iv fluid management
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IV Fluid Management
Dr Andrew Stein, Consultant NephrologistCaroline Letchford, Practice Development Nurse, UHCW
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Background Humans are 60% water 70kg man (43L water / 70kg = 61%): Intracellular (28L) Extracellular
Interstitial (10L) Intravascular (5L = 9 Pints)
Frail elderly = Hyponatraemic and ‘dry’ with SOA, on a LOOP diuretic (Na↓, K↓), and ACE/ARB/SPIRONO (K↑), .. ie ‘charged dry kidneys’, waiting AKI (UTI, gastro, drugs)
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Normal maintenance requirements- Depends on weight. For 70 kg man
Amount/kg/time Amount/day Ideal
H20 in 1.5 ml/kg/h 2.5L
Na+ in 1-2 mmol/kg/24h 100 mmol (70-140)
K- in 0.5 mmol/kg/24h 50 mmol (35-70)
UO out >0.5 ml/kg/h Approx 0.8L Input = 2.5L
Output = 2.5L =
Urine = 1.5L (5 x 300 ml)Sweat = 0.5LLungs + faeces = 0.5L
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Contents Available Fluids
Na+ Cl- K+ HCO3- Gluc Notes
Normal pl 135-145 100-120 3.5-5.0 22-26 3.5-7.8
0.9% NaCL 154 154 0 0 0 Not ‘normal’. pH 5.5
Hartmanns 131 111 5 29 (lactate) 0 PhysiologicalpH 6.5
5% Dext 0 0 0 0 50g (170 cals)
Water
Dext-Saline 4%/0.18%
30 30 0 0 40g
Gelofusin 154 120 0 0 0 Colloid
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Fluid State AssessmentSeverity Clin Pulse BP JVP
(not CVP)Severe SOB++.
DrowsyTachyc++ ? V high
Mod SOB+ Tachyc+ ? High
Hypervolaemia Mild N Tachyc N NEuvolaemia N N N
Hypovolaemia Mild N Tachyc N NMod Drowsy Tachyc+ Low (<100
systolic)Not seen
Severe Unconscious Tachyc++ V low <80) Not seen
Tachycardia = Acute ProblemBradycardia = (Prob) Problem
Patient = (centrally) ‘wet’, ‘dry’ or ‘middle’, not 2/3 or 3/3) ..you have to decide
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Hartmann’s Solution
‘Physiological’: Na+ 131 (135-145 Cl- 111 (100-120) K+ 5 (3.5-5.0) HCO3- 29 (22-26) as lactate
Good as a plasma replacement fluid, esp post-op Good for sepsis Complications 1930s. American pediatrician Alexis Hartmann for treating
acidosis
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‘Normal’ Saline – 0.9% Not ‘normal’ at all Not physiological, so no role as a maintenance
fluid - if given alone Hypernatraemic (Na+ 154 mmol/L) Hyperchloraemic (Cl- 154 mmol/L) Acidotic (pH 5.5)
Complications 1831. William Brooke ‘Shaughnessy, E’burgh. Just qualified. Indian Blue
Cholera pandemic 1882-83. Hartog Jacob Hamburger. Dutch physiologist coined term
‘normal’
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5% Dextrose
Is water Given instead of pure water (maintenance) No role as a replacement fluid (plasma or blood), as not
physiological If can drink, give water orally (or by NG if cannot) Not sugar and not a food Complications
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Dextrose Saline – 4%/0.18%
Na+ 30 mmol/L Cl- 30 mmol/L Good maintenance fluid No role as a replacement fluid as not
physiological
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Colloid
Eg gelofusin, albumin Given to keep fluid in intravascular space Not inert (like crystalloids) Complications Not recommended by NICE
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Where Do IV Fluids Go?
Given IV, so initially into intravascular space Then distributed across all fluid departments So .. NB: can get premade crystalloids with K in (eg
20 or 40 mmol/L)
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Blood Packed cells (300 ml) vs whole blood (450-500 ml) Replacement (Emergency, ie bleeding)
Do not wait for blood. Give anything eg 0.9% Saline Whole blood (stat) O negative if necessary
Maintenance – packed cells, 2h Does ‘maintenance blood transfusion’ exist
Consider FRUS ‘cover’ (NB: normal dose, if creat >200, give 80 mg)
Check K+ if necessary
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Principles - Choosing IV Fluid
1. Overall requirements = replacement then maintenance fluids
2. Give what they lack, at rate they need (prop to loss and weight)
• Plasma• Na, K• Blood
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Replacement Fluids
Hartmanns Occ N Saline, 2N Saline, Dext-saline
(Colloids) 50% Dext if hypoglycaemic Blood
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Acutely Hypotensive Patient
Needs IV fluids (usually). Rarely FRUS! Anything (physiological, not, colloid, blood) 250-500 ml/15 min then re-assess More (much) if bleeding (or might be) If little/no response (feels better, BP, UO), call
reg, ICU (? more fluids ?inotropes)
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Maintenance Fluids Dextrose-saline Alternating “1 salty and 2 sweet, with a leetle but of K in”
(0.9% Saline/5% Dext (+ K 20 mmol/L)) This gives: 3L H2O, 154 mmol Na+, 60 mmol K+ Vs Hartmanns: 3L H2O, 393 Na+, 15 K+ Vs requirements: 2.5L H2O, 100 Na+, 50 K+
3L a day Too much for 70 kg man, esp if drinking Far too much for 40kg old lady Too little for 120 kg man
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Special Situations
Post-op. Give if need only. K is intracellular CCF. Not >2L/day CLF (esp if unsure fluid state). 5% Dext only CRF/AKI (esp if unsure fluid state) Sepsis. ‘Third space’. Eg warm hands, tachyc, low
BP. Hartmanns. May need inotrope Alcohol. Give Pabrinex before any 5% Dext Cerebral haemorrhage. 0.9% Saline. No Dext
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IV Fluids - Complications Affect Na
0.9% NaCl 0.9% - ↑ 5% Dext - ↓
Affect K Hartmanns, Blood – ↑
Acid/base 0.9% NaCl - acidosis
Any Fluid overload (incl pulmonary oedema), esp blood
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IV Fluids - Ten Commandments1. Humans = 60% water. Know where it is (compartments). Think about ‘Third Space’
2. IV fluids are a drug. Only give if patient needs them
3. Assess fluid state before prescribing. 1. Examination (esp JVP, not SOA), 2. Obs (incl UO) and 3. U+E. Ask the patient! Clinical mainly. Beware CVP errors
4. Patient is hypervolaemic, hypovolaemic or euvolaemic. Decide, or ask.
5. Overall requirements = replace + maintain1. Replace plasma with physio fluids (noting K)
2. Replace blood with blood
3. Maintain with NaCl/Dext
6. All drugs have side-effects. IV fluids cause/worsen biochem disturbance (eg Na or K up, or acidosis) or cause pulmonary oedema
7. If BP (or UO) not up after replacement .. ?inotropes (call reg)
8. Young patients will not drop BP until >30% blood/fluid loss
9. Do not copy previous fluids. Go and see, assess patient, then prescribe/stop
10. If in doubt .. do ABGs and ask