수액 요법의 내과적 원칙 경희대학교 동서신의학병원 신장내과 문 주 영

내용 1. 수액용법의 목적 2. 수액 치료 목적에 따른 수액제의 선택 3. 수액제의 종류 4. 수액요법의 원칙과 단계

단위 정리 1mol =(Molecular weight, MW)g mmol/L = mg/dL x 10/ MW Na+ 1mol = 23g, Na+ 1M (molarity, 몰농도) = 23g/L 1 mol Na+ (23g) + 1 mol Cl- (35.5g)= 1 mol NaCl (58.5g) NaCl 1g = NaCl 17 mmol mmol/L = mg/dL x 10/ MW mEq/L = mmol/L x valence msoml/kg = n x mmol/L (n=number of particles per unit volume of solvent) Substance Atomic or molecular weight mmol mEq mosmol Na+ 23 1 Cl- 35.5 NaCl 58.5 2 1.75 CaCl2 111 4 3 Glucose 180

60kg 인 28세 남성에서의 intravascular volume의 량은? Total body water = 60 x 0.6 =36L Intravascular volume = 36 x 1/12 = 3L

Total Body Water and Fluid Compartments ECF ECF IV IV ISF ICF ISF ICF 1 1 Plasma(Colloid) 4 4 8 Sodium(Crystalloid) 12 12 Water (Dextrose in water)

Barriers of Fluid Compartments (ECF) IV ISF ICF H2O, urea H2O, urea Na+ = 130-140 mEq/L K+ =3.5-5.0 mEq/L Cl- HCO3- K+ =130-140 mEq/L Na+ = 10-20 mEq/L Phosphate- 2K+ Na-K ATPase RBC 3Na+ albumin Semipermeable cell membrane Basement memb + Endothelial cell

Distribution of 1,000ml Infusion of Each Solution Replacement amount of volume deficit Volume added(ml) Solution Distribution IV ISF ICF 5% Dextrose water Water space 83 250 667 X 8-12 0.9% Saline ECF 250 750 0 X 2.5-4 0.45% Saline X 5-6 500ml water Water space 40 125 335 500ml 0.9% saline ECF 125 375 0 Plasmanate IV 1,000 0 0 X 1

그러면 serum albumin =2.0g/dL 인 환자에서albumin 한 병이 증가시키는 intravascular volume은? 20% albumin 100cc = 20g/dL 의 albumin 함유 따라서 1000 cc 의 intravascular volume 증가

Tonicity (Osmotic Forces) by Effective Osmoles pressure Na+ + H2O Urea urea Ineffective osmole Effective osmole 총 혈장 삼투압 = 2x혈장 나트륨농도 + 포도당 농도(mg/dL)/18+ BUN(mg/dL)/2.8 유효 혈장 삼투압 = 2x혈장 나트륨농도 + 포도당 농도(mg/dL)/18 혈장 삼투압 = 2x혈장 나트륨농도

Sodium concentration = Water Balance Sodium content Sodium concentration = Water volume 1. Water gain : hyponatremia 2. Water loss : hypernatremia

Sodium Balance ECF volume Sodium gain : ECF  1) Sodium gain> Water gain: intravascular volume  hypertension 2) Water gain > Sodium gain : ISF , IV edema, hyponatremia 2. Sodium loss : ECF  (volume depletion, hypotension) 1) Sodium loss > Water loss : hyponatremia 2) Water loss > Sodium loss : hypernatremia

Volume Depletion vs Dehydration Volume depletion (hypovolemia) - extracellular volume depletion - most often due to sodium loss >> water loss Dehydration - presence of hypernatremia due to pure water loss

1. 수액요법의 목적 1. 체액량의 유지 (Volume replacement) 2. 결핍이 있거나 부족한 전해질이나 수분의 보충 (Deficit replacement) 3. 매일 필요한 생리적 요구량의 수분 및 전해질 공급 (Maintenance replacement)

2. 수액 치료 목적에 따른 수액제의 선택 체액량의 유지 (Volume replacement) 유지 수액 요법 (Maintenance replacement)

체액량의 유지 (Volume replacement) 1. Saline Isotonic saline (0.9% NaCl) Hartmann’s solution 2. Blood component Whole blood Plasma Albumin 3. Colloidal solution Dextran, Starches

유지 수액 요법 (Maintenance replacement) 1. Water : 30 ml/kg (2,000 ml/day) Fever : 10 - 15% ↑ / 1C ↑ 2. Sodium : 100 – 150 mmol (6 – 9 g NaCl) Sweating : ⅓ 0.9% saline ⅔ dextrose water 3. Potassium : 40 – 80 mmol (3 – 6 g KCl) 4. Glucose : 100 – 150 g Reduction of protein breakdown

Water Losses in a NPO patient Daily Average (mL) Range (mL) Medium Maximum A. Sensible loss Urine 500-1500 1200 1500 Feces 100 - 200 100 100 B. Insensible loss Lungs 600-800 600 800 Sweat 100-300 200 300 Total water loss 2100 2700 C. Catabolism= water gain -300 -300 Overall loss 1,800 2,400 ≒ 30 mL/kg of ideal body weight

