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RRCCPA Clinical Decision Making II > IV Fluids (Final) > Flashcards

IV Fluids (Final) Flashcards

1
Q

Fluid compartments

A
  • Intracellular
  • Extracellular
    • Intravascular
    • Interstitial
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2
Q

Total body water volume

A
  • 40L
  • 60% body weight
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3
Q

Intracellular fluid volume

A
  • 25L
  • 40% body weight
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4
Q
  • Extracellular fluid volume
    • Intravascular?
    • Interstitial?
A
  • 15L
  • 20% body weight
  • Intravascular (plasma)
    • 3L
    • 20% of Extracellular fluid (ECF)
  • Interstitial
    • 12L
    • 80% of (ECF)
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5
Q

Primary Intracellular ions

A
  • K+
  • PO43-
  • Non-penetrating anions
    • Proteins
    • Organic anions
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6
Q

Primary extracellular ions

A
  • Na+
  • Cl-
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7
Q

Components of a chemistry panel (CHEM-7, BMP)

A
  • Na
  • K
  • Cl
  • HCO3
  • BUN
  • Cr
  • Glucose
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8
Q

Normal value for Na+

A

135-145 mEq/L

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9
Q

Normal value for K+

A

3.5-5 mEq/L

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10
Q

Normal value for Cl-

A

95-105 mEq/L

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11
Q

Normal value for HCO3-

A

22-28 mEq/L

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12
Q

Normal value for BUN

A

7-18 mg/dL

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13
Q

Normal value for Cr

A

0.6-1.2 mg/dL

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14
Q

Normal value for Glucose

A

70-115 mg/dL

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15
Q

What is third spacing?

A
  • Shift of fluid from intravascular to interstitial space
  • Loss of integrity of vascular endothelium leading to increased permeability
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16
Q

Name some areas of third spacing loss

A
  • Pancreatitis
  • Sepsis
  • Surgery
  • Hypoalbuminemia (Cirrhosis, etc)
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17
Q

What are the goals of giving IV fluids?

A
  • Replacement/Resuscitation
  • Maintenance
  • Electrolyte balance
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18
Q

Questions to consider before beginning IV fluids

A
  • For replacement, how much extra volume is needed?
  • How can we assess volume status?
  • What are the sources of volume loss?
  • What does it take to maintain normal fluid balance?
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19
Q

Common sites/causes of fluid and electrolyte loss

A
  • Renal
  • GI
    • N/V
    • NG tube
    • Fistula
  • Respiratory
  • Skin
    • Especially burns
  • Hemorrhage
  • Third-space losses
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20
Q

Daily causes for water loss

A
  • Urine
    • At least 0.5 l/day
  • Stool
    • 200 mL/day
  • Insensible (skin and respiratory)
    • 400-500 mL/day
  • Endogenous metabolism
    • 250-350 mL/day
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21
Q

Daily water requirements? How much for maintenance?

A
  • Total
    • 1400 mL/day
  • Maintenance
    • Minimum 60 mL/hr
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22
Q

Causes for insensible fluid loss

A
  • Increased respiratory rate
  • Changes in metabolic state
  • Body temperature
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23
Q

Daily Na+ requirement

A

75-175 mEq Na+/day

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24
Q

Daily K+ requirement

A

20-60 mEq K+/day

25
Q

Daily carbohydrate requirements? What does achieving this do?

A
  • 100-150 g/day dextrose
  • Reduce protein catabolism and prevent starvation ketoacidosis
26
Q

D5 ½ NS with 20 mEq/L KCL running at 75 mL/hr maintenance will result in what after one day?

A
  • 1.8 L of solution
  • 36 mEq K+ (need 20-60 per day)
  • 139 mEq Na+ (need 75-175 per day)
  • 90 g dextrose (need 100-150 g/day)

Covers nearly all of the needs of the patient

27
Q

How to assess volume status

A
  • Clinical assessment
  • Daily Weights
  • Intake and Output
  • Serum Creatinine
28
Q

Signs of hypervolemia

A
  • AMS
  • Increased hepato-jugular reflux
  • Increased JVP
  • Increased body weight
  • Increased fluid balance
  • Increased cumulative fluid balance
  • Altered capillary refill
  • Pitting edema
  • 2nd, 3rd space fluid sequestration
  • Orthopnea
29
Q

Signs of hypovolemia

A
  • Hypotension
  • Tachycardia
  • Oliguria
  • Decreased skin turgor
  • Dry mucous membranes
30
Q

Examples of crystalloid fluids

A
  • Normal saline (NS)
  • Lactated Ringer’s (LR)
31
Q

Example of colloid fluid?

