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Shock & IV Fluids. Dr. Ahmed Khan Sangrasi Associate Professor, Department of Surgery, LUMHS Jamshoro. Shock. Shock is a life threatening medical condition that occurs due to inadequate substrate for aerobic cellular respiration.

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Shock iv fluids

Shock & IV Fluids

Dr. Ahmed Khan SangrasiAssociate Professor, Department of Surgery,

LUMHS Jamshoro


Shock

Shock

  • Shock is a life threatening medical condition that occurs due to inadequate substrate for aerobic cellular respiration.

  • Shock is a common end point of many medical conditions and one of the most common causes of death for critically ill people


Objectives

Objectives

  • Definition

  • Approach to the hypotensive patient

  • Types

  • Specific treatments


Definition of shock

Definition of Shock

  • Inadequate oxygen delivery to meet metabolic demands

  • Results in global tissue hypoperfusion and metabolic acidosis

  • Shock can occur with a normal blood pressure and hypotension can occur without shock


Understanding shock

Understanding Shock

  • Inadequate systemic oxygen delivery activates autonomic responses to maintain systemic oxygen delivery

    • Sympathetic nervous system

      • NE, epinephrine, dopamine, and cortisol release

        • Causes vasoconstriction, increase in HR, and increase of cardiac contractility (cardiac output)

    • Renin-angiotensin axis

      • Water and sodium conservation and vasoconstriction

      • Increase in blood volume and blood pressure


Understanding shock1

Understanding Shock

  • Cellular responses to decreased systemic oxygen delivery

    • ATP depletion → ion pump dysfunction

    • Cellular edema

    • Hydrolysis of cellular membranes and cellular death

  • Goal is to maintain cerebral and cardiac perfusion

    • Vasoconstriction of splanchnic, musculoskeletal, and renal blood flow

  • Leads to systemic metabolic lactic acidosis that overcomes the body’s compensatory mechanisms


Global tissue hypoxia

Global Tissue Hypoxia

  • Endothelial inflammation and disruption

  • Inability of O2 delivery to meet demand

  • Result:

    • Lactic acidosis

    • Cardiovascular insufficiency

    • Increased metabolic demands


Multiorgan dysfunction syndrome mods

Multiorgan DysfunctionSyndrome (MODS)

  • Progression of physiologic effects as shock ensues

    • Cardiac depression

    • Respiratory distress

    • Renal failure

    • DIC

  • Result is end organ failure


Shock iv fluids

1. ANTICIPATION STAGE


Shock iv fluids

2. PRE-SHOCK STAGE


Shock iv fluids

3. COMENSATED SHOCK STAGE


Shock iv fluids

4. DECOMPENSATED SHOCK STAGE (REVERSABLE)


Shock iv fluids

5. DECOMPENSATED SHOCK STAGE (IRREVERSABLE)


Approach to the patient in shock

Approach to the Patient in Shock

  • ABCs

    • Cardiorespiratory monitor

    • Pulse oximetry

    • Supplemental oxygen

    • IV access

    • ABG, labs

    • Foley catheter

    • Vital signs including rectal temperature


Diagnosis

Diagnosis

  • Physical exam (VS, mental status, skin color, temperature, pulses, etc)

  • Infectious source

  • Labs:

    • CBC

    • Chemistries

    • Lactate

    • Coagulation studies

    • Cultures

    • ABG


Further evaluation

Further Evaluation

  • CT of head/sinuses

  • Lumbar puncture

  • Wound cultures

  • Acute abdominal series

  • Abdominal/pelvic CT or US

  • Cortisol level

  • Fibrinogen, FDPs, D-dimer


Approach to the patient in shock1

Approach to the Patient in Shock

  • History

    • Recent illness

    • Fever

    • Chest pain, SOB

    • Abdominal pain

    • Comorbidities

    • Medications

    • Toxins/Ingestions

    • Recent hospitalization or surgery

    • Baseline mental status

  • Physical examination

    • Vital Signs

    • CNS – mental status

    • Skin – color, temp, rashes, sores

    • CV – JVD, heart sounds

    • Resp – lung sounds, RR, oxygen sat, ABG

    • GI – abd pain, rigidity, guarding, rebound

    • Renal – urine output


Is this patient in shock

Is This Patient in Shock?

