Infusion therapy. Principles of infusion therapy goals, tasks, directions

There are several types of infusion therapy: intraosteny (limited, osteomyelitis possibility); intravenous (main); intraarterial (auxiliary, to summarize drugs to the hearth inflammation).

Value Access Options:

• puncture of the Vienna - applied with non-block infusions (from several hours to days);
• veneziction - if necessary, continuous administration of drugs for several (37) days;
• catheterization of large veins (femoral, jugular, subclavian, barny) - with proper care and aseptics ensures infusion therapy with a duration of 1 week to several months. Plastic catheters, disposable, 3 sizes (by outer diameter 0, 6, 1 and 1.4 mm) and from 16 to 24 cm long.

For inkjet injection of drugs, syringes ("Luer" or "Record") are used, made of glass or plastic; Preference is given to one-time syringes (the likelihood of infection with viral infections is reduced by viral infections, in particular HIV and viral hepatitis).

Currently, drip infusion therapy systems are produced from inert plastics and are intended for disposable. The rate of administration of ps is measured among the drops of 1 min. It should be borne in mind that the number of drops in 1 ml of r-ra depends on the size of the dropper in the system and the forces of the surface tension created by the solution itself. Thus, in 1 ml of water, an average contains 20 drops, in 1 ml of fat emulsion - up to 30, in 1 ml of alcohol - up to 60 drops.

Volumetric peristaltic and syringe pumps provide high accuracy and uniformity of the introduction of ps. On the pumps there is a mechanical or electronic speed regulator, which is measured in milliliters per hour (ml / h).

Solutions for infusion therapy

Infusion therapy solutions include several groups: volume (voltic); basic, basic; corrective; Preparations for parenteral nutrition.

Volume-substituting drugs are divided into artificial plasma substitutes (40 and 60% of the dextran rf, starch solutions, hemodez, etc.); Natural (autogenous) plasma substitutes (native, freshly frozen - SPP or dry plasma, 5, 10 and 20% of human albumin, cryoprecipitate, protein, etc.); Actually blood, erythrocytic weight, or suspension of washed red blood cells.

These drugs are used to reimburse the circulating plasma volume (ODC), the deficiency of erythrocytes or other plasma components, in order to sorption toxins, to ensure the rheological function of the blood, to obtain the osmodioretic effect.

The main feature of the preparations of this group: the more their molecular weight, the longer they circulate in the vascular bed.

Hydroxyethyl strokesal is produced in the form of a 6 or 10% solution on the physiological P-RE (NaS-Steril, InfoCol, Stabizol, etc.), has a high molecular weight (200-400 kD) and therefore it is currently circulating in vascular bed (up to 8 days). It is used as anti-co-preparation.

Polyglyukin (dextran 60) contains a 6% dextran solution with a molecular weight of about 60,000 D. prepared by 0.9% p-re sodium chloride. Half-life (T | / 2) - 24 hours, persists in circulation up to 7 days. Children are rarely applied. Anti-shock preparation.

Reopoliglukin (dextran 40) contains a 10% dextran rr and 0.9% rr sodium chloride or 5% glucose (indicated on the bottle). T1 / 2 - 6-12 hours, actions time - up to 1 day. Note that 1 g of dry (10 ml R-ra) dextran 40 binds 20-25 ml of fluid coming into the vessel from the interstitial sector. Anti-deposit drug, the best reoprotector.

Hemodheus includes a 6% solution of polyvinyl alcohol (pyrrolidone polyvinyl), 0.64% sodium chloride, 0.23% sodium bicarbonate, 0.15% - potassium chloride. The molecular weight is 8000- 12,000 D. T1 / 2 - 2-4 hours, the time of action is up to 12 hours. The sorbent has moderate disinfecting, osmodioretic properties.

In recent years, the so-called dextre syndrome, due to the part of patients, the special sensitivity of the epithelial cells of the lungs, kidney and endothelium of vessels to dextranum is distinguished. In addition, it is known that with prolonged use of artificial plasma refinaries (especially hemodesa), blockade of macrophages may develop. Therefore, the use of such drugs for infusion therapy requires caution and strict indications.

Albumin (5 or 10% solution) is an almost perfect volume, especially with infusion therapy with shock. In addition, it is the most powerful natural sorbent for hydrophobic toxins, transporting them to liver cells, in microsomes of which the detoxification itself occurs. Plasma, blood and their components are currently used in strict indications, mainly with a substitution goal.

With the help of basic (basic) p-mages, medicinal and nutrients are introduced. P-p glucose 5 and 10% has osmolarity, respectively, 278 and 555 mosm / l; pH 3,5-5.5. It should be remembered that the osmolarity of ps is provided by sugar, the metabolization of which in glycogen with the participation of insulin leads to a rapid decrease in the OSMA of the influence of the injected fluid and, as a result, the threat of the development of osmolal syndrome hypo.

Ringer's solutions, Ringer-Locke, Hartman, Lactasol, Azesol, District, Trisole, and others. The closest in the composition of the liquid part of the person's plasma and adapted to the treatment of children, contain sodium, potassium, calcium, chlorine ions, lactate. In the Ringer Ringer-Locke there are also 5% glucose. Osmolarity 261-329 mosm / l; pH 6.0-7.0. Isosmolar.

Curigating solutions are used in ion imbalances, hypovolemic shock.

Physiological 0.85% PR chloride sodium due to excessive chlorine content is not physiological and almost does not apply in young children. Sour. Isosmolar.

Hypertensive pits sodium chloride (5.6 and 10%) in pure form are rarely used - with a sharp sodium deficiency (

Pling of sodium bicarbonate (4.2 and 8.4%) are used to correct acidosis. They are added to R-Ringer, the physiological p-ru sodium chloride, less often to the p-ru glucose.

Program of infusion therapy

When drawing up a program of infusion therapy, a certain sequence of actions is required.

1. Install the diagnosis of violations of WEO, drawing attention to voluminous, state of cardiovascular, urinary systems, central nervous system (CNS), determine the degree and characteristic of the deficit or excess water and ions.
2. Taking into account the diagnosis to determine:
   1. the purpose and objective of infusion therapy (disintellation, rehydration, treatment of shock; maintaining water balance, microcirculation restoration, diurea, administration of drugs, etc.);
   2. methods (stove, drip);
   3. access to vascular channel (puncture, catheterization);
3. tools of infusion therapy (dropper, syringe pump, etc.).
4. To make a promising calculation of current pathological losses on a certain period of time (4, 6, 12, 24 hours), taking into account the qualitative quality assessment of the severity of shortness of breath, hyperthermia, vomiting, diarrhea, etc.
5. Determine the deficiency or excess of the extracellular volume of water electrolytes, which developed for a preceding a similar period of time.
6. Calculate the physiological need of a child in water and electrolytes.
7. To summarize the volume of physiological needs (FP), the deficit predicted by water losses and electrolytes (before potassium and sodium ions).
8. Determine the part of the calculated volume of water and electrolytes, which can be introduced to a child for a certain period of time, taking into account the detected aggravating circumstances (cardiac, respiratory or renal failure, brain edema, etc.), as well as the correlation of the enteral and parenteral route of administration.
9. To relate the estimated need for water and electrolytes with their amount in solutions intended for infusion therapy.
10. Select the starting P-P (depends on the driving syndrome) and the basis, which is more often 10% glucose.
11. Determine the need to introduce special-purpose drugs based on the established syndromic diagnosis: blood, plasma, plasma substitutes, reoprotectors, etc.
12. To resolve the question of the number of inkjet and drip infusions with the determination of the drug, the volume, duration and multiplicity of administration, compatibility with other means, etc.
13. Detailing the infusion therapy program, while playing (on resuscitation cards) the order of appointments, taking into account the time, speed and sequence of drug administration.

Calculation of infusion therapy

Promising calculation of infusion therapy and current pathological losses (CPP) of water based on accurate measurements of actual losses (by weighing diapers, urine collection and feces, vomit, etc.) for the previous 6, 12 and 24 hours allowing them to determine their volume for the upcoming time interval. Calculation can be conducted and tentatively according to the available standards.

The deficiency or excess of water in the body is easy to consider if the dynamics of infusion therapy for the past time is known (12-24 hours). More often deficiency (excess) of extracellular volume (DVO) is determined on the basis of a clinical assessment of dehydration degrees (hyperfed) and the deficit (excess) of MT observed. In accordance with I degree of dehydration, it is 20-50 ml / kg, with II - 50-90 ml / kg, with III - 90-120 ml / kg.

For infusion therapy for the purpose of rehydration, only the MT shortage that has developed over the past 1-2 days is taken into account.

The calculation of infusion therapy in children with normo and hypotrophy is carried out on the actual MT. However, in children with hypertrophy (obesity), the amount of total water in the body is 15-20% less than that of thin children, and the identical loss of MT has a higher degrees.

For example: "Thick" child at the age of 7 months has MT 10 kg, over the past day, it lost 500 g, which is 5% of MT deficiency and corresponds to I degree of dehydration. However, if we consider that 20% of MT is represented by additional fat, then the "degreased" MT is 8 kg, and the MT deficiency due to dehydration is 6.2%, which corresponds to its II degree.

It is permissible to apply the caloric method for calculating the infusion therapy of the need for water or in terms of the child's body surface: for children up to 1 year - 150 ml / 100 kcal, older than 1 year - 100 ml / 100 kcal or for children up to 1 year - 1500 ml per 1 m 2 body surfaces, older than 1 year - 2000 ml per 1 m 2. The surface of the child's body can be installed on nomograms, knowing its growth and MT.

The volume of infusion therapy

The total amount of infusion therapy on the current day is calculated by the formulas:

• to maintain the water balance: OH \u003d FP, where the FP is the physiological need for water, the coolant of the liquid;
• during dehydration: OH \u003d DVO + TPP (in the first 6, 12 and 24 hours of active rehydration), where the DVO is the deficiency of the extracellular volume of the liquid, the CCP is the current (predicted) pathological loss of water; After the liquidation of the DVO (usually from 2 days of treatment), the formula takes the form: OH \u003d FP + TPP;
• for disintellation: OH \u003d FP + ATS, where ATS is the volume of age daily diurea;
• with OPN and Oligognuria: OK \u003d PD + OP, where PD is actual diuresis for the previous day, OP is the volume of per day;
• with the main degree: ож 2/3 of the FP; II degree: OH \u003d 1/3 FP; III degree: ож \u003d 0.

General rules for compiling an infusion therapy algorithm:

1. Colloidal preparations contain sodium salt and belong to the salt r-frames, so their volume should be taken into account when determining the volume of salt r-mo. In sum, colloid drugs should not exceed 1/3 of the coolant.
2. In young children, the ratio of glucose and salts solutions is 2: 1 or 1: 1, older is changing towards the predominance of saline solutions (1: 1 or 1: 2).
3. All r-rs should be separated on portions, the volume of which usually does not exceed 10-15 ml / kg for glucose and 7-10 ml / kg for salt and colloidal solutions.

The choice of starting solution is determined by the diagnosis of violations of WEO, volienia and the tasks of the initial stage of infusion therapy. So, when the shock is needed in the first 2 hours, the preparations of volulic action are mainly introduced, with a hyper of sidersia - glucose pls, etc.

Some principles of infusion therapy

With infusion therapy for dehydration, 4 stages are distinguished:

1. anti-deposit measures (1 -3 h);
2. reimbursement of DVO (4-24 hours, with severe dehydration to 2-3 days);
3. maintaining WEO in the conditions of continuing pathological loss of fluid (2-4 days or more);
4. PP (full or partial) or enteral healing nutrition.

