Daily fluid balance

INTRAVENOUS FLUID THERAPY

Presented byDr. Anil Kumar Gangwar

JR-1

Moderator - Dr. S. C. Chaudhary M.D

Objectives• Volume of distribution • IV fluid choices available• Types of fluid depletion• Specific clinical examples and treatment

Volume of Distribution of Water

60%-Males

50%-FemalesH2O

Solids

Intracellular

(2/3)

Extracellular

(1/3)

Solids 40% of Wt

H2O H2O

Na

Intra-vascular1/4

E.C.F. COMPARTMENTS

Interstitial 3/4

H2O H2O

NaNaColloids & RBC

Third Space

• Acute sequestration in a body compartment that is not in equilibrium with ECF

• Examples:– Intestinal obstruction– Severe pancreatitis– Peritonitis– Major venous obstruction– Capillary leak syndrome– Burns

Daily Fluid Balance

Insensible fluid loss = 500 ml through skin = 400 ml through lungs = 100 ml through stool

Insensible fluid input = 300 ml due to Oxidation

Daily insensible fluid loss = 1000 ml – 300 ml = 700 ml

Electrolyte concentration of body fluids (mEq/L) Electrolytes ECF ICF

Sodium Potassium Chloride Bicarbonate Calcium Magnesium Phosphate and Sulphate

142.00 4.30 104.00 24.00 5.00 3.00 8.00

10.00 150.00 2.00 6.00 0.01 40.00 150.00

ECF ICFMajor Cation Sodium Potassium and

Magnesium

Major Anion Chloride and Bicarbonate

Phosphate, Sulphate and Protein

Calculating Plasma OsmolalityPlasma = 2 X Na + Glucose ( mg/dl) /18 + BUN(mg/dl) /2.8osmolality

The effective plasma osmolality is determined by those solutes in the plasma which do not freely permeates cell wall and act to hold water within the ECF.So Lipid soluble solutes such as urea which can cross the cell memebrane does not contribute to osmotic pressure gradient between ECF and ICF.

Effective osmolality = 2 X Na (mEq/L) + Glucose (mg/dl) / 18 (mOsm / Kg)

BASIC PRINCIPLES OF I.V. FLUID THERAPY

Advantage :-1) Accurate, controlled & predictable way of administration.2) Immediate response.3) Prompt correction of serous fluid & electrolyte disturbances.

Indication :-4) Condition when oral intake not possible. E.g.- coma, surgery.5) Moderate to severe dehydration and shock.6) Severe vomiting and diarrhea.7) Hypoglycemia ,where 25% dextrose is life saving.8) As vehicle for various I.V. medication. E.g.- antibiotics9) Total parenteral nutrition10) Treatment of critical problems like – Shock, Cardiac arrest, forced

diuresis in drug overdose, poisoning

Disadvantage :-1) More expensive , need strict asepsis.2) Improper selection of type of fluid used can lead to serious problems.3) Improper volume & rate of infusion can be life threatening.4) Improper technique of administration can lead to complication.

Contraindication:-5) Preferable to avoid in patients with congestive heart failure & volume

overdose.

Complication :-6) Local - Hematoma, infiltration , infusion phlebitis.7) Systemic - Circulation overload, Rigors, air embolism ,septicemia.8) Others - Fluid contamination, mixing of incompatible drugs

Classification of I.V. FluidsCRYSTALLOIDS :Isotonic salineDextrose saline5 % Dextrose10 % Dextrose25% DextroseRinger lactateIsotype – MIsotype – E

SPECIAL FLUIDS :Sodium BicarbonatePotassium chloride

COLLOID SOLUTION :AlbuminDextranGelatin polymersHetastarchPentastarch

BLOOD

CRYSTALLOIDS

Isotonic or normal saline (0.9% NaCl) Composition:- One litre fluid contains - Na+ = 154 mEq Cl- = 154 mEqDistributed chiefly in extracellular fluid, so it will increase intravascular volume

substantially

Indication:-1) Resuscitation fluid in diarrhea, vomiting , excessive diuresis.2) Treatment of Hypovolemic shock.3) Initial fluid therapy in Diabetic ketoacidosis. 4) Fluid challenge in pre-renal ARF.5) AS vehicle for certain drugs and can be safely given with blood.

Contraindication:1) Avoid in hypertensive or pre-eclamptic patients.2) CHF ,Renal diseases and cirrhosis.

Dextrose normal saline( 5% dextrose with 0.9%NaCl )

Composition:- One litre fluid contains - Glucose = 50 gm Na+ = 154 mEq Cl- = 154 mEqDistributed chiefly in extracellular fluid,

Indication:-1) Correction of salt depletion and hypovolemia with supply of energy.2) Fluid compatible with blood transfusion.3) Correction of vomiting or nasogastric aspiration indused alkalosis.

