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Flashcards in Fluid therapy Deck (48):
1

Reasons for fluid therapy - 4

Replace excessive fluid losses, restore organ perfusion, correct metabolic disturbances, nutritional support, enhance excretion of a toxin (if it can be cleared by the kidneys) if inducing diuresis (e.g. if the animal is azotaemic; especially useful if the underlying cause of the azotemia is kidney hypoperfusion, as fluid therapy will restore perfusion and induce diuresis)

2

Reasons - fluid loss - 5

Bleeding, vomitting, diarrhoea, third-space pooling (thorax, abdomen or GIT), dehydration

3

Define fluid resuscitation

Re-expansion of the intravascular fluid volume

4

Describe the physical exam findings associated with dehydration and hypovolaemia

DEHYDRATION (fluid deficit in interstitial and intercellular spaces) -oral mucous membranes (dryness), skin turgor, and eye moisture. Severe cases - weak rapid pulse, acute weight loss
HYPOVOLAEMIA - cardiovascular signs more prominent - assess heart rate (tachycardia), CRT, mucous membrane colour and peripheral pulses

5

How does anaesthesia affect vasomotor tone?

It causes vasodilation (dramatic; i.e. decreased vasomotor tone) --> volume depletion, hypotension and possibly hypoperfusion

6

Other causes of decreased vasomotor tone.

Pathological conditions - anaphylaxis and sepsis. Leads to maldistributive shock

7

Composition of fluids - 3

Water, electrolytes and +/-buffers, +/- dextrose

8

Why is metabolic acidosis often corrected with fluid therapy?

Metabolic acidosis also tends to be related to perfusion problems

9

Suggest some agents that are administered via fluids

-Drugs that need to be delivered at a constant rate infusion (insulin, metoclopramide, lidocaine, catecholamines)
-glucose infusions (2.5-5% dextrosefor hypoglycaemia correction)

10

Differentiate enteral and parenteral nutrition

Enteral = fed using the GIT

Parenteral (PN) = animal is fed not using the GIT but intravenously, not commonly used in general practice

11

What does PN contain? (3)

amino acid solution, concentrated dextrose and lipids. can be adapted to meet specific energy and protein needs of patient

12

2 forms of PN = ? What are the advantages of each?

-Total PN (TPN) = meets virtually all energy and nutrient requirements, administered centrally (via jugular catheters)

-Partial PN (PPN) = meets 40-70% of an animal's energy needs. Advantages over TPN are that it has a lower osmolarity, can be administered via peripheral catheters (versus TPN which is only administered centrally), less expensive.

13

Indications of commercial ready-to-use preparations of glucose and amino acids

general practice, <50% required calories provided (when administered at maintenance fluid rate), short term or interim nutritional support

14

How can fluids be described? (4)

-electrolyte content (hyper/iso/hypo - tonic)
-presence of large particles (crystalloids= smaller, colloids = larger)
-nature of the particles present (natural vs. synthetic colloids)
-physiological purpose (replacement, maintenance, nutrition)

15

Distinguish crystalloids and colloids (about 5 each)

CRYSTALLOIDS: contains only small particles (electrolytes, glucose, buffers; irrespective of their concentrations), freely permeable through capillary membranes, distribute largely by diffusion and this is rapid when administered intravenously, can dilute the concentration of natural colloids (albumin, immunoglobulins) and therefore lower the patient's COP which decreases the host's ability to retain fluid within the intravascular space (increasing the risk of peripheral oedema)

COLLOIDS: particles larger than 30kD (plasma proteins, synthetic polymers), largely restricted from diffusing through capillary membranes, impart an oncotic pressure which interferes with fluid dynamics, the colloidal particles act as 'little sponges' and help hold fluid within the intravascular space, do not 'pull fluids' from other compartments, tend to persist within the intravascular space longer and so achieve more effective and longer lasting intravascular volume expansion

16

Advantages - colloid therapy

-preserving/increasing plasma COP (this increases intravascular fluid retention, necessitating smaller volumes of fluids required for recussitation)

17

Disadvantages - colloid fluids

more expensive
risk of complications

18

Natural colloids for vet use (3)

-Blood products - whole blood, packed RBCs, fresh frozen plasma (Packed RBCs exert little oncotic pressure (approx. 5mmHg) and is not expected to affect plasma COP)
-Concentrated albumin products (human/canine/feline albumin - latter two not widely available)

19

When are human albumin solutions (5%, 25%) used?

-Natural colloids
-potential to cause anaphylactic reactions with repeated use
-successful one-time use in dogs reported

20

Synthetic colloids are commonly used to increase COP in vet practices - examples?

-Starchy ones (Hetastarch, dextrans, pentastarch, tetrastarch)
-Haemoglobin-based oxygen carrying fluids (Oxyglobin Biopure)
-Other synthetic colloids

21

Characteristics of all synthetic colloids (2)

-Heterogenous mixtures of molecules
-various molecular weights (range 100kD (better intravascular expansive properties and longer intravascular persistence.

22

Distinguish fluids intended for replacement and maintenance

REPLACEMENT (e.g. rehydration and shock resuscitation): include crystalloids and colloids, contain electrolyte concentrations similar to normal plasma concentrations and are referred to as replacement fluids

MAINTENANCE - if only requiring replacement of daily sensible and insensible water and electrolyte losses, typically contain half of the sodium content of plasma, since they are hypotonic ot normal plasma - dextrose is added as a 2.5% concentration to restore tonicity to normal. As animal metabolises the dextrose, a greater amount of free water is delivered.

N.B. generally all animals can be treated with conventinal replacement fluids and there is rare need for maintenance fluids.