Anhydremmic shock occurs with the fast (hours-day) development of the dehydration of II-III degree. Upon shock, the indicators of central hemodynamics must be reduced in 2-4 hours by introducing a fluid in a volume of approximately equal to 3-5% MT. In the first minutes, the pls can be introduced insert or quickly drip, however, the average speed should not exceed 15 ml / (kg * h). In case of decentralization of blood circulation, infusion begins with the introduction of sodium bicarbonate p-mards. It is then introduced 5% of albumin or plasma substitutes (REOPOLIGLUKIN, HYDROXYTILCHARMAL), then or in parallel with it salt r-ry. In the absence of significant microcirculation disorders, a balanced saline solution can be used instead of albumin. Considering the presence of a mandatory hypo of osmolal syndrome during anhydremic shock, the introduction into infusion therapy of non-electrical ps (glucose solutions) is possible only after restoring satisfactory indicators of central hemodynamics!

The duration of the 2nd stage is usually 4-24 hours (depending on the type of dehydration and adaptive capabilities of the child's body). Intravenously and (or) inwards are injected (coolant \u003d two + TPP) at a speed of 4-6ml / (kg h). In case of dehydration degration, it is preferable to introduce the entire fluid inside.

In hypertensive dehydration, 5% of Glucose and hypotonic solutions NaCl (0.45%) are introduced in a ratio of 1: 1. With other types of dehydration (isotonic, hypotonic), 10% of glucose ppl and physiological concentration of NaCl (0.9%) are used in balanced salt solutions in the same ratios. For the reduction of diuresis, potassium chloride hydroe is used: 2-mmol / (kgf), as well as calcium and magnesium: 0.2-0.5 mmol / (kgf). Salt solutions 2 of the last ions is better to introduce intravenously droplets but without mixing in one bottle.

Attention! Potassium ions deficiency is eliminated slowly (within a few days, sometimes weeks). Potassium ions are added to glucose solutions and are introduced into a vein at a concentration of 40 mmol / l (4 ml of 7.5% P-Ra KCl per 100 ml of glucose). It is forbidden quickly, and even more so the inkjet introduction of Pokali in Vienna!

This stage is completed by an increase of MT child, which is no more than 5-7% compared with the initial (before treatment).

The 3rd stage continues more than 1 day and depends on the conservation or continuation of pathological water losses (with a chair, vomiting masses, etc.). Formula for calculation: OH \u003d FP + TPP. During this period, MT child should stabilize and increase no more than 20 g / days. Lolzhna infusion therapy is evenly carried out during the day. Infusion rate usually does not exceed 3-5 ml / (kg h).

Disinfection using infusion therapy is carried out only with the saved renal function and provides:

1. breeding the concentration of blood toxins and EDCS;
2. increase the speed of glomerular filtration and diuresis;
3. improving blood circulation in the reticullendothelial system (RES), including the liver.

Hemodiilution (breeding) is provided by the use of colloidal and salt solutions in a normal or moderate hyper of voluble hemodilution (NK 0.30 l / l, BCC\u003e 10% norm).

Diuresis in a child in conditions of postoperative, infectious, traumatic or other stress should not be less than the age norm. When stimulating uricating diuretics and injection of liquid, diuresis may increase by 2 times (more - rarely), it is possible to strengthen disorders in the ionogram. Mt a child should not change (which is especially important in children with the defeat of the central nervous system, the ditigation system). The rate of infusion is on average 10ml / kg * h), but may be greater when mining small volumes in a short time.

In case of insufficient disinfection using infusion therapy, it is necessary to increasing the volume of liquid and diuretic tools, but to include methods of efferent detoxification, vitro purification of blood in a complex of treatment.

Treatment of hypershydration is carried out taking into account its degrees: I - an increase in MT to 5%, II - in the range of 5-10% and III - more than 10%. The following methods are applied:

• restriction (non-cancellation) of water and salt;
• restoration of the BCC (albumin, plasma substitutes);
• application of diuretics (mannitol, lazis);
• conducting hemodialysis, hemodialyfiltration, ultrafiltration or low-threshing ultrafiltration, peritoneal dialysis with OPN.

In hypotonic hyperhydration, the preliminary introduction of small volumes of concentrated solutions (20-40%) of glucose, chloride or sodium bicarbonate, as well as albumin (in the presence of hypoprotemia) can be useful. It is better to use osmotic diuretics. In the presence of OPON, emergency dialysis is shown.

With hypertensive hyperhydration, diuretic drugs (Laziks) are effective against the background of cautious intravenous administration of 5% ral glucose.

With isotonic hypershydration, a liquid restriction and table salt are prescribed, the diuresis is stimulated with a diurea with Lazix.

In the course of infusion therapy necessary:

1. Continuously evaluating its effectiveness to change the state of central hemodynamics (pulse) and microcirculation (skin color, nails, lips), kidney functions (diuresis), respiratory system (CH) and CNS (consciousness, behavior), as well as a change in clinical signs of dehydration or hyperhydration .
2. The instrumental and laboratory monitoring of the patient's functional state is required:

• hourly measured heart rate, CH, diuresis, losing volumes with vomiting, diarrhea, shortness of breath, etc., according to the testimony - blood pressure;
• 3-4 times (sometimes more often) during the day the temperature of the body, blood pressure, CVD is recorded;
• prior to the start of infusion therapy, after its initial stage and then the NaCl indicators, the content of the total protein, urea, calcium, glucose, osmolarity, ionogram, the parameters of the CBC and WEO, the level of Protrombina, the blood coagulation time (VSK), the relative density of urine (OPM ).

1. The amount of infusion and its algorithm is subject to mandatory correction, depending on the results of infusion therapy. With the deterioration of the condition of the patient, infusion therapy is terminated.
2. With the correction of significant WEO shifts, the sodium level in the blood plasma should not increase or decrease faster than 1 mmol / ls) (20 mmol / l per day), and the osmolarity indicator is 1 moss / ls) (20 mos / l in day).
3. In the treatment of dehydration or hypershydration, the mass of the child's body should not be changed more than 5% of the initial one.

In the container for drip administration, it should not be simultaneously placed more than% of the coolant.

When carrying out infusion therapy, errors are possible: tactical (incorrect calculation of coolant, OI and the definition of component parts of IT; incorrectly compiled program of infusion therapy; errors in determining the IT speed, in measuring the parameters of the Hell, FVD, etc Conducting IT or its absence) or technical (incorrect access choice; the use of substandard drugs; care defects for transfusion systems; improper mixing of r-martes).

Infusion therapy in anesthesiology and resuscitation it is an integral part of the treatment of patients in critical states. Enjoy the greatest popularity international Recommendations UK (British Consensus Guidelines on Intravenous Fluid Therapy for Adult. Surgical Patients. 2011) and Germany (INTRAVASCULAR VOLUME THERAPY IN ADULTS. GUIDELINES FROM THE ASSOCIATION OF THE SCIENTFIC MEDICAL SOCIETIES IN GERMANY. 2016).

INTUZIONIC Therapy in Resuscitation It is conditionally divided into preoperative and postoperative. For example, for the purpose of preoperative preparation Patient conduct infusion therapy in resuscitation for hypovolemia correction, electrolyte imbalance and heart rate disorders Before an emergency operation for acute intestinal obstruction (assigned). In this case, the goals and tasks of treatment are extremely clear. Wherein, the duration of intensive infusion therapy in resuscitation should not be more than 1 hour. Calculation of infusion therapy in intensive care in the postoperative period.

In anesthesiology infusion therapy depends Based on knowledge. The purpose of infusion therapy is both the restoration of the vascular volume (the normalization of cardiac output) and the liquid balance in general.

Infusion therapy in surgery basically applied in the postoperative period : parenteral nutrition, correction of protein-electrolyte disorders, etc. In the department of surgery, infusion-transfusion therapy therapy should be carried out under the control of anesthesiologist-resuscitator ().

Classification of preparations used in anesthesiology-resuscitation (and, and)

Disorders of the water and electrolyte balance

In anesthesiology resuscitation water-electrolyte balance It is essential for perioperative patient management - it depends on it reasonable selection of drugs for infusion therapy . In maintaining normopesia, the regulation of the water balance, the main role belongs to antidiuretic hormone (ADG) and the renin-angiotensin-aldosterone system, which always react to hypovolemia or hypervolemia on the principle of feedback.

Types of violations

The main impairment of water and electrolyte balance includes hypovolemia and hypervolemia, hypokalemia and hypercalemia, hyponatremia and hypernatremia.

Hypovolemia

Hypovolemia - inconsistency of the volume of circulating blood and the capacity of the vascular bed. Central venous pressure (CVD) decreases less than 60 mm water. Art. Or becomes negative. Hypovolemia develops as a result of abnormal losses of fluid (bleeding, vomiting, diarrhea, etc.), and as a result of endogenous intoxication syndrome, anaphylactual reactions, etc. Different pathogenesis of hypovolemia can lead to different types of disorders of the acid-base, osmolar or electrolyte balance. Compensatory mechanisms for hypovolemia include an increase in the stimulation of the sympathetic nervous system (tachycardia and an increase in peripheral vascular resistance), thirst, ADG and Aldosterone emissions.
Perioperative replenishment of hypovolemia Improves the outcomes of operational treatment, but also overloading volume, sodium and chloride is considered to be the leading cause of increasing mortality and elongation of hospitalization terms. Thus, apparently, it should be paid particular attention to the danger of the uncontrolled intravenous introduction of large volumes of fluid and to recommend the minimum sufficient replenishment of the scope of volume, i.e. guided by the principles of restrained tactics Infusion therapy.
Hypovolemia enhances the action of common anesthetics , as well as drugs causing the release of histamine (morphine, atraurium) and potentiate the sympatholic effects of regional anesthesia (epidural, spinal).

Hypervolemia

Hypervolemia - increasing the volume of extracellular fluid. It is observed with excessive (yatrogenic) infusion therapy and renal failure. Central venous pressure more than 120 mm waters. Art . Hypervolemia can lead to a lung edema , especially in patients with chronic cardiac pathology and acute damage syndrome. The compensatory mechanisms of hypervolemia include NT Pro-BNP emissions, leading to an increase in filtering and excretion of sodium kidneys, as well as reduced emission of aldosterone and ADG. Hypervolemia must be eliminated before surgery (diuretic therapy, ultrafiltration) or, if possible, postpone operational intervention, because There is a high risk of cardiovascular and respiratory complications.

