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IV FLUIDS
Basic Principles
BASIC PRINCIPLES
1. Osmolality/Osmolarity
2. Tonicity
3. Sodium & Water balance
What is Osmolality
?
OSMOLALITY
Measurement of concentration of particles in a solution
(Total concentration of penetrating & nonpenetrating solutes)
i.e. Concentration of electrolytes, drugs, glucose in a solution such as serum or urine
OSMOLALITY
Normal = 285-295 mOsm/kg
The ICF and ECF are in osmotic equilibrium
OSMOLALITY
OSMOLALITY = mOsm/kg of solvent
OSMOLARITY = mOsm/liter of a solution
What is Tonicity?
TONICITY
measure of the ability of a solution to cause a change in the volume or tone of a cell by promoting osmotic flow of water
(Total concentration of penetrating solutes only)
TONICITY
Who regulates osmolality?
Water
WATER BALANCE
Important in the regulation of osmolality
Modification of water intake and exretion
60%
ICF
ECF
TOTAL BODY WATER
Interstitial Fluid
Plasma
FORCES THAT MOVE WATER
Osmolality
Tonicity
Na/K ATPase pump
Hydrostatic pressure
Oncotic pressure
SODIUM BALANCE
The main regulator of intravascular volume status
Electrolyte composition
EXTRACELLULAR FLUID INTRACELLULAR FLUID
WHAT IS THE BODY’S GOAL?
PHYSIOLOGIC HOMEOSTASIS
EUVOLEMIA
ISOTONIC ENVIRONMENT
What mechanisms in the body makes sure that the balance of sodium and water is normal?
What hormones play a big role in the maintenance of physiologic homeostasis?
There are upper & lower limits to the amount
needed to achieve ideal physiologic homeostasis
WATER REPLACEMENT
1.5 to 2 liters / day
SODIUM REQUIREMENT
DIET: RDA = < 2400mg/day (1 teaspoon/day)
or < 104 meq/day
PLASMA : Normal levels = 135-145meq/L
FOR Na CORRECTION: Maintenance of 2-4 meq/kg/day
Intravenous Fluids
INTRAVENOUS FLUIDS
chemically prepared solutions
Achieve and maintain a euvolemic and isotonic environment within the body
They are tailored to the body’s needs and used to replace lost fluid and/or aid in the delivery of IV medications
ISOTONIC IV FLUIDS
created to distribute evenly between the intravascular, interstitial, and cellular spaces.
HYPOTONIC IV FLUIDS
What IV fluids are specifically designed so the fluid leaves the intravascular space and enters the interstitial and intracellular spaces?
HYPERTONIC IV FLUIDS
What IV fluids are designed to stay in the intravascular space (intra, within; vascular, blood vessels) to increase the intravascular volume, or volume of circulating blood?
ISOTONIC SOLUTIONS = 285-295 mOsm/L
Na = 135-145meq/L
HYPERTONIC SOLUTIONS = > 300 mOsm/L
Na = > 150meq/L
HYPOTONIC SOLUTIONS = < 260 mOsm/L
Na < 130meq/L
CRYSTALLOIDS
contain electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids.
classified according to their “tonicity.”
describes the concentration of electrolytes (solutes) dissolved in the water, as compared with that of body plasma (fluid surrounding the cells).
COMPOSITION OF IV FLUIDS
IV FLUID OSMOLARITY(mosm/L)
Na+ (mmol/L)
K+ Cl- Base
PNSS 308 154 0 0 ?
PLR 273 130 ? ? ?
D5LR 525 130 4 109 28
D5NR 552 140 ? 98 50
D50.3NaCl 355 51 0 51 0
D5IMB 350 25 20 22 23
D5NM 368 40 3 40 16
D5W 255 0 0 0 0
COLLOIDS
contain solutes in the form of large proteins or other similarly sized molecules.
Remain in the blood vessels for long periods of time and can significantly increase the intravascular volume (volume of blood).