  • Patient looks ill

  • Altered mental status

  • Skin cool and mottled or hot and flushed

  • Weak or absent peripheral pulses

  • SBP <110

  • Tachycardia

Yes!

These are all signs and symptoms of shock


Shock1

Shock

  • Do you remember how to quickly estimate blood pressure by pulse?

60

  • If you palpate a pulse,

  • you know SBP is at

  • least this number

70

80

90


Goals of treatment

Goals of Treatment

  • ABCDE

    • Airway

    • control work of Breathing

    • optimize Circulation

    • assure adequate oxygen Delivery

    • achieve End points of resuscitation


Airway

Airway

  • Determine need for intubation but remember: intubation can worsen hypotension

    • Sedatives can lower blood pressure

    • Positive pressure ventilation decreases preload

  • May need volume resuscitation prior to intubation to avoid hemodynamic collapse


Control work of breathing

Control Work of Breathing

  • Respiratory muscles consume a significant amount of oxygen

  • Tachypnea can contribute to lactic acidosis

  • Mechanical ventilation and sedation decrease WOB and improves survival


Optimizing circulation

Optimizing Circulation

  • Isotonic crystalloids

  • Titrated to:

    • CVP 8-12 mm Hg

    • Urine output 0.5 ml/kg/hr (30 ml/hr)

    • Improving heart rate

  • May require 4-6 L of fluids

  • No outcome benefit from colloids


Maintaining oxygen delivery

Maintaining Oxygen Delivery

  • Decrease oxygen demands

    • Provide analgesia and anxiolytics to relax muscles and avoid shivering

  • Maintain arterial oxygen saturation/content

    • Give supplemental oxygen

    • Maintain Hemoglobin > 10 g/dL

  • Serial lactate levels or central venous oxygen saturations to assess tissue oxygen extraction


End points of resuscitation

End Points of Resuscitation

  • Goal of resuscitation is to maximize survival and minimize morbidity

  • Use objective hemodynamic and physiologic values to guide therapy

  • Goal directed approach

    • Urine output > 0.5 mL/kg/hr

    • CVP 8-12 mmHg

    • MAP 65 to 90 mmHg

    • Central venous oxygen concentration > 70%


Persistent hypotension

Persistent Hypotension

  • Inadequate volume resuscitation

  • Pneumothorax

  • Cardiac tamponade

  • Hidden bleeding

  • Adrenal insufficiency

  • Medication allergy


Practically speaking

Practically Speaking….

  • Keep one eye on these patients

  • Frequent vitals signs:

    • Monitor success of therapies

    • Watch for decompensated shock

  • Let your nurses know that these patients are sick!


Types of shock

Types of Shock

  • Hypovolemic

  • Cardiogenic

  • Septic

  • Anaphylactic

  • Neurogenic

  • Endocrine

  • Obstructive


What type of shock is this

What Type of Shock is This?

  • 68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin

Types of Shock

  • Hypovolemic

  • Septic

  • Cardiogenic

  • Anaphylactic

  • Neurogenic

  • Obstructive

Hypovolemic Shock


Hypovolemic shock

Hypovolemic Shock


Hypovolemic shock1

Hypovolemic Shock

  • Non-hemorrhagic

    • Vomiting

    • Diarrhea

    • Bowel obstruction, pancreatitis

    • Burns

    • Neglect, environmental (dehydration)

