Intravenous Fluids

1
Intravenous Fluids

• A Clinical Approach
• JAI RADHAKRISHNAN, MD
• Division of Nephrology

2
Objectives

• Volume of distribution
• IV fluid choices available
• Types of fluid depletion
• Specific clinical examples and treatment

3
Volume of Distribution of Water
Solids
60-Males 50-Females
H2O
4
Solids 40 of Wt
Intracellular (2/3)
Extracellular (1/3)
H2O
H2O
Na
5
E.C.F. COMPARTMENTS
Intra-vascular1/4
Interstitial 3/4
H2O
H2O
Na
Na
Colloids RBC
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Third Space

• Acute sequestration in a body compartment that is
  not in equilibrium with ECF
• Examples
• Intestinal obstruction
• Severe pancreatitis
• Peritonitis
• Major venous obstruction
• Capillary leak syndrome
• Burns

7
Daily Fluid Balance
Intake1-1.5L
Insensible Loss-Lungs 0.3L -Sweat 0.1 L
Urine 1.0 to 1.5L
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MATH-70 kg male
Total body water60 body wt 0.6X7042 liters
ECF1/3 0.3X4213 liters
ICF2/3 0.6 X4225 liters
Blood1/4 (ECF) 0.25X133. 3 liters
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Principles of Treatment

• How much volume?
• Need estimate of fluid deficit
• Which fluid?
• Which fluid compartment is predominantly
  affected?
• Need evaluation of other acid/base/electrolyte/nut
  rition issues.

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The IV Fluid Supermarket

• Crystalloids
• Dextrose in water
• D5W
• D10W
• D50W
• Saline
• Isotonic (0.9 or normal)
• Hypotonic (0.45, 0.25)
• Hypertonic
• Combo
• D51/2NS
• D5NS
• D10NS
• Ringers lactate physiologic.
• (K, HCO3, Mg, Ca)

• Colloids
• Albumin
• 5 in NS
• 25 (Salt Poor)
• Dextrans
• Hetastarch
• Blood

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1 Liter 0.9 saline
Total body water
ECF1 liter
ICF0
Interstitial3/4 of ECF750ml
Intravascular 1/4 ECF250 ml
12
1 liter 5 Dextose
Total body water1 liter
ECF1/3 300ml
ICF2/3 700ml
Intravascular 1/4 of ECF75ml
13
1 liter 5 Albumin
Intravascular1 liter
14
A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Unit
N Engl J Med. 2004 May 27350(22)2247-56.
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Volume Deficit-Clinical Types

• Total body water
• Water loss (diabetes insipidus, osmotic diarrhea)
• Extracellular
• Salt and water loss (secretory diarrhea, ascites,
  edema)
• Third spacing
• Intravascular
• Acute hemorrhage

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Clinical Diagnosis

• Intravascular depletion
• MAP CO x SVR
• Hemodynamic effects
• BP HR JVP
• Cool extremities
• Reduced sweating
• Dry mucus membranes

• E.C.F. depletion
• Skin turgor, sunken eyeballs
• Weight
• Hemodynamic effects

• Water Depletion
• ThirstHypernatremia

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Example- GI Bleed
A 25 year old patient presents with massive
hematemesis (vomiting blood) x 1 hour. He has a
history of peptic ulcer disease. Exam
Diaphoretic, normal skin turgor. Supine BP
120/70 HR 100 Sitting BP 90/50 HR140 Serum
Na140

• What is the nature of his fluid deficit ?
• What IV fluid resuscitation would you prescribe ?
• What do you expect the hematocrit to be
• - at presentation ?
• - after 12 hours of Normal Saline treatment?

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Example-Diarrhea and Vomiting

• A 18 year old previously healthy medical student
  returns from a Caribbean vacation with a healthy
  tan and severe diarrhea and vomiting x 48 hours.
• Sunken eyeballs, poor skin turgor and dry mucus
  membranes
• BP 80/70 HR 130 supine.
• Labs Na 130 K2.8
• HCO3 12
• ABG 7.26/26/100

• What is the nature of his fluid deficit ?
• What fluid will you prescribe ?
• What would happen if D5W were to be used?

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Example-Hyperosmolar State
A 85 year old nursing home resident with
dementia, and known diabetes was admitted with
confusion. Exam Disoriented BP 110/70 supine
90/70 sitting. Decreased skin turgor. Labs Na
150meq/L Wt50kgs BUN/Cr50/1.8 Blood sugar
1200 mg/dl Hct45
What is the pathogenesis of her fluid and
electrolyte disorder ? How would you treat her ?
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Calculation of Water Deficit
Healthy
Dehydrated
Osm (P Na) x volume
Osm (P Na) x volume

• A 50 kg female with Na150
• Na x Normal Body Water Na x Current Body
  Water
• 140 x NBW 150 x (0.5
  x 5025 liters)
• NBW 26.8 liters
• Water deficit NBW-CBW 26.8-251.8 liters

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A Cirrhotic

• A 40-year-old patient with known alcoholic
  cirrhosis, portal hypertension and ascites is
  admitted with a rising creatinine.
• Exam BP 100/70 (no orthostasis), JVP 5cms,
  ascites, no peripheral edema, asterixis.
• BUN12mg/dL Creat2mg/dL Alb2.0g/dL
• Urine lytes Na6meq/L, FeNa0.5
• Urine volume has been 200cc/24h.
• Comment on his fluid status
• If volume-depleted how would you treat him?

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Example-Post Op Abdominal Distension
A 60 year old male with pancreatic carcinoma has
undergone total pancreaticoduodenectomy and
gastrojejunal bypass. On post-operative day-3 he
develops abdominal distension.BP 110/60 and HR
increases from 100 to 130 on sitting. Bowel
sounds are absent. AXR reveals multiple fluid
levels in the abdomen. N-G suction is initiated.
What is the nature of his fluid deficit ? How
will you treat ?
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A Nutritional Dilemma
The patient is being treated with D5W-NS _at_
100ml/hour (5 dextrose in 0.9 saline) Is the
caloric supply adequate ? Total
volume100mlx24h2400ml Total dextrose
(5g/100ml) 5x24120g/day Total calories 120gx
4kcals/g480 kcals. Use D10W-NS instead
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Conclusions

• Crystalloids are generally adequate for most
  situations needing fluid management.
• The composition of the solution and rate of
  administration are important when addressing a
  specific situation.
• Colloids may be indicated when more rapid
  hemodynamic equilibration is required (inadequate
  data).