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The State Of IV Fluids Grand Rounds
Transcript of The State Of IV Fluids Grand Rounds
September 14, 2012
GOALS AND OBJECTIVES
IV Fluid Infusion in history
keep it simple
...but they aren't your enemy either
Fluids ARE drugs......
Colloids aren't your friends
.............the way it was
choose your fluid wisely.........
Brief History of
The State Of
1/2 normal saline,
1/4 normal saline,
Grand Rounds By
Dr. Anton Kelly, PGY 4
A Little Bit About the Science
So, Just what are we talking about today??
All We Have????
Establish or maintain a fluid or electrolyte balance
Administer continuous or intermittent medication
Administer bolus medication
Administer fluid to keep vein open (KVO)
Administer blood or blood components
Administer intravenous anesthetics
Maintain or correct a patient's nutritional state
Administer diagnostic reagents
Monitor or adjust hemodynamic functions
So, what’s the need to use IV fluid? What exactly are we trying to do?
The indications for IV therapy are as follows
..But, before you top off the tank
There are a couple of things to consider before starting therapy
Who Is the Patient?
What is their fluid status?
Well, then... Give 'em some Fluid......
will set us free
Do the 'squint test' on your
2 General Fluid Types
Recall the the human body has essentially 3 compartments for fluid to go
Typically affected by colloids in solution which cannot cross membranes
Total Body Water
Think about it, then think about it again...
So Which One do we use? Colloid or Crystalloid? Which is more optimal?
We have a number of choices when it comes to fluid to use in the treatment of hypovolemia, which do we use?
Hemorrhagic shock is usually treated with colloid replacement pending the availability of blood. Blood out, blood or the equivalent in, right?
Non-hemorrhagic shock following an initial crystalloid infusion is also treated with colloid after a set volume resuscitation, but is this standard of care?
The Ideal Colloid for infusion??
But there's hope
If you know which fluid to choose and it's indication
Assess your patient. What State are they in? Maintenance? Resuscitation?
It's probably best that you know your fluid...........
Don't look at them too hard, they won't come right out and tell you!!
Feel like your head is in the clouds? Step back and breath, take a look at the big picture and then narrow down to your fluid.
"So, it all comes down to choice..............................."
Oh Yes.. there's a menu of fluids to choose from!
...... and this is who's choosing them..
A Closer Look
Clear solutions –fluids- made up of water & electrolyte solutions; small molecules.
These fluids are good for volume expansion.
Both water & electrolytes will cross a semi-permeable membrane into the interstitial space and achieve equilibrium in 2-3 hours.
Remember: 3mL of isotonic crystalloid solution are needed to replace 1mL of patient blood.
This is because approximately 2/3rds of the solution will leave the vascular space in approx. 1 hour.
In the management of hemorrhage, initial replacement should not exceed 3L before you start using whole blood because of risk of edema, especially pulmonary edema.
easy to store with long shelf life
very low incidence of adverse reactions
a variety of formulations are available
effective for use as replacement fluids or maintenance fluids
no special compatibility testing is required.
no religious objections to their use
So Now What......?
Current Fluid Therapies
Current Fluid Therapies controversies
Colloids vs Crystalloids
Pros and Cons of IV Therapy
Our Current State of Therapy
The Perfect Fluid...?
Where do we go from here??
1492: First Recorded Attempt At Intravenous Infusion
Dr William Harvey
1658: Sir Christopher Wren
Quill and Pig's Bladder
1664: JD Major made first injections of unpurified substances into humans.
1830: Dr. Hendon develops the gold-plated 14-gauge needle
1831: Dr William Brooke O’Shaughnessy – Published the conclusion that “…the injection of tepid water with normal salts of the flood into the blood stream” was indicated in the desperate cases surrounding cholera. The Lancet, 1892
1832: Dr. Thomas Latta – able to save 8 of 25 cholera patients using intravenous hypotonic saline solution composed of sodium, chloride and bicarbonate.
