ds Na 137

  33. H2O Na K • maintenance 700 21 14 • deficit 700 60% ECF 420 61 40% ICF 280 42 • 24 hours total 1400 82 56 • 1 st 8 hours 1/3 mt 233 7 5 + 1/2 def 350 31 21 (Na 65 meq/L=0.42NS) 583 38 26 • next 16 hours 2/3 mt 467 14 9 + 1/2 def 350 30 21 (Na 54 meq/L=0.35NS) 817 44 30

  34. Q.B : 7 kg infant with 10% dehydration 4 Ds Na 115

  35. H2O Na K • maintenance 700 21 14 • deficit 700 60% ECF 420 61 40% ICF 280 42 • excess Na deficit(135-115)x0.6x7kg 84 • 24 hours total 1400 166 56 • 1 st 8 hours 1/3 mt 233 7 5 + 1/2 def 350 73 21 (Na 137 meq/L=0.89 NS) 583 80 26 • next 16 hours 2/3 mt 467 14 9 + 1/2 def 350 72 21 (Na 105 meq/L=0.68NS) 817 86 30

  36. Q.C : 7 kg infant with 10% dehydration 4 Ds Na 155

  37. H2O Na K • maintenance 700 21 14 • deficit 700 free water(155-145)x4ml/kgx7kg Solutes fluid 60% ECF x 420=252;0.252x145= 420 37 40% ICF x 420=168; 0.168x150= 280 25 • 24 hours total 1400 58 39 • 1 st 24hours 24 hrs mtx 700 21 14 + 1/2 FW def 140 solute fluid 420 37 25 (Na 46 meq/L=0.3NS) 1260 58 39

  38. Thanks for your attention

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