Therapeutic, Nutritional, Fluid and Electrolyte Replacement

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Total body Water in adults and neonates
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50-70% in adults 80% in neonates
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What is total body waters comprised of
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intracellular and extracellular fluid compartmentss
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Intracellular fluids (ICF)
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60% of TBW
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Extracellular fluids (ECF)
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40% of TBW
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Interstitial fluids
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75% of ECF (30% of TBW)
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Intravascular fluid
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25% of ECF (10% of TBW)
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When giving IV fluids
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intravascular space-> interstitial space -> intracellular fluid
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When fluids are lost from the body:
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they are first lost from the ECF (intravascular and interstitial space), then from the ICF (Intracellular fluids)
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Most abundant electrolytes ECF
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Na+, Ca++, Cl-, HCO3- (bicarbonate)
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most abundant electrolytes ICF
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K+, Mg++, PO4-, proteins
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therapeutic fluids that are balanced resemble ECF in composition
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Na, Cl, HCO3-
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LRS? (Lactated Ringers Solution)
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balanced solution
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Saline?
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unbalanced solution
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weight of the solute per 100 ml of solution (g%)
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0.9%=o.9/100ml or 900 mg/100 ml per liter (mEq/L) or per ml (mEq/ml)
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what does milliequivalents express?
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express the concentration of electrolytes
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Osmosis
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solutes move from area of high to lower concentration through a *semipermeable membrane*
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larger solutes/impermeable to membrane:
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water will be attracted towards solute
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Osmotic pressure:
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the ability f particles in solution to attract water
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Osmolarity and osmolaltiry
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measures of the osmotic pressure of a solution based on the number f particles in that solution
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Osmolarity
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based on # of particles/Liter solution
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Osmolality
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based on # of particles/Kg of solution
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Effective osmoles
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particles capable of generating osmotic pressure
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tonicity
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total effective osmolarity of a solution
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Osmolarity of dog/cat serum:
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300 mOsm/L
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Fluids @ 300 mOsm/L
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isotonic fluid – fluids move in and out of cell and between all fluid spaces at an equal rate
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Fluids greater than 300 mOsm/L
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hypertonic fluid – causes fluid to shift into intravascular space from the interstitial space and cells so cells shrink
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Fluids less that 300 mOsm/L
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hypotonic fluid – causes fluid to shift out of intravascular space into the interstitial space and so cells swell
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Indications for fluid therapy
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dehydration: water loss greater than water intake maintain hydration: normal hydration but losing excessive amounts of fluid replace electrolytes and nutrients correct hypovolemia: decrease in blood volume/plasma volume: bleeding or dehydration correct acid-base imbalances maintain an open IV line for administering medications
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Sources of water intake
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water that is drunk water that is ingested with food water that results from normal metabolism
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normal routs of water loss
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urine fecal water sweat (horses) respiration (panting)
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Sensible losses (measurable losses)
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urine
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Insensible losses (cannot be easily measured)
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fecal and respiratory losses
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Why do we need to supplement fluids
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decreased fluid intake (decreased appetite/anorexia) increased fluid loss: diarrhea, vomiting, polyuria, hemorrhage, burns, body cavity effusions
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Vomiting
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Na+, K+, and Cl- loss
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Diarrhea
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Na+ loss, K+ loss chronically
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Skin Turgor test evaluates what?
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evaluates hydration
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the longer the skin takes to return to normal
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the more dehydrates the animal is
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Is it more or less reliable in older animals
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less reliable because they have a decrease in elasticity
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What are other indicators of dehydration
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dry mucous membranes increased capillary refill time increased heart rate weak, thready pulses reduced jugular distension (especially in horses)
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Not detectable
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<5%
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Slight loss of skin elasticity
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5-6%
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Delay in return of skin to normal position, increase CRT, dry mucous membranes
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10-12%
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Prominent signs of shock and/or death
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12-15%
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Packed cell volume (PCV)
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increases with dehydration always evaluate in conjunction with TP (anemia)
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Total plasma protein (TP)
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increases with dehydration
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Urine specific gravity
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increases with dehydration as well
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routes of fluid administration
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depends on nature of condition being treated, its duration and severity
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methods of fluid administration
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intravenous subcutaneous oral intraperitoneal intraosseous
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intravenous (IV)
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preferred when loss is great or disorder is severe *quicker more precise delivers of fluids*
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Where do you put an IV?
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Cephalic, jugular, saphenous
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Should you monitor the IV?
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yes! it requires close monitoring
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What can happen if you dont watch the catheter
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obstruction, septiccemia, embolism, phlebitis
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How long should you flush the catheter
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6-12 hours with heparinized saline
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When should you replace the catheter
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72 hours
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Subcutaneous (SQ)
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Needs not severe & not a good route if significant dehydration is already present
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amount administered depends on size of animal and amount of loose skin
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generally between 50-200 ml per site
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What happens if you overfill?