  • Hemorrhagic

    • GI bleed

    • Trauma

    • Massive hemoptysis

    • AAA rupture

    • Ectopic pregnancy, post-partum bleeding


Hypovolemic shock2

Hypovolemic Shock

  • ABCs

  • Establish 2 large bore IVs or a central line

  • Crystalloids

    • Normal Saline or Lactate Ringers

    • Up to 3 liters

  • PRBCs

    • O negative or cross matched

  • Control any bleeding

  • Arrange definitive treatment


Evaluation of hypovolemic shock

Evaluation of Hypovolemic Shock

  • CBC

  • ABG/lactate

  • Electrolytes

  • BUN, Creatinine

  • Coagulation studies

  • Type and cross-match

  • As indicated

    • CXR

    • Pelvic x-ray

    • Abd/pelvis CT

    • Chest CT

    • GI endoscopy

    • Bronchoscopy

    • Vascular radiology


Infusion rates

Infusion Rates

AccessGravityPressure

18 g peripheral IV 50 mL/min 150 mL/min

16 g peripheral IV 100 mL/min 225 mL/min

14 g peripheral IV 150 mL/min 275 mL/min

8.5 Fr CV cordis 200 mL/min 450 mL/min


What type of shock is this1

What Type of Shock is This?

  • An 81 yo F resident of a nursing home presents to the ED with altered mental status. She is febrile to 39.4, hypotensive with a widened pulse pressure, tachycardic, with warm extremities

Types of Shock

  • Hypovolemic

  • Septic

  • Cardiogenic

  • Anaphylactic

  • Neurogenic

  • Obstructive

Septic


Septic shock

Septic Shock


Sepsis

Sepsis

  • Two or more of SIRS criteria

    • Temp > 38 or < 36 C

    • HR > 90

    • RR > 20

    • WBC > 12,000 or < 4,000

  • Plus the presumed existence of infection

  • Blood pressure can be normal!


Septic shock1

Septic Shock

  • Sepsis (remember definition?)

  • Plus refractory hypotension

    • After bolus of 20-40 mL/Kg patient still has one of the following:

      • SBP < 90 mm Hg

      • MAP < 65 mm Hg

      • Decrease of 40 mm Hg from baseline


Sepsis1

Sepsis


Pathogenesis of sepsis

Pathogenesis of Sepsis

Nguyen H et al. Severe Sepsis and Septic-Shock: Review of the Literature and Emergency Department Management Guidelines. Ann Emerg Med. 2006;42:28-54.


Septic shock2

Septic Shock

  • Clinical signs:

    • Hyperthermia or hypothermia

    • Tachycardia

    • Wide pulse pressure

    • Low blood pressure (SBP<90)

    • Mental status changes

  • Beware of compensated shock!

    • Blood pressure may be “normal”


Ancillary studies

Ancillary Studies

  • Cardiac monitor

  • Pulse oximetry

  • CBC, Chem 7, coags, LFTs, lipase, UA

  • ABG with lactate

  • Blood culture x 2, urine culture

  • CXR

  • Foley catheter (why do you need this?)


Treatment of septic shock

Treatment of Septic Shock

  • 2 large bore IVs

    • NS IVF bolus- 1-2 L wide open (if no contraindications)

  • Supplemental oxygen

  • Empiric antibiotics, based on suspected source, as soon as possible


Treatment of sepsis

Treatment of Sepsis

  • Antibiotics- Survival correlates with how quickly the correct drug was given

  • Cover gram positive and gram negative bacteria

    • Zosyn 3.375 grams IV and ceftriaxone 1 gram IV or

    • Imipenem 1 gram IV

  • Add additional coverage as indicated

    • Pseudomonas- Gentamicin or Cefepime

    • MRSA- Vancomycin

    • Intra-abdominal or head/neck anaerobic infections- Clindamycin or Metronidazole

    • Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae

    • Neutropenic – Cefepime or Imipenem


Persistent hypotension1

Persistent Hypotension

  • If no response after 2-3 L IVF, start a vasopressor (norepinephrine, dopamine, etc) and titrate to effect

  • Goal: MAP > 60

  • Consider adrenal insufficiency: hydrocortisone 100 mg IV


Treatment algorithm

Treatment Algorithm

Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001:345:1368-1377.


What type of shock is this2

What Type of Shock is This?

