Fluid Therapy PDF

FLUID THERAPY VPP 5343 I PHARMACOLOGY Natalia Forno, DVM, PhD – [email protected] Credits to: Dr. Ronan Chapuis Objectives List the option available in veterinary medicine for fluid therapy Recall the device options to administer fluid Select a route of administration of fluid Recall properties &...

FLUID THERAPY VPP 5343 I PHARMACOLOGY Natalia Forno, DVM, PhD – [email protected] Credits to: Dr. Ronan Chapuis Objectives List the option available in veterinary medicine for fluid therapy Recall the device options to administer fluid Select a route of administration of fluid Recall properties & indications for the Angiocath and the MILA catheter Build a fluid plan for a patient Monitor a patient on IV fluid patients, fluid requirements are best estimated based on lean body mass. Very young animals are about 70– 75% water, with TBW declining with advancing age. Table 23.2 provides estimates of selected volumes in dogs. TBW is broadly divided into two types: intracellular (ICF) and extracellular fluid (ECF). The ECF is further divided into four subcompartments: plasma volume, interstitial lymph fluid, transcellular fluid, and fluid Fluid and Electrolyte Distribution Body solutes are not distributed homogeneously throughout TBW. Like drugs, every solute has a defined space or volume of distribution that can be assessed experimentally. As with estimation of body compartment volumes, determination of solute distribution is limited by the features of the labeled solute used. Because Table . Approximate volumes of selected fluid compartments in the dog. Source: Data from Kohn and DiBartola, 1992. Table . Approximate values for blood volumes of various animals expressed as percentages of body weight. Values represent averages from approximately 30 references. % Body weight Total blood volume Plasma volume RBC volume 8.5 6.7 6.5 5.7 7.0 4.5 4.7 4.5 3.8 5.4 4.0 2.0 2.0 1.9 1.6 7.0 10.0 7.7 7.5 6.5 4.0 6.0 5.2 4.8 4.5 3.0 4.0 2.5 2.7 2.0 Compartment Total body water (TBW) Extracellular fluid (ECF) Red blood cells (RBC) Plasma volume (PV) Total blood volume (BV) Interstitial lymph fluid Transcellular fluid Bone and dense connective tissue Intracellular fluid (ICF) Method Species 5.7–10 15 1–6 5 Indicator substance Indicator substance Counted + calculations Indicator substance Calculated: RBC volume + PV Calculated: ECF − BV Estimated Estimated 33–40 TBW − ECF Dogs Cats Chickens Cattle Goats Horses Draft Thoroughbred Saddle Pigs Sheep 60 20–27 3 5 ume, interstitial lymph fluid, transcellular fluid, and fluid limited by the features of the labeled solute used. Because Table . Approximate volumes of selected fluid compartments in the dog. Source: Data from Kohn and DiBartola, 1992. Table . Approximate values for blood volumes of various animals expressed as percentages of body weight. Values represent averages from approximately 30 references. Compartment Total body water (TBW) Extracellular fluid (ECF) Red blood cells (RBC) Plasma volume (PV) Total blood volume (BV) Interstitial lymph fluid Transcellular fluid Bone and dense connective tissue Intracellular fluid (ICF) https://petralyte.com/science/ % Body weight Method Species 5.7–10 15 1–6 5 Indicator substance Indicator substance Counted + calculations Indicator substance Calculated: RBC volume + PV Calculated: ECF − BV Estimated Estimated 33–40 TBW − ECF Dogs Cats Chickens Cattle Goats Horses Draft Thoroughbred Saddle Pigs Sheep 60 20–27 3 5 Total blood volume Plasma volume RBC volume 8.5 6.7 6.5 5.7 7.0 4.5 4.7 4.5 3.8 5.4 4.0 2.0 2.0 1.9 1.6 7.0 10.0 7.7 7.5 6.5 4.0 6.0 5.2 4.8 4.5 3.0 4.0 2.5 2.7 2.0 Fluid replacement Supplement Nutrition TYPES OF FLUID Ronan C. VPP 5343, SPRING 2024 5 Types of Fluid v Fluid replacement Ø Crystalloid: mostly electrolytes (polyionic) Differ in the amount of ions and tonicity (concentration and cell permeability) ü Isotonic: same osmolality as extracellular fluid (ECF) = 310mOsm/L) ü Hypertonic: higher osmolality than ECF, can be irritant ü Hypotonic: lower osmolality than ECF INNOVATIONS IN PHARMACY PRACTICE: Clinical Practice Misunderstandings about Tonicity and Osmolality Can Lead to Patient Harm John Robert Manderville, Keigan M More, and Karthik Tennankore Can J Hosp Pharm. 