2 L half-saline (77 mmol/L x 2) /day Daily Sodium Loss Most important cation of the ECF loss of Na in the urine= 100 –140 mmol/day 2 L half-saline (77 mmol/L x 2) /day Daily Potassium Loss Most important cation of the ICF Need to supply K to meet obligatory urine loss (40-80 mmol/d) 20 – 40 mmol KCl / L of IV fluid Daily Chloride Loss Determined by Cl intake, pH, HCO3 Not need to calculate the Cl requirements when usually given in IV fluids as NaCl and KCl

Maintenance Fluid Therapy Stable NPO state, fever(-), drainage(-) Water : 30 ml/kg (2,000 ml) 5 % D/W x 2L Glucose : 100 g Sodium : 100 – 150 mmol 77 mmol/L x 2L Potassium : 40 – 80 mmol 20 – 40 mmol/L x 2L D5Na77K30 (NAK1) or D5Na77K20 (NAK2): 2,000ml 10%DW 1L + (NS 1L + KCL 40mEq)

Average Electrolyte Contents of GI Secretions (mmol/L) Source Na K Cl HCO3- H+ Stomach 60 10 130 60 Duodenum 140 5 80 65 Jejunum/ileum 130 5 105 30 Bile 140 5 110 35 Pancreas 140 5 55 90 Colon 50 20 40 30

Replacement of GI Loss 1. Stomach : 5% dextrose + ½ saline with 20 mmol KCl/L 2. Small intestine, biliary tract, pancreas : Ringer’s lactate (Hartmann solution) + 1) 20 mmol NaHCO3/L : duodenal loss 2) 50 mmol NaHCO3/L : pancreatic loss 3. Colon : half saline with 20 mmol K acetate/L

3. 수액제의 종류 1. Glucose solutions (carbohydrate in water) 2. Saline 3. 수액제의 종류 1. Glucose solutions (carbohydrate in water) 2. Saline isotonic and hypotonic saline hypertonic saline 3. Ringer’s and Hartmann’s solution 4. Potassium solution 5. Colloidal solutions

Glucose Solutions (Carbohydrate in Water) Physiological properties 1) Water supply (water + 0.6 ml/g glucose) 2) Calorie supply (4.1 kcal/g) 3) Reduction of protein breakdown ** Never for volume replacement !! 2. Solutions - Dextrose in water (D/W) : 5, 10, 20, 50 % 3. Caution : thrombophlebitis 4. Rate of administration with normal insulin - Glucose : 0.5 g/Kg/hr

For replacement for water deficit TBW1 X Osm1 = TBW2 X Osm2 TBW1 X 2[Na]1 = TBW2 X 2[Na]2 [Na]2 [Na]1 TBW1 = X TBW2 Water deficit = TBW1 - TBW2 = [ Na]2/ [ Na ] 1 X TBW2 - TBW2 [Na]2 140 = ( -1) X BW X 0.6 Hct2 45 = ( -1) X BW X 0.6

Saline (NaCl ) Solutions Physiologic Properties 1) Sodium (volume) supply 2) More chloride than plasma (dilutional acidosis) ** Never for water supply !! 2. Solutions - Isotonic saline : volume replacement - Hypotonic saline : hyperosmolar condition ex) diabetic coma, diuretic phase of renal failure - Hypertonic saline : severe hyponatremia (remove water from brain cells)

Rate of Administration of Isotonic Saline 1. Volume replacement - 400 – 500 ml/hour 2. Volume challenge - 250- 500 ml/15-30 min - maximum : 2,000 ml/hour

Correction of Severe Hyponatremia by 3% Saline 1. Target 1) Serum sodium : 120 – 125 mmol/L 2) Loss of symptoms and signs 2. Rate of correction 1) Raise serum sodium < 0.5 – 1 mmol/L/hour 2) Raise serum sodium < 12 mmol/L/24 hours < 18 mmol/L/48 hours 3) Maximum : 200 – 250 ml/hour

Ringer’s and Lactated Ringer(Hartmann)’s Solution 1. Ringer’s solution : normal saline + KCl + CaCl2 2. Lactated Ringer’s solution (Hartmann's solution) - sodium lactate for Cl- overload - no definite beneficial effect of buffer action Compositions (mmol/L) Na Cl HCO3- K Ca Ringer’s Solution 147.5 156 4 2.2 Hartmann’s Solution 130 109 28 4 3

Potassium Solutions 1. Physiologic properties - Mixed to the basic solution - Never mix to D/W in severe hypokalemia 2. Rate - Concentration : 40-60 mEq/L (saline) - Rate : 10 – 20 mEq/hour (rapid correction 시) - Amount : 80 – 160 mEq/24 hours 3. Monitoring : ECG, serum K, ionized Ca, Mg

Concentration(mmol/L) Colloidal Solutions Concentration(mmol/L) Na K Cl Whole Blood 60 10 130 Packed RBC 140 5 80 Plasma 130 5 105 20% Albumin 140 5 110 Dextran in isotonic saline 140 5 55

Colloids Indications Safe? Effective? Volume deficit Major hypovolemia For tissue perfusion When increased capillary permeability Safe? Effective?

