This action might not be possible to undo. Are you sure you want to continue?
Types of Fluids (Crystalloid) 1) Normal Saline (isotonic) a. Na 154 mEq/L b. Cl 154 mEq/L c. Water 1 L 2) Lactated Ringer (isotonic) a. Na 130 mEq/L b. Cl 110 mEq/L c. Lactate 28 mEq/L lactate converted to HCO3- in liver (lactate is unstable in solution) d. K 4 mEq/L e. Ca 3 mEq/L 3) D5W a. 5% dextrose 50g in 1L of water Determinants of fluid requirements: 1) Rate of metabolism 2) Weight 3) Body surface area Fluid Loss and Fluid Replacement 1) Basic principles: a. Determine maintenance requirements b. Determine deficits and resuscitation c. Determine ongoing losses d. Replace losses with appropriate fluid (NS or LR) e. Replace 3x amount lost (3:1 rule) b/c ~1/4 of fluid stays intravascular after 1hr, rest equilibrates interstitially (even less stays intravascular after 5hrs) 2) Normal loss a. Fluid loss from urine > respiration > sweat > feces i. B1, G2, S3 mneumonic bile 1 L, gastric 2L, small bowel 3L b. Normal daily electrolyte losses i. Na: 100 mEq ii. K: 100mEq iii. Cl: 150 mE 3) Pathologic loss a. Third-spacing i. Post-op leaky, vasodilatory state ↓ intravascular fluid ↑ fluid in interstitium ii. Sx: tachycardia, ↓ UOP iii. Tx: isotonic IVF iv. Lasts until ~POD3, then fluid starts returning to intravascular space v. ↓ MIVF and +/- use hypotonic solutions b. Vomiting/NGT i. Lose fluid + HCl + Na + K from stomach hypokalemic hypochloremic metabolic alkalosis with paradoxic aciduria ii. loss of volume + electrolyte imbalances reabsorption of Na+ for volume, and other electrolytes for stability iii. ↓ K+ because alkalosis drives K+ intracellularly iv. ↓Na+ kidneys attempt to reabsorb Na+ but loses K+ in process via Na+/K+ exchanger in collecting duct
airway obstruction. weight gain. ↑ urine specific gravity 2) ↓ Hematocrit (nl at first. smaller vessels and longer distance to heart 4) BUN:Cr ratio >20 (BUN ↑ b/c absorption of blood by GI tract) 5) ↑ Lactic acid b/c of anaerobic ATP formation due to hypotension -1 unit of blood (250mL of packed RBCs) ≈ 3L of crystalloid for resusitation purposes (b/c crystalloid equilibrates with surrounding tissue. but RBCs stay intravascular) -If patient is tachycardic expect about 10-20% blood loss ~. if active bleeding give blood right away. KCl provides K+ that ↑ Na+ reabsorption c. as K+ ↓. Na+/K+ exchanger function ↓. possibly fatigue.1L loss (if total blood = ~5L) give one unit of blood (250mL packed RBCs or 3L of crystalloid expect ↓in tachycardia) -If patient’s tachycardia improves but then returns. Vomiting. Hypoventilation. combined with extra glucose released by stress hormones (i. not crystalloid -Resusitation fluid NS. distended veins. Diarrhea Electrolyte Loss 1) Metabolic acidosis a. pain with breathing 4) Respiratory alkalosis a. Tx: NS with KCl 1. ↑ acid: lactic acidosis. ketoacidosis 2) Metabolic alkalosis a. then ↓ b/c fluids go intravascularly to compensate. but may have problems (K+. continue with alternating cystalloid replacement and blood transfusion. check @ 24 hrs) a. Na+ reabsorption proceeds in collecting duct but excretes H+ in process via Na+/H+ exchanger paradoxic aciduria vii. Cl. cortisol) Assessing hypervolemia: look for edema. ↓ skin turgor Labs of acute blood loss/volume status: 1) ↓ Urinary output (should make ~30mL/kg/hr).e. distal measures of CVP (i. resistance is proportional to length and inversely proportional to cross sectional area i. pneumothorax. orthostatic hypotension: systolic pressure is lower by 20mmHg when standing than sitting (blood pools when sitting. etc). alkali ingestion. no D5 b/c sugar ↑osmolality. thus can better help with Na+ reabsorption 2.needed for Na+ reabsorption in ascending loop and DCT. mineralocorticoid excess 3) Respiratory acidosis a. NGT.5 . NS has higher [Cl-] than LR. carbonic anhydrase inhibitor b. Hyperventilation Assessing hypovolemia Physical Exam: 1) <10% no real Sx. hematocrit can increase if fluid volume low (6-8 points for 1L fluid deficit) 3) ↓ Central venous pressure (nl = 2-3) a.e. ↓ bicarb: diarrhea. femoral vein) not as good b/c valves + higher resistance b.v. doesn’t compensate fast enough) 2) 10-20% tachycardia 3) 20-30% hypotension @ rest + tachycardia 4) 30+% organ dysfxn 5) Other PE findings: thirst. LR good. mucosal membranes . fistula. but ↓Clcompromises this process vi. lung dz.