Hypokalemia

Hypokalemia - a condition in which the level of potassium concentration is reduced below 3.5 mmol / l ( the norm to + 3.5-5.0 mmol / l). It occurs with significant potassium losses: vomiting, diarrhea, intestinal obstruction, yatrogenic use of diuretics, adrenal crisis, etc. or insufficient flow of potassium into the body. With a decrease in K + in the plasma of blood from 4 mmol / l to 3 mmol / l, the total potassium deficiency in the body is 100-200 mmol / l. True hypokalemia and hypokalemia, associated with the redistribution of K + ions between the water sectors, should be distinguished.
While the concentration of potassium will not decrease less than 3 mmol / l Cyboralmia in most cases proceeds asymptomatic. Clinical manifestations of hypokalemia occur with a decrease in the level K + to less than 3 mmol / l. The most frequent manifestations: muscle weakness, dynamic intestinal obstruction, metabolic alkalosis, violations from the cardiovascular system (arrhythmia, unstable hemodynamics). ECG signs of hypokalemia : The horizontal decrease in the RS-T segment below is a decrease in the amplitude of the teeth T or the formation of a two-phase or negative teeth. In addition, the decrease in the potassium concentration in the cell is accompanied by an increase in the teeth u, which becomes clearly visible to the ECG. There is also an elongation of electric ventricular electrical systole, the Q-T interval.
It is believed that the planned operation is recommended at concentration to + not lower than 3-3.5 mmol / l It should take into account the speed of the development of hypokalemia. Moderately pronounced hypokalemia without the characteristic changes to the ECG significantly does not increase the risk of developing anesthetic complications. The treatment consists in finding out the causes of the disease and replenishing the level K + (0.2 MEQ / kg / h in / c). No need to correct chronic hypokalemiaif the level K + is more than 2.5 MEKV / L in front of the introductory anesthesia, because Fast correction can create more problems than existing hypokalemia. During the operation, it is necessary to constantly monitor the level K +, and, if necessary, to replenish its loss (0.5-1.0 MEQ in / in to the normalization of the content). Indication to intraoperative infusion to + It is the emergence of atrial and ventricular arrhythmias. Hypokalemia should be expected with long and traumatic surgical interventions.

Hypercalemia

Hypercalemia - a condition in which potassium concentration is above 5.5 mmol / l. The causes of the occurrence include the movement of K + from cells into the extracellular space, a decrease in renal filtration, acidosis, ischemia, massive hemolysis, potassium yathedral infusion. Clinical symptoms: muscle weakness, paresthesia, heart excitability disorders, which become especially disturbing when the level is exceeded to + more than 7 mmol / l. ECG Signs: High, narrow, pointed positive teeth and gradual shortening of electric ventricular electrical systole - Q-T interval. In addition, hypercalemia is often accompanied by a slowdown in atrioventricular and intraventricular conductivity and a tendency to sinus bradycardia.
Treatment of hypercalemia Depends on the level K + in the blood plasma and on the type of ECG disorders. As a rule, calcium gluconate (10 ml-10%) or calcium chloride (5 ml-10%) partially eliminate the cardiotoxic effects of hypercalemia. It is possible to re-introduce in 5-7 minutes if the ECG changes are preserved. In case of metabolic acidosis, the introduction of sodium bicarbonate causes the movement of potassium into the cells, thus, can be administered to NaHCO 3 to 50 MEQ every 10-15 minutes before the ECG normalization. It should be remembered that hyperventilation causes moving to + into extracellular space. Glucose with insulin contribute to moving to + to intracellular space. 18 ml of 40% glucose solution of glucose every 5-7 min are introduced. Hypercalemia more than 7 mmol / l is an indication for holding in extracorporeal dialysis.
When hypercalemia, planned operations it is recommended to postpone Prior to normalization of concentration K +. The administration of succinylcholine and solutions of ions containing K + (Ringer's solution, KMA), and IVL conducted under conditions of moderate hyperventilation.

Hyponatremia

Hyponatremia - A condition in which the level of sodium concentration is reduced below 135 mmol / l. This causes a hypoosmotic state, which leads to an outflow of fluid from extracellular space into the cellular. If an increase in the concentration of substances capable of substantially affect plasma osmolarity (glucose, urea, alcohol, mannitol, etc.), the growth of osmolarity is noted in spite of the low concentration of Na +.
Sodium deficiency is usually manifested by hypovolemia. The clinical picture of hyponatremia is a progressive headache, a violation of the level of consciousness and is often a neurological deficit. Hyponatremia causes instability of cells, deterioration of cardiac activity, the appearance of arrhythmias. A rapid decrease in sodium concentration is below 120 mmol / l leads to the phenomena of edema of the brain.

:

• in hypovolemia arising from the loss of sodium (in vomiting, strong sweating, diarrhea) or diuretics overdose, it is necessary to restore the volting status due to the transfusion of isotonic solutions of crystalloids;
• under normal rule (It is found in the diseases of the kidneys, with pathological disorders of osorlagulation). It is possible to achieve success with the help of a slow infusion of a hypertensive solution of sodium chloride;
• with hypervolemia arising due to CNS diseases, heart failure, nephrotic syndrome, it is necessary to use hemodialysis.

Most of the symptoms of hyponatremia disappears after reaching the Na concentration of more than 125-130 mmol / l, so before total anesthesia should not be fully normalized by sodium levels. With transuretral resection of the prostate gland during the washing of the bladder, some of the infusion water is absorbed, which can lead to severe complication (tour syndrome).

Hypernamentia

Hypernamentia - a condition in which the level of sodium concentration increases more than 145 mmol / l . This leads to plasma hyperosmolarness and fluid outflow from intracellular space in extracellular. Clinical manifestations: weakness, apathy, disturbances of consciousness. Hypernamentia, in contrast to hyponatremia, more often flows with phenomena of brain damage and neurological symptoms. With cell dehydration may be a central veins thrombosis. In chronic heart failure and cirrhosis, hypernatremia leads to edema.

Treatment depends on the true voltage status of the patient:

• patients with hypovolemia . This state occurs due to abundant water loss (diarrhea, vomiting, uncontrolled application of osmotic diuretics or inadequate replenishing disorders). In case of impairment of hemodynamics or visible microcirculation disorders, infusion therapy begins with 0.9% sodium chloride. After replenishing the vascular volume, the further correction is carried out with 5% glucose solution;
• patients with normsolemia . This state occurs primarily with diabetes mellitus. Treatment is the therapy of diabetes and replenishing water deficiency with 5% glucose solution;
• patients with hypervolemia . This state may occur due to the overload of sodium as a result of an adrenal crisis, hemodialysis, with a hypertonic solution or an infusion of a hypertensive solution and large sodium bicarbonate. Excess sodium can be removed using dialysis or diuretic therapy with subsequent reimbursement of water loss of 5% r-rum glucose. Water deficit must be fill out gradually to avoid the development of brain edema.

Infusion therapy in the intraoperative period

When performing surgical interventions in anesthesia, it is an integral part of infusion therapy. It should be remembered that on the eve of the planned operation of the patient abstained from intake of food and fluid, while in the first hours a person loses the water about 3 ml / kg / hour.

ASA recommendations on preoperative starvation

Thus, with a six-hour anhydrous period, the patient's fluid deficiency is 18 ml / kg . In addition, many patients do nothing across, starting in the evening before the operation, i.e. more than 10-12 hours before the start of anesthesia . This is especially important for patients with chronic cardiovascular pathology for which moderate preoperative hypovolemia can cause hypotension during introducing anesthesia. Therefore, in the preoperative period, it is necessary to evaluate the dramatics status of the patient, and begin anesthesia only with stable hemodynamic parameters.

Calculation of infusion therapy during anesthesia

In the intraoperative period occur additional fluid losses associated with evaporation from the surface of the internal organs. As a result of the operating injury, the tissue edema and the delay of the extracellular fluid occurs, while the renin angiotensin-aldosterone system is triggered and an increase in ADG generation occurs, thereby maintaining the autoregument of the aqueous-electrolyte balance.

Calculation of infusion therapy during anesthesia depends on the volume of operation because Different amount of liquid is lost: for small operations on the body surface (for example, lipoma removal) 1-2 ml / kg / hour, with mean (for example, hangeal) 5-10 ml / kg / hour, at large (for example, pancreatododenal resection) 10-15 ml / kg / hour. Speed \u200b\u200bof infusion therapy It depends on the volume of circulating blood, which is estimated on the basis of blood pressure and heart rate, central venous pressure (according to indications) and diurea.

Infusion-transfusion therapy during surgery

Tasks of intraoperative infusion transfusion therapy:

• maintenance of adequate circulating blood volume;
• maintaining the effective level of oxygen transport;
• maintaining the optimal colloid-osmotic blood pressure;
• correction of the acid-base state of blood.

With operations that are not related to significant blood loss, the main problem of infusion therapy is the compensation of intraoperative losses of the liquid and the correction of acid-alkaline equilibrium. The average rate of infusion, during operations of this type, should be 5-8 ml / kg / hour.

Indications for transfusion therapy

Transfusion of blood components is shown if the formation is reduced, the destruction is accelerated, the function is broken or there is a loss of specific blood components (erythrocytes, platelets or blood coagulation factors).

Anemia

1. Hematokritis. The main indication for transfusion of red blood cells is the desire to maintain an effective level of oxygen transport to tissues. Healthy people or patients with chronic anemia, as a rule, easily carry the reduction of HT to 20-25% with a normal amount of circulating fluid. It is considered mandatory to maintain a higher level of HT in patients with coronary insufficiency or occlusive diseases of peripheral vessels, although the effectiveness of this situation is proved by Nichemene.

1. In the event of anemia in the intraoperative period, it is necessary to find out its etiology; It may be a consequence of insufficient formation (iron deficiency anemia), blood loss or accelerated destruction (hemolysis).

1. The only indication to the hemotransphus is anemia.

• Typically, blood loss is based on the number of napkins used, the amount of blood in the jar for suction, etc.

Thrombocytopenia

Spontaneous bleeding can be expected with a decrease in the number of platelets less than 20,000, but no less than 50,000 platelets are desirable for the intraoperative period. Thrombocytopenia may also be a consequence of decreasing formation (chemotherapy, tumor, alcoholism) or increased destruction (thrombocytopenic purpura, hyperplaneism, therapy with specific drugs (heparin, H2-blockers) platelets. It may occur again due to the development of syndromemassive hemotransfuses.

Coagulopathy

The diagnosis of coagulopathic bleeding should be based on the results of the study of the blood coagulation system: bleeding time (norm 5-7 min); Activated coagulation time (norm 90-130 seconds).

Principles of infusion and transfusion therapy

Principles of infusion therapy Based on the understanding of the physiology of the water-electrolytic balance and an objective assessment of the voltage status. Described in detail.

Basic principles of infusional transfusion therapy:

Infusion therapy is carried out under the control of the CVD (the norm is 10-12 mm Hg. Art.);
Temp, the volume and qualitative composition of infusion therapy varies depending on the operation phase;
Blood or erythrocytic mass is transfused depending on the level of hemoglobin and hematocrit, and not the magnitude of blood loss. At the final stage, hemoglobin operation should not be below 90-100 g / l;
The ratio of colloidal and crystalloid solutions is maintained at 1: 3; 1: 4;
When blood loss, over 1000 ml, the use of quick blood return devices are shown (for example, the SELLSAVER device).

Infusion therapy in the postoperative period

The daily need of an adult in a liquid is approximately 2000-3000 ml (1.5 l / m 2), of which, in norm, 1500-1700 ml, a person gets orally, 700-800 ml with eaten food and 150-250 ml of endogenous water is formed in The result of carbohydrate oxidation. Daytime losses are: 1300-1500 ml with urine (0.7 ml / kg / hour), 100-200 ml with a feet, 300-500 ml with breathing, 500-700 ml evaporates from the body surface. Water loss increases with fever (approximately 500 ml / hail / day), as well as with hyperglycemia, diuretic therapy, adrenal disease (feochromocytoma, aldosteroma).

