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DFM Fellows Summer 2010

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Objectives Understand the basics of fluid administration Review basics of various fluid options Be able to calculate maintenance fluid rates based on patient weight Be able to estimate fluid losses Be able to calculate fluid replacement

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The Learning Curve The 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 therapy 1. Maintenance 2. Replacement

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Normal Plasma Electrolyte Composition CATIONConcentration mEq/L ANIONConcentration mEq/L Sodium Chloride Potassium Phosphate Calcium Sulfate1.0 Magnesium Organic acids 2.0 Osmolarity Protein1.6

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Commonly Used IV Solutions

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Components of Fluid and Electrolyte Therapy 1. 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 Act IN 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 Needs Replace Urine and insensible losses (1-2 L/day) Replace sodium and potassium loss Na: need mEq/day (1-3mEq/kg/day) K: leak about 20mEq/day Osmola rity (mOsm/ L) Glucose(gm/L) Na+ (mEq/L) K+(mEq/L) Cl- (mEq/L) Lactate (mEq/L) Ca++ (mEq/L) 0.9%NS ½ NS (.45%N S)

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Calculating Maintenance Dosing rule to calculate hourly rate In 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) rule for daily requirements In one day a person needs: 100 mL/kg for the first 10kg 50 mL/kg for the second 10kg 20 mL/kg for the remaining *Remember to divide by 24 for hourly rate*

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Maintenance Considerations Fever or high ambient temperatures Water loss increases by ml/day for every degree above 37C Sweating Consider 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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Example Calculate maintenance fluids for a 75 kg patient who is NPO Rule 10 x 4 = 40 mL 10 x 2 = 20 mL 55 x 1 = 55 mL Total 115 mL/hr Rule 10 x 100 = 1000mL 10 x 20 = 200 mL 55 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? Dehydration Electrolyte imbalance Decrease in blood pressure What do you want to do? Administer medication for nausea Normalize Electrolytes Expand 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 Dehydration FeatureMild dehydration (<5%) Moderate dehydration (5%-10%) Severe dehydration (>10%) Heart Rate NormalSlight increase Rapid, weak Systolic BP NormalNormal/ orthostatic Hypotension Mucous Mb Slightly dryVery dryParched Urine Output DecreasedOlguria < 500ml/day Anuria < 50ml/day

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Clinical Signs of Dehydration This is an objective finding This is a rough estimate of fluid loss Clinical signs may not be evident in adults Adults are able to compensate better than children Calculation Fluid 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 Weight 1 L of fluid = 1 kg of weight 1kg= 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 Deficits After deficit is determined Our pt has a 2.3L deficit by weight Replace half in 8 hours 1,150mL/8hrs =143mL/hr for the first 8 hrs Replace other half in the next 16 hours 1150mL/16hrs =72mL/hr for the next 16hrs

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Total Flow Rate for Maintenance Maintenance 4mL/kg x 10kg = 40mL (0-10) plus 2mL/kg x 10kg = 20mL (10-20) plus 1cc/kg x 30kg = 30mL (20-50) TOTAL maintenance= 90mL/hr Deficit 1,150mL/8hrs=143mL/hr for the first 8 hrs 1150mL/16hrs=72mL/hr for the next 16hrs Add maintenance to deficit and youll have a flow rate Our 50kg patient with gastroenteritis has had a 5lb (2.3kg) weight loss

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Total Flow Rate For the first 8 hrs 90mL/hr + 143mL/hr = 233mL/hr For the next 16 hours 90mL/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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Answer Maintenance 176lb = 80kg 40mL (0-10) plus 20mL (10-20) plus 60mL (20-80) Total= 120mL/hr Deficit = 8lb = 3.6kg =3.6L = 3,600mL loss 1,800mL/ 8 = 225ml/hr = 345 mL/ hr for the 1 st 8 hrs 1,800/16 = 112.5mL/hr = mL/ hr for the next 16 hrs

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