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3. Cat & Dog > ECC Fluid Therapy > Flashcards

ECC Fluid Therapy Flashcards

1
Q

Body Water Distribution

A
  • total body water = 60% BW
  • ICF 40%
  • ECF 20%
    > interstitial fluid 15%
    > plasma 5%
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2
Q

Indications of Fluid Therapy

A

Ø Resuscitation
- Is the patient in shock / hypovolemic?
Ø Rehydration
- Is the patient dehydrated?
Ø Maintenance
- Is the patient eating or drinking?
ØOngoing losses
- How to predict?

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3
Q

The 4D’s of Fluid Therapy

A

Drug
Dose
Duration
De-escalation

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4
Q

Assessment of Hydration & Volume Status
> what do we look at?

A

Ø Subjective: no single index

Ø Change in body weight
- 90% of acute ∆ body mass = ∆ TBW
- 3rd spacing, anorexia

Ø Physical examination
- ∆ interstitial volume
- ∆ intravascular volume

Ø ∆ intracellular (ICF) volume: unable on PE

Ø Laboratory findings:
- PCV/TS
- Electrolytes - Lactate
- BUN
- USG

Ø Dehydration = water deficit in interstitial & ICF compartment (% of BW)
- Rehydration / replace water deficit

ØHypovolemia = ↓ intravascular volume (plasma water or whole blood loss)
- Intravascular volume resuscitation

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5
Q

what lab tests to asses hydration and volume status?

A
  • PCV/TS
  • Electrolytes
  • Lactate
  • BUN
  • USG
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6
Q

Hypovolemia / Shock
> what are the signs and parameters?

A

Ø Normal or altered (depressed) mentation

Ø Perfusion parameters:
- injected / pale, grey muddy, white MM
- rapid / prolonged, absent CRT
- warm / cool extremities, hypothermia
- ↑ lactate

Ø Cardiovascular signs:
- tachycardia, bradycardia, inappropriate normocardia
- bounding / poor pulse quality, hypotension
- collapse of peripheral veins

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7
Q

Resuscitation Phase
- what are our goals? what shock syndromes are responsive to fluid resuscitation? contraindications?

A

Ø Rapid IV fluid bolus: expand intravascular space, correct perfusion deficits

Ø Shock syndromes responsive to fluid resuscitation:
- Hypovolemic
Less so:
- Distributive
> Vasopressor
> Positive inotropes
- Obstructive
> Surgical intervention
> Thrombolysis

Ø Contraindicated: cardiogenic shock!

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8
Q

Balanced Electrolyte Solutions

A
  • plasmalyte A
  • lactated ringer
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9
Q

Isotonic Crystalloids
- shock dose? fluid challenge? how do they distribute?

A

Ø Shock dose: 1 blood volume
- Dog: 80-90 mL/kg/hr
- Cat: 50-60 mL/kg/hr

Ø Fluid challenge:
- Dog: 10-20 mL/kg over 10-20 mins
- Cat: 5-10 mL/kg over 10-20 mins

Ø Rapidly redistribution into ECF compartment
- 30 mins: ∼25% remains in intravascular space
- capillary leak, ↓ oncotic pressure

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10
Q

The Origin of Shock Dose

A

Ø Total blood volume
- Dog: 8-9% of BW (80-90 mL/kg)
- Cat: 5-6% of BW (50-60 mL/kg)

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11
Q

when do we see detectable shock signs? mild vs moderate?

A

ØDetectable shock signs: 10-30% blood volume loss
- Mild signs (compensated shock): 10-15% loss
- Moderate signs (early decompensated): 15-30% loss

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12
Q

target of shock dose

A

Target: expand blood volume by 30%
- Dog: 30 mL/kg
- Cat: 20 mL/kg

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13
Q

Hypertonic Saline
> what is its use and how does it work? additional benefits?

A

Ø Small volume resuscitation (hypovolemic, hemorrhagic, septic shock)
- Dose: 2-3-5 mL/kg, <1 mL/kg/min

Ø Transient (<30 mins) > osmotic diuresis + rapid Na+ redistribution
- ∴ combined with other resuscitative fluids

ØAdditional benefits:
- ↓ cerebral edema, ↓ ICP (traumatic brain injury, intracranial hypertension)
- ↓ endothelial swelling
- mild peripheral vasodilation
- ↑ cardiac contractility
- immunomodulatory effects

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14
Q

Synthetic Colloids
- what are they? what can they be used for? adverse effects?