  • A 55 yo M with hx of HTN, DM presents with “crushing” substernal CP, diaphoresis, hypotension, tachycardia and cool, clammy extremities

Types of Shock

  • Hypovolemic

  • Septic

  • Cardiogenic

  • Anaphylactic

  • Neurogenic

  • Obstructive

Cardiogenic


Cardiogenic shock

Cardiogenic Shock


Cardiogenic shock1

Cardiogenic Shock

  • Signs:

    • Cool, mottled skin

    • Tachypnea

    • Hypotension

    • Altered mental status

    • Narrowed pulse pressure

    • Rales, murmur

  • Defined as:

    • SBP < 90 mmHg

    • CI < 2.2 L/m/m2

    • PCWP > 18 mmHg


Etiologies

Etiologies

  • What are some causes of cardiogenic shock?

  • AMI

  • Sepsis

  • Myocarditis

  • Myocardial contusion

  • Aortic or mitral stenosis, HCM

  • Acute aortic insufficiency


Pathophysiology of cardiogenic shock

Pathophysiology of Cardiogenic Shock

  • Often after ischemia, loss of LV function

    • Lose 40% of LV clinical shock ensues

  • CO reduction = lactic acidosis, hypoxia

  • Stroke volume is reduced

    • Tachycardia develops as compensation

    • Ischemia and infarction worsens


Ancillary tests

Ancillary Tests

  • EKG

  • CXR

  • CBC, Chem 10, cardiac enzymes, coagulation studies

  • Echocardiogram


Treatment of cardiogenic shock

Treatment of Cardiogenic Shock

  • Goals- Airway stability and improving myocardial pump function

  • Cardiac monitor, pulse oximetry

  • Supplemental oxygen, IV access

  • Intubation will decrease preload and result in hypotension

    • Be prepared to give fluid bolus


Treatment of cardiogenic shock1

Treatment of Cardiogenic Shock

  • AMI

    • Aspirin, beta blocker, morphine, heparin

    • If no pulmonary edema, IV fluid challenge

    • If pulmonary edema

      • Dopamine – will ↑ HR and thus cardiac work

      • Dobutamine – May drop blood pressure

      • Combination therapy may be more effective

    • PCI or thrombolytics

  • RV infarct

    • Fluids and Dobutamine (no NTG)

  • Acute mitral regurgitation or VSD

    • Pressors (Dobutamine and Nitroprusside)


What type of shock is this3

What Type of Shock is This?

  • A 34 yo F presents to the ER after dining at a restaurant where shortly after eating the first few bites of her meal, became anxious, diaphoretic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her “throat closing off”. She is currently hypotensive, tachycardic and ill appearing.

Types of Shock

  • Hypovolemic

  • Septic

  • Cardiogenic

  • Anaphylactic

  • Neurogenic

  • Obstructive

Anaphalactic


Anaphalactic shock

Anaphalactic Shock


Anaphylactic shock

Anaphylactic Shock

  • Anaphylaxis – a severe systemic hypersensitivity reaction characterized by multisystem involvement

    • IgE mediated

  • Anaphylactoid reaction – clinically indistinguishable from anaphylaxis, do not require a sensitizing exposure

    • Not IgE mediated


Anaphylactic shock1

Anaphylactic Shock

  • What are some symptoms of anaphylaxis?

  • First- Pruritus, flushing, urticaria appear

  • Next- Throat fullness, anxiety, chest tightness, shortness of breath and lightheadedness

  • Finally- Altered mental status, respiratory distress and circulatory collapse


Anaphylactic shock2

Anaphylactic Shock

  • Risk factors for fatal anaphylaxis

    • Poorly controlled asthma

    • Previous anaphylaxis

  • Reoccurrence rates

    • 40-60% for insect stings

    • 20-40% for radiocontrast agents

    • 10-20% for penicillin

  • Most common causes

    • Antibiotics

    • Insects

    • Food


Anaphylactic shock3

Anaphylactic Shock

  • Mild, localized urticaria can progress to full anaphylaxis

  • Symptoms usually begin within 60 minutes of exposure

  • Faster the onset of symptoms = more severe reaction

  • Biphasic phenomenon occurs in up to 20% of patients

    • Symptoms return 3-4 hours after initial reaction has cleared

  • A “lump in my throat” and “hoarseness” heralds life-threatening laryngeal edema


