iv fluids2`

8/8/2019 Iv FLUIDS2`

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CONFUSIONy 1.Why am I giving fluid?

y 2.How will I give fluid (is IV necessary)?

y 3.What fluid?y 4.How much fluid?

y 5.How will I monitor?


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We areapproximately two-thirds water


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Fluid shifts / intakes

Intracellular

30 litres

Interstitial 9litres

IV 3litres

Kidneys Guts Lungs Skin

Extracellular fluid 12 litres


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Daily Fluid BalanceIntake:2-2.5L

Insensible Loss-Lungs 0.3L-Sweat 0.1 L

Urine: 1.0 to 1.5L

STOOL:0.5 L

100ml / hour

70 KG

MALE

1. Why give fluid?


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1. Maintenance variesy More

y Stool loss (diarrhoea)

y Skin loss (fever, burns)y Urine loss (DI)

y Other losses (drains, capp leak)

y Less

y SIADH

y Heart failure

y Renal failure


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Thi k of 3 compo ts

DeficitMaintenance

Ongoing losses


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Volume Deficit-Clinical Types

y Total body water:y Water loss (diabetes insipidus, osmotic diarrhea)

y Extracellular:y Salt and water loss (secretory diarrhea, ascites, edema)y Third spacing

y Intravascular:y Acute hemorrhage


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Clinical Diagn sis

y Intravascular depletionMAP= CO x SVR

Hemodynamic effectsy BP HR JVP

y Cool extremities

y Reduced sweating

y Dry mucus membranes

E.C.F. depletion Skin turgor, sunken eyeballs

Weight

Hemodynamic effectsWater Depletion

Thirst

Hypernatremia


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1. Fl i ficit

y Mild (< 4 %)

y No clinical signs

y Moderate (6 %)

y Some clinical signs

y Severe (8% +)y Multiple signs

y +/-acidosis, hypotension

Example

10 kg child

Mild 3 % of 10 kg = 300ml

Moderate 6 % of 10 kg= 600 ml

Severe 8 % of 10 kg =800 ml


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Mild (40% BloodVolume)

Cool extremities

Increased capillary refilltimeDiaphoresisCollapsed veinsAnxiety

Same, plus:

TachycardiaTachypneaOliguriaPostural changes

Same, plus:

Hemodynamic instabilityMarked tachycardiaHypotensionMental status

deterioration (coma)

Example :70 kg male 5 litres blood volumeSevere 40 % of 5 L = 2 litres


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1. goi g loss s

y Urine

y Stool

y Skiny Drains

y Redistribution


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Third S aceyAcute sequestration in a body compartment

that is not in equilibrium with ECF

y Examples:

y Intestinal obstructiony Severe pancreatitis

y Peritonitis

y Major venous obstruction

y

Capillary leak syndromey Burns


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2. How will I giv fl i ?

y 2. Options

y Enteraly Oraly Nasogastricy

Othery Parenteral

yIVy other


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WHATARETHE OPTIONS?y Crystalloids:

y 0.9% saline - not normal !

y 5% dextrosey DNS

y RL

y Colloids:

y bloody plasma / albumin

y synthetics


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C siti n

Fluid Osmo-

lality

Na Cl K

D5W 253 0 0 0

0.9NS 308 154 154 0

LR273

130 109

4.0

5% Albumin 308 145 145 0

3%Saline1027

5

13

513

0

Pluscalcium+ lactate

ECF 270 140 110 4


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Os lality / t nicityy Plasma osmolality = 2 (Na) + glucose/18 + BUN/2.8

y = 2 X140 + 90/18 + 14/2.8 = 280 +10 = 290 mosm/ kg

water


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Os tic / nc tic ressure

Na+

Na+

PP

Intracellular Interstitial Intravascular

BRAIN

CELL

00 g f Na

00 g

Hyper tonic

Water

Na pump


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Hy er s lar but n r al t nicity

BRAIN CELL Intravascular

00 g f urea

150 g f urea150 g f urea

No net movement of water


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Crystall ids & c ll ids

0 litres

9 litres litres

2 litres f

bl d


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0 litres

9 litres litres

2 litres f

c ll id


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0 litres

9 litres 5 litres


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29 litres

8 litres 7 litres


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0 litres

9 litres litres

2 litres f

0.9% saline


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0 litres

9 litres 5 litres


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0 litres

10.3. litres 3.7litres


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30 litres

9 litres 3 litres

2 litres f

5% dextr se


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31.4 litres

9.6 litres 3.15

litres


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The rules f fluid re lace ent:

Re lace bl d ith bl d in 1: 1 rati

Re lace las a ith c ll id 1: 1 rati

Resuscitate ith crystall id in sh ck 1: 3 rati

Re lace ECF de leti n ith saline

Rehydrate ith dextr se


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N te

y Daily requirement of one day one litre NS 154meq/l ( 1- 2meq/kg /day)

y

Daily requirement of K+- 1 meq/kg/dy Excess Na+ given body takes 3 4 days to get rid of

the unnecessary Na

y Only 5 % Dextrose excess free water dilutional

hyponatremiayAvoid 5 % Dextrose in hypoperfusion states


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N tey NS and RL can be used interchangeably

y Prefer NS when hyperkalemia, hypercalcemia,

hyponatremia, hypochloremia and metabolic alkalosis.


