Perspiration calculation in adults

Calculation of patient losses

This implies the need to solve the following tasks after surgery: 1) maintaining water and electrolyte balance; 2) maintaining the body’s energy supply, 3) preventing and treating protein deficiency, which is inevitable due to stressful effects on the body.

Table of contents:

• Calculation of patient losses
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• Hydrobalance calculation
• About this calculator
• Physiological losses:
• Pathological losses
• Formula
• Infusion composition
• additional information
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• Perspiration
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• INFUSION THERAPY DURING OPERATION
• Bektursinov B.U.
• Perspiration calculation in adults
• Physiological requirements for water and essential ions
• Infusion therapy
• Infusion therapy: goals and objectives
• Types of infusion therapy
• Solutions for infusion therapy
• Volume of infusion therapy
• Some principles of infusion therapy
• Complications of infusion therapy
• Medical Expert Editor
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We will briefly discuss the principles of water balance correction. To correctly calculate the necessary needs, you need to be able to assess the state of water balance and accurately determine the patient’s volume of renal and extrarenal losses.

Here is an approximate calculation of losses for a patient weighing 80 kg:

Constant V - daily diuresis (proper amount of urine) 1 ml/(kg-h).

The patient has V = 1200 ml.

Constant P - losses by perspiration through the skin and lungs (so-called imperceptible losses) - 10-15 ml/(kg-day).

The patient has P = 10 X 80 == 800 ml.

Constant T - losses during fever: with an increase in body temperature by 1 ° C above 37 ° C (the patient loses 500 ml/day).

The patient's body temperature is 39 °C. T = 500X2 = 1000 ml. Constant Y is pathological extrarenal losses (with vomiting, diarrhea, through a tube, through fistulas, etc., their volume is accurately taken into account). The patient's gastric tube released 2500 ml of gastric and intestinal contents. Y = 2500 ml.

After calculating all 4 constants, the losses are summed up. In this case, the amount is 5500 ml. However, it should be taken into account that 300-350 ml of endogenous water is formed in the body per day; this volume should be subtracted from the total volume of losses. Thus, the patient’s total fluid deficit will be equal to: 5300-300 = 5200 ml. This fluid deficiency must be replenished.

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Hydrobalance calculation

About this calculator

*This calculator allows you to calculate the hydrobalance per day both with and without operational and other losses.

Hydrobalance is the ratio of fluid injected and excreted by the body over a certain period of time (day, 12 hours, 6 hours, time of surgery).

Fluid administered - the sum of the volume of intravenous infusion and enterally (per os, into a tube) fluid administered

The fluid excreted by the body can be represented by physiological and pathological losses.

Physiological need (PD) is the body’s need for fluid per unit of time (day). Depends on age: up to 65 years old - 30 ml/kg/day, years old - 25 ml/kg/day, over 75 years old - 20 ml/kg/day.

Physiological losses:

• Русский
• Normal breathing
• Perspiration through the skin
• Normal stool
• Physiological diuresis

In general, physiological losses are about 40% of the physiological requirement, and diuresis per day is approximately equal to 60% of it, or 20 ml/kg/day.

Pathological losses

• Русский
• Losses with fever: 3 ml/kg/day. (10% FP) for every degree above 37.5 o C. Electrolytes are also lost.
• Loss with dyspnea: 10 ml/kg/day. for every 10 breaths per minute above 25.
• Losses during mechanical ventilation without warming and humidifying the gas mixture: 1000 ml/day.
• Losses during mechanical ventilation with warming and humidification of the gas mixture: 0 ml/day.
• Intraoperative losses
  • Perspiration from the wound during surgery with minimal trauma: 2 ml/kg/hour.
  • Perspiration from a wound during surgery with moderate trauma: 4 ml/kg/hour.
  • Perspiration from a wound during surgery with severe trauma: 6 ml/kg/hour.
• Vomiting, discharge through tubes
• Other losses. This may include external and internal bleeding, diarrhea, polyuria, and more.

Formula

Fluid balance = Intravenous infusion + Enteral administration - Diuresis - Physiological extrarenal losses - Pathological losses

Infusion composition

Physiological fluid needs are provided with saline solutions and glucose in an equal ratio (1:1).

Losses through drainage, tube, vomiting - saline solutions and glucose (1:1).

Losses with breathing and during mechanical ventilation without warming and moistening the mixture - only with glucose.

If the infusion volume exceeds 2400 ml/day, at least 1/3 of its volume should be colloidal solutions.

additional information

From the point of view of electrolyte composition, colloidal solutions, amino acid solutions, and lipid emulsions are considered crystalloids.

A 5% glucose solution is considered as a source of free water.

A 10% glucose solution is considered as a source of free water and an energy donor. 1200 ml of 10% glucose provides minimal protein-sparing effect.

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Perspiration

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INFUSION THERAPY DURING OPERATION

Bektursinov B.U.

In our work, we relied more on clinical and laboratory studies, thanks to which we developed a qualitative and quantitative composition of infusion-transfusion therapy in patients undergoing surgical interventions. Of particular interest were patients with initial hypovolemia and blood loss. Here, the quality composition of infusion therapy has a ratio of 3:1, crystalloids and colloids, and in some cases 3.5:1. According to our observations, the adequacy of anesthesia directly depends on the degree of compensation of blood volume.

Key words: Blood loss, infusion therapy, hypovolemia.

One of the most important aspects of intensive care is infusion and transfusion, carried out for almost any condition that requires the intervention of an anesthesiologist-resuscitator. Determining the qualitative and quantitative composition is a pressing problem of modern anesthesiology and resuscitation /1,2/. A huge number of monographs, articles and scientific works are devoted to the tactics of infusion therapy for various diseases, although this is not entirely logical - it is the patient who needs to be treated, not the disease. There are enough works where infusion therapy is determined by the patient’s condition, disorders of his homeostasis, taking into account clinical and laboratory data. This is the most correct approach, but an anesthesiologist-resuscitator working in a regular clinic does not always have access to complex laboratory tests and functional examination methods, such as determining central hemodynamic parameters. But in emergency anesthesiology there is simply no time for these examinations. A particularly important stage of treatment in these cases is the surgical period, when not only anesthesia and surgical correction are performed, but also intensive therapy. There is very little information in the literature on intraoperative infusion. In these cases, the quantitative and qualitative composition of the infusion is determined based on the knowledge and experience of the doctor.

