IV Fluids

1
IV Fluids

• Intern Boot Camp 2008
• Michelle Kahlenberg, MD PhD

2
Saline

• Normal 154 mEq/L of Na and Cl-
• Half-normal saline (0.45 NaCl) contains 77 mEq/L
  of Na and Cl-
• ¼ NS contains 39 mEq/L of Na and Cl and always
  contains 5 dextrose for osmolality reasons

3
D5W

• 50 gm/L of dextrose in water isotonic but
  doesnt provide sodium

4
Lactated Ringers

• 130 mEq of sodium ion 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 .

5
Case 1

• 45 yo woman with hx of HTN admitted with
  gallstone pancreatitis and is unable to take PO.
  She has no evidence of infection and is
  hemodynamically stable.
• What IVF do we give?

6
Case 1

• For maintence fluids adhere to the 4/2/1 rule for
  water balance.
• 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 of
  approx 125 ml per hour of ¼ NS with 20 mEq of KCl
  per bag per day will give approx 100 meq of Na
  and 60 meq of K per day.
• (adjustments should be made for those with CHF,
  renal failure, or on K sparing medications.

7
Case2

• 65 yo man with history of DLD, tobacco use,
  obesity, diabetes admitted with chest pain with
  small troponin elevation and progressive T wave
  changes on ECG. He is started on heparin drip,
  BB, statin, ASA and is kept NPO for possible cath
  in the AM.
• What about his IVF?

8
Case 2 Continued

• Gentle hydration with normal saline prior to
  contrasted procedures can help prevent contrast
  induced nephropathy
• Usually 75 ml per hour of normal saline (roughly
  1 ml/kg/hr) 12 hours before and 12 hours after
  the procedure /- mucomyst is helpful
• Could add D5 if he has DM meds on board

9
Case 3

• You are called on cross cover to see an 86 yo NH
  resident with EF 35 admitted for UTI and mental
  status changes. She has a blood pressure of
  86/45, HR 120 (sinus tachycardia) and is not
  responsive.
• What next?

10
Case 3 continued

• Sepsis protocols recommend IVF bolus until CVP
  reaches 10-12. Obviously on the 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!

11
Case 4

• 67 yo man with parkinsons with dysphagia
  requiring PEG tube getting tube feeds on the
  floor. You are called that patient is becoming
  more somnolent.
• 37.0 78 140/89 12 98 RA
• What next?

12
Case 4 continued

• Further chart review suggests that free water
  flushes have been left out of tube feed regimen.
  
• Serum sodium comes back at 161.
• Now what?

13
Case 4 continued

• Calculate the free water deficit
• 0.6wt(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 of
  approx 30 ml water per hour-so if NPO, need D5W
  at approx 150 per hour.

14
Case 4.5

• 40 yo woman with no previous past medical hx
  presents with N/V/D x3 days with inability to
  keep anything down PO
• 37.6 105 110/75 98 RA ( orthostatics)
• Labs show 7.3gt14/42lt256
• 151/112/31
• -------------lt125
• 4.2/28/1.3
• How do we treat her?

15
Case 4.5 continued..

• Hypovolemic hypernatremia is the most common
  cause of hypernatremia
• This is corrected with volume repletion with
  normal saline until she no longer has evidence of
  volume depletion. Then, recheck Na and
  calculate free water deficit. (Usually,
  hydrating them will improve the majority of the
  hypernatremia).

16
Case 5

• 46 yo woman with hepatitis C and cirrhosis
  admitted with profuse hematemesis.
• 36.5 140 79/50 24 97 RA
• 7.9gt6/24lt67 131/100/47
• -------------lt135
• 3.3/24/1.4
• What first?

17
Case 5 continued

• She was given 5 L NS and 3 units PRBC. The
  bleeding continues intermittently. While
  awaiting the arrival of the GI team
• 37.0 125 89/54 21 94 1L NC
• Repeat labs show
• 6.9gt7.4/27lt51 140/115/35
• -------------lt135
• 3.1/16/1.2
• What do we do now?

18
Case 5 Continued

• LR!
• 130 mEq of sodium ion 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 .

19
Case 6

• 45 yo woman with progressive, metastatic T cell
  lymphoma admitted with lethargy and nausea.
• Serum sodium is 111

20
Case 6 continued

• Hypertonic saline is given ONLY IN ICU and is
  reserved for severely symptomatic patients
  (seizures, impending herniation) as severe
  symptoms are likely due to brain 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.

21
Case 6 continued

• For her, mildly symptomatic, so correct 10 meq
  over 24 hours or until no longer symptomatic 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)/261.65 mEq increase per L of NS given,
  so she would need about 5L of NS over 24 hours.

22
Case 6 continued

• For asymptomatic hyponatremia, free water
  restriction or vasopressin receptor antagonists
  are the treatment of choice,
• There is evidence that improving serum sodium
  even if they are asymptomatic can reduce falls
  in the elderly and improve subtle neurological
  deficits

23
Thank you.

• Questions?