**Author details**

diarrhea, too. Management includes stabilizing the patient; maintaining the airway patency; effective breathing; prompt use of epinephrine, fluid resuscitation, parenteral steroids, and

Trauma in elderly patients needs special attention as cardiac compliance decreases with age. The heart cannot compensate for blood loss as efficiently as in youngsters. There is a decrease

antihistamine; and the use of bronchodilators, if necessary [3] (**Figure 6**).

**11. Special considerations**

**Figure 6.** Anaphylaxis management algorithm [8].

36 Essentials of Accident and Emergency Medicine

**11.1. Advanced age**

Rana Jaffer Hamed Hussein

Address all correspondence to: ranajaffer1979@yahoo.com

Hamad Medical Corporation (HMC), Doha, Qatar

### **References**

[1] Tintinalli's Emergency Medicine. A Comprehensive Study Guide. 8th ed

[2] American College of Surgeons. Advanced Trauma Life Support, Student Course Manual. 9th ed

**Chapter 3**

**Provisional chapter**

**Approach to Fluid Therapy in the Acute Setting**

**Approach to Fluid Therapy in the Acute Setting**

DOI: 10.5772/intechopen.74458

In the acute medicine, fluid therapy is a common intervention. Clinicians may have different preferences in prescribing the fluids—the type, the volume and rate, and the monitoring of response—but there is a growing argument in the literature for a more consistent and evidence-based approach to these prescriptions. This coincides with the call to treat fluids as drugs and to strategize the fluid management of individual patients. A good start toward observing this call will be an appreciation of the underlying physiology. The hemodynamic, biochemical, and microcirculatory responses to fluid therapy will influence the end-organ and clinical effects. In translating these physiological insights into practice, recent studies in several acute cohorts like trauma, sepsis, and postoperative and intensive care offer valuable guides. With all this in mind, the chapter aims to review the optimal approach to fluid therapy in the acute setting, from the understanding of the

**Keywords:** intravenous infusions, crystalloid solutions, colloids, emergency medicine,

Majority of patients, in the early and immediate phase of their presentations to the hospital, will require fluid therapy. These fluids are given for various indications, from hemodynamic instability to the delivery of medications [1]. The clinical scenarios that demand the administration of fluids in the acute phase of these patients' stay in the hospital are often complex, yet the task in deciding the fluid regimen is often delegated to junior staff who may lack the necessary insight and experience [2]. Such attitude is compounded by the inadequate knowledge, among the doctors, on the essentials of intravenous fluids like the electrolyte components [3].

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Nor'azim Mohd Yunos

Nor'azim Mohd Yunos

**Abstract**

critical care

**1. Introduction**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

relevant basic sciences to the practice at the bedside.

http://dx.doi.org/10.5772/intechopen.74458


#### **Approach to Fluid Therapy in the Acute Setting Approach to Fluid Therapy in the Acute Setting**

DOI: 10.5772/intechopen.74458

#### Nor'azim Mohd Yunos Nor'azim Mohd Yunos

[2] American College of Surgeons. Advanced Trauma Life Support, Student Course Manual.

[3] Rosen's Emergency Medicine. Concepts and Clinical Practice. 7th ed

[7] http://nursingcrib.com/critical-care-and-emergency-nursing/cardiogenic-shock/

9th ed

[4] www.uptodate.com

[5] www.survivingsepsis.org

38 Essentials of Accident and Emergency Medicine

[6] https://en.wikipedia.org/wiki/Sepsis

[8] https://www.resus.org.uk/resuscitation-guidelines/

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.74458

**Abstract**

In the acute medicine, fluid therapy is a common intervention. Clinicians may have different preferences in prescribing the fluids—the type, the volume and rate, and the monitoring of response—but there is a growing argument in the literature for a more consistent and evidence-based approach to these prescriptions. This coincides with the call to treat fluids as drugs and to strategize the fluid management of individual patients. A good start toward observing this call will be an appreciation of the underlying physiology. The hemodynamic, biochemical, and microcirculatory responses to fluid therapy will influence the end-organ and clinical effects. In translating these physiological insights into practice, recent studies in several acute cohorts like trauma, sepsis, and postoperative and intensive care offer valuable guides. With all this in mind, the chapter aims to review the optimal approach to fluid therapy in the acute setting, from the understanding of the relevant basic sciences to the practice at the bedside.

**Keywords:** intravenous infusions, crystalloid solutions, colloids, emergency medicine, critical care

### **1. Introduction**

Majority of patients, in the early and immediate phase of their presentations to the hospital, will require fluid therapy. These fluids are given for various indications, from hemodynamic instability to the delivery of medications [1]. The clinical scenarios that demand the administration of fluids in the acute phase of these patients' stay in the hospital are often complex, yet the task in deciding the fluid regimen is often delegated to junior staff who may lack the necessary insight and experience [2]. Such attitude is compounded by the inadequate knowledge, among the doctors, on the essentials of intravenous fluids like the electrolyte components [3].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Intravenous fluids are drugs, and like other drugs, there are potential complications. In the acute setting where these fluids are commonplace, it is imperative that the practice aims at administering the right patient the right fluids, at the right volume and rate, with the right overall fluid balance.

membrane also contains active pumps and transporters that distribute individual solutes, including electrolytes. These electrolytes account for the effective osmolality (tonicity) that governs the water movement. The mechanisms of these electrolyte movements are further defined by the Gibbs-Donnan effect of the nondiffusible large anions like protein. The end

The ECF is further divided into the interstitial fluid and the plasma compartments, the two separated by the capillary wall. Except for plasma proteins and blood cells, the pores on the capillary wall permit the flux of water and small solutes. This contributes to the two compartments having almost similar electrolyte composition with only small differences contributed by the Gibbs-Donnan effect of the plasma proteins. By volume, these plasma proteins constitute 7% of the plasma volume with the remaining 93% plasma water. As a side note, these proteins are solids in the plasma, and the changes in their plasma load will affect the water-

A complex interaction of regulatory mechanisms from different organs helps the body to maintain an effective fluid volume in different circumstances. The key pathway that underpins this volume regulation is the hormonally mediated renin-angiotensin II-aldosterone-system (RAAS), with the faster neutrally mediated baroreceptor reflex contributing an indirect role through its interplay of the pressure regulation. In the context of the fluid therapy scope of the

The RAAS pathway is activated by a decrease in the renal perfusion pressure, detected by the juxtaglomerular apparatus (JGA) (**Figure 2**). In the JGA, the reduced renal perfusion stimulates the granular cells of the afferent arteriole to secrete the proteolytic enzyme renin through a direct intrarenal baroreceptor activity and detection of reduced sodium chloride concentrations by the macula densa in the wall of the ascending limb of the loop

) as the predominant ion and an ECF com-

Approach to Fluid Therapy in the Acute Setting http://dx.doi.org/10.5772/intechopen.74458 41

) as the predominant ions [5].

results are an ICF compartment with potassium (K<sup>+</sup>

based measurements of plasma electrolyte concentrations [6].

) and chloride (Cl−

partment with sodium (Na<sup>+</sup>

**2.2. The body fluid regulation**

**Figure 2.** The juxtaglomerular apparatus.

chapter, the RAAS will be elaborated below.