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sloughing can occur (dissects skin away from the blood supply)
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Oral
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practical route as long as no severe disorders of the gastrointestinal tract: common in large animal
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Intraperitoneal
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– large volumes of fluid can be given but absorption is slow – peritonitis s complicated – uncommon route
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Intraosseous (femur, ilium, humerus)
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– very small animals and/or those with poor veins – sterile technique to avoid osteomyelitis
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Volume of fluid to administer
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hydration deficit (Rehydration dose) maintenance requirement (maintenance dose) ongoing losses
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hydration deficit (rehydration dose)
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amount of fluid that needs to be replaced to return animal to a normal hydration state
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maintenance requirement (maintenance dose)
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amount of fluid requires to sustain the body on a daily basis- includes sensible and insensible losses
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ongoing losses
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losses due to vomiting and diarrhea- estimated
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*REHYDRATION DOSE* Give 80% over the first 24 hours Give last 20% over the next 24 hours
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*rehydration dose (ml) = (%dehydration X BW in kg) X 1000* convert % to a decimal – ex 10% = 0.1
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example of rehydration dose
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8 lb cat 10% dehydrated 8lb = 3.6 kg total ml for rehydration = (0.1 x 3.6 kg) X 1000 = 0.36 x 1000 = 360 ml rehydration dose first 24 hours = 360 X 0.8 = 288 ml second 24 hours = 360 X 0.2= 72 mls
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* MAINTENANCE DOSE *
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maintenance dose (ml)= 60 ml X BW in kgs
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example of maintenance dose
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8 lb cat 8 lb = 3.6 kgs maintenance dose = 60 ml X 3.6 kg = 216 ml per day
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Ongoing losses
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estimate volume of diarrhea or vomiting and then double- add to tally of daily fluids
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example of ongoing losses
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cat vomited 10 ml, ongoing losses: 20 ml
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PUT IT ALL TOGETHER!
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8 lb cat, 10% dehydrated, vomited 10 ml overnight- second day of rehydration * total ml for rehydration = (0.1 x 3.6) X 1000 = 360 mls * second 24 hours 360 ml X 0.2 = 72 mls * maintenance dose = 60 ml X 3.6 kg = 216 ml/day * ongoing losses = 20 ml * day 2 total 72 + 216 + 20 = 308 ml *day 1 total (0.8 X 360) = 216 + 0 =504 ml
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Fluid resuscitation
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reverse shock, correct hypovolemia, increase low blood pressure, reverse hypoglycemia
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dog shock dose
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60 – 90 ml/kg
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cat shock dose
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44 – 60 ml/kg
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emergency dose
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administer 1/4 of calculated dose as rapidly as possible (10-15 min) then reassess the patient VIA HR, CRT, mm color, BP, temp
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example of shock 8 lb shocky cat
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8 lb = 3.6 kgs *cat shock dose*: 44-60 ml/kg 44 ml/kg X 3.6 kg = 158 ml administer 1/4 quickly- 40 ml, the reassess. give remaining fluids over next hour
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drip rate
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(volume of infusion (ml) / time of infusion (min)) X drop factor (gtt/ml)
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why should you not administer fluids too rapidly
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administering fluids too rapidly or in too great a volume can be *life threatening*
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Careful monitoring is necessary
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physical exam labratory findings- PCV, TP Central venous pressure mental status hydration status heart- rate and rhythm respiration body weight body temperature (hypothermia) body position urine output
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signs of overhydration
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restlessness increased lung sounds (crackles) tachycardia dyspnea serous nasal discharge
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are bags or bottles labeled?