2023;76(4):324-6 INTRODUCTION https://doi.org/10.4212/cjhp.3417 10% dextrose in water, D10W) could lead to hyponatremia because the solution being administered is very hypotonic. In contrast, D10NS—an IV solution with the same concentration of dextrose but, concurrently, 0.9% sodium chloride (NaCl)—would not be expected to cause hyponatremia, because the NaCl contributes to tonicity (i.e., the solution is hyperosmotic yet isotonic). Put another way, administration of 1000 mL of D5W is analogous to administering 1000 mL of electrolyte-free water, given that dextrose, once administered under normal physiologic conditions, will be quickly metabolized, leaving only free water. Similarly, administration of 1000 mL of 0.45% NaCl can be considered equivalent to administering 500 mL of isotonic (0.9%) NaCl plus 500 mL of free water. Finally, no free water is administered when 1000 mL of isotonic (0.9%) NaCl is given. Hyponatremia, Fluids that most closely the most common electrolyte disorder in resemble the ECF are: hospitalized patients, is associated with both morbidity and mortality.1-6 The use of hypotonic IV fluids has been identified as an important potential cause of hospital-acquired hyponatremia, especially among children.1-6 During patient care rounds, one of the authors (J.R.M.) serendipitously discovered a bag of hypotonic IV fluid that was inappropriately labelled (at the manufacturing level). This observation prompted a more in-depth review of IV fluid labelling practices across randomly selected Canadian and US manufacturers to better understand the scope of this issue. ü isotonic; ↑ sodium; ↓potassium; may be acidifying or alkalinizing. The use of hypotonic IV fluids à potential cause of hospital-acquired hiponatremia. Mislabelling: hyperosmolar ≠ hypertonic WHYIn patientPATIENTS with normal serum sodium: AREa HOSPITALIZED AT RISK FOR HYPONATREMIA? release of antidiureticin hormone üRisk factors E.g,for non-osmotic 10% dextrose water, D10W (hyperosmolar IV solution without sodium)à (ADH) include pain, nausea, stress, and certain medications. WHY IS THIS A PARTICULAR CONCERN IN Hospitalized patients regularly experience these symptoms hypotonicàhyponatremia YOUNGER PATIENTS? and often have changes to their medication regime, which may impair their ability to excrete free water because of fluctuations in ADH release. In the setting of increased ADH, the free water available in hypotonic IV solutions can rapidly lead to clinically significant hyponatremia.1-6 Because of physiological differences, children are at higher risk than adults for hyponatremia-related complications.3 Cases of iatrogenic hyponatremia in children (and adults) have been outlined in recent publications by the Institute for Safe Medication Practices Canada.7,8 Partly in response to these reports, our local children’s hospital established a policy listing several hypotonic solutions, which are mostly restricted to critical care areas.9 The American Academy of Pediatrics5 and the Canadian Paediatric Society1 recommend the use of isotonic IV solutions as the standard for ü D10NS, IV solution with the same concentration of dextrose but, concurrently, 