Theoretically, patients should undergo elective surgery without disturbances in water-electrolyte balance and without a deficiency of blood volume. In order to correct existing disorders, preoperative preparation should be carried out under the control of biochemistry, coagulogram, plasma electrolytes, acid-base balance /3/. In practice, when preoperative preparation is carried out blindly or not at all, the anesthesiologist is most often faced with hypovolemia, dysproteinemia and electrolyte disturbances. Patients with gastrointestinal pathology present a particular challenge - partial or complete disturbances of enteral nutrition bring complete disorder to homeostasis: deficiency of water, electrolytes, energy substrates, predominance of catabolism, etc. /4/.

The main task facing the anesthesiologist during surgery is to ensure sufficient perfusion of all tissues and oxygen delivery to them.

The basic infusion during surgery should be at least 5 ml/kg per hour (for 70 kg this is 350 ml per hour). This volume compensates for fluid loss due to perspiration (this is especially important when using ventilators without a humidifier), sweating and “sweating” of the peritoneum or pleura. The volume of infusion above the base increases in the following cases:

- With initial hypovolemia. If the patient has a deficiency of blood volume (enteral nutrition disorders, diarrhea, vomiting, fistulas, a history of hyperthermia, hypotension or arterial hypertension, hemoconcentration, etc.), then before the start of anesthesia it is necessary to administer up to 1 liter of saline solutions at a high rate /4 /. The same infusion is carried out if after premedication or induction and intubation there is a significant decrease in blood pressure (by more than 30% of the initial level). A similar tactic is also acceptable in patients without hypovolemia, if blood loss is expected - this is one of the new blood-saving technologies in surgery (hypervolemic hemodilution) - with more fluid blood, fewer red blood cells are lost /5/. In cases where initial hypovolemia is associated with ongoing bleeding, there can be no talk of any preoperative preparation to stabilize blood pressure - anesthesia and incision - it is necessary to surgically stop the bleeding as quickly as possible! Infusion at a sufficient pace (up to 200 ml per minute!) is carried out in parallel.

- In case of blood loss. Even with normal blood loss, the volume of the basic infusion is increased by a multiple of the volume of spilled blood in a ratio of 1:2 - 1:3 (for each ml of lost blood, 2-3 ml of solutions are administered). Hypervolemic hemodilution performed in advance can reduce this ratio to 1:1 /5/.

The qualitative composition of infusion therapy is of particular importance during long-term, large-scale operations in initially severe patients. The general rule in this case is: the ratio of crystalloids to colloids is no less than 3:1. When drawing up an infusion plan, the anesthesiologist must take into account the initial condition of the patient: with initial hypoproteinemia, albumin is transfused, with initial or emerging changes in the coagulogram - FFP, with initial anemia and intraoperative blood loss - er.mass (during the operation it is injected into a separate vein or through a separate system so as not to reduce the rate of infusion). In other cases, they manage with colloidal drugs - polyglucin, stabizol, refortan.

The need to use colloids is justified by the fact that crystalloids quite quickly go into the transcellular space and can cause complications in the postoperative period - cardiac and respiratory failure, intestinal paresis and enteritis.

It is justified to use a solution of glucose with insulin (possibly with potassium) during surgery as an energy substrate. For each liter of infusion - ml of 5-10% glucose. With laboratory confirmed hyperosmolar dehydration (high Na concentration), glucose is the main component of the infusion.

The criteria for the adequacy of infusion therapy must be considered in combination: adequacy of mechanical ventilation + adequacy of anesthesia + adequacy of infusion. The inadequacy of one component nullifies everything else - leads to tissue hypoxia (shock), dooming the patient to further complications (DIC, ARDS, renal-liver failure, anastomotic leakage, etc.). This is not always obvious, and few people associate complications after surgery with the fact that during the operation the patient was “driven into shock” and brought to the ward cold, but with normal blood pressure and heart rate.

The adequacy of anesthesia as a complex of the above measures is assessed by the adequacy of perfusion in the periphery and the degree of tissue oxygenation. Unfortunately, indicators of macrohemodynamics - blood pressure, heart rate and central venous pressure - are not sufficient criteria for the adequacy of anesthesia - their normal values ​​can only indicate imaginary well-being. Along with hemodynamic indicators, the optimal method of monitoring is the determination of acid base and blood gases. The most informative is the arteriovenous difference in oxygen and plasma pH. Normal values ​​will indicate that mechanical ventilation provides good oxygenation of arterial blood and maintains normal CO ₂ , and sufficient anesthesia and infusion ensure good tissue perfusion and oxygen delivery to them.

Currently, when this method of monitoring is not always available, you can use a pulse oximeter with graphical recording of the perfusion wave. Normal saturation and good amplitude of the perfusion wave will also confirm the adequacy of anesthesia in the complex.

The condition of the patient’s skin should also be considered an important criterion for the adequacy of anesthesia. If the operating room temperature is optimal, they should be pink and warm, reflecting good ventilation, analgesia, sedation and infusion. If they are hot and humid, and the blood pressure is high, tachycardia, then most likely there are problems with mechanical ventilation - hypercapnia. If blood pressure and heart rate are normal or reduced, there are metabolic disorders leading to vasodilation, and too deep anesthesia can be assumed.

A more difficult option is when the skin is cool and pale. Changes in blood pressure and heart rate can be multidirectional. There may be several reasons:

— Inadequacy of anesthesia - blood pressure and heart rate values ​​may be normal or increased;

- Inadequate infusion or blood loss - blood pressure is normal or reduced, heart rate is normal or tachycardia;

— Inadequacy of mechanical ventilation – hypoxia (hypoventilation, device malfunction, circuit leakage, etc.) or hypocapnia (high respiratory rate);

- Heart failure - blood pressure is reduced, heart rate - tachycardia. Heart failure can be a consequence of all of the above conditions.

Another important criterion for the adequacy of anesthesia is diuresis. Normally it should be at least ml per hour. If it decreases, hypovolemia can be assumed (BP is normal or reduced, heart rate is normal or tachycardia) or inadequate analgesia and/or sedation (BP is normal or increased, heart rate is normal or tachycardia).

With high diuresis - hyperinfusion (rarely), or vasodilation (deep anesthesia, metabolic or respiratory disorders), or hyperglycemia.

