Maintenance Fluid

Therapy
Iyan Darmawan, MD
Medical Department
Otsuka, Indonesia

RESUSCITATION

MAINTENANCE

NUTRITION
Crystalloid


1. Replace acute loss
(hemorrhage, GI loss,
3
rd
space etc)
1. Replace normal loss
(IWL + urine+ faecal)
2. Nutrition support

ELECTROLYTES
FLUID THERAPY
Colloid
Electrolyte composition

mEq/L ICF ECF
Plasma Interstitial
15 142 144
150 4 4
2 5 2.5
27 3 1.5
1 103 114
10 27 30
100 2 2
20 1 1
- 5 5
63 16 6
Na
+
K
+

Ca
2+

Mg
2+

Cl
-
HCO
3
-

HPO
4
2-

SO
4
2-
Organic acid
Protein
142
150
144
.

COMPARTMENT CATION ANION Suitable solution

ICF K
+
Mg
++
HPO4
-
, Prot containing K
+
Mg
+

and HPO4
-

ECF PLASMA Na
+
Cl
-,
HCO3
-
Prot. High Na
+
and Cl
-


ISF Na
+
Cl
-
HCO3
-


Ion Distribution
Dehydration
Hypovolemia
* thirst
* urine output
headache
nausea
syncope
hypotonic
electrolytes
isotonic
electrolytes
5% Dextrose
N/2-D5

Ringers acetate
Ringers lactate
Normal saline
.
Deficit
Fluids can be described as being
from three categories
.
Isotonic - Fluid has the same osmolarity as plasma
Normal Saline (N/S or 0.9% NaCl),
Ringers Acetate(RA), Ringers lactate (RL)

Hypotonic -Fluid has fewer solutes than plasma
Water, 1/2 N/S (0.45% NaCl), and D5W
(5% dextrose in water) after the sugar is
used up

Hypertonic-Fluid has more solutes than plasma
5 % Dextrose in Normal Saline (D5 N/S),
3% saline solution, D5 in RL.



Most Common form of Dehydration

Occurs when fluids and electrolytes are lost in
even amounts

There are no intercellular fluid shifts in
isotonic dehydration

Common Causes
diuretic therapy
excessive vomiting
excessive urine loss
hemorrhage
decreased fluid intake
Isotonic Dehydration
Hypertonic Dehydration
Second most common type of dehydration.

Occurs when water loss from ECF is greater than
solute loss

hyperventilation, pure water loss with high fevers,
and watery diarrhea.

Diabetic Ketoacidosis and Diabetes Insipidus

Iatrogenic Causes
prolonged NPO, excessive hypertonic fluids, sodium
bicarbonate, or tube feedings with inadequate water
Hypotonic Dehydration
Relatively Uncommon - Loss of more solute
(usually sodium) than water.

Hypotonic Dehydration causes fluid to shift from the
blood stream into the cells, leading to decreased
vascular volume and eventual shock
Seen in Heat Exhaustion

Increased cellular swelling -causes increased
intracrainial pressure - H/A and Confusion.
Seen in Heat Stroke








increases ECF
ICF ISF Plasma
Replace acute/
abnormal
loss
Isotonic infusion
800 ml 200 ml
Ringers acetate
Ringers lactate
Normal saline









increases ICF > ECF
ICF ISF Plasma
Replace Normal
loss (IWL + urine)
Hypotonic infusion
5% dextrose


85 ml 255 ml 660 ml
Replacement
Maintenance
Repair deficit
Fluid Therapy
BACIC PRINCIPLES
Replace
Maintain
Repair
Abnormal loss: GIT, 3
rd
space,
Ongoing loss, septic and
Hypovolemic shock

IWL + urine
Acid base, electrolyte imbalances
FLUID SELECTION
Replace : RA, RL, NS

Maintain: N/2 + D (adult) + K
+
20 mEq
N/4 + D (chlldren) + K
+
20 mEq

Repair : NaHCO3 8,4%
KCl 25 mEq/25 ml
NaCl 3%
Maintenance
IWL + urine
Adults/children : 4:2:1
eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 =
100ml/hr
Requirements
Fever
Restless/delirium
Warm ambient temperature
Hyperventilation

Requirements
Hypothermia
High humidity
Oliguria/anuria
Reduced consciousness
Retention/oedema
Increased intracranial pressure
Rationale of maintenance
solutions
Fluid redistribution
Basal requirement of potassium &
sodium
electrolyte concentration in
infusion solutions
Ready for use solutions
minimizes risk of contamination
Electrolyte solutions
Plasma
Isotonic
solutions
Hypotonic solutions
Normal
saline
Ringers
acetate/ lactate
KAEN 3B*
290
308 273
278
D5
290 278
* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol
Cl-, 20 mmol lactate, 27 g dextrose per L.
Basal requirement of
Potassium
K
+
intake ranges from 40-150 mEq daily
Homeostasis (minimum req) 20-30 mEq/day
Increased requirement in heart failure and
hypertension
-900 -600 -300 0 +300
K
+
deficit (meq) K
+
excess (meq)
10 -
-
8 -
-
6 -
-
4 -
-
2 -
-
-
serum K
+
(meq/L)
Relationship between serum K
+
serum and
TBK at various levels of deficit and excess
05 10 15 20 25 K
+
deficit (%)
5 -
-
4 -
-
3 -
-
2 -
-
1 -
-
-
serum K
+

(meq/L)
Decreased serum K
+

and deficit of TBK (%)
total body K
+
= 50 mEq/kg body weight
A c i d o s i s
A l k a l o s i s
Blood pH 7.2 7.3 7.4 7.5 7.6
5.0 4.5 4.0 3.5 3.0 0 mEq
4.5 4.0 3.5 3.0 2.5 100 mEq
4.0 3.5 3.0 2.5 2.0 200 mEq
3.2 3.0 2.5 2.0 1.5 400 mEq

cell
DCC
ECF
3 K
+
H
+
2 Na
+
3 K
+
H
+
2 Na
+
K
+
H
+
Urine
K
+
low urine K
+


H
+
acid urine
3 K
+
H
+
2 Na
+
3 K
+
H
+
2 Na
+
K
+


H
+
Urine Alkali
K
+
H
+
Urin
Cell Tubulus distal ECF
K
+
and acid-base status
Serum K
+

K
+
depletion
K
+
urin tinggi
Cnc: <40 mEq/L 1
Rate of adm: <20 mEq/hr 2
daily dosage : <100 mEq/day 3
Monitor ECG and serum K
+
4
U r i n e output: >0.5 ml/kg/hr 5
< 40mEq/L
KCl


Standard K
+
concentration in i.v.
solutions
KCl bolus


Rate of administration of
Electrolyte & glucose
Na
+ 100 mEq/hr

K
+ 20 mEq/hr

Ca
++ 20 mEq/hr
Mg
++ 20 mEq/hr

HCO
3
-

100

mEq/hr

Glucosa
0,5 gr/kg/hr ( 4 mg/kg/min)*

* Neonates 6-8 mg/kg/min
Conclusion
Maintenance fluid therapy : normal loss
(IWL + Urine)
Suitable in hypertonic dehydration
Minimized risk of potassium depletion in cases
of prolonged inadequate oral intake
Ready for use product associated with less
risk of contamination
Can be combined with amino acids