Contraindication:1) Anasarca – cautious use in anasarca of cardiac , hepatic and renal disease2) Hypovolemic shock- Rapid infusion can cause Hyperglycemia and osmotic diuresis even in

presence of fluid deficit.

RINGER’s LACTATE Composition:- Each 1 Litre of fluid contains - Sodium = 130 mEq Calcium = 3 mEqPotassium = 4 mEq Bicarbonate = 28 mEq Chloride = 109 mEq

Ringer lactate is the most physiological fluid as its electrolyte content is nearly similar to that of plasma.

Because of high Sodium conc. It rapidly expands intravascular volume and so very effective in treatment of severe hypovolemia.

Indication:-1) Correction of severe Hypovulemia rapidly with large fluid volume.2) For replacing fluid in post operative patients, burns , fractures etc.3) Treatment of Diarrhia induced hypovolemia with hypokalemic metabolic acidosis. 4) In Diabetic keto acidosis , RL provides glucose free water.5) For maintaining normal ECF fluid and electrolyte balance during and after surgery.

Contraindication:1) Ringer lactate can lead to lactic acidosis in patients with Liver disease ,

Hypoxia and shock2) Severe CHF.3) Addison’s disease4) In vomiting or continuous Nasogastric aspiration5) Along with Blood transfusion6) The calcium in RL binds with certain drugs like amphotericin, thiopental

and reduces their bioavailability and efficiency.

ISOLYTE – M (maintenance sol. With 5% dextrose)

Composition:- One litre fluid contains - Glucose = 50 gm Phosphate = 15 mEq Na+ = 40 mEq Acetate = 20 mEq Cl- = 38 mEq K+ = 35 mEq • Isolyte – M is the richest source of potassium so very useful in treatment of hypokalemia• Proportions of electrolytes in Isolyte-M is almost similar to maintenance requirement of the body

Indication:-1) For Parenteral fluid therapy ,it’s the ideal maintenance fluid.2) To correct hypokalemia secondary to diarrhea , bilious vomiting etc.

Contraindication:1) Acute and chronic renal failure.2) Hyponatremia .3) Adrenocortical insufficiency.4) In patients with burns.

ISOLYTE – E (Extracellular replacement solution )

Composition:- One litre fluid contains - Glucose = 50 gm Acetate = 47 mEq Na+ = 140 mEq Ca ++ = 5 mEq Cl- = 103 mEq Mg++ = 3 mEq K+ = 10 mEq Citrate = 8 mEq

• Isolyte – E has electrolyte similar to ECF except double the conc. of potassium and acetate.• Only I.V. fluid available that can correct magnesium deficiency.

Indication:-1) Diarrhea.2) Metabolic acidosis.3) Maintenance of ECF volume preoperatively.

Contraindication:1) Vomiting 2) Continuous Nasogastric aspiration.3) In metabolic alkalosis due to drugs and bicarbonate

SPECIAL FLUIDS

Sodium Bicarbonate ( NaHCO3)

Composition:- Commonly used preparation is 7.5%, 25 ml ampoule One ampoule contains 22.5 mEq Sodium and 22.5 mEq Bicarbonate

Amount to be infused :-

Approximately 50% of the calculated deficit is corrected in 4 Hrs and rest gradually over 24 hrs

Amount of NaHCO3 required (in mEq/L) = 0.5 X weight in Kg X ( Desired HCO3 - actual HCO3 )

Special precautions 1) Sodium bicarbonate should not be given as bolus except in

emergency.2) Avoid overdose and alkalosis by giving repeated small doses and

monitoring pH3) Never treat Acidosis without treating the etiology.4) In presence of renal failure , treatment with sod. Bicarbonate

may cause tetany and pulmonary oedema.5) Never correct acidosis without correcting the assosiated

hypokalemia. NaHCO3 will shift potassium from ECF to ICF , this will aggravate hypokalemia

6) Never mix inj. Calcium with inj. NaHCO3 in same syringe as it may precipitate calcium carbonate.

7) Avoid mixing of inj. NaHCO3 with inotropes.

Indication:-1) Metabolic acidosis.2) Cardiopulmonary resuscitation and shock.3) Treatment of Hyperkalemia.4) Alkaline forced diuresis in acute poisoning of barbiturates and

salicylates.

Complication:Hypokalemia , volume overload , hypocalcaemia

Contraindication:1) Respiratory and metabolic alkalosis.2) Hypokalemia.3) Cautious use in CHF , CRF , cirrhosis.

