Wednesday, 24 February 2016
Sunday, 21 February 2016
Update on Maintenance Fluid Therapy
INTRODUCTION
Maintenance fluid therapy is one important
component of comprehensive management of inpatients.Patients with severely
deficient oral intake of fluid and nutrients due to various reasons need attention,
although the main focus of clinicians is the diagnosis and management of exact
causal therapy. Giving proper
maintenance fluids can help a patient's recovery faster and patient can
return to physical activity earlier.
Definition of Maintenance Fluid Therapy
Maintenance fluid therapy can
be defined as giving IV fluids to hospitalized patients with the following
criteria:
•
In moderate dehydration but cannot be adequately
treated orally
•
No hemodynamic disturbances (eg MAP > 65-70
mmHg, without signs of peripheral vasoconstriction, tachycardia and prolonged
capillary refill time)
•
No severe electrolyte disorders
•
Fulfil the daily
basal requirement of fluid, electrolyte and nutrients
Normal saline (0.9% NaCl) and Lactated Ringer’s
or Acetated Ringer’s are not suitable as maintenance solutions
Normal saline (NaCl 0,9%),
Lactated Ringer’s and A cetated Ringer’s are replacement solutions NOT
maintenance solutions because of the two
reasons:
• Sodium content is above 100 mEq/L, as isotonic
solutions are more suitable as resuscitation fluid to replace acute abnormal or
massive fluid loss.
• 0.9% NaCl does not contain potassium, whereas
Lactated Ringer’s and acetated Ringer’s contain only 4 mEg/L. They cannot meet
the minimum requirement of potassium, ie 10-20 mEq per day Table 1.
Resuscitation Solutions
Glu
(g/dl)
|
Electrolytes (mEq/L)
|
||||||||
PRODUCTS
|
Na+
|
K+
|
Ca++
|
Cl-
|
Lactate-
|
Acetate-
|
mOsm/L
|
Vol(ml)
|
|
OTSU-NS
(0.9% NaCl)
|
-
|
154
|
-
|
-
|
154
|
-
|
-
|
308
|
500
|
Ringer Solution
|
-
|
147
|
4
|
4.5
|
155.5
|
-
|
-
|
310
|
500
|
OTSU-RL
(Lactated
Ringer’s)
|
130
|
4
|
3
|
109
|
28
|
-
|
272.5
|
500
|
|
ASERING
(Acetated
Ringer’s)
|
130
|
4
|
3
|
109
|
-
|
28
|
272.5
|
500
|
|
ASERING-5
(Acetated
Ringer’s
+D5W)
|
50
|
130
|
4
|
3
|
109
|
-
|
28
|
272.5
|
500
|
RL-D5
|
50
|
130
|
4
|
3
|
109
|
28
|
-
|
272.5
|
500
|
RD-5
|
50
|
147
|
4
|
4.5
|
155.5
|
-
|
-
|
310
|
500
|
What about D5W ? Can it be considered as maintenance fluid?
D5W in small volume (eg 50 ml,100 ml) are
usually used as drug diluent for intermittent IV drip. However, when used as
maintenance fluid, the calorie content is too small, 200 kcal/L (glucose anhydrate)
or 170 kcal/L (glucose monohydrate), and associated with high risk of
hyponatremia and hypokalemia if given in maintenance requirement (eg 30
ml/kg/day). Nowadays, even fluid containing glucose and low sodium (eg 0.18% saline + D5W) have been reported to cause hyponatremia in pediatric patients (1).
Are KAEN 3B and KAEN 4A ideal
maintenance soluitions ?
KAEN 3B and KAEN 3 A are basic maintenance
solutions suitable for patients with moderate dehydration with risk of
hypokalemia owing to insufficient oral intake or after acute fluid loss
(severe diarrhea) has been replaced with isotonic fluids (Latated Ringer and
ASERING®). Therefore the use of KAEN3B and KAEN3A helps restore potassium
homeostasis.Clinically, the effect of KAEN3B and KAEN3A is obvious with the
absence of abdominal distention. Hypokalemia in hospitalized patients have been
recorded by three investigators in Indonesia, as shown in the following table:
Principal
Investigator
|
Centre
|
Number
of
patients
|
% of
Hypokalemia
on
admission
|
% of
Hypokalemia
on discharge`
|
Untung
Sudomo (2)
|
RSPAD Gatot Subroto
|
100
|
28
|
45
|
Djoko Widodo
(3)
|
RSCiptomangunkusumo
|
100
|
22,9
|
52,4
|
Nasronudin (4)
|
RS Dr SUtomo
|
110
|
36,36
|
50,91
|
Nevertheless, very often that
patients are admitted in poor condition with systemic symptoms, such as
fatigue, weakness and loss of appeti te, so provision of simple electrolyte
and glucose solutions is not enough.
Lack of oral intake may be
attributable to the following:
•
Patients
with moderate dehydration may have dry and bitter tongue. Dry tongue can also
be caused by medication (antihistamines, anticholinergics).
•
Anxiety,
depression and fear
•
The
same hospital food for different types of patients.
•
Too weak to chew and swallow
food
•
Gastrointestinal
symptoms due to effects of illness or side effects of medication
•
Reduced consciousness
• Poor dentition in elderly etc
In the above circumstances, the response will be
better if patients receive a practical and complete maintenance solution. Thus,
on top of glucose and basic electrolytes (sodium, potassium), patients also
need glucose, amino acids, microminerals to facilitate the metabolic processes
and prevent protein catabolism.