COLLOIDS/PLASMA EXPANDERS
Albumin = 1-2 kg/dose infused in 2 hours
Haes-teryl = 20-40ml/kg
Voluven = 20-40ml/kg
Gelofuschin = 20-40ml/kg
Fresh frozen plasma = 10-15ml/kg x 4 hours
Dextran 40 or 60
BLOOD AND BLOOD PRODUCTS
are the most desirable fluids for replacement but are not the first choice for immediate volume expansion in children with shock
Not only is the intravascular volume increased, but the fluid administered can also transport oxygen to the cells.
BLOOD AND BLOOD PRODUCTS
BLOOD PRODUCT COMPUTATION
pRBC 10 ml/kg to run for 4 hours
Fresh whole blood 10-20 ml/kg in 4-6 hours
Platelet Concentrate
15-20 ml/kg as fast drip
Cryoprecipitate 1 unit/6kg/dose
Computation
OVERALL GOALS
STEP ONE: Estimate LossesSEVERITY OF DEHYDRATION
INFANT (ml/kg)
ADOLESCENT (ml/kg)
CLINICAL SIGNS
MILD 5% (50) 3% (30) •Dry mucous membranes•Oliguria
MODERATE 10% (100) 6% (60) •Poor skin turgor•Sunken fontanel•Marked oliguria•Tachycardia•Quiet tachypnea
SEVERE 15% (150) 9% (90) •Marked tachycardia•Weak to absent distal pulses•Narrow pulse pressure•Quiet tachypnea•Hypotension and altered mental status
STEP TWO: In shock?
1. MACRODRIP SETS = 10 – 15 drops (gtts)/ml
2. MICRODRIP SETS= 60 microdrops (ugtts)/ml)
(Volume in mL) x (drip set) gtts
------------------------------------ = ------
(Time in minutes) min
CONVERSION FACTORS
1 ml = 15 drops (gtts) = 60 microdrops (ugtts)
1 drop (gtt) = 4 microdrops (ugtts)
1 microdrop (ugtts)/min = 1 ml/hour
FLUID DEFICITSLudan’s Method
WEIGHT MILD DEHYDRATIONml/kg/8 hours
MODERATE DEHYDRATION
SEVERE DEHYDRATION
<15 kg 50 100 150
>15 kg 30 60 90
•Give ¼ in 1 hr•Give ¾ in 7 hr
•Give 1/3 in 1 hr•Give 2/3 in 7hr
•PLAIN LR/PLAIN NSS•D5LR
•PLAIN LR/ PLAIN NSS•D5LR
FLUID DEFICITS – WHO*Use Ringer’s Lactate
AGE FIRST GIVE 30ml/kg in:
THEN GIVE70ml/kg in:
Infants under 12 months
1 hour 5 hours
Older 30 minutes 2 ½ hours
SEVERE DEHYDRATION
SOME DEHYDRATION75ml/kg in 4 hours
SODIUM CORRECTION
1. DEFICIT CORRECTION: desired-actual x weight x 0.6 * Desired Na+ is 135-145 meq
2. MAINTENANCE COMPUTATION: maintenance x weight *Maintenance is 2-4meq/kg
3. COMPUTE FOR ACTUAL Na+ Needed to be incorporated in your IV FLUID = Maintence + Deficit
*Give the First ½ in 8 hours then ¼ in each succeeding 8 hour shifts to complete your 24 hour correction
POTASSIUM CORRECTION
1. COMPUTE FOR THE K+ REQUIREMENT = 2-4meq/kg/day
2. DETERMINE how much KCL you will be incorporating in your IV fluid to complete a 24 hour correction
a) Check IV fluid rate
b) *Maximum 40meq/Liter of KCL incorporation in IV Fluid
3. CHECK POTASSIUM INFUSION RATE (KIR) =meq of KCL x IV rate (ml/hour) x weight
(maximum of 0.2meq/kg/hour)
MAINTENANCE REQUIREMENTSHolliday-Segar Method
BODY WEIGHT WATER (ml/kg/day)
First 10 kg 100 ml/kg
Second 10 kg (<20kg) 50ml/kg for each kg > 10kg + 1000ml
Each additional kg (>20kg)
20ml/kg for each kg > 20kg + 1500ml
MAINTENANCE REQUIREMENTSLudan Method
BODY WEIGHT (kg) TOTAL FLUID REQUIREMENT (TFR)
at ml/kg/day
> 3-10 kg 100ml/kg/day
> 10-20 kg 75ml/kg/day
> 20-30 kg 50-60ml/kg/day
>30-60 kg 40-50ml/kg/day
IV FLUID SELECTION
INITIAL REPLACEMENT (GOAL: Restore Intravascular volume & Tissue Perfusion)– always with an ISOTONIC SOLUTION PNSS , PLR, PNR
FOLLOW UP HYDRATION (For Ongoing Losses) – Isotonic/Hypertonic, can be Glucose containing D5LR, D5NR
MAINTENANCE – Usually Hypotonic D5IMB , D5NM
FLUIDS NOT WORKING?
