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Intravenous Fluid Management

Monash University Back-to-Base Week 2010
by

Stewart Morrison

on 18 May 2014

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Transcript of Intravenous Fluid Management

IV Fluid Management
Dr. Stewart Morrison MBBS (2008)
Assessing the Patient
Fluid Choices
What is the Goal?
Scenario 1
Background Theory
Body: 70 kg
Bone/Fat etc: 28kg
Total Body Water: 42 L
ICF: 28 L
ECF: 14 L
Intravascular 3 L
Interstitial 11 L
Daily Requirements
Fluid Distribution
50-70 mmol/day
70-150 mmol/day
30-35 ml/kg/day
=2.5-3 L /day
Normal
Abnormal
Urine 1400 ml
Faeces 100 ml
Sweat 100 ml
Insensible Skin - 350 ml
Insensible Lungs - 350 ml
Diarrhea
Vomiting
NGT Output
Stoma Output
Drain Output
Ascites
3rd Space Sequestration

... Bleeding
1. Correcting Fluid Deficit

2. Correcting Electrolytes

3. Ongoing Maintenance ( + losses)
Age and Comorbidities

Eating and Drinking? TPN? Infusion?

Clinical Examination

Observations

Fluid Chart

Electrolytes + Renal Function
Crystalloid
Colloid
Normal Saline
Hartman's
Voluven
Gelofusine
Haemaccel
Mr Darren Smith is a 55 year old 70kg man, presenting to admissions at 7 am for a elective right total knee joint replacement. His operation has been delayed due to several urgent trauma cases. You are asked to write up maintenance fluid for him.
PMHx: HT, Gout, OA MEDS: Paracetamol, Perindopril
2.4 - 2.8L water over 24 hours

80 - 160mmol Na+

50 - 80mmol K+
Assumptions:
An Option:
8/24 N/Saline + 30 mmoL KCl
8/24 5% dextrose + 30 mmoL KCl
8/24 5% dextrose
... hence in 24 hours, 3 L water, 150 mmol Na+, 60 mmol K+
Mrs. Emilija Stojanovski, 66, 6 hrs post elective R) hemicolectomy. BP 90/50. HR 100. Urine 15 ml /hr for 2 hours. Pt comfortable. pls r/v fluid orders. Currently on 12/24 bag of 5% Dextrose.
Potassium Management
K+ Theory
Hypokalaemia
Hyperkalaemia
Daily requirement:
50-70 mmol/L
Out
Renal excretion.
In
3.5 - 5 mmol/L
Normal
Where
20%
80%
of inpatients
of patients
on diuretics
...severe hypokalaemia is uncommon.
< 2.5 2.5-3.0 3.0-3.5
severe moderate mild
Causes
↑ Entry into Cells
↓ Intake
↑ Losses
Other
Medications
Alkalosis ( ECF pH)
↑ Insulin availability
↑ adrenergic activity (Stress)
Hypokalaemic periodic paralysis
↑ Blood cell production, Hypothermia
GIT Losses (Vomiting, Diarrhoea, Laxative Abuse, Tube Drainage)

Urinary Losses( Diuretics, Renal Tubular Acidosis, Hyperaldosteronism, Hypomagnesaemia)
Rare on its own - kidney compensates
May be superimposed on another cause of K+ (ie diuretics)
Diuretics
Beta Agonists (Salbutamol)
Steroids
Theophylline
Aminoglycosides
Sweat losses
Dialysis (particularly PD)
ECG if K+ <3.0

U&E, Mg2+

? ABG, Urinary K+, Renin and aldosterone

Review the drug chart
Treat Cause + Ix
Fix It.
10 mmol K / 100 ml N. Saline

30 mmol K+ / 1000 ml N. Saline

30 mmol K+ / 1000 ml 5% Dextrose
IV Replacement
Slow K - 8mmol/tab

Chlorvescent - 15mmol/tab
Oral Replacement
max 10 mmol/hr on ward
1-10%
inpatients
Clinically
vague, non-specific Sx
weakness, depressed tendon reflexes, parasthaesia
severe:
Fix it
1. Cardiac Stabilisation

