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Fluid therapy is an integral part of treatment of the equine emergency patient. In this article, general principles of fluid therapy are discussed, including formulas for calculation of fluid volumes, fluid types and their indications, and specific therapy for several emergency conditions.
Although large intestine impactions are commonly treated with i.v. fluids combined with the osmotic laxative MgSO4, enteral fluids are less expensive and also appear to be efficacious for impactions. Therefore, this study was conducted to compare the systemic and gastrointestinal effects of enteral fluids with the changes produced by i.v. fluids combined with MgSO4. Four horses with a fistula in the right dorsal colon alternately received both treatments in 2 periods one week apart. Sixty litres of fluids were administered continuously (10 l/h) through a venous catheter or a nasogastric tube. Magnesium sulphate (1 g/kg bwt) was administered via nasogastric tube before i.v. fluid therapy. Two horses had mild abdominal discomfort at the end of enteral fluid therapy. Pollakiuria, hypostenuria, increased bodyweight, increased faecal and ingesta hydration, and decreased PCV, plasma protein and plasma magnesium were produced by both treatments. Abdominal distention and more pronounced changes in bodyweight and ingesta hydration were seen with enteral fluids. Intravenous fluids plus MgSO4 produced hypocalcaemia and more pronounced changes in plasma protein. These results indicate that enteral fluid therapy is more effective in promoting ingesta hydration and produces less pronounced systemic effects than i.v. fluid therapy plus MgSO4.
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Parenteral fluid therapy is a basic component of the care of hospitalized infants and children. Clinicians who care for inpatients must be able to assess the need for parenteral fluid therapy and to specify the composition of fluid and rate of administration. Fluid and electrolyte problems can be challenging but generally can be "tamed" by an organized approach, application of a few principles of physiology, and careful monitoring of the patient. It can be useful to consider separately the amount of fluid needed and the electrolyte composition for maintenance needs, deficit, and ongoing losses. Because maintenance is not as directly related to weight as deficit or as directly measureable as ongoing losses, it tends to cause the most confusion. It will, therefore, be discussed first and in more detail than deficit or ongoing losses.
Fluid therapy in children is based on biochemical and physiologic principles qualitatively and quantitiatively different from adults. The limitations imposed by body size requires greater precision in calculating fluid therapy for children. General methods of computing maintenance and deficit pediatric fluid therapy, and specific fluid therapy involved in treating acute problems associated with genitourinary disorders with be discussed.
The indications for use of large-volume parenteral solutions are reviewed, and the types of fluids administered and their potential hazards are described. The indications discussed are replacement therapy, maintenance therapy and emergency venous access. Hazards presented include thrombophlebitis, infection, volume overload, air embolism, particulate matter and chemical contamination. The indications for specific parenteral fluids, such as saline solutions, dextrose solution, fructose and alkaline solutions are discussed. Also reviewed are agents used to treat alkalosis, intravenous potassium therapy, calcium salts, magnesium salts and mixed solutions. Most clinical situations can be managed with judicious use of 0.9% saline and 5% dextrose with the addition of other electrolytes as determined by the needs of the individual patient.
Perioperative fluid therapy is the subject of much controversy, and the results of the clinical trials investigating the effect of fluid therapy on outcome of surgery seem contradictory. The aim of this chapter is to review the evidence behind current standard fluid therapy, and to critically analyse the trials examining the effect of fluid therapy on outcome of surgery. The following conclusions are reached: current standard fluid therapy is not at all evidence-based; the evaporative loss from the abdominal cavity is highly overestimated; the non-anatomical third space loss is based on flawed methodology and most probably does not exist; the fluid volume accumulated in traumatized tissue is very small; and volume preloading of neuroaxial blockade is not effective and may cause postoperative fluid overload. The trials of 'goal-directed fluid therapy' aiming at maximal stroke volume and the trials of 'restricted intravenous fluid therapy' are also critically evaluated. The difference in results may be caused by a lax attitude towards 'standard fluid therapy' in the trials of goal-directed fluid therapy, resulting in the testing of various 'standard fluid regimens' versus 'even more fluid'. Without evidence of the existence of a non-anatomical third space loss and ineffectiveness of preloading of neuroaxial blockade, 'restricted intravenous fluid therapy' is not 'restricted', but rather avoids fluid overload by replacing only the fluid actually lost during surgery. The trials of different fluid volumes administered during outpatient surgery confirm that replacement of fluid lost improves outcome. Based on current evidence, the principles of 'restricted intravenous fluid therapy' are recommended: fluid lost should be replaced and fluid overload should be avoided.
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Intravenous fluid therapy is often the only effective treatment of severely dehydrated calves. In farm animal practice, application of IV fluid therapy is still comparatively rare. A protocol for treatment of dehydration and acidosis in the field is described, along with the rationale behind each fluid used. Even without the support of sophisticated laboratory analysis, an estimated 50% of calves that are expected to die of dehydration recover after IV fluid therapy is given.
Fluid therapy is a universally used therapeutic modality in critical care patients. To effectively deliver fluids to neonates., an understanding of their fluid physiology is necessary. Neonates, as they make the transition from fetal physiology, have increased capillary filtration and a compliant interstitium producing a large ISF reserve. This reserve helps the neonate to adapt to fluid challenges, serving as a ready source of fluids in times of need, but it also frustrates therapeutic fluid administration by damping the effect of intravenous fluid therapy when treating hypovolemia. Additionally,it explains the difficulty neonates have in handling fluid overload. Successful treatment of hypovolemia requires aggressive volume repletion using 20-mL/kg fluid boluses. Once euvolemia is restored and ongoing losses are replaced, maintenance fluid rates should be conservative so as to avoid fluid overload. The neonate's unique sodium handling must also be recognized. Many critical neonates benefit from sodium restriction, whereas others may have high ongoing losses and require careful sodium replacement therapy. Careful attention to fluid therapy formulation ensures positive fluid support without adding to the physiologic stress of the critical neonate.
