RENAL Last edited: 11/26/2024
13. IV FLUIDS
I. PHYSIOLOGY OF IV FLUIDS VII. APPROACH TO FLUID THERAPY
II. HYPOTONIC FLUIDS A. IDENTIFY THE VOLUME STATUS OF PATIENTS
III. ISOTONIC FLUIDS B. IDENTIFY THE HEMODYNAMICALLY UNSTABLE PATIENT
IV. HYPERTONIC FLUIDS C. INITIATE MAINTENANCE FLUIDS
V. COLLOIDS D. MONITOR FOR FLUID RELATED COMPLICATIONS
VI. ACCESS SITES FOR IV FLUIDS
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I. Physiology of IV Fluids
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II. Hypotonic Fluids
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III. Isotonic Fluids
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IV. Hypertonic Fluids
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V. Colloids
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VI. Access sites for IV Fluids
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VII. Approach to Fluid Therapy
A. Identify The Volume Status of Patients
1. Obtain a Thorough History and Physical Examination
Indications:
o Assess volume status for IV fluid administration
Abnormal Findings:
i) Hypovolemic ii) Hypervolemic
o History of fluid loss: o History of fluid retention:
Renal loss: Diuretics and cerebral salt wasting CHF, Cirrhosis, CKD, iatrogenic fluid resuscitation
Extrarenal Na+ loss: Vomiting and diarrhea o Physical Exam:
o Physical exam: Normal skin turgor, moist membranes
↓Skin turgor, dry membranes ↑JVP and ↑CVP
↓JVP and ↓CVP Oliguria (↑venous congestion)
Oliguria (↓perfusion) ↑BP
↓BP, ↑HR Pulmonary edema/effusions
Peripheral edema
Ascites
Weight gain
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B. Identify The Hemodynamically Unstable Patient
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1. Obtain Vitals
Indications:
o Determine the need for aggressive fluid resuscitation
Abnormal Findings:
i) Hypovolemia and HD Unstable
(↓BP and ↑HR)
o Administer Bolus ~ 500ml-1L of LR or NS over 15-30 min
o Administer 500ml of 5% Albumin over 15-30 min
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2. Perform a Fluid Challenge
Indications:
o Assess if fluid is responsive (they may need more fluids)
Abnormal Findings:
i) Fluid Responsiveness
o After 250-500mL of NS or LR given over 15-20 minutes or
perform a passive leg raise and the following may occur:
≥ 10-15%↑ in CO or SV
>12% change in Stroke volume variation
↑BP and ↓HR
↑Urine output
↓Lactate levels (if initially elevated)
ii) Not Fluid Responsive
o After 250-500mL of NS or LR given over 15-20 minutes or a
passive leg raise, the following may occur:
Findings of hypervolemia (edema/effusions, ↑CVP/JVP)
No further ↑ in CO or SV
< 12% change in stroke volume variation
No change in urine output
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C. Initiate Maintenance Fluids D. Monitor for Fluid Related Complications
1. Obtain Maintenance Rate and Free Water Deficit 1. Monitor Volume Status, Electrolytes, and HCO3- Levels
Indications: Indications:
o Stable HD’s, but ongoing fluid losses (e.g. vomiting, diarrhea, o During fluid resuscitation and maintenance, fluid therapy
polyuria, burns, etc.) Findings:
Findings:
i) Hypervolemia
i) Maintenance Rate o ↑JVP and ↑CVP, ↑BP, Pulmonary edema/effusions,
o Pediatric patients use the holiday segar formula only (4-2-1) Peripheral edema, Ascites, Weight gain
Rate = 4ml/kg for first 10 kg + 2mlkg for next 10kg + 1ml/kg o Stop fluid therapy and consider diuretics
for remaining weight
• Example of 25kg child: ii) Hyperkalemia
o 4ml/kg x 10kg (now left with 15kg after this)
o This can be due to normal saline
