fluid management-.ppt it is about fluids

Fluid management in hospital

1. A Clinical Approach
Dr Anil Dutt
Reader & incharge
Section of Sangyaharan
R.G.Govt. Ayu.P.G. College, Paprola,
Distt. Kangra, H.P

2. Objectives
Volume of distribution
IV fluid choices available
Types of fluid depletion
Specific clinical examples and treatment

3. 60%-Males
50%-
Females
H
2
O
Solids

4. Intracellular
(2/3)
Extracellular
(1/3)
Solids 40% of Wt
H
2O H
2O
Na

5. Intra-
vascular
1/4
E.C.F. COMPARTMENTS
Interstitial 3/4
H
2
O H
2O
NaNa
Colloids
& RBC

6. “Third Space”
Acute sequestration in a body compartment that is
not in equilibrium with ECF
Examples:
Intestinal obstruction
Severe pancreatitis
Peritonitis
Major venous obstruction
Capillary leak syndrome
Burns

7. Intake:
1-1.5L
Insensible Loss
-Lungs 0.3L
-Sweat 0.1 L
Urine: 1.0 to 1.5L

8. Total body water=60% body wt
=0.6X70=42 liters
ECF=1/3
0.3X42=13 liters
ICF=2/3
0.6 X42=25 liters
Blood=1/4 (ECF)
0.25X13=3. 3 liters

9. Principles of Treatment
How much volume?
Need estimate of fluid deficit
Which fluid?
Which fluid compartment is predominantly
affected?
Need evaluation of other
acid/base/electrolyte/nutrition issues.

10. The IV Fluid Supermarket
Crystalloids
Dextrose in water
D5W
D10W
D50W
Saline
Isotonic (0.9% or “normal”)
Hypotonic (0.45%, 0.25%)
Hypertonic
Combo
D51/2NS
D5NS
D10NS
Ringer’s lactate “physiologic”.
(K, HCO3, Mg, Ca)
Colloids
Albumin
5% in NS
25% (Salt Poor)
Dextrans
Hetastarch
Blood

11. To calculate drip rates /
transfusion rates
To calculate the drip rate (drops / minute)
Drip Rate gtt = Volume to be infused (ml) x Drop
Factor (gtt/ml)
min Time (minutes)
1 unit of blood is approximately 400ml in volume
E.g. A unit of blood is prescribed to run over 2
hours; The giving set has a drop factor of 20 gtt
/ml. What is the drip rate (drops /min)?
(See next slide for answer and calculation)

12. Example one – Calculate the
Transfusion rate
E.g. A unit of blood is prescribed to run over 4 hours; The
giving set has a drop factor of 20 gtt /ml. What is the drip
rate (drops /min) ?
Drip rate = 400 ml x 20 gtt ; Drip Rate is drops / minute
4 hour 1ml
Thus Drip Rate = 400ml x 20 gtt x 1 hour
4 hour 1 ml 60 minutes
By multidimensional analysis units are correct (drops /
minute)
Drip Rate = 100 / 3 = 33 drops / minute
Drop rate is rounded up or down to the nearest drop
In the clinical setting to be able to count drops / minute it is
sensible to have a number divisable by 4 - Thus you would
set this drip at 32 drops per minute

13. Converting drip rate (gtt /min)
to ml /hour
In high dependency areas caring for critically ill
patients it may be necessary to know the infusion
rate in ml/hour – this is important in setting infusion
pumps (usually set in ml/hour) and when calculating
fluid balance.
E.g. What is the transfusion rate in ml /hour of a
blood transfusion being run at 40 drops / minute
through a giving set with drop factor of 20 gtt /
ml?

