Principles of Fluid Therapy (LO7) Flashcards
When giving fluid therapy to patients, always consider the following five questions:
- Why am I giving fluids?
- How will I give fluids?
- What type of fluid will I use?
- How much fluid?
- How will I monitor?
Why am I giving fluids?
Your reasons for giving fluids may include:
- Resuscitation
- Deficit replacement
- Ongoing losses
- Maintenance
How will I give fluids?
- Parenteral – Intravenous
What type of fluid will I use?
- Normal Saline
- Ringers Lactate
- D5W or D10W
How much fluid should I give?
- This will be based on your patient’s clinical presentation.
How will I monitor?
- This will be accomplished through continuous reassessment of your patient and their vital signs.
Electrolytes
, circulate through the body and help to regulate everything from water levels in the body to cardiac activity and muscle contractions
- Electrolytes can either have a negative or positive charge
The major electrolytes found in the body are:
- Sodium
- Potassium
- Calcium
- Magnesium
- Bicarbonate
- Chloride
- Phosphorus
Sodium
the principle extracellular cation
required to help regulate the volume of total water as well as the distribution of water throughout the body
important for proper nerve and muscle function
If levels are high it can lead to edema, lethargy, and weakness
If the levels are low, it can result in pulmonary or cerebral edema
Potassium
the principle intracellular cation
establishing resting membrane potential
most dangerous of any electrolyte imbalance
too low can result in decreased skeletal muscle function, GI disturbances, and cardiac arrhythmia.
High levels lead to hyperstimulation of neural cell transmission which may lead to cardiac arrhythmias including cardiac arrest.
Calcium
the principle cation that is required for bone growth.
role in heart muscle function, muscle contraction, nerve transmission, and blood clotting.
Levels that are too low can result in skeletal muscle cramps, abdominal cramps, carpopedal spasms, hypotension, and vasoconstriction.
High levels can result in the patient displaying signs of skeletal muscle weakness, lethargy, ataxia (involuntary lack of coordination or muscle control), cardiac arrhythmia, vasodilation, and flushed skin.
Magnesium
the second most common intracellular cation.
It plays an important role in the metabolism of proteins and carbohydrates.
essential for normal neuromuscular activity, synaptic transmission, and myocardial function.
Low levels may result in the patient presenting with weakness, irritability, tetany, delirium, convulsions, confusion, anorexia, nausea, emesis, and cardiac arrhythmia.
High levels may result in the patient presenting with hypotension, muscular weakness, nausea, vomiting, and altered mental function.
Bicarbonate
the second most prevalent extracellular anion.
It is the primary buffer used in all circulating body fluids.
Bicarbonate levels determine acidosis or alkalosis in the body.
Chloride
the most prevalent anion in extracellular fluid and is strongly linked to sodium.
o if sodium is either retained or excreted the same action will occur with chloride.
contributes to the formation of stomach acids and helps to regulate fluid balance and pH.
Low levels may result in the patient presenting with muscle spasms, metabolic acidosis, shallow respiration, hypotension, and tetany.
High levels may result in the patient presenting with lethargy, weakness, metabolic acidosis, and rapid, deep breathing.
Phosphorus
important component in adenosine triphosphate (ATP), which is a source of energy for the body
Fluid and Electrolyte Movement
- Water and electrolytes move within the body according to the principle of balance
- When the concentration of charge or compounds are greater on one side of the cell membrane, a gradient is created
- The tendency is for materials to move from areas of higher concentration to areas of lower concentration in an attempt to balance things out
There are different means of movement within the body:
- Diffusion
- Facilitated Diffusion
- Osmosis
- Active Transport
- Filtration
Diffusion
- the passive movement of solute from an area of higher concentration to an area of lower concentration.
- If it is classed as simple diffusion, it occurs without the help of membrane transport proteins.
- The movement of oxygen is classed as simple diffusion.
Facilitated Diffusion
- Facilitated diffusion is a type of passive diffusion that requires assistance of an integral membrane protein to move a solute across the membrane when it is too highly charged to cross alone.
- It can be either channel mediated facilitated diffusion as is with the movement of potassium or it may be carrier mediated facilitated diffusion as is with glucose across the plasma membrane.