0.9% sodium chloride (NaCl) à hyperosmotic yet isotonic à NaCl contributes to tonicity à not hyponatremia WHAT IS TONICITY AND OSMOLALITY? It is important for clinicians to understand the difference between tonicity and osmolality. Tonicity is a property of a Types of Fluid v Fluid replacement = Balanced electrolyte solutions (BES) May be given in large volumes at a rapid rate to patients in shock to reestablish perfusion without altering electrolyte concentrations Alkalinizing solutions depend upon metabolism of substrates to alkalinizing equivalents: Lactate metabolized àliver; acetate à muscle; gluconate à body Perfusion and function of the liver are required Acidemia: diarrhea, vomiting renal disease, trauma, shock postsurgical support Types of Fluid v Fluid replacement = Balanced electrolyte solutions (BES) Normal saline and Ringer’s solution are considered acidifying solutions ↑chloride; promote excretion bicarbonate Metabolic alkalosis. Both solutions are high in chloride and promote renal excretion of bicarbonate. Normal saline is also commonly used in treatment of patients with electrolyte disorders. Absence of electrolytes in parenteral fluids is desirable. Types of Fluid v Fluid replacement Ø Colloids: polysaccharides, proteins ü Hyperosmotic ü Natural: whole blood, plasma, albumin ü Synthetic colloids: dextran 40, dextran 70, hetastarch, pentastarch, oxypolygelatin ü Large particles retained within the vascular space readily à smaller volumes cause greater volume expansion than crystalloids Ø Blood products ü Whole blood ü Plasma Types of Fluid v Fluid replacement Ø Colloids: polysaccharides, proteins ü Synthetic colloids: dextran 40, dextran 70, hetastarch, pentastarch, oxypolygelatin Original Study Journal of Veterinary Emergency and Critical Care 26(1) 2016, pp 35–40 doi: 10.1111/vec.12412 Retrospective cohort study on the incidence of acute kidney injury and death following hydroxyethyl starch (HES 10% 250/0.5/5:1) administration in dogs (2007–2010) Galina Hayes, PhD, DVM, DACVECC, DACVS; Leontine Benedicenti, DVM and Karol Mathews, DACVECC, DVSc Abstract Ø The adverse effects of HES in the human patient population are well documented include volume Objective – To determine the incidence of in-hospital adverse outcomes including acute kidney injury (AKI) death in a population of dogs admitted to the intensive care unit (ICU) receiving 10% hydroxyethyl starch overload, coagulopathy, acute kidney injury and (AKI), proinflammatory effects, and allergic reactions. (HES) [250/0.5/5:1] compared with the general ICU population, while controlling for illness severity. – Cohort study conducted between January 2007 and March 2010. Ø New boxed warning in the package insert. Design Setting – Veterinary teaching hospital. Animals – Consecutive sample of dogs receiving HES (n = 180) were compared with a randomly selected sample of dogs (n = 242) admitted to the ICU over the same period. Interventions – None Measurements and Main Results – AKI was defined as an at least 2-fold increase in baseline creatinine concentration or new onset of oliguria/anuria persisting for !12 hours. The primary outcome was a composite of in-hospital death or AKI. Unadjusted and adjusted analysis controlling for illness severity using the acute patient physiologic and laboratory evaluation (APPLEfast ) score and other confounders was performed. HES was administered either as incremental boluses (median dose 8.2 mL/kg/day, interquartile range [IQR] 5.0– 11.3 mL/kg/day) or as a continuous rate infusion (CRI; median dose 26mL/kg/day, IQR 24.0–48 mL/kg/day). In unadjusted analysis, HES administration was associated with increased risk of mortality (odds ratio [OR] = 2.33, 95% confidence interval [CI] = 1.51–3.58, P < 0.001) or AKI (OR = 3.87, 95% CI = 1.21–12.37, P = 0.02). In an adjusted analysis after controlling for illness severity, admission type, and concurrent administration of Ø Dose response relationship (kg/h) Ø Appears to be due to accumulation of lysosomes in the proximal tubule caused by the pinocitosis of colloid particlesà swelling and interstitial inflammation. Ø Oncotic force also decreases renal filtration pressure. Types of Fluid v Supplements § Supplementation = molecules that can be added in the fluid bag Ø Electrolytes ü Potassium ü Chloride ü Calcium ü Bicarbonate ü … Ø Drugs ü Can be administered by CRI without being diluted Types of Fluid v Nutrition Ø Hypoalbuminaemia, anaemia, or low blood urea nitrogen (BUN) levels secondary to malnutrition Ø Parenteral nutrition = IV nutrition Ø Provision of variable mixtures of amino acids, lipids, and dextrose, along with vitamins, minerals Ø Primarily: amino acid solution, fat emulsion solution, and glucose (dextrose) solution. ü Partial parenteral nutrition Dextrose Dextrose + a.a. ü Total parenteral nutrition Dextrose + a.a. + lipids osmolarity of >800 mOsm/L (via a large (central) vein) Types of Fluid v Nutrition In commercially available solutions: total parenteral nutrition: 40–50% glucose solution partial parenteral nutrition: 5–10% glucose solution Higher fluid rate necessary to meet energy requirement Specific patient needs à proportions of calories coming from protein, fat, and carbohydrate Ø Ideally, parenteral nutrition is adapted to the needs of the individual patient ü low carb” àpatients with compromised pulmonary function and hypercapnia ü low protein àpatients with hepatic encephalopathy or renal disease Ø Ø Ø Route of Administration v Routes of administration Ø IV Ø Intraperitoneal Ø SC Ø PO (per os à by mouth) Ø IO v Devices for administration Ø Gravity (drops/time): regulates infusion rate using a clamp on the tubing - can be inaccurate Ø Fluid pump (mL/hr): infusion rate is regulated by an electronic pump – correct rate and volume Ø Syringe driver: constant rate of infusion (CRI) – small rate of volume of administration Route of Administration Routes of Administration v PO Advantages Simplest Can correct mild salt toxicity and mild cases of dehydration If no voluntary consumption, a catheter should be used nasogastric. Oral rehydration solutions should include major ions (Na+, K+, Cl- and, NaHCO3). Disadvantages In patients with gastrointestinal pathology (i.e., parvovirus infection) or unable to consume adequate amounts of water à other means of fluid resuscitation must be used to maintain homeostasis and urine production Routes of Administration v Intraosseous Advantages When it is not possible to obtain vascular access In case of severe hypotension or complete cardiovascular collapse Tiny patients Fast to central circulation Same liquids than IV Disadvantages Complications: osteomyelitis, fluid loss from the site of administration, fat embolism, among others. Rigorous sepsis: infiltrate the area with lidocaine. Routes of Administration v IV Advantages Preferred when severe illness Specific fluids Electrolytes hypertonic fluids can be administered Route of administration of parenteral nutrition Disadvantages Volume administered can be limited Venous access necessary: challenge in case of severe hypovolemia Material + technics: catheter placement Close monitoring: catheter site, hydration, impaired fluid delivery (septic/thrombo/phlebitis, obstruction, air embolism, overhydration…) Small vein (cephalic, saphenous): limited fluid volume, do not use irritant solution Routes of Administration v IV Material Polypropylene