Principles of Intravenous fluid therapy

Principles of intravenous fluid Principles of intravenous fluid therapytherapy

BYBYOmar Mohammad SalehOmar Mohammad Saleh

Assistant Lecturer of Tropical Medicine and Assistant Lecturer of Tropical Medicine and GastroenterologyGastroenterology

HUCOMHUCOM

22ndnd April 2012 April 2012

Learning objectivesLearning objectives

Historical aspect of intravenous fluid therapyHistorical aspect of intravenous fluid therapyBasics of fluid therapyBasics of fluid therapyPatient assessmentPatient assessmentTypes of I.V fluid therapyTypes of I.V fluid therapyIndications of I.V fluid therapyIndications of I.V fluid therapyComplications of I.V fluid therapyComplications of I.V fluid therapy Take home messagesTake home messages

Why is fluid therapy so importantWhy is fluid therapy so important ? ?

11 - -It maintains the shape and integrity of all cells in It maintains the shape and integrity of all cells in the bodythe body

22 - -It maintains blood pressure/ volumeIt maintains blood pressure/ volume33 - -A transport medium forA transport medium for; ;

11 . .Delivery of nutrients and oxygen to the Delivery of nutrients and oxygen to the tissuestissues

22 . .Removal of waste products from the bodyRemoval of waste products from the body44 - -A medium for all the biochemical reactions A medium for all the biochemical reactions

necessary for lifenecessary for life Approximately 60% of the body is waterApproximately 60% of the body is water!!

The British Medical Journal published a letter sent from The British Medical Journal published a letter sent from a concerned clinical researcher and a senior professor a concerned clinical researcher and a senior professor of surgery from of surgery from Edinburgh (1). They surveyed 33 Edinburgh (1). They surveyed 33 Foundation Year 1 doctorsFoundation Year 1 doctors (interns) during their first (interns) during their first hospital rotation as doctors, testing their knowledge of hospital rotation as doctors, testing their knowledge of fluid and electrolyte balance, and ability to prescribe fluid and electrolyte balance, and ability to prescribe fluids correctly. They described the results as fluids correctly. They described the results as “alarmingly poor”,“alarmingly poor”, and called for better and more and called for better and more formalized teaching of fluid administration in medical formalized teaching of fluid administration in medical schoolsschools..

MSJA • Volume 3 Issue 2 • October 2011MSJA • Volume 3 Issue 2 • October 2011

Composition of fluid compartmentsComposition of fluid compartments

Uses of intravenous fluidsUses of intravenous fluids

11--ResuscitationResuscitation

22--Rehydration / ReplacementRehydration / Replacement

33--MaintenanceMaintenance

44--Special purposeSpecial purpose

Goals of fluid therapyGoals of fluid therapy

11 - -To maintain adequate oxygen delivery to To maintain adequate oxygen delivery to the tissuesthe tissues

22--To maintain normal electrolytes To maintain normal electrolytes concentrationconcentration

33 - -To maintain normoglycemiaTo maintain normoglycemia

Assessment of volume statusAssessment of volume status

Look at the patient:Look at the patient:- PulsePulse- Blood pressureBlood pressure- Capillary refillCapillary refill- Skin turgorSkin turgor- Mucous membranesMucous membranes- Peripheral circulationPeripheral circulation

Autotransfusion by passive leg raising resulting in changes in systemic hemodynamic variables such as stroke volume or venous pressure.

Assessment of volume statusAssessment of volume status

Try a more invasive approachTry a more invasive approach::--Urine outputUrine output

--Central venous lineCentral venous line --PA catheterPA catheter

--Esophageal dopplerEsophageal doppler

““If the eyes are the windows to the If the eyes are the windows to the soul, then the kidneys are the soul, then the kidneys are the

windows to the bodywindows to the body ” ” Sandra OuelletteSandra Ouellette..