Osmosis
- Osmosis is a form of diffusion that involves the movement of water across a semipermeable membrane.
- The water moves from the side with the lesser number of particles and greater concentration of water, to the side of the membrane with the greater number of particles and lesser concentration of water.
Active Transport
- Active transport is not a passive process as it requires energy to occur.
- When a solute must move against its concentration gradient (from lower to higher), they cannot do this alone.
- The primary source of energy is adenosine triphosphate (ATP).
- An example of active transport is the sodium-potassium pump.
Filtration
- Filtration is the passage of materials through a membrane by a physical force such as gravity.
- In the body filtration is also achieved by means of a physical pump, the heart, which effects the rate of filtration by effecting the pressure of the blood through the blood vessels.
Intravenous Solutions
When choosing the fluid to administer, it is important to know the type of fluid it is and the effect it has on the body.
There are 5 basic types of IV fluid:
- Isotonic
- Hypotonic
- Hypertonic
- Crystalloid
- Colloid
Isotonic Solution
- has the same concentration of solute as serum and bodily fluids.
- will not cause the cells to either swell or shrink
- works by expanding the contents of intravascular space without shifting fluid to or from other compartments
- Examples of isotonic solutions
normal saline and lactated ringers.
Hypotonic Solution
- has a concentration of solute less than that of serum which results in a fluid shift
- Since the concentration of solute is less than that of the interstitial fluid, hypotonic fluid placed in the intravascular space causes fluid to move from the vascular compartment into the interstitial compartment.
- causes cells to swell and possibly burst.
- work to hydrate the cells while depleting intravascular compartments.
- should not be used for fluid replacement but rather to maintain a lifeline.
example of a hypotonic solution
D5W once administered
Hypertonic Solution
- has a concentration of solute greater than that of serum which results in a fluid shift.
- Since the concentration of solute is greater than that of the interstitial fluid, hypertonic solution placed in the intravascular space causes fluid to move from the interstitial and intracellular compartments to the vascular compartment.
- causes cells to shrink and possibly collapse.
- Hypertonic solutions work to help stabilize blood pressure, increase urine output, and reduce edema.
- These types of fluid are rarely used prehospital.
An example of a hypertonic fluid
D5 in lactated ringers.
Crystalloid Solutions
- are dissolved crystals in water
- have the ability to cross membranes and alter fluid levels so it makes them a good choice for prehospital patients that require fluid replacement.
- When administering crystalloid solutions for fluid replacement it is important to remember the 3 to 1 rule.
- For every 1 mL of fluid lost, the patient requires 3 mL of crystalloid solution because within one hour, two thirds of the fluid will leave the vascular space.
Examples of crystalloid solutions
normal saline and lactated ringers
Colloid Solutions
- contain molecules that are too large to cross the capillary membranes and therefore remain in the vascular compartment.
- high osmolarity.
- fluid is drawn from interstitial compartments and intracellular compartments into vascular compartments.
- it is important to closely monitor a patient receiving a colloid solution.
- reducing edema while expanding the vascular compartment.
- rarely administered prehospital.
Examples of colloid solutions
albumin, dextran, and pentaspan
Fluid Replacement Products
• Lactated Ringer’s • Normal Saline • 5% Dextrose in Water (D5W) • Colloids o Dextran o Pentaspan
Lactated Ringer’s
- classification
- description
Classification
- Isotonic Crystalliod Solution
Description - Sterile water with multiple electrolytes: o Sodium (Na) - 130mEq/L. o Potassium (K) - 4mEq/L. o Calcium (Ca) - 30mEq/L. o Chloride - 109mEq/L. o Lactate - 28mEq/L.
Lactated Ringer’s
- indications
- contraindications
- precautions
Indications
- This solution is indicated for use in adults and pediatric patients as a source of electrolytes, calories and water for hydration
- Significant burns and hypovolemia.