Teflon Polyurethane Silastic: inert silicone elastomer Comment Highly thrombogenic Less thrombogenic (every 3-4d) Lesser thrombogenic (can last up 2 weeks) Least thrombogenic Example PE tubing, Medicut Angiocath Mila Centrasil Routes of Administration v Intraperitoneal Advantages If no venous access (severe hypovolemia…) Moderately rapid administration possible Can be used for peritoneal dialysis Disadvantages Do not administer hypertonic fluids Risk of peritonitis Routes of Administration v SC Advantages Cats & small dogs If no venous access At home administration Relatively large volume may be administered Disadvantages No hypertonic fluids, no dextrose solution May not be absorbed in case of severe hypovolemia/shock due to lack of absorption Indications 1 2 Problem-oriented approach Chief complaint THOROUGH DATABASE SIGNALMENT – HISTORY PHYSICAL EXAMINATION +/- ancillary tests 3 PROBLEM LIST DIFFERENTIAL DIAGNOSIS 4 PLAN ANCILLARY TESTS TREATMENT Presence of or risk for Dehydration Dysorexa/anorexia Electrolytes disturbances Need for renal support? FLUID PLAN Fluid Plan v Calculate Ø Replacement Ø Maintenance Total volume include maintenance +/- replacement +/- on-going losses Ø On-going losses *Re-assess patient + adapt plan: Regularly q1-2 hours When objectives are reached Fluid Plan v Replacement Ø Calculate deficit (L) = % dehydration x BW (kg) © Dr. Dowling Trisha, DVM, MS, DACVIM-LA, DACVCP Fluid Plan v Replacement Ø Bolus/shock rates ✓ Adult large animals 80 mL/kg/h ✓ Cats 50-55 mL/kg/h ✓ Dogs 80-90 mL/kg/h Remember - Large animals, dogs: 80mL/kg/h - Cats: 50mL/kg/h Ø Replace ✓ ¼ to ½ of this volume over the first 2 to 4 hours ✓ then replace the remaining volume over the next 20 to 22 hours è Fluid rate changes ✓ When reached è Fluid rate changes: only maintenance +/- on-going losses systolic arterial blood pressure in cats. Am J Vet Res 1992;53(7):1166–9. 15. Aarnes TK, Bednarski RM, Lerche P, et al. Effect of intravenous administration of lactated Ringer’s solution or hetastarch for the treatment of isoflurane-induced hypotension in dogs. Am J Vet Res 2009;70(11):1345–53. 16. Monk TG, Saini V, Weldon BC, et al. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005; 100(1):4–10. 17. Bednarski R, Grimm K, Harvey R, et al. AAHA anesthesia guidelines for dogs and cats. J Am Anim Hosp Assoc 2011;47(6):377–85. 18. 18. Paige CF, Abbott JA, Elvinger F, et al. Prevalence of cardiomyopathy in apparently healthy cats. J Am Vet Med Assoc 2009;234(11):1398–403. 19. de Brito Galvao JF, Center SA. Fluid, electrolyte, and acid-base disturbances in liver disease. In: DiBartola SP, ed. Fluid, electrolyte, and acid-base disorders in small animal practice. 4th ed. St. Louis (MO): Elsevier Saunders; 2012:462. 20. Pang DS, Boysen S. Lactate in veterinary critical care: pathophysiology and management. J Am Anim Hosp Assoc 2007;43(5):270–9. 21. Fall PJ, Szerlip HM. Lactic acidosis: from sour milk to septic shock. J Intensive Care Med 2005;20(5):255–71. 22. Lagutchik MS, Ogilvie GK, Hackett TB, et al. Increased lactate concentrations in ill and injured dogs. J Vet Emerg Crit Care 1998;8(2):117–27. 23. Graefe U, Milutinovich J, Follette WC, et al. Less dialysis-induced morbidity and vascular instability with bicarbonate in dialysate. Ann Intern Med 1978;88(3):332–6. 24. Iseki K, Onoyama K, Maeda T, et al. Comparison of hemodynamics induced by conventional acetate hemodialysis, bicarbonate hemodialysis and ultrafiltration. Clin Nephrol 1980;14(6):294–8. 25. Saragoca MA, Bessa AM, Mulinari RA, et al. Sodium acetate, an arterial vasodilator: haemodynamic characterisation in normal dogs. Proc Eur Dial Transplant Assoc Eur Ren Assoc 1985;21:221–4. 