Tuyin: Bul zhumysta bez kobіrek clinic laboratory zertteuler natizhesіne suyendik.Bastapki hypovolemiasa zhan kan ketuden kayingі na naukastarga erekshe konil bolindi.Anesthesia n kalypts otui ainalymdagy kan moulsherin kalpyna keltirumen ticles bailanysty ekendіgі anaktaldy.

Summary: In our work, we basically relied on clinical and laboratory research, through which we developed a qualitative-quantitative composition of the infusion-transfusion therapy of patients undergoing surgery. Of particular interest were the patients with an initial hypovolemia and blood loss. Here, the quality of the infusion therapy has 3:1 crystalloids to colloids ratio, and in some cases 3.5:1. According to our observations, the adequacy of anesthesia depends on the degree of compensation of volume of circulating blood.

1. Ryabov G.A. Critical illness syndromes. – M., Medicine, 1994.
2. Ryabov G.A. Hypoxia of critical conditions. – M., Medicine, 1988.
3. Bunatyan A.A. and others. Anesthesiology and resuscitation. – M., Medicine, 1984.
4. Lukomsky G.A. and others. Volemic disorders in surgical pathology. – M., Medicine, 1988.
5. Chibunovsky V.A. New approaches to transfusion and therapeutic hemodilution. Practical guide. – Almaty, 2001.

Source: http://kaznmu.kz/press/2012/07/19/%D0%B8%D0%BD%D1%84%D1%83%D0%B7%D0%B8%D0%BE%D0%BD %D0%BD%D0%B0%D1%8F-%D1%82%D0%B5%D1%80%D0%B0%D0%BF%D0%B8%D1%8F-%D0%B2%D0%BE -%D0%B2%D1%80%D0%B5%D0%BC%D1%8F-%D0%BE%D0%BF%D0%B5%D1%80%D0%B0%D1%86%D0%B8 /

Perspiration calculation in adults

1.6. Control of water and electrolyte balance

Water supply. A person should consume as much water as necessary to replace the daily loss through the kidneys and extrarenal routes. A person’s normal balanced need for water ranges from 1000 to 2500 ml/day and depends on body weight, age, gender and a number of other factors.

In the process of exchange and utilization of all three main metabolic components - proteins, carbohydrates and fats - one of the end products is water. Consequently, the body is able to partially cover its needs by using the endogenous water formed in it.

When the body produces 100 kcal (420 kJ), about 10 ml of water is formed [Moore F., 1963]. Since the daily energy output for an adult is 1500–2000 kcal (6300–9240 kJ), the volume of metabolic water formed in this case is about 150–220 ml, i.e., about 8–10% of the daily requirement. The oxidation of 100 g of proteins is accompanied by the formation of 41 ml of water, 100 g of fats - 107 ml and 100 g of carbohydrates - 55 ml of water. Obviously, metabolic water does not contain electrolytes. Fever, trauma, infections and other serious illnesses lead to an increase in the formation of endogenous water by 2-3 times.

Diuresis and perspiration losses. The most subtle and sensitive indicator of fluid balance in the body is diuresis. A healthy person is able to excrete all metabolic products during the day in a relatively small volume of urine (400-600 ml). The optimal diuresis is 3-4 times higher and amounts to 1400-1600 ml/day. In addition, under normal temperature conditions and normal air humidity, the body loses from 800 to 1000 ml of water through the skin and by evaporation through the respiratory tract, forming so-called intangible losses. Thus, the total excretion of water (with urine and perspiration) should be 2200-2600 ml/day.

In intensive care practice, there are three options for determining diuresis: collection of daily urine (for uncomplicated disease), determination of diuresis every 8 hours (with infusion therapy of any type) and hourly determination of diuresis (in patients with severe disorders of water-electrolyte balance, in shock and with suspected development of renal failure with a catheterized bladder). Renal function in the postoperative period is considered satisfactory if in the first 2 days after surgery, diuresis averages 25-35 ml/h. This is the lower limit of normal. In subsequent days, with a favorable course and subject to adequate infusion therapy, it is advisable to achieve diuresis close to 80-90 ml/h, i.e. 1700-2000 ml/day.

However, our experience shows that in patients undergoing resuscitation or in patients in critical condition, as well as in the first days after major operations, it is almost difficult to obtain such diuresis. This is possible only with a significant water and salt load, which is dangerous in critical conditions, since water overload of the lungs and impaired renal function are possible. In order for a patient to excrete 2 liters of urine per day in the first 2 days after major surgery, when the antidiuresis factor is active, it is necessary to administer intravenous fluids, including saline solutions, in an amount of 4.5-5 liters/day. Apparently, on average, a satisfactory diuresis for a seriously ill patient, ensuring complete elimination of waste, should be 60 ml/hour (1500±500 ml/day).

Oliguria is considered to be diuresis below 25-30 ml/h (less than 500 ml/day). Currently, there are three types of oliguria (taking into account anatomical and functional factors): prerenal, renal and postrenal [Dougan L. R., Flnaly W. E., 1973]. Type 1 oliguria occurs as a result of renal vascular block or inadequate circulation. Oliguria of the second type is characterized by parenchymal renal failure, and the third is associated with impaired outflow of urine from the kidneys. From the point of view of a resuscitator, the first two are practically the most important. To assess the significance and quality of oliguria, it is important to know the circulating blood volume (CBV), systemic volumetric blood flow (cardiac output), the content and distribution of electrolytes in the body and a number of other equally important indicators. Urine density exceeding 1.016-1.018 g/l indicates a prerenal type of oliguria. A high concentration of Na + in the urine (above 30 mmol/l) indicates renal failure. In this case, oliguria is of renal origin (damage to the reabsorption function of the tubular apparatus). The nature of oliguria can also be judged by the urea content in the blood and urine. A blood urea concentration exceeding 25-33 mmol/l (normally 2.5-6.5 mmol/l) may indicate renal failure. Low urea content in urine (less than 10 g/l) also indicates renal failure.

When assessing renal function in a seriously ill patient, it is also important to take into account the ratio of urine osmolality to plasma osmolality [Kennedy S., 1968] (Table 1.3).

Table 1.3. Determination of the type of oliguria by the ratio of osmolality and urea content in urine and plasma

Urine osmolality varies widely - from 400 to 1500 mOsmol/kg. After an overnight (12-hour) abstinence from urination, urine osmolality should be at least 850 mOsmol/kg. Normal urine osmolality and a urine pH of 5.8 or lower indicate normal kidney function. The normal ratio of urine osmolality to plasma osmolality is 3.4: 1—4.2: 1.