Calculation of infusion therapy in the postoperative period

How to calculate the amount of infusion therapy in the postoperative period? If the patient can not drink fluid, and the installation of the nasogastric probe is not shown, then physiological needs are replenished by infusion therapy, volume which depends on weight patient. Calculation of infusion therapy In the postoperative period is made by the formula: 30-40 ml / kg / day. For example, a patient weighing 80 kg the volume of infusion therapy There must be about 3000 ml per day (35 x 80 \u003d 2800 ml).

In the postoperative period, the correction of the water and electrolyte balance is paid to a special meaning. If the initial deficiency of the fluid was not compensated during the operation, then it is necessary to continue infusion therapy or oral fluid intake in the following hours. To maintain water-electrolyte equilibrium, Introduction is necessary: \u200b\u200bsodium 1-1.5 mmol / kg / kg /, potassium 1 mmol / kg, calcium, magnesium and phosphate 0.1-0.2 mmol / kg. It is necessary to take into account and pathological losses associated with the peculiarities of surgical tactics, such as gastric or thick-body discharged by pronom, fistula, drainage, and others. At the same time, the volume of infusion therapymust be summed with the daily need of a patient in liquid (30-40 ml / kg / day). Insufficient infusion therapy leads to stimulation of Osoricceptors and baroreceptors, which stimulate ADG, which leads to the appearance of a feeling of thirst in patients. It is impossible to use an isotonic solution of NaCl in order to replenish the volume in the peripheral period.

Solutions for infusion therapy

Infusion therapy solutions are divided into crystaloids and colloidal .
Crystaloid solutions - These are aqueous solutions of sodium and chlorine ions or glucose. Most of them are isotonic plasma. The following balanced crystalloid solutions are available in Russia: Steroff (B | Braun, Germany); Ionosteril (Fresenius, Germany) and Plasmalit 148 (Baxter, USA). Thus, Ringer's solutions, Ringer lactate, Hartman, and, moreover, the disol, chille, trisol, etc. balanced solutions are not!

Colloid solutions Call aqueous solutions of large molecules whose weight exceeds 10,000 daltons. These molecules are badly penetrated through the endothelium capillaries, so colloidal solutions increase the oncotic pressure plasma pressure.

Crystaloid solutions

Sodium chloride solutions

Sodium chloride (NaCl 0.9%)

Indications. Disorders of the electrolyte balance, sodium deficiency, dehydration for dissolving various medicinal substances.

Contraindications. Do not pour isotonic prn NaCl with hypernatremia, circulatory disorders that threaten the brain and lungs.

Contraindications. You should not pour an isotonic prn NaCl with hypernatremia, circulatory disorders that threaten the edema of the brain and the lungs, the treatment of GK in large doses.

Side effects. The introduction of a large amount of isotonic solution of sodium chloride can lead to sodium accumulation, edema, hyperchloremic metabolic acidosis, strengthening the elimination of potassium from the body, etc.

Cautions. Violation of kidney function, heart failure, arterial hypertension, peripheral edema, pregnant toxicosis.

Ringer's solution: calcium chloride 330 mg, potassium chloride 300 mg, sodium chloride 8.6 g (sodium 147 mmol / l, potassium 4 mmol / l, calcium 2.25 mmol / l, chlorides 155.6 mmol / l).

Ringer's solution with lactate(Р-Р Hartman): B 1 l R-ra contains sodium chloride 6.02 g, sodium lactate 3.138 g, potassium chloride 373 mg, calcium chloride 294 mg [ionic composition (in mmol): Na + - 131, k + - 5, Ca 2+ - 2, lactate - 28, Cl - - 112].

Ringer Laktat, Hartman Solution (Russia); rr d / inf. (bottles), 200 and 400 ml.

Hartman solution (Hemofarm A.D., Serbia); rr d / inf. (Flac.), 500 ml.

Glucose solutions

5% glucose solution It is used mainly to reimburse the shortage of water and administered it is isolated by patients without significant losses of electrolytes. On average, the daily need for water of a healthy adult is 1.7-2.5 liters. This quantity is necessary to ensure normal urination and replenishing losses through the skin, lungs and gasts. Dehydration (dehydration) occurs when water loss exceeds it into the body, for example, at a coma, dysphagia or in elderly apathetic people who may not drink water in sufficient quantities on their own initiative. Excessive water loss without significant losses of electrolytes are found in clinical practice quite rarely, for example, with fever, hyperthyroidism, hypercalcemia, nonachon diabetes. The volume of a 5% glucose solution required to eliminate the lack of water depends on the severity of violations, but usually within 2-6 liters.

5% glucose solution Also prescribed after the hyperglycemia correction during the treatment of diabetic ketoacidosis against the background of continuing insulin infusion. Hypertensive solutions of glucose (for example, 10-20%) are administered together with insulin and calcium (or sodium hydrocarbonate) for emergency hypercalemia therapy.

Indications. Reimbursement of fluid deficit, as a source of energy.

Contraindications. Sugar diabetes and conditions accompanied by hyperglycemia.

Side effects. Glucose solutions, especially hypertensive, have a low pH and can cause vein irritation and thrombophlebitis.

Doses and application. For reimbursement of fluid deficit; As an energy source apply v / B. 20-50% solution in combination with insulin in the calculated dose.

Glucose (Russia); PR D / IN.: AMP. - 5%, 10%, 25% and 40%, 5, 10 and 20 ml; PR D / INF.: Flak. - 5%, 100, 250 and 500 ml; 10% and 20%, 250 and 500 ml; Flac. for blood substitutes - 5% and 10% 200, 250, 400 and 500 ml; 20% and 40%, 200, 400 and 500 ml; Containers - 5%, 10% and 20%, 100, 250, 500 and 1000 ml; Polyethylene tanks. - 5%, 10%, 20% and 40%, 100, 200, 250, 400 and 500 ml; Bottles - 5%, 10%, 20% and 40%, 100, 200, 250, 400 and 500 ml.

Glucosteril (Fresenius Kabi Deutschland GmbH, Germany); rr d / inf. 20% (Flac.), 250, 500 and 1000 ml.

Colloid solutions

Albumin solutions

Contraindications. Heart failure, human anemia, hypervolemia, pulmonary swelling.

Side effects. Possible nausea, vomiting, raising savory, fever and chills.

Cautions. When indicating a history of cardiovascular disease, drugs should be introduced slowly to avoid rapidly lifting blood pressure, so blood circulation and respiratory monitoring is needed; Need a dehydration correction when applying concentrated solutions.

Isotonic solutions (4-5%) for infusion therapy

Indications. Acute or concurring loss of circulating plasma volume, for example, in burns, pancreatitis, injuries, complications of surgical interventions, etc.; Plasma exchange transfusion.

Concentrated solutions (20-25%) for infusion therapy

Indications. Severe hypoalbuminemia, associated with a decrease in the volume of circulating plasma and generalized edema, when an increase in the volume of circulating plasma is necessary with the simultaneous restriction of water and salts; Additional means for the treatment of hyperbilirubinemia newborns by the method of exchange transfusion.

Solution of albumin plazentar (Russia); PR D / INF.: Stabilized (Flac. for blood substitutes), 5%, 10% and 20%, 50, 100, 200 and 400 ml.

Albumen (Russia); PR D / INF.: AMP, 5%, 10% and 20%, 10 and 20 ml; Flac. for blood substitutes, 5%, 10% and 20%, 50, 100, 200 and 400 ml; bottles, 10%, 20, 50, 100, 200 and 400 ml; 20%, 50 and 100 ml.

Albumin (Russia), albumin Human 20% (Baxter AG, Austria).

Plasmatic solutions

Dexts (glucose polymers), gelatin preparations (gelatinoly et al.) and hydroxyethyleted starch (GEC; Geetadartch, Pentavarch, etc.) - macromolecular compounds that are slowly metabolized in the body; they can be used as preparations of 1 row to increase and maintain the volume of circulating plasma , for example, with a burn and septic shock. They are rarely necessary when shocked caused by losses of salts and water, since in such situations shock amenable to treatment with reimbursement of water and electrolytes. They cannot be used to maintain the volume of circulating plasma during burns or peritonitis, when the loss of plasma proteins, water and electrolytes last for more than several days or weeks. In such situations, plasma should be applied or preparations containing albumin in large quantities. Plasma substitutes can be used when bleeding as a short-term first aid measure until it becomes possible to overflow blood.

Dextran 40.

10% dextran r-p-p with an average relative molecular weight of about 40,000 in a 5% glucose solution or 0.9% NaCl solution.

Indications. States associated with slowing peripheral blood flow; disorders of microcirculation with shock, burns, fat embolism, pancreatitis, peritonitis, etc.; Prevention of postoperative and post-traumatic thromboembolism, thrombosis on grafts, etc.

Contraindications. Hypersensitivity to dextranum, thrombocytopenia, bleeding, kidney disease (with oliginia or Anuria), severe heart failure.

Side effects. Ozchovob, feeling of heat, fever, nausea, skin rash, anaphylactic reactions with a collapse development are possible. It can provoke bleeding, cause acute renal failure.

Cautions. Renal impairment; Before use, it is necessary to proceed dehydration and introduce a sufficient amount of fluid during treatment; To be very careful to apply with an existing threat of circulatory overload (especially in heart failure) and the development of pulmonary edema; Pregnant women are prescribed only on life indications. Dexts are capable of enveloping the surface of the erythrocytes, which may interfere with the definition of blood type, so it is necessary to use washed red blood cells.

Doses and application. As v / B. inf. First, 500-1000 ml, further treatment is carried out depending on the state of the patient.

Reopolyiglyukin (Russia); rr d / inf. (in P-re NaCl 0.9%), 100 mg / ml: Flak. for blood substitutes, 100, 200 and 400 ml; Polyethylene tanks, 250 and 500 ml; Bottles, 200 and 400 ml.

Dextran 70 (Dextran, Average Molecular Weight 50 000-70 000)

6% of the dextran R-p-p-p-p-p-r-5% r-re glucose or 0.9% P-re NaCl (for v / B. infusions).

Indications. To rapidly increase the volume of circulating plasma, prevention of postoperative thromboembolic complications.

Contraindications. Hypersensitivity to dextranum, severe heart and renal failure, cranial and brain injury, intracranial hypertension, hemorrhagic stroke, bleeding associated with thrombocytopenia and hypophybrinogenemia.

Side effects. Mostly allergic reactions (urticaria, etc.), severe anaphylactic reactions are rare.

Doses and application. After moderate or pronounced blood loss or in the shock stage of the burn disease (the first 48 h) by v / B. inf. 500-1000 ml are quickly introduced, then with another 500 ml, if necessary; The total dose of £ 20 ml / kg in the first 24 hours.

Neontex. (Russia); rr d / inf. 6% (Flac. For blood substitutes), 400 ml.

Polyglyukin (Russia); rr d / inf. 6% (Flac. For blood substitutes and bottles), 100, 200 and 400 ml.

Polyglusol:dextran (50 000-70 000 Dalton): 60 g, potassium chloride 0.37 g, calcium chloride hexahydrate 0.55 g, magnesium chloride hexahydrate 0.3 g - 1 liter.

Polyglusol (Russia); rr d / inf. (Flac. For blood substitutes), 100, 200 and 400 ml.

