Fluid Therapeutics

How can our vasculature be accessed?

How can our vasculature be accessed?

peripheral intravenous (IV) line (16 gauge to 22 gauge), central IV line, “mid line”, PICC

What is a Y site?

the point in an IV administration setup where a secondary line can be connected to the primary IV line (allows for simultaneous delivery of two fluids or medications through a single IV access point)

what is extravasation?

when intravenous fluids or medications leak out of the vein into the surrounding tissue

what are balanced crystalloids?

they mimic electrolyte concentrations and are closer to neutral pH compared to normal saline (pH = 5.5)

compared to normal saline, some studies show that balanced crystalloids decreased __________________

risk of death, need for kidney replacement therapy, and persisted kidney dysfunction

Which electrolytes are in Lactated Ringers?

Sodium (130 mEq/L), Chloride (105 mEq/L), Lactate (28 mEq/L), Potassium (4 mEq/L), and Calcium (3 mEq/L)

What is the pH of lactated ringers?

6.5

What is lactate metabolized to?

acetate —> bicarbonate

what is the pH of Plasma-Lyte A

7.4

Which electrolytes are in Plasa-Lyte A?

Sodium (140 mEq/L), Chloride (98 mEq/L), Potassium (5 mEq/L), Magnesium (1.5 mEq/L), Acetate (27 mEq/L), and gluconate (23 mEq/L)

What is acetate metabolized to?

bicarbonate

what is the tonicity of D5W?

hypotonic

what is the tonicity of 0.45% NaCl?

Hypotonic

what is the tonicity of 0.9% NaCl?

isotonic

what is the tonicity of 3% NaCl?

hypertonic

what is the tonicity of lactated ringers?

Isotonic <3

what is the tonicity of 5% albumin?

Isotonic

T/F: fluids required for 24-hour period to maintain basic homeostatic functions

True

How to calculate maintenance fluid for an infant 3.5-10 kg?

100 mL/kg

4 mL/kg/hr for first 10 kg

How to calculate maintenance fluid for children weight 11-20 kg?

1000 mL + 50mL/per kg > 10 kg

2 mL/kg/hr for the next q0 kg

How to calculate maintenance fluid for children > 20 kg?

1500 mL + 20mL/kg per kg > 20 kg

Up to a max of 2400 mL

How to calculate maintenance fluid for an adult?

follow > 20 kg rule (1500 mL + 20mL/kg per kg > 20 kg) OR 30-35mL/kg

What is the typical rate of maintenance fluids for adults?

~100-125 mL/hr

What are common OTC fluids?

Gatorade, Powerade, Pedialyte, and Liquid IV

What is the tonicity of OTC fluids?

HYPOtonic

What happens if you give an IV isotonic fluid?

It will stay in the extracellular fluid space

What happens if you give an IV hypotonic fluid?

It will shift water into the intracellular space

What happens if you give an IV hypertonic fluid?

It will pull water out of the intracellular space

T/F: fluid losses should be replaced with the opposite type of fluid

falsee

What is intravascular volume directly linked to?

hemodynamics (BP, HR)

What does a patient need if they are experiencing hemodynamic instability (decreased BP or increased HR)?

bolus isotonic crystalloids or bolus iso-oncotic colloids until improvement in hemodynamics

Which IV fluid is free water?

Dextrose 5% in water (D5W)

What happens when D5W is adminstered?

Free water will shift into the intracellular space to maintain tonicity (cells swell and can burst)

What happens if you give a hypertonic fluid such as 3% NaCl?

rapid extracellular fluid expansion (water shifts from ICF to ECF) which balances tonicity

cells shrink

What does ECF expansion = ?

EDEMAAAAaaaa

What happens if you give a hypotonic fluid?

Free water will shift from ICF to ECF to maintain tonicity

how much is intravascular volume increased when 1000mL of D5W is given?

100 mL

how much is intravascular volume increased when 1000mL of normal saline is given?

250 mL

how much is intravascular volume increased when 1000mL of Lactated Ringers/PlasmaLyte is given?

250 mL

how much is intravascular volume increased when 1000mL of ½ normal saline is given?

175 mL

how much is intravascular volume increased when 1000mL of 5% albumin is given?

1000 mL

how much is intravascular volume increased when 1000mL of 3% saline is given?

832 mL (but pulled 2331 mL from ICF)

what is the tonicity of NS D5W?

isotonic (308)

what is the tonicity of NS D5W with 20 mEq KCl?

hypertonic (348)

what is the tonicity of ½ NS D5W?

hypotonic (154)

what is the tonicity of 1/2NS D5W with 20 mEq KCl?

hypotonic (194)

what is the tonicity of1/2 NS D5W with 40 mEq KCl?

hypotonic (234)

what is a complication of fluids especially with sodium containing solutions?

volume overload

How to monitor for volume overload?

objective calculation and assessment of volume status

What is a complication of using saline solutions?

hyperchloremic metabolic acidosis

what is a complication of using lactated ringers?

alkalosis

what is a complication of using D5W?

hyponatremia - especially in pediatric patients

what is a complication of using NS?

hypernatremia

Which patients should receive less than the maintenance fluid amount?

CKD, chronic liver disease, mild HF, severe HF, end-stage renal disease

Which patients should receive maintenance fluid amounts?

Patient is NPO for procedure, CKD with mild dehydration, ESRD with severe dehydration, and HF with moderate dehydration

Which patients should receive more than the maintenance fluid amount?

mild dehydration, moderate dehydration, severe dehydration, and large volume boluses for hemodynamic shock

Which IV fluids are the gold-standard for fluid resuscitation?

isotonic crystalloids (normal saline, lactated ringers, etc.)

T/F: 5% albumin offers no survival advantage compared to NS in resuscitation

True

When may albumin be beneficial?

hypoalbuminemia and/or sepsis

T/F: albumin is likely not harmful in patients with brain trauma

FALSEE

When would you add D5W to sodium based solutions?

for nutrition - poor PO intake

Which IV fluid should be avoided in diabetics due to risk of hyperglycemia?

D5W :(

What can occur if a patient receives too much fluids?

volume overload, increased pre-load (undue cardiac stress), edema (peripheral and pulmonary)

what can occur if a patient receives too little fluids?

lack of correction of dehydration and worsening of underlying process (e.g. AKI)

T/F: individualization is critical for giving IV fluids

True :)

what should be used in determining individualization of IV fluids

past medical history, current indication, and objective calculations

what fluids are recommended first-line in patients with sepsis?

IV crystalloids

why do you always need to check fluid compatibility when more than 1 fluid is administered intravenously?

may cause chemical or physical interactions such as: precipitation (particulate emboli), inactivation of compound (therapeutic failure), and tissue irritation due to pH changes or damage from toxic solutions

why are ceftriaxone and calcium incompatible?

cause precipitation

why are sodium bicarbonate and calcium incompatible?

precipitation

why are sodium bicarbonate and epinephrine incompatible?

inactivation of epinephrine

why are diazepam and sodium chloride incompatible?

causes precipitation

T/F: IV diazepam is incompatible with most fluids and drugs

TRUE :(

what are other common incompatable fluids?

pantoprazole, cefotaxime, and vancomycin