Maintenance Fluid Therapy for

GI Disorders

Iswan A.Nusi
Division of Gastroentero-Hepatology
Department of Internal Medicine University of Airlangga-
Dr Soetomo Teaching Hospital.
SURABAYA

Symposium Update on Parenteral Fluid Therapy in Internal Medicine

Sheraton Hotel Surabaya , September 22 th 2012
 Introduction

Patients in the internal medicine ward mild to

severe diseases.
Moderate-severely ill patients intravenous
infusion can not drink/food enough, need
intravenous route for drug injection, fluid-
electrolyte resuscitation and fluid-electrolyte
maintenance therapy.
Maintenance therapy patients with good
hemodynamic and can still drink or eat.
Hill GL. Buku ajar Nutrisi Bedah. 2000
Mustafa I. Kumpulan makalah symposium terapi cairan dan nutrisi parenteral. RSPAD Gatot Subroto.
Jakarta 10 Agustus 1991. PT Otsuka Indonesia.
Common reasons to infuse intravenous
fluids
To maintain normal blood pressure
Returning the intracellular fluid volume to normal
Replacing ongoing renal loosses
Giving maintenance fluids to match insensible
losses
To fulfil the need for glucose as a fuel for the
brain
Keeping a vein open
Ensuring the continuous supply of drugs
Providing complete intravenous nutrition.
Wingfield WE. Fluid and electrolyte therapy. http://www.cvmbs.colostate.edu/clinsci/wing/fluids/fluids.htm.
Dehydration. Merck manual online medical library. http://www.merck.com/mmpe/print/sec19/ch276/ch276b.html
Clinical fluid and electrolyte management. https://www.seattlechildrens.org/health_care_professionals/pdf/clinical_fluid.pdf.
Shafiee MAS, Bohn D, Hoorn EJ, Halperin ML. QJ Med 2003;96: 601-10.
 The composition of normal body fluid and
electrolyte

Amount body fluid variable age, body

weight & gender.
More fat content lesser fluid in the body.
Normal fluid in the body 60% of the body weight:
*extracellular fluid 20%(15% interstitial fluid +
5% intravascular fluid) and *intracellular fluid
40%.
Maintenance fluid requirement 1500 ml/m2/24
hours.
Ruchili A. Kumpulan makalah simposium terapi cairan dan nutrisi parenteral. PT Otsuka Indonesia. Palangkaraya, 27 Juli 1991.
Kasim YA. Simposium Terapi cairan dan elektrolit pada penderita gawat. Perhimpunan critical care medicine indonesia. Jakarta. 7 November 1981.
Kartowisastro H. Simposium Terapi cairan dan elektrolit pada penderita gawat. Perhimpunan critical care medicine indonesia. Jakarta. 7 November 1981.
Eastham RD. A guide to water, electrolyte and acid-base metabolism. Wright-PSG. Bristol-London-Boston. 1983.
Puruhito. Dasar-dasar pemberian cairan dan elektrolit pada kasus-kasus bedah. Cetakan ke III. Airlangga university press. 1982.3-9
 Table 1. Body fluid compartment
composition
Electrolyte Atomic Intracellular Extracellular(mEq/L)
weight (mEq/l) Intravascular Interstitial

Natrium 23.0 10 145 142

Kalium 39.1 140 4 4
Calcium 40.1 <1 3 3
Magnesium 24.3 50 2 2
Chloride 35.5 4 105 110
Bicarbonat 61.0 10 24 28
Phosphat 31.0 75 2 2
Protein(gr/L) 16 7 2
 Table 2. Basic Requirement of
water and electrolyte
Young Adult Older Elderly
.
Patients patient (16- (25-55 yo) patient (>65 yo)
25 yo) (56-65 yo)
Water 40 ml/kg 35 ml/kg 30 ml/kg 25 ml/kg

Natrium(mmol) 60-100 60-100 > 60 > 50

Kalium(mmol) >60 >60 >60 >50

Calcium(mEq) 15 15 15 10

Phosphate(mmol) 20-50 20-50 20-50 20-50

Magnesium(mEq) 8-20 8-20 8-20 8-20

 Factors predispose to additional fluid

Fever (every additional 10C above 37.50C the

water requirement need more 12% total body
fluid)
Hyperventilation
Bodyweight above 35 kg need more 500 ml
High room temperature
High activity.

