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Fluids Intro to Clinical Practice (ICP) 2017
FluidsIntro to Clinical Practice (ICP) 2017
Faculty/Presenter Disclosure• Faculty: Anthony Seto
• Relationships with commercial interests:– Not applicable
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• http://library.ucalgary.ca/copyright/fair-dealing
• Thismaterialwascreatedforstudentsofficiallyenrolled intheUndergraduateMedicalEducationprogramandcannotbereproduced,retransmittedorcopied.
• Ihaveproperlycitedthirdpartymaterialinoneofthewaysoutlinedbelow.
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©OttawaHealthResearchInstitute,1053CarlingAvenue,Ottawa,Ontario,Canada,K1Y4E9
Fluids Objectives1. Markersofvolumestatus2. Pediatriclevelofdehydration(Gorelick)3. Shockddx review4. Fluidstypes5. Fluidsboluses6. Maintenancefluids7. Fluidadminroutesandstrategies8. Practicecalculationsthroughcases
BrainstormMARKERSOFVOLUMESTATUS
Point-of-careULTRASOUND
JVP – Bedside U/S
Source: “The EDE Book”
IVC – Bedside U/S
Source: “The EDE Book”
Adult classes of shock
HR/RR BP Lethargy
1L 2L >2L
https://lifeinthefastlane. com/wp-content/upl oads/2011/06/Cl ass -of-haemorrhagic-shock-JPEG2.j pg
Peds Gorelick Criteria• Caprefill>2secs• Absenttears• Drymucousmembranes• Illgeneralappearance
• 0to1:<5%dehydration• 2:5-10%dehydration• 3to4:>10%dehydration
AHSPathway(normalvitals)
AHSPathway(normalvitals)
http://pert.ucalgary.ca/pathways/reference/Revised%20ED-UCC%20pathway%20Oct%2025%202011.pdf
AlbertaHealthServicesAcuteChildhoodVomitingandDiarrheaPathway
ReviewSHOCKSCHEME
Fluid Types• Crystalloid(e.g.NS,RL)• Blood/bloodproducts(e.g.RBCs)• Other• Dextrose(e.g.D5W“5gDin100mLW”)• Bicarbonate• Colloid– (e.g.albumin)
Fluid Combo Examples• D5W-NS• KCl 20mmolinNS
Fluid Boluses• Adult• Typical:1Lstartwithr/a• Resus:1-2Lor30mL/kgstartwithr/a• Cautious:250-500mL(i.e.concernof
fluidoverload/pulmonaryedema)• Peds• Typical:20mL/kg x3prn
Routes of admin• Peripheralline• IV• IO
• Centralline• CVC
• Special• Hypodermoclysis (clysis)• EasyIJ
Strategies of Bolus• Gravity• Infusionpump• Pressurebag• Rapidinfuserpumps• Push-pull
http://cdnll.marketlab.com/images/xxl/disposablepressurei nfusionbag.jpghttps://www.smiths-medical. com/~/media /M/Smiths-medi cal_ com/Images/Import%20Images/Level%201/H1200sil opng.png?mw=391
Maintenance Fluids• 4-2-1rule(togetmL/hour)• 4mL/kgperhourforfirst10kg+• 2mL/kgperhourfornext10kg+• 1mL/kgperhourforeachkgafter20kg
• Weight+40(togetmL/hour)if20kg+• 40+20+1*(weight– 20)
Parkland Formula• Tocalculatefluidsrequiredforburnpts• RLusedsincelargevolumerequiredand
morephysiologicthanNS• DetermineTBSA(totalbodysurfacearea)
with2° burns(partialthickness)orgreater• Parklandformula:4xkgx%TBSAburned• 50%ofthattotalvolumeinfirst8h• 50%ofsametotaloverfollowing16h
http://www.hardyakka.co
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Cases• Peds Sepsis• Peds Gastroenteritis• Burn
Urosepsis• Case:8monthFwithUTI.Tachycardic,
poorcaprefill,lethargic.• Weight=10kg• WhatisyourIVfluidstrategyand
amount?
Gastro• Case:5 y.o.Mwithgastroenteritis.After
fluidresuscitationintheERtoneareuvolemia,hestillfeelsunwellandrefusestoeat.Hewillbekeptovernight.
• Weight=18kg• WhatisyourIVfluidstrategyand
amount?
Burn• Case:30y.o.M(70kg)hasburnstohalf
hisback,posteriorfullrightleg,andposteriorfullrightarm.
• WhatisyourIVfluidstrategyandamount?
Summary• Usemultiplemarkerstogetherto
determinevolumestatus+freq reassess.• Gorelick:caprefill,tears,MM,look• Shockddx:hypovolemic,distributive,
cardiogenic,obstructive• Peds bolus:20mL/kgx3prn• 4-2-1rulecheat:wt +40(if20kg+)• Parklandformula:4xkgx%TBSA
