IV Fluid Management

Dr Andrew Stein
Consultant Nephrologist, UHCW
Keep up with the fluids
IV Fluids = Drug
Structure of Talk

• Background: Human water content + distribution

• Fluid requirements
• Fluid state assessment
• Available fluids
• Replacement (incl acute hypotensive patient)
• Advantages and Disadvantages
• Special situations
Background

• Humans are 60% water

• 70kg man (42L water / 70kg = 60%):

• Intracellular (28L)
• Extracellular (15L)
• Interstitial (10L)
• Intravascular (5L = 9 Pints)
What is?
• Interstitial space = small, narrow spaces between cells, tissues
or parts of organ
• Oedema = excessive fluid accumulating in interstitial space
• ‘Third space’ =
– Space where fluid does not normally collect in large
amounts
– Small amounts of fluid normally exists in such spaces, and
function as lubricant (pleural fluid)
– But can contain large amounts of fluid (usually ‘hidden’), eg
pleural cavity, pancreatitis, burns, major fractures,
obstruction, peritoneal cavity (ascites, visible). Hence ..
– Patient may be truly hypovolaemic but fluid loss not obvious
 Normal maintenance requirements
- Depends on weight. For 70 kg man
Amount/kg/time Amount/day Ideal

H20 in 1.5 ml/kg/h 2.5L

Na+ in 1-2 mmol/kg/h 100 mmol (70-140)

K- in 0.5-1 mmol/kg/h 50 mmol (35-70)

Min UO out >0.5 ml/kg/h Approx 0.9L Output = 1.5L

Output = 2.5L =
Urine = 1.5L (5 x 300 ml)
Sweat = 0.5L
Lungs + faeces = 0.5L
Increased Water Requirements
• Fever/Sweating. Increase by 100 to 150 mL/day
for each C degree body temperature↑
• Burns
• Tachypnoea
• Surgical drains
• Polyuria
• Gastrointestinal losses (eg vomiting or diarrhoea)
Fluid State Assessment
Severity Clin Pulse BP JVP
(not CVP)
Severe SOB++. Tachyc++ ? V high
Drowsy
Mod SOB+ Tachyc+ ? High
Hypervolaemia Mild N Tachyc N N
Euvolaemia N N N
Hypovolaemia Mild N Tachyc N N
Mod Drowsy Tachyc+ Low (<100 Not seen
systolic)
Severe Unconscious Tachyc++ V low <80) Not seen
Patient = (centrally) ‘wet’, Tachycardia = Acute Problem
‘dry’ or ‘middle’, not 2/3 or 3/3) .. Bradycardia = (Prob) Problem
you have to decide
Contents Available Fluids
Na+ Cl- K+ HCO3- Gluc Notes
Normal pl 135-145 95-105 3.5-5.3 22-26 3.5-7.8
0.9% NaCL 154 154 0 0 0 Not ‘normal’.
pH 5.5
Hartmanns 131 111 5 29 (lactate) 0 Physiological
pH 6.5
5% Dext 0 0 0 0 50g Water
(170 cals)
Dext-Saline 30 30 0 0 40g
4%/0.18%
Gelofusin 154 120 0 0 0 Colloid

Other normal values: Urea 3-7, Creat 60-120,

Ca 2.2-2.6 (1.1-1.3 ionised), Mg 0.75-1.0, Osmolality 285-295
Principles - Choosing IV Fluid
1. Replacement .. then maintenance fluids
2. Give what they lack, at rate they need (prop to loss
and weight)
– Crystalloid (with correct Na, K)
– Colloid
– Blood
Replacement Fluids

• Hartmanns
• Occ N Saline, 2N Saline, Dext-saline
• (Colloids)
• 50% Dext if hypoglycaemic
• Blood
Hartmann’s Solution

• ‘Physiological’:
• Na+ 131 (135-145)
• Cl- 111 (95-105)
• K+ 5 (3.5-5.3)
• HCO3- 29 (22-26) as lactate
• Good as a plasma replacement fluid, esp post-op
• Complications
• 1930s. American paediatrician Alexis Hartmann for treating
acidosis
 Sydney Ringer (1834-1910)
and Alexis Hartmann (1898-1964)

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.
1981.tb08698.x/pdf
Colloid

• Eg gelofusin, albumin
• Given to keep fluid in intravascular space
• Not inert (like crystalloids)
• Complications
• Not recommended by NICE (CG174)
Blood
• Packed cells (300 ml) vs whole blood (450-500 ml)
• Remember humans have a 3L blood volume
• Replacement (Emergency, ie bleeding)
• Do not wait for blood. Give anything eg 0.9% Saline
• Whole blood (stat)
• O negative if necessary
• Maintenance – packed cells, 2h
• Does ‘maintenance blood transfusion’ exist
• Consider FRUS ‘cover’ (NB: normal dose, if creat >200,
give 80 mg)
• Check K+ if necessary
Acutely Hypotensive Patient
• What is hypotension
• What is normal BP
• Needs IV fluids (usually). Rarely FRUS!
• Anything (physiological (or colloid) or blood)
• ‘Fluid challenge’ = 250-500 ml/15 min then re-assess
• If little/no response (feels better, BP, UO), call reg ±
ICU. As either
• Is patient bleeding? .. don’t just give more fluids
• Needs an operation?
• If not, ICU/inotropes?
Maintenance Fluids

