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27 Haziran 2021 Pazar

“The Next Day Method” in Fluid Therapy


In my first two articles on fluid therapy, I tried to summarize the pharmacokinetic and pharmacodynamic properties and clinical uses of crystalloid (https://bit.ly/2J00511) and colloid fluids (https://bit.ly/2J6ScXI) without going into detail. These articles have reached a total of 5500 reads as of today, thank you for your interest. 

In this article, I would like to summarize how I do the fluid selection and daily dose adjustment while planning the daily fluid therapy, without going into too much detail.


To count my assistant years, dealing with volume-loaded patients was a part of my daily practice in the first year I came to the intensive care unit after 10 years of internal medicine practice. In fact, I remember like it was yesterday that in the sixth month of my ICU practice, at the beginning of the postop cerebral mass case, I said, “the person who finds a solution to this volume load should be given a Nobel Prize”.

Today, the dose setting of fluid therapy in ICUs can be very different, I usually determine an hourly total amount of fluid that I observe and add a positive inotrope, nutritional fluid, etc. to it. that the dose of maintenance fluid determined when added is changed every hour. One day, a nurse friend said, "I'm sorry, sir, I calculated the patient's hourly fluids, Isolate was supposed to go from 1cc per hour, I checked that there were 14 hours left, and I gave it to the 20-gauge injector".


I tried like this in the first periods, but when patients were taking the planned total maintenance fluid, they were loaded with much more fluid than planned due to the antimicrobial treatments they took in two or three doses a day, then they took high doses of diuretics to remove this excess, which made it difficult to maintain electrolyte balance.


The order I was accustomed to until then was to determine the fluid need of the patient by eye, for example, I would order 1000 cc SF and 1000 cc 5% Dx today. Afterwards, according to the patient's hydration status and urine output (A= Ç+30 cc/hour), with the philosophy of whether it is forty cents more, for example, 1/3 of it is SF, according to the electrolyte balance; I would say it's like 5% in 2/3 J I don't know if this tactic still exists in internal medicine practice?


I have experienced that YB is not very practical in these two methods. I tried to make a fluid planning by myself by mixing the literature. The topic that I will talk about after this point is how I do the daily maintenance fluid plan. The subject I would like to point out before I begin is that this article is not about fluid resuscitation and fluid responsiveness in the hemodynamically impaired patient, that is the subject of another article.


Whatever the patient's cause of shock is, it is necessary to have an idea about it and, if necessary, you provided fluid and/or positive inotrope/vasopressor support, or the patient was hemodynamically stable, but will continue to be followed up in the ICU for different reasons. You need more or less fluid support.


Before I do how I do it, I would like to state that I have been using this method for about three years and have experienced that it provides great convenience in clinical follow-up. It turned out that most volume loads were caused by me, not by underlying diseases. During my faculty minor education, I was able to monitor weight quantitatively because our patient beds were weighed. However, although we do not have scales in our state hospital beds, I do not remember experiencing treatment-induced iatrogenic hypervolemia during my three-month experience.


Also, another point I should mention is that I haven't been following CVP for almost three years in order to give an idea about the patient's volume status and fluid therapy.



Here's the summary of what I did:


First of all, I determine the daily fluid requirement as 30-35 cc/kg/day according to the patient's weight. Like 1800 cc for a 60 kg patient, 2400 cc/day for an 80 kg patient.


Secondly, I get an idea about the hydration status by looking at the fluid balance, skin turgor tone, presence of edema, and mucous membranes that the patient has taken and removed the day before, evaluate the renal laboratory parameters, if any, and determine the amount of maintenance fluid I need to give today and the diuretic dose if necessary.


Sometimes it happens that patients can meet almost daily needs with the fluids they take to dilute two different antimicrobial agents or other medications they already take.


Third, does the patient have acidosis/alkalosis? How much sodium? For a relatively stable patient, daily biochemistry examination may not be required, some days may be sufficient to direct the fluid therapy of ABG or VKG.


I do not prefer Ringer Lactate (RL) or Ringer acetate (ISOLEN/ISOLAYT) in patients with alkalosis, instead I prefer SF or Mixt fluid (5% Dx + 45% NaCL). I also observe that patients taking ISOLAYT are more hypernatremic. If the patient is hypernatremic, I give 5% Dx maintenance fluid and switch to Nepro food.


Apart from potassium, I see Magnesium and Phosphorus levels more frequently, if not required, at least twice a week and make necessary replacements.


Finally, the patient came using a long-term diuretic or if I give high-dose diuretics in the clinical follow-up, I give Bemiks ampoule (25 mg Thiamine) support in terms of possible Thiamine deficiency.


Finally, let me finish by giving an example of a patient as a practical application. The patient is around 70 kilos (unfortunately about), I think that a daily fluid support of 2100 cc is needed, let the patient be euvolemic, by the way, I also consider the hourly amount of enteral nutrition that the patient receives as an hourly fluid input.


The patient received 3400 cc of fluid yesterday, I gave Isolate infusion at 80 cc/h yesterday. Also, even if metabolic alkalosis has developed in the patient's AKG, I switch to SF infusion and decrease the hourly maintenance dose to 30cc/hour. Thus, I adjust the daily total fluid level without having to determine an hourly total for the patient.


At first, the nurse friends were quite awkward, but within a week they quickly got used to it. Adjusting the amount of fluid we need to give hourly total is out of our field of interest. We don't have a problem whether we add this or that. For example, our patient receives SF Infusion at 30 cc/h, receives Enteral Nutrition support from 40 cc/h, and takes fluids including vitamins, A.Bs and other drugs, if any, and takes 2500 all-inclusive the next day. Thus, we reduced the risk of hypervolemia, and also reduced the need for diuretics.


I didn't know what to call the method I described. Although it evokes a different treatment, this one was the most appropriate. “The Next Day Method” in Fluid Therapy"



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