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Prescription for IV Fluids

DEFICIT (ACTUAL VS. ESTIMATE)


Pediatric Clinical Assessment of Dehydration
Percent Infant Child Clinical Signs and Symptoms
Dehydration
Mild 5% 3-4% Increased thirst, tears present, mucous
membranes moist, ext. jugular visible
when supine, capillary refill >2 seconds
centrally, urine specific gravity > 1.020
Moderate 10% 6-8% Tacky to dry mucous membranes,
decreased tears, pulse rate may be
elevated somewhat, fontanelle may be
sunken, oliguria, capillary refill time
between 2 and 4 seconds, decreased skin
turgor
Severe 15% 10% Tears absent, mucous membranes dry,
eyes sunken, tachycardia, slow capillary
refill, poor skin turgor, cool extremities,
orthostatic to shocky, apathy, somnolence
Shock >15% >10% Physiologic decompensation: insufficient
perfusion to meet end-organ demand,
poor oxygen delivery, decreased blood
pressure.

Adult Clinical Assessment of Dehydration


Percent of Body Severity Signs & Symptoms
Water Lost
3% Mild Reduced sweating (dry axilla),  dry
mucous membranes (not very useful)
6% Moderate Oliguria, orthostatic hypotension with
increased heart rate, cool peripheries,
apathy
9% Severe Profound oliguria with compromised CNS
function

Water as % of Body Weight


• Newborns 75-80%
o D5W/0.2% NS for <15 kg
• At one year 65%
o D5w/0.45% NS for >15 kg
• Adult Male 60%
• Adult Female 50%
• Elderly 45%

Water Distribution
• TBW = 2/3 ICF + 1/3 ECF
• ECF = 2/3 interstitial + 1/3 intravascular
• Intravascular volume (L) = (Wt [kg] x Percent Body Water)  9

Rate: Give half of deficit in the first eight hours and the next half over 16
hours.

MAINTENANCE (4/2/1)
1. Average healthy adult requires approximately 2,500 mL water/day
a. 200 mL/day GI losses
b. 800 mL/day insensible losses (respiration, perspiration)
c. 1,500 mL/day urine (Caution: assess for renal failure)
2. Increased requirements? Common examples include fever, sweating, GI
(vomiting, diarrhea, NG suction).
3. Decreased requirements? Common examples include anuria/oliguria,
SIADH, high humidity, CHF.
4. 4/2/1 Rule
a. 4 mL/kg/hour for 1st 10 kg
b. 2 mL/kg/hour for 2nd 10 kg
c. 1 mL/kg/hour for each kg over 20 kg
5. Maintenance Lytes
a. Na+ 3 mEq/kg/day
b. K+ 1 mEq/kg/day
6. Maintenance Glucose (to prevent protein loss)
a. Adults 100 – 200 g/day
b. Children 100 – 200 mg/kg/hr

Example: 50 kg patient maintenance requirements.


• Fluid: 40 + 20 + 30 = 2,160 mL/day
• Na+ = 150 mEq/day, 150 mEq/day  2.16 L/day = 69 mEq/L
• K+ = 50 mEq/day, 50 mEq/day  2.16 L/day = 23 mEq/L
• Therefore give 0.45 NS with 20 mEq KCl/L at a rate of 90 mL/hour
• The order would be written like this:
“IV 0.45 NS with 20 mEq KCl/L at 90 mL/hr”

IV Solutions
ECF Ringer’s 0.9 0.45 D5W Alb 0.2
NS NS 25% NS
D5W D5W
mEq/L Na+ 142 130 154 77 - 130 34
K+ 4 4 - - - - -
Ca++ 4 3 - - - - -
Mg++ 3 - - - - - -
Cl- 103 109 154 77 - 120 34
HCO3- 27 28* - - - - -
Gms/L Dextrose N/A - - 50 50 - 50
Mosm/L OSMO 280 - 273 308 407 253 269 321
310
* Converted from Lactate
Note: Dextrose can be added to all IV solutions
D5W = 50 grams of dextrose/L; D10W = 100 grams dextrose/L
ON-GOING LOSSES
• Gastric Losses (Nasogastric tube, Emesis)
o D5 0.45 NS with 20 mEq/L potassium chloride (KCl)
• Diarrhea
o D5 Ringer’s Lactate with 15 mEq/L KCl
o Use body weight as a replacement guide (1 kg = 1 litre)
• Blood loss
o Packed Red Blood Cells (PRBC) Type & Matched
o Assess Platelets, INR, and Calcium
o Stop anticoagulant medications
o Consider Vitamin K (if on warfarin)
o Consider replacing clotting factors
▪ Fresh Frozen Plasma (FFP)
▪ May need factor VII in the event of severe bleeding
o Consider replacing Platelets