Contraindications
- DON’T USE: Heart failure, renal failure, or suspected hyperkalemia
- pts with ;liver problems
Precautions
- Monitor closely for signs of circulatory overload
Normal Saline
- class
- description
Classification
- Isotonic crystalloid
Description
- 0.9% Solution Sodium Chloride
Normal Saline
- indications
- contraindications
Indications
- Hypovolemia, heat exhaustion/stroke, DKA
Contraindications
- Hypersensitivity, heart failure
Normal Saline
-precautions
- Use caution in patients with renal impairment to avoid volume overload
- Use with Caution if signs of heart failure, CHF or crackles
- Shock in peds manifested as:
o Tachycardia - Poor skins signs - ALOC
o Weak distal pulse - Delayed Cap Refill - Low Blood Pressure
5% Dextrose in Water (D5W)
- class
- description
Classification
- isotonic solution
Description
- 5% Dextrose Injection, USP solution is sterile and nonpyrogenic.
- It is a parenteral solution containing dextrose in water for injection intended for intravenous administration.
- Each 100 mL of 5% Dextrose Injection, USP, contains dextrose, hydrous 5 g in water for injection.
5% Dextrose in Water (D5W)
- indications
- contraindications
- precautions
Indications
- hypoglycaemia
Contraindications
- D5W should not be used as a fluid replacement for hypovolemic states
-hyperglycemia
Precautions
- May produce venous irritation
Pentaspan
- class
- description
Classification
- Colloid solution- plasma volume expander
Description
- (10% Pentastarch in 0.9% Sodium Chloride Injection)
Pentaspan
- indications
- contraindications
Indications
- the management of shock due to hemorrhage, surgery, sepsis, burns or other trauma
Contraindications
- patients with sepsis.
- patients with severe liver disease
- patients with known hypersensitivity to hydroxyethyl starch, or with bleeding disorders, or with congestive heart failure where volume overload is a potential problem
- renal disease with oliguria or anuria not related to hypovolemia.
Pentaspan
-precautions
- Caution should be used when the risk of pulmonary edema and/or congestive heart failure is increased
- Special care should be exercised in patients who have impaired renal clearance since this is the principal route by which pentastarch is eliminated
- patients allergic to corn because such patients can also be allergic to PENTASPAN
- possibility of circulatory overload
- not a substitute for red blood cells or coagulation factors in plasma
Dextran
- class
- description
Classification
- Colloid solution- plasma volume expander
Description
- 10% LMD in 0.9% Sodium Chloride Injection
Dextran
- indications
- contraindications
Indications
- treat hypovolemia and/or hemorrhage from trauma, burns, surgeries, or other causes if ABO compatibility tests are not possible in time
Contraindication
- patients with heart failure, as rapid administration may prove dangerous due to the plasma volume expansion effects, potentially leading to circulatory overload and acute decompensation
- patients with untreated bleeding disorders
- patients with underlying renal disease, failure to clear dextran can lead to worsening of renal function
- include severe liver disease, preexisting edema, asthma, diabetes, epilepsy, and seizures
Dextran
-Precautions
- Hypersensitivity Reactions
- Delayed Reactions
- Increased Risk Of Toxicity In Patients With Underlying Conditions
WHEN ARE Volume expanders USED
used when a patient has lost fluid as a result of hemorrhage, diarrhea, vomiting, heat exhaustion, or burns
The most effective way to increase a patient’s intravascular fluid levels
administer colloid solutions
PCP scope of practice, if volume expansion needs to occur
crystalloid fluid will need to be administered
When administering a crystalloid solution to increase intravascular volume it is important to not only remember
the rule of 3:1 but also that crystalloid solution cannot carry oxygen
Vascular Access (Peripheral Intravenous) -purpose
Purpose
-Provides access to the circulation to administer drug therapy or fluids.
Equipment
- PPE
- Appropriate size catheter
- Tourniquet
- Swabs
- Gauze
- Tape
- Drip
- Set
- IV bag with solution Sharp Container
Vascular Access (Peripheral Intravenous) technique according to SCOP
- PPE
- Choice of insertion site:
- Procedure
a. Explain the procedure, including why IV therapy is necessary.
b. Select the appropriate size cannula.
c. Prepare equipment and cannulation site.
d. Stabilize vein and insert needle bevel up.
e. Confirm IV placement by flashback and advance further into thevein. f. Advance catheter over the needle and into the vein.
g. Retract needle while stabilizing the vein.
