Intravenous Fluid Intravenous Fluid Therapy Therapy

Dr. Ahmed Abbas Elsaid Dr. Ahmed Abbas Elsaid

King Khalid Hospital – NajranKing Khalid Hospital – Najran

February,2014February,2014

How to prescribe the proper IV fluid How to prescribe the proper IV fluid for your patient ?for your patient ?

Understanding the physiology of fluid and electrolyte balance in patients with normal physiology and during illness.

Assessing patients’ fluid and electrolyte needs.

Understanding the nature and composition of the common IV fluids.

About 60% of a 70 kg (42 litres) human adult is water.

two-thirds is intracellular (28 litres) and one third is extracellular.

The latter comprises the interstitial fluid (10.5 litres) and plasma (4.5 litres). Minor components include CSF, synovial fluid and vitreous humour

Approximate daily water balance in health

Average Daily Intake

Water :25-35 ml/kg/day Water :25-35 ml/kg/day

Sodium :Approx.1 mmol/kg/daySodium :Approx.1 mmol/kg/day

Potassium :Approx. 1 mmol/kg/dayPotassium :Approx. 1 mmol/kg/day

ICF (mmol/l)ICF (mmol/l) ECF (mmol/l)ECF (mmol/l)

CationsCations K+ = 150 K+ = 150 (main (main Cation)Cation)

Na+ = 10Na+ = 10

Na+ = 150 Na+ = 150 (main (main cation)cation)

K+ = 4-5K+ = 4-5

AnionsAnions Organic Po4= 25 Organic Po4= 25 (main anion)(main anion)

C HCO3 = 10C HCO3 = 10

Cl - = 110 Cl - = 110 (main (main anion)anion)

HCO3 = 25HCO3 = 25

OsmolalityOsmolality 280- 295280- 295 280-295280-295

Osmolarity Osmolarity

Expected osmolarity of plasma can be Expected osmolarity of plasma can be calculated according to the following calculated according to the following formula:formula:

Osmolarity (mOsm/kg) = 2×[mmol/L Na+] Osmolarity (mOsm/kg) = 2×[mmol/L Na+] + glucose+ BUN+ glucose+ BUNConcentration of sodium is the major Concentration of sodium is the major determinant. „determinant. „Normal serum osmolarity ranges from Normal serum osmolarity ranges from about 280 - 295 mOsm /kg.about 280 - 295 mOsm /kg.

IV fluidsIV fluids

A.A. Crystaloids.Crystaloids.

B.B. Colloids.Colloids.

C.C. Free water solutions.Free water solutions.

D.D. Blood products.Blood products.

CrystalloidCrystalloid

Normal slaine (0.9% Na Cl)Normal slaine (0.9% Na Cl)

Hypertonic saline (3% Na Cl) Hypertonic saline (3% Na Cl) considered plasma expanders.

Hypotonic saline (0.45% and 0.225%)Hypotonic saline (0.45% and 0.225%)

Ringers Ringers

Isotonic Saline

Expand blood volume by only a quarter to a third of the volume infused. The normal daily requirements of sodium are only 70-100mmol but one litre of NS contains 154mmol.Produces a degree of hyperchloraemia due to its high chloride content compared with plasma. lead to significant reductions in renal blood flow and glomerular filtration as well as hyperchloraemic acidosis, gastrointestinal mucosal acidosis and ileus.Some GI fluid losses and occasionally renal losses are very high in sodium chloride and hence sodium chloride 0.9% use may be appropriate.

Balanced Crystalloid Solutions

similar efficacy to Na Cl 0.9% in plasma volume expansion.They contain somewhat less sodium and significantly less chloride, and they have some potassium, calcium and magnesium content. Less likely to cause the possible problems linked to NaCl 0.9% use for resuscitation or routine maintenance, particularly some of the more modern preparations which come in more specialized ‘resuscitation’ and ‘maintenance’ versions with their content more tailored to meet theoretical requirements for these different circumstances.

Colloids Colloids

A.A. Synthetic colloid: Synthetic colloid: hydroxyethyl starch, succinylated gelatin (Gelofusine), urea-linked gelatin (Haemaccel), penta- and hexa-starches.

B. Albumin: 4-5% and 20-25%

C. Human plasma protein fraction (HPPF): 5 g selected plasma proteins (approximately 88% normal human albumin, 12% alpha and beta globulins and not more than 1% gamma globulin )

Colloids

Theoretically better in resuscitation, but actually there is no evidence of better outcome. renal dysfunction, disturbances of coagulation, allergy or other colloid-induced physiological disturbance.hydroxyethyl starch, succinylated gelatin (Gelofusine), urea-linked gelatin (Haemaccel) are commonly used

Colloids

Albumin

Intravascular volume expansion + solve + solve fluid redistribution problems

Used in some patients with hepatic failure and ascites

Expensive

Free Water SolutionsFree Water Solutions

D5W (5% dextrose in water), D10W, D5W (5% dextrose in water), D10W, D20W, D50W D20W, D50W

Dextrose/crystalloid mixes (D5 NS, ….)Dextrose/crystalloid mixes (D5 NS, ….)

