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Fluid therapy
- 1. FLUID THERAPY CHRIS MOWATT CONSULTANT ANAESTHETICS AND ICM
- 2. FLUID THERAPY • HOW MUCH FLUID DOES SOMEONE NEED? • MAINTENANCE • PRE EXISTING LOSSES • ONGOING LOSSES • HOW DO YOU MAKE THAT ASSESSMENT?
- 3. FLUID THERAPY • HYPOVOLAEMIA VS HYPOVOLAEMIA • SIGNS? • HISTORY/EXAMINATION/SPECIAL INVESTIGATIONS • CAN YOU LIST SOME?
- 4. FLUID THERAPY • ELECTROLYTES • HOW MUCH SODIUM DO YOU NEED A DAY? • HOW MUCH POTASSIUM? • IS MAGNESIUM IMPORTANT? • PHOSPHATE?
- 5. RESUSCITATION • SIGNS OF HYPOVOLAEMIA • WHAT IS THE MECHANISM…….. • THIRST • HR > 100 • HYPOTENSION SBP < 90 • CAPILLARY REFILL • TESTS? • ABG • UREA/CREATININE RATIO?
- 7. Contents of IV Fluid Preparations Na (mEq/L) K (mEq/L) Cl (mEq/L) HCO3 (mEq/L) Dextrose (gm/L) mOsm/L D5W 50 278 ½ NS 77 77 143 D51/2NS 77 77 50 350 NS 154 154 286 D5NS 154 154 50 564 Ringers Lactate (RL) 130 4 109 28 50 272
- 8. Where is my bolus going? 1L D5W distributed into Total Body Water Interstitial 226cc Intra- vascular 114cc!! Free water content ICF ECF Interstitial Intravascular D5W 1000cc 660cc 340cc 226cc 114cc (11%) ½ NS 500cc 500cc 500 330cc + 55cc from free water content 170cc + 55cc =225cc (22%) NS 0 0 1000cc 660cc 330cc (33%)
- 10. FLUID THERAPY
- 11. FLUID THERAPY • MAINTENANCE • WHAT INFORMATION DO I NEED • HISTORY/EXAMINATION • WEIGHT • ELECTROLYTES • FLUID BALANCE
- 12. FLUID THERAPY • WHAT’S THE BEST WAY TO DELIVER FLUID? • HOW MANY CALORIES?
- 13. FLUID THERAPY Hyponatraemia (Serum Na < 135) Hypernatraemia (Serum Na > 145) Hypokalaemia (Serum K <3.5) Hyperkalaemia (Serum K >5.5) Establish underlying cause of hyponatraemia. Encourage oral intake if possible Check ECG for changes MEDICAL EMERGENCY* Assess using ABCDE approach Send VBG AND laboratory sample to confirm Check ECG for changes Correct hyponatraemia slowly to prevent complications. Correct hypernatraemia slowly to prevent complications. MILD (3.0 – 3.4) Sando-K 2 tablets TDS Kay Cee L 25ml TDS Check level in 3 days MILD (5.5–5.9) Repeat in 6 hours in unwell patients or daily if stable Review medications & diet SEEK SENIOR ADVICE Seek expert advice before considering hypertonic saline (1.8% NaCl) Manage as per SaTH guidelines on the intranet. SEEK SENIOR ADVICE MODERATE (2.5 – 2.9) Sando-K 2 tablets QDS Kay Cee L 25ml QDS Check level in 3 days MODERATE/SEVERE (>6) Give 10ml Calcium Gluconate 10% IV over 3-5 mins via large vein. Give 10units Actrapid IV in 100ml of 20% glucose over 15 – 30 mins. Give 10-20mg nebulised salbutamol. DO NOT USE FLUIDS CONTAINING SODIUM SEVERE (<2.5) IV Replacement using 40mmol KCl in fluids BD or TDS Check level within 24h SEEK SENIOR ADVICE Manage as per SaTH guideline on intranet
- 14. Give a STAT crystalloid fluid bolus (up to 500 ml in less than 30 minutes) Reassess the patient using the ABCDE approach and monitor urine output If no response > Repeat fluid bolus as above > If adequate response > Initiate maintenance fluids and monitor the patient Reassess using ABCDE approach If inadequate response after 2000ml of fluid boluses > Escalate to a senior member of the team Resuscitation Normal daily IV fluid and electrolyte requirements IV water volume: 1.25 ml/kg/hr Na/K/CL: 1mmol/kg/day Glucose: 50-100 g/day Urine Output: 0.5-1 ml/kg/hr Review excess losses from fluid chart If patient requires IV fluids for more than 24 hours the patient will require daily monitoring of U&Es Maintenance
- 15. 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 80’s 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?
- 16. 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 • Don’t 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 require IVF
Editor's Notes
- Important to understand the differences between the types of fluid we administer and the osmolality of each solution. Recognize that although D5 appears isotonic, the dextrose is metabolized quickly and therefore becomes a hypotonic solution rather rapidly.
- To understand what happens to the IV fluids we give our patients- recognize that if D5W is given, only 10% of it will end up in the intravascular space. This is the reason we don’t give D5W for resuscitation. Normal saline has no free water and is confined to ECF space.
- Answers: 1) Initial choice of fluids would be bolus of Normal Saline (1-2L) while awaiting PRBC transfusion and reassess parameters. 2) D51/2NS: - 45kg x 35cc/kg/24hr= 67cc/hr - 4/2/1= 40+20+25=85cc/hr - 45kg +40= 85cc/hr Have the team recognize that the second part of the question is now a focus on maintenance therapy. Initially calculate the rate based on the three approaches previously discussed. The next slides will discuss adjusting the rate and type of fluids based on co-morbid conditions (CHF, etc)