Fluid Management-Online (1)

7/28/2019 Fluid Management-Online (1)

1/24

Intravenous Fluids

A Clinical Approach

JAI RADHAKRISHNAN, MD

Division of Nephrology


2/24

Objectives

Volume of distribution

IV fluid choices available

Types of fluid depletion

Specific clinical examples and treatment


3/24

Volume of Distribution of Water

60%-Males

50%-

FemalesH2O

Solids


4/24

Intracellular

(2/3)

Extracellular

(1/3)

Solids 40% of Wt

H2O H

2O

Na


5/24

Intra-

vascular

1/4

E.C.F. COMPARTMENTS

Interstitial 3/4

H2O H2O

NaNa

Colloids

& RBC


6/24

Third Space

Acute sequestration in a body compartment thatis not in equilibrium with ECF

Examples: Intestinal obstruction

Severe pancreatitis

Peritonitis

Major venous obstruction

Capillary leak syndrome

Burns


7/24

Daily Fluid Balance

Intake:

1-1.5L

Insensible Loss

-Lungs 0.3L

-Sweat 0.1 L

Urine: 1.0 to 1.5L


8/24

MATH-70 kg male

Total body water=60% body wt

=0.6X70=42 liters

ECF=1/3

0.3X42=13 liters

ICF=2/3

0.6 X42=25 liters

Blood=1/4 (ECF)

0.25X13=3. 3 liters


9/24

Principles of Treatment

How much volume?

Need estimate of fluid deficit

Which fluid?

Which fluid compartment is predominantly

affected? Need evaluation of other

acid/base/electrolyte/nutrition issues.


10/24

The IV Fluid Supermarket

Crystalloids

Dextrose in water

D5W

D10W

D50W

Saline

Isotonic (0.9% or normal)

Hypotonic (0.45%, 0.25%)

Hypertonic

Combo

D51/2NS

D5NS

D10NS

Ringers lactate physiologic.

(K, HCO3, Mg, Ca)

Colloids

Albumin

5% in NS

25% (Salt Poor) Dextrans

Hetastarch

Blood


11/24

Total body water

ECF=1 liter ICF=0

Intravascular

=1/4 ECF=250 ml

1 Liter 0.9% saline

Interstitial=3/4

of ECF=750ml


12/24

1 liter 5% Dextose

Total body water=1 liter

ECF=1/3 = 300ml ICF=2/3 = 700ml

Intravascular

=1/4 of ECF~75ml


13/24

1 liter 5% Albumin

Intravascular=1 liter


14/24

A Comparison of Albumin and Saline for Fluid

Resuscitation in the Intensive Care Unit

N Engl J Med. 2004 May 27;350(22):2247-56.


15/24

Volume Deficit-Clinical Types

Total body water: Water loss (diabetes insipidus, osmotic diarrhea)

Extracellular:

Salt and water loss (secretory diarrhea, ascites, edema) Third spacing

Intravascular: Acute hemorrhage


16/24

Clinical Diagnosis

Intravascular depletionMAP= CO x SVR

Hemodynamic effects

BP HR JVP

Cool extremities

Reduced sweating

Dry mucus membranes

E.C.F. depletion Skin turgor, sunken eyeballs

Weight

Hemodynamic effectsWater Depletion

Thirst

Hypernatremia


17/24

Example- GI Bleed

A 25 year old patient presents with massive hematemesis

(vomiting blood) x 1 hour. He has a history of peptic ulcer

disease.

Exam: Diaphoretic, normal skin turgor.

Supine BP: 120/70 HR 100Sitting BP: 90/50 HR=140

Serum Na=140

What is the nature of his fluid deficit ?What IV fluid resuscitation would you prescribe ?

What do you expect the hematocrit to be :

- at presentation ?

- after 12 hours of Normal Saline treatment?


18/24

Example-Diarrhea and Vomiting

A 18 year old previouslyhealthy medical studentreturns from a Caribbeanvacation with a healthy tan

and severe diarrhea andvomiting x 48 hours.

Sunken eyeballs, poor skinturgor and dry mucusmembranes

BP 80/70 HR 130 supine. Labs: Na 130 K=2.8

HCO3 =12

ABG: 7.26/26/100

What is the nature of

his fluid deficit ?

What fluid will you

prescribe ?

What would happen if

D5W were to be used?


19/24

Example-Hyperosmolar State

A 85 year old nursing home resident with dementia, and

known diabetes was admitted with confusion.

Exam: Disoriented

BP: 110/70 supine 90/70 sitting. Decreased skin turgor.

Labs: Na= 150meq/L Wt=50kgs

BUN/Cr=50/1.8Blood sugar= 1200 mg/dl Hct=45

What is the pathogenesis of her

fluid and electrolyte disorder ?

How would you treat her ?


20/24

Calculation of Water Deficit

Osm (P Na) x

volume

Osm (P Na) x

volume

Healthy Dehydrated

A 50 kg female with Na=150

Na x Normal Body Water = Na x Current Body Water

140 x NBW = 150 x (0.5 x 50=25 liters)

NBW = 26.8 liters

Water deficit = NBW-CBW= 26.8-25=1.8 liters


21/24

A Cirrhotic

A 40-year-old patient with known alcoholic cirrhosis, portal

hypertension and ascites is admitted with a rising

creatinine.

Exam: BP 100/70 (no orthostasis), JVP 5cms, +++ascites, noperipheral edema, +asterixis.

BUN=12mg/dL Creat=2mg/dL Alb=2.0g/dL

Urine lytes: Na=6meq/L, FeNa=0.5%

Urine volume has been 200cc/24h.

1. Comment on his fluid status

2. If volume-depleted how would you treat him?


22/24

Example-Post Op Abdominal Distension

A 60 year old male with pancreatic carcinoma has

undergone total pancreaticoduodenectomy andgastrojejunal bypass.

On post-operative day-3 he develops abdominal

distension.BP= 110/60 and HR increases from 100 to

130 on sitting. Bowel sounds are absent.

AXR reveals multiple fluid levels in the abdomen. N-Gsuction is initiated.

What is the nature of his fluid deficit ?

How will you treat ?


23/24

A Nutritional Dilemma

The patient is being treated with D5W-NS @

100ml/hour

(5% dextrose in 0.9% saline)

Is the caloric supply adequate ?

Total volume=100mlx24h=2400ml

Total dextrose (5g/100ml)= 5x24=120g/day

Total calories=

120gx 4kcals/g=480 kcals.

**Use D10W-NS instead**


24/24

Conclusions

Crystalloids are generally adequate for most

situations needing fluid management.

The composition of the solution and rate ofadministration are important when addressing

a specific situation.

Colloids may be indicated when more rapid

hemodynamic equilibration is required(inadequate data).

Documents

Fluid Management-Online (1)