Preparations of hydroxyethylined starch(GEK)

GEK is a high molecular weight compound consisting of polymerized glucose residues. It is prepared by hydroxyethylilation of amylopectin (natural polysaccharide contained in the starch of potatoes and corn), which quickly (for 20 minutes) is hydrolyzed in the blood. Therefore, to increase the stability of starch and an increase in the duration of its action, amylopectin is subjected to hydroxyethylation (the depth of this process is characterized by the degree of substitution). The severity and duration of the volume of the GEC preparations are determined by the molecular weight and the degree of substitution of the GEK substance. For example, GEK preparations with a Sumum about 200,000 and the degree of substitution 0.5 refer to the Pentavarch group, and GEC preparations with high specified indicators (respectively 450 000-480,000 and 0.6-0.8) - to the Geetadarch group.

Indications. Prevention and therapy of hypovolemia and shock of various genesis (hemorrhagic, traumatic, burn, septic, etc.), iso-organic hemodilution, therapeutic hemodilution, etc.

Contraindications, Side Effects, Caution. With caution in severe chronic liver diseases, contraindicated with hypersensitivity to GEC, intracranial bleeding, hyperhydration or severe dehydration; With prolonged use, it is difficult to treat skin itching, sometimes pain in the field of kidneys and others occurs.

In 2012, experts of the European Intensivist Association decided: synthetic colloids based on hydroxyethyl starch (GEK) and gelatin should not be applied in everyday medical practice. In 2013, the Risk Assessment Committee for Drug Security, the European Medicine Agency (PRAC EMA) issued that the use of hydroxyethyl starch solutions in comparison with crystalloids is associated with a higher risk of damage to kidney, requiring dialysis, as well as with a risk of fatal increase Exodues.

A domestic document (Russia) (Russia) appeared quickly: a letter to the Federal Health Supervision Service of July 10, 2013 N 16I-746/13 "On the new data of hydroxyethyl starch drugs". The letter provides an updated instruction in Berlin-Hemi AG on the drugs produced.

The document says that in critical states:

The HEK solution of physicians can only be used if there is not enough use of crystalloid solutions for treatment. After the initial normalization of the plasma volume, the resumption of GEC is allowed only with the re-appearance of hypovolemia. A doctor who is engaged in the treatment of the patient should decide on the use of GEK, only thoroughly weighing everything for and against the use of this medicine.

The GEK can be used in treatment, provided that hypovolemia has been pre-confirmed in a patient's positive test methods for fluid load (for example, passive lifting of legs and other types of liquid load). After that, the smallest possible dose is appointed.

GEC infusion solutions are not recommended:

In renal failure in a patient (if there is an aburiety or creatinine in plasma, more than 2 mg / dL (more than 177 μmol / l) or in patients who are on renal renal therapy);

In patients with sepsis;

In patients with severe disruption of the liver function.

In a letter, in contrast to European recommendations, colloid solutions based on modified gelatin (geofusin) are not mentioned. Therefore, today there is one "right" colloid - albumin, which doctors can assign a patient without risk to have comments from advanced experts. It is worth noting that Albumin has one very serious and unrelated disadvantage - it is always lacking.

A natural question arises: if there is no albumin, is it worth using synthetic colloids. Given the above information, many doctors when conducting infusion therapy in all cases began to apply alone saline solutions. Moreover, in relation to the realities of domestic medicine, in the overwhelming majority of cases, this means that the treatment is carried out by one 0.9% sodium solution of chloride.

Parts of specialists This approach is not optimal. According to them, it is impossible to oppose colloids and crystaloids among themselves. In many clinical situations, their sharing provides better long-term hemodynamic stability and acceptable security parameters. According to these specialists, it seems unlikely that the use of solutions of modern synthetic colloids (GEK 130/04 or modified liquid gelatin) in low daily doses (10-15 ml per 1 kg of human body per day) may worsen the results of therapy.

It is worth considering such a moment: at the same time, when carrying out infusion therapy, it is worth fully from the appointment of plasma-substituting solutions based on GEK 450 / 0.7, GEC 200/05, polyhydric alcohols, not modified gelatin.

What should be considered when appointing intravenous infusion therapy

In patients in the perioperative and postoperative periods, insufficient infusion therapy causes a reduction in cardiac output, reduces the delivery of oxygen to damaged tissues and, as a result, causes an increase in complications after the operation.

An excessive amount of fluid in the body can also lead to various complications - a violation of coagulation, the development of acidosis, lungs. Maintaining the optimal voluble status is the most complex task. If the patient is not able to take the liquid alone, or absorb enterally, use its intravenous administration. For more information with these questions, it is better to take advantage of modern recommendations that allow you to standardize and optimize this process.

In patients who suffered heavy damage to the tissues and organs, whether it is surgical intervention, sepsis, injury, pancreatitis or peritonitis, dramatically reduces the ability to maintain optimal voliable and osmolarity. In response to the initial hypovolemia (redistribution of fluid, blood loss, vomiting, etc.), standard physiological reactions are developing: an increase in the level of catecholamines, vasopressin, an activation of the renin angiotensin-aldosterone system. Which naturally leads to oliguria, water and sodium delay. The development of the system inflammatory response is also promoted.

Suppose, by conducting infusion therapy, hypovolemia has been eliminated. But the stress reaction due to the disease is preserved. And if we carry out infusion therapy at the same speed, the reinforced water and sodium delay will occur, there will be no adequate diurea even with significant hypervolemia and.

It is worth noting that Oliguria in the postoperative period does not always indicate the presence of hypovolemia in the patient. Renal damage, which is often developing in critical states, can aggravate this process. Hydhiothithmation, hypovolemia quickly goes into hyperfedration, in some cases in hypervolemia with all accompanying complications - the deterioration of gas exchange, hypertension, edema of the lungs and tissues. The tissue edema is aggravated by the capillary leakage of albumin into the intercellular space (18 ml per each albumin gram).

This phenomenon is particularly pronounced in sepsis, when the destruction of the endothelium due to the systemic inflammatory response is generalized. Increased intraperous pressure due to peritonene edema during peritonitis and pancreatitis can lead to the development of the compartments. All patients are different, and the severity of these disorders is very disturbed.

At this time, most doctors adheres to the opinion that hyperifolding should be avoided, and a moderate negative water balance in the early postoperative period after severe surgical interventions is accompanied by less mortality. To fulfill these recommendations is very difficult, even having relevant diagnostic capabilities (invasive monitoring).

Attention. In patients with hypovolemia immediately after the primary stabilization of hemodynamics, the infusion rate of 70-100 ml / hour (25-35 ml / kg / day) should be reduced and carry out a comprehensive assessment of the patient's voltage status.

Choose further treatment tactics depending on the result obtained. Invasive methods for monitoring hemodynamics make it possible to more accurately monitor the dramatics status of the patient, but do not replace the data of dynamic observation.

Application of colloidal solutions Provides greater, compared with crystalloids, the hemodynamic stability of the patient in the first 12 hours after the operation. So in cases of severe hypovolemia, it is recommended to combine the introduction of colloid and crystalloid drugs. As already mentioned earlier, albumin solution is the best preparation for these purposes. The combination of infusion is 500 ml of 10% albumin, followed by intravenous administration of furosemide at a dose of 1-2 mg / kg - a very effective technique aimed at mobilizing the tissue fluid, which is often used part of specialists with ORDS, oliguria, intestinal paresis.

If hypovolemia is associated with sepsis and other inflammatory states, as well as in patients with heart failure, use long-term albumin infusion - due to a decrease in infusion, the likelihood of hemodynamic overload and pulmonary edema decreases. And the less the possibility of separation in monitoring and monitoring patients in the postoperative period, the greater the indications for the implementation of this recommendation.

The introduction of significant volumes of sodium solution of chloride 0.9% is often accompanied by the development of hyperchloremia, which in turn causes the narrowing of the kidney vessels and reduces the flushing filtration rate, which further reduces the ability to output sodium and water. And, compared with modern saline, balanced solutions, its use in the postoperative period is accompanied by a large level of mortality. Balanced salt solutions (Ringer-lactate, Hartman, Steroff, etc.) contain less chlorine, and their use is recommended in all cases, with the exception of those where hypovolemia is due to the loss of gastric and intestinal contents (vomiting, gastric strokes). In these cases, the preference is given to 0.9% sodium solution of chloride. The infusion of hypertonic bolus (100-200 ml of 7.5-10%) of the solution did not show its advantages from community patients and is recommended mainly in patients with intracranial hypertension.

The red blood cell or blood is recommended when the hemoglobin level falls below 70 g / l in the peripheral period. But if the patient's hemodynamics remains unstable, there is a risk of bleeding (or continued bleeding), blood transfusion can be shown at higher hemoglobin values \u200b\u200b(less than 100 g / l).

It is advisable to often control and maintain the level of potassium in the blood near the upper boundary of its norm (4.5 mmol / l). The disadvantage of potassium not only causes muscle weakness, increases the likelihood of arrhythmias and a passer of the intestines, but also reduces the ability of the kidney to carry out an excess of sodium. Potassium is often injected with glucose solution (polarizing mixture). But it is rather tribute to tradition than the real necessity. With the same success, potassium chloride can be administered to / in the dispenser, or together with the salt solution.

If there is no hypoglycemia, in the first day after the operation, glucose solutions are better not to use, as they can cause the development of hyperglycemia, hyponatremia and hyposmolyarity. The last two violations also reduce the ability of the kidney to remove urine and contribute to the development of the inadequate secretion of antidiuretic hormone syndrome (Siadh).

Most authors believe that loop diuretics (usually) should be used only in the case of expressed hyperhydration and (or) pulmonary edema. Before appointing diuretic products, the hemodynamics of the patient should be sufficiently stabilized.

Attention! When conducting infusion therapy, an individual approach is required. The recommendations given above and below are just starting points when choosing therapy.

Postoperative need for patients in liquid and electrolytes

The need for water (orally, or enteral, or parenterally - 1.5-2.5 liters (thin - 40 ml / kg / day, normal nutrition - 35 ml / kg per day, increased nutrition and over 60 years - 25 ml / kg / day. This adds perpicious losses - 5-7 ml / kg / day. For each degree above 37 ° C. The daily need of sodium is 50-100 mmol. The daily demand of potassium is 40-80 mmol. Introduction of albumin is recommended when it is reduced in blood concentration less than 25 g / liter, or a total protein less than 50 g / liter.

Criteria for the effectiveness and optimality of infusion therapy:

• lack of thirst, nausea, shortness of breath;
• average hell - 75-95 mm Hg. st;
• cardiac frequency - 80-100 ° C in min;
• FLOLD 6-10 mm Hg. Art. or 80-130 mm of water. st;
• cardiac index - more than 4.5 l / m2;
• pressure pressure of the pulmonary artery - 8.4-12 mm Hg. st;
• at least 60 ml / hour or\u003e 0.5 ml / kg / h;
• total blood protein 55-80 g / l;
• blood urea 4-6 mmol / l;
• blood glucose 4-10 mmol / l;
• albumin level of 35-50 g / l;
• hematocrit 25-45%.

Diagnostic test for hypovolemia

When the diagnosis of hypovolemia causes doubts and the FVD is not increased, you can spend a test with a quick infusion load (intravenously introduced in 10-15 min 200 ml of colloid or crystalloid). The parameters of hemodynamics are determined before, and 15 minutes after, infusion. Increased blood pressure, reducing the frequency of heart abbreviations, improving the filling of capillaries and a slight growth of FVD confirm the presence of hypovolemia in a patient. If necessary, the test can be repeated several times. The lack of further improvement of the parameters of hemodynamics will indicate that the optimal degree of voliable is achieved.

08.05.2011 56691

Dear colleagues, in this article I would like to reflect the basic principles of infusion therapy (IT) at the prehospital stage from the point of view of the anesthesiologist-resuscitator.

