Dr. Carlos Fernando Estrada Garzona. Departamento de Farmacología Universidad de Costa Rica

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1 Dr. Carlos Fernando Estrada Garzona Departamento de Farmacología Universidad de Costa Rica

2 OBJETIVOS FISIOLOGIA LIQUIDOS CORPORALES SOLUCIONES PARENTERALES PRINCIPIOS DE FLUIDOTERAPIA CRISTALOIDE VS COLOIDE

3 FISIOLOGIA LIQUIDOS CORPORALES

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5 REQUERIMIENTOS FISIOLOGICOS Na: mmol/d 6-8 g NaCl K: mmol/d Calorías: 25 kcal/kg/d

6 Table 2 1. Factors affecting body sodium balance. Increased body sodium content (increased extracellular volume) Increased sodium intake (in absence of increased sodium excretion) Decreased sodium excretion by kidneys Decreased glomerular filtration Increased renal tubular sodium reabsorption Increased renin, angiotensin, aldosterone Excessive mineralocorticoid activity Decreased body sodium content (decreased extracellular volume) Decreased sodium intake (in presence of normal sodium excretion) Increased sodium excretion Renal: Renal failure Salt-losing nephropathy Osmotic diuresis Diuretic drugs Atrial natriuretic peptide Decreased renin, angiotensin, aldosterone, or cortisol Extrarenal: Diarrhea Vomiting Sweating Surgical drainage

7 Table 2 2. Hypovolemia (decreased effective intravascular volume). With decreased extracellular volume Increased fluid losses Gastrointestinal tract (diarrhea, vomiting, fistulas, nasogastric suction) Renal (polyuria with renal sodium wasting, osmotic diuresis) Skin or wound losses (sweating, burns) Hemorrhage (trauma, other bleeding site) Decreased intake of sodium and water Impaired normal capacity to retain sodium and water Renal sodium wasting (polycystic kidneys, diuretics) Adrenal insufficiency Osmotic diuresis (hyperglycemia) With increased or normal extracellular volume Cirrhosis with ascites Protein-losing enteropathy Congestive heart failure Increased vascular permeability (sepsis, shock, trauma, burns)

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10 SOLUCIONES PARENTERALES

11 NaCL AL 0,9% 9 g / L NaCl INDICACIONES: 308 mosm 154 mmol NaCL por litro Expansor de volumen del LEC Contracción isotónica del LEC

12 DEXTROSA AL 5% 50 g glucosa por litro INDICACIONES: 277 mosm HIPOTONICA EXPANSOR LIC Y LEC Contracción hipertónica del LEC

13 MIXTA 9 g NaCl + 50 g dextrosa por litro 585 mosm Tonicidad à 308 mosm EXPANSOR DEL LEC INDICACIONES: APORTE CALÓRICO- REQUERIMIENTO FISIOLOGICO

14 NaCL AL 0,45% 4,5 g NaCl por litro 154 mosm INDICACIONES: EXPANSOR LIC Y LEC 66%LEC 33% LIC Contracción hipertónica del LEC DKA-HHS

15 SALINA HIPERTONICA NaCL al 3% 30 g NaCl por litro INDICACIONES: 1026 mosm LIC ààà LEC HIPONATREMIA SINTOMATICA < 0,5 mmol/l/h < 12 mmol/l en 24 h

16 DACA 5 g NaCl 10 g glucosa 1 g KCl 6,5 g acetato de sodio 348 mosm Tonicidad à 279 INDICACIONES: Contracción isotónica del LEC Diarrea aguda alta tasa

17 COLOIDALES Albúmina 5% y 25% INDICACIONES: P oncótica 25 vs 100 mmhg Expansor del IV < 24 h 100 vs 500 cc / 100 cc EXPANSOR DE VOLUMEN INTRAVASCULAR HIPOALBUMINEMIA SEVERA

18 Table 2 3. Fluids for intravenous replacement of extracellular volume or water deficit. Crystalloids [Na + ] (meq/l) [Cl ] (meq/l) [osm] (mosm/l) Other 0.9% NaCl (normal saline) % dextrose in 0.9% NaCl Glucose, 50 g/l Ringer s lactate K +, Ca 2+, lactate 1 5% dextrose in water Glucose, 50 g/l 0.45% NaCl % dextrose in 0.45% NaCl Glucose, 50 g/l Colloids Albumin (5%) Albumin (25%) 6% hetastarch in 0.9% NaCl 1 K + 4 meq/l, Ca 2+ 3 meq/l, lactate 28 meq/l. 2 Not recommended for rapid correction of intravascular or extracellular volume deficit.