A

Ø Hydroxyethyl starch (e.g. Vetstarch, Voluven)
- Draw fluid (controversial) + retain fluid (not if “leaky” vessels) within intravascular space

Ø Small volume resuscitation: 2-5 mL/kg over 10-30 mins
- Dog: 10-20 mL/kg
- Cat: 5-10 mL/kg

Ø Hypoproteinemia (TS <3.5 g/dL), ↓ oncotic pressure

ØAdverse effects:
- Human: ↑ mortality, AKI, coagulopathy
- Veterinary: dose-dependent coagulopathy (>20 mL/kg/d)

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15
Q

Blood Component Therapy
> what are our options? dose rate?

A
  • Fresh / stored whole blood
  • Fresh frozen plasma (FFP) / Frozen plasma (FP)
  • Packed RBCs
  • etc.

Ø Dose rate: underlying condition + hemodynamics
- 1.5 mL/kg/min over 15-20 mins vs. 4-6 hours
- whole blood: 20-30 mL/kg
- pRBCs: 10-20 mL/kg
- FFP: 10-20 mL/kg

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16
Q

Clinical hemodynamic parameters:

A
  • HR
  • BP, pulse quality
  • Mentation
  • MM colour, CRT
  • Extremities & core temperatures
  • Lactate <2.5 mmol/L, ∆ lactate better predictor of survival
  • POC bloodwork (PCV, TS, electrolytes, acid-base)
    ()
  • Other parameters:
  • UOP (indirect measurement of renal blood flow) ≥ 1 mL/kg/hr
  • PCV/TS
  • BG
  • Electrolytes
  • Acid-base balance
  • Oxygenation
  • Ventilation
17
Q

Interstitial Dehydration Estimation

A
  • < 5%
    > not detectable
    > history of volume loss
  • 5-6% (mild)
    > tacky mucous membranes
  • 7-10% (moderate)
    > decreased skin turgor
    > prolonged capillary refill times
    > dry mucous membranes
    > retracted globes with orbits
  • 10-12% (severe)
    > CV effects (tachycardia, poor pulse quality, +/- hypotension)
    > Dull corneas
    > persistent skin tent (complete loss of skin elasticity)
    > signs of compensated shock
  • > 12% (moribund)
    signs of decompensated shock
    imminent death
18
Q

Replacement Phase
- how is fluid deficit calculated?
- how long do we do fluid therapy for? what are we trying to replace?

A

Ø Fluid deficit (L) = estimated % dehydrated x ideal BW (kg)

Ø Sustained fluid therapy for 12-36 hours: replace interstitial + ICF losses

Ø Analogy: dried-up sponge
- Different sponges: intrinsic rate of fluid absorbency
- Impossible to predict which type of sponge

Ø Rehydrate over 24 hr ± front loading > reassessment

19
Q

Maintenance Phase
- what is this? what is this requirement?

A

Ø Not eating / drinking: unable to maintain own fluid balance

Ø Daily maintenance fluid requirements:
- Energy (water) to maintain homeostasis in fed, thermoneutral environment
- Non-linear relationship: BSA
- Over-conditioned / anorexic patient: ↓ fluid rate
- Puppies & kittens: ↑ fluid rate

20
Q

Estimated Ongoing Losses
- due to what conditions?

A

Ø GI losses: diarrhea, vomiting, ptylism
- Double the crude estimated volume

Ø Renal losses: polyuria
- Free catch, catheter collection system, metabolic cage, weigh litter/bedding

Ø Additional losses:
- Fever: + 10% maintenance fluid for every ↑ 1°C
- 3rd space loss: drain production
- Burn (mL/h): [25 + % total BSA burned] x BSA (m2)

21
Q

Formulating IV Fluid Therapy Plan

A
  1. Replacement: Fluid deficit = estimated % dH2O x ideal BW
  2. Maintenance: RER = BW0.75 x 70 or pre-made charts
  3. Ongoing losses: ~100mL x 2

> reassess & adjust

22
Q

Types of Intravenous Fluids

A

Crystalloids
- small solutes (electrolytes)
- readily cross endothelial membrane
- equilibrate throughout ECF space

Colloids
- large macromolecules
- restricted by healthy* endothelium
- ↑ COP, retain* fluid in intravascular space

23
Q

what are isotonic solutions? examples? what are they for / indications?