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yes, they are labeled to indicate any additives tape should be placed to indicate the volume that should be delivered by certain time
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Crystalloid solution
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Electrolyte solutions that can enter all body compartments Isotonic high-sodium (replacement solutions) Hypotonic low-sodium (maintenance solutions) Hypertonic saline solutions
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Colloid solution
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Large molecular weight particles, confined to vascular space; used to expand the plasma volume Synthetic colloids Starch based colloids Natural colloids
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crystalloid solutions
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Administration results in rapid equilibration of fluid between the intravascular and extravascular spaces 10 % intravascular, 30 % interstitial, 60 % intracellular Isotonic high-sodium (replacement solutions) Hypotonic low-sodium (maintenance solutions) Hypertonic saline solutions
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Isotonic crystalloid solution
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Sodium content and osmolality close to ECF Large percentage of infused fluid will leave intravascular space within 30 minutes Treat shock, vomiting, diarrhea, pancreatitis Used with caution or not at all in patients in which sodium retention may be a problem (heart or renal disease)
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Hypotonic Crystalloid Solutions
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Sodium content and osmolality less than ECF Infusion hydrates the extracellular space Extracellular space has a higher osmolality that pulls the fluid out of the vasculature into space Treat hypernatremia or conditions which sodium retention is a problem
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Hypertonic Crystalloid Solutions
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Osmolality greater than that of ECF Causes fluid to move out of the intracellular/interstitial space and into intravascular space Treat shock (by increasing intravascular volume) May be beneficial in treating brain edema
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Crystalloid Solutions Isotonic high-sodium
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Physiologic Saline Lactated Ringer’s Solution Ringer’s Solution Normosol R Plasma-Lyte
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Crystalloid Solution Hypotonic solution
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Dextrose 5% in Water Dextrose 2.5% with 0.45% Saline Half-strength Lactated Ringer’s Solution with 2.5% Dextrose
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Isotonic Crystalloid Solutions Physiologic Saline
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0.9% NaCl, normal saline, isotonic saline Osmolarity = 308 mOsm/L Replacement solution used to increase plasma volume or correct a Na+ deficiency (hyponatremia) Nonbalanced solution, not suitable for maintenance
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Isotonic Crystalloid Solutions Lactated Ringer’s Solution (LRS)
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LRS-commonly used – can be administered by any route Balanced electrolyte replacement solution Also used for maintenance (usually w/ added K+) Contains lactate which the liver converts to bicarbonate to buffer acidosis
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Isotonic Crystalloid Solutions Ringer’s Solution
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Balanced replacement solution More sodium, calcium and chloride than LRS Also used for maintenance (usually w/ added K+) No lactate (buffer) – can be used for metabolic alkalosis Limited use in veterinary medicine
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Isotonic Crystalloid Solutions Multisol-R or Normosol-R
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Balanced multiple electrolyte replacement solutions with a dual buffering system (acetate and gluconate) Acetate and gluconate metabolized outside the liver (advantage with liver disorders) Calcium free (Ca++ can cause clotting of transfused blood) Normosol-M in 5% Dextrose 5% dextrose in a balanced maintenance solution with acetate as a buffer (use instead of D5W if need maintenance fluids with dextrose)
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Isotonic Crystalloid Solutions
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Plasma-Lyte Balanced replacement solution with acetate (47 mEq/L) and lactate (8 mEq/L) as buffers Plasma-Lyte M in 5% Dextrose Balanced maintenance solution with acetate and lactate in equal amounts (12 mEq/L)
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Hypotonic Crystalloid Solutions
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Dextrose 5% in Water D5W – non-balanced solution that contains only dextrose and water Only provides 170 kcal/L – cannot meet the daily caloric needs of most small animals Not administered SQ Not used as a maintenance solution 2.5% Dextrose in Half-strength (0.45%) Saline with potassium added Used as a maintenance solution for patients with sodium restriction
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Hypertonic Saline Solutions
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3%, 4%, 5%, 7%, 7.5% Especially useful in treating hypovolemic shock – small volumes 7.5% solution considered the upper limit of concentration to avoid phlebitis
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Hypertonic Saline Solutions side effects
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Phlebitis Tissue irritation Re-hemorrhage in traumatic shock Electrolyte imbalances Fast administration Hypotension Bronchoconstriction Bradycardia
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Colloid Solutions
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Contain large molecular weight particles, cannot cross cell membranes Fluid stays in intravascular space Particles are effective osmoles and pull fluid from the interstitial space into the vascular space = expands the plasma volume Useful when crystalloid therapy has not been successful Used for expansion of the plasma volume in patients with hypovolemia NOT due to dehydration, septic shock, or hypoalbuminemia Most effective fluid type for Tx of acute hypovolemia
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Colloid Solutions Dextrans
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Large molecular weight polysaccharide solutions Used in the treatment of shock Remains in the vascular space for 4 to 8 hours Dextran 70 – most commonly used dextran solution 6% solution in 0.9% saline Contraindicated in patients with coagulopathies (clotting deficits) May cause allergic reactions in some animals
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Colloid Solutions Hetastarch