for 1st 10kg. needs more fluids if producing less than 30mL/hr or 720 mL/day) b. 100mL for 1st 10kg b. 1mL x 50kg (remaining weight) = 50mL/hr iv. 100mL x 10kg (1st 10kg) = 1000mL ii.5 -1 mL/kg/hr a. 4-2-1 rule i. example 70kg person: 70 – 20 = 50 x 20 = 1000 + 1500 = 2500mL/day c. for 2nd 10kg. 40 + 20 + 50 = 110mL/hr 4) Determine HOURLY fluid intake (shortcut) a. shortcut works for patients >20kg 3) Determine HOURLY fluid intake (long way) a. Minimum adult trauma urine output = 50mL/hr 2) Infant/child expected urine output = 1-2mL/kg/hr a. 1000mL / 24 hr = ~4mL/hr ii. for remaining weight. weight + 40 = mL/hour b.6oz) 5) Bolus should be normal saline (NS) or lactated ringer (LR) Post surgical patients need more fluid than maintenance rate. in acute distress. 70kg adult. reduce fluids c. shortcut only works for patients >20kg 5) Consider ↓ fluid intake of older person or any patient with heart disease (i. 50mL for 2nd 10kg c. 500mL / 24 hr = ~2mL/hr iii. consider 1. give bolus of 700mL or 23oz of fluid b/c 30mL in 1oz) b. 20mL / 24 hr = ~1mL/hr b. body needs ~3mEq/kg of Na+ per day = 210mEq for 70kg patient . 50mL x 10kg (2nd 10kg) = 500mL iii.e. example: 70kg person i.e if not peeing enough) = 10mL/kg a. CHF) Calculating Urine Output 1) Adult expected urine output = .2 mL/kg/hr or 80-100mL/hr for 70kg adult.5 maintenance rate BUT. 70kg – 20kg = remaining weight = 50kg. Minimum normal adult urine output = 35mL/hr or 840 mL/day). beware of hypernatremia for 70kg patient. 10kg child. example: 70kg person i. 20mL x 50kg = 1000mL iv. 4mL x 10kg (1st 10kg) = 40mL/hr ii. Too much if urine output ≈ 1.75L D5 ½ NS = 289mEq of Na+. give bolus of 200mL or 6. 20mL for every kg after 20kg d. 10kg child should produce at least 10mL/hr or 240 mL/day) 3) Bolus for adults (i. 1. 2mL x 10kg (2nd 10kg) = 20mL/hr iii. example: 70kg person: 70 + 40 = 110mL/hr c. Total = 1000mL + 500mL + 1000mL = 2500mL/day 2) Determine DAILY fluid intake (shortcut) a. can give up to 20mL/kg a. can give up to 20mL/kg bolus 4) Bolus for children in acute distress.Calculating Fluid Input 1) Determine DAILY fluid intake (long way) a.5 maintenance fluid = 3. [(weight – 20) x 20] + 1500 b.
