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Intravenous Fluid Management
Transcript of Intravenous Fluid Management
Dr. Stewart Morrison MBBS (2008)
Assessing the Patient
What is the Goal?
Body: 70 kg
Bone/Fat etc: 28kg
Total Body Water: 42 L
ICF: 28 L
ECF: 14 L
Intravascular 3 L
Interstitial 11 L
=2.5-3 L /day
Urine 1400 ml
Faeces 100 ml
Sweat 100 ml
Insensible Skin - 350 ml
Insensible Lungs - 350 ml
3rd Space Sequestration
1. Correcting Fluid Deficit
2. Correcting Electrolytes
3. Ongoing Maintenance ( + losses)
Age and Comorbidities
Eating and Drinking? TPN? Infusion?
Electrolytes + Renal Function
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+
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.
3.5 - 5 mmol/L
...severe hypokalaemia is uncommon.
< 2.5 2.5-3.0 3.0-3.5
severe moderate mild
↑ Entry into Cells
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)
Beta Agonists (Salbutamol)
Dialysis (particularly PD)
ECG if K+ <3.0
? ABG, Urinary K+, Renin and aldosterone
Review the drug chart
Treat Cause + Ix
10 mmol K / 100 ml N. Saline
30 mmol K+ / 1000 ml N. Saline
30 mmol K+ / 1000 ml 5% Dextrose
Slow K - 8mmol/tab
Chlorvescent - 15mmol/tab
max 10 mmol/hr on ward
vague, non-specific Sx
weakness, depressed tendon reflexes, parasthaesia
1. Cardiac Stabilisation
2. Reduce intravasc. K+
3. Removal from Body
Some Medications ( K+ salts of Pen.)
Tissue Distruction (burns)
Drugs (digoxin, beta blockers)
Shift out of Cells
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)
Onset 1-3 min, lasts 30-60 min
Onset 2-3 hrs, duration 4-6 hrs
Onset 15-30 min, lasts 4 hrs
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
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
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
10 units Novarapid IV
50ml of 50% Dextrose IV
30 g Resonium oral or PR
... and Potassium Management
Dr. Stewart Morrison MBBS Monash 2008
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
T wave flattening
Appearance of U Waves
Depressed tendon reflexes
Worsening of hepatic encephalopathy
4% Dextrose 1/5 N.S
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"
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?
... Hb, UEC, G+S
? 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.
Most recent UEC?
pt needs assessment.
check op notes.
check observations trend.
2% of K+ is extracellular
ICF and ECF concentrations are maintained by basolateral Na+ / K+ ATPase pump
(for major surgery)