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Large molecular weight starch 6% solution in 0.9% saline Used to treat hypovolemia and hypoproteinemia May also reduce intravascular inflammation and reduce vascular permeability and leakage Expands the plasma volume longer (12-36 hours) and has fewer side effects than dextrans Can cause volume overload, coagulopathies, and hypersensitivity reactions Expensive
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Natural Colloid Solutions Fresh Frozen Plasma
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Centrifuged from whole blood and frozen within 6 hours of collection Contains albumin, other plasma proteins, and clotting factors Used to treat rodenticide coagulopathies, patients needing Factor VII or von Willenbrand’s factor, or DIC Stored up to one year with preservation of the unstable clotting factors After one year becomes stored plasma – loses clotting factors
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Natural Colloid Solutions Albumin
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Albumin produces over 75% of the oncotic pressure in plasma Useful in critically ill patients needing intravascular volume expansion Especially if hypoalbuminemic, edematous, or suffering from vascular leakage of fluid Caution if using the human form of Albumin
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Natural Colloid Solutions Whole Blood
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Primarily used to treat patients with anemia Contains all the coagulation factors and platelets – can be used in patients with platelet and clotting disorders Transfusion given when PCV drops below 20% or hemoglobin drops below 7g/dL Should be started slowly and monitored for signs of transfusion reaction Panting Urticaria, vomiting
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Fluid Additives
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Substances added to IV fluids to enhance the therapeutic effect Correct acid-base abnormalities, electrolyte imbalances, supplement calories, provide supplemental vitamins (replace those “washed out” by fluid therapy)
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Fluid Additives Sodium Bicarbonate
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Correct metabolic acidosis, hypercalcemia, hyperkalemia Measured bicarbonate level in patient and subtract from 24 mEq/L = bicarbonate deficit Amount for supplementation (mEq) bicarbonate deficit x 0.3 x weight (kg) CI: patient’s with CHF, hypertension, hypocalcemia or hypokalemia, oliguria Incompatible with some products, esp. solutions with calcium (precipitates) Replacement done over several hours Available as: 8% = 1 mEq/ml 5% = 0.6 mEq/ml
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Fluid Additives Potassium Chloride
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Supplement potassium deficits (hypokalemia) Normal serum K+ = 3.5 – 5.5 mEq/L Table 15-5 on page 317 for a guide to supplementation based on patient’s potassium level (Scott’s Sliding Scale) Diluted before administration – usually added to maintenance fluids *Rate of infusion is critical: Do not exceed 0.5 mEq/kg/hr (can cause life-threatening cardiac arrhythmias)*
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Fluid Additives Potassium Chloride more
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Side effects May be life threatening – usually due to excessive rate Muscle weakness, cardiac conduction disturbances CI: hyperkalemia, renal failure, Addison’s disease, acute dehydration Available as: 2 mEq/ml in 10 or 20 ml vials
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Fluid Additives Calcium Supplements
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Treatment of milk fever, eclampsia, parathyroid gland disorders, downer cow syndrome, grass tetany Administered slowly to prevent cardiac complications (arrhythmias, cardiac arrest) Available as: Calcium gluconate – 10%, 23% Calcium chloride – 10% Combination products containing calcium, phosphorus, magnesium, potassium, dextrose
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Fluid Additives 50% Dextrose
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Caloric supplementation Treat hypoglycemia – insulin overdose, parasites (puppies/kittens), insulinoma, fever, sepsis, liver disease Treat ketosis in ruminants Used as a stock solution to add to other fluids Available as 50% dextrose solution (500mg/ml)
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Parenteral Vitamin/Mineral Products Water-Soluble Vitamins
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Vitamin B complex Thiamine (B1), riboflavin, niacin, d-panthenol, pyridoxine, cyanocobalamine (B12), biotin, choline and folic acid B vitamins are coenzymes for many metabolic reactions Added to IV fluids to restore normal levels Given parentally to stressed and debilitated animals Side effects: pain at injection site, allergic reactions Check label if giving IV to make sure formula is compatible with IV injection
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Thiamine Hydrochloride (Vitamin B1)
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Treatment of thiamine deficiency in domestic animals Thiaminase in raw fish (cats) Polioencephalomalacia (ruminants) Side effects: hypersensitivity reactions and muscle soreness at intramuscular injection sites
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Vitamin B12 (Cyanocobalamin)
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Used to manage Vit B12 deficiencies (anemia) Side effects: allergic reactions
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Vitamin A
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Needed for eyes, skin, bone Prevention and treatment of vit A deficiencies Usually combined with Vit D or E
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Vitamin D
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Prevention or treatment of vit D deficiencies (rickets, osteomalacia) Usually combined with Vit A or E
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Vitamin E (alpha-tocopherol)
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Prevention and treatment of Vit E and selenium deficiency syndromes common in cows, sheep, pigs and horses
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Vitamin K
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Required for the formation of vitamin K dependent clotting factors (II, VII, IX, and X) Discussed under poisoning treatments (anti-coagulant rodenticide poisonings)
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Oral Electrolyte Preparations
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Often packaged as powders that can be mixed with water and given free choice or by stomach tube Used for calf scours (diarrhea in diary calves), replacement of electrolytes in performance horses (lost via sweat), dogs recovering from prolonged vomiting and diarrhea, hypokalemia in dogs and cats (chronic renal failure) Dosage forms: numerous; for potassium supplementation = Tumil-K®
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How long should you flush the catheter
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6-12 hours with heparinized saline

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