14. We are
approximately
two-thirds water

15. The rules of fluid replacement:
Replace blood with blood
Replace plasma with colloid
Resuscitate with colloid
Replace ECF depletion with saline
Rehydrate with dextrose

16. Signs of hypo / hypervolaemia:
Signs of …
Volume depletion Volume overload
Postural hypotension Hypertension
Tachycardia Tachycardia
Absence of JVP @ 45
o
Raised JVP / gallop rhythm
Decreased skin turgor Oedema
Dry mucosae Pleural effusions
Supine hypotension Pulmonary oedema
Oliguria Ascites
Organ failure Organ failure

17. What are the expected losses ?
Measurable:
urine ( measure hourly if necessary )
GI ( stool, stoma, drains, tubes )
Insensible:
sweat
exhaled

18. What are the potential gains ?
Oral intake:
fluids
nutritional supplements
bowel preparations
IV intake:
colloids & crystalloids
feeds
drugs

19. Total body water
ECF=1 liter ICF=0
Intravascular
=1/4 ECF=250 ml
Interstitial=3/4
of ECF=750ml

20. Total body water=1 liter
ECF=1/3 = 300ml ICF=2/3 = 700ml
Intravascular
=1/4 of ECF~75ml

21. Intravascular=1 liter

22. N Engl J Med. 2004 May 27;350(22):2247-56.

23. Volume Deficit-Clinical Types
Total body water:
Water loss (diabetes insipidus, osmotic diarrhea)
Extracellular:
Salt and water loss (secretory diarrhea, ascites, edema)
Third spacing
Intravascular:
Acute hemorrhage

24. Clinical Diagnosis
Intravascular depletion
MAP= CO x SVR
Hemodynamic effects
BP HR JVP
Cool extremities
Reduced sweating
Dry mucus membranes
•E.C.F. depletion
–Skin turgor, sunken eyeballs
–Weight
–Hemodynamic effects
•Water Depletion
Thirst
Hypernatremia

25. A 25 year old patient presents with massive hematemesis
(vomiting blood) x 1 hour. He has a history of peptic ulcer
disease.
Exam: Diaphoretic, normal skin turgor.
Supine BP: 120/70 HR 100
Sitting BP: 90/50 HR=140
Serum Na=140
What is the nature of his fluid deficit ?
What IV fluid resuscitation would you prescribe ?
What do you expect the hematocrit to be :
- at presentation ?
- after 12 hours of Normal Saline treatment?

26. Example-Diarrhea and Vomiting
A 18 year old previously
healthy medical student
returns from a Caribbean
vacation with a healthy tan
and severe diarrhea and
vomiting x 48 hours.
Sunken eyeballs, poor skin
turgor and dry mucus
membranes
BP 80/70 HR 130 supine.
Labs: Na 130 K=2.8
HCO3 =12
ABG: 7.26/26/100
What is the nature of
his fluid deficit ?
What fluid will you
prescribe ?
What would happen if
D5W were to be used?

27. Colloids and Crystalloids - What Surgeons and
Anaesthetists talk about over coffee
Intravenous fluids may be divided into
Crystalloid solutions - clear fluids made up of
water and electrolyte solutions; Will cross a semi-
permeable membrane e.g Normal, hypo and
hypertonic saline solutions; Dextrose solutions;
Ringer’s lactate and Hartmann’s solution.
Colloid solutions – Gelatinous solutions
containing particles suspended in solution. These
particles will not form a sediment under the
influence of gravity and are largely unable to
cross a semi-permeable membrane. e.g. Albumin,
Dextrans, Hydroxyethyl starch [HES]; Haemaccel
and Gelofusine

28. A 85 year old nursing home resident with dementia, and
known diabetes was admitted with confusion.
Exam: Disoriented
BP: 110/70 supine 90/70 sitting. Decreased skin turgor.
Labs: Na= 150meq/L Wt=50kgs
BUN/Cr=50/1.8Blood sugar= 1200 mg/dl Hct=45
What is the pathogenesis of her
fluid and electrolyte disorder ?
How would you treat her ?

29. Osm (P Na) x
volume
Osm (P Na) x
volume
Healthy Dehydrated
A 50 kg female with Na=150
•Na x Normal Body Water = Na x Current Body Water
•140 x NBW = 150 x (0.5 x 50=25 liters)
•NBW = 26.8 liters
•Water deficit = NBW-CBW= 26.8-25=1.8 liters

30. Conclusions
Crystalloids are generally adequate for most
situations needing fluid management.
The composition of the solution and rate of
administration are important when
addressing a specific situation.
Colloids may be indicated when more rapid
hemodynamic equilibration is required
(inadequate data).