Za Objectives e 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 e Be able to calculate fluid replacementThe Learning Curve e 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. e And as you screw up you will learn!IV Fluids e The role of IV fluid administration is to e Provide volume replacement e Administer medications, electrolytes, blood products, or diagnostic reagents e Maintenance/correction of nutritional status e Components of fluid and electrolyte therapy 1. Maintenance 2. ReplacementCATION Concentration mEq/L Ss ~ Normal Plasma Electrol ANION yte Composition Concentration mEq/L Sodium 135-145 Chloride 95-105 Potassium 3.5-5.0 Phosphate 2.5-30 Calcium 4.0-5.5 Sulfate 1.0 1.5-2.5 Organic acids 2.0 Osmolarity 285-295 Protein 1.6“Commonly Used IV Solutions Osmolarity Glucose Na+ K+ Lactate | Ca++ (mOsm/L) ——(gm/L)_ (MEQ/L) (mEq/L) aan) (mEq/L) | (mEq/L) 0.9% 308 154 154 NS % NS 1 (asm | 14 7 ZT NS) LR 274 30 864.0. 109 28 3 Dsw 278 50 D5% a 406 507 7“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)The Balancing Act ° IN © OUT (~1-1.6L/day for ave. * Drinking edu « Eating e Urine * Metabolism. : : az-ismL/kg/day «© 3mL/kg Soak ° IV Fluids? 3mL/kg. ¢ Insensible losses + 10-13mL/kg/day With no unusual stresses or losses and normal renal function intake can be balanced to outputsviaintenance: Water an Electrolyte Needs Replace Urine and insensible losses (1-2 L/day) © Replace sodium and potassium loss e Na: need 47-147 mEq/day (1-3mEq/kg/day) K: leak about 2omEq/day Osmola | Glucose | Na+ rem ce ; rity (gm/L)_ | G@aEq/L) | (mEq/L) | @nEg/L) | (mE (mOsm/ f |a Calculating Maintenance Dosing © 4-2-1 rule to calculate © 100-50-20 rule for daily hourly rate requirements e Inone hour, a person In one day a person needs: needs: ° 4mL/kg for the first * 100 mL/kg for the first tokg (0-10) 1okg ° 2mL/kg for the next ¢ 50 mL/kg for the second 1okg (10-20) 1okg e umL/kg for the ° 20 mL/kg for the remaining kg (>20) remaining © *Remember to divide by 24 for hourly rate*Maintenance Considerations Fever or high ambient temperatures e Water loss increases by 100-150ml/day for every degree above 37C ° Sweating ° Consider using a hypotonic solution for fluid replacement (0.45% saline) e Humidity ¢ Breathing humid air decreases loss while dry air may increase relative losses- Example Calculate maintenance fluids for a 75 kg patient who is NPO © 4-2-1 Rule © 100-50-20 Rule *° 10x4=40mL © 10x100 = 1000mL © 10x2=20mL © 10x 20=200 mL © 55x1=55mL © 55X20= 00 ¢ Total 115 mL/hr ¢ Sub total 2300mL/day © Total 96 mL/hrSo you know how to calculate fluid maintenance requirements but what happens if the patient has an initial deficit requiring rehydration other than maintenance?“Think About [t A 50 kg patient comes into the ED with gastroenteritis She has had vomiting and has diarrhea x 3days What are you concerned about? What do you want to do? © Dehydration © Administer medication for nausea ¢ Electrolyte imbalance © Normalize Electrolytes © Decrease in blood pressure e Expand her intravascular volume ° Maintain normal fluid homeostasis (maintenance) ° Replace lost fluid (resuscitation) * Account for ongoing losses if present (replacement)Moderate Severe dehydration |dehydration | dehydration (<5%) (5%-10%) —_| (> 10%) Normal Slight Rapid, weak increase Normal Normal/ Hypotension orthostatic Slightly dry | Very dry Parched Decreased | Olguria Anuria < 500mI/day |< 50ml/day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 e Adults are able to compensate better than children ° Calculation e Fluid Deficits(L) = weight (kg) x % dehydration e Example: Our 50 kg patient with 5% dehydration: © 50kg x 5%= 2.5L deficitEstimate Deficit by Weight Example: Suppose our gastroenteritis patient reports a 5b weight loss with illness Fluid and Weight Lof fluid = 1 kg of Se Calculate his fluid deficit weight ° ikg= 2.2 Ibs 5lb = 2.3kg = Use weight change to = 2.3L fluid deficit determine fluid loss/gain- Fluid Deficits e 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 ¢ u5omL/16hrs =72mL/hr for the next 16hrsTotal Flow Rate for Maintenance eAdd maintenance to deficit and you'll have a flow rate *Our 50kg patient with gastroenteritis has had a 5!b (2.3kg) weight loss Maintenance © 4mL/kg x 10kg = 4omL (0-10) plus © amL/kg x 10kg = 2omL (10-20) plus © 1cc/kg x 30kg = 3omL (20-50) TOTAL maintenance= gomL/hr Deficit © 4150mL/8hrs=143mL/hr for the first 8 hrs © u50mL/16hrs=72mL/hr for the next 16hrs- Total Flow Rate ¢ For the first 8 hrs © gomL/hr + 143mL/hr = 233mL/hr e For the next 16 hours © gomL/hr + 72mL/hr = 162mL/hr- Try it! ° A176lb 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- Answer Maintenance 176lb = 80kg © 4omL (0-10) plus © 20mL (10-20) plus © 6omL (20-80) Total= 120mL/hr Deficit 184 - 176= 8lb = 3.6kg =3.6L = 3,60omL loss © 1,800mL/ 8 = 225ml/hr + 225 +120= + 345 mL/hr for the 1° 8 hrs © 1,800/16 = 12.5mL/hr + 112.5 +120 = + 232.5 mL/hr for the next 16 hrs