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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
↑ acid: lactic acidosis. Na+/K+ exchanger function ↓. no D5 b/c sugar ↑osmolality. etc). 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. airway obstruction. continue with alternating cystalloid replacement and blood transfusion. mucosal membranes . but RBCs stay intravascular) -If patient is tachycardic expect about 10-20% blood loss ~. hematocrit can increase if fluid volume low (6-8 points for 1L fluid deficit) 3) ↓ Central venous pressure (nl = 2-3) a. cortisol) Assessing hypervolemia: look for edema. doesn’t compensate fast enough) 2) 10-20% tachycardia 3) 20-30% hypotension @ rest + tachycardia 4) 30+% organ dysfxn 5) Other PE findings: thirst. Hyperventilation Assessing hypovolemia Physical Exam: 1) <10% no real Sx. Vomiting. combined with extra glucose released by stress hormones (i. distended veins. pneumothorax. but may have problems (K+.5 . then ↓ b/c fluids go intravascularly to compensate. thus can better help with Na+ reabsorption 2. distal measures of CVP (i. ketoacidosis 2) Metabolic alkalosis a. NS has higher [Cl-] than LR. Tx: NS with KCl 1. pain with breathing 4) Respiratory alkalosis a. ↓ bicarb: diarrhea. Na+ reabsorption proceeds in collecting duct but excretes H+ in process via Na+/H+ exchanger paradoxic aciduria vii. orthostatic hypotension: systolic pressure is lower by 20mmHg when standing than sitting (blood pools when sitting. resistance is proportional to length and inversely proportional to cross sectional area i. as K+ ↓. possibly fatigue. LR good. ↑ urine specific gravity 2) ↓ Hematocrit (nl at first. but ↓Clcompromises this process vi. alkali ingestion. Hypoventilation. Diarrhea Electrolyte Loss 1) Metabolic acidosis a. check @ 24 hrs) a. if active bleeding give blood right away. weight gain. Cl. NGT. fistula.e. carbonic anhydrase inhibitor b. lung dz.needed for Na+ reabsorption in ascending loop and DCT.v.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.e. femoral vein) not as good b/c valves + higher resistance b. ↓ skin turgor Labs of acute blood loss/volume status: 1) ↓ Urinary output (should make ~30mL/kg/hr). not crystalloid -Resusitation fluid NS. KCl provides K+ that ↑ Na+ reabsorption c. mineralocorticoid excess 3) Respiratory acidosis a.
Too much if urine output ≈ 1. 1.2 mL/kg/hr or 80-100mL/hr for 70kg adult. 10kg child should produce at least 10mL/hr or 240 mL/day) 3) Bolus for adults (i. shortcut only works for patients >20kg 5) Consider ↓ fluid intake of older person or any patient with heart disease (i.5 -1 mL/kg/hr a. 70kg – 20kg = remaining weight = 50kg. Total = 1000mL + 500mL + 1000mL = 2500mL/day 2) Determine DAILY fluid intake (shortcut) a. 20mL / 24 hr = ~1mL/hr b. beware of hypernatremia for 70kg patient. 4-2-1 rule i.e if not peeing enough) = 10mL/kg a.Calculating Fluid Input 1) Determine DAILY fluid intake (long way) a. for 1st 10kg. needs more fluids if producing less than 30mL/hr or 720 mL/day) b. 100mL for 1st 10kg b. 20mL for every kg after 20kg d. example: 70kg person i. give bolus of 700mL or 23oz of fluid b/c 30mL in 1oz) b. Minimum adult trauma urine output = 50mL/hr 2) Infant/child expected urine output = 1-2mL/kg/hr a. 500mL / 24 hr = ~2mL/hr iii. for remaining weight. for 2nd 10kg. 20mL x 50kg = 1000mL iv. 1000mL / 24 hr = ~4mL/hr ii. example: 70kg person i. reduce fluids c. 2mL x 10kg (2nd 10kg) = 20mL/hr iii. example: 70kg person: 70 + 40 = 110mL/hr c. 10kg child. weight + 40 = mL/hour b. 50mL for 2nd 10kg c. [(weight – 20) x 20] + 1500 b. 100mL x 10kg (1st 10kg) = 1000mL ii.75L D5 ½ NS = 289mEq of Na+. CHF) Calculating Urine Output 1) Adult expected urine output = . 1mL x 50kg (remaining weight) = 50mL/hr iv.5 maintenance fluid = 3. 40 + 20 + 50 = 110mL/hr 4) Determine HOURLY fluid intake (shortcut) a.6oz) 5) Bolus should be normal saline (NS) or lactated ringer (LR) Post surgical patients need more fluid than maintenance rate. Minimum normal adult urine output = 35mL/hr or 840 mL/day). example 70kg person: 70 – 20 = 50 x 20 = 1000 + 1500 = 2500mL/day c. give bolus of 200mL or 6. 70kg adult.5 maintenance rate BUT. can give up to 20mL/kg bolus 4) Bolus for children in acute distress. can give up to 20mL/kg a. shortcut works for patients >20kg 3) Determine HOURLY fluid intake (long way) a. 4mL x 10kg (1st 10kg) = 40mL/hr ii. body needs ~3mEq/kg of Na+ per day = 210mEq for 70kg patient . consider 1. in acute distress.e. 50mL x 10kg (2nd 10kg) = 500mL iii.