Regulation of water balance. It is carried out by activating (inhibiting) the osmoreceptors of the hypothalamus, which respond to changes in plasma osmolality and changes in the concentration of the main plasma electrolyte - Na +. In this case, stimulation or, conversely, suppression of the feeling of thirst occurs and, accordingly, changes in the secretion of ADH. The general mechanism for regulating water balance is presented in Diagram 1.2.

In a healthy person, when plasma osmolality decreases to the lower limit of normal (280 mOsmol/kg), the secretion of ADH is completely suppressed and the excreted urine has a very low osmolality - up to 30 mOsmol/kg. An increase in plasma osmolality leads to a corresponding increase in plasma ADH levels, and when plasma osmolality reaches 295 mOsmol/kg, the maximum antidiuretic effect occurs with an increase in urine osmolality to 1200 mOsmol/kg [Feig P. U ., McCurdy D . K., 1977].

Thus, normally, water balance is regulated through the feeling of thirst and changes in ADH secretion within a fairly narrow range of changes in plasma osmolality - or 280 to 295 mOsmol/kg.

Water balance regulation scheme

However, in pathological conditions, other factors arise that affect the level of ADH release, the appearance of thirst and, consequently, the water balance: loss of blood volume, pain, injury, vomiting, the effect of drugs [Goldberg M. 1981]. Thirst can be stimulated by a decrease in blood volume and an increase in the level of angiotensin in the blood.

In recent years, important importance in the regulation of the body's water balance has been attached to a recently discovered factor, the so-called 'atrial natriuretic peptide, j It is assumed that the factor is released from the atria during their filling and stimulates natriuresis and general diuresis by increasing the glomerular filtration rate and reducing Na + reabsorption. It has been experimentally shown that the peptide quickly reduces plasma volume and thus reduces the absolute level of blood pressure. However, the effects of the peptide are quickly neutralized by other regulatory factors, such as hypotension or an increase in the tone of the sympathetic innervation of the kidneys [Trippodo N., 1989]. A study of the effect of atrial natriuretic peptide in hypertension (primary hypertension) has begun. Its correlation with age, blood pressure level, the presence or absence of left ventricular hypertrophy and a negative correlation with plasma renin levels were found [Wambach G. et al., 1989].

Loss of fluids and their pathological movements in the body. The main causes of disturbances in water-electrolyte balance are external losses of fluids and pathological redistribution between the main fluid environments. They can occur due to pathological activation of natural processes in the body, in particular with polyuria, diarrhea, excessive sweating, as well as with profuse vomiting, and finally, due to losses through various drainages and fistulas or from the surface of wounds and burns. Internal movements of fluids are possible with the development of edema in injured and infected areas, but are mainly due to changes in the osmolality of fluid environments. Specific examples of internal movements are the accumulation of fluid in the pleural and abdominal cavities during pleurisy and peritonitis, blood loss in tissue during extensive fractures, movement of plasma into injured tissue during crush syndrome, etc.

A special type of internal movement of fluid is the formation of so-called transcellular pools in the gastrointestinal tract (with intestinal obstruction, volvulus, intestinal infarction, severe postoperative paresis).

The formation of transcellular pools is equivalent to external pathological losses of fluids, because sequestration of fluid with a high content of electrolytes occurs. The total volume of daily secretion at various levels of the gastrointestinal tract is normally 8-10 liters, including saliva 1000-1500 ml, gastric juice - about 2500 ml, bile - 750-1000 ml, pancreatic juice - over 1000 ml, secretion small intestine - about 3000 ml. Normally, this entire amount of liquid (minus 100-150 ml excreted in feces) is absorbed in the small intestine (Table 1.4).

Table 1.4. Composition of the main electrolytes in the gastrointestinal tract and volumes of losses during intestinal fistulas and diarrhea

Electrolyte content, mmol/l

gastric juice (pH<4.0)

intestinal juice (mixed)

For intestinal fistulas:

With fecal fistula

With the exception of bile and pancreatic juice, the contents of the gastrointestinal tract are hypotonic in electrolyte composition. In severe conditions, such as repeated vomiting of any origin, volvulus, intestinal obstruction at various levels, or as a result of postoperative intestinal motility disorders, intraintestinal sequestration reaches several liters. This leads to severe biochemical disturbances in all aqueous environments - cellular, interstitial and vascular, and a significant amount of proteins is lost. Each liter of such liquid can contain up to 30 g of proteins, mainly albumin. The content of globulin fractions in plasma increases with a general decrease in the amount of circulating protein. Significant external losses of fluids occur with extensive wounds and burns.

In clinical practice, especially in surgical patients, significant internal movements often occur; liquids that are in the nature of pathological redistribution of water in the form of its accumulation in certain areas of the body, for example in the area of ​​a burn, wound or extensive trauma. In contrast to obvious external losses, internal sequestration, like the formation of transcellular pools, does not cause significant changes in body weight.

The contents of the third space are usually a mixed fluid, which includes both intracellular and interstitial fluid and plasma. The formation of a third space is usually accompanied by a clinical picture of fluid deficiency, characterized by a drop in diuresis, a decrease in central venous pressure and blood thickening due to the loss of part of the plasma.

The most significant and pronounced movements of fluid in the body and its sequestration are observed with peritonitis. In terms of its significance and pathophysiological role, fluid sequestration during peritonitis is similar to disturbances in water balance during severe burns in the acute phase. In both cases, hemoconcentration, plasma deficiency, protein loss and general dehydration occur; depending on the nature of peritonitis, sequestration develops at different rates, but in severe cases the process can be almost lightning fast. With adequate treatment with antibiotics or after successful surgery, a fairly rapid (within 1-2 weeks) reverse development of the process occurs, ending with almost complete absorption of fluid and even proteins from the abdominal cavity.

Significant fluid sequestration into the third space can also occur with widespread venous thrombosis, especially the femoral and iliac veins.

Sequestered fluids return to the interstitial space and plasma as the cause of sequestration is eliminated. With the elimination of the third space and the resorption of sequestered fluid, additional amounts of electrolytes enter the circulating plasma and interstitial space along with water. This circumstance must be taken into account during treatment. In case of renal failure, the process of natural elimination of the third space can become dangerous due to the possibility of pathological retention of electrolytes in the blood.

