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Fluid Therapy in
GE Shock Vs. DSS(update 2016)
Dr. Aung Kyi WynnSenior consultant Pediatrician
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IntroductionHypovolemic shocksDifferent pathophysiologyDifferent management
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Scenario4 years old childBody weight 15 kg
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GE SHOCK OR CHOLERA SHOCK
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PathophysiologySecretory diarrheaExternal fluid loss
(water+electrolytes)-RapidFrom extravascular space ---
dehydration10% 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 doseR/L or N/S or 5% D/S25% glucose or 10% dextrose
(for hypoglycemia)
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Loading dose20 ml/kg within 15 min(300 ml)Second Loading dose if not
improved
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T0TAL FLUID PER DAYRMO/ 24 hour
Rehydration, Maintenance, Ongoing loss
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Rehydration-Plan C10% loss – 100 ml/kg100 ml * 15 kg = 1500 ml30 ml/kg in first ½ hr (450 ml)70 ml/kg in 2 ½ hr (1050 ml)Without loading dose in 30
ml/kg
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MaintenanceHolliday-Segar Method (15kg = 10 +
5 )
1st 10 kg 100ml/kg 1000ml2nd 10 - 20 kg 50ml/kg
250mlOver 20 kg 20ml/kg _ 1250 ml
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RateResuscitation loading 80ml/kg/hr
for15 minInitial 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 RMORehydration 1500 mlMaintenance 1250 ml
2750 mlOngoing loss ?
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Ongoing lossFrom intake-output chart10ml/kg (150 ml) for one time of
loose motionORS(old formula) or IV line
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At least total 6 bottles of drip for 24 hr
Wide therapeutic indexLow risk for overloading
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DSS
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Pathophysiology
Immune reaction Increase vascular permeabilityPlasma leakage (directly from vascular
space)-moderate to slowThird space loss (serous cavity-internal
loss)-water+electrolytes+proteinNo dehydrationWill 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 onlyR/L or N/S for loading , initial
replacement and maintenance Colloid - dextran 40, gelofusine
or ?Plasma 10ml/kg/hr for ongoing loss
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Type of fluidInitial stage
Isotonic fluid – R/L , N/S
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Later stageTo remain in IVS longer in later period
Osmolality and
Oncotic pressure must be above that of plasma
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OsmolalityR/L 273mosm/lNS 308mosm/l5%D/S 560mosm/l1/2strength D/S 406mosm/lDextran 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 25 100–120 200–400Dextran 70 (Macrodex) 6 56–68 120 Dextran 40 (Rheomacrodex) 10 168–191 200 Fluid gelatin (Geloplasma) 3 26–29 70 Plasma 28
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RateResuscitation loading 80ml/kg/hr
for15 min (or) 20ml/kg/hr for 1 hour Initial(compensated shock) 10ml/kg/hr for 1 hourLater 6ml/kg/hr for
1hourMaintenance 3ml/kg/hrAdjustment 1-2ml/kg/hr
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Replacement4% 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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MaintenanceSame 1250mlwith crystalloid (N/S , ½ 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 VOLUME1 ½ of maintenance1250 * 1 ½ = 1875 mlLess than 2 times of
maintenance (<2500ml)
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BleedingShock 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 checkRaised Hb G% = FWB ml/kg /6 = 10/6
=1.6 G
If raised 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 casesA-acidosisB-bleedingC-calcium(hypocalcemia)S-sugar(hypoglycemia or
hyperglycemia)
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Narrow therapeutic indexType 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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ReferencesHandbook for clinical management of dengue –
WHO 2012The 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