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IV Fluid ManagementDFM Fellows
Summer 2010
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ObjectivesUnderstand the basics of fluid
administrationReview basics of various fluid optionsBe able to calculate maintenance fluid
rates based on patient weightBe able to estimate fluid losses Be able to calculate fluid replacement
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The Learning CurveThe information provided is general
information regarding fluid administration. Keep in mind that different clinical situations require you to integrate your clinical knowledge of the body and its physiology to make an educated decision. Always consider the patients age, condition, medications and co morbidities before administering fluids.
And as you screw up you will learn!
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IV Fluids The role of IV fluid administration is to
Provide volume replacement Administer medications, electrolytes, blood
products, or diagnostic reagents Maintenance/correction of nutritional status
Components of fluid and electrolyte therapy1. Maintenance2. Replacement
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Normal Plasma Electrolyte CompositionCATION Concentrati
on mEq/LANION Concentrati
on mEq/L
Sodium 135-145 Chloride 95-105
Potassium 3.5-5.0 Phosphate
2.5-30
Calcium 4.0-5.5 Sulfate 1.0
Magnesium
1.5-2.5 Organic acids
2.0
Osmolarity
285-295 Protein 1.6
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Commonly Used IV SolutionsOsmolarity (mOsm/L)
Glucose(gm/L)
Na+ (mEq/L)
K+(mEq/L)
Cl- (mEq/L)
Lactate (mEq/L)
Ca++ (mEq/L)
0.9%NS
308 154 154
½ NS (.45%NS)
154 77 77
LR 274 130 4.0 109 28 3
D5W 278 50
D5 ½ NS
406 50 77 77
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Components of Fluid and Electrolyte Therapy1. Maintenance
• meeting the requirements for fluid and electrolyte intake that balance daily obligatory losses
2. Replacements (Ongoing Losses)• providing for ongoing and additional losses
that occur during the course of therapy (surgery phases: pre/intra/post operative)
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The Balancing ActIN
Drinking Eating Metabolism
3mL/kg IV Fluids?
OUT (~1-1.6L/day for ave. adult) Urine
12-15mL/kg/day Feces
3mL/kg Insensible losses
10-13mL/kg/day
With no unusual stresses or losses and normal renal function intake can be balanced to outputs
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Maintenance: Water and Electrolyte NeedsReplace Urine and insensible losses (1-2
L/day)Replace sodium and potassium loss
Na: need 47-147 mEq/day (1-3mEq/kg/day)K: leak about 20mEq/dayOsmol
arity (mOsm/L)
Glucose(gm/L)
Na+ (mEq/L)
K+(mEq/L)
Cl- (mEq/L)
Lactate (mEq/L)
Ca++ (mEq/L)
0.9%NS
308 154 154
½ NS (.45%NS)
154 77 77
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Calculating Maintenance Dosing4-2-1 rule to
calculate hourly rateIn one hour, a
person needs:4mL/kg for the first
10kg (0-10)2mL/kg for the next
10kg (10-20)1mL/kg for the
remaining kg (>20)
100-50-20 rule for daily requirements
In one day a person needs:100 mL/kg for the
first 10kg50 mL/kg for the
second 10kg20 mL/kg for the
remaining*Remember to divide by
24 for hourly rate*
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Maintenance ConsiderationsFever or high ambient temperatures
Water loss increases by 100-150ml/day for every degree above 37C
SweatingConsider using a hypotonic solution for fluid
replacement (0.45% saline)Humidity
Breathing humid air decreases loss while dry air may increase relative losses
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ExampleCalculate maintenance fluids for a 75 kg patient
who is NPO
4-2-1 Rule10 x 4 = 40 mL10 x 2 = 20 mL55 x 1 = 55 mL
Total 115 mL/hr
100-50-20 Rule10 x 100 = 1000mL10 x 20 = 200 mL55 x 20 = 1100
Sub total 2300mL/day
Total 96 mL/hr
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So you know how to calculate fluid maintenance requirements but what happens if the patient has an initial deficit requiring rehydration other than maintenance?
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Think About It
What are you concerned about?
DehydrationElectrolyte imbalanceDecrease in blood pressure
What do you want to do?
Administer medication for nausea
Normalize ElectrolytesExpand her intravascular
volume Maintain normal fluid
homeostasis (maintenance) Replace lost fluid
(resuscitation) Account for ongoing losses if
present (replacement)
A 50 kg patient comes into the ED with gastroenteritis
She has had vomiting and has diarrhea x 3days
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Clinical Signs of DehydrationFeature Mild
dehydration (<5%)
Moderate dehydration(5%-10%)
Severe dehydration (>10%)
Heart Rate
Normal Slight increase
Rapid, weak
Systolic BP
Normal Normal/ orthostatic
Hypotension
Mucous Mb
Slightly dry
Very dry Parched
Urine Output
Decreased
Olguria < 500ml/day
Anuria < 50ml/day
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Clinical Signs of DehydrationThis is an objective finding
This is a rough estimate of fluid lossClinical signs may not be evident in adults
Adults are able to compensate better than children
CalculationFluid Deficits(L) = weight (kg) x % dehydration
Example: Our 50 kg patient with 5% dehydration:50kg x 5%= 2.5L deficit
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Estimate Deficit by Weight
Fluid and Weight1 L of fluid = 1 kg of
weight1kg= 2.2 lbs
Use weight change to determine fluid loss/gain
Calculate his fluid deficit
5lb = 2.3kg == 2.3L fluid deficit
Example: Suppose our gastroenteritis patient reports a 5lb weight loss with illness
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Fluid DeficitsAfter deficit is determined
Our pt has a 2.3L deficit by weight
Replace half in 8 hours1,150mL/8hrs =143mL/hr for the first 8 hrs
Replace other half in the next 16 hours1150mL/16hrs=72mL/hr for the next 16hrs
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Total Flow Rate for Maintenance
Maintenance4mL/kg x 10kg = 40mL (0-10) plus2mL/kg x 10kg
= 20mL (10-20) plus
1cc/kg x 30kg= 30mL (20-50)
TOTAL maintenance= 90mL/hr
Deficit1,150mL/8hrs=143mL/hr
for the first 8 hrs
1150mL/16hrs=72mL/hr for the next 16hrs
• Add maintenance to deficit and you’ll have a flow rate• Our 50kg patient with gastroenteritis has had a 5lb (2.3kg)
weight loss
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Total Flow RateFor the first 8 hrs
90mL/hr + 143mL/hr = 233mL/hr
For the next 16 hours90mL/hr + 72mL/hr = 162mL/hr
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Try it!A 176lb athlete presents to the ER after
collapsing during football practice. He weighed 184lbs at the beginning of practice. Write an order for IV fluids to correct for deficit and maintenance for the next 24 hours
Note: Use patients current weight to determine maintenance
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AnswerMaintenance176lb = 80kg40mL (0-10) plus20mL (10-20)
plus60mL (20-80)
Total= 120mL/hr
Deficit184 - 176= 8lb = 3.6kg
=3.6L = 3,600mL loss
1,800mL/ 8 = 225ml/hr• 225 + 120= • 345 mL/ hr for the 1st 8
hrs 1,800/16 = 112.5mL/hr
• 112.5 + 120 =• 232.5 mL/ hr for the next
16 hrs