Injectable Potassium Chloride

Composition:- Commonly used preparation is 15% KCl 10ml ampoule.1 ml = 150 mg KCl = 2mEq Potassium.So 1 ampoule = 10 ml = 20 mEq Potassium.

Indication:-1) Added in potassium free I.V. fluids for prevention of Hypokalemia2) For treating Hypokalemia.3) Added to potassium free peritoneal dialysis fluid for maintaining proper K+

levels

Basic rules for using Inj. KCl :-1) Never give direct I.V. KCl injection.2) Always use injection potassium chloride diluted in infusion.3) Never add more than 40 mEq / litre.4) Never infuse more than 10 mEq / hr.5) Never add KCl in Isolyte – M.6) Moniter serum K+ levels closely.

Contraindication:-1) Cautious use in renal failure as hyperkalemia is a potential risk.2) Never use injection KCl without knowing potassium status.

COLLOIDS

ALBUMINComposition:- Albumin is a physiological plasma protein. Heat treated preparation of human serum albumin is commercially available in

a 5% solution (50 gm/dl) and a 25% solution (250 gm/dl). As Sodium load is small, 25% albumin is also called salt poor albumin

Indication:-1) For Plasma volume expansion in cases of acute hypovulemic shock, burns.2) Correction of hypoproteinemia as in liver disease, nephrotic syndrome etc.3) As an exchange fluid to replace removed plasma in therapeutic plasmapheresis.

Adverse effect:1) Nausea and vomiting.2) Febrile reaction .3) Allergic reaction and anaphylactic shock.

Precautions and contraindications :-

1) Fast infusion will rapidly increase circulatory volume with resultant overload and pulmonary oedema.

2) Infusion of albumin solution is contraindicated in patients with severe anemia or cardiac failure

3) Should be given with caution to patients with low cardiac reserves.

4) Albumin solution should not be used for parenteral nutrition.

DEXTRANComposition:- Dextrans are glucose polymers produced by bacteria incubated in sucrose media. Available in

two forms : DEXTRAN 70 -- mol.wt 70,000 DEXTRAN 40 – mol.wt 40,000 Both forms effectively expand Intra vascular volume but can not be a substitute for whole

blood due to lack of oxygen carrying capacity and no clotting factors

Indication:-1) For short term rapid expansion of plasma volume for correction of hypovolemia.2) Prophylaxis of Deep vein thrombosis and postoperative thromboembolism.3) To improve blood flow and microcirculation in threatened vascular gangrene.

Adverse effect:1) Acute renal failure.2) Hypersensitivity reaction.3) It may interfere with blood grouping and cross matching..

Contraindication:1)Severe oligo-anuria and renal failure.2) Known hypersensitivity to dextran.3) Severe CHF or circulatory overload.4) Bleeding disorders.5) Severe Dehydration.

Preacution:1) The hematocrit should not be allowed to fall below 30.2) Correct dehydration during dextran infusion to maintain

adequate urine flow.3) Anticoagulant effect of heparin enhanced by dextran.4) Along with dextran infusion patient may require blood

coagulation factor or electrolyte.

Volume Deficit-Clinical Types

• Total body water:– Water loss (diabetes insipidus, osmotic diarrhea)

• Extracellular:– Salt and water loss (secretory diarrhea, ascites, edema)– Third spacing

• Intravascular: – Acute hemorrhage

Clinical Diagnosis

Intravascular depletionMAP= CO x SVR

Hemodynamic effects• BP HR JVP• Cool extremities• Reduced sweating• Dry mucus membranes

E.C.F. depletion– Lost skin turgor, – sunken eyeballs – Weight loss– Hemodynamic effects

Water Depletion

Thirst Hypernatremia

Approach to IVF in the Medical Pt• First let’s review the equation for estimating serum

osmolality:Serum osmolality = 2 (Na+) + Glucose/18 + BUN/2.8

• See how much more sodium adds to your osmolality then glucose does?

• That’s why D5 ½NS is inappropriate for most medical patients who are hypovolemic.

• They need isotonic fluids (normal saline). • Also, remember that dextrose gets almost immediately

metabolized to water and CO2 when it enters the circulation so it is not osmotically active for too long.

The 4 Types of PatientsWhen considering appropriate IV fluids as you are writing

admission order, keep in mind that in general, there are 4 types of medical patients when it comes to administering IV fluids:

Hypovolemic Patient Pneumonia, Sepsis, Hemorrhage, Gastroenteritis

Hypervolemic Patient CHF, renal failure, cirrohsis

NPO Patient, surgical patient, euvolemic Awaiting surgery, unsafe swallow

Eating/drinking normally

Determining Appropriate IVF

Step 1: Assess volume status • What is the volume status of my patient? • Do they have ongoing losses?• Can my patient take PO safely? • Are the NPO for a reason?