1855: Invention of the first hollow needle and syringe
1876: Sidney Ringer, a clinical pharmacologist – developed a physiologic solution consisting of sodium, potassium, chloride and calcium suitable for perfusion purposes. Ringer’s IV solution
1896: Beidl and Krause - first successful infusion of a glucose containing fluid
1900 – 1925: IV saline used only on critically ill patients
20TH CENTURY, BABY!!!
1945: First plastic catheter introduced
1950: Plastic Tubing replaces rubber IV tubing
1960: Central line catheterization first described
1965: First PICC Line Introduced
1966: Dr. Stanley Dudrick First IV hyperalimentation introduced
What's the hubbub, bub??
Osmolarity is similar to that of serum.
These fluids remain intravascularly momentarily, thus expanding the volume.
Helpful with patients who are hypotensive or hypovolemic.
Risk of fluid overloading exists. Therefore, be careful in patients with left ventricular dysfunction, history of CHF or hypertension.
Avoid volume hyperexpansion in patients with intracranial pathology or space occupying lesions.
Less osmolarity than serum (meaning: in general less sodium ion concentration than serum)
These fluids DILUTE serum thus decreasing osmolarity.
Water moves from the vascular compartment into the interstitial fluid compartment interstitial fluid becomes diluted osmolarity descreases water is drawn into adjacent cells.
These are helpful when cells are dehydrated from conditions or treatments such as dialysis or diuretics or patients with DKA (high serum glucose causes fluid to move out of the cells into the vascular and interstitial compartments).
Caution with use because sudden fluid shifts from the intravascular space to cells can cause cardiovascular collapse and increased ICP in certain patients.
These have a higher osmolarity than serum.
These fluids pull fluid and sometimes electrolytes from the intracellular/interstitial compartments into the intravascular compartments.
Useful for stabilizing blood pressure, increasing urine output, correcting hypotonic hyponatremia and decreasing edema.
These can be dangerous in the setting of cell dehydration.
Calculating Osmolarity: (2 x Na) + (glucose/18) + (BUN/2.8)
Bloody Blood: 280 - 295
Colloids are large molecular weight solutions (nominally MW > 30,000 daltons)> These solutes are macromolecular substances made of gelatinous solutions which have particles suspended in solution and do NOT readily cross semi-permeable membranes or form sediments.
Because of their high osmolarities, these are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries.
These work well in reducing edema because they draw fluid from the interstitial and intracellular compartments into the vascular compartments.
Albumin solutions are available for use as colloids for volume expansion in the setting of CHF.
There are other solutions containing artificial colloids available.
The general problems with colloid solutions are:
Much higher cost than crystalloid solutions
Small but significant incidence of adverse reactions
Because of gelatinous properties, these can cause platelet dysfunction and interfere with fibrinolysis and coagulation factors thus possibly causing coagulopathy in large volumes.
Side by side
• Colloids have no clinical advantage compared to crystalloids for fluid resuscitation in critically ill adults or children
• Hypovolemic patients given albumin instead of saline does not reduce mortality
• Albumin does not reduce mortality in critically ill patients with burns and hypoalbuminemia
• In critical traumatic brain injury treatment with albumin compared to saline is likely to be ineffective or harmful
• In intensive care, serum albumin concentration is irrelevant, outcome is the same with saline or albumin
American Thoracic Society. Evidence-based colloid use in the critically ill: American Thoracic Society Consensus Statement. Am J Respir Crit Care Med. 2004;170:1247-1259.
Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ. 1998;317:235-240.
Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. The effect of intravenous lactated Ringer's solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth Analg. 1999;88:999-1003
Now and Then, the History of Parenteral Fluid Administration, Am J Nephrol 2002;22:284–289
Corbett EC. Nutrition: Salt. Becker DM, Gardner LB, Eds. Prevention in Clinical Practice. New York: Plenum Publishing Corp., 1988:351-354.
Parrish CR, Krenitsky J, McCray S. University of Virginia Health System Nutrition Support Traineeship Syllabus. Available through the University of Virginia Health System Nutrition Services in January 2003. E-mail Linda Niven at ltn6m@ virginia.edu for details.
Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr 2008; 27(2): 179-88.