IV fluids Workshop 101104 Bruce R Wall M
IV fluids Workshop 10/11/04 Bruce R. Wall, M. D.
IV fluid orders § § § Does the patient need IV fluids? Volume status Water status Potassium balance Acid base balance
What are our choices? § For intravascular volume depletion: normal saline 0. 9 gm% PRBC’s albumin/plasma proteins § For Hypernatremia: D 5 W or D 10 W § D 5 ½ normal saline… primary maintenance fluid…
Volume status § History: Congestive heart failure Total body weight Diuretic use Fluid loss via NG or third spacing § Physical: Vital signs Orthostatic change in BP Pulmonary edema S 3 gallop Peripheral edema Ascites
Therapy for volume issues § Hypovolemia: normal saline (Ringers) blood product tranfusions albumin § Hypervolemia: diuretics natrecor® dialysis – HD vs CVVHD after load reduction oxygen and morphine sulfate phlebotomy
Water balance § Hypernatremia § Hyponatremia: hypovolemic euvolemic hypervolemic shock thyroid CHF burns SIADH liver disease pancreatitis adrenal nephrosis
Water status: therapy § § Restrict fluids (unless volume depleted) Assess patient’s volume status Diuretics with salt and fluid restriction Avoid hypotonic TPN
Potassium balance § § § § Intake – output = accumulation Oral potassium supplementation IV potassium Estimation of deficit Role of underlying acidosis or alkalosis Renal insufficiency Magnesium deficiency
Acid base disorders § § § Respiratory vs metabolic disorders Mixed acid base Role of sodium bicarbonate therapy
ARF § 73 yo male S/P AAA 10 yrs ago § Admitted with aorto-enteric fistula, Hgb 5, hypotensive, normal renal function § Surgery to ligate aorta, below renal arteries; post op renal function preserved § Orders? § Surgery II: Axillary artery to femoral bypass CPK 120, 000 Na+ 128 BUN 50 creat 2 orders?
ARF continued § 3 weeks post surgery: oligoanuric with gastric output 1. 5 to 2 liters per day Hemodialysis continues, although marked hypotension, and mild diarrhea from feedings § OBS Eventually gastric jejunostomy stent placed § IV fluid orders?
CHF § § § 70 yo diabetic male smoker CRI creat 2 No anion gap K+ 6 meq/l (recent vioxx) Severe CP – acute inferior MI (RV infarct? ) BP 80/50 AV block; en route to cath lab Rales loud S 3 gallop mild LE edema Orders?
CHF continued § § § § S/P CPR temporary pacemaker ACLS Received 2 amps Na. HCO 3 during code Intubated dopamine and dobutamine Na+ 150 BUN 80 creat 3 HCO 3 12 UOP 200 ml/day, despite BUMEX infusion CHF on exam and xray Orders?
Hyponatremia § § § 65 yo WF smoker small cell carcinoma ‘mild confusion’ – chronic dementia dyspnea with exertion - COPD out patient Na+ 122 m. Eq/l K+6. 1 No acidosis GFR normal
Hyponatremia: continued § PE: normal vitals (no tilt) § comfortable at rest dullness L chest extremities - no edema § Random Urine Na+ 40 m. Eq/L § U osm 600 § 1) Differential Dx? § 2) IV fluid orders?
SIADH § § § Receives 125 ml/hr normal saline Na+ next morning is 118 meq/l Confusion is worse… § Urine osmolality of 600 can excrete the sodium chloride in one liter of NS in 500 ml § Therefore: kidney is able to remove the Na. Cl and RETAIN 500 ml of free water
DKA § § § 45 yo WF IDDM X 20 yrs Non-functional glucometer… N&V for 18 hrs… indigestion/pain for 2 hrs No dyspnea No blood in emesis or stool ‘too sick to take insulin’ PMH: DM HBP Lipids CRI smoker retinopathy neuropathy § Family Hx: early CAD
DKA: continued § PE: 130/60 tilting to 95/50 P 110 R 24 afebrile Neck: veins impossible to assess Lungs: few rhonchi, WOB increased Cor: I/VI m, soft S 3? ? , increased HR Abd: benign, non-distended Ext: 1+edema § Lab: WBC 12 K Hct 35% 2+proteinuria 510 WBC/HPF on urinalysis § EKG: 2 mm ST elevation III and AVF
DKA: continued § § § § Na+ 131 K+ 3. 2 Cl- 104 HCO 3 5 m. Eq/l BUN 70 Creat 2. 0 anion gap 22 m. Eq p. H 7. 18 p. CO 2 17 p. O 2 80 (1. 5)(HCO 3) + 8 [+/- 2 m. Eq] = p. CO 2 Dx? Volume status? Na+? K+? acid/base issues? IV fluids?
Rhabdo § § § 24 yo SWAT team member of GPD August 98 “ 106 degrees in the shade” full gear running drill - collapse in field BP 100/60 P 130 T 102. 8 rectal Skin warm Neck veins: nl Lungs: clear Cor: increased HR MS: tender back/gluteal region, no edema
Rhabdo § § § § Urine looks red… scant volume… heme + U Na+ <10 Fe. Na+ low Na+ 149 K+ 5. 9 Anion gap 22 Bun 10 Creat 2. 4 Ca++ 6. 5 Phos 8. 5 CPK 50, 000 “As you rapidly cool down the patient: ” Diagnosis? Volume status? Cause of hypernatremia? Hyperkalemia? IVF orders?
Ascites § § § 65 yo retired politician known cirrhosis ETOH exposure Hx GIB/varices Meds: Betablocker aldactone furosemide no NSAID’s § Decreased intake for several days; increasing abd pain - severe, diffuse, no radiation; min emesis no obvious blood in stool
Ascites: continued § PE: barely awake confabulates follows? § tremulous T 101. 8 BP 90/60 red palms spider angiomata muscle wasting massive ascites very tender abdomen guaiac positive stool edema 2+ ankles § Lab: WBC 20 K Hct 34% Bili 4 albumin 2. 4 PT 24 sec AG 12 Na+128 K+ 5. 0 Fe. Na<1 ascites=2000 WBC (GPC) BUN 80 Creat 3
Ascites: continued § § § Differential diagnosis? Volume status? Acid base status? IV fluids? (TPN? ) Effect of administration of vassopressin?
Final thought § Good judgment comes from experience; unfortunately, experience often comes from bad judgment…
- Slides: 25