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IV Fluid The
IV Fluid The
EABV
Body Fluid Compartments
• The composition of the ECF is roughly the same
as the interstitial space with the exception of
proteins which are trapped within the vascular
lumens.
• The distribution of fluid between these two spaces
is determined by Starling Forces.
Volume Homeostasis
• ECF Volume is linked to total body sodium
• Important: Total body sodium is not concentration
• Orthostatic hypotension
• Tachycardia
• Flat neck veins
• Dry mucous membranes
• Absent axilliary sweat
• Decreased skin turgor
• Decreased CVP
Common IV Fluids
Solution Glucose Na+ K+ Ca++ Cl- Lactate PO4= Mg++
D5W 50 0 0 0 0 0 0 0
NS 0 154 0 0 154 0 0 0
D5½NS 50 77 0 0 77 0 0 0
LR 0 130 4 3 109 28 0 0
Management of Hypovolemia
• The primary fluid prescribed for hypovolemia is
Normal Saline
• In the management of hypovolemia, there is no
place for ½NS or D5W….
• Transfusion
• Albumin
• Hetastarch (Hespan ®) or Plasmanate ®
IV fluids: continued
• Addition of an isotonic fluid (0.9% NaCl)
expands the ECF but doesn’t change the
IntraCellularFluid
• Addition of a hypotonic fluid (D5W) will cause
movement of water into the cells.
• Addition of a hypertonic fluid (3% saline) will
cause movement of water out of the cells.
Why is Normal Saline the “drug of
choice”?
The water deficit should be fixed in the form of water (D5W or tap
water).
Water repletion is over and above the maintenance fluids which may be
either isotonic or hypotonic.
How do you write IV Fluid orders?
Input – output = accumulation
• Volume balance
• Water balance
• Potassium (deficit, CKD, Mg++, presence of
acidosis or alkalosis)
• Acid base (administration of bicarbonate or HCl)
Case I: Mild Hyponatremia
• 65 yo WF smoker @ small cell carcinoma
• No evidence of CHF on physical exam
• Na+ 122 mEq/l K+6.1
• Mild respiratory acidosis GFR normal
• No dyrenium, amiloride, or aldactone
• Positive history for Lovenox (DVT) for 2 weeks
Case I: hyponatremia - continued
• PE: normal vitals (no tilt) comfortable at rest
extremities - no edema no confusion
• Random U Na+ elevated at 40 mEq/L
• Uosm 600 TSH is WNL
• 1) Differential Diagnosis
• 2) IV fluid orders (NPO for cardiac evaluation)
Patient receives saline
• Diagnosis = SIADH
• Differential diagnosis?
• Volume status?
• Acid base status?
• IV fluids? (TPN?)
Case VII – Metabolic acidosis
• Patient with recurrent diarrhea complains of
muscle weakness
• No carpopedal spam, Trousseau’s of Chvostek’s
• EKG reveals ST-segment and T-wave changes
and PVC’s compatible with hypokalemia
Case VII: continued
• Plasma [Na+] = 140 meq/L
• [K+] = 1.3 meq/L
• [CL-] = 117 meq/L
• [HCO3] = 10 meq/L
• [albumin] = 4.1 g/dL (3.5 – 5 g/dL)
• [Ca++] = 6.3 mg/dL (8.8 – 10.5 mg/dL)
• arterial pH = 7.26
• pCO2 = 23 mm Hg
• Correction MA effect K+? Correct hypo Ca++?
Case VIII: Chronic Li+
• 40 yo female NPO X 48 hours post complicated
cholecystectomy
• Admission [Na+] = 146 mmoles
• Developes profound hypotension requiring
transfer to ICU (without myocardial infarction)
• Current [Na+] = 175 mmoles
• IV fluid orders?
Case IX: AKI
• 60 yo attorney ANURIC AKI SEPSIS
• MSOF: lungs, cardiac, liver, renal, bone marrow,
nutrition, skin, CNS
• Intermittent HD
• [Na+] 130 [K+] 3.3 BUN 40 mg% Creat 5mg%
• IVF orders? TPN? Tube feeds?
Case X: acute water intoxication
• 20 yo SMU student brought to ER by fraternity
• Unresponsive hypothermic hypotensive
• Sodium 106 mEq/L Mild azotemia
• Calculated water load > 8 liters…
• IVF?
Summary
Hyponatremic Patient
Symptomatic Asymptomatic
Acute Chronic
(<48 (>48 hrs)
Central Pontine Myelinolysis
hrs)
Risk Factors for
Neurologic
Complications?
Symptoms and Signs of Hyponatremia
Symptoms Signs
Lethargy Abnormal sensorium
Headache Depressed deep tendon reflexes
Apathy Hypothermia
Muscle Cramps and weakness Pathologic reflexes
Anorexia Pseudobulbar palsy
Nausea Seizures
Agitation *Tentorial Herniation
Psychosis *Cheyne-Stokes respiration
*Coma
Death
Acute Symptomatic Hyponatremia
• Duration <48 hrs
• Increase serum [Na] rapidly by approximately 2 mM/L/hr until
resolution of symptoms.
• Full correction probably safe, but not necessary
• Hypertonic Saline 1-2 ml/kg/hr
• Coadministration of Furosemide
Note: The sum of urinary cations (U Na + U K ) should be less than the concentration of infused sodium
to ensure excretion of electrolyte free water.
Cerebral Adaptation to Hyponatremia
Chronic Symptomatic Hyponatremia
• Duration >48 hrs or unknown
• Initial increase in serum [Na] by 10% or 10 mM/L
• Hypertonic Saline 1-2 ml/kg/hr
• Co-administration of Furosemide
• Perform frequent neurologic evaluations; correction rate may be reduced
with improvements in symptoms
• Perform frequent measurement of serum and urine electrolytes
• At no time should correction exceed rate of 1.5 mM/L/hr, or increment of
15 mmol/day
• Change to water restriction upon 10% increase of [Na], or if symptoms resolve
Note: The sum of urinary cations (U Na + U K ) should be less than the concentration of infused sodium
to ensure excretion of electrolyte free water.
Treatment of Severe Euvolemic Hyponatremia (<125 mmol/L)
Severe Hyponatremia (<125 mM/L)
Symptomatic
Symptomatic Asymptomatic
• Hypervolemic Hyponatremia
•
•
•
•
•
SM Lauriat, T Berl: The Hyponatremic patient: Practical Focus on Therapy. J Am Soc Nephrol,
1997, 8(11):1599-1607.
The Hypernatremic Patient
Guidelines for the Treatment of
Symptomatic Hypernatremia
• Correct at a rate of 2 mM/L/hr
• Replace half of the calculated water deficit over the first
12-24 hrs.
• Replace the remaining deficit over the next 24-36 hrs.
• Perform serial neurologic examinations - prescribed rate
of correction can be decreased with improvement in
symptoms
• Measure serum and urine electrolytes every 1-2 hrs.
Note: If U[Na] + U[K] is less than the concentration of P[Na], then there are ongoing water losses that
need to be replaced
Treatment of Hyponatremia
• Three Key Questions
• Is the patient symptomatic?
• What is the duration of Hyponatremia?
• Are there any risk factors for the development of
neurologic complications?