Composition of Some Common IV Composition of Some Common IV Fluid Fluid

Provide intravenous (IV) fluid therapy only for patients whose needs cannot be met by oral or enteral routes and

stop as soon as possible

““NICENICE” IV Fluid Therapy ” IV Fluid Therapy Algorithms.Algorithms. (NICE- December (NICE- December

2013)2013)

Standard principles

1. When prescribing IV fluids, remember the 5 Rs:

ResuscitationRoutine maintenance

ReplacementRedistribution

Reassessment.

Assess patients’ fluid and electrolyte needs following Algorithm 1:

Assessment.

How do I know someone needs How do I know someone needs fluid?fluid?

Assess the patient’s likely fluid and electrolyte needs from their history, clinical examination, clinical monitoring and laboratory investigations

History should include any previous limited intake, the quantity and composition of abnormal losses and any comorbidities

Clinical examination should include an assessment of the patient's fluid status, including:

- pulse, blood pressure, capillary refill and jugular venous pressure

- presence of pulmonary or peripheral oedema

- presence of postural hypotension.

Clinical monitoring should include current status and trends in:

- NEWS

- Fluid balance charts

- Weight.

Laboratory investigations should include current status and trends in:

- Full blood count

- Urea, creatinine and electrolytes

If patient need IV fluids for resuscitation, follow Algorithm 2:

Resuscitation.

Indicators of urgent resuscitation include

Systolic blood pressure is less than 100 mmHg Heart rate is more than 90 beats per minute Capillary refill time is more than 2 seconds or peripheries are cold to touch Respiratory rate is more than 20 breaths per minute National Early Warning Score (NEWS) is 5 or more Passive leg raising test is positive.

There is no evidence that colloids have There is no evidence that colloids have any benefit over crystalloids regarding the any benefit over crystalloids regarding the outcome.outcome.

Use crystalloids that contain sodium in the range 130–154 mmol/l, with a bolus of 500 ml over less than 15 minutes. Consider human albumin solution 4–5% only for resuscitation in patients with severe sepsis. “NICE guidelines 2013”“NICE guidelines 2013”

A classification of haemorrhagic shock(ATLS_2012)

Fluid Therapy in trauma Fluid Therapy in trauma “ATLS 2012”“ATLS 2012” ::

Fluid bolus: Fluid bolus: 1-2 liters for an adult and 1-2 liters for an adult and 20mL/kg for a pediatric patient20mL/kg for a pediatric patient

3:1 rule3:1 rule

39 39 CC

Fluid warming is important to minimize:

1. Bradycardia and ↓COP.

2. Left shift of ODC.

3. Shivering & ↑ lactic acidosis

4. coagulopathy associated with massive transfusion

5. Wound infection

If patients need IV fluids for routine maintenance, follow Algorithm 3:

Routine maintenance.

Restrict the initial prescription to:

25–30 ml/kg/day of water

approximately 1 mmol/kg/day of potassium, sodium and chloride and

approximately 50–100 g/day of glucose to limit starvation ketosis (dextrose 5% contains 5g/100ml)

Normal maintenance requirements Normal maintenance requirements in infants (holiday & segar)in infants (holiday & segar)

Wt (kg)Wt (kg) H2O(ml/kg/dy)H2O(ml/kg/dy) Na(mmol/kg/dy)Na(mmol/kg/dy) K(mmol/kg/dyK(mmol/kg/dy

First 10 kgFirst 10 kg 100100 22 1.5-21.5-2

Second 10 kgSecond 10 kg 5050 1-21-2 0.5-1.50.5-1.5

Subsequent kgSubsequent kg 2020 0.5-10.5-1 0.2-0.70.2-0.7

Normal maintenance requirements Normal maintenance requirements in infants (holiday & segar)in infants (holiday & segar)

11stst 10 kg BW : 4ml/kg/h 10 kg BW : 4ml/kg/h

22ndnd 10 kg BW: 2ml/kg/h 10 kg BW: 2ml/kg/h

Each remaining kg: 1ml/kg/hEach remaining kg: 1ml/kg/h

For patients who are obese, adjust the IV fluid prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of 3 litres of fluid per day)

IBW can be estimated from the formula: IBW can be estimated from the formula:

IBW(KG)= Height (cm) – xIBW(KG)= Height (cm) – x

(where (where xx = 100 for adult males and 105 for  = 100 for adult males and 105 for adult females). adult females).

Consider prescribing less fluid (for example, 25 ml/kg/day fluid) for patients who:

Are older

Have renal impairment or cardiac failure.

Consider delivering IV fluids for routine maintenance during daytime hours, if possible.

Include the following information in IV fluid prescriptions:

The type of fluid to be administered

The rate and volume of fluid to be administered

If patients need IV fluids to address existing deficits or excesses, or ongoing abnormal losses, follow

Algorithm 4: Replacement and redistribution.

Preoperative fluid Preoperative fluid

D5 1/4 NS is used for neonates and D5 1/4 NS is used for neonates and infant up to 1 year due to their limited infant up to 1 year due to their limited ability to handle Na+ loads.ability to handle Na+ loads.

D5 1/2 NS is used for children more than D5 1/2 NS is used for children more than 1 year.1 year.

For adults D5 NS will be better to avoid For adults D5 NS will be better to avoid hypoglycemiahypoglycemia

Central Venous PressureMonitoring

A central venous pressure is a useful tool for assessment and treatment of more complex patients.

Central lines are not the preferred way for resuscitation in acute situations. Flow rates of fluids increase with the diameter of the cannula but decrease with increasing length.

Questions ?????Questions ?????