fluid balance and iv fluid therapy
TRANSCRIPT
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Fluid Balance and IV Fluid Therapy
Mike Bowe
Critical Care Pharmacist
Queen Elizabeth Hospital, Gateshead
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Learning outcomes
• Understand principles of fluid distribution within the
adult body
• Understand the principles of fluid balance
• Understand the differences between fluid
maintenance and resuscitation
• List available fluids and their place in treatment
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Fluid distribution
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• Haemodynamic forces:
• Changes in blood
volume affect cardiac
output & circulation
• Autonomic control
• Starling’s hypothesis:
• If hydrostatic
pressure>osmotic
pressure, fluid leaves
capillary & vice versa
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Normal composition of major body fluid compartments
Plasma (mmol/L) Interstitial Fluid (mmol/L)
Intracellular Fluid(mmol/L)
Na+ 142 144 10
K+ 4 4 160
Ca2+ 2.5 2.5 1.5
Mg2+ 1.0 0.5 13
Cl- 102 114 2
HCO3- 26 30 8
PO42- 1.0 1.0 57
Protein 16 0 55
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Intracelluar fluid
• Volume controlled by water balance:
• Intake controlled by thirst
• Excretion controlled by ADH
• Volume decreases with illness
• Most potassium is intracellular
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Extracellular fluid
• Made up of interstitial and intravascular (plasma)
compartments
• Volume controlled by sodium balance
• Volume increases with illness
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Fluid balance
• Vital to know what goes in and what comes out
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Water balance
• Osmolarity
• Plasma osmolarity >280mOsmol/kg
• Sensitises central osmoreceptors stimulates thirst response
• ADH secreted water reabsorbtion
• Circulating volume
• blood volume (atrial stretch receptors) and BP (baroreceptors)
• ADH secreted water reabsorbtion
Intake controlled by thirst
Excretion controlled by ADH (vasopressin)
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Where Do We Gain Fluid?
• Need around 25-30ml/kg/day (but may range from 20-60ml/kg/day)
• Women = 2l/day
• Men = 2.5l/day
• Need 1mmol/kg each of K+ & Na+
• Need 50-100g/day glucose
Ingested Liquids
(1500ml/day)
Ingested Moist Food
(800ml/day)
Metabolic Water
(200ml/day)
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Where Do We Lose Fluid?
• Water loss:
• Dehydration
• From ICF & ECF
• Na+ & H2O loss:
• From ECF (plasma – small
quantity & ISF)
• Blood loss:
• From ECF (plasma then
interstitial fluid)
Kidneys
(1500ml/day)
Skin
(600ml/day)
Lungs
(300ml/day)
GI Tract (100ml/day)
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NICECG 1742013
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Urine
• Minimum 0.5ml/kg/hour
• Usually 1.5-2L/day (20 x weight)
• Needed to excrete metabolic waste products
• Patient’s with oliguria/anuria may need fluid
restriction
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Signs of Dehydration
• Thirst
• Dry membranes
• Urine output
• Headache
• Fatigue
• Sunken eyes (&
fontanelle in
babies)
• Skin turgor
• BP (& CVP)
• HR
• Weak, thready
pulse
• Cold peripheries
• Weight loss
• capillary refill
• Serum Na+
• Serum osmolality
• haematocrit
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Hypovolaemia
• Refers to isotonic fluid loss from extracellular space
• Excess fluid loss:
• haemorrhage, GI losses, abdo surgery, excess diuretic/laxative Tx,
fever, DM with polyuria
• 3rd space fluid shifts:
• capillary membrane permeability, osmotic pressure
• (also seen in acute intestinal obstruction, acute peritonitis,
pancreatitis, burns, crush injuries, heart failure, hip fracture,
hypalbuminaemia, liver failure, pleural effusion)
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Hypervolaemia
• Excess fluid in extracellular space
• Excess Na+ or fluid intake (IVT, blood/plasma products, dietary
Na+)
• Na+ and fluid retention (heart failure, cirrhosis, nephrotic
syndrome)
• Fluid shifts (remobilisation after aggressive IVT, hypertonic fluid
administration)
• Prolonged hypervolaemia oedema (hydrostatic
pressure)
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Setting a fluid balance
• Parenteral fluids, parenteral medication,
enteral feeds, enteral fluids
• Urine, N&V&D, filtrate (if RRT),
insensible losses, drain & stoma losses
