Today our topic of discussion is Correction of Acidosis and Fluid Replacement.
Correction of Acidosis and Fluid Replacement
Correction of Acidosis and Fluid Replacement
It is necessary to have a proper venous access for correction of acidosis administration of other drugs and fluid replacement. Peripheral veins are conveniently used during arrest but in case of vasoconstriction and venous collapse, central venous cannulation should be attempted making sure that it does not interfere with resuscitative efforts.
Correction of acidosis should be attempted if the arrest has continued for few minutes. Acidosis can be respiratory acidosis which results from failure of carbon dioxide elimination. Carbon dioxide production is continuous but the gas cannot be removed because of pulmonary and cardiac failure. PaCO, rises and PO, lowers.
Metabolic acidosis develops with tissue hypoperfusion occurs. Blood gas shows an acid pH. It is due to reduction in the (HCO) which is associated with an equivalent rise in chloride leaving the anion gap unchanged or the fall in (HCO) which is accompanied by equivalent rise in anion gap..
By ensuring adequate alveolar ventilation carbon dioxide removal can be achieved and residual metabolic acidosis corrected by the administration of sodium bicarbonate. The actual amount of bicarbonate required in each case is determined on the basis of blood gas results that are the patient’s base deficit.
Sodium bicarbonate is used sparingly as against the earlier practice because major part of metabolic acidosis can be corrected by adequate alveolar ventilation. The initial dose of sodium bicarbonate is I mEq/ kg which is given slowly.
Further administration should be guided by blood gas determination. Formula which could be used. 0.3 x wt (kg) x based deficit. If blood gas result is not available half of the initial dose every 10-15 minutes is appropriate.
Volume replacement: Isotonic crystalloid is the best for rapid expansion of circulatory blood volume. Collapsed jugular and peripheral veins, dryness of mucous membranes, absence of normal secretions, and peripheral vasoconstriction with appropriate history suggest dehydration and volume deficit.
Volume replacement should be attempted and restored until cardiac function is restored. It can be initiated with ringer lactate or normal saline. If the quantity of fluid required is in excess of 1-2 liters for adults, colloids is added. Volume infusion can be guided by central venous pressure and pulmonary capillary wedge pressure.
Drugs in Advanced Cardiac Life Support
Drug therapy for advanced cardiac life support is discussed in Table 30.1.
Termination of Cardiopulmonary Resuscitation
It is difficult to decide to terminate unsuccessful resuscitative efforts. Inability to restore adequate cardiovascular function is the basis of the decision. Most definitive signs which act as a guideline are absence of reactive pupils, lack of spontaneous activity and response to deep pain and absent brainstem reflexes.
Family of the patient should receive high priority in making the decisions of terminating the life support. Postresuscitation support: In case of a successful resuscitation. postresuscitation support plays an important role in deciding the final outcome.
Transition from emergency service to critical care unit need to be carried out smoothly. A thorough assessment and examination should be carried out. Diagnostic Studies required further should be completed.
Ventilatory support is continued at optimal level. Cardiac support with minimal cardiac work is maintained with appropriate drugs. Transportation is arranged only after proper stabilization and critical care unit is ready to receive the patient.
Patient should be accompanied by a nurse and a physician with adequate equipment. Portable ventilators are available which can be used while transferring the patient from emergency unit to critical care unit. If it is not available Ambu bag with an oxygen source can be used during shifting to provide artificial ventilator.
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