IV Fluids (Intravenous Fluid Therapy)

Last updated 20.09.12

 

Index

 

-  Types of Fluid

-  Fluid Resuscitation

-  IV Fluid Orders

-  Adult

-  Paediatric

-  Fluid Balance Chart (FBC)

 

 

 

IV Fluid Types

<Fluids>

 

-  Blood Products

 

-  Crystalloids

-  Normal Saline (NS)

-  Half Normal Saline (N2)

-  4% Dextrose + 1/5 NS

-  5% Dextrose (D5)

-  Hartmans

 

-  Colloids

-  Dextran

-  Gelatin

 

 

 

Crystalloids

<Fluids>

 

Features

- Distributes throughout ECF including pulmonary interstitium (APO)

 

- Normal Saline (NS) (0.9% NaCl)

-  154mmol NaCl + water

-  Large volumes may cause hyperchloraemic acidosis

-  Avoid in ascities

-  3:1 rule

-  3L NS = 1L blood

-  1/3 stays intravascular

-  2/3 disperses

-  t/2 2-3 hrs

-  Available in 1L or 100ml bags

-  Also comes w pre-added 30mmol KCL

 

- Half Normal Saline (N/2) (0.45% NaCl)

-  77mmol NaCl + water

 

- 4% Dextrose + 1/5 Normal Saline

-   

 

- Dextrose 5% (D5)

-  837 kJ/L (glucose) + water

-  30 mmol NaCl

-  Large volumes may cause hyponatraemia

-  Prefered IV fluid in ascities

-  12:1 rule

-  12L Dextrose = 1L blood

-  1/12 stays intravascular

-  11/12 disperses

-  Also comes w pre-added 30mmol KCL

 

- Hartmanns (Sodium Lactate, Ringers Lactate)

-  131mmol/L NaCl + water

-  29mmol/L bicarb

-  5mmol/L potassium

-  2mmol/L calcium

-  Large volumes may cause hyponatraemia

-  Distributes to ECF

 

 

 

Colloids

<Fluids>

 

- Predominately stays in intravascular compartment

- Dextran

-  Most common colloid

-  By molecular weight Dextran 40 or 70

-  Dextran 40 has shorter t/2

-  Hypertonic

-  Interferes w blood cross matching

-  Reduced platelet aggregation

-  1-5% anaphylaxis

- Gelatin

-  t/2 3-4 hrs

-  Isotonic

-  May cause bleeding diathesis

-  Risk of anaphylaxis

-  Gelofusine

-  4% Gelatin + NaOH + water

-  Bovine gelatin (protein)

-  Haemaccel

-  3.5% Gelatin + water

-  145mmol/L NaCl

-  5mmol/L potassium

-  6.25mmol/L calcium

-  Intrvascular t/2 2-3hrs

 

 

 

Fluid Resuscitation (Bolus)

<Fluids>

 

-  Stat bag for rapid administration

-  Used for adults & children

-  Severe dehydration in children

-  NS (0.9% NaCl): 10-20ml/kg as bolus

-  Large bore IV canula

-  Gravity assisted, hand pump..

-  10-20 minutes

-  Not included in other calculations

-  If no response by 2x boluses in children or 2L in adults consider blood transfusion..

 

 

 

Adult IV Fluids

<Fluids>

 

Indication

-  Dehydration, burns

-  TPN

-  Trauma

-  Post-op

 

Administration

-  Written up in aliquots of 1L bags

-  Target urine output of > 1 ml/kg/hr

-  70kg = 70ml/hr

-  Expectation of > 30ml/hr

-  U&E prior to fluid administration & for monitoring

 

Total Volume = maintainence +/- correction +/- bolus

(minus oral intake or via other IV source ie: infusions, Abx)

 

-  Maintainence

-  Calculation of 24 hr requirements

-  Water

-   30 ml/kg/day

-   50 kg pt = 3 L/day

-   70 kg pt = 2.1 L/day

-   100 kg pt = 3 L/day

-  Sodium (Na)

-   1-1.4 mmol/kg/day

-   50 kg pt = 50-70 mmol/day

-   70 kg pt = 70-98 mmol/day

-   100 kg pt = 100-140 mmol/day

-  Potassium (K+)

-   0.7-0.9 mmol/kg/day

-   50 kg pt = 35-45 mmol/day

-   70 kg pt = 49-63 mmol/day

-   100 kg pt = 70-90 mmol/day

-  Glucose

-   100g/day spares protein metabolism

-  Cookie Cutter approach

-  Bag 1: 0.9% NS + 30 mmol KCl

-  Bag 2: 5% Dextrose + 30 mmol KCl

-  Bag 3: 5% Dextrose

-  Rate

-   Average size: 125 ml/hr (q8h)

