Applied Sciences Lecture Course

IV fluid therapy
Dr Cathy Armstrong
SpR In Anaesthesia & Clinical Fellow in Undergraduate Medical Education
Manchester Royal Infirmary

April 2011

Objectives
Review relevant physiology IV fluid preparations Clinical Assessment of fluid balance IV fluid strategies Special circumstances Practice scenarios

Physiology

Body Fluid Compartments

Total Body water is:
60% of total body weight in males 55% of total body weight in females

Body Fluid Compartments

70Kg Man
Solids
(40%)

Interstitial fluid

Water
(60%)

ECF 14 Litres

11 Litres Plasma 3 Litres

42 Litres ICF 28 Litres

Body fluid compartments

Daily Input Vs Output

Input 2500ml Fluids 1400ml Food 750ml Metabolism 350ml Output 2500ml Water
Urine 1500ml Skin 500ml Lungs 400ml Faeces 100ml
Insensible losses 1000ml

Na 1-1.5mmol/kg/day K 0.8 - 1 mmol/kg/day

Electrolyte Composition of fluid Compartments

rd 3

space losses

1st Spacing: Normal distribution within ECF and ICF

2nd spacing: accumulation within the interstitial compartments: oedema formation but available for physiological exchange between compartments

3rd spacing: Accumulation in parts of the body where it s not available for exchange between the different compartments: Ascitis, tissue inflammation, oedema from burns/surgery

IV Fluid Types

IV fluid types
Crystalloids Colloids
Synthetic Human

Crystalloid
A substance in solution that can diffuse through a semipermeable membrane Electrolyte-containing solutions that are formulated to match to a greater or lesser extent the biochemical & osmotic features of the plasma They do not contain high molecular weight compounds

Crystalloids
Examples
0.9% Saline (Normal saline) Hartmann s (compound sodium lactate) Glucose containing solutions
5% Glucose 10% Glucose Dex-saline
4% glucose & 0.18% saline 5% glucose & 0.45% saline

Crystalloids composition
Solution
0.9% Sodium Chloride Hartmanns 5% Dextrose 10% Dextrose 4% glucose & 0.18% sodium chloride

Na
154 131

Cl
154 111

K
mmol/l

Ca

Bicarb

Glucose g/L

Tonicity

29
(as lactate)

50 100 40

Isotonic Isotonic Isotonic

(hypotonic once metabolised)

30

30

Hypertonic
(hypotonic once metabolised)

Isotonic

Colloids
Solutions that contain high molecular weight proteins as well as electrolytes Unable to diffuse through normal capillary membranes

Colloids
Examples
Gelatin-based
Gelofusine Haemaccel

Hydroxyethyl starches (HES)

Pentastarch
5% - Hemohes 10% - HAES-steril

Max 1.5l / 24hr Max 2.5l / 24hr 50ml/kg/24hr (3.5l) Use in trauma, (Max 1l)
250ml followed by isotonic fluids Severe allergic reactions, coagulation effects

Tetrastarch - 6% (HES)
Voluven Volulyte

Dextran 70
Rescuflow

Human albumin solutions

HAS 5% HAS 20%

Colloid composition
Solution Na Cl K
mmol/l Gelofusine Voluven 6% Volulyte 6%

mg

Bicarb

MW Daltons

154 154 137

120 154 110

1.5

34
(as acetate)

30,000 130,000 130,000

Distribution of IV fluids

Balanced vs unbalanced solutions

Large volumes of 0.9% saline based products have been shown to cause hyperchloraemic acidosis Balanced solutions e.g Hartmanns, volulyte are now becoming more popular

Basis of IV fluid therapy

Does my patient need IV fluid therapy? Why does my patient need IV fluid therapy?
Maintenance
To supply daily needs

Replacement
To replace on-going losses

Resuscitation
To correct an intravascular or extracellular deficit

Assessment of Fluid balance

Definitions
Dehydration
the loss of water and salts essential for normal body function.

Hypovolaemia
Decreased circulating plasma volume

Shock
Systemic hypoperfusion & tissue hypoxia

Types of shock
Hypovolaemic Cardiogenic Septic (distributive) Obstructive

Causes of dehydration / hypovolaemia

Increased loss
Pyrexia Vomiting Diarrhoea 3rd space loses peritonitis / ascites / sepsis Diuretics Metabolic derangements e.g diabetes mellitus Diabetes insipidus Blood loss

Reduced intake

Presentation of dehydration
Severity of Dehydration Mild
Up to 5% total body water
(3L in 70kg man)

Clinical Findings
Normal mental state Dry mucous membranes Usually thirsty Blood pressure & heart rate normal Lower than normal urine output Skin turgor almost normal Disinterest in surroundings, can be drowsy Increased heart rate & respiratory rate Orthostatic hypotension Decreased skin turgor Reduced urine output Reduced conscious level Fast heart rate Low blood pressure Respiratory distress Oliguria / anuria

Moderate
5-10% total body water
(5L in 70kg man)

Severe
10-15% total body water
(8L in 70kg man)

Patient observations
General ward
HR BP Temp RR Urine output (oliguria = <0.5ml/kg/hr (30ml/hr)