19 PRINCIPIOS FLUIDOTERAPIA

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21 Hypovolemia ESSENTIALS OF DIAGNOSIS Evidence of decreased intravascular volume: hypotension, low central venous or pulmonary artery wedge pressures Indirect evidence of decreased effective intravascular volume: tachycardia, oliguria, avid renal sodium reabsorption Circumstantial evidence of depleted effective intravascular volume: end-organ dysfunction, peripheral vasoconstriction Potential source of loss of extracellular volume or evidence of inadequate repletion

22 Hypervolemia ESSENTIALS OF DIAGNOSIS Edema, ascites, or other evidence of increased extracellular volume Intravascular volume may be normal, low (hypovolemia), or high Potential causes of increased extracellular volume: renal insufficiency, congestive heart failure, liver disease, or other mechanism of sodium retention or excessive sodium administration

23 Hyponatremia ESSENTIALS OF DIAGNOSIS Plasma sodium <135 meq/l Altered mental status (confusion, lethargy) or new onset of seizures Most cases discovered by review of routinely obtained plasma electrolytes 140 TBW (L) = normal TBW (L) + [Na ]

24 Hypernatremia ESSENTIALS OF DIAGNOSIS Plasma sodium >145 meq/l Serum osmolality >300 mosm/kg Evidence of increased solute administration, polyuria with dilute urine (diabetes insipidus), or inadequate water intake Altered mental status TBW (L) = normal TBW (L) [Na ] + Plasma [Na ] = + + fluid [Na ] plasma[na ] TBW + 1

25 Table 2 4. Guidelines for replacement of fluid losses from the gastrointestinal tract. Gastric (vomiting or nasogastric aspiration) Small bowel Biliary Large bowel (diarrhea) Replace ml per ml with 5% dextrose in 0.45% NaCl 5% dextrose in 0.45% NaCl 5% dextrose in 0.90% NaCl 5% dextrose in 0.45 NaCl Add KCl, 20 meq/l KCl, 5 meq/l NaHCO 3, 22 meq/l NaHCO 3, 45 meq/l KCl, 40 meq/l NaHCO 3, 45 meq/l

26 Coloide vs Cristaloide

27 Coloide vs Cristaloide Comparison 1. Colloid versus crystalloid (add-on colloid) Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1Deaths 52 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 1.1 Albumin or plasma Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.93, 1.10] protein fraction 1.2 Hydroxyethyl starch Risk Ratio (M-H, Fixed, 95% CI) 1.10 [0.91, 1.32] 1.3 Modified gelatin Risk Ratio (M-H, Fixed, 95% CI) 0.91 [0.49, 1.72] 1.4 Dextran Risk Ratio (M-H, Fixed, 95% CI) 1.24 [0.94, 1.65] Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2012, Issue 6. A r t. N o. : C D D O I : / CD pub5.

28 Coloide vs Cristaloide (... Continued) Study or subgroup Colloid Crystalloid Risk Ratio Risk Ratio n/n n/n M-H,Fixed,95% CI M-H,Fixed,95% CI Fries /20 0/ [ 0.0, 0.0 ] Ngo /56 0/ [ 0.0, 0.0 ] Tollofsrud /10 1/ [ 0.02, 7.32 ] Upadhyay /29 9/ [ 0.49, 2.32 ] Verheij /16 0/ [ 0.13, ] Wahba /10 0/ [ 0.0, 0.0 ] Wu /18 3/ [ 0.11, 3.11 ] Subtotal (95% CI) [ 0.49, 1.72 ] Total events: 13 (Colloid), 15 (Crystalloid) Heterogeneity: Chi 2 =1.48,df=4(P=0.83);I 2 =0.0% Test for overall effect: Z = 0.28 (P = 0.78) Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2012, Issue 6. A r t. N o. : C D D O I : / CD pub5.

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