Anaphylactic shock diagnosis

Anaphylactic Shock- Diagnosis

  • Clinical diagnosis

    • Defined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systems

  • Look for exposure to drug, food, or insect

  • Labs have no role


Anaphylactic shock treatment

Anaphylactic Shock- Treatment

  • ABC’s

    • Angioedema and respiratory compromise require immediate intubation

  • IV, cardiac monitor, pulse oximetry

  • IVFs, oxygen

  • Epinephrine

  • Second line

    • Corticosteriods

    • H1 and H2 blockers


Anaphylactic shock treatment1

Anaphylactic Shock- Treatment

  • Epinephrine

    • 0.3 mg IM of 1:1000 (epi-pen)

    • Repeat every 5-10 min as needed

    • Caution with patients taking beta blockers- can cause severe hypertension due to unopposed alpha stimulation

    • For CV collapse, 1 mg IV of 1:10,000

    • If refractory, start IV drip


Anaphylactic shock treatment2

Anaphylactic Shock - Treatment

  • Corticosteroids

    • Methylprednisolone 125 mg IV

    • Prednisone 60 mg PO

  • Antihistamines

    • H1 blocker- Diphenhydramine 25-50 mg IV

    • H2 blocker- Ranitidine 50 mg IV

  • Bronchodilators

    • Albuterol nebulizer

    • Atrovent nebulizer

    • Magnesium sulfate 2 g IV over 20 minutes

  • Glucagon

    • For patients taking beta blockers and with refractory hypotension

    • 1 mg IV q5 minutes until hypotension resolves


Anaphylactic shock disposition

Anaphylactic Shock - Disposition

  • All patients who receive epinephrine should be observed for 4-6 hours

  • If symptom free, discharge home

  • If on beta blockers or h/o severe reaction in past, consider admission


What type of shock is this4

What Type of Shock is This?

  • A 41 yo M presents to the ER after an MVC complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities

Types of Shock

  • Hypovolemic

  • Septic

  • Cardiogenic

  • Anaphylactic

  • Neurogenic

  • Obstructive

Neurogenic


Neurogenic shock

Neurogenic Shock


Neurogenic shock1

Neurogenic Shock

  • Occurs after acute spinal cord injury

  • Sympathetic outflow is disrupted leaving unopposed vagal tone

  • Results in hypotension and bradycardia

  • Spinal shock- temporary loss of spinal reflex activity below a total or near total spinal cord injury (not the same as neurogenic shock, the terms are not interchangeable)


Neurogenic shock2

Neurogenic Shock

  • Loss of sympathetic tone results in warm and dry skin

  • Shock usually lasts from 1 to 3 weeks

  • Any injury above T1 can disrupt the entire sympathetic system

    • Higher injuries = worse paralysis


Neurogenic shock treatment

Neurogenic Shock- Treatment

  • A,B,Cs

    • Remember c-spine precautions

  • Fluid resuscitation

    • Keep MAP at 85-90 mm Hg for first 7 days

    • Thought to minimize secondary cord injury

    • If crystalloid is insufficient use vasopressors

  • Search for other causes of hypotension

  • For bradycardia

    • Atropine

    • Pacemaker


Neurogenic shock treatment1

Neurogenic Shock- Treatment

  • Methylprednisolone

    • Used only for blunt spinal cord injury

    • High dose therapy for 23 hours

    • Must be started within 8 hours

    • Controversial- Risk for infection, GI bleed


What type of shock is this5

What Type of Shock is This?