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N te

yAvoid RL if K+ levels high

yAvoid NS ifBP high

yAvoid plain 5 % D or DNS if diabetic


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C ll ids

yAlbumin-

y Expensive

y

25%(100 ml ) and 5% (500ml )y Dont use if alb / prot levels > 2.5mg/dl / 5 mg/dl

y Not for increasing albumin in chronic illness

y Not a nutritional source


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C ll idy Hydroxyethyl starch

y 6 % soln in 0.9% Nacl

y

Less expensivey Increases urine output due to osmotic diuresis!!

y Dose 500- 1000ml (30-50 g)

y Dont give more than 1500ml

y Rate 20ml /kg /hry Example : 1400 ml /hr in 70 kg male

y Reduce after the initial dose to 50% if creatinineclearance low


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Hy ert nic S luti ns Fluids containing sodium concentraions greater

than normal saline.

Available in 1.8%, 3%, 5%, 7.5%, 10% solutions.

Hyperosmolarity creates a gradient that drawswater out of cells; therefore, cellular dehydration isa potential problem.


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4. How m ch will I giv ?

y 4. Deficit

y Hypovolaemiay Give boluses 10-20 ml/kg 0.9% saliney May be repeated

y Replace deficity Quickly in gastroenteritis (enteral fluids) 6Hy SHOCK - as fast as possible


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Maintenance fluids

y

Bodyweight Fluid required per 24 hours Fluid required perhour

y 1st10 kg 100 ml/kg 4 ml/kg

y 2nd10 kg 50 ml/kg 2 ml/kg

y Subsequent kg 20 ml/kg 1 ml/kg


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y 15 kg 3 yr old

y What is her normal daily fluid requirement?y What is her fluid requirement per hour?


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y 3 yo, 15 kg, daily fluids

y 10 kg x 100 ml/kg/d + 5 kg x 50 ml/kg/d

y 1250 ml/d

y 1250/24 = ~ 50 ml/h


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y 30 kg male

yWhat is his normal daily fluid requirement?

y What is his fluid requirement per hour?

y 10 kg x 100 ml/kg/d + 10 kg x 50 ml/kg/d+10 x20ml/kg/d

y 1700 ml/d

y 1700/24

y


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Exa le- GI Bleed

A 25 year old patient presents with massive hematemesis (vomitingblood) x 1 hour. He has a history of peptic ulcer disease.

Exam: Diaphoretic, normal skin turgor.

Supine BP: 120/70 HR 100

Sitting BP: 90/50 HR=140

Serum Na=140

What is the nature of his fluid deficit ?What IV fluid resuscitation would you prescribe ?


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Orth static Hy tensi n Systolic blood pressure decrease of greater than

20mmHg from supine to standing

Indicates fluid deficit of 6-8% body weight

- Heart rate should increase as a compensatorymeasure

- If no increase in heart rate, may indicate autonomicdysfunction or antihypertensive drug therapy


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Exa le-Diarrhea and V iting

y A 18 year old male with severediarrhea and vomiting x 48hours.

y Sunken eyeballs, poor skinturgorand dry mucusmembranes

y BP 80/70 HR 130 supine.

y Labs: Na 130 K=2.8HCO3 =12

ABG: 7.26/26/100

y What is the nature of hisfluid deficit ?

y

What fluid will youprescribe ?

y What would happen ifD5W were to be used?


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Exa le-Hy er s lar State

A 85 year old female known diabetes was admitted withconfusion.

Exam: Disoriented

BP: 110/70 supine 90/70 sitting. Decreased skin turgor.

Labs: Na= 150meq/L Wt=50kgs

BUN/Cr=50/1.8 Blood sugar= 1200 mg/dl Hct=45

What is the pathogenesis of her fluidand electrolyte disorder ?

How would you treat her ?


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Calculati n fWater Deficit

Osm (P Na) x volume Osm (P Na) x volume

Healthy Dehydrated

A 50 kg female with Na=150

Na x Normal Body Water = Na x Current Body Water

140 x NB W = 150 x (0.5 x 50=25 liters)

NBW = 26.8 liters

Water deficit = NBW-CBW= 26.8-25=1.8 liters


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What ab ut nutriti n ?