A similar process of reabsorption and elimination of the third space occurs when intestinal obstruction is eliminated and intestinal motor function is restored.

In therapeutic tactics, especially when determining the volume of replacement of water and electrolyte losses in such patients, the described trends should be taken into account. During the recovery period, one should not strive to completely compensate for the increased excretion of electrolytes, since it may be a reflection of an increased supply of electrolytes into the circulating plasma and interstitial space from the third space. In some patients during this period, a decrease in body weight is detected in combination with increased diuresis without signs of dehydration. Hematocrit, protein content, as well as Na + and C1 - in the blood quickly normalize. Usually during this period there is no need to continue infusion therapy.

Clinical manifestations of water and electrolyte imbalances. Most often, disorders occur in acute diseases of the abdominal organs, interventions on the gastrointestinal tract, burns, severe chronic diseases with the presence of fistulas, as well as in severe external fluid losses.

In assessing the degree of dyshydria, anamnesis is of great importance. Indications of frequent vomiting preceding the period of medical observation or diarrhea suggest that there is a significant water-electrolyte imbalance, even if signs of it are not yet apparent during the initial examination.

In acutely developed peritonitis or intestinal obstruction, water-electrolyte imbalance, along with intoxication, is the first link in the pathogenetic chain of the disease. The absence of visible losses in such patients does not mean well-being: signs of dehydration appear suddenly and progress at lightning speed. Lost water and electrolytes are concentrated in the intestinal cavity and, to a lesser extent, in the abdominal cavity. Determining water balance and the dynamics of this indicator using bed scales often gives erroneous results, since in such cases water does not leave the body. The use of bed scales is advisable in cases where there is complete confidence in the absence of sequestration of fluid into the natural cavities of the body. In advanced cases of acute intestinal obstruction, especially when mesenteric circulation is impaired, the intestinal cavity can accumulate up to 5-7 liters of fluid with a high content of electrolytes.

Thirst is one of the main and most characteristic symptoms of water deficiency. Thirst must be clearly differentiated from dryness of the oral mucosa, which can be eliminated by rinsing the mouth and throat; thirst is not eliminated by this technique. (The presence of thirst shows that the volume of water in the extracellular space is reduced relative to the salt content in it. Therefore, if a patient with true thirst has access to water, then he is able to quickly eliminate its deficiency. Loss of pure water and the occurrence of thirst in this connection are possible also with profuse sweating (high fever), diarrhea and osmotic diuresis (high glucose levels in diabetic coma, use of mannitol or urea).

Dryness in the armpits and groin areas is an important symptom of water loss and indicates that the water deficit in the body is at least 1500 ml.

A decrease in tissue and skin turgor should be considered as an indicator of a decrease in the volume of interstitial fluid. In older people and in normal conditions, the skin is often dry and inelastic. In obese people, even with severe dehydration, the skin can maintain elasticity.

The appearance of the tongue largely reflects the state of dyshydria. Under normal conditions, the tongue has a single, more or less pronounced median longitudinal groove. With dehydration, additional grooves appear parallel to the median.

The tone of the eyeballs is a valuable symptom, indicating not only dehydration (decreased tone), but also overhydration of the body, especially the brain (eyeball tension).

Changes in body weight over a short period of time (eg, after an hour) are an indicator of changes in extracellular fluid volume. However, the weighing results must be treated with great caution and evaluated only in combination with other indicators. The formation of a third space, for example, may not be reflected in changes in body weight, meanwhile, in the presence of a large third space, the body is in a state of relative dehydration. Another difficulty in assessing changes in body weight is that in a critically ill patient it is necessary to take into account the nature of metabolism at the time of weighing: the catabolic phase is usually associated with tissue loss (up to 500 g/day), the anabolic phase is characterized by an increase in tissue mass (about 150 g/day). days). Postoperative patients are characterized by a decrease in tissue mass by approximately 300 g/day. In most cases, weight gain should be considered water retention. Body weight loss exceeding 500 g/day indicates water loss. Treatment should never be based solely on changes in body weight. The entire clinical picture must be taken into account.

Changes in blood pressure and pulse reflect significant losses of water in the body, but to a greater extent they are associated with a decrease in blood volume. Tachycardia is a fairly early sign of a decrease in blood volume. In patients with blood volume depletion, tachycardia usually correlates with postural blood pressure responses. The first signs of a decrease in blood pressure can be observed only when there is a significant deficit of blood volume, exceeding at least 1 l with hypotension in a sitting position and 1.5 l with the development of hypotension in a horizontal position.

The state of filling of the external jugular vein. In a healthy person in a horizontal position, the external jugular vein at the level of the anterior edge of the sternocleidomastoid muscle is filled with blood and is well contoured under the skin. The filling of this vein quite accurately reflects the value of the central venous pressure. Increased central venous pressure is observed with an increase in plasma or blood volume or with heart failure. As plasma volume decreases, central venous pressure decreases. Collapse of the neck veins in a horizontal position indicates that the patient has a reduced plasma volume and indicates the need to administer saline solutions. In order to differentiate heart failure from increases in plasma volume, which are equally manifested by distention of the jugular veins, the hepatojugular reflux test is used. The patient in a sitting or semi-sitting position is pressed on the stomach in the area where the liver is located, trying to cause compression. In heart failure, this test causes increased distension of the jugular veins; with an increased plasma volume (in the absence of heart failure), hepatojugular reflux is absent and the distension of the veins decreases.

Edema always reflects an increase in interstitial fluid volume and may indicate that the total amount of Na + in the body is increased. However, edema is not a highly sensitive indicator of Na + balance: the total amount of exchangeable Na + in the body can increase by 20-25% without the appearance of edema. This is due to the fact that the redistribution of water between the vascular and interstitial spaces is due to the high protein gradient between these two environments. With normal protein balance, the appearance of a barely noticeable dimple when pressing with a finger in the area of ​​​​the anterior surface of the tibia indicates that the body has an excess of at least 400 mmol Na +, which is more than 2.5 liters of saline solution.

The appearance of moist rales in the lungs indicates the accumulation of water in the alveoli and, in the absence of signs of heart failure, may indicate the presence of excess water in the body.

The study of BCC provides important information about the degree of hydration of the interstitial and mainly intravascular space.