Step 2: Determine Access • Peripheral IV• Central line• IO line

Determining… Continued

Step 3: Select Type of Fluid

Determining… ContinuedHypovolemic Patient Always use Normal Saline for goal of volume resuscitation Normal saline is almost isotonic with blood so it is the best choice! On surgery or if going to administer more than 3-4L often use LR. (Addition of lactate that is metabolized to

bicarbonate to help buffer acidosis) Hypervolemic Patient Avoid additional IVF Maintain access IV access with HepLockNPO Patient now euvolemic Administer maintenance fluids. Goal is to maintain input of fluids to keep up with ongoing losses and

normal fluid needs For average adult NPO for more than 6-12 hours, consider D51/2NS at 75-100cc/hr Consider pt co-morbidities Constantly reassess, at least 2x day or with any change Don’t give fluids blindly ie: if the patient is pre-procedure but is old (predisposed to fluid overload because

of stiff LV) or has history of CHF, be CAREFUL! Pearl: the reason for giving dextrose (D5) is to prevent catabolism. Daily I/O’s, watch lytes Normal PO Intake No need for fluids if they are taking PO without problems! Avoid IVF

Determining… ContinuedStep 4: Determine Rate • In medical patients, the rate is always a ballpark and

you have to use your clinical judgement. (Not applicable for PEDS!)

• If you are trying to fluid resuscitate that patient, you might be giving fluids “wide open” or 500 cc/hr.

• The hypovolemic pt may need multiple 1L bolus to reestablish intravascular volume

• If you are just giving fluids to the average patient, give fluids at 75-100 cc/hr. Adjust for individual patient

Holiday Segar MethodA peds method that can be helpful:

So a quick example:For a 55 kg patient, the maintenance IV fluid rate would be

4*10 + 2*10 + 35*1 = 95 mL/hour.

Calculating Drip RateIn the age of machines, we barely have to do this anymore… but if

you ever need to go old skool, here is how to calculate the drip rate (drops/minute):

gtt = Volume to be infused (mL) x (gtt/mL) min Time (minutes)

Drip Factor = (gtt/mL) Of the TUBING which is found on the manufacturers pacakging

Example: Volume = 4000 ml Time = 24 hours Drip factor of tubing = 15 gtt/ml.

So…. [4000mL/(24h x 60min/h)] X 15gtt/ml = approx 42 drops/min

Example- GI Bleed

A 25 year old patient presents with massive hematemesis (vomiting blood) x 1 hour. He has a history of peptic ulcer disease.

Exam: Diaphoretic, normal skin turgor.

Supine BP: 120/70 HR 100

Sitting BP: 90/50 HR=140

Serum Na=140

What is the nature of his fluid deficit ?What IV fluid resuscitation would you prescribe ?What do you expect the hematocrit to be :

- at presentation ?

- after 12 hours of Normal Saline treatment?

Example- Diarrhea and Vomiting

• A 18 year old previously healthy medical student returns from a Caribbean vacation with a healthy tan and severe diarrhea and vomiting x 48 hours.

• Sunken eyeballs, poor skin turgor and dry mucus membranes• BP 80/70 HR 130 supine.• Labs: Na 130 K=2.8

HCO3 =12ABG: 7.26/26/100

• What is the nature of his fluid deficit ?• What fluid will you prescribe ?• What would happen if D5W were to be used?

Example- Hyperosmolar State

A 85 year old nursing home resident with dementia, and known diabetes was admitted with confusion.

Exam: Disoriented, Decreased skin turgor

BP: 110/70 supine 90/70 sitting..

Labs: Na= 150meq/L Wt=50kgs

BUN/Cr=50/1.8 Blood sugar= 1200 mg/dl Hct=45

What is the pathogenesis of her fluid and electrolyte disorder ?

How would you treat her ?

Calculation of Water Deficit

Osm (P Na) x volume

Osm (P Na) x volume

Healthy Dehydrated

A 50 kg female with Na=150•Na x Normal Body Water = Na x Current Body Water•140 x NBW = 150 x (0.5 x 50=25 liters)•NBW = 26.8 liters•Water deficit = NBW-CBW= 26.8-25=1.8 liters

Protocol group

The take-home message!• Resuscitate with fluids early and aggressively– They won’t get overloaded– They won’t get pulmonary oedema– They will be less likely to need ICU

• Be guided by markers of tissue perfusion– Urine output– Lactate– Consider central venous oxygen saturations

Conclusions• Crystalloids are generally adequate for most

situations needing fluid management.• The composition of the solution and rate of

administration are important when addressing a specific situation.

• Colloids may be indicated when more rapid hemodynamic equilibration is required (inadequate data).

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