Dr. Carlos Fernando Estrada Garzona Departamento de Farmacología Universidad de Costa Rica
OBJETIVOS FISIOLOGIA LIQUIDOS CORPORALES SOLUCIONES PARENTERALES PRINCIPIOS DE FLUIDOTERAPIA CRISTALOIDE VS COLOIDE
FISIOLOGIA LIQUIDOS CORPORALES
REQUERIMIENTOS FISIOLOGICOS Na: 100-150 mmol/d 6-8 g NaCl K: 60-80 mmol/d Calorías: 25 kcal/kg/d
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
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)
SOLUCIONES PARENTERALES
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
DEXTROSA AL 5% 50 g glucosa por litro INDICACIONES: 277 mosm HIPOTONICA EXPANSOR LIC Y LEC Contracción hipertónica del LEC
MIXTA 9 g NaCl + 50 g dextrosa por litro 585 mosm Tonicidad à 308 mosm EXPANSOR DEL LEC INDICACIONES: APORTE CALÓRICO- REQUERIMIENTO FISIOLOGICO
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
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
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
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
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) 154 154 308 5% dextrose in 0.9% NaCl 154 154 560 Glucose, 50 g/l Ringer s lactate 130 109 273 K +, Ca 2+, lactate 1 5% dextrose in water 2 0 0 252 Glucose, 50 g/l 0.45% NaCl 77 77 154 5% dextrose in 0.45% NaCl 77 77 406 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.
PRINCIPIOS FLUIDOTERAPIA
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
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
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 ]
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) 140 + [Na ] + Plasma [Na ] = + + fluid [Na ] plasma[na ] TBW + 1
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
Coloide vs Cristaloide
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 24 9920 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.93, 1.10] protein fraction 1.2 Hydroxyethyl starch 21 1385 Risk Ratio (M-H, Fixed, 95% CI) 1.10 [0.91, 1.32] 1.3 Modified gelatin 11 506 Risk Ratio (M-H, Fixed, 95% CI) 0.91 [0.49, 1.72] 1.4 Dextran 9 834 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 0 0 0 5 6 7. D O I : 10.1002/14651858.CD000567.pub5.
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 2004 0/20 0/20 0.0 [ 0.0, 0.0 ] Ngo 2001 0/56 0/111 0.0 [ 0.0, 0.0 ] Tollofsrud 1995 0/10 1/10 0.33 [ 0.02, 7.32 ] Upadhyay 2004 9/29 9/31 1.07 [ 0.49, 2.32 ] Verheij 2006 1/16 0/16 3.00 [ 0.13, 68.57 ] Wahba 1996 0/10 0/10 0.0 [ 0.0, 0.0 ] Wu 2001 2/18 3/16 0.59 [ 0.11, 3.11 ] Subtotal (95% CI) 224 282 0.91 [ 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 0 0 0 5 6 7. D O I : 10.1002/14651858.CD000567.pub5.