• Alternating “1 salty and 2 sweet, with a leetle but of K

in” (0.9% Saline/5% Dext (+ K 20 mmol/L))
• This gives: 3L H2O, 154 mmol Na+, 60 mmol K+
• Hartmanns: 3L H2O, 393 Na+, 15 K+
• Dextrose-saline
• 3L a day
• Too much for 70 kg man, esp if drinking
• Far too much for 40kg old lady
• Too little for 120 kg man
• Too little if dehydrated
‘Normal’ Saline – 0.9%
• Not ‘normal’ at all .. major misnomer
• Not physiological, so no role as a maintenance fluid - if given
alone
• Na+ 154 mmol/L (135-145)
• Cl- 154 mmol/L (95-105)
• Acidotic (pH 5.5)
• Complications
• 1831. William Brooke ‘Shaughnessy, E’burgh. Just qualified.
Indian Blue Cholera pandemic
• 1882-83. Hartog Jacob Hamburger. Dutch physiologist
coined term ‘normal’
Hartog Jacob Hamburger (1859-1924)
5% Dextrose

• Is water
• Given instead of pure water (maintenance)
• No role as a replacement fluid (plasma or blood), as not
physiological
• If can drink, give water orally (or by NG if cannot)
• Not sugar and not a food
• Complications
Dextrose Saline – 4%/0.18%

• Na+ 30 mmol/L
• Cl- 30 mmol/L
• Good maintenance fluid
• No role as a replacement fluid as not physiological
Where Do IV Fluids Go?

• Given IV, so initially into intravascular space

• Then distributed across all fluid departments
• So ..
• NB: can get premade crystalloids with K in
(eg 20 or 40 mmol/L)
How do you know when to stop?

1. Clinical signs (eg, ↑UO + BP; ↓HR + cap refill time)

2. Biochemical (eg, normalisation Na, urea + creat)
3. Patients’ subjective experiences (eg, they “feel
better” or are no longer thirsty)
Advantages of IV Fluids

• Immediate / Therapeutic effect

• Control over the rate of administration
• Necessary if patient cannot tolerate fluids orally
• Some drugs cannot be absorbed by any other route
• Pain and irritation is avoided compared to some
substances when given SC/IM
Disadvantages (1) - Systemic

• Cannot reverse action of drug (fluid)

• Fluid overload, ie can cause shock (also Rx for)
• Anaphylaxis/Allergic reactions .. esp blood + colloid
• Administration time
• Catheter embolism
• Air embolism
 Disadvantages (2) - Local
• Microbial contamination/Infection
• Phlebitis – hot, red, tender,
not hard and swollen
• Thrombophlebitis – hot, red,
tender, hard and cordlike vein
• Extravasation → Tissue damage
Disadvantages (3) – Biochemical

• Na
• 0.9% NaCl → Na ↑
• 5% Dext → Na ↓
• K
• Hartmanns, Blood → K↑
• Acid/base
• 0.9% NaCl → pH ↓
Special Situations

• Post-op. Give if need only. Rem: K is intracellular

• CCF. Not >2L/day
• CLF (esp if unsure fluid state). 5% Dext only
• CRF/AKI (esp if unsure fluid state). V variable needs
• BP↓/Sepsis. ‘Third space’. Eg warm hands, tachyc, low BP.
Hartmanns. May need inotrope
• Alcohol. Give Pabrinex before any 5% Dext
• Cerebral haemorrhage. 0.9% Saline. No Dext
 IVF – Ten Commandments
1. IV fluids = drug. Treat them as such and only give if patient needs them
2. Humans = 60% water. Think about ‘Third Space’
3. (Like) all drugs, they have side-effects. IV fluids treat/worsen biochemical
disturbance (eg Na or K or acidosis ↑ or ↓) or cause pulmonary oedema
4. Assess fluid state before prescribing: 1. Examination (esp JVP, not SOA),
2. Obs (incl UO) and 3. U+E (know your normal ranges). Ask the patient!
Clinical mainly. Beware CVP errors
5. Patient is hypervolaemic, hypovolaemic or euvolaemic. Decide, or ask.
6. Replace with appropriate fluid - plasma with physiological fluids (noting K);
blood with blood
7. Maintain with appropriate fluids
8. If BP (or UO) not up after replacement .. ?bleeding ?inotropes (call reg).
NB: Young patients will not drop BP until >30% blood/fluid loss
9. Do not copy previous fluids. Go and see, assess patient, then
prescribe/stop
10. If in doubt .. do ABGs and ask
Thankyou
• http://www.oscestop.com/Adult%20IV%20Fluids.pdf
• https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0082773/
• https://www.nice.org.uk/guidance/cg174
• caroline.letchford@uhcw.nhs.uk
• andrew.stein@uhcw.nhs.uk ..
•