Rate of replacement depends on rate of loss. Rapid losses require more


frequent measurement and adjustment of infusion rate.
E.g., Measure NG losses Q2H and replace with IV D5 0.45 NS with 20
mEq/L KCl over the next 2 hours, Reassess in A.M.
How to order the right IV fluids for your patients.
Answers.

1. Newborn infant, weighing 3.5 kg on admission. This baby is tachycardic, her mucous
membranes are dry, and her fontanelle may be sunken (you are not sure). Her
parents think that she has the same number of wet diapers as usual.

DEFICIT
1. Moderate – 10% for an infant.
2. 3.5 kg on admission
3. May assume normal weight is 3.5, as long as you recognize that this will
underestimate the deficit and reassess this patient’s fluid status in 24 hours. If you
wanted to be more exact you could get a better estimate by solving for weight in this
equation. Wt –3.5 kg = 0.1(TBW) → Wt – 3.5 kg = 0.1(Wt x 0.8). The final result is
Wt = 3.8 kg.
4. Using 3.5 kg. TBW = 0.8(3.5 kg) = 2.8 L
5. Deficit = TBW x 0.1 = 2.8 x 0.1 = 0.28 L or 280 mL
6. First half in 8 hours (140 mL), second half in 16 hours (140 mL)

IV 0.9 NS at 18 ml/hr for 8 hours, then 9 ml/hr for 16 hours.

(If you used Wt = 3.8 kg the order would look like this: IV 0.9 NS at 19 ml/hr for 8
hours, then 10 ml/hr for 16 hours.

MAINTENANCE
• Water (4/2/1): 4 x 3.5 = 14 mL/hr, (24 x 14 = 336 mL/day = 0.336 L/day)
• Sodium 3 mEq/kg/day: 3 x 3.5 = 10.5 mEq/day, (10.5 / 0.336 = 31 mEq/L)
• Potassium 1 mEq/kg/day: 1 x 3.5 = 3.5 mEq/day, (3.5 / 0.336 = 10 mEq/L)
• Glucose Children ~200 mg/kg/hr: 200 x 3.5 = 700 mg/hr, 0.7 x 24 = 16.8
gm/day, (16.8 / 0.336 =50 gm/L)

IV 0.2 NS D5W with 10 mEq/L KCl at 15 mL/hr. Reassess in a.m.

ONGOING LOSSES
1) None.

FINAL ORDER
1) IV 0.9 NS at 18 ml/hr for 8 hours, then 9 ml/hr for 16 hours.
2) IV 0.2 NS D5W with 10 mEq/L KCl at 15 mL/hr. Reassess in a.m.
Both fluids can be run at the same time – “piggybacked” or separate IV sites.
How to order the right IV fluids for your patients.
Answers.

2. Toddler admitted for asthma exacerbation, weighing 25 pounds. He does not seem
to have any signs of dehydration, but he is not eating or drinking well at the time of
admission.

DEFICIT
2) None.

MAINTENANCE
3) Wt pounds x 0.454 = Wt kg; 25 x 0.454 = 11.35 kg ~ 11 kg
• Water (4/2/1): 4 x 10 = 40 mL/hr, 2 x 1 = 2 mL/hr, 40 + 2 = 42 mL/hr
• (24 x 42 = 1008 mL/day = 1.008 L/day)
• Sodium 3 mEq/kg/day: 3 x 11 = 33 mEq/day, (33 / 1.008 = 33 mEq/L)
• Potassium 1 mEq/kg/day: 1 x 11 = 11 mEq/day, (11 / 1.008 = 11 mEq/L)
• Glucose Children ~200 mg/kg/hr: 200 x 11 = 2200 mg/hr, 2.2 x 24 = 52.8
gm/day, (52.8 / 1.008 =52 gm/L)

IV 0.2 NS D5W with 10 mEq/L KCl at 40 mL/hr. Reassess in 24 hours.