Albumin 1. Advantage 2. Disadvantage 3. Albumin usage only in Natural colloid Less anaphylaxis 2. Disadvantage Risk of increased interstitial edema No advantages over crystalloid No advantages in hypoalbuminemia 3. Albumin usage only in Large volume paracentesis (in liver cirrhosis) Spontaneous bacterial peritonitis Nephrotic syndrome (resistant to diuretics) Plasmapheresis

Dextran 1. Advantage 2. Disadvantage - Tissue perfusion in stroke (?) - Volume effect and duration - Tissue perfusion in stroke (?) 2. Disadvantage Acute renal failure : critically ill patients Uterine hypertension : contraindicated to hypovolemia in pregnancy!

Hydroxyethyl Starch(HES) 1. Advantage (Best) - Volume effect and duration - Involving inflammatory process - “Seal the leak” Improved microcirculation 2. Disadvantage Coagulation abnormalities, platelet dysfunction ↓vWF, ↑aPTT : rare

Colloids Maximal volume effect (%) Duration of volume effect (hr) COP (mmHg) Dose limit (ml/kg/day) Daily Use Amount Crystalloid 25 0.5 Albumin 5% 100 - 150 4 20 None Albumin 20% > 400% 4 – 6 74 None Gelatin MF 3% 100 1 – 2 24 None Dextran 60, 6% 130 4 – 6 26 20 1.5L Dextran 40, 10% 175 3 – 4 170 20 1.5L HES 200/0.5, 6% 100 4 26 33 2L HES 200/0.5, 10% 150 4 64 20 1.5L HES 200/0.62, 6% 110 6 28 20 2L

4. 수액 요법의 원칙과 단계 1. Avoid unnecessary fluid 2. Stabilize volume status (vital signs) 3. Determine the type of deficit : water vs sodium 4. Maintain daily requirement, and replace continuing loss 5. Monitoring adequacy and complications of fluid therapy Daily body weight Intake and output Urine volume, electrolytes and osmolality Serum BUN, creatinine, glucose, electrolytes,total CO2 and osmolality IV sites (thrombophlebitis)

46-year old male with many bruises on the head and unconsciousness - BW 60 kg, BP 140/80 mmHg, PR 75/min, RR 15/min, BT 36.8 C - Skull X-ray : skull base fracture Chest PA : pneumonia on right middle lobe - Hb 14 g/dL, Hct 45 %, Na 172 mmol/L, K 4.2 mmol/L, Cl 132 mmol/L, BUN 46 mg/dL, Glucose 108 mg/dL

1. Type of deficit Water 2. Amount of water deficit 0.6 X 60 X (1 - 140/172) = 8.2 L 3. Choice of Fluid therapy 5% DW 4. Rate of correction Decrease serum Na = 0.5 – 1 mmol/L/hour

52-year old male who has been treated with hydrochlorthiazide and on a low Na+ diet for hypertension. 10 days after the therapy, nausea, fatigue, postural dizziness and muscle clamp were developed. - BW 70 kg, BP 130/80(supine) 100/70 mmHg(sitting), PR 100/min, JVP < 4 cmH2O, poor skin turgor - Hb 17 g/dL, Na 118 mmol/L, K 2.5 mmol/L, Cl 86 mmol/L, BUN 42 mg/dL, Glucose 110 mg/dL, urine Na 8 mmol/L

1. Type of deficit Sodium deficit, relative water excess 2. Amount of sodium deficit 0.6 X 70 X (140-118) = 924 mmol 3. Choice of fluid therapy (1) Isotonic saline ( >> hypertonic saline) Never use hypotonic saline or D/W (2) KCI

58-year old male with severe diarrhea after two weeks broad-spectrum antibiotics treatment for pneumonia - Confused state - Dry skin, axillae, decreased skin turgor - BW 70 kg, BP 110/70 mmHg, PR 95/min, RR 18/min, BT 37 C - Hb 17 g/dL, Hct 50%, Na 158 mmol/L, K 4.0 mmol/L, Cl 128 mmol/L, Glucose 100 mg/dL, Creatinine 1.3 mg/dL

1. Type of deficit Water > Sodium 2. Amount of water deficit 0.6 X 70 X (1-140/158) = 4.6L 0.6 X 70 X (1-45/50) = 4.2L 3. First fluid 5% D/W till serum Na < 155 mmol/L 4. Second fluid Isotonic or 1/2 saline

Clinical Conditions and Choice of Fluids 1. Volume depletion, hyponatremia - sodium deficit > water excess isotonic >> hypertonic saline 2. Volume depletion, hypernatremia - sodium deficit < water deficit 5% D/W till serum sodium < 155 mmol/L hypotonic or isotonic saline 3. Volume excess, hyponatremia - sodium excess < water excess restrict water and salt hypertonic saline