Fluid therapy

A detailed discussion of fluid therapy is given by DirummiondiiM(1995]. Fluid therapy is titrated to clinical and laboratory assessment of volume status, but generally involves the administration of about 2.5 to 3 l/day of maintenance in the average adult (30-40 ml/kg/day). Unlike other vascular beds, capillaries in the brain are impermeable to most small molecules including sodium, and fluid flux across an intact blood-brain barrier is primarily governed by osmolality rather than plasma oncotic pressure. Consequently, plasma osmolality is often elevated with mannitol (up to 320 mosmol/l), and it is important to avoid hypotonic fluids, which may reduce plasma osmolality and worsen cerebral edema. Glucose-containing solutions are generally avoided, since the water that accompanies the active transport of dextrose across the blood-brain barrier can worsen cerebral edema, and hyperglycemia can worsen outcome in cerebral ischemia. Disruption of the blood-brain barrier might be expected to reduce the effects of osmolality on fluid flux and increase the relevance of plasma oncotic pressure, but this issue is as yet unresolved. It would seem prudent, however, to avoid marked reductions in colloid oncotic pressure.

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