IV Fluids

IV Fluids
Intern Boot Camp 2008
Michelle Kahlenberg, MD PhD

Saline
 Normal: 154 mEq/L of Na+ and Cl−

 Half-normal saline (0.45% NaCl)
contains 77 mEq/L of Na and Cl−
 ¼ NS contains 39 mEq/L of Na and Cl
and always contains 5% dextrose for
osmolality reasons
D5W
 50 gm/L of dextrose in water: isotonic

but doesn’t provide sodium
Lactated Ringers
 130 mEq of sodium ion = 130 mmol/L.

 109 mEq of chloride ion = 109 mmol/L.
 28 mEq of lactate = 28 mmol/L.
 4 mEq of potassium ion = 4 mmol/L.
 3 mEq of calcium ion = 1.5 mmol/L .
Case #1
45 yo woman with hx of HTN admitted with

gallstone pancreatitis and is unable to
take PO. She has no evidence of
infection and is hemodynamically stable.
What IVF do we give?

Case #1
 For maintence fluids adhere to the 4/2/1 rule for water
balance.
 Require 1-2 mmol/kg of Na+ per day
 Require 0.5-1 mmol/kg of K+ per day
 So for a usual sized, euvolemic person a rate of

approx 125 ml per hour of ¼ NS with 20 mEq of KCl
per bag per day will give approx 100 meq of Na+ and
60 meq of K+ per day.
 (adjustments should be made for those with CHF,

renal failure, or on K+ sparing medications.
Case#2
65 yo man with history of DLD, tobacco

use, obesity, diabetes admitted with
chest pain with small troponin elevation
and progressive T wave changes on
ECG. He is started on heparin drip, BB,
statin, ASA and is kept NPO for possible
cath in the AM.
What about his IVF?

Case #2 Continued
 Gentle hydration with normal saline prior
to contrasted procedures can help
prevent contrast induced nephropathy
 Usually 75 ml per hour of normal saline
(roughly 1 ml/kg/hr) 12 hours before and
12 hours after the procedure +/-
mucomyst is helpful
 Could add D5 if he has DM meds on
board
Case #3
You are called on cross cover to see an 86

yo NH resident with EF 35% admitted for
UTI and mental status changes. She
has a blood pressure of 86/45, HR 120
(sinus tachycardia) and is not
responsive.
What next?
Case #3 continued…
 Sepsis protocols recommend IVF bolus

until CVP reaches 10-12. Obviously on
the floor we don’t have CVPs but you
shouldn’t be shy about giving IVF bolus
(at least 2-3 L before you call the MICU)
even if patient has HF. If they’re septic,
they need fluids!
Case #4
67 yo man with parkinson’s with dysphagia

requiring PEG tube getting tube feeds on
the floor. You are called that patient is
becoming more somnolent.
37.0 78 140/89 12 98% RA
What next?
 Further chart review suggests that free

water flushes have been left out of tube
feed regimen.
 Serum sodium comes back at 161.
 Now what?
 Calculate the free water deficit
 0.6*wt*(pNa+-nl Na+)/Nl Na+
 If he weights 70 kg, his deficit is 6.3 L

 Want to correct deficit 10 mEq per 24 hours so
need 6.3 L over 48 hours or roughly 3L/day
(D5W at 125 per hour)
 Also need to account for insensible losses of
approx 30 ml water per hour-so if NPO, need
D5W at approx 150 per hour.
Case #4.5
 40 yo woman with no previous past medical hx
presents with N/V/D x3 days with inability to
keep anything down PO
 37.6 105 110/75 98% RA (+ orthostatics)
Labs show 7.3>14/42<256

151/112/31
-------------<125
4.2/28/1.3
How do we treat her?
Case 4.5 continued…..
 Hypovolemic hypernatremia is the most
common cause of hypernatremia
 This is corrected with volume repletion
with normal saline until she no longer
has evidence of volume depletion. Then,
recheck Na+ and calculate free water
deficit. (Usually, hydrating them will
improve the majority of the
hypernatremia).
Case #5
46 yo woman with hepatitis C and cirrhosis
admitted with profuse hematemesis.
36.5 140 79/50 24 97% RA
7.9>6/24<67 131/100/47
-------------<135
3.3/24/1.4
What first?
 She was given 5 L NS and 3 units PRBC. The
bleeding continues intermittently. While awaiting the
arrival of the GI team:
 37.0 125 89/54 21 94% 1L NC
 Repeat labs show

6.9>7.4/27<51 140/115/35
-------------<135
3.1/16/1.2
What do we do now?
Case #5 Continued…
 LR!
 130 mEq of sodium ion = 130 mmol/L.

 109 mEq of chloride ion = 109 mmol/L.
 28 mEq of lactate = 28 mmol/L.
 4 mEq of potassium ion = 4 mmol/L.
 3 mEq of calcium ion = 1.5 mmol/L .
Case #6
 45 yo woman with progressive,

metastatic T cell lymphoma admitted
with lethargy and nausea.
 Serum sodium is 111

 Hypertonic saline is given ONLY IN ICU

and is reserved for severely symptomatic
patients (seizures, impending herniation)
as severe symptoms are likely due to
brain swelling from initial drop in sodium.
 Correct 1.5-2 meq per hour for the first
few hours until no longer symptomatic,
no more than 10 meq in 24 hours.
 For her, mildly symptomatic, so correct 10 meq
over 24 hours or until no longer symptomatic
then free water restrict.
 Increase in PNa = (Infusate [Na] - PNa) ÷
(TBW + 1)
TBW = (lean body weight times 0.5 for women,
0.6 for men).
(154-111)/26=1.65 mEq increase per L of NS
given, so she would need about 5L of NS over
24 hours.
 For asymptomatic hyponatremia, free

water restriction or vasopressin receptor
antagonists are the treatment of choice,
 There is evidence that improving serum
sodium even if they are “asymptomatic”
can reduce falls in the elderly and
improve subtle neurological deficits
Thank you.
 Questions?

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IV Fluids

Intern Boot Camp 2008

Michelle Kahlenberg, MD PhD

 Normal: 154 mEq/L of Na+ and Cl−

 50 gm/L of dextrose in water: isotonic

 130 mEq of sodium ion = 130 mmol/L.

45 yo woman with hx of HTN admitted with

What IVF do we give?

 So for a usual sized, euvolemic person a rate of

 (adjustments should be made for those with CHF,

65 yo man with history of DLD, tobacco

What about his IVF?

You are called on cross cover to see an 86

 Sepsis protocols recommend IVF bolus

67 yo man with parkinson’s with dysphagia

37.0 78 140/89 12 98% RA

 Further chart review suggests that free

 If he weights 70 kg, his deficit is 6.3 L

Labs show 7.3>14/42<256

36.5 140 79/50 24 97% RA

 Repeat labs show

 130 mEq of sodium ion = 130 mmol/L.

 45 yo woman with progressive,

 Serum sodium is 111

 Hypertonic saline is given ONLY IN ICU

 For asymptomatic hyponatremia, free

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