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IV Fluids

Intern Boot Camp 2008 Michelle Kahlenberg, MD PhD

Saline
Normal: 154 mEq/L of Na+ and Cl Half-normal saline (0.45% NaCl) contains 77 mEq/L of Na and Cl NS contains 39 mEq/L of Na and Cl and always contains 5% dextrose for osmolality reasons

D5W

50 gm/L of dextrose in water: isotonic but doesnt provide sodium

Lactated Ringers
130 mEq of sodium ion = 130 mmol/L. 109 mEq of chloride ion = 109 mmol/L. 28 mEq of lactate = 28 mmol/L. 4 mEq of potassium ion = 4 mmol/L. 3 mEq of calcium ion = 1.5 mmol/L .

Case #1
45 yo woman with hx of HTN admitted with gallstone pancreatitis and is unable to take PO. She has no evidence of infection and is hemodynamically stable. What IVF do we give?

Case #1

For maintence fluids adhere to the 4/2/1 rule for water balance. Require 1-2 mmol/kg of Na+ per day Require 0.5-1 mmol/kg of K+ per day

So for a usual sized, euvolemic person a rate of approx 125 ml per hour of NS with 20 mEq of KCl per bag per day will give approx 100 meq of Na+ and 60 meq of K+ per day. (adjustments should be made for those with CHF, renal failure, or on K+ sparing medications.

Case#2
65 yo man with history of DLD, tobacco use, obesity, diabetes admitted with chest pain with small troponin elevation and progressive T wave changes on ECG. He is started on heparin drip, BB, statin, ASA and is kept NPO for possible cath in the AM. What about his IVF?

Case #2 Continued
Gentle hydration with normal saline prior to contrasted procedures can help prevent contrast induced nephropathy Usually 75 ml per hour of normal saline (roughly 1 ml/kg/hr) 12 hours before and 12 hours after the procedure +/mucomyst is helpful Could add D5 if he has DM meds on board

Case #3
You are called on cross cover to see an 86 yo NH resident with EF 35% admitted for UTI and mental status changes. She has a blood pressure of 86/45, HR 120 (sinus tachycardia) and is not responsive. What next?

Case #3 continued

Sepsis protocols recommend IVF bolus until CVP reaches 10-12. Obviously on the floor we dont have CVPs but you shouldnt be shy about giving IVF bolus (at least 2-3 L before you call the MICU) even if patient has HF. If theyre septic, they need fluids!

Case #4
67 yo man with parkinsons with dysphagia requiring PEG tube getting tube feeds on the floor. You are called that patient is becoming more somnolent. 37.0 78 140/89 12 98% RA What next?

Case #4 continued
Further chart review suggests that free water flushes have been left out of tube feed regimen. Serum sodium comes back at 161.

Now what?

Case #4 continued

Calculate the free water deficit 0.6*wt*(pNa+-nl Na+)/Nl Na+

If he weights 70 kg, his deficit is 6.3 L Want to correct deficit 10 mEq per 24 hours so need 6.3 L over 48 hours or roughly 3L/day (D5W at 125 per hour) Also need to account for insensible losses of approx 30 ml water per hour-so if NPO, need D5W at approx 150 per hour.

Case #4.5

40 yo woman with no previous past medical hx presents with N/V/D x3 days with inability to keep anything down PO 37.6 105 110/75 98% RA (+ orthostatics)

Labs show 7.3>14/42<256 151/112/31 -------------<125 4.2/28/1.3 How do we treat her?

Case 4.5 continued..


Hypovolemic hypernatremia is the most common cause of hypernatremia This is corrected with volume repletion with normal saline until she no longer has evidence of volume depletion. Then, recheck Na+ and calculate free water deficit. (Usually, hydrating them will improve the majority of the hypernatremia).

Case #5
46 yo woman with hepatitis C and cirrhosis admitted with profuse hematemesis. 36.5 140 79/50 24 97% RA 7.9>6/24<67 131/100/47 -------------<135 3.3/24/1.4 What first?

Case #5 continued

She was given 5 L NS and 3 units PRBC. The bleeding continues intermittently. While awaiting the arrival of the GI team: 37.0 125 89/54 21 94% 1L NC

Repeat labs show 6.9>7.4/27<51 140/115/35 -------------<135 3.1/16/1.2


What do we do now?

Case #5 Continued

LR!

130 mEq of sodium ion = 130 mmol/L. 109 mEq of chloride ion = 109 mmol/L. 28 mEq of lactate = 28 mmol/L. 4 mEq of potassium ion = 4 mmol/L. 3 mEq of calcium ion = 1.5 mmol/L .

Case #6

45 yo woman with progressive, metastatic T cell lymphoma admitted with lethargy and nausea. Serum sodium is 111

Case #6 continued
Hypertonic saline is given ONLY IN ICU and is reserved for severely symptomatic patients (seizures, impending herniation) as severe symptoms are likely due to brain swelling from initial drop in sodium. Correct 1.5-2 meq per hour for the first few hours until no longer symptomatic, no more than 10 meq in 24 hours.

Case #6 continued

For her, mildly symptomatic, so correct 10 meq over 24 hours or until no longer symptomatic then free water restrict. Increase in PNa = (Infusate [Na] - PNa) (TBW + 1) TBW = (lean body weight times 0.5 for women, 0.6 for men). (154-111)/26=1.65 mEq increase per L of NS given, so she would need about 5L of NS over 24 hours.

Case #6 continued
For asymptomatic hyponatremia, free water restriction or vasopressin receptor antagonists are the treatment of choice, There is evidence that improving serum sodium even if they are asymptomatic can reduce falls in the elderly and improve subtle neurological deficits

Thank you.

Questions?

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