  • A 24 yo M presents to the ED after an MVC c/o chest pain and difficulty breathing. On PE, you note the pt to be tachycardic, hypotensive, hypoxic, and with decreased breath sounds on left

Types of Shock

  • Hypovolemic

  • Septic

  • Cardiogenic

  • Anaphylactic

  • Neurogenic

  • Obstructive

Obstructive


Obstructive shock

Obstructive Shock


Obstructive shock1

Obstructive Shock

  • Tension pneumothorax

    • Air trapped in pleural space with 1 way valve, air/pressure builds up

    • Mediastinum shifted impeding venous return

    • Chest pain, SOB, decreased breath sounds

    • No tests needed!

    • Rx: Needle decompression, chest tube


Obstructive shock2

Obstructive Shock

  • Cardiac tamponade

    • Blood in pericardial sac prevents venous return to and contraction of heart

    • Related to trauma, pericarditis, MI

    • Beck’s triad: hypotension, muffled heart sounds, JVD

    • Diagnosis: large heart CXR, echo

    • Rx: Pericardiocentisis


Obstructive shock3

Obstructive Shock

  • Pulmonary embolism

    • Virscow triad: hypercoaguable, venous injury, venostasis

    • Signs: Tachypnea, tachycardia, hypoxia

    • Low risk: D-dimer

    • Higher risk: CT chest or VQ scan

    • Rx: Heparin, consider thrombolytics


Obstructive shock4

Obstructive Shock

  • Aortic stenosis

    • Resistance to systolic ejection causes decreased cardiac function

    • Chest pain with syncope

    • Systolic ejection murmur

    • Diagnosed with echo

    • Vasodilators (NTG) will drop pressure!

    • Rx: Valve surgery


Fluid therapy

FLUID Therapy


Fluid and electrolyte balance is an extremely complicated thing

Fluid and electrolyte balance is an extremely complicated thing.


Importance

Importance

  • Need to make a decision regarding fluids in pretty much every hospitalized patient.

  • Aggressive IV fluids are recommended in most types of shock eg. 1-2 litres of NS bolus over 10mins or 20ml/kg in a child

  • Can be life-saving in certain conditions

  • Choice of IV fluid whether crystalloid or colloid is superior: remains undetermined

  • For persistent shock after initial resuscitation, packed RBCs should be given to keep Hb% > 100gms


Shock iv fluids

  • loss of body water, whether acute or chronic, can cause a range of problems from mild lightheadedness to convulsions, coma, and in some cases, death.

  • Though fluid therapy can be a lifesaver, it's never innocuous, and can be very harmful.

  • Permissive hypotension: For haemorrhagic shock current evidence supports that, limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension. (Target: MAP of 60mmHg, SBP: 70-90 mmHg


Kinds of iv fluid solutions

Kinds of IV Fluid solutions

  • Hypotonic - 1/2NS

  • Isotonic- NS, LR, albumen

  • Hypertonic – Hypertonic saline.

  • Crystalloid

  • Colloid


Crystalloid vs colloid type of particles large or small

Crystalloid vs ColloidType of particles (large or small)

  • Fluids with small “crystalizable” particles like NaCl are called crystalloids

  • Fluids with large particles like albumin are called colloids, these don’t (quickly) fit through vascular pores, so they stay in the circulation and much smaller amounts can be used for same volume expansion. (250ml Albumin = 4 L NS)

    • Edema resulting from these also tends to stick around longer for same reason.

    • Albumin can also trigger anaphylaxis.


Shock iv fluids

There are two components to fluid therapy:

  • Maintenance therapy replaces normal ongoing losses, and

  • Replacement therapy corrects any existing water and electrolyte deficits.


Maintenance therapy

Maintenance therapy

  • Maintenance therapy is usually undertaken when the individual is not expected to eat or drink normally for a longer time (eg, perioperatively or on a ventilator).

  • Big picture: Most people are “NPO” for 12 hours each day.

  • Patients who won’t eat for one to two weeks should be considered for parenteral or enteralnutrition.


Shock iv fluids

Maintenance Requirements can be broken

into water and electrolyte requirements:


Water

Water —

  • Two liters of water per day are generally sufficient for adults;

  • Most of this minimum intake is usually derived from the water contentof food and the water of oxidation, therefore

  • it has been estimated that only 500ml of water needs be imbibed given normal diet and no increased losses.