32
Q

Composition of normal saline and risks associated with it

A
  • 154 mEq/L Na+ (140 in plasma)
  • 154 mEq/L Cl- (103 in plasma)
  • Can lead to hyperchloremic metabolic acidosis (due to high Cl- content)
  • Can cause Chloride-mediated renal vasoconstriction
33
Q

A 2018 study of 15,802 critically ill adults given normal saline or a balanced crystalloid (LR or Plasmalyte) found?

A
  • Giving a balanced crystalloid instead of normal saline resulted in:
    • Decreased death from any cause
    • Decreased new renal replacement therapy
    • Decreased persistent renal dysfunction
34
Q

Composition of LR compared to plasma

A
  • Na
    • LR: 130 mEq/L
    • Plasma: 140 mEq/L
  • Cl
    • LR: 109
    • Plasma: 103
  • K
    • LR: 4
    • Plasma: 4
  • Ca
    • LR: 3
    • Plasma: 4
  • Mg
    • LR: 0
    • Plasma: 2
  • Osm
    • LR: 273 mOsm/L
    • Plasma: 290 mOsm/L
35
Q

Problems with LR

A
  • Blood samples from IV’s running LR can give spuriously high serum lactate measurements
  • Ionized Ca in LR can bind to citrated anticoagulant in pRBC’s and cause clots
  • 4 mEq/L of K
  • Can cause hyperkalemia
    • USe caution in Pts with renal insufficiency
36
Q

Describe colloid fluids such as albumin

A
  • High molecular weight solutions; increase plasma oncotic pressure
  • Stay in intravascular space longer than crystalloid fluids
    • Albumin has an intravascular half-life of 16 hours
    • NS or LR have intravascular half-lives of 30-60 minutes
37
Q
  • Describe the following dextrose containing solutions
    • D5W
    • D5NS
    • D10LR
A
  • D5W
    • 50g dextrose in 1L free water (5% dextrose)
  • D5NS
    • 50g dextrose in 1L NS
  • D10LR
    • 100g dextrose in 1L LR
38
Q

Describe the protein-sparing effect of dextrose containing solutions

A
  • Enough non-protein calories to help prevent endogenous protein catabolism
  • Not complete nutrition
  • Tube feeds/TPN better
  • Dextrose containing fluids can be used to treat ongoing hypoglycemia
39
Q

Main uses of D5W

A
  • Treatment of hypernatremia
  • Slowing down correction of hyponatremia
40
Q

Goals of giving maintenance fluid

A
  • Maintain homeostasis in euvolemic patients who cannot accomplish this with oral intake
41
Q
  • Examples of common rates of maintenance fluid
A
  • D5 ½ NS with 20 mEq/L of K at 75 mL/hr
  • NS at 75 mL/hr (less hypoNa risk) with PRN K repletion
  • Decrease to 50 mL/hr in Pts with CHF, CKD, etc.
  • Many healthier Pts can tolerate higher rates (e.g. 100-125 mL/hr)
  • Be sure to frequently reassess volume status
42
Q

What is the risk of giving maintenance fluids at too high a rate ( > 50 mL/hr) in Pts with fluid balance disorders such as CHF or CKD

A

Risk of flash pulmonary edema

43
Q

Goals of fluid replacement (not mantinance)

A
  • Maintain hemodynamic stability
  • Replenish intravascular volume
  • Fluid Boluses
    • 1 L
    • 500 mL
    • 250 mL
    • Special situations
  • Reassessment
44
Q

Which patients need aggressive IV fluid treatment?

A
  • Sepsis
  • Acute pancreatitis
  • DKA/Hyperosmolar hyperglycemic syndrome (HHS)
45
Q

Replacement fluid guide for Spesis

A
  • Initial crystalloid bolus of 30 mL/kg
  • More fluid guided by serum lactate and hypotension
46
Q

Replacement fluid guide for Acute Pancreatitis

A
  • LR
    • Initial fluid bolus: 20 mL/kg over 30 minutes, followed by 3 mL/kg/hr for 8-12 hours
47
Q

Replacement fluid guide for DKA/HHS

A
  • 15-20 mL/kg/hr for first 2 hours
    • Approx. 1L/hr
  • 250-500 mL/hr next few hours
    • Then reduce to 150 mL/hr
48
Q

What should you keep in mind about complications of giving replacement fluids?

A
  • Risk of aggressive replacement is acute (flash) pulmonary edema
  • In Pts with CHF if boluses are needed for hypotension
    • Use 250 mL at most and reassess
49
Q

Guidelines for potassium repletion

A
  • Serum K 3.0-3.4 mEq/L (mild)
    • Anticipate 10 mEq administration to increase serum K by 0.1 mEq/L
  • Serum K < 3.0 mEq/L
    • Requires more aggressive repletion
      • Can do PO and IV
    • Recheck more than daily
  • Whole-body K deficit often more severe than serum K would suggest
50
Q

In cases where a Pt has low potassium, what else should you check?

