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Jakarta, 29 Jan 2010
Supportive Fluid Therapy In DHF
Abstract*
Unlike many bacterial infectious diseases and parasitic diseases which require specific drug therapy, treatment of DHF depends merely on proper fluid management and monitoring. Correction of moderate dehydration due to fever, hyperventilation and decreased oral intake must be initiated, because in addition to improving general condition, it obviates the misinterpretation of hemoconcentration as a hallmark of capillary leakage.
In general, parenteral fluid therapy can be classified into three categories: Resuscitation, Repair and Maintenance. Since, severe electrolyte and acid-base disorders rarely complicate DHF, repair fluid therapy is seldom administered for DHF patients.
Hitherto, resuscitation fluid therapy is defined as giving isotonic infusion solution (lactated ringer’s, acetated ringer’s, 0.9% NaCl and/or colloid at high infusion rate to patient with hemodynamic derangement or hypovolemic shock (1). The most common place is grade 3 and 4 , aka dengue shock syndrome. Given the widespread availability of isotonic infusion solutions, they are commonly given also to patients with grade 1 and 2 DHF, simply to satisfy the comfort level of the attending physicians that in leakage conditions isotonic solutions would be preferred although there are no strong reasons, except in mild hyponatremia.
Maintenance fluid therapy can be viewed as an important supportive therapy for hospitalized patients. Unlike resuscitation fluid therapy where the goal is to restore hemodynamic derangement, maintenance therapy is aimed at maintaining homeostasis in patients who have insufficient oral intake of fluid
Goal of maintenance fluid therapy can be summarized as follows:
- Fulfills daily physiological requirements for homeostasis. Restore quickly the depleted fluid and electrolyte content of intracellular compartment
- Prevents electrolyte & acid base disorders
- Supports primary therapy of patients’ illness
- Enzymatic process & protein synthesis
- Facilitates recovery
What are the features of a good maintenance solution ? (2)
- Practical, easy and safe to administer
- In addition to basic electrolytes (Na+,K+,Cl-) also contains microminerals (Mg++,Ca++,P) which are required for cellular metabolism
- The presence of value added zinc helps to promote tissue healing
- Contains high quality amino acids (BCAA enriched, high in EAA) to promote protein synthesis
- Glucose to maintain euglycemia, prevent ketosis, and protein-sparing effects.
One of possible candidates to fulfill the above criteria is Aminofluid®. Compositions of Aminofluid and other maintenance solution (KAEN3B) and Ringer’s lactate are shown below:
Table 1. Composition of Aminofluid compared with Ringer’s Lactate & KAEN3B
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Composition
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Aminofluid„¥
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KAEN3B„¥
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Ringer’s lactate
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ASPEN guideline(2)
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Water
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2000
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2000
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2000
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30-40 ml/kg/day
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Na+
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70
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100
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260
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1-2 mEq/kg/day
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K+
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40
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40
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8
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1-2 mEq/kg*/day
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Cl-
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70
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100
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218
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as needed
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Mg++
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10
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-
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-
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8-20 mEq/day
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Ca++
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10
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-
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-
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10-15 mEq/day
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P
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20
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-
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-
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20-40 mEq/day
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Zn
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10 µmol
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-
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-
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2.5-5 mg
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Amino acid
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AA 60 g
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-
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-
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0.8 g/kg/dayƒÖ
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Glucose
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150 g ¥
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54 g
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-
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* basic requirement for K+ homeostasis 20-30 mEq/daily (10); ƒÖ basal amino acid requirement in nonstressed patients; ¥ protein-sparing effect
Maintenance IV fluid therapy can be considered to substitute the oral intake of water and nutrients. Its place in grade 1 and 2 must be encouraged when oral intake is severely impaired by nausea, anorexia and vomiting. The rationale of new generation maintenance solution as supportive fluid therapy in grade 1 & 2 DHF is based on the following:
- Although patients feel thirsty due to probable hypertonic dehydration, they might not be able to consume enough water and nutrient owing to abdominal discomfort/pain, hepatomegaly
- Elevated levels of cytokines, such as interferons (IFNs), interleukin-2 (IL-2), IL-8, and tumor necrosis factor alpha, have been reported in DHF(3) One of their pleiotropic effects is delaying gastric emptying
- Patients might experience loss of appetite because of dry mouth (dehydration), malaise and fatigue besides other systemic symptoms(4) .
Therefore, once body fluid homeostasis is restored, systemic symptoms might be alleviated and further progression to more severe illness is prevented.
* Abstract from Proceedings of Lunch Symposium Advances in Maintenance Fluid Therapy in medical Patients. The 5th International Symposium and the 8th International Course on Metabolism and Clinical Nutrition (ISCMCN) FKUI 2010
References:
- Prevention and Control of Dengue and Dengue Haemorrhagic Fever. WHO Regional Publicaiton, SEARO No 29.
- Darmawan I. Paradigma Baru dalam Terapi Cairan Meintenance. Simposium Nasional Penyakit Tropik Infeksi, HIV & AIDS, J W Marriott Hotel, Surabaya 22 Maret 2008
- Anon Srikiatkhachorn, Chuanpis Ajariyakhajorn, Timothy P. Endy, Siripen Kalayanarooj, Daniel H. Libraty, Sharone Green, Francis A. Ennis, and Alan L. Rothman Virus-Induced Decline in Soluble Vascular Endothelial Growth Receptor 2 Is Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. 2007 February; 81(4): 1592–1600.
- Othman N.Clinical profile of dengue infection in children versus adults.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page S435
Iyan Darmawan, MD
Medical Director
iyan@ho.otsuka.co.id
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