8 Normal osmolality = 290 mOsm/L . 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.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). 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. Women. because they have more fat than men. 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. need to give IV fluids. 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. need small amount of dextrose to inhibit gluconeogenesis During surgery: vasodilatory state. have less water (50% of body weight) Blood volume: 7% of body weight. Muscle has more water than fat. so measured plasma osmolality is good estimate of total body osmolality Osmolality (mOsm/L) = 2 x serum Na + glucose/18 + BUN/2. ¼ of extracellular water is plasma (or 5% of extracellular water is plasma) b. for 70kg person. thus obese patients have less water than lean patients b. ¾ of extracellular water is interstitial (or 15% of extracellular water is interstitial) 4) Modifications: a.
hyperparathyroidism. cardiac arrhythmias 1. Mg deficiency c.Measured Posm > 15 Electrolyte imbalances 1) hyperkalemia a. weakness iii. Give Ca+ 5) Hypernatremia a. Na administration c. Tx: give water slowly 6) Hyponatremia a. Sx: restless. Kayexalate: increases GI loss of K 2) Hypokalemia a. Sx: . Tx: i. paget’s dz of bone. sarcoid d. diabetes insipidus. addision’s.“Osmolal gap” when Calculated Posm . neoplasm. seizures b. Sx: i. Sx: i. tumor) iii. A. Chvostek’s sign: tapping on cheek causes facial spasm iii. Tx: give K 3) Hypercalcemia a. personality changes ii. Shortened QT interval c. ataxic. Tx: hydration. Causes: CHIMPANZEES i. meds. Neuro: confusion. renal loss (hyperaldosteronism) d. Alkalosis intracellular shift of K ii. Causes: dehydration. EKG: peaked T waves. Sx: cardiac arrhythmias b. Ca supp. Glucose + insulin: brings K into cells iv. Causes i. iatrogenic. excess vit D. NaHCO3: brings K into cells iii. wide QRS c. Sx: i. Tx: i. Renal: htn. K+ competes with digoxin for binding on cardiac transporters. hyperactive reflexes (brisk DTR) ii. renal failure. EKG: U waves c. GI loss (diarrhea. thus ↓ K+ means ↑ digoxin leading to dysrhythmia ii. GI ileus b. diuresis 4) Hypocalcemia a. EKG i. stones b. Musculoskeletal: fatigue. weakness/paralysis iii. Trousseau’s sign: compression of upper arm carpopedal spasm/parasthesia b. Neuro: parasthesias. ZES. Calcium gluconate: protects membranes of cardiac cell by preventing Ca from leaving ii. Causes: hypoparathyroidism.
Tx: IV Mg . Vomiting. ↑ ADH secretion post-trauma/surgery excess free water ii. drains c.i. diarrhea. Sx: i. Water restriction in post surgical patients ii. Tx: give Ca b/c it anatagonizes Mg 8) Hypomagnesemia a. prolonged IVF w/o Mg c. NGT. Causes: renal failure c. Musculoskeletal: depressed neuromuscular fxn b/c inhibition of Ach release b. avoid rapid correction b/c possible central pontine myelinolysis 1. coma ii. Tx: i. defect in aldosterone. Causes: i. weakness b. Causes: loop diurectics. renal failure. Musculoskeletal: fatigue. give 3% saline solution at <0.5mEq/L/hr 7) Hypermagnesemia a. Neuro: confusion seizures. Neuro: ↓ DTR ii. N/V iii. Sx: similar to hypocalcemia b. Renal loss from diuretics. GI: anorexia. fistula. CVS: hypotension/cardiac arrest iii. Hypertonic saline solution. check fractional excretion of Na iii.
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