I.v. fluid selection depends on the estimated fluid loss, the primary fluid compartment involved, the patient's underlying problem and the physiological and haemodynamic impact of the i.v. solution. Clinically, the most important problem is intravascular fluid volume deficit, which is associated with hypotension, inadequate tissue oxygenation and hypoperfusion of essential organs. Intravascular volume resuscitation is therefore of primary importance. Crystalloid solutions have the disadvantage of only small amounts remaining in the IVS whereas colloids are known as plasma volume expanders due to predominantly remaining in the IVS in the presence of an intact capillary endothelium. Managing i.v. fluid administration requires close observation of the patient's subtle responses that may indicate states of fluid depletion or overload. Understanding the physiological principles of the body's fluid distribution in relation to the clinical assessment of the patient's hydration status, together with knowledge of the selected i.v. solution's properties, will enable the nurse to provide quality nursing care and improve patient outcomes.
Fluid therapy took nearly a century to gain acceptance in human medicine, despite excellent early work demonstrating its rationale and its effectiveness. Progress in veterinary fluid therapy lagged behind, partly because of skepticism and partly because of real practical difficulties. From the earliest to the most recent developments, human cholera has provided the impetus for much of the progress in fluid therapy. The challenge of treating such a severe diarrhoea in primitive surroundings with severe limits on cost and supervision has led to the emergence of oral fluid therapy as the prime technique. It is not simply an alternative to parenteral treatment but, in most cases, a superior approach relating more directly to the underlying problem--electrolyte malabsorption. Similar principles can be applied to other forms of diarrhoea and in various species. The example is clear for those concerned with veterinary fluid therapy. Repair of extracellular fluid volume is the key objective in all forms of fluid therapy; oral hydration offers not only a practicable way of achieving this in farm animals but one with the potential for outstanding clinical and economic success.
The optimal fluid therapy for plasma volume support at major surgical procedures and in the treatment of critically ill patients has been a matter of considerable controversy during the last few years. The impact of the ongoing debate on Swedish routines has been assessed from a detailed questionnaire sent to all operation (OP) and intensive care units (ICU) in Sweden (n=130) in September 2004. Response was obtained from 92% of the units. It was found that major changes in fluid treatment regimes had occurred in recent years. In spite of the anti-colloid debate in the 1990s the continued use of colloids was evident. The use of albumin was reduced while that of other colloids had increased. Dextran was no longer the dominating colloid since a majority of the departments reported a switch to hydroxyethyl starch (HES). The switch was based on recent information on the advantages and disadvantages of the various products available. Gelatin was only marginally used since it was no longer available on the market. The fluid treatment profile documented on the basis of the responses to the questionnaire agreed well with the recent sale figures of albumin and artificial colloids. A restrictive fluid therapy at surgical procedures is recently advocated based on administration of colloid but only a rather limited volume of crystalloid. Some caution in the application of such a fluid therapy approach seems justified. More liberal fluid administration has recently been found rather to improve recovery after laparoscopic surgery.
Fluid therapy restores circulation by expanding extracellular fluid. However, a dispute has arisen regarding the nature of intravenous therapy for acutely ill children following the development of acute hyponatraemia from overuse of hypotonic saline. The foundation on which correct maintenance fluid therapy is built is examined and the difference between maintenance fluid therapy and restoration or replenishment fluid therapy for reduction in extracellular fluid volume is delineated. Changing practices and the basic physiology of extracellular fluid are discussed. Some propose changing the definition of "maintenance therapy" and recommend isotonic saline be used as maintenance and restoration therapy in undefined amounts leading to excess intravenous sodium chloride intake. Intravenous fluid therapy for children with volume depletion should first restore extracellular volume with measured infusions of isotonic saline followed by defined, appropriate maintenance therapy to replace physiological losses according to principles established 50 years ago.
Intravenous fluid therapy is valuable as primary or ancillary therapy for many conditions in calves. The first step in developing an intravenous fluid plan is determination of the volume needed to replace the fluid deficit, estimated on the basis of clinical signs. The parenteral solution to be used is chosen to be similar in electrolyte composition to the fluid lost. Abnormalities of specific electrolytes, acid-base balance, and energy metabolism can be addressed during volume replacement; this requires an understanding of the pathophysiology of the primary clinical abnormality. The fluid delivery system is composed of an administration set and an intravenous catheter. The administration set allows sterile delivery and regulation of the rate of administration. An intravenous catheter is selected, inserted, and maintained to minimize the potential for catheter-related complications.
The following basic rules of parenteral fluid therapy are formulated with the aim of alleviating concern and confusion about i.v. fluid orders that are experienced by most physicians: Don't be generous with fluid; in determining the water intake, one must know the usual water output through the kidney, skin and lung; one must know the quantities of the electrolytes and nutrients that are being given, and know the initial volume of distribution (usually the ECF); one must know the aim of fluid therapy; one must not give and remove the same substance at the same time; one must be aware that hypertonic saline contains less water for a given amount of Na than isotonic saline; one must be familiar with different i.v. solutions and i.v. additives; one must be aware that the kidney does not manufacture water or electrolytes except for bicarbonate; for short-term fluid therapy, divalent ions (Ca, Mg, and P) do not need replacement; one should think about COP-wedge gradient in determining the type of fluid to be given.