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IV Fluids

Intern Boot Camp 2008

Michelle Kahlenberg, MD PhD

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D5W

50 gm/L of dextrose in water: isotonic butdoesnt provide sodium

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Lactated Ringers

130 mEq of sodiumion = 130 mmol/L.

109 mEq of chloride ion = 109 mmol/L.

28 mEq of lactate = 28 mmol/L. 4 mEq of potassium ion = 4 mmol/L.

3 mEq of calcium ion = 1.5 mmol/L .

http://en.wikipedia.org/wiki/Milliequivalenthttp://en.wikipedia.org/wiki/Sodiumhttp://en.wikipedia.org/wiki/Ionhttp://en.wikipedia.org/wiki/Molarityhttp://en.wikipedia.org/wiki/Chloridehttp://en.wikipedia.org/wiki/Lactic_acidhttp://en.wikipedia.org/wiki/Potassiumhttp://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Potassiumhttp://en.wikipedia.org/wiki/Lactic_acidhttp://en.wikipedia.org/wiki/Chloridehttp://en.wikipedia.org/wiki/Molarityhttp://en.wikipedia.org/wiki/Ionhttp://en.wikipedia.org/wiki/Sodiumhttp://en.wikipedia.org/wiki/Milliequivalent

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Case #1

45 yo woman with hx of HTN admitted withgallstone pancreatitis and is unable totake PO. She has no evidence of

infection and is hemodynamically stable.

What IVF do we give?

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Case #1

For maintence fluids adhere to the 4/2/1 rule for waterbalance.

Require 1-2 mmol/kg of Na+ per day Require 0.5-1 mmol/kg of K+ per day

So for a usual sized, euvolemic person a rate ofapprox 125 ml per hour of NS with 20 mEq of KClper bag per day will give approx 100 meq of Na+ and60 meq of K+ per day.

(adjustments should be made for those with CHF,renal failure, or on K+ sparing medications.

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Case#2

65 yo man with history of DLD, tobaccouse, obesity, diabetes admitted withchest pain with small troponin elevation

and progressive T wave changes onECG. He is started on heparin drip, BB,statin, ASA and is kept NPO for possiblecath in the AM.

What about his IVF?

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Case #2 Continued

Gentle hydration with normal saline priorto contrasted procedures can helpprevent contrast induced nephropathy

Usually 75 ml per hour of normal saline(roughly 1 ml/kg/hr) 12 hours before and12 hours after the procedure +/-mucomyst is helpful

Could add D5 if he has DM meds onboard

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Case #3

You are called on cross cover to see an 86yo NH resident with EF 35% admitted forUTI and mental status changes. She

has a blood pressure of 86/45, HR 120(sinus tachycardia) and is notresponsive.

What next?

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Case #3 continued

Sepsis protocols recommend IVF bolusuntil CVP reaches 10-12. Obviously onthe floor we dont have CVPs but you

shouldnt be shy about giving IVF bolus(at least 2-3 L before you call the MICU)even if patient has HF. If theyre septic,

they need fluids!

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Case #4

67 yo man with parkinsons with dysphagia

requiring PEG tube getting tube feeds onthe floor. You are called that patient is

becoming more somnolent.

37.0 78 140/89 12 98% RA

What next?

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Case #4 continued

Further chart review suggests that freewater flushes have been left out of tubefeed regimen.

Serum sodium comes back at 161.

Now what?

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Case #4 continued

Calculate the free water deficit

0.6*wt*(pNa+-nl Na+)/Nl Na+

If he weights 70 kg, his deficit is 6.3 L Want to correct deficit 10 mEq per 24 hours so

need 6.3 L over 48 hours or roughly 3L/day(D5W at 125 per hour)

Also need to account for insensible losses ofapprox 30 ml water per hour-so if NPO, needD5W at approx 150 per hour.

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Case #4.5

40 yo woman with no previous past medical hxpresents with N/V/D x3 days with inability tokeep anything down PO

37.6 105 110/75 98% RA (+ orthostatics)

Labs show 7.3>14/42

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Case 4.5 continued..

Hypovolemic hypernatremia is the mostcommon cause of hypernatremia

This is corrected with volume repletion

with normal saline until she no longerhas evidence of volume depletion. Then,recheck Na+ and calculate free waterdeficit. (Usually, hydrating them willimprove the majority of thehypernatremia).

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Case #5

46 yo woman with hepatitis C and cirrhosisadmitted with profuse hematemesis.

36.5 140 79/50 24 97% RA

7.9>6/24

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Case #5 continued

She was given 5 L NS and 3 units PRBC. Thebleeding continues intermittently. While awaiting thearrival of the GI team:

37.0 125 89/54 21 94% 1L NC

Repeat labs show

6.9>7.4/27

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Case #6

45 yo woman with progressive,metastatic T cell lymphoma admittedwith lethargy and nausea.

Serum sodium is 111

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Case #6 continued

Hypertonic saline is given ONLY IN ICUand is reserved for severely symptomaticpatients (seizures, impending herniation)

as severe symptoms are likely due tobrain swelling from initial drop in sodium.

Correct 1.5-2 meq per hour for the first

few hours until no longer symptomatic,no more than 10 meq in 24 hours.

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Case #6 continued

For her, mildly symptomatic, so correct 10meq over 24 hours or until no longersymptomatic then free water restrict.

Increase in PNa = (Infusate [Na] - PNa) (TBW + 1)

TBW = (lean body weight times 0.5 for women,0.6 for men).

(154-111)/26=1.65 mEq increase per L of NSgiven, so she would need about 5L of NS over24 hours.

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Case #6 continued

For asymptomatic hyponatremia, freewater restriction or vasopressin receptorantagonists are the treatment of choice,

There is evidence that improving serumsodium even if they are asymptomatic

can reduce falls in the elderly and

improve subtle neurological deficits

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