2. Reduce intravasc. K+

3. Removal from Body
Causes
IV Fluids
Some Medications ( K+ salts of Pen.)
Blood Transfusions
Increased Intake
ARF/CRF
Drugs
Addison's Disease
Factitious
Acidaemia
Insulin Deficiency
Tissue Distruction (burns)
Drugs (digoxin, beta blockers)
Torniquet
Haemolysis
Leukocytosis
Thrombocytosis
Shift out of Cells
Decreased Excretion
mild moderate severe
5.5-6.0 6.1-6.9 >7.0
10ml 10% Calcium Gluconate IV
Insulin - 10 Units Actrapid/Novarapid IV
Dextrose - 50ml of 50% dextrose IV)
Resonium - 15 or 30g oral or PR (with 20ml Lactulose)
Haemodialysis
Onset 1-3 min, lasts 30-60 min
Onset 2-3 hrs, duration 4-6 hrs
Onset 15-30 min, lasts 4 hrs
Scenario 1
Mrs. Elaine Wang is a 32 year old woman with 24 hours of vomiting and diarrhea. Everyone in her family has had it. No medical history. She has dry mucous membranes, HR 100. K+ 2.9 in ED.
Can replace fluid fairly aggressively.
4/24 30 mmol KCl in 1L N/Saline
4/24 30 mmol KCl in 1L NSaline
8/24 30 mmol KCl in 1L 5% Dextrose
Scenario 2
Mrs. Maria Caruana is a 82 year old lady with pneumonia. She has a PHx of CCF, and is currently receiving Frusemide 40 mg IV BD. UEC shows Na+ 142, K+ 2.8.
1/24 10 mmol KCl in 100 ml N/Saline
1/24 10 mmol KCl in 100 ml N/Saline
1/24 10 mmol KCl in 100 ml N/Saline
12/24 30 mmol KCl in 1L 5% Dextrose
Go Slower.
Scenario 3
70 year old man with CCF, recently worsening, and GP started Spironolactone one week prior. Now asked to present to ED by GP, as K+ = 6.7 on routine UEC. PHx: IHD, HT, CRI. MEDS: Perindopril, Spironolactone, Carvedilol, Aspirin, Clopidogrel, Atorvastatin, Frusemide, Slow K
Manage Issue


Manage Cause
ECG
10 units Novarapid IV
50ml of 50% Dextrose IV
30 g Resonium oral or PR
Slow K
Spironolactone
IV Fluids
... and Potassium Management
Dr. Stewart Morrison MBBS Monash 2008
... Questions?
http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/corbettarticle.pdf
Introduction
Inappropriate intravenous fluid therapy is a significant cause of patient morbidity and mortality

Fluid overload can be precipitated by, and lead to strain on, existent cardiorespiratory disease and acute illness

Inadequate fluid administration can lead to inadequate circulation, organ perfusion, and ATN

Inappropriate electrolyte administration can lead to arrthymias, neurological injury, or death
Cardiac disturbances






Neuromuscular





Other
Ventricular arrhythmias
Prolonged QT
ST Depression
T wave flattening
Appearance of U Waves


Weakness
Depressed tendon reflexes
Paraesthesia
Ileus


Metabolic Alkalosis
Worsening of hepatic encephalopathy
Blood Products
5% Dextrose
4% Dextrose 1/5 N.S
PRBC
Platelets, etc
Water
Rapidly distributes in ECF and ICF. Not useful to increase intravascular volume.
Distributes in ECF. Half life in intravascular space is approx 1-3 hours. Can increase IV volume
Distribute in intravascular space. Half-life of albumin in the IV space is 17-20 hours. Can be used to increase IV volume.
Patient is relatively “normal”

Patient is “nil-by-mouth”

Patient is euvolaemic.
normal size, relatively well, no kidney failure, no heart failure,
no electrolyte disturbance, no particular abnormal losses
Dr. Andrew Foote, B2B Week Presentation 2009: IV Fluids

Dr. Andrew Foote, B2B Week Presentation 2009: Electrolyte Balance

Eugene C. Corbett MD, Intravenous Fluids, Practical Gasteroenterology, July 2007

Guyton & Hall: Textbook of Medical Physiology, 11th Edition

Fry, AC et al. Management of acute renal failure, Postgraduate Medical Journal 2006

Shami S., Understanding fluid balance, Student BMJ April 1997

Hilton AK et al., Avoiding Common Problems Associated with Intravenous Fluid Therapy, MJA 189(2008):9 509-511

The Medicine Box: Standard Post-Operative Fluid Management in Adults

Marshall & Ruedy’s On Call Principles and Protocols pages 8 – 17.

Burton Rose's book "Clinical Physiology of Acid-Base and Electrolyte Disorders"
http://vitualis.wordpress.com/2006/05/12/standard-post-operative-fluid-management-in-adults/
This is not an exact science.

But doing it correctly is important.
Charting fluids for patients with hyper or hyponatraemia is complex.
Don't chart fluids too far in advance.
If in doubt, review more regularly.
... Balance this against the need to leave orders for a cover intern to write up.
Day 1 Post Op: Considerations
Increased aldosterone as response to surgery
Theoretical K+ increase from tissue damage
Increased ADH - retain H20
1 L N/Saline STAT ... response?
1 L N/Saline over 1/24 ... response?
Possibility:
... Hb, UEC, G+S
... XM?
? abdomen tense
? blood in drain
? little response to fluid
? unable to increase urine output
? nurses seemingly very concerned
? you're concerned or unsure
... call registrar.
document. set parameters.
discuss with nursing staff.
Bleeding? .... Replace with blood, and call someone.
Vomiting/Diarrhea? ... Replace Na+ and K+ lost
Third Space Loss? ... Again, often large amounts of Na+ and K+ lost.
Cardiac Disease?
Renal Impairment?
Liver Impairment?
Most recent UEC?
pt needs assessment.
feel abdomen.
check op notes.
check drains.
check observations trend.
Why deficit?
2% of K+ is extracellular
ICF and ECF concentrations are maintained by basolateral Na+ / K+ ATPase pump
(for major surgery)
http://stew.is/VbV5
Losses
Full transcript