Fluids

When not to insert NG tube? (insert OG [orogastric] tube instead)

-Nasal injury or nasal obstruction -Cribriform plate / basilar skull fx NG might go into cranium (skull)

More advanced cardiovascular monitoring - central lines Tip of catheter is in "central" circulation (in the heart). In what two locations?

-Subclavian vein -Internal Jugular Vein

1 mL (or cc) of water weighs ___ ______.* 1000 mL of water weighs ___ ________. (1 liter of water weighs 1 kilo - approx 2.2 lbs)

1 gram, 1 kilogram

IV *maintenance* rate for *children* *One traditional formula* (or whatever the pediatrician tells you!) -0 - 10 kg ____ ml / kg / day (~4 ml / kg / hr) -10 - 20 kg add ___ ml / kg / day (~2 ml / kg / hr) for wt > 10 kg -> 20 kg add ___ ml / kg / day (~1 ml / kg / hr) for wt > 10 kg *Children* -*10 kg* -> 1000 ml / d ~ *___ ml* / hr (41.7 ml/h per the formula) -*20 kg* -> 1500 ml / d ~ *___ ml* / hr (62.5 ml/h) -*30 kg* -> 1700 ml / d ~ *___ ml* / hr (70.8 ml.h) When writing orders, we give fluid rate in mL per hr, not per day.

100 ml 50 ml 20 ml *40 ml* *60 ml* *70 ml*

IV *maintenance* rate for *children* Is the child dehydrated? Hypovolemic? *start with a fluid bolus:* ___ ml / kg NS or RL (may repeat if needed) -What is a bolus volume for a 10 kg child? -What about 20 kg? *Oral* fluids are ~1.5 times IV calculation

20 ml *200ml* *400ml*

*Umbilical vein catheter in neonate* How many umbilical veins are in the umbilical cord? How can you tell the umbilical vein from the arteries?

*1 vein, 2 arteries* *Vein is larger, with thinner wall.*

*More blood products* Has clotting factors -Used for coag deficiency *plus* active bleeding -Not used for volume expansion alone -Takes ~ ___ minutes to *thaw* - --Can keep it thawed and refrigerated for ___ days * -Unlike RBC, give Group O only to blood type O --Rh is not an issue?

*FFP (fresh frozen plasma),* 30 mins, 5 days

-Don't use D5W for routine maintenance or resuscitation. -If you do, it will result in *low serum sodium.* -This will cause lethargy, and eventually *seizure or coma.*

*Hyponatremia*

*Blood products (colloids) * Blood *type* takes a few mins; *Crossmatch* takes ~ 1 hour Contain little plasma *-Normally used,* rather than whole blood -1 unit raises Hct ~___% (Hgb ~1)

*RBCs ("packed" red blood cells),* 3%

Volume deficit: patient needs *more than maintenance* fluids *History * -Vomiting, diarrhea -Fever, profuse sweating -Thirst -Weight loss (in past few days) *Physical exam* -Skin turgor, mucosal hydration *-Tachycardia,* orthostatic hypotension -Oliguria = low urine output --Treat with fluids, not diuretic

*Start with fluid bolus:* -*Adult: 500 mL - 1000 mL* -*Child: 20 mL / kg*

New topic: What does this patient need? If he can eat, feed him. If he can't eat....

*TPN* = total *parenteral* nutrition (*IV* hyperalimentation -glucose, protein, vitamins, minerals) *TEN* = total *enteral* nutrition (*GI tract* tube feedings)

_________________, with ports hanging out of the skin (Hickman, Broviac, Groshong, etc) Used for chemotherapy, long term antibiotics, hyperalimentation (parenteral nutrition - "intravenous feeding." Alimentation meaning nourishment)

*Tunneled catheter*

*Blood products (colloids) * Blood *type* takes a few mins; *Crossmatch* takes ~ 1 hour RBC + plasma (clotting factors) -If from walking donors, it might even be warm -Important source of clotting factors -Best for active hemorrhage, but rarely available -More immunologic reaction than RBCs (why?)

*Whole blood*

Commonly used for *maintenance* fluids (patient is not hypovolemic): -*Adults* use what fluids? -*Children* use what fluids?

-*Adults* - 5% dextrose and .45% NaCl ~ D5 ½ NS ("D5 half normal") -Add 20 meq KCl / L to replace K and Cl in case of much vomiting or NG suction -*Children* - --Classically used to give D5 ¼ NS --Recent recommendation D5 ½ NS * --Or whatever the pediatrician says!