Assess volume status – Input vs. Output
Assess clinical status – resuscitation/stabilisation/recovery
Inputs
Outputs
Not an exact science and many need to be adapted according to patient clinical condition
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Assessment of fluid status
• Systolic BP <100mgHg
• HR >90bpm
• CRT >2sec or peripheries cold to the
touch
• Resp rate >20bpm,
• NEWS >4
• FBC, U&E’s
• Passive leg raising suggests fluid
responsiveness
• Fluid balance charts
• Weight
Assess whether the patient is hypovolaemic and need of urgent fluid resuscitation:
Lab investigations should include current status and trends in:
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Type of fluid replacement
Intravenous Fluid
Crystalloids Colloids
NaClHartmann’s
Balanced solutions
Glucose
Blood ProductsPRC
Plts, FFPAlbumin
GelatinsStarches
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Crystalloids
• Iso-osmotic with plasma
• Distribution determined by sodium concentration
• Contain low molecular weight salts or sugars dissolved in water
• Require several times more crystalloid than colloid to achieve the same
degree of vascular filling
• Move rapidly into the interstitial space
• Can result in interstitial oedema
• No anaphylactic risk
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Solution Na+
(mmol/L)
K+
(mmol/L)
Cl-
(mmol/L)
Ca2+
(mmol/L)
HCO3-
(mmol/L)
Glucose (g/L)
Plasma 135-145 3.5-5 94-111 2.2-2.6 23-27 0.72-1.26
NaCl 0.9% 154 - 154 - - -
Hartmann’s 131 5 111 2 29 -
Plasmalyte 141 4.5 98 - 26 -
Dex/Saline(+ KCl)
31 (0-40) 31 - - 40
Glucose 5% - - - - - 50
Target for 70kg pt
70 70 70 50-100
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Sodium Chloride 0.9%
• Disperses throughout ECF not ICF
• Uses:
• Fluid resuscitation
• Replacement of upper GI fluid losses
• Problems:
• Hypochloraemic acidosis
• Hypernatraemia
• 20% remains intravascular at 1 hour
• Commonly used in drug preparations
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Glucose 5%
• Electrolyte free, disperses through ICF and ECF as water
• Very small % remains in blood after distribution
• Good source of free water
• Can cause water intoxication, hyponatraemia, hyperglycaemia
• 1L provides 200kcal
• Used for immediate hydration, supply of water over and above
electrolyte requirements, drug administration
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Balanced solutions
• Hartmann’s, Plasmalyte
• Electrolyte and pH profile similar to plasma/interstitial fluid
• vs. NaCl 0.9% less hyperchloraemic acidosis
• Shaw et al. compared NaCl 0.9% vs. Plasmalyte in patients undergoing open abdo surgery:
• Less electrolyte disturbances
• Fewer blood transfusions
• Less renal failure requiring dialysis
• Less post-op interventions
• Lactate metabolised and acts as buffer to acidosis
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Balanced solutions
• Uses:
• Resuscitation fluid
• Maintenance fluid
• Replacement of large stoma losses
Hartmann’s first choice for resuscitation and maintenance
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Glucose 4%/Sodium Chloride 0.18%(+KCl)
• Isotonic solution
• Useful where fluid depletion from all compartments eg. diabetes
insipidus
• Useful for maintenance but not to be used for resuscitation or
replacement
• Risk of hyponatraemia, especially in the elderly
Ideal maintenance fluid??
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Colloids
• Large osmotically active molecules in an electrolyte solution (NaCl
0.9% or balanced solution)
• Remain in the plasma for longer than crystalloids so faster and more
prolonged plasma expansion
• Issues:
• Lack of evidence for benefit over crystalloids
• More expensive
• Anaphylactic risk
• Can effect coagulation
• Some evidence of harm
• Unsuitable for the Tx of dehydration
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Gelatins
• Plasma volume expander
• Derived from bovine gelatin
• Wide variation in molecule size
• Provide good initial volume expansion ( 1 hour)
• Plasma t1/2 2-4 hours
• May impair haemostasis by affecting platelet function and coagulation
• May cause more kidney injury
• Stimulates histamine release
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Human Albumin Solution
• Prepared from whole blood
• Contains soluble proteins suspended in NaCl
• Expensive
• Can worsen oedema as albumin will leak into interstitium
4.5%Isotonic
Volume replacementBurns
Ascitic fluid loses?
