Fluid Hydration Support - Essay Example

Fluid Hydration Support Human body has been provided with an ability to control and maintain its requirement for water and electrolytes along with other essentials. This is accomplished by a collaborative effort of predominantly higher centres, a type of hormones, lungs and kidneys. Hydration required by human body varies in various situations. The requirement is different in normal healthy individual as compared to the one who is sick or requires some medical interventions. As those individuals who are candidates for some surgical procedures, usually, have to under g o some sort of anesthesia. If it is general anesthesia then the individual has to be in a state of fasting for a certain period of time but the immediate requirements of hydration are met through intravenous infusions. The requirement for water and minerals ranges from saline fluids to Hartmann's solutions depending upon the severity of the physical condition and duration of the illness and period of remaining in a state of nothing per orum (NPO). Apart from the physical condition and the severity of the disease, climate also plays an important role in determining and maintaining the body requirements for hydration. A hot and dry climate demands some additional volumes of fluids to be infused other than what has been calculated. Comparatively, in a cold and humid atmosphere, the fluids requirement may need just the replacement of 24 hours needs based on excretion and perspiration if any exist. Gender may not be an important determining factor but the extreme of age and size of the body influence the daily needs of the individuals who are o fluids. Calculations for fluid requirements in paediatrics category is strictly based on body weight as compared to rough estimation in adults. Also, elderly patients need to be replaced with fluids with care. Similarly, monitoring fluid intake and output may need some judicious efforts as compared to healthy and adult individuals. In the same context, individuals with some chronic disease, like, diabetes mellitus or congestive heart disease require special care in the replacement of fluids. In the following paragraphs, discussion is made to address the issue of fluid replacement in patients with elective surgical procedures, usually without any complications; followed by fluid requirements and discussion in burn patients. The last topic is on fluid replacement in trauma patients followed by a summary. Elective surgical procedures Elective surgical procedures which involve handling of gut may be required not to take something orally so that gut returns to its normal working state after it has gone through some trauma or put to a stage of disturbance. Usually, it takes about six to eight hours postoperatively to start taking some fluids and then light diet orally. During the state of NPO, an adult individual is needed to be infused with some appropriate fluids to replace routine losses. Major sources of fluid losses are urine, insensible loss and faeces. This routine loss of fluid also takes away some important electrolytes from the body; about 80 mmol of sodium and 70 mmol of potassium is excreted (Principles of fluid, 2008) In addition to this routine loss in normal state of health, some changes take place in human body to cope with the situation. These can be termed as 'stress response', 'third space losses' and losses from the gastrointestinal tract (Principles of fluid, 2008). So body requirements may be the losses in addition to through urine or stoll. In such situation, replacement is carried out by crystalloids, the solutions with a similar composition as that of extracellular fluids. These fluids are given till a patient is kept in a state of fasting (Pandey, 2003; Roberts, 2001; Udeani, 2006). The best replacement of fluids can be accomplished by weighing the patient and monitoring any change in weight. This may not be a feasible practice so replacing the losses with addition of insensible loss may be sufficient to maintain a continuous supply of essentials till the individual is not taking through oral cavity. In such type of surgical patients, the stress response of surgery may induce reduction in insulin production and availability which in turn leads to hyperglycemia. So whenever the plan is to infuse for maintenance purposes then it should be better to avoid giving dextrose and if really necessary in low volumes. But diabetic should be monitored closely for blood glucose level and they should be infused with dextrose with titration through insulin. In paediatric surgical procedures, the infusion of fluid needs to be even more judiciously monitored. Minor shifts from what is actually required may lead to some devastating consequences. Apart from difference volume infused in adults and children, the electrolyte concentration does not need to be changed in elective surgical procedures for maintaining the fluid and electrolyte balance. However, premature babies and neonates on specific solutions and infants of diabetic mothers may need some special are in monitoring the blood glucose level. This may be accomplished by monitoring glucose levels and infusing glucose solutions with insulin (Filtson, 1982). Fluid and electrolyte requirements in Burn patients Management of burn patients depends on the level of injury or trauma to the body. Specific to the burns, damage to skin is extremely important. Level of damage to the skin layers and the body surface area involved in such injuries pay key roe in predicting the prognosis of a patient. Burns have been classified