Vascular Access (Peripheral Intravenous) Choice of insertion site: according to SCOP
- General drug administration
i. Small to medium gauge cannula (i.e. adult: 18 – 20 G, child: 22 – 24G).
ii. Best most distal available vein.
iii. Use non-dominant limb when possible. iv. Avoid joints.
- Likely need for fluid replacement
i. Large gauge cannula sited in a large vein (i.e. adult: 16 – 18 G, child: 20 – 22 G).
ii. In significant trauma a 16 G cannula is sufficient to facilitate rapidfluid replacement.
- Difficult IV access/poor vein presentation
i. Consider the lower limbs, or external jugular vein.
ii. Consider IO access (Note: a small gauge cannula provides more reliable access than
the IO route).
Vascular Access (Peripheral Intravenous) Indications according to scop
- For volume expansion in patients with the clinical diagnosis of shock (hypovolemic, neurogenic or anaphylactic). Patients with suspected cardiogenic shock will have an intravenous initiated TKO, with OLMC required to establish the rate of flow for PCP and ICP.
- To obtain an intravenous route for administration of essential emergency drugs. Examples include, but not limited to the following circumstances:
a. Cardiac arrest.
b. Diabetic shock.
c. Anaphylactic shock.
d. Unconsciousness of unknown etiology or significanttrauma.
Vascular Access (Peripheral Intravenous) contraindications according to scop
- Whenever possible avoid sites of burns, infection or localized cellulitis.
Vascular Access (Peripheral Intravenous) precautions according to scop
Precautions
1. Because of the increased risk of phlebitis in IVs started in the pre-hospital scene, strict attention must be placed on an aseptic technique and secure taping of the IV.
- The following sites are not to be used for IV access:
a. Lower limbs when pelvis, abdominal or thoracic trauma issuspected.
b. Distal to a complex limb injury.
c. Limb with a fistula present.
d. An area of phlebitis or cellulitis.
e. When a limb has potential or existing lymphedema (e.g. the same side as lymph node clearance).
A peripheral intravenous saline lock may be used in those patients where
IV access has been obtained for the purpose of administering IV medications
. A saline lock is not to be used for
patients who require or may require bolus IV fluid therapy for hypotension.
Each dose of IV medication administered during a cardiac arrest
is followed by a bolus of IV fluid (to accelerate its entry to the central circulation) as follows:
a. Under the age of six years: 5 mL (including IO infusions)
b. Between six and twelve years: 10 mL
c. Over the age of 12 years: 20 mL
The IVs should be established enroute unless:
a. There is delay in extrication of the patient.
b. Airway management during transportation will not allow for IV initiation.
c. In patients with “controlled hemorrhage” where ongoing blood loss will not be a problem.
d. Transport time of greater than 30 minutes in length.
e. Crystalloids will be the fluid administered. The decision as to which fluid will be utilized
- Solvent:
- Solute:
- Solvent: the fluid that does the dissolving
- Solute: the dissolved particles contained in the solvent
Dehydration
overhydration
dehydration
-define does inadequate total systematic fluid volume
overhydration
-when the body’s total systematic fluid volume increases
Dehydration signs and symptoms
Signs and symptoms include decreased level of consciousness, orthostatic hypotension, tachypnea, dry mucous membranes, tachycardia, poor skin turgor, flushed dry skin
dehydration causes
include diarrhea, vomiting, gastrointestinal drainage, haemorrhage and insufficient fluid or food intake
overhydration signs and symptoms
include shortness of breath, puffy eyelids, edema, polyuria, moist crackles and acute weight gain
overhydration causes
o Causes include monitored IV lines, kidney failure and prolonged hyporventilation
intracellular fluid
-is the water contained inside the cells it normally accounts for 45% about 28 L of body weight
Extra cellular fluid
The water outside the cells accounts for 15% of body weight about 14 L and is further divided into two types of fluids interstitial fluid and intravascular fluid
interstitial fluid
The water bathing the sales accounts for approximately 10.5% of the body weight about 10 L
include special fluid collections such as cerebrospinal fluid and intraocular fluid
Intravascular fluid
plasma
The water within the blood cells carry his red blood cells white blood cells and vital nutrients
Normally accounts for approximately 4.5% of body weight or 4 L
tonicity
The concentration of a solution or ability to draw or give water