*Nasogastric tube (or oro-gastric tube)* -*Name a risk of using it for tube feeding?* -Normally use it to remove air and fluid from stomach. -Usually put it on suction. (otherwise why have it?) -When to insert it? -When *NOT* to insert NG (use oro-gastric [OG] tube instead)?

-*Aspiration* --Persistent vomiting --Bowel obstruction other --Nasal injury --Cribriform plate or basilar skull fx

*WHY* do we give *IV* fluids? *Provide hydration when patients can't eat or drink.* -Or patients not eating or drinking *enough* -Give post-op until patient is eating or drinking *enough.* -Patient must be able to meet his maintenance needs plus additional losses (diarrhea, vomiting, sweating), otherwise he needs IV fluids. *-IV fluids alone will suffice for about a week. After that, consider the need for more nutrition. For example?* *Resuscitation in cases of hypovolemia* -Low intra-vascular volume due to blood loss or dehydration

--Enteral - through the GI tract --TPN = total parenteral nutrition - thru central line --PPN = peripheral parenteral nutrition

*Not* used for *maintenance* or resuscitation

-D5W -20 meq KCL in D5W -TPN

*Hematocrit (Hct) = % of RBC in blood compared to plasma* If there is no loss or gain of RBC: -Add fluids -> ? -Lose fluids -> ? Example - -A dehydrated patient enters the hospital and receives IV fluids. The next day his Hct is lower than on admission. Does that mean he has lost blood? *What is the normal Ranges of Hemoglobin and Hematocrit?*

-Decreased Hematocrit (hemodilution) -Increased Hematocrit (hemoconcentration - as in dehydration) *Hematocrit:* Male: 38.8-50.0 percent Female: 34.9-44.5 percent *Hemoglobin:* Male: 13.5-17.5 grams/dL*** (135-175 grams/L) Female: 12.0-15.5 grams/dL (120-155 grams/L)

Most Na (sodium) is in what part of the cell? Most K (potassium) is in what part of the cell?

-Extra-cellular -Intra-cellular

*Oral Rehydration Solution (ORS)* recommended by WHO and UNICEF: Total osmolality between _____ to _____ mmol/L *ORS consists mostly of WATER, SUGAR, and SALT in a standard ratio -* *-______ sugar and ______ salt in 1 liter of water* *-2 tbl. sugar and ½ tsp. salt in 1 liter (quart) of water tbl* = tablespoon; tsp = teaspoon A simple solution, Gerlin *"a large pinch of salt and a fistful of sugar dissolved in a jug of clean water,"* the simplest recipe for oral rehydration solution."

200-310 mmol/L 30 mL 2 1/2 mL

Daily fluid requirements *Intake - at least ______ mL of water per day* -75% from oral intake -25% extracted from solid foods *Losses occur as result of* -Urine output - about 1 liter / day - easy to measure --At least 500 - 800 mL /d needed to clear products of metabolism -"Insensible" loss - about ____ mL / day - hard to measure --skin 75% (sweating) = water + electrolytes --lungs 25% = pure water -GI tract - about ____ mL / day --Of course, increased with vomiting or diarrhea *Generally, fluid requirements taken orally are estimated at 1.5 times IV fluids.*

2000, 600, 250

1 cup= ____ mL 4 cups = 1 ________ (960 mL) 8 oz = 1 cup 1 quart = .96 L 1 ounce (oz) = 1/8 cup=___ mL 1 cup = ___ tablespoons 1 Tbsp = ____ mL 1 Tbsp = ___ teaspoons (tsp) Approx. how many mL in 1 teaspoon?

240 mL, Quart, 30mL, 16 Tbsp, 15mL, 3 tsp

How many of these will fill a cup? 30 mL syringe contains _____ cc _____ Tbsp ____ tsp _____ oz

8 (8 mL x 30 mL = 240 mL) -30 -2 -6 -1

Volume excess: patient might need *less than maintenance* fluids How much is maintenance for adult? *History* --Fluid retention, weight gain (past few days) --Symptoms of CHF *Physical exam* --Pedal or presacral edema --Ascites, anasarca (Generalized edema) --S3 gallop, JVD