An approximate relationship between water deficiency and clinical manifestations of dehydration is presented in table. 1.5.

Table 1.5. Clinical signs of dehydration depending on water deficiency

Thirst, normal hemodynamics

Severe thirst, dryness of the tongue, mouth, armpits and groin areas, increased Na + content in plasma and relative density of urine, a tendency towards hypotension or normotension.

Excruciating thirst, severe hypernatremia, oliguria, weight loss, moderate increase in hematocrit, hypotension, tachycardia, apathy, stupor. If the condition is not corrected in time, hyperosmolal coma and death occur.

The main signs of water deficiency in the body are thirst, oliguria and hypernatremia.

In assessing the water-electrolyte balance in a patient in critical condition, careful consideration of the amount of fluid entering the body and lost in various ways plays an invaluable role. Fluid balance studies should be started immediately after the patient is admitted to the intensive care unit. The almost optimal time limit for determining fluid balance is considered to be 8 a.m., when there is a change of treating staff. The use of bed scales, despite certain caveats that require caution in interpreting changes in body weight, provides significant assistance in assessing body fluid balance.

All physiological and pathological losses of body fluids must be strictly taken into account and sent to the laboratory for analysis of the content of electrolytes and other components in them. Such fragments of fluid losses can be urine, liquid feces, vomit, intestinal contents obtained during intestinal lavage during surgery, separated through drainages, etc.

Table 1.6. Additional water loss depending on body temperature, ambient temperature and respiratory rate [Condon R. E., 1975]

In normal clinical practice, the doctor has to deal with both conditions characterized by excess water and conditions caused by its deficiency.

The concept of “fluid loss” in clinical practice can be interpreted very broadly. This can indicate various conditions, ranging from limited extracellular and fully compensated dehydration in mild diseases to the loss of huge volumes of fluids, equal to the volume of plasma or even the total volume of blood and sometimes measured in tens of liters. Such huge losses occur, for example, with strangulation intestinal obstruction or intestinal infarction, severe peritonitis or pancreatic necrosis. Typically, these diseases, accompanied by severe dehydration, have an extremely severe, sometimes malignant course and are difficult to treat. In addition to the influence of the intoxication factor itself, profound disturbances of almost all types of metabolic functions develop.

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Physiological requirements for water and essential ions

Clinically, the pelvis is called narrow, creating an obstacle to the advancement of the fetus during labor. The reasons for the resulting disproportion are: anatomically narrow pelvis, large fetus, poor ability of the fetal skull bones to change during post-term pregnancy, unfavorable insertion of the heads.

The problem of the immunological relationship between the fetus and the maternal body remains relevant until recently and combines a number of issues that require immediate solutions in obstetrics and micropediatrics. Establishing the fact that isoantigenic incompatibility for individual blood factors is possible.

With subclavian access, several points in the subclavian region can be used: Aubaniak, Wilson and Giles points. Aubaniak's point is located 1 cm below the collarbone along the line separating the inner and middle third of the clavicle; Wilson's point 1 cm below the clavicle along the midclavicular line; That.

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Infusion therapy

Infusion therapy is a method of parenterally providing the body with water, electrolytes, nutrients and medications.

Infusion therapy: goals and objectives

The purpose of infusion therapy is to maintain body functions (transport, metabolic, thermoregulatory, excretory, etc.), determined by VEO.

The objectives of infusion therapy are:

• ensuring the normal volume of water spaces and sectors (rehydration, dehydration), restoration and maintenance of normal plasma volume (volume reconstruction, hemodilution);
• restoration and maintenance of VEO;
• restoration of normal blood properties (fluidity, coagulation, oxygenation, etc.);
• detoxification, including forced diuresis;
• long and uniform administration of drugs;
• implementation of parenteral nutrition (PN);
• normalization of immunity.

Types of infusion therapy

Venous access options:

• vein puncture - used for short-term infusions (from several hours to a day);
• venesection - if continuous administration of drugs is necessary for several (37) days;
• catheterization of large veins (femoral, jugular, subclavian, portal) - with proper care and asepsis, provides infusion therapy lasting from 1 week to several months. Catheters are plastic, disposable, 3 sizes (outer diameter 0, 6, 1 and 1.4 mm) and length from 16 to 24 cm.

Methods of infusion therapy include intermittent (jet) and continuous (drip) administration of solutions.

For jet injection of drugs, syringes (“Luer” or “Record”) made of glass or plastic are used; preference is given to disposable syringes (the likelihood of children becoming infected with viral infections, in particular HIV and viral hepatitis, is reduced).

Currently, drip infusion therapy systems are made from inert plastics and are intended for single use. The rate of administration of solutions is measured in the number of drops per minute. It should be borne in mind that the number of drops in 1 ml of solution depends on the size of the dropper in the system and the force of surface tension created by the solution itself. So, 1 ml of water contains on average 20 drops, 1 ml of fat emulsion - up to 30, 1 ml of alcohol - up to 60 drops.

Volumetric peristaltic and syringe pumps provide high accuracy and uniformity of solution administration. The pumps have a mechanical or electronic speed control, which is measured in milliliters per hour (ml/h).

Solutions for infusion therapy

Solutions for infusion therapy include several groups: volume-substituting (volemic); basic, basic; corrective; preparations for parenteral nutrition.

Volume-substituting drugs are divided into: artificial plasma substitutes (40 and 60% dextran solution, starch solutions, hemodez, etc.); natural (autogenous) plasma substitutes (native, fresh frozen - FFP or dry plasma, 5, 10 and 20% solutions of human albumin, cryoprecipitate, protein, etc.); blood itself, erythrocyte mass or a suspension of washed erythrocytes.

These drugs are used to compensate for the volume of circulating plasma (CVP), deficiency of red blood cells or other plasma components, to absorb toxins, to ensure the rheological function of the blood, to obtain an osmodiuretic effect.

The main feature of the action of drugs in this group: the greater their molecular weight, the longer they circulate in the vascular bed.

Hydroxyethyl starch is available in the form of a 6 or 10% solution in physiological solution (HAES-steril, infucol, stabizol, etc.), has a high molecular weight (kD) and therefore circulates in the vascular bed for a long time (up to 8 days). Used as an antishock drug.

