Mini Lecture: IV Fluids

William Graham, PGY2

January 2014
Department of Medicine
UC Irvine Medical Center
Objectives

Understand daily fluid and electrolyte

requirements for an average adult

Understand the major components of

replacement fluid

Maintenance vs. Resuscitation

Complications of fluid therapy

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Water Input and Output of the Normal Adult
Minimal Obligatory Daily Water input:
Ingested water: 500mL
Water content in food: 800mL
Water from oxidation : 300mL

TOTAL: 1600mL
Minimal Obligatory Daily water output:
Urine: 500mL
Skin: 500mL
Respiratory tract: 400mL
Stool: 200mL

TOTAL: 1600mL
Average adult input/output is 30-35mL/kg/day
(2.4L/day)
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Contents of IV Fluid Preparations
Na K Cl HCO3 Dextros mOsm/L
(mEq/L (mEq/L) (mEq/L) (mEq/L) e
) (gm/L)

D5W 50 278
NS 77 77 143
D51/2NS 77 77 50 350
NS 154 154 286
D5NS 154 154 50 564
Ringers 130 4 109 28 50 272
Lactate
(RL)

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Daily Electrolyte Requirements

- Sodium: 100-250meq (western diet)

mostly excreted in urine

- Potassium: 50-100meq
mostly excreted in urine, 5% in feces

- Chloride: 60-150meq
Example: 1/2NS @ 100cc/hr provides ~180mEq of sodium
and chloride/day!
- this is why NS should not be used for maintenance fluid
in patients with normal renal function- risk of
hyperchloremic metabolic acidosis

- Bicarb: 1 meq/kg/day

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Case Vignette

58 y/o male with h/o HTN, dyslipidemia, admitted for

cough and atypical chest pain. Found to have
abnormal CXR and CT Thorax concerning for
malignancy . Kept NPO overnight for possible
bronchoscopy with biopsy in the morning. He is
placed on NS @ 75cc/hr.

1. Was the right solution picked?

2. Is the rate correct?

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Maintenance Therapy

Purpose: Replace ongoing losses of water and

electrolytes under normal physiological conditions

- Used when the patient is not expected to eat or

drink normally for prolonged period of time

- In general, patients who are afebrile, not eating, not

physically active require less that 1 L of free water
daily

- Patients with ESRD or edematous states (ex.

cirrhosis, heart failure) require less maintenance due
to decreased output and/or altered fluid distribution

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Maintenance Therapy
3 approaches to determine the appropriate rate:
1) Calculate maintenance based on average requirement
of 35cc/kg/day

2) 4/2/1 rule
4 ml/kg/hr for the first 10 kg (0-10kg)
2 ml/kg/hr for the next 10kg (11-20kg)
1 ml/kg/hr for remaining weight (21 kg and up)

3) Weight in kg + 40

Vignette: Pt weight 85kg.

85kg x 35cc/kg/24hr= 3L/24 hr= 125cc/hr
40 + 20 + 65 = 125cc/hr
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85 + 40 = 125cc/hr
Maintenance Therapy
What type of fluid for maintenance?
- D51/2NS + 20 mEq KCl provides:
a) ~180 mEq/day sodium and chloride (100-250 sodium and 60-
150 chloride needed/day)
b) ~50 mEq/day potassium (50-100 mEq needed/day)
- avoid dextrose in patients with uncontrolled DM or hypokalemia
- not much data to support addition of D5, however can be added
to prevent muscle catabolism

- Therefore, 1/2NS or D51/2NS + 20 mEq KCL would be

appropriate choices.

- adjust maintenance fluids based on serum sodium

concentration (ex. Change from 1/2NS to NS or D5NS if
hyponatremia develops)

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Clinical Vignette

86y/o female admitted with nausea and

vomiting and c/o rectal bleeding. She has a
history of recent admission for CHF exacerbation.
Weight is 45kg. SBP 80s in the ED. She is started
on IV pantoprazole.
1. What is your initial choice of fluids?

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Fluid Resuscitation

Purpose: Correct existing abnormalities in volume

status or serum electrolytes

Objective parameters used to assess volume deficit:

Blood pressure
Jugular venous pressure
Urine sodium concentration
Urine output
Pre and post deficit body weight

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Rate of Repletion

Severe volume depletion or hypovolemic shock?

-> Rapid infusion of 1-2L isotonic saline (NS), then reassess
parameters
- use Lactated Ringers if concern for re-expansion acidosis
(ex. acute pancreatitis)

Mild to moderate hypovolemia?

1) Estimate fluid losses:
Recall: Average output 2.4L/day for 70kg patient
estimate additional losses such as GI (diarrhea, vomiting) and high
fever
-> add 100ml/day for each degree of temp > 37C

2) Choose rate 50-100mL/h greater than estimated losses

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3) Select fluid based on type of fluid that has been lost and any
co-existing electrolyte disorders
Clinical Vignette
86y/o female admitted with nausea and vomiting and
c/o rectal bleeding. She has a history of recent
admission for CHF exacerbation. Weight is 45kg. SBP
80s in the ED. She is started on IV pantoprazole.
1. What is your initial choice of fluids?

2. She is kept NPO for EGD and colonoscopy

the next morning. After receiving 2u PRBC and
normal saline you decide to start maintenance
fluids. What rate and type of fluid do you choose?

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Complications of IVF

The team decides to put her on D51/2NS @ 125cc/hr.

Her repeat serum sodium level is 130 the next
morning and she is complaining of some SOB. She is
thought to have an infiltrate on CXR and started on
IV Zosyn and Vancomycin for hospital acquired
pneumonia.
3. What could be contributing to the
hyponatremia?

4. What is likely contributing to the SOB?

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Where is my bolus going?
1L D5W distributed into Total Body
Water

Free water ICF ECF Interstitial Intravascular Interstiti Intra-

content al vascula
r
D5W 1000cc 660cc 340cc 226cc 114cc (11%)
NS 500cc 500cc 500 330cc 170cc + 55cc 226cc
+ 55cc from =225cc (22%) 114cc
free water !!
content
NS 0 0 1000cc 660cc 330cc (33%)

Normal saline has no free water and is confined to

ECF space; this is why it is the preferred IVF for
resuscitation!

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Summary
Treat IV fluids as a prescription just like any other
medication, with consideration of renal function
and clinical picture
Determine if patient needs maintenance or
resuscitation
Choose fluid type based on co-existing electrolyte
disturbances
Dont forget about additional IV medications
patient is receiving
Choose rate of fluid administration based on
weight and minimal daily requirements
Avoid fluids in patients with ECF volume excess
Assess DAILY whether the patient continues to
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