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Fluid Therapy

in
GE Shock Vs. DSS
(update 2016)

Dr. Aung Kyi Wynn


Senior Consultant
Pediatrician
Introduction
Hypovolemic shocks
Different pathophysiology
Different management

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Scenario
4years old child
Body weight 15 kg

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GE SHOCK OR
CHOLERA SHOCK

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Pathophysiology
Secretory diarrhea
External fluid loss
(water+electrolytes)-Rapid
From extravascular space
---dehydration
10% of body weight loss S/S of
shock

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Principle for GE shock treatment

Fluid out volume = Fluid in


volume
Rapid
Refill

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Pre-illness BW estimation

Pre-illness BW = measured BW + 10%


of BW
15kg = 13.5kg +
1.5kg

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Resuscitation
Fluid loading dose
R/L or N/S or 5% D/S
25% glucose or 10% dextrose
(for hypoglycemia)

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Loading dose
20 ml/kg within 15 min(300 ml)
Second Loading dose if not
improved

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T0TAL FLUID PER DAY
RMO/ 24 hour

Rehydration, Maintenance,
Ongoing loss

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Rehydration-Plan C
10% loss 100 ml/kg
100 ml * 15 kg = 1500 ml
30 ml/kg in first hr (450 ml)
70 ml/kg in 2 hr (1050 ml)
Without loading dose in 30
ml/kg

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Maintenance
Holliday-Segar Method (15kg = 10
+5)

1st10 kg 100ml/kg 1000ml


2nd 10 - 20 kg 50ml/kg 250ml
Over 20 kg 20ml/kg _

1250
ml
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Rate
Resuscitation loading 80ml/kg/hr
for15 min
Initial 60ml/kg/hr for
30 min
Later 30ml/kg/hr for
2 1/2hrs
Maintenance 3ml/kg/hr for
24hrs

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Total RMO
Rehydration 1500 ml
Maintenance 1250 ml

2750 ml
Ongoing loss ?

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Ongoing loss
From intake-output chart
10ml/kg (150 ml) for one time of
loose motion
ORS(old formula) or IV line

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At least total 6 bottles of drip for
24 hr
Wide therapeutic index
Low risk for overloading

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DSS

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Pathophysiology

Immune reaction
Increase vascular permeability
Plasma leakage (directly from vascular
space)-moderate to slow
Third space loss (serous cavity-internal
loss)-water+electrolytes+protein
No dehydration
Will reenter into IVS and excreted by
kidneys in recovery phase (risk of
overload)
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Loss in 4-6% of body weight (no
actual weight loss) S/S of shock
If coagulation defect +

GI bleeding

External loss

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Cause of death
overload or bleeding

Death

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Principle of fluid therapy
in DSS
Just adequate the least fluid
volume to correct shock
Fresh whole blood transfusion
is mandatory if indicated

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Loading dose (20ml/kg)-300ml
within 15 minutes if BP zero (or)
20 ml/kg/hr if hypotension only
R/L or N/S for loading , initial
replacement and N/S for
maintenance
Colloid - dextran 40, gelofusine
or ?Plasma 10ml/kg/hr for
ongoing loss
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Type of fluid
Initial stage

Isotonic fluid R/L , N/S

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Later stage
To remain in IVS longer in later
period

Osmolality and

Oncotic pressure must be above


that of plasma

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Osmolality
R/L 273mosm/l
NS 308mosm/l
5%D/S 560mosm/l
1/2strength D/S 406mosm/l
Dextran 40,70 310mosm/l

Gelofusine 274mosm/l
Plasma 285-295mosm/l

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Indian J Anaesth. 2009 Oct; 53(5)

Characteristics of some available


colloids
.
Product (Brand name) Conc. (%) Oncotic pressure (mmHg) Initial volume
expansion (%)
Albumin 25 100120 200
400
Dextran 70 (Macrodex) 6 5668 120

Dextran 40 (Rheomacrodex) 10 168191


200
Fluid gelatin (Geloplasma) 3 2629
70
Plasma 28

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Rate
Resuscitation loading 80ml/kg/hr
for15 min
(or) 20ml/kg/hr for
1 hour
Initial
(compensated shock) 10ml/kg/hr
for 1 hour
Later 6ml/kg/hr for
1hour
Maintenance 3ml/kg/hr
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Replacement
4% loss 5% loss 6 % loss

40 ml/kg 50 ml/kg 60 ml/kg

600 ml 750 ml 900 ml

Rate ---20ml/kg+10ml/kg+ 6ml/kg + 3ml/kg= 39ml/kg

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Maintenance
Same 1250ml
with crystalloid (N/S , S D/S)

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1. Replacement 4% loss 5% loss 6% loss
Crystalloid+colloid 600 ml 750 ml 900 ml

2. Maintenance
Crystalloid 1250 ml 1250 ml 1250 ml

3. Ongoing loss

Colloid(or) ? ? ?
Fresh whole blood ? ? ?

1850 ml 2000 ml 2150 ml


10ml/kg 10ml/kg

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Ongoing loss
Plasma leakage colloid
10ml/kg/hr
Dextran 40

Bleeding fresh whole blood


10ml/kg

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OPTIMUM VOLUME
1 of maintenance
1250 * 1 = 1875 ml
Less than 2 times of
maintenance (<2500ml)

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Bleeding
Shock not revived when close to
24 hr and more than 1850ml
infused (OR)
Condition not improved in spite of
stable PCV (OR)
Decreased PCV 20% suddenly

Fresh whole blood


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Counter check
Raised Hb G% = FWB ml/kg /6 = 10/6
=1.6 G

Ifraised PCV >5% wrong


decision-risk of overload

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If not give FWB timely for
bleeding
Shock hypoxia-----------death(or)

Overload

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CRITICAL POINT DECISION

(OVERLOAD or BLEEDING)

CAN SAVE LIFE

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Complicated cases
A-acidosis
B-bleeding
C-circulatory
overload
calcium(hypocalcemia)
S-sugar(hypoglycemia or
hyperglycemia)

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Narrow therapeutic index
Type of fluid, rate, duration,
appropriate volume, timely

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Fluid Therapy in Cholera shock Vs.
DSS

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CLOSE

MONITORING

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References
Handbook for clinical management of dengue
WHO 2012
The Harriet Lane Handbook the Johns Hopkins
Hospital, twentieth edition,2015
Kalayanarooj Siripen and et al, clinical practice
guidelines of dengue/dengue hemorrhage fever
management for Asian Economic Community,
2014
Paediatric Management Guideline Myanmar
Paediatric Society 2nd edition - 2011
Paediatric Protocols for Malaysian hospitals
Malaysian Paediatric Association 2nd edition
2010
Sukanya Matra and Purva Khandelwal, Are all
colloids same? How to select the right colloid?,
Indian journal of anesthesia 2009 Oct 53(5)
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THANK
YOU

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