fluid therapy

0.9% NaCl

Normal Saline Solution; crystalloid isotonic IV fluid with Na 154 mEq/L, Cl 154 mEq/L, osmolality 308 mOsm/L, no calories

D5W

Dextrose 5% in Water; initially isotonic (252 mOsm/L), becomes hypotonic after dextrose metabolism; expands ECF and ICF; provides <200 kcal and 50g glucose per liter

D5LRS

Lactated Ringer's 5% Dextrose in Water; contains Na 130, K 4, Ca 3, Cl 109 mEq/L; has HCO3 precursors; no calories or Mg; metabolized in liver

0.45% NaCl

Half-strength normal saline; hypotonic IV solution; osmolality 154 mOsm/L; Na and Cl 77 mEq/L each

D2.5W

2.5% Dextrose in Water; hypotonic IV solution used for dehydration and low Na & K; do not administer with blood products

3% NaCl

Hypertonic saline; causes cell shrinkage; draws water from ICF to ECF

0.45% NaCl effect on cells

HypO = Oval-Oedema of cells; causes cell swelling

5% Albumin

Colloid derived from plasma; used to increase circulating volume and restore protein levels in burns, pancreatitis, trauma

20% Albumin

Colloid used with sodium and water restriction to reduce excessive edema

Dextran 40

Low-molecular-weight dextran; average molecular weight 40,000 Dalton

Dextran 70

High-molecular-weight dextran; average molecular weight 70,000 Dalton

Dextran 75

High-molecular-weight dextran; average molecular weight 75,000 Dalton

Severe sepsis fluid dose

30 ml/kg actual body weight; start within 1 hour, finish within 3 hours

Severe sepsis resuscitation targets

CV Oxy-Hb ≥70%, CVP 8-12 mmHg, MAP ≥65 mmHg, UOP ≥0.5 ml/kg/hr

Acute pancreatitis standard fluid rate

5-10 ml/kg/hr isotonic crystalloid (NS or RL)

Acute pancreatitis severe depletion bolus

20 ml/kg IV over 30 min, then 3 ml/kg for 8-12 hours

Lactic acidosis bicarbonate dose

1-2 mEq/kg IV NaHCO3 bolus if pH <7.1 or S.HCO3 ≤6

Lactic acidosis refractory mixture

3 amp of 8.4% NaHCO3 in 1 L of 5% GW

ARDS target CVP

<

DKA hypovolemic shock fluid

0.9% NS 1 L/hr ASAP

DKA euvolemic fluid

NS at lower rate guided by clinical assessment

DKA switch to dextrose

When S.glucose reaches 200-250 mg/dl, change to 5% Dextrose + 0.45% NaCl

HHS switch to dextrose

When S.glucose reaches 250-300 mg/dl, change to 5% Dextrose + 0.45% NaCl

Cirrhosis ascites sodium restriction

2 gm/day

Cirrhosis severe hyponatremia management

Fluid restriction to make intake less than UOP; ice chips or lollipops for thirst

ADHF sodium restriction

<

ADHF refractory fluid restriction

1.5-2 L/day

ADHF severe hyponatremia restriction

<

Chronic stable HF sodium restriction

<

Chronic stable HF stage D fluid restriction

1.5-2 L/day in class 4 or severe hyponatremia <120 meq/L

Prerenal azotemia fluid challenge

250-500 ml over 10-20 min (or 100 ml in 1 min mini-challenge)

Prerenal azotemia hypovolemic bolus

1-3 liters buffered crystalloid (RL or Ringer acetate)

Prerenal azotemia maintenance rate

≥75 ml/hr depending on ongoing loss

Prerenal azotemia no improvement action

Think intrinsic renal disease; stop continued volume expansion

Rhabdomyolysis initial resuscitation

1-2 L NS/hr

Rhabdomyolysis CK goal

<

Hemolysis initial rate

100-200 ml/hr NS

Hemolysis UOP target

200-300 ml/hr once diuresis established

TLS hydration protocol

2-3 L/M2/day isotonic saline; 2 days pre and 2-3 days post-chemotherapy

TLS UOP target

80-100 ml/M2/hr

TLS urine alkalinization rate

150-300 cc/hr of 0.45% NaHCO3 in NS + 5% GS; maintain urine pH 7.0-7.3

TLS hypocalcemia dose

1 gm calcium gluconate if ECG changes

TLS hyperuricemia drug

Rasburicase

Stable CKD maintenance formula

UOP + insensible loss

Stable CKD blood loss ratio

Crystalloid replacement at 1.5:1 ratio

Stable CKD acute on chronic limit

1-1.5 L per day with loop diuretics

Dialysis patient daily fluid limit

Not >900 cc per day

Myeloma cast nephropathy goal UOP

~3 L/day

Myeloma cast nephropathy initial fluid

0.45% NS at 150 ml/hr

Myeloma cast nephropathy urine pH goal

7.0 using isotonic NaHCO3 if acidic urine

Spontaneous ICH maintenance fluid

Isotonic fluids (NS); hypotonic fluids contraindicated; goal S.Na >135 mEq/L

Spontaneous ICH raised ICP treatment

23.4% saline intermittent bolus 15-30 ml every 6 hours via central line

Spontaneous ICH mild symptoms treatment

3% saline via peripheral line

Spontaneous ICH sodium goal

145-155 mEq/L

Orthostatic intolerance 30-20-10 Rule

HR increase 30 bpm sitting to standing OR SBP drop >20 mmHg OR DBP drop >10 mmHg = 6-8% fluid deficit

Normal serum osmolarity

275 – 295 mOsm/kg

Colloid summary

Double expander of intravascular volume (by protein, by fluid)

Crystalloid vs colloid molecule size

Crystalloids contain small molecules; colloids contain large molecules that do not pass semipermeable membranes

D5W summary

Dual side expansion (ECF, ICF)

Heart failure fluid restriction rationale

IV NS + loop diuretics in first 2 days worsens outcome in ADHF

Tumor lysis syndrome dialysis indications

Failure of medical therapy, severe oliguria/anuria, severe hyperkalemia, hyperphosphatemia, refractory volume overload

Prerenal azotemia colloid contraindication

Do not use colloids for hypovolemia in AKI

Myeloma cast nephropathy diuretic caution

Loop diuretics can cause cast formation; use only in hypervolemia

ACE inhibitor and albumin interaction

Withhold ACE inhibitors 24 hours before albumin due to risk of hypotension and flushing

Albumin contraindications

Severe anemia, heart failure, known sensitivity to albumin

Dextran precaution

Interferes with blood crossmatching; draw blood before administration if crossmatch anticipated

LRS caution

Do not give to patients who cannot metabolize lactate (liver disease, lactic acidosis); use caution in heart and renal failure

D5W caution

Do not use for fluid resuscitation; can cause hyperglycemia

0.45% NaCl caution

Excess use may cause hyponatremia, especially in patients prone to water retention

D2.5W caution

Do not administer with blood products; causes hemolysis of RBCs

0.9% NaCl caution

Avoid in heart failure, pulmonary edema, renal impairment, sodium retention conditions

Hypovolemia signs

Fatigue, thirsty, dizziness when standing, low urine, muscle cramps, dry mucosa, confusion, sweating, cool/clammy skin, tachycardia, tachypnea, loss of consciousness, shock

Orthostatic HR failure significance

Indicates autonomic dysfunction (e.g., DM) or anti-hypertensive drug effect

Fluid therapy resources

Harrison's principles of medicine, Uptodate.com