  • These sources of water are markedly reduced in patients who are not eating and so must be replaced by maintenance fluids.


Shock iv fluids

  • water requirements increase with:fever, sweating, burns, tachypnea, surgical drains, polyuria, or ongoing significant gastrointestinal losses.

  • For example, water requirements increase by 100 to 150 mL/day for each C degree of body temperature elevation.


Several formulas can be used to calculate maintenance fluid rates

Several formulas can be used to calculate maintenance fluid rates.


4 2 1 rule a k a weight 40

4/2/1 rule a.k.a Weight+40

  • I prefer the 4/2/1 rule (with a 120 mL/h limit) because it is the same as for pediatrics.


Shock iv fluids

  • 4/2/1 rule4 ml/kg/hr for first 10 kg (=40ml/hr)then 2 ml/kg/hr for next 10 kg (=20ml/hr)then 1 ml/kg/hr for any kgs over thatThis always gives 60ml/hr for first 20 kgthen you add 1 ml/kg/hr for each kg over 20 kg

    This boils down to: Weight in kg + 40 = Maintenance IV rate/hour.For any person weighing more than 20kg


What to put in the fluids

What to put in the fluids


Start d5 1 2ns 20 meq k @ wt 40 hr

Start: D5 1/2NS+20 meq K @ Wt+40/hr

  • a reasonable approach is to start 1/2 normal saline to which 20 meq of potassium chloride is added per liter. (1/2NS+20 K @ Wt+40/hr)

  • Glucose in the form of dextrose (D5) can be added to provide some calories while the patient is NPO.

  • The normal kidney can maintain sodium and potassium balance over a wide range of intakes.

  • So,start:

    D5 1/2NS+20 meq K

    at a rate equal to their weight + 40ml/hr, but no greater than 120ml/hr.

  • then adjust as needed, see next page.


Start d5 1 2ns 20 meq k then adjust

StartD5 1/2NS+20 meq K, then adjust:

  • If sodium falls, increase the concentration (eg, to NS)

  • If sodium rises, decrease the concentration (eg, 1/4NS)

  • If the plasma potassium starts to fall, add more potassium.

  • If things are good, leave things alone.


Usually kidneys regulate well but altered homeostasis in the hospital

Usually kidneys regulate well, but:Altered homeostasis in the hospital

  • In the hospital, stress, pain, surgery can alter the normal mechanisms.

  • Increased aldosterone, Increased ADH

  • They generally make patients retain more water and salt, increase tendency for edema, and become hypokalemic.


Shock iv fluids

Now onto Part 2 of the presentation:


Hypovolemia

Hypovolemia

  • Hypovolemia or FVD is result of water & electrolyte loss

  • Compensatory mechanisms include: Increased sympathetic nervous system stimulation with an increase in heart rate & cardiac contraction; thirst; plus release of ADH & aldosterone

  • Severe case may result in hypovolemic shock or prolonged case may cause renal failure


Causes of fvd hypovolemia

Causes of FVD=hypovolemia:

  • Gastrointestinal losses: N/V/D

  • Renal losses: diuretics

  • Skin or respiratory losses: burns

  • Third-spacing: intestinal obstruction, pancreatitis


Replacement therapy

Replacement therapy.


Shock iv fluids

  • A variety of disorders lead to fluid losses that deplete the extracellular fluid .

  • This can lead to a potentially fatal decrease in tissue perfusion.

  • Fortunately, early diagnosis and treatment can restore normovolemia in almost all cases.


Shock iv fluids

  • There is no easy formula for assessing the degree of hypovolemia.

  • Hypovolemic Shock, the most severe form of hypolemia, is characterized by tachycardia, cold, clammy extremities, cyanosis, a low urine output (usually less than 15 mL/h), and agitation and confusion due to reduced cerebral blood flow.

  • This needs rapid treatment with isotonic fluid boluses (1-2L NS), and assessment and treatment of the underlying cause.