We will consider in a compressed form the physiological basics of infusion therapy, the most common infusion media in the practice, readings for IT, conducting IT in some particular cases. I apologize for the possible abundance of some schemes and formulas (I tried to reduce them as much as possible), but, in my deep conviction, it is an understanding of the foundations of IT guarantees its correct conduct.

So, infusion therapy is parenteral liquid therapy, the main goal of which is the restoration and maintenance of the volume and the qualitative composition of the liquid in all aqueous spaces of the body.

Little physiology and physics

Let's start with the physiology of water exchange. It is necessary to clearly represent that all the water of the human body focuses in several sectors, the exchange between which is governed by the laws of osmosis. Below are their simplified scheme.

The total volume of water in humans decreases with age (in the newborn it is 80% of MT). Intracellular liquid - the main part of the protoplasm. Extracellular fluid includes an intravascular sector (it is he who is most important for us in terms of IT) and the interstitial sector. The intercellular sector is also isolated (liquid inside the gastrointestinal custody of the joints, pleural cavity, etc.), but I intentionally did not include it in the scheme to simplify the latter. The daily need for water in an adult averages 2-3 liters (in the absence of its increased consumption by the body, physical work, for example). The liquid is released normally through the kidneys (3/5 from all the output fluid), through the gastrointestinal tract (1/5) and through the skin (also 1/5). The amount of urine isolated by the kidneys depends primarily on the volume of extracellular fluid, which is why diuresis in resuscitation traditionally is considered a peripheral marker.

For us, it is also very important to such a thing as circulating blood volume (BCC)which is:
in men - 70 ml / kg;
In women - 60 ml / kg.

Blood according to vessels (normally, outside the branching) flows laminar flow, and therefore all its laws are applicable to it. In particular, the law of Poiseile is very important for us:

Q - Flow

It follows from the formula that the basic value for the flow has a viscosity of the liquid, the radius of the cross section of the tube and its length. Please note that pressure is just one of the variables of the flow formula. This suggests that the use of alone pressure (Hell, CVD, Dzlk ....) As an indicator that characterizes perfusion, in the root is incorrect.
The dependence of the stream from the diameter and the length of the tube also plays fundamental importance for us. Note that with a decrease in the diameter of the tube 2 times, the flow rate through it is reduced 16 times! An increase in the length of the tube is also negatively reflected at the flow rate through it.
Viscosity also contributes a significant contribution to the flow rate. For blood, the main indicator simplifies its viscosity is hematocrit. In this regard, it should be remembered that the optimal amount of hematocrit in this aspect is 0.30. Also, the viscosity of solutions must be taken into account when choosing between crystalloids and colloids, the latter have a greater viscosity, and, therefore, slowly transfers with other things being equal.

Equipment and vascular access

To date, the main methods of delivering infusion media into the vascular channel are intravenous and intraoste. The transfusion of solutions in the artery, not to mention the subcutaneous administration, represents only historical interest. Diverse manufacturers produced various systems for infusions, peripheral and central venous catheters, needles for intraosny infusions. Consider the main practical aspects of their choice.

Infusion Systems . Here the rule is one thing - the longer the system, the lower the flow through it. It is possible to raise the reservoir with a solution higher above the body level, thereby increasing the pressure and, accordingly, the flow, but the possibility of this maneuver in the SMP car is limited, it should be understood.

Reservoirs for infusion media. Here we return to one sick topic for domestic health care - we continue throughout the use of solutions in glass containers, which not only increases the weight of the capacity and increases the risk of damage, but also increases the likelihood of various types of reactions associated with the patient's injection . Lipid A, which solutions are often contaminated in the process of their preparation. The solutions in plastic bags are lightweight, mobile and very convenient for use in the practice of SMP. With a massive IT, it is possible to overflow from such bags by laying them under the patient's body (of course, while completely filling the system dropper to avoid air embolism).

Catheters . Peripheral catheters are produced different diameters. It is necessary to clearly imagine the planned speed and amount of infusion, and in accordance with this, choose the diameter of the catheter. Remember that the infusion rate is determined by the diameter of the narrow part of the system for C / in the introduction of solutions; As a rule, this part is a catheter. The diameter of the vein and its anatomical affiliation (peripheral or central) no role in the rate of infusion does not play if the permeability of the veins is normal. Moreover, through the central venous catheter, due to its greater length compared with the peripheral, the rate of infusion (with the same diameter of catheters) will be lower. All of the above suggests that the catheterization of the central vein to "increase the rate of infusion" with the possibility of establishing the peripheral catheter of the large diameter looks like a completely unjustified invasive manipulation that can lead to the mass of life-threatening complications.

The color marking of the peripheral catheter reflects its diameter:

Flow speed through catheters of various diameters, ml / min:

Central venous catheters typically have a similar structure; The range of diameters is significantly lower. They can be issued both in themselves and as part of various sets for catheterization of the central veins. The last option is the most convenient.

Inexious infusion needles . Internal access recently is becoming increasingly popular, becoming the method of choice in patients on DHE with the unavailability of peripheral veins. This topic was discussed and on our website. Despite the fact that intraosseous access is quite possible to implement the usual needle with Mandren (a thick spinal needle, for example), is still more convenient to use special devices for this purpose.

Infusion infusion speed also depends on the diameter of the needle used.

To the selection of vascular access in DHE conditions should be approached very carefully. If there is a normal peripheral venous network, it is necessary to limit the installation of peripheral catheters (one or several). The lack of a developed subcutaneous venous network, when access to peripheral veins is either completely absent, or is not sufficient to install a sufficient number of catheters of the required diameter, if there are absolute readings to IT, requires the implementation of intraosnial or central venous access. At the same time, due to the significant number of complications, the catheterization of the central veins in the conditions of the prehospital stage should be avoided in every way. Do not forget about the outer yapper vein!

Infusion media

Preparations used for IT are called infusion media. We will not shy away from the traditional separation of all infusion media on crystaloids and colloids, consider infusion environments precisely on this principle, but separately select the group of blood substitutes with a specific action. Understanding that autogenic colloids do not apply in the practice of SMP, we will consider only synthetic drugs. When discussing certain drugs, we will discuss such a concept as the drain effect - the ability of the drug to attract water into the vascular channel from the interstice due to its higher osmolarity, thereby increasing the intravascular volume.

Crystaloids. This group of infusion environments includes solutions of electrolytes and sugars. The safest drugs, in terms of the development of possible reactions during transfusion and remote consequences. Osmolarity and composition are close to these plasma indicators and extracellular fluid, therefore, crystalloid solutions there is no voluble effect. Some time after the introduction into the vascular channel, the crystalloids are evenly distributed among the intestial and intravascular sectors, while in the intravascular sector it remains about a quarter of the injected volume (see the scheme above). This is necessary to consider when calculating the volume and speed of infusion. This rule does not concern glucose solutions, but we will consider this question later.

Consider some individuals.

Isotonic (0.85-0.9%) NAT-RIA chloride solution (saline) It was the first solution applied to the treatment of blood loss and dehydration.
1 l solution contains: Na + - 154 mmol, C1 - 154 mmol. General OSMO-Larity 308 MOS / L, which is slightly higher plasma osmolarity. pH 5,5-7.0. It is used mainly in the hypovolemic states of the most varied genesis, as a donator sodium and chlorine at sweat of the extracellular fluid. It is a starting solution for most states requiring IT. The solution is well combined with all the blood resources. Use isotonic solution as a universal solution in a hospital can not, since it is not enough free water, there is no potassium; The solution has an acidic reaction and enhances hypokalemia, but this rule can be neglected at the prehospital stage. Contraindicated in suspected hypernatremia and hyperchloremia.

Ringer's solution - isotonic electrolyte solution, 1 l of which contains: Na + - 140 mmol, K + - 4 mmol, Ca2 + - 6 mmol, CL- 150 mmol. Osmolarity 300 mosm / l. This solution is used as a blood substitute from the end of the last century. Ringer's solution and its modifies are widely used and now. This is a physiological substitution solution with low acidic acid properties.
Used in hypovolemia of various genesis, for replacing the loss of extracellular fluid, including blood. Contraindicated in massive burns (potassium!), Suspected hyperchloremia and hypernatremia.

Polyionic solutions (ion supplies, plasmalit, etc..) have an electrolyte composition close to the composition of blood plasma. Optimal for replacing the deficit of extracellular fluid (shock, hypovolemia).

Curigative solutions (disol, chille, azesol, soda, etc.) appointed only after analyzing the ionic composition of plasma and the acid-base state, therefore it should not be used at the prehospital stage.

Glucose solutions it was previously used to replenish the BCC during hypovolemia of various genes. However, from their use in this purpose, in recent years, they completely refused due to the fact that glucose after a short time after the administration, passing all the cycles of their metabolism, turns into free water, which goes into the intracellular sector. Currently, the only indication for the purpose of glucose solutions on DGE is proven hypoglycemia.

Colloids. We will consider only synthetic colloids, for obvious reasons. Colloidal solutions contain in its composition high molecular weight substances with high oncotic pressure, which allows them to attract a liquid from an interstice into a vascular channel (dramatically effect). In my opinion, the use of drugs of this group is most justified with the hypovolemic (traumatic, hemorrhagic) shock of the 2nd and 3rd stages, when it is impossible to refund the required volume of one crystaloids due to their insufficient amount (in contrast to the hospital, where the patient can easily be pouring For an hour of 3-4 liters of crystalloids, not all SMP brigades can boast of such a reserve of solutions). On the contrary, the use of some colloids in the first stage of shock (when the dehydration of the interstitial space) is inappropriate, as they enhance the transition of fluids from the interstice into the vascular channel. In the therapy of this stage, an interstitial volume is reimbursed, therefore the use of crystalloids is most justified.

Consider groups of colloid drugs.

Dexts. First colloids, their analogues began to be applied during the First World War. These are substances consisting of glucose polymers with an average molecular weight of 40,000 (Reopolyglyukin) and 70,000 (polyglyukin) D. The voltage effect of polyglyukin lasts 5-7 hours, Reopolyglyukina - 1-2 hours. Low molecular weight tribes (REOPOLIGLUKIN) have a pronounced disaggregation effect. All dexts are very common on the SIS expanses due to their cheapness, and are still widely used by inertia. They have a number of disadvantages to which, first of all, there is a negative effect on the hemocoagulation system (provoke and enhance fibrinolysis, inactivate the sixth factor). Also, do not forget about the negative effects of these drugs on the kidney parenchyma ("dextran burn"). Dextans in the body are metabolized extremely slowly, accumulating in the reticulous histiocytic system. Allergic reactions (including fatal) are found during the transfusion of dextrans quite often, and the risk of obtaining a fatal allergic reaction to the dextrey is estimated by the researchers as well as the risk to die from acute appendicitis.
Indications:deficiency of intravascular volume (acute hypovolemia). Reopolyglyukin is also used in violations of microcirculation of various genesis.
The maximum daily dose of dextran preparations is 1000 ml.
Preparations:polyglyukin, Reopolyglyukin, Macrodeks, Reomakodex, etc.