About 100mL/hr

IV *maintenance* rate for *adults* Another formula for adults 35 ml / kg / d (for adults) = 2250 ml / d 70 kg person (adults) using child formula -0 - 10 kg @ 100 ml / kg = 1000 ml -10 - 20 kg @ 50 ml / kg = 500 ml -20 - 70 kg @ 20 ml / kg = 1000 ml 2500 ml / d 2500 ml / d *~100 ml* / hr (or more for large pt) -Dehydrated? Hypovolemic? *start with a fluid bolus:* 500 mL - 1 liter NS or RL (may repeat if needed) *-Persistent vomiting or NG suction add what?*

Add 20 meq KCl / liter

-Connected to pressure transducer -We keep it open by injecting fluids, but it is *not* for volume replacement. -See characteristic insertion site in radial artery. --Neonate is what locations?

Arterial lines Umbilical artery catheter

-More advanced lines, usually in subclavian or internal jugular v. -Used for giving fluids, total parenteral nutrition (TPN), blood products, and for measuring CVP, PA pressures, others. *-Complications:*

Central lines -Complications: pneumothorax, hematoma, infection, injury to heart valve, others

*I&O (intake and output) is measured in some patients.* -Low urine output in surgery patient: *What concerns do you have?* -Hypovolemia -> oliguria -> treat with fluids, not diuretic. -How we measure urine output - from low tech to higher tech

Consider hypovolemia or bladder outlet obstruction 1st

-We want to see *metallic tip* of feeding tube in duodenum rather than stomach --Think patient safety - Minimize chance of aspiration. -Generally, let tube feedings *drain in by gravity,* rather than pushing in with a syringe --Minimize chance of aspiration.

Feeding tube (Dobhoff)

*Complications of what catheter?* -Infection, DVT -Often inserted as emergency; remove ASAP to prevent these complications

Femoral vein catheter

-Has more than 3 times the amount of NaCl as normal saline (3% - 5% NaCl instead of the usual .9%) -*Draws interstitial fluid into intravascular space.* --Hemorrhage - to increase intravascular vol --Head injury ----To increase cerebral perfusion pressure ----*To decrease tissue swelling* ------Decreases cerebral edema. ------Decreases intra-cranial pressure. -But studies do not yield conclusive data to support its routine use.

Hypertonic Saline

-Common causes: diuretics and NG suction -NG suction can result in loss of HCl from the stomach. --To avoid metabolic alkalosis, the body responds by losing K in the urine. --Serum K can be low after prolonged NG suction. --Low K can cause _______ (also high K can cause them.) --Prevent by adding KCl to each liter of IV fluids (20 mEq KCl / L) when patient is on NG suction. --Not all maintenance fluids require addition of KCl.

Hypokalemia = low serum K, PVCs

-Reservoir completely under the skin with no catheter exposed -Special curved needle is used to access reservoir and give fluids -For chemotherapy, long term antibiotics, hyperalimentation (parenteral nutrition - "intravenous feeding")

Implanted Central Line

Dehydration (no blood loss) ->same RBCs, less plasma -> Hct increases or decreases? Add fluids (not blood) -> Hct increases or decreases?

Increases, Decreases

-In child - tibia, femur, maybe others -In adult - tibia, humerus, sternum --Sternal I.0. autopsy results - 80% successful placement in the field [Feedback to the field: an assessment of sternal intraosseous (IO) infusion. -Can infuse fluids and drugs -*Contra-indication* - fracture - can result in compartment syndrome when fluid leaks out of bone into soft tissues. -*Complication* - --Intra-osseous infusion was started in L tibia. --Maybe they didn't know about the L ankle fx. --Extravasated fluids -> compartment syndrome in L leg (see ischemic foot) --Other leg was mangled -> amputation. --Now has R BK amp and impaired L leg.

Intra-osseous infusion (I.O.)

-____= keep vein open -____ = to keep open Heparin lock or saline lock - for intermittent meds -No fluids running -Irrigate periodically to keep the line from clotting. -Useful for antibiotics, pain meds, etc Patient needs IV fluids *at least maintenance rate, not just KVO...* -If he has continuing fluid losses (vomiting, diarrhea). -If he will be NPO for more than 12 hours or so. --Children and elders are at more risk for dehydration. ---NPO = nil per os = nothing by mouth

KVO TKO

How do we know we are giving the patient enough (or too much) fluids? -_________ - skin turgor, heart rate, BP, "tilts" -___________ --Hematocrit (Hct) --*I & O* = measured *intake and output* (urine) --Urine specific gravity - reference point is 1.010 ----Dehydration -> Increase spec grav -___________- CVP, wedge pressure, etc.

