Fluids

Questions

  • Does pt need IVF

  • what type of IVF

  • if no longer need, what is maintenance

Symptoms

Symptoms of hypovolemia:

  • low bp

  • tachycardia: best indicator for hypovolemia but not response

  • low urine output: best for response for resuscitation. 35 cc/hr good for 70 kg adult

  • orthostatic hypotension

  • BUN/creatinine: greater than 20

  • altered mental status

  • hypernatremia: advanced

  • hyponatremia: early

  • osmolarity, FeNa

  • weight loss

  • CR delayed

  • acidosis, contraction alkalosis

Requirements

  • 35 ml/kg/day requirements

  • weigh more than 20 kg, 60 + kg

Resusiscation Indicator

  • pulse: 100-120

  • good urinary output

  • clearance of lactate

  • resolution of base deficit: look at bicarb before and after surgery. Usually mildly lower after surgery.

Management

  • hemorrhaging: blood products

  • if no hemorrhage: IV fluids (crystalloids/isotonic: NS, LR)

  • Give 3 L for every 1 L loss. 2/3 goes to third space

    • bowel wall: ileus

    • lung: pulmonary edema

    • heart: CHF

Maintenance

Maintenance IVF: D5, 1/2NS + 20 meq KCL at 125cc/hr

  • dextrose: slow down depletion of glycogen before catabolic state

  • diabetics: still use sugar. Give dextrose

  • KCl: cardio protection

LR vs NS

  • NS: mildly acidotic. Pure gastric outlet obstruction, use NS instead of LR.

  • LR: acidotic, but has bicarb for buffer. Lactate cleared by liver into bicarb once fluid is restored. Better for patients that can easily be fixed. Also looks closer to plasma

Acid/Base

  • improve ventilation (CO2): respiratory rate, tidal volume

  • improve oxygenation (O2): FiO2 (immediate) + PEEP (takes time)

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