IV fluids Workshop 10/11/04

1. IV fluids Workshop 10/11/04 Bruce R. Wall, M.D.

2. IV fluid orders • Does the patient need IV fluids? • Volume status • Water status • Potassium balance • Acid base balance

3. What are our choices? • For intravascular volume depletion: normal saline 0.9gm% PRBC’s albumin/plasma proteins • For Hypernatremia: D5W or D10W • D5 ½ normal saline… primary maintenance fluid…

4. Volume status • History: Congestive heart failure Total body weight Diuretic use Fluid loss via NG or third spacing • Physical: Vital signs Orthostatic change in BP Pulmonary edema S3 gallop Peripheral edema Ascites

5. Therapy for volume issues • Hypovolemia: normal saline (Ringers) blood product tranfusions albumin • Hypervolemia: diuretics natrecor® dialysis – HD vs CVVHD after load reduction oxygen and morphine sulfate phlebotomy

6. Water balance • Hypernatremia • Hyponatremia: hypovolemic euvolemic hypervolemic shock thyroid CHF burns SIADH liver disease pancreatitis adrenal nephrosis

7. Water status: therapy • Restrict fluids (unless volume depleted) • Assess patient’s volume status • Diuretics with salt and fluid restriction • Avoid hypotonic TPN

8. Potassium balance • Intake – output = accumulation • Oral potassium supplementation • IV potassium • Estimation of deficit • Role of underlying acidosis or alkalosis • Renal insufficiency • Magnesium deficiency

9. Acid base disorders • Respiratory vs metabolic disorders • Mixed acid base • Role of sodium bicarbonate therapy

10. ARF • 73 yo male S/P AAA 10 yrs ago • Admitted with aorto-enteric fistula, Hgb 5, hypotensive, normal renal function • Surgery to ligate aorta, below renal arteries; post op renal function preserved • Orders? • Surgery II: Axillary artery to femoral bypass CPK 120,000 Na+ 128 BUN 50 creat 2 orders?

11. ARF continued • 3 weeks post surgery: oligoanuric with gastric output 1.5 to 2 liters per day Hemodialysis continues, although marked hypotension, and mild diarrhea from feedings • OBS Eventually gastric jejunostomy stent placed • IV fluid orders?

12. CHF • 70 yo diabetic male smoker CRI creat 2 • No anion gap K+ 6meq/l (recent vioxx) • Severe CP – acute inferior MI (RV infarct?) • BP 80/50 AV block; en route to cath lab • Rales loud S3 gallop mild LE edema • Orders?

13. CHF continued • S/P CPR temporary pacemaker ACLS • Received 2 amps NaHCO3 during code • Intubated dopamine and dobutamine • Na+ 150 BUN 80 creat 3 HCO3 12 • UOP 200ml/day, despite BUMEX infusion • CHF on exam and xray • Orders?

14. Hyponatremia • 65 yo WF smoker small cell carcinoma • ‘mild confusion’ – chronic dementia • dyspnea with exertion - COPD • out patient Na+ 122 mEq/l K+6.1 • No acidosis GFR normal

15. Hyponatremia: continued • PE: normal vitals (no tilt) • comfortable at rest dullness L chest extremities - no edema • Random Urine Na+ 40 mEq/L • U osm 600 • 1) Differential Dx? • 2) IV fluid orders?

16. SIADH • Receives 125ml/hr normal saline • Na+ next morning is 118meq/l • Confusion is worse… • Urine osmolality of 600 can excrete the sodium chloride in one liter of NS in 500ml • Therefore: kidney is able to remove the NaCl and RETAIN 500 ml of free water

17. DKA • 45 yo WF IDDM X 20 yrs • Non-functional glucometer… • N&V for 18 hrs… indigestion/pain for 2 hrs • No dyspnea No blood in emesis or stool • ‘too sick to take insulin’ • PMH: DM HBP Lipids CRI smoker retinopathy neuropathy • Family Hx: early CAD

18. DKA: continued • PE: 130/60 tilting to 95/50 P110 R24 afebrile Neck: veins impossible to assess Lungs: few rhonchi, WOB increased Cor: I/VI m, soft S3??, increased HR Abd:benign, non-distended Ext: 1+edema • Lab: WBC 12K Hct 35% 2+proteinuria 5-10 WBC/HPF on urinalysis • EKG: 2mm ST elevation III and AVF

19. DKA: continued • Na+ 131 K+ 3.2 Cl- 104 • HCO3 5mEq/l BUN 70 Creat 2.0 • anion gap 22 mEq • pH 7.18 pCO2 17 pO2 80 • (1.5)(HCO3) + 8 [+/- 2mEq] = pCO2 • Dx? Volume status? Na+? K+? • acid/base issues? IV fluids?

20. Rhabdo • 24 yo SWAT team member of GPD • August 98 “106 degrees in the shade” • full gear running drill - collapse in field • BP 100/60 P 130 T 102.8 rectal • Skin warm Neck veins: nl Lungs: clear • Cor: increased HR MS: tender back/gluteal region, no edema

21. Rhabdo • Urine looks red… scant volume… heme + • U Na+ <10 FeNa+ low Na+ 149 • K+ 5.9 Anion gap 22 Bun 10 Creat 2.4 • Ca++ 6.5 Phos 8.5 CPK 50,000 • “As you rapidly cool down the patient:” • Diagnosis? Volume status? • Cause of hypernatremia? Hyperkalemia? • IVF orders?

22. Ascites • 65 yo retired politician known cirrhosis • ETOH exposure Hx GIB/varices • Meds: Betablocker aldactone furosemide no NSAID’s • Decreased intake for several days; increasing abd pain - severe, diffuse, no radiation; min emesis no obvious blood in stool

23. Ascites: continued • PE: barely awake confabulates follows? • tremulous T 101.8 BP 90/60 red palms spider angiomata muscle wasting massive ascites very tender abdomen guaiac positive stool edema 2+ ankles • Lab: WBC 20K Hct 34% Bili 4 albumin 2.4 PT 24 sec AG 12 Na+128 K+ 5.0 FeNa<1 ascites=2000WBC (GPC) BUN 80 Creat 3

24. Ascites: continued • Differential diagnosis? • Volume status? • Acid base status? • IV fluids? (TPN?) • Effect of administration of vassopressin?

25. Final thought • Good judgment comes from experience; unfortunately, experience often comes from bad judgment…