NS NO NUTRITIONRL NO NUTRITION5 % DEXTROSE 50 G IN 1000ML

DNS 5OG IN 1000 ML10 % DEXTROSE - 100 G IN 1000 ML


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Peri erative Fluid Require ents The following factors must be taken into account: Maintenance fluid requirements

NPO and other deficits: NG suction, bowel prep

Third space losses

Replacement of blood loss

Special additional losses


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NPO and ther deficits NPO deficit = number of hours NPO x

maintenance fluid requirement.

Bowel prep may result in up to 1 L fluid loss.

Measurable fluid losses, e.g. NG suctioning,vomiting, ostomy output.


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Re lacing Third S ace L sses Superficial surgical trauma: 2 ml/kg/hr

Minimal Surgical Trauma: 4 ml/kg/hr

hernia

Moderate Surgical Trauma: 6 ml/kg/hr

- pyelolithotomy

Severe surgical trauma: 8 ml/kg/hr (or more)

- Explorative laparotomy


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Exa le 62 y/o male, 70 kg, for hemicolectomy

NPO after 2200, surgery at 0800, received bowelprep

3 hr. procedure, 500 cc blood loss

What are his estimated intraoperative fluidrequirements?


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Exa le (c nt.)

Fluid deficit: 1.5 ml/kg/hr x 10 hrs = 1000 ml + 1000 mlfor bowel prep = 2200 ml total deficit: (Replace 1/2 firsthr, 1/4 2nd hr, 1/4 3rd hour).

Maintenance: 1.5 ml/kg/hr x 3hrs = 300mls

Third Space Losses: 6 ml/kg/hr x 3 hrs =1260 ml

Blood Loss: 500ml x 3 = 1500ml

Total = 2200+360+1440+1500=5500mls


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EXAMPLEy 70 kg male has underwent hernia surgery.

yWhat is fluid requirement?

y

Npo for 12 hours= 1.5 ml / kg /hr= 100 x12= 1200 mly 1 hour procedure = 100 ml ( 1.5 x 70 x1 )

y Third space loss = 4 ml / kg /hr = 4 x 50 x 1 = 280

y Total = 1480 ml


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N tey Continous sequestration of fluids postop for 12 hrs

y Mobilisation of the third space loss after 2-3 days


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Exa ley 70 kg male underwent gastrectomy . 1st pod intake 3.5

L. urine 800 ml

y Ryle tube 400 ml

y Drain tube 150 ml

y Insensible loss 1000 ml

y Total intake total output = 3500 ( 800 + 400+150 +1000) = 3500 2350 = 1150 ml ( deficit)

y Days maintainence = 1.5 ml / kg / hr = 1.5 x 70 x 24 =2400 ml

y Total need = 1150 + 2400 =3550 ml


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How to give ?y Total Na requirement = I litre normal saline

y Drain / Ryles tube loss 1 L RL

y

Rest give DNS/ 5% D = 1 litresy Take antibiotics into consideration = may account for

200 ml 500 ml

y K + --replacement necessary after 2nd post op day even

if K+ levels are normal

Cli i l E l tio of Fl id


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Clinical Evaluation of Fluid

Re lace ent

1. Urine Output: at least 1.0 ml/kg/hr2. Vital Signs: BP and HR normal (How is the

patient doing?)

3. Physical Assessment: Skin and mucousmembranes no dry; no thirst in an awakepatient

4. Invasive monitoring; CVP or PCWP may beused as a guide

5. Laboratory tests: periodic monitoring ofhemoglobin and hematocrit


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Exa ley 70 kg diabetic male undergoes open cholecystectomy.

How do order post op fluids?

y

Total fluid he needs: 2.5 Ly 1.5 L RL

y 1 L GIK DRIP-1000 ml 5 % D + 10 U units regularinsulin + 20 meq K+


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Head injuryy 50 kg male head injury patient

y Give NS or RL

y

NEVER 5 % Dextrose( hypotonic )y if not at least give DNS

y Never give mannitol if intracerebral bleed / EDH /SDH


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Tak hom m ssag s

5 questionsWhy?How, do they need IV?What fluid?

How much fluid?Monitoring?


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Re e ber

y 4:2:1 formula for maintainence

y 2/3rd formula for body fluids

y

Never give in excess only NS or RL in post opyAlways add free water in form of 5 % D in post op

y Resuscitation always start with NS or RL

y Give as fast as possible in shock

y One litre NS and 1 meq/kg of potassium per day

y Nothing can replace blood atleast O ve

yAdd K+ after 2nd post op day even if K+ is normal


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yThank you

iv fluids2`

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