in three degrees based on the level of damage to skin layers. Moreover, the body surface area burnt is also very important for the outcome of trauma. So, management of a burn trauma varies depending upon the types of burn as well as the surface area of the body affected. Generally, a first degree or partial thickness burn of about 30% body surface area needs aggressive management to restore the fluid loss and care of wound (Rose, 1999). The higher degree burns require additional exercise in multiple steps for the reconstruction of affected areas (Rose, 1999). Multiple factors are involved in the blood volume loss after an incidence of burn. Mainly, fluids, electrolytes and proteins are lost leading to the hypovolemia while catecholamine, serotonin, histamine and other chemicals are important in increasing the vascular resistance. These conditions depress the cardiac output and eventually the overall functions of heart. However, an aggressive fluid replacement well within time may bring the situation in control resulting in the improvement of cardiac functions towards normal. The situation controlled by fluid management then moves to the hyperdynamic state where the metabolic rate of the body increases so that body could be repaired. This phase requires, in addition to the fluids and electrolytes, amino acids, and oxygen; in turn the metabolism produce lactic acid as well as carbon dioxide in the proportion of the in puts (Rose, 1999). So, at this time tachycardia would be there along with other signs like, hyperthermia but these reflect a recovery stage with better outcomes if continued in the same proportion. Fluid requirements change based burn involving the total body surface area, degree of burns, and the age of the victim. Usually, burn of 15 percent of the total body surface area may not need intravenous fluid if it does then moderate efforts can address the issue. When the total body surface area increases beyond 15 percent, intravenous resuscitation seems necessary and it becomes mandatory to maintain fluid replacement through monitoring the central venous pressure at 30 percent or more involvement of total body surface area in the burn. As there is a difference between the adults and children as far as the attribution of different parts of the body towards total body surface area is concerned, therefore, the calculation for the total body surface area burnt may change in the two groups. Figure 1: Representation of different parts of the body towards total body surface area. What so ever be the surface area, there are some guidelines which help in planning the resuscitation and management of burn victims. Among the various formulae, the Parkland formula has been preferred over others (Rose, 1999). In an adult, according to this formula, no colloid solution should be infused during the first 24 hours but crystalloids should be infused vigorously. The solution of choice is Ringer's Lactate (RL) which should be given based on the degree of burn and weight of the patient. It is better to give 4 ml of RL/ % of total body surface area burn / kg body weight. It is required that the total volume of the fluid should be divided in two halves and first half should be infused efficiently within eight hours whole the remaining half during the next 16 hours. This way first 24 hours requirement will be accomplished. If this has been achieved then in the next 24 hours maintenance fluids can be infused with D5W. However, it is good to add colloidal solutions at the rate of 0.5 ml/ % of total body surface area burn / kg body weight (Rose, 1999). There are some other formulae for calculating the fluid requirements for burn patients. These are Brook formula and MGH formula. The calculation made by these formulae is less than that of Parkland formula. Although, Parkland formula calculations have also been criticized by Csaba et al for low volumes of fluids infused than what should have been replaced (Csaba, 2007). So in such circumstances, it is better to prefer Parkland formula to minimize the chances of more deficits in burn patients. Because of difference in the weight and representation of total body surface area burnt, it is recommended to calculate fluid replacement in children by utilizing individual fluid management strategy. For infants, addition of about 1500 ml maintenance fluid to the Parkland calculation is recommended (Rose, 1999). These formulae, Parkland, Brook and MGH have been somewhat specific as far as solution types and concentration is concerned. A group of surgeons from Bangladesh tried to assess some other fluids with different concentrations than the conventional fluids. They had to look for other formulae or solutions because of the non-availability of these specifc solution in the small and remote areas of the country. Shahid et al has suggested some what simpler fluids which can be utilized if some plasma expanders and other solutions are not available for infusions (Shahidul, 2003). Ascorbic acid (vitamin C) has been studied to counter the action of free radicals. As free radicals are among the key factors involved in mediation of burn injury, so employing some infusions of ascorbic acid may help in reducing the effect of free radicals and eventually the cellular damage. Recommendations are to provide a continuous solution of ascorbic acid in burn patients with burn involving more than 30 percent of the total body surface area. The volume of solution infused should be included in the total calculations made by using the Parkland formula (Ascorbic acod, 2008; Tanaka, 2000; Oliver, 2006). This