20%Hypertonic
Volume expanderHypo-oncotic intravascular volume
depletion with oedemaAscitic fluid loses
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• Compared the effects of HAS 4% vs. NaCl 0.9% in 7000 critically ill pts
• No difference in all cause mortality at 28 days
• Subgroup analysis revealed possible association between the use of
HAS and increased mortality in patients with TBI
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Where Does 1L Fluid Go?
Fluid IntracellularFluid
Extracellular Fluid
Interstitial Space Intravascular Space
Glucose 5% 666ml 222ml 111ml
Sodium chloride 0.9%
666ml 333ml
Colloid 1000ml
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Does the patient need IV fluid?
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5 R’s
Resuscitation
Routine maintenance
Replacement and Redistribution
Reassessment
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Sepsis – why do you need fluids?
Activation of inflammatory cascade
vascular permeability and fluid shifts
Hypovolaemia Shock
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Sepsis Fluid Resuscitation
• 1st line Hartmann’s (preferred) or NaCl 0.9%
• Consider HAS 4.5% as resuscitation fluid for severe
sepsis
• Fluids very important but aggressive early
treatment does not give improved outcome
(Mouncey, NEJM, 372:14)
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Burns – why do you need fluids?
Activation of inflammatory cascade
vascular permeability and fluid shifts
Hypovolaemia Shock
Burn (>15%)
Exudation
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Burns Fluid Resuscitation
• Treat from time of burn, not time of arrival
• Aims:• Adequate CVP, BP & cardiac output• Urine output 0.5-1ml/kg/hour
• First 24 hours:• Hartmanns (preferably) or NaCl 0.9%• 3-4ml/kg/%burn• Give first half in first 8 hours then rest over 16 hours
• After 24 hours:• Adapt fluids (colloids or crystalloids) to patient• May need Glucose 5%• Give electrolytes
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Post-op – why do you need fluids?
• Fluids given in Theatre & Recovery to replace deficit from fasting and
intra-op blood loss
• Routine maintenance fluid should not be needed for minor procedures
(unless not drinking for several hours-days)
• Fluids may be required to manage ongoing fluid losses
• Monitor drain losses, vital signs, urine output, biochem
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Pharmacist’ Role With Fluids
• Fluids are drugs and just as dangerous
• Awareness:
• What is the patient on? Rate?
• Appropriateness:
• Reasonable fluid for situation?
• Response:
• Urine output? Electrolytes?
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Summary
• How fluids are distributed in the body
• Types of fluid
• Associated with organ dysfunction
• Resuscitation Stabilisation ReassessmentHypovolaemia
• Think Hartmann’s (or NaCl 0.9%)
• Not colloids in ITU (?HAS in severe sepsis)Resuscitation
• Remember normal daily fluid and electrolyte requirements
• 25-30ml/kg/day water
• 1mmol/kg Na+/K+/Cl-
• 50-100g/day glucose
• Avoid too much Na+ and Cl-
Maintenance
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References• NICE, Intravenous fluid therapy in adults in hospital, CG 174, 2013
• British consensus guidelines on intravenous fluid therapy for adult surgical
patients (GIFTASUP), 2012
• Myburgh, J. A. & Mythen, M. G., Resuscitation fluids, NEJM, 2013, 369; 13:
1243-1251
• Mouncey, P. R. et al, Trial of early, goal-directed resuscitation for septic
shock, NEJM, 2015, 372; 14 1301-1311
• Shaw AD et al. Major complications, mortality, and resource utilization
after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann
Surg, 2012 May;255(5):821-9
• National Plasma Product Expert Advisory Group. Clinical Guidelines for
Human Albumin Use. www.nsd.scot.nhs.uk
Thanks to Nic Corkhill, Emma Boxall, Fraser Hanks & Ruth Roadley-Battin