Polyglucin (dextran 60) contains a 6% dextran solution with a molecular weight of about D. Prepared with 0.9% sodium chloride solution. The half-life (T|/2) is 24 hours, remains in circulation for up to 7 days. Rarely used in children. Antishock drug.

Reopolyglucin (dextran 40) contains 10% dextran solution with molecular weight D and 0.9% sodium chloride solution or 5% glucose solution (indicated on the bottle). T1/h, duration of action - up to 1 day. Note that 1 g of dry (10 ml solution) dextran 40 binds ml of liquid entering the vessel from the interstitial sector. Antishock drug, the best rheoprotector.

Hemodez includes a 6% solution of polyvinyl alcohol (polyvinyl pyrrolidone), 0.64% sodium chloride, 0.23% sodium bicarbonate, 0.15% potassium chloride. The molecular weight is 000 D. T1/h, the action time is up to 12 hours. The sorbent has moderate detoxification and osmodiuretic properties.

In recent years, the so-called dextran syndrome has been identified, which is caused in some patients by the special sensitivity of the epithelial cells of the lungs, kidneys and vascular endothelium to dextrans. In addition, it is known that with long-term use of artificial plasma substitutes (especially hemodez), blockade of macrophages can develop. Therefore, the use of such drugs for infusion therapy requires caution and strict indications.

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

With the help of basic (basic) solutions, medicinal and nutrients are introduced. Glucose solutions of 5 and 10% have an osmolarity of 278 and 555 mOsm/L, respectively; pH 3.5-5.5. It should be remembered that the osmolarity of solutions is ensured by sugar, the metabolization of which into glycogen with the participation of insulin leads to a rapid decrease in the osmolarity of the injected liquid and, as a consequence, the threat of developing hypo-osmolal syndrome.

Solutions of Ringer, Ringer-Locke, Hartmann, lactasol, acesol, disol, trisol, etc. are closest in composition to the liquid part of human plasma and are adapted for the treatment of children; they contain sodium, potassium, calcium, chlorine, and lactate ions. Ringer-Locke solution also contains 5% glucose. Osmolaritymosm/l; pH 6.0-7.0. Isoosmolar.

Corrective solutions are used for ion imbalance and hypovolemic shock.

Physiological 0.85% sodium chloride solution is not physiological due to excessive chlorine content and is almost never used in young children. Sour. Isoosmolar.

Hypertonic solutions of sodium chloride (5.6 and 10%) in their pure form are rarely used - in cases of severe sodium deficiency (2 body surfaces, older than 1 year, ml per 1 m2. The child’s body surface can be determined using nomograms, knowing the indicators of his growth and MT.

Volume of infusion therapy

The total volume of infusion therapy for the current day is calculated using the formulas:

• to maintain water balance: coolant = FP, where FP is the physiological need for water, coolant is the volume of fluid;
• during dehydration: CO = DVO + TPP (in the first 6, 12 and 24 hours of active rehydration), where DVO is the deficit of extracellular fluid volume, TPP is the current (predicted) pathological water loss; after the elimination of DVO (usually from the 2nd day of treatment), the formula takes the form: OB = AF + TPP;
• for detoxification: OB = AF + OVD, where OVD is the volume of age-related daily diuresis;
• for acute renal failure and oligoanuria: coolant = FD + OP, where FD is the actual diuresis over the previous day, OP is the volume of perspiration per day;
• with grade I AHF: coolant = 2/3 AF; II degree: coolant = 1/3 AF; III degree: coolant=0.

General rules for drawing up an infusion therapy algorithm:

1. Colloidal preparations contain sodium salt and belong to saline solutions, so their volume should be taken into account when determining the volume of saline solutions. In total, colloidal preparations should not exceed 1/3 of the coolant.
2. In young children, the ratio of glucose and salt solutions is 2:1 or 1:1, in older children it changes towards the predominance of saline solutions (1:1 or 1:2).
3. All solutions should be divided into portions, the volume of which usually does not exceed ml/kg for glucose and 7-10 ml/kg for saline and colloidal solutions.

The choice of starting solution is determined by the diagnosis of VEO disorders, volemia and the tasks of the initial stage of infusion therapy. So, in case of shock, it is necessary to administer mainly volemic drugs in the first 2 hours, in case of hyper natremia - glucose solutions, etc.

Some principles of infusion therapy

When infusion therapy for the purpose of dehydration there are 4 stages:

1. anti-shock measures (1-3 hours);
2. compensation for DVO (4-24 hours, for severe dehydration up to 2-3 days);
3. maintaining VEO in conditions of ongoing pathological fluid loss (2-4 days or more);
4. PN (full or partial) or enteral nutrition therapy.

Anhydremic shock occurs with the rapid (hours to days) development of degree II-III dehydration. In case of shock, central hemodynamics should be restored within 2-4 hours by administering fluid in a volume approximately equal to 3-5% of BW. In the first minutes, solutions can be administered in a stream or quickly by drip, but the average speed should not exceed 15 ml/(kg*h). When blood circulation is decentralized, the infusion begins with the introduction of sodium bicarbonate solutions. Then a 5% albumin solution or plasma substitutes (reopolyglucin, hydroxyethyl starch) are administered, then or in parallel with it, saline solutions. In the absence of significant microcirculatory disorders, a balanced salt solution can be used instead of albumin. Considering the presence of obligatory hypo-osmolal syndrome in anhydremic shock, the introduction of electrolyte-free solutions (glucose solutions) into infusion therapy is possible only after restoration of satisfactory central hemodynamic parameters!

The duration of the 2nd stage is usually 4-24 hours (depending on the type of dehydration and the adaptive capabilities of the child’s body). Liquid is administered intravenously and (or) orally (OJ = DVO + TPP) at a rate of 4-6 ml/(kg h). In case of I degree of dehydration, it is preferable to administer all the liquid internally.

For hypertonic dehydration, 5% glucose solution and hypotonic NaCl solutions (0.45%) are administered in a 1:1 ratio. For other types of dehydration (isotonic, hypotonic), a 10% glucose solution and a physiological concentration of NaCl (0.9%) in balanced salt solutions in the same ratios are used. To restore diuresis, use solutions of potassium chloride: 2-3 mmol/(kg day), as well as calcium and magnesium: 0.2-0.5 mmol/(kg day). Solutions of salts of the last 2 ions are best administered intravenously, but without mixing in one bottle.