What are the indication of Aminofluid ?
Aminofluid is a PPN solution produced by Otsuka Pharmaceutical , which can generally be given to all inpatients
except renal failure because its potassium content of 20 mEq/L can increase the
risk of hyperkalemia.
Best response to
administration of Aminofluid can be observed in the
following conditions:
•
Febrile illnesses followed by excessive loss of
IWL (insensible water loss) and hyperventilation. Normally fever is a symptom of acute
infections such as pneumonia, hepatitis A, Dengue hemorrhagic fever etc.
•
Gastrointestinal disorders
•
Pre and postoperative Nutritional supplemention
•
Acute exacerbation of COPD.
Table Maintenance Solutions
Glu
(g/dl)
|
Electrolytes (mEq/L)
|
||||||||
PRODUCTS
|
Na+
|
K+
|
Ca++
|
Cl-
|
Lactate-
|
Acetate-
|
mOsm/L
|
Vol(ml)
|
|
KAEN 3A
|
27
|
60
|
10
|
-
|
50
|
20
|
-
|
290
|
500
|
KAEN 3B
|
27
|
50
|
20
|
-
|
50
|
20
|
-
|
290
|
500
|
DG2A
(Half-strength
Darrow)
|
25
|
61
|
17.5
|
-
|
52
|
26.5
|
-
|
296
|
500
|
KAEN MG3
|
100
|
50
|
20
|
-
|
50
|
20
|
-
|
695
|
500
|
AMINOFLUID
|
75
|
35
|
20
|
5
|
50
|
20
|
13
|
817
|
500 &
1000
|
In
addition to electrolytes and glucose,Aminofluid contains 30 g amino
Acids, P,Mg and Zinc
Is there strong rationale of giving Aminofluid to patients with acute infection?
Three important factor which
justify the administration of Aminofluid to patients with acute infections:
1.
Despite thirst due to hypertonic dehydration,
many patients may not be able to ingest
enough water and nutrient owing to abdominal discomfort/pain,
hepatomegaly.
2.
Elevated levels of cytokines, such as
interferons (IFNs), interleukin-2 (IL-2), IL-8, and tumor necrosis factor
alpha, have been reported in DHF(5) One of their pleiotrophic
effects is delaying gastric emptying
3.
Patients might experience loss of appetite because of dry mouth (dehydration),
malaise and fatigue besides other systemic symptoms(6)
QUESTION
1.
Does patient have dehydration?
2.
Are there any electrolyte imbalances? 3. How do
you handle the hyperglycemia in this patient? Can we give Aminofluid this time?
Case Illustration:
Electrolyte & Metabolic Panel (Na+ 145, K+ 3,Cl- 102,HCO3- 22, BUN 22,Glu 240,Creatinine 0.8)
QUESTIONS:
- Does patient have dehydration?
- Are there any electrolyte imbalances?
- How do you handle the hyperglycemia in this patient? Can we give Aminofluid now?
ANSWERS:
1. Correct. The patient has some degree of
dehydration. How do we know it? Firstly,
the BUN to cratinine ratio is 20 indicating the presence of dehydration.
Secondly, the plasma osmolarity in this patient is high, i.e. 2 x [Na+] + glu/18 = 2 x 145 +
240/18 = 290 + 13.33 =303.33. Hyperosmolarity is defined as plasma
osmolarity above 296 mOsm/L.
2. Patient has mild hypokalemia which does not
require correction but can be prevented from worsening by giving maintenance
solution. .
3. Hyperglycemia
need to be corrected with insulin until the blood sugar level reaches
150 mg/dl. Parenteral glucose may be administered when the blood sugar reaches
150 mg/dl but require addition of regular insulin, 1 U/10 g glucose. When 1 L Aminofluid (75 g glucose)is
administered 7.5 unit regular insulin
(drip) is added, if possible separately using syringe pump (7,8)
References:
- Friedman JN. Risk of acute hyponatremia in hospitalized children and youth receiving maintenance intravenous fluids. Paediatr Child Health 2013;18(2):102-104
- Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy vol.5. Ed: Dec 2004. Page: 115-120
- Widodo D, Setiawan B, Khie Chen. The prevalence of hypokalemia in hospitalized patients with infectious diseases problems at Ciptomangun-kusumo HospitalJakarta. Acta Med Indones, 2006;38(4):202-5
- Nasronudin et al. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients. Medika 2006 Vol XXXII,No 12, p 732-734
- Anon Srikiatkhachorn, Chuanpis Ajariyakhajorn, Timothy P. Endy, Siripen Kalayanarooj, Daniel H. Libraty, Sharone Green, Francis A. Ennis, and Alan L. Rothman Virus-Induced Decline in Soluble Vascular Endothelial Growth Receptor 2 Is Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. 2007 February; 81(4): 1592–1600.
- Othman N.Clinical profile of dengue infection in children versus adults.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page S435
- Perkeni 2007 Petunjuk Praktis Terapi Insulin pada Pasien Diabetes Mellitus
- Campbell KB, Braithwaite. Hospital management of hyperglycemia CLINICAL DIABETES • Volume 22, Number 2, 2004.
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