Ruchili A. Kumpulan makalah simposium terapi cairan dan nutrisi parenteral. PT Otsuka Indonesia. Palangkaraya, 27 Juli 1991.
Kasim YA. Simposium Terapi cairan dan elektrolit pada penderita gawat. Perhimpunan critical care medicine indonesia. Jakarta. 7 November 1981.
Kartowisastro H. Simposium Terapi cairan dan elektrolit pada penderita gawat. Perhimpunan critical care medicine indonesia. Jakarta. 7 November 1981.
Eastham RD. A guide to water, electrolyte and acid-base metabolism. Wright-PSG. Bristol-London-Boston. 1983.
Puruhito. Dasar-dasar pemberian cairan dan elektrolit pada kasus-kasus bedah. Cetakan ke III. Airlangga university press. 1982.9
 Factors predispose lesser fluid requirement

Decrease body temperature(1 0C below

36.50C the requirement minus 12%)
High room humidity
Oliguria/anuria
Cerebral edema
Very inactive-immobilized

Ruchili A. Kumpulan makalah simposium terapi cairan dan nutrisi parenteral. PT Otsuka Indonesia. Palangkaraya, 27 Juli 1991.
Kasim YA. Simposium Terapi cairan dan elektrolit pada penderita gawat. Perhimpunan critical care medicine indonesia. Jakarta. 7 November 1981.
Kartowisastro H. Simposium Terapi cairan dan elektrolit pada penderita gawat. Perhimpunan critical care medicine indonesia. Jakarta. 7 November 1981.
Eastham RD. A guide to water, electrolyte and acid-base metabolism. Wright-PSG. Bristol-London-Boston. 1983.
Puruhito. Dasar-dasar pemberian cairan dan elektrolit pada kasus-kasus bedah. Cetakan ke III. Airlangga university press. 1982.9
 The normal mean fluid-electrolyte
losses/excretion in normal adult

Fluid Na mEq/l K mEq/l

Urine : 1500 ml 100 180 60 - 90
Lungs/respiration: 400 ml 58 10
Sweat : 600 ml 35 72
Stool/feces : 100 ml
------------------
Total Excretion: 2000 ml
Cairan Pengganti vs Maintenance

Plasma Pengganti Maintenance

290 308 273 455 290

177 140
+ +
278 150

Normal AR/ LR NaCl 0.45%-D5 KAEN 3B

saline
 Infus isotonik
Acetated Ringers
1 L of Lactated Ringers
Normal saline

Mengganti kehilangan
meningkatkan ECF Akut/abnormal

ICF ISF Plasma

800 ml 200 ml
 Infus hipotonik
1L Dektrosa 5%/ KAEN 3B

Mengganti
Menambah ICF > ECF
kehilangan
normal (IWL + urine)

ICF ISF Plasma

660 ml 255 ml 85 ml
 Infus Albumin
100 ml L Albumin 25%

Syok hemoragik
Menambah volume intravskular
Sekarang jarang
digunakan

ICF ISF Plasma

300-600 ml dalam 30-60 menit

Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 221
 Definition

Maintenance fluid-electrolyte therapy is one

of the fluid-electrolyte therapy to maintain
the normal homeostasis in patients
admitted in the hospital with good
hemodynamic.
This type therapy is using combination
solutions contain water-electrolyte &
partial nutrition(carbohydrate, aminoacid).
Hill GL. Buku ajar Nutrisi Bedah. 2000
Mustafa I. Kumpulan makalah symposium terapi cairan dan nutrisi parenteral. RSPAD Gatot Subroto.
Jakarta 10 Agustus 1991. PT Otsuka Indonesia.
The indication of fluid-electrolyte therapy
1. Ressuscitation therapy:
- To replace acute fluid-electrolyte looses(such as
hemorrhage, severe dehydration, fluid-electrolyte
movement to the 3rd space etc.
- Solution: isotonic crystalloid (ringer-lactate, ringer-
acetate, NaCl 0.9%) and colloid(dextran, gelatin and
HAES).