ONGOING LOSSES
4) None.

FINAL ORDER
IV 0.2 NS D5W with 10 mEq/L KCl at 40 mL/hr. Reassess in 24 hours.
How to order the right IV fluids for your patients.
Answers.

3. Teen admitted for an urgent appendectomy weighing, 100 pounds. She is


complaining of a dry mouth and is NPO prior to the surgery.

DEFICIT
1. None.

MAINTENANCE
5) Wt pounds x 0.454 = Wt kg; 100 x 0.454 = 45.4 kg
• Water (4/2/1): 4 x 10 = 40 mL/hr, 2 x 10 = 2 mL/hr, 1 x 25.4 = 25.4, 40 + 20 +
25.4 = 85.4 mL/hr
• (24 x 85.4 = 2049.6 mL/day = 2.05 L/day)
• Sodium 3 mEq/kg/day: 3 x 45.4 = 136 mEq/day, (136 / 2.05 = 66 mEq/L)
• Potassium 1 mEq/kg/day: 1 x 45.4 = 45.4 mEq/day, (45.4 / 2.05 = 22 mEq/L)
• Glucose Children ~200 mg/kg/hr: 200 x 45.4 = 9080 mg/hr, 9.08 x 24 = 218
gm/day, (218 / 2.05 = 106 gm/L)

IV 0.45 NS D10W with 20 mEq/L KCl at 85 mL/hr. TKVO when called to the
OR.
(TKVO = to keep vein open. In adults this is ~ 30 mL/hour)

ONGOING LOSSES
6) None.

FINAL ORDER
IV 0.45 NS D10W with 20 mEq/L KCl at 85 mL/hr. TKVO when called to the
OR.
How to order the right IV fluids for your patients.
Answers.

4. Elderly woman admitted for community-acquired pneumonia, weighing 95 pounds.


Was in to see her family doctor three days prior to admission and weighed 102
pounds. She looks unwell and is not talking very much. She is not eating or drinking.

DEFICIT
1. 102 – 95 = 7 pounds. 7 x 0.454 = 3.2 kg ~ deficit of 3.2 L
2. 102 pounds = 46.3 kg
3. Using 46.3 kg. TBW = 0.45(46.3 kg) = 20.8 L
4. % Deficit = Deficit / TBW = 3.2 / 20.8 = 0.15 or 15% Deficit!
5. First half in 8 hours (1.6 L), second half in 16 hours (1.6 L)

IV 0.9 NS at 200 ml/hr for 8 hours, then 100 ml/hr for 16 hours, then D/C.

MAINTENANCE
• Water (4/2/1): 4 x 10 = 40 mL/hr, 2 x 10 = 20 mL/hr, 1 x 26.3 = 26.3, 40 + 20
+ 26.3 = 86.3 mL/hr
• (24 x 86.3 = 2071.2 mL/day = 2.07 L/day)
• Sodium 3 mEq/kg/day: 3 x 46.3 = 138.9 mEq/day, (138.9 / 2.07 = 67 mEq/L)
• Potassium 1 mEq/kg/day: 1 x 46.3 = 46.3 mEq/day, (46.3 / 2.07 = 22 mEq/L)
• Glucose Adults 100 – 200 g/day: 200 / 2.07 = 97 gm/L

IV 0.45 NS D10W with 20 mEq/L KCl at 85 mL/hr. Reassess in a.m.

ONGOING LOSSES
• None.

FINAL ORDER
1) IV 0.9 NS at 200 ml/hr for 8 hours, then 100 ml/hr for 16 hours, then D/C.
2) IV 0.45 NS D10W with 20 mEq/L KCl at 85 mL/hr. Reassess in a.m.
Both fluids can be run at the same time – “piggybacked” or separate IV sites.
How to order the right IV fluids for your patients.
Answers.

