fluidslecture.ppt

8/10/2019 Fluidslecture.ppt

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Indications for Intravenous Tx

Volume replacement

Biochemical correction

Retention of RBCs Provision of nutrition

Filtering of noxious products


3/26

Signs of Dehydration

Poor skin turgor

Tachycardia

Poor capillary refill (>3 sec)

Dry mucous membranes

Sunken eyes

Sunken fontanelles

No tears


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Rehydration Solutions

CrystalloidsDistribute across ECF

ColloidsRemain intravascular


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Crystalloids

Normal saline (NS)

Lactated Ringers (LR)

NormosolPlasma-Lyte


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NS vs.LR

154 meq Na, Cl

Often has 20 meq

KCl/L added

NEVER bolus fluid

with KCl added

pH 5.7; 308 mOsm/L $7 / L

130 meq Na

109 meq Cl

4 meq K

3 meq Ca

28 meq lactate

pH 6.4; 273 mOsm/L

$22 / L

Cant use with blood

Normal Saline Lactated Ringers

n.b. Plasma-Lyte and Normosol approximate plasma more closely.


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Colloids(Greek: glue)Dextrans (anaphylaxis, bleeding)

10% Dex-40

6% Dex-70

Starch

6% Heta- (T1/217 d, but oncotic 24 h)

10% Penta-

Albumin (expensive)

5%

25% (not for volume rescusc; ICF)


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Rehydration

BOLUS

1-2 L (NS or LR)

MAINTENANCE

75-125 cc/hr

REPLENISH

20 meq KCl/L

BOLUS

20 cc/kg (NS or LR)

MAINTENANCE (with ?-NS)

4 cc/kg/hr (1st10 kg)

2 cc/kg/hr (2nd10 kg)

1 cc/kg/hr (additional kg) REPLENISH

20 meq KCl/L

Adults Children

Na requirement: 3 meq/kg/d

K requirement: 2 meq/kg/d


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A good heart and kidneys cansurmount all but the most

willfully incompetent offluid regimens.

The Whole Internists Catalog


10/26

What about D5W?

Poor volume expander (50 cc intravascular/L)

Poor supply of calories (170 kcal/L)

Hypertonic (278 mOsm just from dextrose)

Increased CO2, lactate production

NOT recommended for ill patientsEXCEPT patients with DKA

on insulin drips


11/26

Electrolyte Replacement

MS changes, szs

Must determine type Hypovolemic

Euvolemic

Hypervolemic Pseudo?

(+1.6 meq/L for each

100 glc above 100

mg/dL)

Treatment varies (


12/26


Muscle weakness, cardiac

toxicity


13/26


Tetany

(Chvosteks sign--cheek) (Trousseaus sign--tourniquet)

Correction factor

(1.0 albumin : 0.8 Ca)

OsCal (CaCO3) po

1 amp 10% soln(1000 mg/10 cc)

CaCl2

Ca gluconate

Calcium8.8-10.5


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Muscle weakness Neutra-Phos or K-Phos po

Severe (


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N/V, tetany

2-6 gm bolus 1-2 gm/hr (for 2-4 hrs)

Acidosis renders heart

arrhythmias refractoryto tx

Some advocate

amps of HCO3

44 meq IV

Magnesium1.8-2.4 HCO321-32


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William Harvey 1578-1657

University of Cambridge; University of PaduaPersonal physician to Charles I

1628:Anatomical Exercises on the Motion

of the Heart and Blood in Animals

1651: Essays on the Generation of Mammals


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Blood Products

Whole blood

Packed RBCsFresh frozen plasma (FFP)

CryoprecipitatePlatelets


18/26

Blood is Blood, right?

Whole blood

Volume expander

35 d shelf life d

Washed RBCs

Pts with allergic

reactions to plasma

proteins

Packed RBCs

Saves volume (250 cc)

42 d shelf life

Leuko-poor RBCs

Pts with febrile, non-

hemolytic reactions to

plasma WBCs


19/26

The Compatibility Game

ABO compatibility Recipient can only

receive ABO proteins

he/she has previouslyseen

O can donate to any

recipient

O recipients can onlyreceive O blood

Rh compatibilityRh- recipient

should receive Rh-

bloodRh+ recipient can

receive Rh+ or Rh-

blood


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Blood Loss:

How much is too much?

5% body wt. in

intravascular space

10% blood loss =

hypovolemic shock

1 unit blood = 500cc(raises HCT 2-3%)

80 cc/kg in intravascular

space

20% blood loss =

hypovolemic shock

Transfuse 10 cc/kg

Adults Neonates


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To transfuse or not to transfuse

HCT


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Platelets

Danger zone:


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Clotting Factors

Fresh frozen plasma (FFP) All clotting factors; no

platelets

Can supplement RBCswhen whole blood not

available for exchange

transfusion

Cryoprecipitate Initially a tx for VW

Dz, Hemophilia

Now a source offibrinogen in

cardiothoracic surgery,

obstetric emergencies


24/26

Doctor, Doctor!

Weve lost our IV!

Subclavian*

Internal Jugular (IJ)*

Femoral*

Umbilical Artery (UAC)

Umbilical Vein (UVC)

Intraosseus (IO)

All patients Peds only

* Utilize Seldinger technique; see handout


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Femoral Line


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Sir William Osler

www.utmem.edu/fpsa/

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