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Mini Lecture: IV Fluids: William Graham, PGY2 January 2014 Department of Medicine UC Irvine Medical Center
Mini Lecture: IV Fluids: William Graham, PGY2 January 2014 Department of Medicine UC Irvine Medical Center
Objectives
TOTAL: 1600mL
TOTAL: 1600mL
Average adult input/output is 30-35mL/kg/day
(2.4L/day)
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50
NS
77
77
D51/2NS
77
77
NS
154
154
D5NS
154
154
Ringers
Lactate
(RL)
130
109
278
143
50
350
286
28
50
564
50
272
- Bicarb: 1 meq/kg/day
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Case Vignette
58 y/o male with h/o HTN, dyslipidemia, admitted for
cough and atypical chest pain. Found to have
abnormal CXR and CT Thorax concerning for
malignancy . Kept NPO overnight for possible
bronchoscopy with biopsy in the morning. He is
placed on NS @ 75cc/hr.
1. Was the right solution picked?
2. Is the rate correct?
Maintenance Therapy
Purpose: Replace ongoing losses of water and
electrolytes under normal physiological conditions
- Used when the patient is not expected to eat or
drink normally for prolonged period of time
- In general, patients who are afebrile, not eating, not
physically active require less that 1 L of free water
daily
- Patients with ESRD or edematous states (ex.
cirrhosis, heart failure) require less maintenance due
to decreased output and/or altered fluid distribution
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Maintenance Therapy
3 approaches to determine the appropriate rate:
1)
2)
4/2/1 rule
4 ml/kg/hr for the first 10 kg (0-10kg)
2 ml/kg/hr for the next 10kg (11-20kg)
1 ml/kg/hr for remaining weight (21 kg and up)
3)
Weight in kg + 40
40 + 20 + 65 = 125cc/hr
85 + 40 = 125cc/hr
Maintenance Therapy
What type of fluid for maintenance?
- D51/2NS + 20 mEq KCl provides:
a) ~180 mEq/day sodium and chloride (100-250 sodium and 60150 chloride needed/day)
b) ~50 mEq/day potassium (50-100 mEq needed/day)
- avoid dextrose in patients with uncontrolled DM or hypokalemia
- not much data to support addition of D5, however can be added
to prevent muscle catabolism
Clinical Vignette
86y/o female admitted with nausea and
vomiting and c/o rectal bleeding. She has a
history of recent admission for CHF exacerbation.
Weight is 45kg. SBP 80s in the ED. She is started
on IV pantoprazole.
1. What is your initial choice of fluids?
Fluid Resuscitation
Purpose: Correct existing abnormalities in volume
status or serum electrolytes
Objective parameters used to assess volume deficit:
Blood pressure
Jugular venous pressure
Urine sodium concentration
Urine output
Pre and post deficit body weight
Rate of Repletion
Severe volume depletion or hypovolemic shock?
-> Rapid infusion of 1-2L isotonic saline (NS), then reassess
parameters
- use Lactated Ringers if concern for re-expansion acidosis
(ex. acute
pancreatitis)
3) Select fluid based on type of fluid that has been lost and any
co-existing electrolyte disorders
Clinical Vignette
86y/o female admitted with nausea and vomiting and
c/o rectal bleeding. She has a history of recent
admission for CHF exacerbation. Weight is 45kg. SBP
80s in the ED. She is started on IV pantoprazole.
1. What is your initial choice of fluids?
2. She is kept NPO for EGD and colonoscopy
the next morning. After receiving 2u PRBC and
normal saline you decide to start maintenance
fluids. What rate and type of fluid do you choose?
Complications of IVF
The team decides to put her on D51/2NS @ 125cc/hr.
Her repeat serum sodium level is 130 the next
morning and she is complaining of some SOB. She is
thought to have an infiltrate on CXR and started on
IV Zosyn and Vancomycin for hospital acquired
pneumonia.
3. What could be contributing to the
hyponatremia?
4. What is likely contributing to the SOB?
Free water
content
ICF
ECF
Interstitial
Intravascular
D5W
1000cc
660cc
340cc
226cc
114cc (11%)
NS
500cc
500cc
500
170cc + 55cc
=225cc (22%)
NS
1000cc
330cc
+ 55cc from
free water
content
660cc
330cc (33%)
Interstiti
al
Intravascula
r
226cc
114cc
!!
Summary
Treat IV fluids as a prescription just like any other
medication, with consideration of renal function
and clinical picture
Determine if patient needs maintenance or
resuscitation
Choose fluid type based on co-existing electrolyte
disturbances
Dont forget about additional IV medications
patient is receiving
Choose rate of fluid administration based on
weight and minimal daily requirements
Avoid fluids in patients with ECF volume excess
Assess DAILY whether the patient continues to
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