23

Examples of hypertonic solutions (3).Indications?

Supraphysiological concentrations of electrolytes (7% saline), or other osmotically active particles (20% mannitol, 50% dextrose)

High osmotic particle concentration imparts high osmotic pressure --> drives fluid shidts form the intracellula rand intersitital compartments to the intravascular compartment. Thus commonly used in resuscitation of severely hypovlaemic animals with normal interstitial hydratiion (e.g. trauma patients). Also used in patients with intracranial hypertension or cerebral oedema (to shift fluids to intravascular compartment for later excretion)

24

How to estimate daily maintenance fluid requirements and for critically ill patients.

40-60ml/kg/day. A common practice is to multiply this by a multiplier (1.5-3) for critically ill patients but this is often not ideal (can result in under- or over-hydration of many patients. More appropriate way = calculate fluid therapy to account for the hydration deficit (sensible+insensible fluid losses, +ongoing (contemporary fluid losses e.g. V/D/PU).

25

When can you discontinue fluid therapy?

When the animal voluntarily consumes enough water to meet its fluid requirements and maintain adequate hydration.

26

How much fluid is in the different body compartments? How do you calculate blood volume?

Total body water = 60% total body weight=TBW(kg)
ECF = 1/3 TBW and ICF is 2/3 TBW. This is divided into interstitial fluid (3/4 ECF, assessed by skin tent and mucous membrane colour) and plasma/intravascular volume (1/4 ECF)

27

How do you calculate blood volume?

Blood volume = Plasma volume/(1-haematocrit)

28

How do you decide if fluid therapy and how to administer it?

Clinical history AND PE findings. Lab tests can support decision but shouldn't be used alone to determine if needed

29

What do tall and narrow pulses indicate?

A large difference between systolic and diastolic beats. high sympathetic drive to the heart.

30

Distinguish bolus and drip routes of administration

Bolus -rapid administration e.g. 10-20 mins.
Drip - slow (e.g. 24h), 1/4 goes to intravascular compartment, 3/4 go to rest of compartments

31

Describe the CRT in a dead animal

Normal - no constriction or dilation of blood vessels therefore always take this measurement with a pinch of salt!

32

Effects of general anaesthetics (4)

Suppress nervous, respiratory and cardiovascular systems. Also cause vasodilation therefore always give supportive therapies.

33

Components of crystalloids.

Water+small molecules (<30kD), electrolytes, +/- buffers, +/- dextrose

34

How/when do you use colloids? (4) When do you get complications?

-Commonest fluid in practice
-Cheapest
-Adminstration variable (PO, IV, SQ, IO, IP)
-Distributes equally amongst all fluid compartments (only a third of volume remains intravascularly after equilibration)

COMPLICATION: relate only to fluid amount used (too little or too much)

35

Components - synthetic colloids - 4

Water+ large molecules (>30kD), electrolytes, +/- buffers

36

Uses of synthetic colloids. Complications?

-Some form of colloid available in most practices
-rather expensive usually
-generates COP (which delays equilibration of fluid with other compartments. this is useful for resuscitation of intravascular volume)

COMPLICATIONS: fluid overload and coagulopathy

37

Examples - crystalloids

-0.9% Sodium chloride.
-Hartmann's/Lactated RInger Solution/Compound Sodium Lactate
-Half strength saline (0.45%)

38

What does tonicity determine?

Distribution of fluid between compartments (i.e. tonicity is what can move fluids from one compartment to another)

39

Distinguish the effects of tonicity on fluids administered by IV method

ISOTONIC - fluid distributed equally amongst all compartments
HYPERTONIC - draws fluid from intracellular and interstitial compartments into intravascular compartment
HYPOTONIC - fluid shifts to the intracellular compartment causing cellular oedema (caution!)

40

Indications - isotonic crystalloids - 5

-Rehydration
-Resuscitation (treatment of hypovolaemia)
-Correction of acid-base electrolytes
-Drug delivery
I-nduce diuresis

41

Indications - colloids - 5. Dose?

-Require rapid resuscitation
-want to increase COP
-need reuscitative effect to last >1h
-typically used when animal is oedematous

most colloids are isotonic

DOSE= 10-20ml/kg/day

42

Uses - mannitol - 4

Most commonly for brain oedema, also treatment of acute glaucoma, sometimes for oliguric renal failure and as an osmotic diuretic (main effect is to shift fluid into the intravascular space to be excreted by the kidneys)

43

Uses - hypertonic saline - 2. Dose?

Not used very much, extremely rapid resuscitation(v effective but patient much be well hydrated for this to work), treatment of brain oedema.

DOSE=v small (4ml/kg)

44

Uses - hypotonic fluids

Not used veyr much, supposed to be a true 'maintenance fluid', short term use (hours only), only for extremely hypernatraemic patients, nicknamed 'devil's fluid, causes too many complications with electrolytes and cellular oedema.

45

Indication for PN

Only if convincing case of bowel failure (uncommon to be used in general practice, more expensive, harder to manage, requires much expertise)

-Dysfunctional GIT (V, D)
-Existing malnutrition or risk of becoming malnourished

46

Advantages - enteral nutrition - 6

-directly supports enterocytes
-preserves mucosal barrier (prevents bacterial translocation)
-immunomodulatory
-physiologically sound (stimulates motility, secretions, neuroendocrine pathways)
-fewer complications
-relatively inexpensive

47

What methods can you use to give enteral nutirion - 4

-force/syringe feed
-nasogastric feeding tube
-oseophagostomy feeding tube
-gastrotomy/PEG tube

48

When is PN contraindicated with enteral feeding? 2

Pancreatitis or unable to protect airway

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