26. Hopper K, Silverstein D, Bateman S. Shock syndromes. In: DiBartola SP, ed. Fluid, electrolyte, and acidbase disorders in small animal practice. 4th ed. St. Louis (MO): Elsevier Saunders; 2012:564. 27. Hiltebrand LB, Kimberger O, Arnberger M, et al. Crystalloids versus colloids for goal-directed fluid therapy in major surgery. Crit Care 2009;13(2):R40. Fluid Plan v Manteinance Ø Large animals – Adult 2-3mL/kg/h / 50-65 mL/kg/d – Neonates 80-120mL/kg/d Ø Cats 2-3 mL/kg/h Ø Dogs 2-6 mL/kg/h 42. Francis AH, Martin LG, Haldorson GJ, et al. Adverse reactions suggestive of type III hypersensitivity in six healthy dogs given human albumin. J Am Vet Med Assoc 2007;230(6):873–9. 43. Bumput S, Haskins S, Kass P. Effect of synthetic colloids on refractometric readings of total solids. J Vet Emerg Crit Care 1998;8(1):21–6. 44. Rucinsky R, Cook A, Haley S, et al. AAHA diabetes management guidelines. J Am Anim Hosp Assoc 2010;46(3):215–24. 45. Davis H. Fluid therapy for veterinary technicians. Available at: http://www.dcavm.org/11%20oct%20 technotes2.pdf. Accessed March 14, 2013. 46. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheterrelated infections, 2011. Department of Health & Human Services, USA. Centers for Disease Control. Available at: www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Accessed March 14, 2013. 47. Wang AZ, Zhou M, Jiang W, et al. The differences between venous air embolism and fat embolism in routine intraoperative monitoring methods, transesophageal echocardiography, and fatal volume in pigs. J Trauma 2008;65(2):416–23. 48. Bertoglio S, Solari N, Meszaros P, et al. Efficacy of normal saline versus heparinized saline solution for locking catheters of totally implantable long-term central vascular access devices in adult cancer patients. Cancer Nurs 2012;35(4):E35–42. 49. DiBartola SP, Bateman S. Introduction to fluid therapy. 3rd ed. St. Louis (MO): Saunders Elsevier; 2006:325–44. 50. Rudloff E, Kirby R. Fluid therapy. Crystalloids and colloids. Vet Clin North Am Small Anim Pract 1998;28(2):297–328. 51. Cunha MG, Freitas GC, Carregaro AB, et al. Renal and cardiorespiratory effects of treatment with lactated Ringer’s solution or physiologic saline (0.9% NaCl) solution in cats with experimentally induced urethral obstruction. Am J Vet Res 2010;71(7):840–6. 52. Allen SE, Holm JL. Lactate: physiology and clinical utility. J Vet Emerg Crit Care. 2008;18(2):123–32. 53. Gajewski M, Hillel Z. Anesthesia management of patients with hypertrophic obstructive cardiomyopathy. Prog Cardiovasc Dis 2012;54(6):503–11. 54. Hansen B. Technical aspects of fluid therapy. In: DiBartola SP, ed. Fluid, electrolyte, and acid-base disorders in small animal practice. 4th ed. St. Louis (MO): Elsevier Saunders; 2012:373. 15 Remember - Adult: 50mL/kg/d - Neonate: 100mL/kg/d deficits, the degree of dehydration, and the severity of electrolyte derangements, among other considerations. BOX 4 lists common fluid therapy calculation formulas. BOX 4 Fluid Therapy Formulas Calculation of Dehydration Deficit1 Body weight (kg) × % dehydration as a decimal = liters of fluid required to correct dehydration Calculation of Maintenance Fluid Requirements* Dogs: Body weight (kg)0.75 × 132 = 24-hour fluid requirement in milliliters Cats: Body weight (kg)0.75 × 80 = 24-hour fluid requirement in milliliters Ongoing losses (e.g., from diarrhea, vomiting, or polyuria) must be calculated and added to the total maintenance requirement obtained from these formulas. *UC Davis School of Veterinary Medicine fluid therapy formula. Fluid Plan v On-going losses Ø Estimate or measure Ø Monitor Catheter site Reevaluate the patient to adjust the plan Rate of administration is accurate