Assessment of volume statusAssessment of volume status

How about blood testsHow about blood tests??--Urea and electrolytesUrea and electrolytes

--HaematocritHaematocrit--Plasma/ urine osmolalityPlasma/ urine osmolality

--Arterial blood gasesArterial blood gases

Types of intravenous fluidTypes of intravenous fluid

CrystalloidsCrystalloids

ColloidsColloids

Blood/blood products and blood substitutesBlood/blood products and blood substitutes

What is the choiceWhat is the choice??

Colloid Vs CrystalloidColloid Vs Crystalloid

CrystalloidsCrystalloids

--Extracellular space expanderExtracellular space expander--Net effect is 1/3 to ¼ of total fluid infusedNet effect is 1/3 to ¼ of total fluid infused

--Limited volume expansionLimited volume expansion--Maintain urine output and renal functionMaintain urine output and renal function

--Reduce plasma oncotic pressure by diluting Reduce plasma oncotic pressure by diluting plasma proteinplasma protein

--Variable electrolyte contentVariable electrolyte content--CheapCheap

Types of crystalloid solutionsTypes of crystalloid solutions

ColloidsColloids

--Intravascular space expanderIntravascular space expander--Volume for volume expansionVolume for volume expansion

--Maintain oncotic pressureMaintain oncotic pressure--Coagulation problemsCoagulation problems

--Variable electrolyte content and half lifeVariable electrolyte content and half life--Adverse reactionsAdverse reactions

--ExpensiveExpensive

Every day in the hospital, physicians are Every day in the hospital, physicians are required to write orders for intravenous fluid, required to write orders for intravenous fluid, but when asked to explain their choices, few but when asked to explain their choices, few are completely comfortable with justification are completely comfortable with justification for the orderfor the order..

Rule 1: Do Not Be Generous with FluidRule 1: Do Not Be Generous with Fluid

Rule 2: The Source and Magnitude of Usual Water Rule 2: The Source and Magnitude of Usual Water Output Must Be KnownOutput Must Be Known

Rule 3: Know the Quantities of the Electrolytes and Rule 3: Know the Quantities of the Electrolytes and Nutrients That Are Being GivenNutrients That Are Being Given

Rule 4: Know the Aim of Fluid TherapyRule 4: Know the Aim of Fluid Therapy

Rule 5: Do Not Give and Remove the Same Rule 5: Do Not Give and Remove the Same Substance at the Same TimeSubstance at the Same Time

Rule 6: Hypertonic Saline Contains Less Water for a Given Rule 6: Hypertonic Saline Contains Less Water for a Given Amount of Na+ than Isotonic SalineAmount of Na+ than Isotonic Saline

Rule 7: Be Familiar with Different i.v. Solutions and i.v. Rule 7: Be Familiar with Different i.v. Solutions and i.v. AdditivesAdditives

Rule 8: Know that the Kidney Does Not Manufacture Rule 8: Know that the Kidney Does Not Manufacture Water or ElectrolytesWater or Electrolytes

Rule 9: For Short-Term Fluid Therapy, Water, Glucose and Rule 9: For Short-Term Fluid Therapy, Water, Glucose and Perhaps NaCl and Phosphate Need to Be Given – Perhaps NaCl and Phosphate Need to Be Given – Divalent Cations (Ca2+, Mg2+) Do Not Need Divalent Cations (Ca2+, Mg2+) Do Not Need ReplacementReplacement

How should fluids be How should fluids be administeredadministered ? ?

Take home messageTake home message!!11 - -Beware of treating a lab valueBeware of treating a lab value!!

22--Fluid needs are not static always re-assessFluid needs are not static always re-assess

33--Remember that % refers to gram/ 100mlRemember that % refers to gram/ 100ml

44 - -Pure water given IV causes massive hemolysis Pure water given IV causes massive hemolysis (dangerous)(dangerous)

55 - -No single sign is pathognomonic for volume No single sign is pathognomonic for volume status assessmentstatus assessment

Say to me I will forgetSay to me I will forget!!! !!! Show me I will rememberShow me I will remember! !

Involve me I will understandInvolve me I will understand