  • But hypovolemia that is less severe and therefore well compensated is more difficult to accurately assess.


History for assessing hypovolemia

History for assessing hypovolemia

  • The history can help to determine the presence and etiology of volume depletion.

  • Weight loss!

  • Early complaints include lassitude, easy fatiguability, thirst, muscle cramps, and postural dizziness.

  • More severe fluid loss can lead to abdominal pain, chest pain, or lethargy and confusion due to ischemia of the mesenteric, coronary, or cerebral vascular beds, respectively.

  • Nausea and malaise are the earliest findings of hyponatremia, and may be seen when the plasma sodium concentration falls below 125 to 130 meq/L. This may be followed by headache, lethargy, and obtundation

  • Muscle weakness due to hypokalemia or hyperkalemia

  • Polyuria and polydipsia due to hyperglycemia or severe hypokalemia

  • Lethargy, confusion, seizures, and coma due to hyponatremia, hypernatremia, or hyperglycemia


Basic signs of hypovolemia

Basic signs of hypovolemia

  • Urine output, less than 30ml/hr

  • Decreased BP, Increase pulse


Physical exam for assessing volume

Physical exam for assessing volume

  • physical exam in general is not sensitive or specific

  • acute weight loss; however, obtaining an accurate weight over time may be difficult

  • decreased skin turgor - if you pinch it it stays put

  • dry skin, particularly axilla

  • dry mucus membranes

  • low arterial blood pressure (or relative to patient's usual BP)

  • orthostatic hypotension can occur with significant hypovolemia; but it is also common in euvolemic elderly subjects.

  • decreased intensity of both the Korotkoff sounds (when the blood pressure is being measured with a sphygmomanometer) and the radial pulse ("thready") due to peripheral vasoconstriction.

  • decreased Jugular Venous Pressure

  • The normal venous pressure is 1 to 8 cmH2O, thus, a low value alone may be normal and does not establish the diagnosis of hypovolemia.


Signs symptoms of fluid volume excess

SIGNS & SYMPTOMS OF Fluid Volume Excess

  • SOB & orthopnea

  • Edema & weight gain

  • Distended neck veins & tachycardia

  • Increased blood pressure

  • Crackles & wheezes

  • pleural effusion


Which brings us to labnormalities seen with hypovolemia

Which brings us to: Labnormalities seen with hypovolemia

  • a variety of changes in urine and blood often accompany extracellular volume depletion.

  • In addition to confirming the presence of volume depletion, these changes may provide important clues to the etiology.


Bun cr

BUN/Cr

  • BUN/Cr ratio normally around 10

  • Increase above 20 suggestive of “prerenal state”

  • (rise in BUN without rise in Cr called “prerenal azotemia.”)

  • This happens because with a low pressure head proximal to kidney, because urea (BUN) is resorbed somewhat, and creatinine is secreted somewhat as well


Hgb hct

Hgb/Hct

  • Acute loss of EC fluid volume causes hemoconcentration (if not due to blood loss)

  • Acute gain of fluid will cause hemodilution of about 1g of hemoglobin (this happens very often.)


Plasma na

Plasma Na

  • Decrease in Intravascular volume leads to greater avidity for Na (through aldosterone) AND water (through ADH),

  • So overall, Plasma Na concentration tends to decrease from 140 when hypovolemia present.


Urine na

Urine Na

  • Urine Na – goes down in prerenal states as body tries to hold onto water.

  • Getting a FENa helps correct for urine concentration.

  • Screwed up by lasix.

  • Calculator on PDA or medcalc.com


Iv modes of administration

IV Modes of administration

  • Peripheral IV

  • PICC

  • Central Line

  • Intraosseous


Iv problem extravasation infiltrated

IV Problem:Extravasation / “Infiltrated”

  • The most sensitive indicator of extravasated fluid or "infiltration" is to transilluminate the skin with a small penlight and look for the enhanced halo of light diffusion in the fluid filled area.

  • Checking flow of infusion does not tell you where the fluid is going


Thank you

Thank you


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