Fluid Therapy

in
GE Shock Vs. DSS
(update 2018)

Dr. Aung Kyi Wynn

Senior consultant Pediatrician
Parami Hospital
 Introduction
 Hypovolemic shocks
 Different pathophysiology
 Different managements

1/26/2019 AKW 2
 Scenario
 4 years old child
 Body weight 15 kg

1/26/2019 AKW 3
GE SHOCK OR
CHOLERA SHOCK

1/26/2019 AKW 4
1/26/2019 AKW 5
 Pathophysiology
 Secretory diarrhea
 External fluid loss (water+electrolytes)
 Rapid
 From extravascular space ---dehydration
 10% of body weight loss S/S of shock

1/26/2019 AKW 6
 Principle for GE shock treatment

Fluid out volume = Fluid in volume

Rapid
Refill
(Must calculate fluid requirement with
pre-illness body weight)

1/26/2019 AKW 7
 Pre-illness BW estimation

Pre-illness BW = measured BW + 10% of BW

15kg = 13.5kg + 1.5kg

1/26/2019 AKW 8
 Resuscitation
 Fluid loading dose
 R/L or N/S or 5% D/S
 25% glucose or 10% dextrose (for
hypoglycemia)

1/26/2019 AKW 9
Loading dose
 20 ml/kg within 15 min(300 ml)
 Second Loading dose if not improved

1/26/2019 AKW 10
 T0TAL FLUID PER DAY
 RMO/ 24 hour

 Rehydration, Maintenance, Ongoing loss

1/26/2019 AKW 11
Rehydration-Plan C
 10% loss – 100 ml/kg
 100 ml * 15 kg = 1500 ml
 30 ml/kg in first ½ hr (450 ml)
 70 ml/kg in 2 ½ hr (1050 ml)
 Without loading dose in 30 ml/kg

1/26/2019 AKW 12
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

1/26/2019 AKW 13
 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

1/26/2019 AKW 14
Total RMO
 Rehydration 1500 ml
 Maintenance 1250 ml

2750 ml
 Ongoing loss ?

1/26/2019 AKW 15
Ongoing loss
 From intake-output chart
 10ml/kg (150 ml) for one time of loose
motion
 ORS(old formula) or IV line

1/26/2019 AKW 16
 At least total 6 bottles of drip for 24 hr
 Wide therapeutic index
 Low risk for overloading

1/26/2019 AKW 17
DSS

1/26/2019 AKW 18
1/26/2019 AKW 19
 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 excess fluid
excreted by kidneys in recovery phase (risk
of overload)

1/26/2019 AKW 20
 Loss in 4-6% of body weight (no actual
weight loss) – S/S of shock
 If coagulation defect +

GI bleeding

External loss

1/26/2019 AKW 21
Cause of death
overload or bleeding

Death

1/26/2019 AKW 22
Principle of fluid therapy in DSS
 “ Just adequate “ the least fluid volume to
correct shock
 “ Fresh whole blood “ transfusion is
mandatory if indicated

1/26/2019 AKW 23
 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
 N/S for maintenance
 Colloid - dextran 40, gelofusine or
?Plasma 10ml/kg/hr for ongoing loss

1/26/2019 AKW 24
Type of fluid
Initial stage

Isotonic fluid – R/L , N/S

1/26/2019 AKW 25
Later stage
To remain in IVS longer in later period

 Osmolality and

 Oncotic pressure must be above that of

plasma

1/26/2019 AKW 26
1/26/2019 AKW 27
 Osmolality
 R/L 273mosm/l
 NS 308mosm/l
 5%D/S 560mosm/l
 1/2strengthD/S 406mosm/l
 Dextran 40,70 310mosm/l
 Gelofusine 274mosm/l
 Plasma 285-295mosm/l

1/26/2019 AKW 28
Indian J Anaesth. 2009 Oct; 53(5)

Characteristics of some available colloids

.
Product (Brand name) Conc. (%) Oncotic pressure (mmHg) Initial volume expansion (%)
Albumin 25 100–120 200–400

Dextran 70 (Macrodex) 6 56–68 120

Dextran 40 (Rheomacrodex) 10 168–191 200

Fluid gelatin (Geloplasma) 3 26–29 70

Plasma 28

1/26/2019 AKW 29
 Rate
 Resuscitation loading 80ml/kg/hr for15 min
 Decompensated shock 20ml/kg/hr for1hour
 Initial
(compensated shock) 10ml/kg/hr for 1 hour
 Later 6ml/kg/hr for 1hour
 Maintenance 3ml/kg/hr
 Adjustment 1-2ml/kg/hr

1/26/2019 AKW 30
 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/hr+10ml/kg/hr+ 6ml/kg/hr + 3ml/kg/hr= 39ml/kg within 4 hrs

1/26/2019 AKW 31
Maintenance
 Same 1250ml
 with crystalloid (N/S , ½ S D/S)

1/26/2019 AKW 32
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/hr 10ml/kg/hr

1/26/2019 AKW 33
Ongoing loss
 Plasma leakage colloid 10ml/kg/hr
Dextran 40

 Bleeding fresh whole blood 10ml/kg

1/26/2019 AKW 34
OPTIMUM VOLUME
 1 ½ of maintenance
 1250 * 1 ½ = 1875 ml
 Less than 2 times of maintenance
(<2500ml)

1/26/2019 AKW 35
 Bleeding
 Shock not revived when close to 24 hr
and more than 1850 ml infused (OR)
 Condition not improved in spite of stable
PCV (OR)
 Associated dengue hepatitis (OR)
 Decreased PCV 20% suddenly

Fresh whole blood

1/26/2019 AKW 36
 Counter check
 Raised Hb G% = FWB ml/kg /6 = 10/6 =1.6 G

 If raised PCV >5% wrong decision-risk

of overload

1/26/2019 AKW 37
If not give FWB timely for bleeding
 If late----Shock – hypoxia---death(or)

 If early---- Overload

 If repeated unnecessarily-
Overload

1/26/2019 AKW 38
CRITICAL POINT DECISION

(OVERLOAD or BLEEDING)

CAN SAVE LIFE

1/26/2019 AKW 39
Complicated cases
 A-acidosis
 B-bleeding
 C-calcium(hypocalcemia)
 S-sugar(hypoglycemia or hyperglycemia)

1/26/2019 AKW 40
 Narrow therapeutic index
 Type of fluid, rate, duration, appropriate
volume, timely-------Influence of many
factors

1/26/2019 AKW 41
Fluid Therapy in Cholera shock Vs. DSS

1/26/2019 AKW 42
 CLOSE

MONITORING

1/26/2019 AKW 43
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 – 3rd edition - 2018
 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)
1/26/2019 AKW 44
1/26/2019 AKW 45