Gelatin and its analogues. Found and are widely used. Contain peptides with different molecular weight. The dramatic effect is lower than the dextrans and lasts only a few hours. Previously it was believed that gelatin preparations do not affect the coagulation system, but it turned out that this is not so. Gelatin increases the time of bleeding, impairs the formation of a clock and platelet aggregation. An interesting situation also developed due to the threat of propagation by means of the gelatin of the causative agent of transmissive spongoform encephalopathy (rabies of cows), which is not destroyed by conventional sterilization modes.
The joint use of dextran preparations and gelatin entails the development of hemorrhages, since their negative effect on the rolling system is mutually enhanced.
Indications: Acute hypovolemia.
Gelatin preparations are undesirable to apply in the late periods of pregnancy - when they are used, endothelium lesions, an increase in its permeability, an increase in the ejection of histamine with all the ensuing consequences is noted.
Preparations:genitarian, gemoral, IFG.

Preparations of hydroxyethyl starch (GEC). Relatively new group of colloidal blood substitutes obtained from amylopectin starch (natural polysaccharide). HEK molecule consists of polymerized glucose residues. GEC preparations give a pronounced voluble effect, the duration of which depends on the molecular weight of the drug and the degree of substitution. Geeks are non-toxic, do not have a pronounced negative effect on the coagulation of blood (although their dose for hypocoagulation should be reduced) and severe allergic reactions are extremely rarely caused.
Indications:acute hypovolemia.
GEC adds to drugs: reform, stabizol, haz-steril, wipes, etc.

Blood substitutes with a specific effect. Here I will touch the individual drugs that somehow found their use on DHE.

Osmodiuretics. The main indication for the appointment on DGE - the edema of the brain. Mannitol is usually used - hyperosmolarium-p-p-p-hexatic alcohol mannitol, stimulating diuresis. In the body, it is not metabolized and highlighted by the kidneys.
Contraindicawith decompensulated renal failure, acute heart failure, shock.
One-time dose is 20% solution - 200 - 400 ml. Enter 30-60 min.

Colloids with disintellation effect. Outdated group of drugs based on polyvinylpyrrolidone and polyvinyl alcohol. Typical representatives: hemodez, neogenesis, polydesis. They give a mass of side effects, starting with severe pyrogenic reactions and ending with the defeat of parenchymal organs. Currently, their use is categorically not recommended.

Algorithm of practical infusion therapy on DGE

1. Determine the testimony for infusion. Infusion therapy for DHA, as well as any other medical agent, should be applied only by strict indications. Driving Mildronat grandmothers by their wishes is not included in the SMP tasks.
2. Determine the place of IT (in place, in the process of transportation).
3. Determine the amount of infusion therapy, and its qualitative composition in accordance with the available drugs and their number.
4. Determine the required infusion rate. In one millilitress of the crystalloid mortar, there is an average of 20 drops.
5. In accordance with a certain amount and speed to resolve the issue of vascular access (peripherals, central, one or more). Never limit yourself with one catheter (even a large diameter) in case of shock - there is a risk of losing a vein during transportation.
6. Carry out vascular access (one or more), the closest attention to pay the fixation of the catheter.
7. Start infusion therapy.
8. In the process of infusion, it is clearly represented:

• infusion rate;
• overclival volume;
• the dynamics of the patient's condition

corringing in accordance with all these therapeutic activities.
9. When passing the patient in the hospital to provide information to the doctor who takes the patient, how much, which is what speed is overclit to the patient. Reflect all this information in the call map and the accompanying sheet.

Conducting infusion therapy in separate clinical situations

Hypovolemic (hemorrhagic, traumatic) shock. Infusion therapy is the main means of treatment of hypovolemic shock. All other events (immobilization, anesthesia, specific therapy) are of secondary importance and are carried out only against the background of adequate infusion. A common mistake is the purpose of the anesthetic drugs at shock without the support of hemodynamic infusion, which often leads to a catastrophic collapse of the latter.
For orientation in the volume and speed of infusion in the hypovolemic shock, I simply impresses the scheme of the American College of Surgeons, in which the calculation of the IT volume is made on the basis of the BCC deficiency. In accordance with this scheme, four classes of hypovolemia stand out:

The blood loss is less than 10% of the OCC (less than 500 ml) of treatment does not require, proceeds asymptomatic.

Clinic.The 1st grade - the clinic may be absent or there is orthostatic tachycardia. There is a liquid deficit in the intersecy sector.
2nd class - orthostatic hypotension, anxiety, easy inhibition.
3rd class - arterial hypotension in a horizontal position, oliguria, stunning.
The 4th grade is pronounced hypotension, Anuria, Sportor and Coma.

Always remember that in addition volume bloodstairs, great importance is speed The latter. Lightning blood loss 50% of the BCC is able to lead to the immediate death of the patient due to the development of the "empty heart" syndrome. At the same time, quite a bulk blood loss, stretched over time, is often transported to patients well enough.

The BCC deficiency is approximately calculated according to the table above.

The replenishment of the volume is made by drugs of crystalloids and colloids. When reimbursement of the BCC deficiency with crystaloid drugs, their volume should be 3- 4 times higher than the estimated deficit of the BCC. When using colloids, their volume should be equal to two thirds or the entire deficiency of the BCC. In practice, combined use of preparations of colloids and crystalloids in the ratio of 1: 1, 1: 2, 1: 3 is used.
Approximate scheme of compensation depending on the class of hypovolemia and the BCC deficiency is presented in the table.

Note to the table. It is clear that there is no need for a full-fledged reimbursement of blood loss 3 and 4 classes on DHE in the absence of blood products, however, the task of the SMP personnel is to stabilize the patient in the presence of solutions.

Multiple infusion therapy In recent years, it was among the employees of the disaster medicine services in recent years. And this is understandable, since it was precisely the volume and the rate of compensation have always been problematic issues for the employees of the pre-hospital stage. The essence of low-pass infusion therapy is to use a hypertensive sodium chloride solution, which by sharp increase in plasma osmolar attracts water into the vascular bed, thereby helping time. The use of a hypertensive solution of sodium chloride with hypovolemic shock, both in the experiment and in the clinic, showed its undoubted advantages.
At the same time, heterogeneous colloidal solutions are used (10% dextran-60-70 solution or hydroxiethyl stroke), which increase the oncotic pressure plasma pressure and thereby have a hemodynamic effect. The simultaneous use of a hypertensive solution of sodium chloride and colloids is manifested in a combined effect associated with an increase in plasma osmolarity and oncotic pressure. The purpose of the use of colloids in this combination is the holding of a reimbursed intravascular volume for a long time.
The main effects observed with the introduction of a hypertensive solution of sodium chloride priest:
Quickly increases adi cardiac output;
increases efficient tissue perfusion;
Reduces the risk of delayed polyorgan deficiency.
At the same time, we should not forget about the dangers of the use of saline solutions. The potential hazards of their use should include the development of a hyperosmolar state, a negative inotropic effect (due to fast infusion), strengthening blood loss in the event of non-represented bleeding.
The main difference of this method is the "low-consuming principle", i.e. The total volume of fluid reimbursement of blood loss should be many times less than when using isotonic crystalloid solutions.

Methods of low-pressure infusion:
The total volume of the entered hypertensive solution of sodium chloride should be 4 ml / kg of body weight, i.e. from 100 to 400 ml;
The solution is introduced fractionally bolunno 50 ml with low interruptions (10-20 minutes);
The introduction of the saline solution is combined with 10% dextran-60-70 rattover, or with GEC preparations;
The introduction of solutions is terminated in the normalization of blood pressure, stable hemodynamics and other signs of lack of shock.

Criteria for the effectiveness of infusion therapy with hypovolemic shock:

1. Increase and stabilization of systolic blood pressure at a level above 100 mm Hg. Art.
2. Reduced heart rate lower than 100 UD / min.
3. Restoration of consciousness (sign of adequate brain perfusion).
4. Improving microcirculation (colors and temperature of skin).

In the presence of a patient with a hypovolemic shock of myocardial deficiency (the signs of which may be the appearance of shortness of breath, wet wheezing in the lower parts of the lungs on the background of a massive infusion) requires the joining of inotropic support (dopamine). I especially want to emphasize that the introduction of inotropic and vaparative drugs is produced only after at least partial reimbursement of the BCC.

Dehydration of various origin. Most often have to deal with isotonic dehydration (loss of water and salts in equal amounts) with intestinal infections, indomitable vomiting, diarrhea, fever. As a rule, they do not require rapid high-volume infusion. To reimburse the liquid deficit, usually crystalloid solutions in the initial dose of 10 ml / kg of the body weight of the patient are used. Colloidal preparations in combination with crystaloids are used only under explicit signs of dehydration shock (significant hypotension, tachycardia, disturbances of consciousness).

Anaphylactic shock it requires rapid infusion of crystalloid drugs in combination with the use of adrenaline. Usually overflow 2,500 - 4000 ml of isotonic sodium chloride solution. In combination with the cessation of capillary leak, which causes adrenaline, infusion therapy contributes to the filling of the vascular channel and stabilization of hemodynamics.

Burns. Heavy common burns are accompanied by severe hypovolemia associated with the leakage of fluid from the vessels in the interstics due to a generalized increase in permeability of capillaries, evaporation of water from the burn surface, the redistribution of fluid into the damning area. Inadequate IT is one of the most frequent causes of the mortality of burn patients. Infusion should begin at the pre-hospital stage and continued in the hospital. In the first day, only crystalloid solutions are used for infusion, since due to the increased climbing leakage, the use of colloids leads to their contact in interstics with the subsequent development of significant edema. Caution should be observed with the introduction of polyionic crystalloid solutions containing potassium - its content in the plasma of burn patients is increased, especially in the absence of adequate diuresis, which can quickly lead to hypercalemia. To calculate the volume of infusion during burns, the formula Parkland is considered to be generally recognized:

Vinfusion \u003d 4 x Mt x% burn

where MT is the patient's body mass.
The volume is calculated on the first day, and its half must be transferred for the first six hours. In accordance with this and build a program of infusion at the pre-hospital stage.

Example of calculation: The patient weighing 70 kg, the burn area is 25% of the body surface. Calculation: 4 x 70 x 25 \u003d 7000 ml. Half of this volume is required to fill in 6 hours - 3500 ml. Consequently, in the first hour, the patient needs to be crowned rounded 600 ml.

The anesthesia and other events of the burn patient are carried out only after the start of infusion therapy.

Card and brain injury. In the absence of hypovolemia, the infusion at CMT is limited only by the daily demand of the patient in the fluid. The optimal starting solution for it is an isotonic solution of sodium chloride. Infusion begins slowly, focusing on hemodynamic records and neurological status of the patient. The forced injection of the fluid can lead to the growing brain edema with all the ensuing consequences; At the same time, unstable hemodynamics in a patient with CHMT is no less dangerous in this regard. Systolic blood pressure in the range of 120-150 mm Hg should be maintained. Art., not allowing the aqueous overload and using vasopressor drugs if necessary.

Patients with cardiac pathology it is usually very poorly tolerated the load volume (if they do not have initial hypovolemia). The exception in cardiology requiring active infusion therapy is the myocardial infarction of the right ventricle. In this case, only with the help of infusion you can maintain an adequate cardiac output. In all other cases, the introduction of a fluid to the patient with cardiac pathology should be as limited as possible. All drugs requiring infusion (nitroglycerin, dopamine, etc.) are divorced in a minimal amount of solvent. Infusion therapy with such patients is extremely careful, focusing on the general condition, hemodynamic indicators, auscultative picture in the lungs.