+
o Switch to Lactated ringers
o 2ml/kg x 10kg (now left with 5kg after this)
+
o 1ml/kg x 5kg iii) Metabolic Acidosis
= o This can be due to normal saline or 3% saline
40 + 20 + 5 = 65ml/hr o Switch to Lactated ringers or ½ Normal saline
o Adults use the Holiday segar formula or the cheat rule
(weight in kg + 40 rule)
• Example of 70 kg adult
o 70kg + 40 = 110ml/hr
o Type of maintenance fluid:
Hyponatremia: Normal saline
Normonatremia: Lactated ringers
Hypernatremia: ½ Normal saline
Addition to these fluids depends on K+, HCO3- and Glucose
levels:
• ↓K+ → Add KCL to the solution
• ↓HCO3- → Add HCO3- to solution
• ↓Glucose → Add D5 to solution
ii) Free Water Deficit Rate
for Hypernatremia
o FWD = TBW x [(Na-140/140)]
• Example of 70kg male adult with Na of 155:
o 70 kg x 0.6 (male) x [(155-140/140)] = 4.5L
o Type of fluid:
Preferred/Most common IV fluid: D5W
Less effective IV fluid: ½ Normal saline
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Physiology of IV Fluids Hypotonic Fluids
Crystalloids 1/2 Normal Saline
Hypotonic Fluid Isotonic Fluid Hypertonic Fluid Components Indications
1/2 Normal Saline, D5W Normal Saline or LR 3% Saline Hypernatremia (Hypovolemic)
Maintenance Fluid (Output > Input)
77mEq/L of Na+
77 mEq/L of Cl-
Water Solutes Water Solutes Water Solutes Water Na+ Na+
NET Movement from ICF or ECF
Solutes Solutes Complications
Solutes
Significance Significance Significance
Na+ Na+
ICF Volume ECF Volume ECF Volume
Administer Rapidly Hemolysis ICF Volume
Most Fluid Stays in ECF
1/2 NS
(Administer too much) Cell Swelling
Colloids Effect on Vascular Space Cerebral Edema
Albumin (5% or 25%)
1L NS or LR
D5 Water
Components Indications
Albumin Plasma by 250 ml
Plasma Hypernatremia
H2O H2O 1L 1/2 NS (Replace FWD)
Osmotic
Pressure Plasma by 167 ml 50g of Dextrose
Interstitial Fluid Water
Na+ Na+
Draws H2O into 1L D5W
Vascular Space Plasma by 83 ml
Significance
25% Albumin
ECF volume Complications
Plasma by 450 ml
Hyperglycemia
Na+ Glucose Na+ Glucose
(Administer too much D5W)
Cell Swelling
Cerebral Edema
Isotonic Fluids Hypertonic Fluids
Normal Saline 3% Saline
Components Components Indications
Indications
Severe/Symptomatic Na
Hypovolemia Cerebral Edema
(Fluid Resuscitation) 513 mEq/L of Na+
Renal 513 mEq/L of Cl-
154 mEq/L Na +
Losses Water Na+
154 mEq/L Cl-
H2O H2O
Water Replace Plasma Na+ Cl- H2O
Components Extrarenal
Losses
Cerebral Edema
Blood Loss Complications
Complications NAGMA/Hyperkalemia
Hypernatremia ODS
NAGMA/Hyperkalemia Hypernatremia Hypervolemia Cl- HCO3- pH ≥6-8 mEq/L in 24 hrs
Cl- HCO3- pH Aggressive IV Fluid Use Aggressive IV Fluid Use +/- CHF or CKD K+ K+
Na+ Na+
H+ H+ H2O
K+ K+
Na+ Na+/H2O BV
H+ H+
+ + Demyelination
Shifting of K+
Dysarthria
Pulmonary
Dysphagia Horizontal
Shifting of K+ Edema Pitting
Edema Eye
Quadriplegia Movements
Components Lactate Ringers Indications
Better in NAGMA Hypovolemia
130 mEq/L of Na+ Renal
Better in Hyperkalemia (Fluid Resuscitation)
109 mEq/L of Cl- Losses Colloids
4 mEq/L of K+
Components Albumin
2.7 mEq/L of Ca++ Indications
28 mEq/L of Lactate Na+ H2O
Hypovolemia
Extrarenal
Water Replace Lost Plasma Albumin Renal
Losses (Fluid Resuscitation)
25 g of Albumin Cirrhosis Losses
Burns 130-160 mEq/L of Na+ HRS, SBP, LVP
Water H2O
Blood Loss Expanding Plasma
Complications Preoperative
Hypervolemia GI
Aggressive Fluid Use Blood Loss Losses
Complications
Lactate Ca++ Hypervolemia Allergic Reaction
Risk of Clots Na+/H2O BV
Citrate BV Protein
Blood
Transfusion
Liver Disease
Pulmonary Pitting Pulmonary Pitting
Edema Edema Edema Edema