2. Maintenance therapy:
- To fulfills daily physiological requirements for
homeostasis in patients with normal hemodynamic
- To prevents electrolyte & acid base disorders
- Supports primary therapy of patients illness
- Help enzymatic process & protein synthesis
- Facilitates recovery.
Hill GL. Buku ajar Nutrisi Bedah. Churchill livingstone. Farmedia. 2000
Mustafa I. Kumpulan makalah symposium terapi cairan dan nutrisi parenteral. RSPAD Gatot Subroto. Jakarta 10 Agustus 1991. PT Otsuka Indonesia.
Ruchili A. Kumpulan makalah simposium terapi cairan dan nutrisi parenteral. PT Otsuka Indonesia. Palangkaraya, 27 Juli 1991.
 Pasien Rawat-Inap (di Jepang)

Dehydrated Dehydrated Previously malnourished

Previously well-nourished Previously well-nourished Or undernourished or
Good appetite Or slightly undernourished Metabolically stressed
Metabolically Non-stressed Hypoalbuminemia
Anorexia Debilitated
Fatigue If EN entirely impossible

Fluid & basic Complete

electrolyte Electrolyte, 3% AA, Parenteral Nutrition :
maintenance 5-10% glucose 10 % AA, High NPC
maintenance (glucose , lipid)
KAEN3B AMINOFLUID NEOPAREN/MIXID
 Maintenance Fluid and Electrolyte

Intravenous: Patients with good

hemodynamic, GI tract can not be used.
Oral/enteral or combination oral/enteral+
IV fluid supplementation: good stabile
condition / hemodynamic, no hypovolemic
shock, only mild dehydration, normal
gastrointestinal tract function.
 The diseases in internal medicine ward which can be
given maintenance fluid-electrolyte therapy

Anxiety, depression or fear

Malaise or fatigue
Unfamiliarity or dislike of hospital food
Insufficient oral intake (too weak to chew
or bitter dry tongue)
Inflexible mealtimes
Anorexia, nausea or pain
Suppressed level of consciousness
Hill GL. Buku ajar Nutrisi Bedah. Churchill livingstone. Farmedia. 2000
Mustafa I. Kumpulan makalah symposium terapi cairan dan nutrisi parenteral. RSPAD Gatot Subroto. Jakarta 10 Agustus 1991. PT Otsuka Indonesia.
Ruchili A. Kumpulan makalah simposium terapi cairan dan nutrisi parenteral. PT Otsuka Indonesia. Palangkaraya, 27 Juli 1991.
 The Criteria of good maintenance solution

Practical, easy and safe to administer

In addition to basic electrolytes (Na+,K+,Cl-) also
contains microminerals (Mg++,Ca++,P) cellular
metabolism
Value added zinc to promote tissue healing
Contains high quality amino acids (BCAA enriched, high
in EAA) to promote protein synthesis
Glucose to maintain euglycemia
Facilitates utility of amino acid & maintain electrolyte
balance(Lypholyte, multilyte, TPN elektrolit) mixed
solution
Source of electrolyte, calories & water(plasma lyte:
dextrose dan elektrolit) mixed solution.
 .