Ketoacidotic and heperosmolar coma with diabetes mellitus. At this time, infusion therapy is limited to infusion of isotonic sodium solution of chloride at a rate of 15-20 ml / min, and the infusion continues in the process of transportation. The total amount of infusion must be 500-1000 ml in adults and 10 ml / kg in children. It is impossible to enter soda, potassium-containing solutions and insulin.

Frequently occurring errors when carrying out infusion therapy

1. Insufficient volume and infusion rate. It is often found when conducting therapy of hypovolemic shock. Leads to ineffectiveness of infusion, further destabilization of hemodynamics and aggravation of polyorgan dysfunction. You should always install such a number of catheters that are necessary for adequate infusion!
2. Excessively active and bulk infusion. Before IT start, you should always assess the condition of the patient's cardiovascular system for the presence of myocardial deficiency. Excessive infusion in children in early age is especially dangerous, which is always better to nourish a little than to pour. Overload of the volume leads to an increase in left-hearted deficiency up to the development of edema of the lungs. Never forget the well-known resuscitation aphorism that infusion therapy has been recessed more people than drowned in La Manne.

Clinical case.Patient M. 47 years old, was in the sea about a severe combined injury. The patient was conducted by IVL. Resortian duty officer, turning attention to low CVD (0 cm of water. Art.) And some hypotension (ad 100/60 mm Hg. Art.), I decided to increase the amount of infusion therapy, despite the fact that the patient's dietary was quite sufficient . The doctor made an infusion 2000 ml of crystalloid solutions in 1 hour, but, having received only a small growth of FLA (2 cm of water. Art.), Overflow the patient with another 2000 ml of crystalloids over the next hour. The patient's condition deteriorated sharply, a picture of acute left-detection deficiency was developed with subsequent swelling of the lungs. The edema of the lungs was stopped, the patient was shot after a day with an IVL, the further course of the disease without particular, with recovery.

The mistake of the doctor was the orientation of one indicator - FVD and ignoring other signs of adequate perfusion fabrics, which led to a completely unreasonable impression of infusion.

1. Refusal of inotropic support in the patient in a patient signs of heart failure in the process of conducting massive infusion therapy also leads to the development of acute left-scale failure.
2. The use of inotrops to at least partial replenishment of the BCC leads to the exacerbation of the centralization of blood circulation, the deterioration of the organ blood flow and the development of polyorgan deficiency. First of all, the liver and kidneys suffer.
3. The purpose of glucose solutions for the purpose of infusion leads to the development of intracellular swelling and the insufficient hemodynamic effect of infusion, since glucose solutions quickly leave the vascular channel.
4. The purpose of colloidal solutions with dehydration syndrome (if no shock) leads to a further exacerbation of the dehydration of the interstitial sector.
5. The appointment of some colloids when filling the BCC with hypovolemic shock also leads to dehydration of interstitial space.

In conclusion, I would like to emphasize that infusion therapy is a powerful weapon in the hands of a specialist in its competent and timely use and often determines the further outcome of the disease. Therefore, the refusal of it in the pre-hospital stage in cases where it is necessary, looks completely unjustified and criminal. Never try to drip "on the eye", it is fraught with both insufficient and excess infusion. Always evaluate and analyze the patient's condition in the process of infusion therapy.

Shvets A.A. (Graph)

Critical conditions of the body can be due to a disadvantage of fluid and in the body. At the same time, the work of the cardiovascular system due to hemodynamic disorders is violated.

Infusion therapy is aimed at restoring the volume of fluid and the concentration of electrolytes in the body. This treatment is often used in infectious diseases.

What is infusion therapy

Infusion therapy - intravenous drug administration

Infusion therapy implies direct infusion of medicinal substances by intravenous by the needle or catheter.

As a rule, this method of administration is aimed at restoring the constancy of the inner environment of the body. It is also an effective way of therapy in the event that the oral method of administering drugs is impossible.

Diseases in which infusion therapy is usually needed include dehydration, gastrointestinal pathology and poisoning.

It has been proven that with certain diseases, an intravenous method of hydration is more efficient. So, if the patient has a constant vomiting against the background of poisoning, the oral administration of the fluid is not possible.

Delivery of water, mineral and nutrients, minor, is not devoid of minuses. Like any other invasive procedure, infusion therapy may cause infectious process, inflammation of veins and hemorrhage.

In addition, for many patients, such a treatment may be painful. Nevertheless, intravenous drug administration may be indispensable for critical states. Annually infusion therapy saves the life of a huge number of people.

This type of therapy was designed at the beginning of the XIX century for the treatment of cholera. Dehydrated patients were administered soda solutions intravenous. Closer to the twentieth century, the solutions of the cook salt showed greater efficiency.

Later, throughout the twentieth century, scientists have developed several types of blood substitutes based on organic and inorganic artificial components.

Physiological aspects

Solutions for infusion therapy

The body contains a huge amount of water in the blood, spinal fluid, intracellular and extracellular components. The flow of fluid together with food and the release of water through the sweat glands and the urinary system allows you to maintain a specific balance.

Various diseases can significantly reduce the volume of fluid and provoke hazardous states. The most dangerous situations include uncontrolled vomiting, reinforced urination, diarrhea on the background and direct blood loss.

Cells and organs suffer from lack of water for various reasons. First, water is a universal solvent and medium for essential intracellular processes. Secondly, the fluid contains the electrolytes necessary for carrying out electrical signals and provide other important processes.

Thus, a significant loss of fluid leads to the following basic disorders:

• Reducing blood pressure against the background of insufficient blood volume.
• The defeat of the nervous system due to the disadvantage of nutrients and minerals.
• Cellular changes associated with disorders of the osmotic balance.
• Muscular weakness due to loss of opportunity to shrink. Also observed in the muscular shell of the heart.

The main electrolytes necessary for the work of the heart are sodium, potassium, and calcium. All these substances are also washed out of the body in vomiting, diarrhea, blood loss and excess urination. Further changes in the acid-alkaline blood balance only exacerbate the situation.

The flow of nutrients and vitamins is also important. With different structural and functional pathologies of the gastrointestinal tract, both the usual power supply and tool methods of the introduction of food substrates can be limited. A long deficit of protein, carbohydrates and fats causes a reduction in body weight and dystrophic processes in organs.

Goals and objectives

The main purpose of infusion therapy is to maintain the constancy of the inner environment of the body. This includes the restoration of mineral and nutrients, rehydration and correction of acid-alkaline balance.

An intravenous method of therapy is often due to a violation of the functions of the gastrointestinal tract, when the usual method of supply is not possible. Also, with severe dehydration, only infusion therapy applies to rehydration.

The secondary targets of therapy include disintellation. Thus, with severe infectious diseases and poisoning in the blood, harmful substances can accumulate, toxins that violate the functions of tissues and organs.

Intravenous replacement of liquids accelerates the process of removing toxins from the body and contributes to the early recovery of the patient.

When using infusion therapy, the following main principles must be taken into account:

• The administration of drug components is necessary for emergency restoration of homeostasis and liquidation of pathophysiological conditions.
• Therapy should not exacerbate the patient's condition.
• Strict laboratory control to avoid over-introducing components.

Compliance with these principles makes such a method of therapy most secure and effective.

Indications for use

Infusion therapy is of great importance in the treatment.

As already mentioned, the main indication is the violation of the balance of liquid, mineral and nutrients in the body.

At the same time, an intravenous way to deliver vital components to blood should be due to the inefficiency of other methods of therapy.

Major States requiring intravenous injections:

• Dehydration is a sharp deficiency of fluid in the body. Signs of this state include severe thirst, weakness, disruption of the gastrointestinal tract and various neurological disorders. The critical indicator is a loss of more than 20% of the fluid.
• Infectious diseases accompanied by abundant vomiting and liquid chair. As a rule, it is infection of digestive organs due to toxins, viruses and bacterial cells with food. The purpose of treatment is not only the restoration of the liquid balance, but also the removal of toxins.
• Toxic lesions of the body against the background of poisoning, drug intake and. Special solutions help neutralize harmful substances and derive them from the body.
• Excess urine release. The condition may be due to electrolyte disorders, the damage to the urinary system, diabetes and other pathologies.
• Significant blood loss against the background of injuries and pathologies of internal organs.
• Burning disease that disrupts the balance of fluid and electrolytes in the tissues.
• Mental diseases in which the patient refuses to eat food.
• Shock conditions requiring resuscitation activities.

Before applying infusion therapy, careful laboratory and instrumental diagnostics are carried out. Even during the physical examination of the patient, doctors can identify a dangerous state when such symptoms appear as dry skin, respiratory impairment and dryness of mucous membranes.

With the help of analyzes, the concentration of electrolytes in the blood and the presence of toxins is determined. As the liquid and electrolyte balance is renewed, doctors also control laboratory indicators.

Methodology and methods

For intravenous infusion therapy, a dropper is usually used. The long tube is connected to the packaging of the medicinal solution on the tripod.

Before the introduction of the drug, the skin in the puncture area is processed by an antiseptic and, if necessary, uses harness. It is then used venopunction, the opening of the clamp and setting the rate of flow of the solution.

The method of puncture of veins can have different traumatic indicators. It may be an ordinary needle or a special catheter. Also, the therapy technique depends on the vessel used. The solution can be introduced into central or peripheral veins.

From the point of view of risk reduction, it is preferable to use subcutaneous veins, but in some cases it is impossible. Also rarely applied intraosny and arterial access.

The doctor will determine which solution is needed to a specific patient. This may be a standard saline solution containing sodium chloride, a nutrient solution or a blood substitute. At the same time, the specialist is focused on the severity of the state and laboratory blood indicators.

Enteral and parenteral nutrition

Infusion therapy should be carried out in strictly sterile conditions

Enterral method of delivering nutrients and fluids to the body is natural. Food substrates come to the gastrointestinal tract and absorbed through the mucous membrane, falling into the blood and lymphatic vessels.

Parenteral administration to which infusion therapy belongs, implies the immediate delivery of vital components into the blood. Each method has its pros and cons.

Readings for parenteral power:

1. Structural intestinal pathology.
2. A pronounced disorder of kidney functions.
3. Changing the intestinal length after surgery.
4. Burns.
5. Insufficient liver activity.
6. and other chronic inflammatory bowel diseases.
7. Refusal to eat because of mental disorders.
8. The obstruction of the gastrointestinal tract departments.

It is in the listed cases that the parenteral method of administering nutrients is preferable and extremely necessary. As a rule, the solutions include proteins, fats, carbohydrates, water, mineral components and vitamins.

Possible contraindications include inflammatory diseases of blood vessels.

Risks and complications

Despite the fact that compliance with the basic principles of infusion therapy ensures high safety rates, the emergence of complications are not excluded.

The main side effects do not differ from any other intravenous therapy and include the formation of subcutaneous hematomas, the occurrence of infectious processes and inflammation of the vessels.

Additional risks associated directly with infusion therapy and rehydration include:

• Excess fluid administration.
• Excessive administration of certain electrolytes. This leads to a violation of the acid-alkaline blood balance and disorder of organ functions.
• on the components of the solution.

In most cases, complications are easily corrected. Methods of physiotherapy are used to eliminate bruises and infiltrates.

Local exposure to heat helps to eliminate the subcutaneous clusters of blood. At home, you can use special compresses. Infectious and allergic processes, in turn, are eliminated by medication.

Thus, infusion therapy is one of the most important methods of emergency care in violation of the constancy of the inner environment of the body. The method is used in resuscitation, therapeutic and other hospitals.

Maximum useful information about infusion therapy - in the video:

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