:: Fluids ::

9.58pm, 18 nov 2010

Dari mlm tadi rasa x sihat badan. Perubahan hormon mmg mengganggu. Sekecik2 hal pn boleh irritated. Tapi kalo hormon x berubah2, x normal plak.

As a result, elok2 je niat nak stadi kt lib this afternoon, turned out to be the other way round. Tido kat bilik. Dekat 2 jam jugak. Sib bek ade teaching kul 3 kalo x mmg akan diteruskan smpai petang/ even malam. Tapi geram betul la, mimpi x best! mimpi duk kat fakulti, ade kelas!! cheh, mimpi ni x leh nk berkompromi lgsg, cubelah bagi yg indah2 sket.. athoyaiii... Bgn terus ke teaching tanpa ku sedari kunci di tinggal di bilik!

Teaching w Prof Tang ( a super duper nice SV )

2 topics, bronchiolitis & acute gastroenteritis.

Berkenaan AGE.

Slame ni x ambik kisah sgt pun pasal Oral Rehydration Solution (ORS).

So, learning issues:

1. Composition

2. How to prepare

3. How long can be used when prepared

4. Can mix with other drinks, eg juice. milk or not?

So, lets answer those questions

1. Based on uphalyte ORS,

each sachet contains:

NaCl 525mg

Sodium bicarbonate 425mg (mcm ni ke symbol dia: Na2CO3 ? makcik lupa la cara nak tulis tuuu, huhu)

KCl 375mg

Glucose anhydrous 6.25gm

ironic concentration in mmol/liter: Na 56, K 20, Cl 56, HCO3 20, Glucose 139

2. Add 250 ml of boiled, cooled water to the contents of 1 sachet n stir/shake well for 2-3 minutes to dissolve.

3. Store in a dry place below 30 C, protect from light. Can be used only for 1 day after mixing with water.

4. Taboley mix dgn ape2 air sekalipun, hoccay!!!

Sekecik2 benda pon kena tau taw! Slame ni main guna je. hikhik.

Next, camane nak kira fluid maintenance?? Haaaa.. meh sini nak bagi taw.

Paeds ni leceh sket. Nak bagi fluid replacement kena based on body weight. X macam adult, suka hati je nak kasi, basically 5 pints (3 Normal Saline + 2 dextrose saline).

Untuk neonate:

* Day 1 (of life) = 60ml/kg/hour

* Day 2 = 90

* Day 3 = 120

* Day 4 = 150

Sampailah umur 6 bulan, kna bagi 150ml/kg/hour.

* 6bln - 1 year = 120ml/kg/hr

* >1 year old,

1st 10kg: 100ml/kg

next 10kg: 50ml/kg

subsequent kg : 20ml/kg

Nilah basic nya. Pastu, sblum kira, kna quantify berapa percent dehydration dia, clinically.
5% ke, 7.5% ke, 10 % ke. 10% dehydration dikira sbg severe dehydration.

Mcm mn nak assess:

1) history

: thirst, urination frequency

2) physical examination

: Sunken eyes, sunken fontanelle, skin turgor, capillary refill time, heart rate, blood pressure

look out for signs of shock: tachycardia, weak pulses, delayed CRT, cold peripheries, depressed mental status, with o without hypotension.

Pastu, determine jugak, isonatremic, hyponatremic or hypernatremic dehydration.

Ala, bnykla pulak nak kena explain... ak explain setakat rajin je ok!!

1. Hyponatremic dehydration.

Sodium kluar lagi banyak dari water yg kluar. As the water moves from a lower to higher concentration area, extracellular fluid will move to intracellular causing reduced vascular volume. At brain, this can cause brain edema and patient can present with convulsion. Symptoms and signs of dehydration are present.

2. Hypernatremic dehydration

Water kluar lg banyak dari sodium kluar. So, sodium akan retain in blood vessel and subsequently, water will move from intracellular to extracellular. This can cause brain shrinkage, and due to that, it will detach from skull, causing rupture/tear of intracerebral and bridging blood vessel causing brain hemorrhage. So patient can present with convulsion. As the water is moving from cell --> outside, it will balance the amount of water loss, so features of dehydration are absent.

3. Isonatremic dehydration

Yg ni biase je, water n sodium loss are the same.

So, management dieeeee...

Cth: 3 years old Malay girl, weight 14 kg, with 5 % dehydration. Sodium is 137.

So, sodium is normal.

Maintenance fluid:

14kg: 1000ml + 200 ml = 1200ml/24hours = 50ml/hour

Deficit:

5% x body weight in g

so 5% x 14000g = 700ml

Yang deficit ni, kena decide, nak kasi dlm 8 hours ke 12 hours ke.

cth nak bg dlm 8hours, so 700/8 = 87.5 = 88ml/hour

So, utk first 8 hours, jumlah fluid kena bagi adelah 50 + 88 = 138ml/hour.

Pastu, tentukan pulak nak bagi solution ape. Normal saline ke, dextrose saline ke.

Haa, utk patient ni maybe boleh kasi 1/2 normal saline + dextrose 5% sebab sodium dia normal. Dextrose mmg kena bagi.

Ok, skrg nak bg patient 138ml/H utk first 8 hours. Jangan pulak g review patient lepas 8 hours. Dlm 2 jam g review balik sbb boleh jadi dehyd jadi 7.5% ke so kena kira balik fluid nak bagi. Takpun dehyd dah correct so x payah bagi yg deficcit. Just bagi 50ml/H tu je.

Potassium chloride pn kena bagi jugak to cover the on-going losses of potassium.
(cara nak kira potassium cari sendiri... lalallalala)

Kalau hyponatremic dehyd pon more or less the same. Cuma tukar jadi dextrose saline ke, instead of half saline.

(ekceli, ni jln singkat, sbetulnya kena kira sodium deficit dahulu yerrr)

Tang hypernatremic pulak. Biasa kita correct in 48-72 hours sbb xboleh cepat2, nnt boleh jadi brain edema!!!

Reduction of sodium not exceed 10 mmol/L per 24hours.

Cth:3 years old Malay girl, weight 14 kg, with 5 % dehydration. Serum Sodium is more than 150 mmol/L.

Solution:

Maintenance:

(spt yg dikira di atas) = 1200ml/24 hours.

Sebab kita nak correct in 48hours, so kali 2 la

1200ml x2 = 2400ml/48hours.

Deficit:

(spt yg dikira di atas)= 700ml

So, to rehydrate over 48 hours, infusion rate will be: (2400ml + 700ml) / 48hrs = 65 ml/H.

haaaaaa.. oleh itu selesai sudah sesi fluid replacement kita pada hari ini.Ni tersangatlah ringkas, kalau nak penjelasan lebih jelas dan lebih senang faham, baca buku sendiri. Ni kiut kefahaman aku sendiri. Kalo salah tlg betulkan jugak ye.. :PP

Oleh itu, nak g blaja mende lain pulak ye..

tata sumeee....

nunyteee..

P/S: belajar & belajar supaya tidak memikirkan hal2 peribadi yg mengganggu!