A

Ø Similar osmolarity & [Na+] as plasma and ECF

Ø Normal saline
- 0.9% NaCl

Ø Balanced electrolyte solutions
- Plasma-Lyte A, Plasma-Lyte 148 (Normosol-R), Lactated Ringer’s solution

Ø Indications: expand intravascular + interstitial space (ECF)
- IV fluid resuscitation
- Replacement
- Maintenance: kidneys excrete excess electrolytes

24
Q

Hypertonic Saline
- what is it? rate? effects? indications?

A

Ø Higher osmolarity + [Na+] than plasma + ECF
- 3%, 5%, 7.5%, 10%, 23.5% NaCl

Ø <1 mL/kg/min > bradycardia, vasodilation, hypotension
- acute hyperosmolarity
- central vasomotor center inhibition
- peripheral vasomotor effect

Ø Indications:
- Small volume resuscitation: hypovolemic / hemorrhagic / septic shock
- Traumatic brain injury, intracranial hypertension
- Severe hyponatremia

25
Q

Hypertonic Saline additional benefits

A
  • ↓ cerebral edema, ↓ ICP, ↑ CPP
  • ↑ rheology: ↓ endothelial swelling
  • mild peripheral vasodilation > ↑ CO + tissue perfusion
  • ↑ cardiac contractility, augment MAP
  • immunomodulatory effects
26
Q

Hypotonic Solutions
- purpsoe and use? indications?

A

Ø Lower osmolarity + [Na+] than plasma and ECF
- 0.45% NaCl, 1⁄2 strength PLA, 1⁄2 strength LRS

Ø Combine with dextrose to ↑ osmolarity
- D5W & 0.45% NaCl, 2/3 & 1/3, Plasma-Lyte 56 (Normosol-M), D5W

Ø Indications: replace free water deficit
- Hypernatremia, hypotonic fluid loss
- Maintenance: ↓ ability to excrete excess electrolytes or tolerate ↑ intravascular volume

27
Q

Hypotonic Solutions contraindications?

A

IV fluid resuscitation (bolus therapy)
- Ineffective intravascular volume expansion
- Intravascular hemolysis
- Life-threatening cerebral edema

28
Q

synthetic colloids - how do they compare to plasma? how do they impact coagulation?

A

Ø Isooncotic (6%) or hyperoncotic (10%) to plasma
Ø Dose-dependent (>20 mL/kg/d) coagulopathy
- Platelet function, vWF, FVIII, ristocetin cofactor activities

29
Q

Natural Colloids
- how do they compare to plasma? issues with certain kinds?

A

ØAllogenic blood products
- Isooncotic to plasma

ØHuman serum albumin (HSA)
- hypersensitivity reactions
- healthy or repeated dosing&raquo_space;> critically ill

ØLyophilized canine serum albumin (CSA)
- acceptable safety profile
- cost prohibitive

30
Q

Distribution of IV Fluids
- colloid vs isotonic vs hypotonic?

A

colloid - stays in plasma
isotonic - plasma and interstitial fluid
hypotonic - plasma, intersticial fluid, and ICF

31
Q

Potential Complications for overzealous fluid support

A
  • increased hydrostatic pressures
  • increased vascular endothelial permeability
  • hypoalbuminemia
32
Q

Predispositions to complications from fluid therapy

A

Predispositions:
- severe inflammation
- severe hypoproteinemia
- cardiac disease
- pulmonary disease

33
Q

somewhat common Potential Complications of fluid therapy

A

Ø Dilutional coagulopathy
Ø Aggravate recent hemorrhage
Ø Reperfusion injury
Ø Volume overload:
- Pulmonary & organ edema
- Cavitary effusion
- Gelatinous subcutaneous tissue
- Peripheral pitting edema
- Increased jugular venous distention
- Chemosis, serous nasal discharges

34
Q

Discontinuation of Fluid Therapy
- how should we do it, to avoid what problems?

A

Gradual weaning over 24 hr if high flow rates
- Renal medullary washout
- Impaired urine concentrating abilities
- Severe dehydration (if drinking insufficiently to keep up)

3. Cat & Dog (33 decks)

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