Critical care
IABP CVP CO monitoring

Electrolyte losses
Site
Stomach Small intestine Bile Pancreatic juice Recent ileostomy Established ileostomy Colostomy Sodium mmol/L Potassium mmol/L Chlorine mmol/L

60 110 150 140 130 50 50

10 5 5 5 10 3 8

85 100 100 80 115 20 40

Input/output monitoring

Fluid replacement strategies

Basis of IV fluid therapy

Does my patient need IV fluid therapy? Why does my patient need IV fluid therapy?
Maintenance
To supply daily needs

Replacement
To replace on-going losses

Resuscitation
To correct an intravascular or extracellular deficit

Maintenance
Output 2500ml Water
Urine 1500ml Skin 500ml Lungs 400ml Faeces 100ml
Daily Requirement for 70kg man Fluid 2-3L Sodium 70 105 mmol Potassium 56 70 mmol

Na 1-1.5mmol/kg/day K 0.8 - 1 mmol/kg/day

Maintenance regimens
Traditional approach
1 salt + 2 sweet Potassium replacement guided by plasma levels but if normal - replace with daily requirements (60mmol)

Exercise 1
Tom Jones - 70Kg man, NBM, No extra losses
Hospital number M10/5678 DOB 12/12/1962 Ward 12 Serum potassium 3.8mmol/l

Prescribe maintenance fluids for the next 24 hrs 1 x 1000mls 0.9% saline with 20mmol potassium chloride 2 x 1000mls 5 % dextrose with 20mmol potassium chloride

Exercise 1 - Answer

Replacement fluids
Maintenance plus replacement of on-going losses Consider the type of loss & it s likely electrolyte content

Electrolyte losses
Site
Stomach Small intestine Bile Pancreatic juice Recent ileostomy Established ileostomy Colostomy Sodium mmol/L Potassium mmol/L Chlorine mmol/L

60 110 150 140 130 50 50

10 5 5 5 10 3 8

85 100 100 80 115 20 40

Replacement example

Resuscitation
Treating deficit of intravascular or extracellular volume Caution
Renal impairment pump failure reduced LV function

Exercise 2
Tom Jones
Hospital number M10/5678 DOB 12/12/1962 Ward 12

Day 3 Post-op laparotomy & ileostomy minimal output from ileostomy HR 118 BP 85/60 RR 22 T 38.50C Urine output 10mls/hr

Currently has 1000mls 5%Glucose with 20mmol KCL running over 8hrs Prescribe appropriate fluids for the immediate period Fluid bags available in store cupboard: 1000mls 0.9% Saline 1000mls 5% Glucose 1000mls Hartmanns 1000mls 0.9% saline with 20mmol KCL 1000ml 5% dextrose with 20mmol KCL 500ml Gelofusine

Exercise 3 - example

Crystalloids vs colloids
Controversial Crystalloids require more volume
5L crystalloid replaces 1L intravascular loss

Colloids
Higher incidence of allergic reactions Compounds persist in the body

Solutions containing 0.9% saline risk of hyperchloraemic acidosis in large volumes

Resuscitation
Do not use dextrose containing solutions

Take care with potassium containing solutions

Guidelines

www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf Forthcoming NICE guidelines IV fluids in Hospitalised patients

Special circumstances - Paediatrics

Maintenance fluids (4,2,1 rule)
4ml/kg/hr for 1st 10kg 2ml/kg/hr for 2nd 10kg 1ml/kg/hr for remaining weight

E.g 24kg child

(4x10) + (2x10) + (1x4) = 64ml/hr

Dehydration (maintenance + estimated deficit)

%dehydration x wt x 10

E.g above child with 5% dehydration

5 x 24 x 10 = 1200ml to replace over 24hrs 1200/24 = 50mls/hr Therefore Maintenance + deficit = 64+50 = 104mls/hr

Special circumstances - Burns

Parklands formula
4ml/kg x % burned body surface area volume given over 1st 8 hours volume given over subsequent 16 hours
E.g 70kg man with 25% burns (4x70) x 25 = 7000ml (7000/2) / 8 = 438mls/hr (for 1st 8 hrs) (7000/2) / 16 = 218 mls/hr (for subsequent 16 hrs)

Exams
Popular OSCE station in Year 5 Involves choice of fluid & prescribing Often twinned with practical skill
I:e changing bag (remember to do appropriate checks incl exp date)
Calculating & setting drip rate
most giving sets 20 drops = 1ml

Calculating drip rate

Most giving sets 20 drops = 1ml
STEP 1 Volume (mls) Time (hrs) = mls/hr

STEP 2

mls/hr = 60 mls/mi n As 2060 = STEP 2 & STEP3 can be combined mls/hr x = drops/min

STEP 3

Mls/min x 20 = drops per min

Exercise - Calculating drip rate

1000mls over 8 hours
STEP 1 1000 (mls) 8 (hrs) = 125mls/hr

STEP 2

125mls/h r 60

2 mls/min

As 2060 = STEP 2 & STEP3 can be combined mls/hr x = drops/min

STEP 3

2 mls/min x 20 = 40 drops per min

Summary
Reviewed physiology Assessing fluid balance IV fluid types Fluid strategies
Maintenance Replacement Resuscitation

Future exam focus