Dextrose included in IV fluids to protect against muscle breakdown caused by gluconeogenesis [hypoglycemia glycogenolysis until glycogen stores depleted in 1-2days gluconeogenesis in liver (substrates used are breakdown of muscle proteins into amino acids). have less water (50% of body weight) Blood volume: 7% of body weight. Muscle has more water than fat. for 70kg person. need small amount of dextrose to inhibit gluconeogenesis During surgery: vasodilatory state. need to give IV fluids. ¼ of extracellular water is plasma (or 5% of extracellular water is plasma) b. check urine output and ↓ if too high Too much urine 1) iatrogenic – too much fluids given 2) diabetes insipidus (central vs nephrogenic) 3) high output renal failure 4) high blood solutes and glucose (above 200. glucosuria) 5) sickle cell anemia Too little urine 1) acute tubular necrosis 2) chronic renal failure/renal insufficiency 3) obstruction 4) SIADH Physiology Distribution of body water: 60-40-20 rule 1) 60% of body weight is water 2) 40% (or 2/3 of total water) of body weight is intracellular water 3) 20% (or 1/3 of total water) of body weight is extracellular water a. also body compensates by release of ADH Postop day #1: want ins and outs to be even Postop day #3: fluid in third space goes to intravascular space. ¾ of extracellular water is interstitial (or 15% of extracellular water is interstitial) 4) Modifications: a. total blood volume ~5L Daily Nutritional Requirements 1) Na 3-4 mEq/kg 2) K 1-2mEq/kg 3) Protein 1g/kg/day Normal values for serum electrolytes (mEq/dL): Content of gastric secretions: Content of intestinal secretions: Na 30 Na140 K 10 K5 Na 140 H+ 100 H+ 0 K4 Cl 140 Cl 100 Cl 100 Bicarb 0 Bicarb 30 Bicarb 24 Tonicity: effect of fluid on cell volume Osmolality: concentration of a solution in fluid 1) osmolality similar amoung fluid compartments. thus obese patients have less water than lean patients b.8 Normal osmolality = 290 mOsm/L . because they have more fat than men. so measured plasma osmolality is good estimate of total body osmolality Osmolality (mOsm/L) = 2 x serum Na + glucose/18 + BUN/2. Women.
seizures b. Glucose + insulin: brings K into cells iv. EKG i. Chvostek’s sign: tapping on cheek causes facial spasm iii. Neuro: confusion. renal loss (hyperaldosteronism) d. paget’s dz of bone. Causes i. Tx: give water slowly 6) Hyponatremia a. Neuro: parasthesias. Na administration c. Musculoskeletal: fatigue. Sx: i. K+ competes with digoxin for binding on cardiac transporters. Causes: hypoparathyroidism. Ca supp. Shortened QT interval c. Sx: i. neoplasm. Sx: restless. stones b. A. sarcoid d. tumor) iii. NaHCO3: brings K into cells iii. Causes: CHIMPANZEES i. GI ileus b. Give Ca+ 5) Hypernatremia a. hyperparathyroidism. EKG: U waves c. diabetes insipidus. Sx: . Renal: htn. EKG: peaked T waves. meds. wide QRS c. ZES. weakness iii. Tx: i. ataxic. cardiac arrhythmias 1. Sx: cardiac arrhythmias b. diuresis 4) Hypocalcemia a.“Osmolal gap” when Calculated Posm . Alkalosis intracellular shift of K ii. Tx: hydration. excess vit D. thus ↓ K+ means ↑ digoxin leading to dysrhythmia ii. Mg deficiency c. weakness/paralysis iii. Kayexalate: increases GI loss of K 2) Hypokalemia a. Trousseau’s sign: compression of upper arm carpopedal spasm/parasthesia b. Tx: i. iatrogenic. GI loss (diarrhea. Sx: i. Calcium gluconate: protects membranes of cardiac cell by preventing Ca from leaving ii. hyperactive reflexes (brisk DTR) ii. personality changes ii. Tx: give K 3) Hypercalcemia a.Measured Posm > 15 Electrolyte imbalances 1) hyperkalemia a. Causes: dehydration. addision’s. renal failure.
Neuro: ↓ DTR ii. ↑ ADH secretion post-trauma/surgery excess free water ii. Causes: loop diurectics. renal failure. give 3% saline solution at <0. GI: anorexia. drains c. Sx: similar to hypocalcemia b. Tx: give Ca b/c it anatagonizes Mg 8) Hypomagnesemia a. Renal loss from diuretics. Musculoskeletal: fatigue. prolonged IVF w/o Mg c. Tx: i. weakness b. CVS: hypotension/cardiac arrest iii. Vomiting. Causes: i. Water restriction in post surgical patients ii. Tx: IV Mg . defect in aldosterone. fistula. Sx: i. diarrhea. coma ii.i. Neuro: confusion seizures. check fractional excretion of Na iii. Causes: renal failure c. N/V iii. Musculoskeletal: depressed neuromuscular fxn b/c inhibition of Ach release b.5mEq/L/hr 7) Hypermagnesemia a. avoid rapid correction b/c possible central pontine myelinolysis 1. NGT. Hypertonic saline solution.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.