solution provides more advantages if started within 6 hours of the injury and continued for 24 hours at the rate of 66 mg per kg per hour. Trauma Patients Usually, trauma takes place in an area where no medical/paramedical staff is available as it is an emergency situation without any intention and planning. Truly, the victims of a moderate level of trauma are not in a position to describe the situation because of physical as well as mental trauma. Till the patient arrive in the operating room and fully assessed by a team of trauma assessment of severity and prognosis before that is very difficult. So a team of health care providers has to be vigilant and assess the situation initially as well as over the time when situation may change or respond to their initial management. National Institute for Clinical Excellence US has developed a list of guidelines for fluid replacement for the health care providers who attend such patients before out of the hospitals. These guidelines are for replacement of fluids before reaching to hospital (Prehospital initiation, 2004). These guidelines are comprehensive in a sense that they address the issue of fluid replacement in patients with all age groups. It is important to continue the basic and advanced life support depending upon the circumstances and transportation to the hospital should never be delayed. So, the following guidelines are, in fact, additional support to utilize the time lag between the trauma venue to the hospital. It is recommended that in the pre-hospital management of adults and older children, IV fluid should not be administered if a radial pulse can be felt (or, for penetrating torso injuries, if a central pulse can be felt). In the absence of a radial pulse (or a central pulse for penetrating torso injuries) in adults and older children, it is recommended that IV fluid should be administered in boluses of no more than 250 mL. The patient should then be reassessed, and the process repeated until a radial pulse (or central pulse for penetrating torso injuries) is palpable. The administration of IV fluid should not delay transportation to hospital, but when given in accordance with the recommendation above, consideration should be given to administration en route to hospital. It is recommended that when IV fluid is indicated in the prehospital setting, crystalloid solutions should be the routine choice. There is inadequate evidence on which the Institute can base recommendations on when pre-hospital use of IV fluid in young children and infants following trauma is appropriate, or on the volumes of fluid to use. However, there is a broad consensus that transfer to hospital should not be delayed by attempts to administer IV fluid. It is recommended that only healthcare professionals who have been appropriately trained in advanced life-support techniques and pre-hospital care should administer IV fluid therapy to trauma patients in the pre-hospital setting. Surgical patients varies as far as the procedures and situation is concerned; but general principles for managing such patients for their fluid requirements remain almost the same in at least one type of category. But in different situations the frequency of infusions, concentration of infusions and volume of infusions given is different. This depends upon, apart from specific characteristics of the patient, on fluid loss, availability of fluids, response of the patients to the infused fluids, age of the patient and cardiovascular and renal status of the patient. So along with general principles addressing the issue of specific situations is also important. References 'Ascorbic Acid (Vitamin C) infusion in the resuscitation of burn patients.' Accessed on February 21, 2008 at http://www.surgicalcriticalcare.net/Guidelines/ascorbic%20acid.pdf Csaba A, Viktor F, Tamas F, & Lajos B. 2007. 'Factors affecting fluid requirement on the first days after severe burn trauma.'ANZ Journal of Surger. 77(9): 745-48. Filston HC, Edwards CH, Chitwood WR, Larson RM Marsicano TH & hill RC. 1982. 'Estimation of postoperative fluid requirements in infants and children.' Annals of surgery, vol. 196, no. 1. Oliver RI, Spain D & Stadeimannl W.2006. 'Burns, Resuscitation and Early Management.' eMedicine, accessed on February 22, 2008 at http://www.emedicine.com/plastic/topic159.htm Pandey CK & Singh RB. 2003. 'Fluid and electrolyte disorders.' Indian J. Anaesth. 47(5):380-87 Roberts KB. 2001. 'Fluid and electrolytes: Parenteral fluid therapy.' Pediatrics in review, vol. 22, no. 11. 'Prehospital initiation of fluid replacement therapy in trauma.' 2004. Technical Appraisal 74. NHS National institute for clinical excellent. Accessed on February 22,2008 at http://www.guideline.gov/summary/summary.aspxss=15&doc_id=8637&nbr=4811 'Principles of fluid and electrolyte balance in surgical patients.' Accessed on February 21, 2008 at www.qub.ac.uk/cm/sur/docs/fluid-electro.ppt Rose DD. 1999. 'Perioperative management of burn patients.' AORN Journal accessed on February 20 at http://findarticles.com/p/article/mi_m0FSL/is_6_69/ai_54912768 Shahidul B, Mahmud CMI, Zeba SF Razee KAA. 2003. 'Fluid resuscitation of burn patients in Bangladesh -"Dhaka Fluid Therapy", An alternative approach.' Annals of Burns and Fire Disasters. volXVI-n.4 Tanaka H, Matsuda T, Miyagantani Y, Yukioka T, Matsuda H & Shimazaki S.2000.'Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study.' Archives of surgery, 2000 135(3):326-31 Udeani J.2006. 'Shock, Hemorrhagic.' eMedicine, accessed on February 22, 2008 at http://www.emedicine.com/med/topic2115.htm Read More