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“Oh yeah, and add an order for IV fluids …”

“Oh yeah, and add an order for IV fluids …”. How to order the right IV fluids for your patients. Objectives. Practical overview of writing orders for IV fluids. Learn about the 3 major goals of IV fluid therapy Deficit correction Maintenance fluids Replacing ongoing losses.

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“Oh yeah, and add an order for IV fluids …”

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  1. “Oh yeah, and add an order for IV fluids…” How to order the right IV fluids for your patients.

  2. Objectives • Practical overview of writing orders for IV fluids. • Learn about the 3 major goals of IV fluid therapy • Deficit correction • Maintenance fluids • Replacing ongoing losses

  3. Additional learning • Anesthesia • Pre and post operative • Surgery • Trauma • Medicine • Sepsis, DKA, etc. • Pediatrics • (Elective) Critical Care Medicine

  4. Basic components: • Route – IV • Fluid type • Added potassium? • Volume • Rate • Total volume, or time to reassess

  5. Example • IV 0.5 NS with 20 mEq/L KCl at 125 ml/hour, Reassess tomorrow morning. Route

  6. Fluid type Potassium added Example • IV 0.5 NS with 20 mEq/L KCl at 125 ml/hour, Reassess tomorrow morning.

  7. Example • IV 0.5 NS with 20 mEq/L KCl at 125 ml/hour, Reassess tomorrow morning. Rate

  8. Example • IV 0.5 NS with 20 mEq/L KCl at 125 ml/hour, Reassess tomorrow morning. Time to reassess.

  9. Example • IV 0.5 NS with 20 mEq/L KCl at 125 ml/hour, Reassess tomorrow morning.

  10. Types of fluids • Blood products • Colloid • Crystalloids

  11. Blood Products • Packed Red Blood Cells (PRBC) • Ordered in units • Fresh Frozen Plazma (FFP) • Contains all plasma clotting factors • Platelets • Albumin – intravascular volume expander • Factor VII – order by Hematology Get Help if ordering blood products.

  12. Colloid • Pentaspan (most commonly available synthetic) • Used to resuscitate and to increase the intravascular volume. • Max. 2 Litres in 24 hours (70 kg) • PRBCs • Albumin

  13. Colloids 2 Litres of colloid 30 Litres Intracellular fluid 9 Litres Interstitial fluid 3 Litres Intravascular fluid

  14. Colloids 30 Litres Intracellular 9 Litres Interstitial 5 Litres Intravascular

  15. Colloids 29 Litres Intracellular 8 Litres Interstitial 7 Litres Intravascular

  16. Crystalloids • Normal Saline = 0.9 saline • 5% dextrose • 0.2 saline with 5% Dextrose • Others

  17. Normal Saline 2 Litres of 0.9% saline 30 Litres Intracellular 9 Litres Interstitial 3 Litres Intravascular

  18. Normal Saline 30 Litres Intracellular 9 Litres Interstitial 5 Litres Intravascular

  19. Normal Saline 29 Litres Intracellular 10.5 Litres Interstitial 4.5 Litres Intravascular

  20. 5% Dextrose (D5W) 2 Litres of 5% dextrose 30 Litres Intracellular 9 Litres Interstitial 3 Litres Intravascular

  21. 5% Dextrose (D5W) 31 Litres Intracellular 9.7 Litres Interstitial 3.3 Litres Intravascular

  22. The rules of fluid replacement: • Replace blood with blood • Replace plasma with colloid • Resuscitate with colloid • Replace ECF depletion with saline • Re-hydrate with dextrose

  23. Deficit - Adult For Pediatrics see your handout.

  24. Approach to IV Fluids • Deficit • Maintenance • Ongoing Losses

  25. Estimating Deficit - Adult

  26. Water as % of Body Weight • Newborns 75-80% • D5W/0.2% NS for <15 kg • At one year 65% • D5w/0.45% NS for >15 kg • Adult Male 60% • Adult Female 50% • Elderly 45%

  27. Water Distribution • TBW = 2/3 ICF + 1/3 ECF • ECF = 2/3 interstitial + 1/3 intravascular • Intravascular volume (L) = (Wt [kg] x Percent Body Water)  9

  28. Rate of replacement General Rule  • Give half of deficit in the first 8 hours and the next half over 16 hours. • This is NOT true for someone in shock.