Attention! Potassium ion deficiency is eliminated slowly (within several days, sometimes weeks). Potassium ions are added to glucose solutions and injected into a vein at a concentration of 40 mmol/l (4 ml of 7.5% KCl solution per 100 ml of glucose). Rapid, and especially jet, injection of potassium solutions into a vein is prohibited!

This stage ends with an increase in the child’s body weight, which is no more than 5-7% compared to the initial one (before treatment).

The 3rd stage lasts more than 1 day and depends on the persistence or continuation of pathological water losses (with stool, vomit, etc.). Formula for calculation: coolant = FP + TPP. During this period, the child’s BW should stabilize and increase by no more than 20 g/day. Infusion therapy should be carried out evenly throughout the day. The infusion rate usually does not exceed 3-5 ml/(kg h).

Detoxification using infusion therapy is carried out only with preserved renal function and includes:

1. dilution of the concentration of toxins in the blood and ECF;
2. increased glomerular filtration rate and diuresis;
3. improvement of blood circulation in the reticuloendothelial system (RES), including the liver.

Hemodilution (dilution) of blood is ensured by the use of colloid and saline solutions in the mode of normo or moderate hypervolemic hemodilution (NC 0.30 l/l, BCC > 10% of normal).

Diuresis in a child under conditions of postoperative, infectious, traumatic or other stress should not be less than the age norm. When urination is stimulated by diuretics and fluid administration, diuresis can increase by 2 times (more is rare), and disturbances in the ionogram may increase. In this case, the child’s body weight should not change (which is especially important in children with damage to the central nervous system and the genital system). The infusion rate is on average 10 ml/kg*h), but may be higher when small volumes are administered in a short time.

If detoxification with infusion therapy is insufficient, the volume of fluid and diuretics should not be increased, but methods of efferent detoxification and extracorporeal blood purification should be included in the treatment complex.

Treatment of overhydration is carried out taking into account its degrees: I - increase in BW up to 5%, II - within 5-10% and III - more than 10%. The following methods are used:

• restriction (not abolition) of the introduction of water and salt;
• restoration of blood volume (albumin, plasma substitutes);
• use of diuretics (mannitol, Lasix);
• carrying out hemodialysis, hemodiafiltration, ultrafiltration or low-flow ultrafiltration, peritoneal dialysis for acute renal failure.

For hypotonic overhydration, it may be useful to pre-administer small volumes of concentrated solutions (20-40%) of glucose, sodium chloride or bicarbonate, as well as albumin (in the presence of hypoproteinemia). It is better to use osmotic diuretics. If acute renal failure is present, emergency dialysis is indicated.

For hypertensive overhydration, diuretics (Lasix) are effective against the background of careful intravenous administration of 5% glucose solution.

For isotonic overhydration, fluid and sodium restriction is prescribed, and diuresis is stimulated with Lasix.

During infusion therapy it is necessary:

1. Continuously evaluate its effectiveness by changes in the state of central hemodynamics (pulse) and microcirculation (skin color, nails, lips), kidney function (diuresis), respiratory system (RR) and central nervous system (consciousness, behavior), as well as changes in clinical signs of dehydration or overhydration .
2. Instrumental and laboratory monitoring of the patient’s functional state is required:

• hourly measure heart rate, respiratory rate, diuresis, lost volumes with vomiting, diarrhea, shortness of breath, etc., according to indications - blood pressure;
• Body temperature, blood pressure, and central venous pressure are recorded 3-4 times (sometimes more often) during the day;
• before the start of infusion therapy, after its initial stage and then daily, NaCl indicators, the content of total protein, urea, calcium, glucose, osmolarity, ionogram, CBS and VEO parameters, prothrombin level, blood clotting time (BCT), relative density of urine (RUD) are determined ).

1. The volume of infusion and its algorithm are subject to mandatory correction depending on the results of infusion therapy. If the patient's condition worsens, infusion therapy is stopped.
2. When correcting significant changes in VEO, the sodium level in the child’s blood plasma should not increase or decrease faster than 1 mmol/lh (20 mmol/l per day), and the osmolarity indicator should not increase or decrease by 1 mOsm/h (20 mOsm/l per day). day).
3. When treating dehydration or hyperhydration, the child’s body weight should not change per day by more than 5% of the original.

The drip container should not simultaneously contain more than % of the coolant calculated for the day.

When carrying out infusion therapy, errors are possible: tactical (incorrect calculation of coolant, fluid volume and determination of the components of infusion therapy; incorrectly drawn up infusion therapy program; errors in determining the rate of infusion therapy, in measuring parameters of blood pressure, central venous pressure, etc.; defective analyzes; unsystematic and incorrect control of IT implementation or its absence) or technical (incorrect choice of access; use of low-quality drugs; defects in the care of systems for transfusion of solutions; improper mixing of solutions).

Complications of infusion therapy

1. local hematomas and tissue necrosis, damage to neighboring organs and tissues (during puncture, catheterization), phlebitis and vein thrombosis (due to high osmolarity of solutions, their low temperature, low pH), embolism;
2. water intoxication, salt fever, edema, dilution acidosis, hypo and hyperosmolar syndrome;
3. reactions to infusion therapy: hyperthermia, anaphylactic shock, chills, circulatory disorders;
4. overdose of medications (potassium, calcium, etc.);
5. complications associated with blood transfusion, transfusion reactions (30 minutes - 2 hours), hemolytic reactions (10-15 minutes or more), massive blood transfusion syndrome (more than 50% of the blood volume per day);
6. overload of the circulatory system due to an excess of administered solutions, high speed of their administration (swelling of the neck veins, bradycardia, expansion of the boundaries of the heart, cyanosis, possible cardiac arrest, pulmonary edema);
7. pulmonary edema due to a decrease in colloid-osmotic pressure in the plasma and an increase in hydrostatic pressure in the capillary (hemodilution with water over 15% of the bcc).

The introduction of a procedure such as infusion therapy into widespread medical practice has made it possible to significantly reduce the mortality rate of children, but at the same time it has given rise to a number of problems that are more often associated with inaccurate diagnosis of VEO disorders and, accordingly, incorrect determination of indications, calculation of volume and compilation of an IT algorithm. Proper implementation of IT can significantly reduce the number of such errors.

Medical Expert Editor

Portnov Alexey Alexandrovich

Education: Kiev National Medical University. A.A. Bogomolets, specialty - "General Medicine"

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