-   Small or old: 100 ml/hr (q10h)

-  Provides

-   3 L water

-   150 mmol sodium

-   60 mmol potassium

-   1674 kJ glucose

 

-  Correction (Rehydration)

-  Post-op

-  Estimation of losses

-  Vomiting, diarrhoea

-  Stomas, drains, fistulas

-  Nasogastric aspirate

-  Pre-operative

 

Post Op Fluids

-  Many pt post of will be in +ve sodium & water balance

-  In addition to maintainence +/- bolus

-  Minimal Dehydration

-  Bags 1 & 2: NS + 30 mmol KCl

-  Bags 3 & 4: NS

-  Rate = 166 ml/hr (q6h)

-  Totals 4L in 24 hrs

-  Moderate Dehydration

-  Bags 1 & 2: NS at 250 ml/hr (q4h)

-  Bags 3 & 4: NS + 30 mmol KCl at 166 ml/hr (q6h)

-  Bag 5: NS at 166 ml/hr (q6h)

-  Totals 4.5L in 24 hrs

-  Post op Oliguria

-  Bag 1: NS 500ml bolus + 500ml at 500 ml/hr (q2h)

-  Bag 2: NS at 250 ml/hr (q4h)

-  Bag 3: NS at 166 ml/hr (q6h)

 

 

 

Paediatric IV Fluids

<Fluids>

 

Indication

-  Dehydration

-  Gastroenteritis

-  Burns

-  TPN

 

Administration

-  Written up in aliquots of 500mls

-  U&E & BSL prior to fluid administration & to monitor

-  Repeat U&E 8 – 12 hrs after initiation of fluids

-  Hyponatraemia fluids as per normal

-  Hypernatraemia

-  Correction of dehydration over 48 hrs

-  Estimate as 5% dehydration

-  Maintainance over 24hrs

-  Use 1/2 Normal Saline + 2.5% dextrose

-  Target urine output 1 ml/kg/hr

 

Fluid

-  1/2 Normal Saline + 5% Dextrose in 500mls

-  Neonates: 0.225% Sodium Chloride + 10% Glucose + 10mmol KCL in 500mls

-  NS for bolus

 

Volume = maintainence +/- correction +/- bolus

-  Maintainence

-  Calculation of 24hr requirements

-  Therefore given over 24 hrs only

-  Maximum 3 ltrs per day

-  100-150ml/kg/day total

-  First 10kg

-  100 ml/kg/day at 4 ml/kg/hr

-  First 10kg = 1000ml at 40 ml/hr

-  Second 10kg

-  50 ml/kg/day at 2 ml/kg/hr

-  Second 10kg = 500ml at 20 ml/hr + above

-  Additional kgs

-  25 ml/kg/day at 1 ml/kg/hr

-  + Continuing losses

-  Estimate volume loss from diarrhoea, vomiting..

- Correction (Rehydration)

-  Body weight (kg) x % dehydration (up to 5) x 10

 

Additions

-  Potassium

-  Added once urine passed w normal serum potassium or initially if hypokalaemia

-  3 mmol/kg/day

-  Rough rule of thumb 10 mmol KCl per 500 ml saline

-  Glucose

-  < 6 months make upto 8% glucose

 

 

 

IV Fluid Orders

<Fluids>

 

Check List for IV Fluid orders

-  Why are fluids needed?

-  NBM, meds, hydration..

-  Patient age

-  Is there a concern for APO?

-  Hx of CCF, CRF, ARF, Chronic Liver Disease or APO

-  Fluid balance as per fluid balance chart (+ or -)

-  O2 sats, RR +/- BP, HR

-  Fluid type: N. Saline unless other indication

-  Dextrose if NBM for extended period

-  +/- KCl

-  How many ltrs already

-  Check U&E: trend

-  How many bags?

-  Cover overnight/day periods as needed

-  Plan ahead for KCl or Dextrose if NBM

 

Documentation

-  Eg: 1/5/10, N. Saline, ---, 1L, 8/24

-  Date

-  Must include month +/- year

-  IV fluid type

-  N. Saline (NS)

-  5% Dextrose..

-  10mmol KCl (in 100ml)

-  Check prev fluids

-  Additives

-  Consider K+ if pt has already had several ltrs

-  Check U&E for K+ & trend

-  Make sure no ARF, CRF

-  30mmol KCL added to 1ltr

-  Volume

-  In ltrs (or mls)

-  Rate

-  x/24

-  8/24 covers the standard 3ltrs/day

-  24/24 to keep veins open

-  Check previous bag rates

-  Stat for a bolus ie: 250ml

-  Sign

-  Can do phone orders

-  Start time

-  Use this for delayed starts

-  If not used bags will run consecutively

-  Chart enough fluid to last as long as needed rather than each bag at a time