1. IV Fluid Management
DFM Fellows
Summer 2010

2. 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

3. 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!

4. 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
Maintenance
Replacement
Maintenance: meeting the requirements for fluid and electrolyte intake that balance daily obligatory losses
Replacement: providing for ongoing and additional losses that occur during the course of therapy (surgery phases: pre/intra/post operative)

5. Normal Plasma Electrolyte Composition
CATION
Concentration mEq/L
ANION
Sodium
Chloride
95-105
Potassium
Phosphate
2.5-30
Calcium
Sulfate
1.0
Magnesium
Organic acids
2.0
Osmolarity
Protein
1.6
What are we maintaining: maintaining electrolyte homeostasis

6. Commonly Used IV Solutions
Osmolarity (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
½ NS (.45%NS) 77 LR
274
130
4.0
109 28 3
D5W
278 50
D5 ½ NS
406
D5 has 170kcal/L

7. Components of Fluid and Electrolyte Therapy
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)

8. The Balancing Act
OUT (~1-1.6L/day for ave. adult)
Urine
12-15mL/kg/day
Feces
3mL/kg
Insensible losses
10-13mL/kg/day IN
Drinking
Eating
Metabolism
3mL/kg
IV Fluids?
The
Metabolism: oxidation of carbs and fat
Water losses from skin and respiratory tract
With no unusual stresses or losses and normal renal function intake can be balanced to outputs

9. 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
Osmolarity (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
½ NS (.45%NS) 77

10. Calculating Maintenance Dosing
4-2-1 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*
Peds vs. adults

11. Maintenance Considerations
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
Sweating: the athelete that weighs in before each practice to assess hydration status

12. Calculate maintenance fluids for a 75 kg patient who is NPO
Example
Calculate maintenance fluids for a 75 kg patient who is NPO
4-2-1 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

13. So you know how to calculate fluid maintenance requirements but what happens if the patient has an initial deficit requiring rehydration other than maintenance?

14. She has had vomiting and has diarrhea x 3days
Think About It
A 50 kg patient comes into the ED with gastroenteritis
She has had vomiting and has diarrhea x 3days
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)

15. Clinical Signs of Dehydration
Feature
Mild dehydration (<5%)
Moderate dehydration
(5%-10%)
Severe dehydration (>10%)
Heart Rate
Normal
Slight increase
Rapid, weak
Systolic BP
Normal/ orthostatic
Hypotension
Mucous Mb
Slightly dry
Very dry
Parched
Urine Output
Decreased
Olguria
< 500ml/day
Anuria
< 50ml/day
Oliguria: < 30ml/hr Anuria: 0.5ml/kg/hr

16. Clinical Signs of Dehydration
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

17. Estimate Deficit by Weight
Estimate Deficit by Weight
Example: Suppose our gastroenteritis patient reports a 5lb weight loss with illness
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

18. Fluid Deficits After deficit is determined Replace half in 8 hours
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

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

20. Total Flow Rate For the first 8 hrs For the next 16 hours
90mL/hr + 143mL/hr = 233mL/hr
For the next 16 hours
90mL/hr + 72mL/hr = 162mL/hr

21. 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

22. Answer Deficit Maintenance 184 - 176= 8lb = 3.6kg =3.6L = 3,600mL loss
Answer
Deficit
= 8lb = 3.6kg =3.6L = 3,600mL loss
1,800mL/ 8 = 225ml/hr =
345 mL/ hr for the 1st 8 hrs
1,800/16 = 112.5mL/hr =
232.5 mL/ hr for the next 16 hrs
Maintenance
176lb = 80kg
40mL (0-10)
plus
20mL (10-20)
60mL (20-80)
Total= 120mL/hr