Review medications: Dopamine Dobutamine Norepinephrine Epinephrine Milrinone Vasopressin Nitroprusside
STEP THREE: Frequent Reassessment
Pulse quality
Heart Rate
Capillary Refill Time
Urine Output
Temperature
Blood Pressure
Neurologic Function
Oxygen saturation
Breath sounds and respiratory rate
STEP FOUR: Ancillary studies & Pharmacologic interventions
ANCILLARY STUDIES
Shock etiology & severity
Organ dysfunction
Metabolic derangements
Response to therapeutic interventions
TREATMENT
Medications
Correct metabolic derangements
Manage pain and anxiety
Subspecialty consult
ADDITIONAL READINGCASES
HYPOVOLEMIC SHOCK
DISTRIBUTIVE SHOCK
OBSTRUCTIVE SHOCK
CARDIOGENIC SHOCK
NEUROGENIC SHOCK
OTHERS
Diarrhea Sepsis Pericardial tamponade
Brain tumor Poisonings
DKA Tension pneumothorax
Brain trauma Nephrotic/Nephritic syndrome
Burns Ductal dependent heart lesions
Fluids for newborns
Dengue Massive pulmonary embolism
Anaphylactic shock
Trauma Surgical cases
BURNSParkland Formula
Crystalloid at 4ml/kg x % BSA burned + Maintenance requirement
Give ½ over the first 8 hours
Then ½ over the next 16 hours
*See Burn Assesment Chart for %BSA burned
DENGUEPPS 2010 Recommendations
NOT in Shock
D5LR/ D5NSS/ D50.9NaCl
Maintenance rate using Holliday Segar/Ludan
Correct in 24 hours
With MILD Dehydration
D5LR/ D5NSS/ D50.9NaCl
Maintenance rate (Ludan) + Mild Dehydration (Ludan)
Give ½ in the first 8 hours
Give the rest in the remaining 16 hours
END
•NELSON’S TEXTBOOK OF PEDIATRICS•HARRIET LANE•PPS DENGUE 2010 GUIDELINES
CASE
1 year old MALE was brought to the ER by his hysterical mother due to sudden generalized tonic clonic convulsions and upward rolling of the eyeballs which occurred five minutes prior to consult. This is reported to be his first attack.
On further investigation, you noted a 3 day history of vomiting followed by diarrhea. The vomiting occurs 2x/day, postprandial, amounting to ½ cup per episode.
The frequency of the diarrhea was 6-8 stools/day amounting to 1 cup/episode, watery, blood streaked;
This was accompanied by fever (tmax 39) and intermittent episodes of abdominal pain;
No known unusual food intake but the child plays with the neighborhood kids a lot and comes home very dirty.
(+) decrease in appetite; Noted progressive decrease in activity
Last urine output noted 9 hours prior to consult;
(+) Family history of BFC – paternal relatives
The rest of the history was unremarkable
PHYSICAL EXAMINATION
Temperature 39; Heart rate 140/ minute;
Respiratory rate 42/min; Blood pressure 90/60
Asleep, arousable; Not in respiratory distress;
Good skin turgor;
Pink, dry lips, no tpc, dry oral mucosa, sunken eyeballs, no clad;
Equal chest expansion, clear breath sounds, no retractions;
Heart with regular rhythm, no murmurs;
Abdomen tympanitic, soft, hyperactive bowel sounds
Full and equal pulses