Low Tech Medium tech Higher tech

Crystalloids - used for volume *resuscitation* in case of hypovolemia

Normal Saline & or Lactated Ringers

-Balloon is inflated with sterile fluid (not air). Why not air? -Balloon "floats" through chambers of right heart; wedges in PA. -Do we want to allow it to stay "wedged" for very long? *Type of catheter?*

PA catheter - "float a Swan"

*HOW* do we give IV fluids? ______________ - most commonly in arm -Can also be in the leg, but only temporary, due to infection, clotting. "Butterfly" - to draw blood or give meds Heparin lock or saline lock - for intermittent administration of what drugs? Cut-down - -Make incision over vein; find vein and dissect it; insert IV catheter, with or without passing ties around vein. -Still a reliable method when peripheral IV fails -Now largely replaced by intra-osseous infusion

Peripheral line

-Very long catheter -Inserted in a peripheral vein -Threaded all the way to SVC -Avoids complication of pneumothorax -But might become infected more readily, can break off, embolize, cause air embolus, etc.

Peripherally Inserted Central Catheter (PICC)

*More blood products* -Usually no need to give unless platelet count <__________ *and* patient is actively bleeding -1 unit from single donor (or "6-pack" pooled) can increase platelet count by ~___________ -Kept at *room temp;* only good for 5 days *What is the normal ranges?*

Platelets 50,000 25,000 >200,000

-Use it to measure central venous pressure (CVP), PA pressure, "wedge" pressure, cardiac output, etc -These measurements can help determine patient's fluid status. --If CVP and wedge pressure are low, he probably needs more fluids. --If high, he might be over-hydrated, or in cardiac failure. -Is his CVP probably high, or low? -What about "wedge pressure"? -Does he need extra fluids? -What else can cause Increased JVP?

Pulmonary Artery (PA) catheter (i.e.Swan-Ganz)

-Warm them! -Hang with NS and use blood filter.

Whole blood and RBC

*WHICH* fluids do we use? -RL = LR = Ringer's lactate or Lactated Ringer's -NS = 1 normal saline = .9% NaCl ("normal" = mol wt in gms/valence) -D5 ½ NS = dextrose 5% in .45% NaCl (Say "D5 half normal.") -D5 ¼ NS = dextrose 5% in .225% NaCl (say "D5 quarter normal.") -D5 ½ NS with 20 meq KCl / L (say "D5 half with 20 of K.") -D5W = dextrose 5% in H2O; D50W = dextrose 50% in H2O

Yup

"bolus" = running in fluids rapidly Does this show a bolus, or KVO rate? Beware: If you squeeze too hard, applying too much pressure, tubing could fly off the bag. (Don't ask me how I know this.)

yup

*Acute blood loss* -> initially no change in Hct because it may take several hours *(plasma and RBC lost in same ratio).* DONT WAIT for CBC to give blood if lost Add IV fluids (not blood) -> Hct goes down (even with no more bleeding)

yup

*Feeding tube versus Nasogastric tube* -Not normally used interchangeably. -Feeding tube is to *insert* tube feedings. -NG tube is to *drain* the stomach (put it on low suction).

yup

*Summary* -Select appropriate IV fluids and rate for maintenance, volume expansion, exsanguination. -Calculate daily fluid requirements based on age and weight. -Select which IV fluids contain electrolytes or clotting factors. -Select appropriate tubes for IV resuscitation, feeding and gastric suction -Discuss complications of IV fluids and tube feedings.

yup

Whole blood and RBC - warm them! -Hang with NS (attach via "piggy-back" to a line running NS). -Patient safety - blood must go to the right patient to avoid ABO incompatibility and transfusion reaction. --This requires attention to detail (and paperwork). --*Two* people check patient ID and blood ID.

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*Check on learning* -What is a reasonable initial maintenance rate for an adult? -What is a reasonable initial maintenance rate for a 10 kg child? --20 kg? --30 kg? -What is a reasonable initial bolus for an adult? -What is a reasonable initial bolus for a... --10 kg child? --20 kg? --30 kg?

~100 mL/hr ~ 40 mL/hr ~ 60 mL/hr ~ 70 mL/hr -500 - 1000 mL wide open -200mL -400mL -600mL