  29. Example: • 45 year-old woman • She weighs 60 kg. • She has a dry axilla & a dry tongue • How much crystalloid should you give her?

  30. Example solved. • TBW = 60 kg x 0.5 • 30 kg  30 Litres • Her symptoms are mild •  3% loss of TBW = 0.9 liters • IV NS at 60 ml/hour for 8 hours, then NS at 30 ml/hour for 16 hours, then discontinue.

  31. Maintenance Fluids

  32. Water requirements • Average healthy adult requires 2.5 L water/day. • GI losses – 200 mL • Insensible losses (respiration, perspiration) – 800 mL • Urine – 1.5 L (Caution: check for renal failure)

  33. Increased requirements • Fever • Sweating • GI • Vomiting • Diarrhea • NG suction

  34. Decreased requirements • Anuria / oliguria • Syndrome of Inappropriate ADH (SIADH) • CHF

  35. 4/2/1 Rule – Maintenance Water • First 10 kg - 4 ml/kg/hour • Second 10 kg – 2 ml/kg/hour • For each kg over 20 kg – 1 ml/kg/hour • Or for those over 20 kg: • 60 ml/hour + ((kg-20)x1)

  36. Maintenance Electrolytes • Sodium • 3 mEq/kg/day • Potassium • 1 mEq/kg/day

  37. Example: 50 kg person

  38. Fluid (4/2/1) • 4: 10 kg x 4 = 40 • 2: 2nd 10 kg x 2 = 20 • 1: (50kg – 20) x 1 = 30 • Total 40 + 20 + 30 = 90 ml/hour • 90 ml/hour x 24 hours = 2,160 ml/day • Or 2.16 Litres

  39. Electrolytes - Sodium • Na+ = 3 mEq/kg/day • 50 kg x 3 = 150 mEq/day • 150 mEq/day  2.16 L/day = 69 mEq/L • Per litre this patient requires 69 mEq/L of sodium.

  40. Electrolytes - Potassium • K+ = 1 mEq/kg/day • 50 kg x 1 = 50 mEq/day • 50 mEq/day  2.16 L/day = 23 mEq/L • Per litre this patient requires 23 mEq/L of potassium.

  41. Overall requirements • Fluid: 2.26 Litres = 90 ml/hour • Sodium: 69 mEq/L • Potassium: 23 mEq/L • Look at the chart of IV solutions on page 2 of your handout. • The best matches is 0.45 NS with 77 mEq/L of sodium.

  42. The order would look like this: • “IV 0.45 NS with 20 mEq KCl/L at 90 mL/hr”

  43. Ongoing Losses

  44. Gastric Losses • Nasogastric tube • Emesis • D5 0.45 NS with 20 mEq/L potassium chloride (KCl)

  45. Diarrhea • D5 Ringer’s Lactate with 15 mEq/L KCl • Use body weight as a replacement guide (1 kg = 1 litre) • An order for daily weights will help.

  46. Blood Loss • Packed Red Blood Cells (PRBC) Type & Matched • Assess Platelets, INR, and Calcium • Stop anticoagulant medications • Consider Vitamin K (if on warfarin) • Consider replacing clotting factors • Fresh Frozen Plasma (FFP) • May need factor VII in the event of severe bleeding • Consider replacing Platelets

  47. Rate of replacement • Depends on rate of loss. • Rapid losses require more frequent measurement and adjustment of infusion rate. • E.g., Measure NG losses Q2H and replace with IV D5 0.45 NS with 20 mEq/L KCl over the next 2 hours, Reassess in A.M.

  48. So remember: • Deficit Fluids • Maintenance Fluids • Ongoing Losses

  49. The best way to learn: • Practice, practice, practice. • Attempt the questions on page 3 of your handout.

  50. And have fun! Thank you.

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