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IV fluids and you

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IV fluids and you

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    1. IV fluids and you Michael J Ryan, MD nephrologist.

    2. Goals Review body fluid compartments. Review effects of addition of salt, water to the body Cases

    7. What happens if you infuse isotonic saline into a normal person?

    9. You drink 3 L of water as part of a bet… Q: What if you add water to a person?

    13. Case You decide to go to Mexico prior to starting your internship. …You get diarrhea. Lots of it… Q: what does ECV depletion look like?

    16. What if it is an osmotic diarrhea, and you don’t keep up with water losses?

    18. How do we measure the ICV of the patient?

    19. Trick Question! We don’t measure the ICV in patients We do take note of changes in the size of the ICV ICV is determined by osmolality Osmolality in the cell = osmolality outside the cell Na+ is the major determinant of the extracellular osmolality Serum [Na+] indicates changes in ICV

    23. How do you measure the ECV? History

    24. History

    25. How do you measure ECV? PE. Weights Posturals Neck veins Dry axilla

    26. Clinical Guidelines for Estimating ECV Loss

    27. What about FeNa+?

    28. How best to correct ECV depletion Hetastarch? May improve physiology in inflammation Alslo may adversely affect clotting Max recommended dose: 20ml/kg/d

    29. Albumin Expensive Risk of infection Recent meta-analysis: Albumin no better than crystalloid How best to correct ECV depletion

    30. What about giving half normal saline? Half-isotonic saline causes both hypo-osmolality and volume expansion. Like giving 500 saline, and 500 CC D5W

    31. Who cares?

    33. Hypernatremia - Ungood Common Iatrogenic Mortality increase by 2-7 fold

    34. Fluid Management General Steps: Good History: Hx of Loss of Salt Water, Weight Loss/Gain (Quantify) etc. Review Medications: Diuretic, Lithium etc. Good Physical Exam: weights, BP, HR, Orthostatic Changes, Neck Veins, Chest Exam, Heart Exam, Presence of Fluid Review the Lab Values Carefully

    35. Case 31 year old admitted to the hospital CC: inability to pass a kidney stone. Cysto planned for the AM. PE: normal BP. No edema nl. urine output [Na+] = 140 NPO after MN. Q: what IVF do you prescribe?

    36. Usual reasons for IV fluids Defend the normal BP Return the ICF to normal Replace ongoing renal losses Give maintenance fluids to match insensible losses Glucose as a fuel for the brain

    37. Fluid Management Specific Steps Assess The Status: Water ECV Acid Base Potassium Plan Therapy: Basic Allowance Correction Write Orders

    38. 1. Assess the status ECV OK? ICV OK Acid base OK? K+ OK?

    39. Fluid Management Specific Steps Assess The Status: Water ECV Acid Base Potassium Plan Therapy: Basic Allowance Correction Write Orders

    40. 2. Basic allowance Heat is produced continuously Dissipated by evaporation (sweat) H2O lost via lungs

    41. Maintenance Fluid Allowance for Normal ECV State/NPO

    42. Plan Therapy Correction: Correction is to be Slow Often Correcting Underlying Problem would Correct Other Abnormality For Example, Correcting NaCl & KCl & Volume Depletion in Metabolic Alkalosis would also Correct Metabolic Alkalosis.

    43. Fluid Management Specific Steps Assess The Status: Water ECV Acid Base Potassium Plan Therapy: Basic Allowance Correction Write Orders

    44. Basic Allowance & Correction Basic Allowance: Vol. Na+ K+ Cl- Urine 1500 50 40 90 S&I 1000 G.I. 0 2. Corrections a. Water 0 0 0 0 b. ECV c. A/B Potassium

    46. That’s it!!! Caveats: It is important to check the [Na+] frequently

    47. Case A Patient Admitted from Nursing Home in a Confused State. He has been somnolent for 3 days. His BP is normal. There is No Edema, Lungs are Clear, Heart Normal. In Last 24 Hrs. He has made 1 liter of Urine His blood test shows: Na 155 mEq/l (Normal 135 – 145) Blood Glucose Normal (80 mg/dl) K Normal (4.0), HCO3 Normal (28), Cl (117) Anion Gap Normal (155 – (117 + 28) = 10

    48. Fluid Management Specific Steps Assess The Status: Water ECV Acid Base Potassium Plan Therapy: Basic Allowance Correction Write Orders

    50. Case 24 year old woman develops UTI. She treats it with cranberry juice. Then develops fever chills flank pain. Her friends told her to drink lots of water. PE: 100/60 HR 110. No postural changes. [Na+] = 130

    51. Fluid Management Specific Steps Assess The Status: Water ECV Acid Base Potassium Plan Therapy: Basic Allowance Correction Write Orders

    53. Who shouldn’t get hypotonic fluid? Patients with [Na+] <138 Patients at risk for hyponatremia High ADH levels CHF Cirrhosis SIADH

    54. Case 55 year old with post op paralytic ilius. 24 hour Intake and output: NG: 2000ml Urine output 400ml [Na+] 140 HCO3- 24. Q: what fluids?

    55. Concentration of stuff in NG output Vol (ml) Na+ mEq K+ mEq Cl- mEq 1000 100 10 110

    56. Basic Allowance & Correction Basic Allowance: Vol. Na+ K+ Cl- Urine 1500 50 40 90 S&I 1000 G.I. 2000 200 20 220 2. Corrections a. Water b. ECV c. A/B Potassium

    57. 0.45 NS with 10meq KCl/l @ 185cc/hr

    59. References Pediatrics: Roberts KB: Fluid and electrolytes: parental fluid therapy Pediatrics in Review vol 22 11 2001 Adults: Meinke: fluid Management in Hospitalized patients Comprehensive Therapy, vol. 31, no. 3, Fall 2005

    60. Summary Systematic Watch serum [Na+] Frequent assessment

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