A
  • Hypomagnesemia
    • Renal potassium wasting
  • Hypokalemia will not correct in the presence of hypomagnesemia

Mg level is not part of BMP, need to order separate Mg level test

51
Q

Pearls of IV potassium

A
  • Risk for phlebitis
  • Painful
  • Limit 10 mEq per 2 hours through peripheral IV
  • Central access for faster repletion
52
Q

Guide to treatment for low Mg

A
  • Need to order serum Mg separately from BMP
  • Oral replacement does not work well
    • Poor GI absorption
  • IV Mg
    • Give 1-4 g at a time and recheck
53
Q

In Pts with cardiac disease, what are the goal serum K and Mg levels?

A
  • Serum K
    • > 4.0 mEq/L
  • Serum Mg
    • > 2.0 mEq/L
54
Q

Quick tips for management of Phosphorus levels

A
  • Need to order serum Phos separately from BMP
  • K-Phos neutral (Phos-Nak) tablets
    • 1.1 mEq K per tab
  • K-Phos IV
    • 22 mEq K per 15 mmol
  • Na-Phos IV
    • No K
  • Consider hypophosphatemia in malnutrition or refeeding
    • Alcoholics
55
Q

A 38 year old male with PMH of ETOH use disorder presents to the hospital in EtOH withdrawal and severe electrolyte depletion.
On exam his vitals are: HR: 109, RR 18, BP 90/70, Pulse Ox 95%
Gen: ill appearing male, HEENT: Dry CV: Tachy RR
Labs: Na: 131, K: 3.0
What do you want to do?

  • A. Give him a beer, it will help his withdrawal
  • B. Start maintenance fluids with D5W at 75 ml/hr and Replete his potassium with 40 mEq
  • C. Start maintenance fluids with NS 50 ml/hr and replete K with 40 mEq
  • D. Give NS bolus 1000ml and replete K with 60 mEq
A
  • D. Give NS bolus 1000ml and replete K with 60 mEq

Bolus will help with low BP

56
Q

A 38 year old male with PMH of ETOH use disorder presents to the hospital in EtOH withdrawal and severe electrolyte depletion.
On exam his vitals are: HR: 109, RR 18, BP 90/70, Pulse Ox 95%
Gen: ill appearing male, HEENT: Dry CV: Tachy RR
Labs: Na: 131, K: 3.0
You give a NS bolus 1000ml and replete K with 60 mEq. However, now he develops Severe Epigastric Pain that radiates to the back … What should you do?

  • A. Nothing continue to treat his EtOH withdrawal
  • B. Order CBC, LFTs, and Lipase
  • C. Start IV PPI and order CBC, LFTs, and Lipase
  • D. Continue IVF, start IV pain meds, and continue to monitor
A
  • B. Order CBC, LFTs, and Lipase
57
Q

A 38 year old male with PMH of ETOH use disorder presents to the hospital in EtOH withdrawal and severe electrolyte depletion.
On exam his vitals are: HR: 109, RR 18, BP 90/70, Pulse Ox 95%
Gen: ill appearing male, HEENT: Dry CV: Tachy RR
Labs: Na: 131, K: 3.0
You give a NS bolus 1000ml and replete K with 60 mEq. He develops Severe Epigastric Pain that radiates to the back so you order a CBC, LFTs, and Lipase.

His Lipase comes back 3x the upper limit of normal, his Bili comes back elevated, Hgb is normal
What should you do now?

  • A. Start IVF- NS 75 ml/hr, start IV pain control, obtain RUQ U/s
  • B. Start IVF- LR 150ml/hr, start IV pain control, Obtain RUQ U/S
  • C. Start IVF- LR 150ml/hr, start IV pain control, Obtain CT Abd
  • D. Start IVF- D5W 150ml/hr, start IV pain control, Obtain CT Abd
A
  • B. Start IVF- LR 150ml/hr, start IV pain control, Obtain RUQ U/S
58
Q

Pearls of acute pancreatitis (this is how she recommends breaking down diseases to study them for the PANCE)

A
  • Etiology: Most common EtOH vs. Gallstones
  • Diagnostics: Presence of two of the following:
    • Acute epigastric pain radiating to back
    • Lipase 3 times the upper normal limit
    • Characteristics of acute pancreatitis on Imaging (CT/MRI/US)
  • Fluid of choice: LR
  • Treatment: IVF, NPO, Pain Control

RRCCPA Clinical Decision Making II (10 decks)

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