5. Young man admitted in acute anuric renal failure, weighing 150 pounds. He has
been vomiting about 250 cc every two hours. He is not eating or drinking. He last
remembers his weight as being 165 pounds. You are not sure if this is significant
because he seems confused and he can’t tell you when he last was weighed.

Anuric = No urine output! This is a potentially dangerous situation. The lack of urine
output could be related to his severe fluid deficit. You must correct his deficit AND watch
carefully for signs of volume overload. Also, potassium should not be given unless you
are certain that he is putting out urine. In this scenario you would inform Nephrology of
this patient if the initial IV fluid did not start his urine output.
One of the first things you need to do is to order a Foley Catheter to rule out a urethral
blockage and to accurately measure urine output.

DEFICIT
1. Severe deficit – 9%
2. Assume his weight is 150 pounds (68.1 kg), as long as you recognize that this will
underestimate the deficit and reassess this patient’s fluid status frequently.
3. Using 68.1 kg. TBW = 0.6(68.1 kg) = 40.9 L
4. Deficit = TBW x 0.09 = 40.9 x 0.09 = 3.68 L or 3680 mL
5. First half in 8 hours (1840 mL), second half in 16 hours (1840 mL)

IV 0.9 NS at 230 ml/hr for 8 hours, then 115 ml/hr for 16 hours, then
reassess.
MAINTENANCE
• Do not give maintenance fluids until you are sure his kidneys are working
(i.e., adequate urine output)
ONGOING LOSSES
• Often with volume replacement the patient will stop vomiting. Also, you can
give IV Gravol to help stop the emesis.
• Since emesis can cause hypokalemia, in this case you would want to replace
the potassium.

Measure emesis Q2H and then replace with IV 0.45 NS D5W with 20 mEq/L
KCl over the next 2 hours.
Repeat electrolytes (stat) Q4H and call MD with results.

FINAL ORDER
• IV 0.9 NS at 230 ml/hr for 8 hours, then 115 ml/hr for 16 hours, then
reassess.
• Measure emesis Q2H and then replace with IV 0.45 NS D5W with 20
mEq/L KCl over the next 2 hours.
• Repeat electrolytes (stat) Q4H and call MD with results.
How to order the right IV fluids for your patients.
Answers.

6. Man 55 years old admitted with myocardial infarction; weighing 100 kg. Your
resident ordered him a Heart Institute Diet as tolerated. The nurses have called to
ask you, “How fast do your want the IV to run?”

DEFICIT
• None.
MAINTENANCE
• It is not clear that this patient needs maintenance fluids; he is not NPO. In this
clinical scenario it makes good sense to have good IV assess should he
situation worsen (i.e., cardiac arrest, arrhythmia, etc.)
• Water (4/2/1): 4 x 10 = 40 mL/hr, 2 x 10 = 20 mL/hr, 1 x 80 = 80, 40 + 20 + 80
= 140 mL/hr
• (24 x 140 = 3360 mL/day = 3.36 L/day)
• Sodium 3 mEq/kg/day: 3 x 100 = 300 mEq/day, (300 / 3.36 = 89 mEq/L)
• Potassium 1 mEq/kg/day: 1 x 100 = 100 mEq/day, (100 / 3.36 = 30 mEq/L)
• Glucose Adults 100 – 200 g/day: 200 / 3.36 = 60 gm/L. However,
hyperglycemia is dangerous following a myocardial infarction and I would not
include dextrose in his IV.

IV 0.45 NS with 30 mEq/L KCl at 140 cc/hr. Switch to TKVO is eating and
drinking. Reassess in the a.m.

OR

IV 0.45 NS TKVO. Reassess in the a.m.


ONGOING LOSSES
• None.

FINAL ORDER
IV 0.45 NS with 30 mEq/L KCl at 140 cc/hr. Switch to TKVO is eating and
drinking. Reassess in the a.m.

OR

IV 0.45 NS TKVO. Reassess in the a.m.

Key Points:
• Always think “Deficit, Maintenance, Ongoing Losses” when writing IV orders.
• It is important not to give 0.9 Normal Saline for maintenance. Too much
sodium can cause edema and more importantly HEART FAILURE.
• Always write your order so that there is a safety mechanism to make sure
your patient does not get volume overloaded or under-resuscitated. (i.e.,
reassess in x)