RESUSCITATION MAINTENANCE

Crystalloid Colloid
BCAA
Dextran P
Asering Gelatin
RL/NS HES
Ca
Na
Cl
Mg
++
+- ++
Zn
K+
Replace acute loss (hemorrhage, Glucose
GI loss, 3rd space)
 The example of maintenance fluid-electrolyte
solution

Aminofluid : Aminofluid solution contains 1000

ml water, Na+ 35 mEq/l, K+ 20 mEq/l, Cl- 35
mEq/l, Mg++ 5 mEq/l, Ca+++ 5 mEq/l, P 10
mEq/l, Zn 5 mEq/l, glucose 75 gram, Amino
Acid(30% BCAA) 30 gram, with total calories
420 kcal, non protein calories 300 kcal.
Panamin G
KAEN series
NaCl 0.45 + Dex 5% + 20 mEq KCL
Etc
 Carbohydrate Electrolyte(mEq/L)

Product Glucose Na+ K+ Ca++ Cl- Lactate Acetate (mOsm/L) Vol

(g/L) (ml)

Normal - 154 - - 154 - - 308 500

saline

Ringers - 147 4 4,5 155.5 - - 310 500

solution

Lactated - 130 4 3 109 28 - 273 500

Ringer (RL)

Asering - 130 4 3 109 - 28 273 500

(acetated
Ringer's)

KAEN 3B 27 50 20 - 50 20 - 290 500

 LOCAL CLINICAL EXPERIENCE

n=58

Ref.: Yakobus Albert Presented during IDDW International Digestive Diseases Week
Borobudur Hotel, April, 4 2008
MONITORING :
in first day and 5th day

Blood glucose,Creatinine,Albumin,
Natrium, Potasium,
SGOT/AST, SGPT/ALT,
Scores of appetite, Fatique and
ADL*), risk of thrombophlebitis

*)
ADL : Activities of Daily Living Score

Ref.: Yakobus Albert Presented during IDDW International Digestive

Diseases Week Borobudur Hotel, April, 4 2008
 LOCAL CLINICAL EXPERIENCE

Monitoring Day 1 Day 5

Blood glucose (mg/dL) 128.05 10.81 130.62 9.51 Parenteral
Creatinine ( mg/dL) 0.92 0.09 0.89 0.04 Nutrition
Albumin (g/dL) 3.89 0.92 3.82 0.90 (others)
SGOT/AST (IU/L) 30.08 6.82 34.09 7.88
SGPT/ALT (IU/L) 32.36 4.86 30.09 4.57
Potasium (mmol/L) 3.44 1.09 3.72 1.02
Natrium (mmol/L) 138.07 12.09 137.01 10.06
Fatigue score 14.34 8.16
Appetite score 3.48 2.06
ADL score 2.13 - 3.34
Thrombophlebitis
(observed at 3th days) 6.97 % 47%
HJA( Rp/ml) 195/ml 250 -650/ml

Ref.: Yakobus Albert Presented during IDDW International Digestive Diseases Week Borobudur Hotel,
April, 4 2008
 Table 3. complications of infusion
therapy
1. Catheter induced complications
- Injury to vein
- Phlebitis and thrombosis
- Infections

2. Metabolic complications
- Sugar balance: hyperglycemia, hypoglycemia
- Protein balance: Amino acid imbalance with cerebrotoxic
and hepatotoxic effect
- Electrolyte balance: hypokalemia, hypophosphatemia

3. Pharmacological complications:
- Incompatibilities between drugs and infusion solutions.
 Catheter complications

Injuries during venipuncture, phlebitis and

thrombosis of the vein carrying the catheter and
infections due to microbial invasion rate of
venous thrombosis higher
Metabolic complications
Dysbalances in the carbohydrate, amino acid
and phosphate metabolism: high percentage
glucose solutions infused blood sugar
increases (diabetes mellitus).
 CONCLUSION
Maintenance fluid therapy should be considered as an
important integral part of disease management.

It has evolved from simply giving water and electrolyte in

simple container to practical and complete composition in
advanced dual-chamber formulation.

Most important goal of maintenance therapy is to correct

homeostasis, improve sense of well-being, combat fatigue,
increase appetite and finally faster recovery.

1. Aminofluid already designed for advance maintenance fluid

therapy today.
Thank You
for Your Kind
Attention