Fluid Management

[Lefty]

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Ever since I've started rotating through hospitals I've been dealing with IV fluid management but still I don't seem to know much about it. Neither do most of the other medical students, interns, or residents. My school did a horrible job teaching us--actually, it didn't teach us anything about this topic. I have yet to find someone who can or will give me a decent explanation about the different kinds of fluids available for use, when to use them, how much for which situations, etc. Does anyone have any suggestions or know of any good books that explain these things simply and understandably???
😕 😕 😕

Any help or suggestions would be appreciated. Thanks.

 

[Smurfette]

I completely understand your problem. That's the way I felt too for a long time. I think a lot of residents/interns have a favorite IV fluid that they use and tend to stick to it without giving a lot of thought to the alternatives.

There are two rotations I would think you could get a good explanation about fluid management. I didn't have these rotations until toward the end, so I had NO concept of fluids whatsoever. The first rotation is Peds...if you can find someone to explain IV fluid rates and electrolyte losses, you should get fairly clued in. I'm talking about maintenance dosing and volume/lyte replacement. Peds is BIG on that, at least in my neck of the woods, about explaining how to prevent volume overload or resolve dehydration, especially since fluid rates are highly weight dependent in kids. That should help you understand how to choose a rate and the whole "D5-1/2" versus "D5-1/4" versus "D5" selections for NS and LR solutions. If they do a good job, they will get out the chart of the different IVF contents and show you how things correlate. The other rotation that is big on fluid/lyte replacement is surgery---while surgeons seem to love LR as their fluid of choice, they seem to have a better grasp on how to use fluids relative to other specialties (with obvious exceptions such as renal excluded). I personally still am confused as to why NS or LR is chosen for a given patient, but having been explained how to calculate losses and maintenance has helped SO much that I no longer get frustrated at the mysterious IVF infusions in my patients.

I'm sure someone out there has a good peds book that explains fluid replacement pretty well...unfortunately, I was given a handout from an unknown reference. Come to think of it, the Harriet Lang manual may have something....ask to borrow it from a Peds resident or attending.

🙂 smurfette

 

[johnd]

Nephrology rotation is probably the one where you will really learn the most. I think the "ICU book" by marino has a pretty decent section on this. Its more practical than most books.

 

[southerndoc]

Nephrology rotation is probably the one where you will really learn the most. I think the "ICU book" by marino has a pretty decent section on this. Its more practical than most books.

Essentials of Surgery by Lawrence also has a great section on electrolytes and fluid management. After reading that, I fully understood fluids.

 

[DocWagner]

IVF is a big issue and typically misunderstood. First and foremost, treat the patient and condition. Therefore if the patient has a history of CHF, MIVF may not be necessary or should be kept to a minimum. If the patient is taking appropriate PO, then MIVF should be kept to a minimum, so on and so on.
Using urine output as a guide is a BIG help and what I usually like to guide my way...using .5-1cc/kg/hr as the goal. Bolus dosing is the key. Understanding roughly 1/3rd of IVF remains intravascular is helpful, as well as realizing that when you bolus a patient with IVF (NS) you need to think of it in practical terms (ie if you have a hypotensive patient 250cc aint gonna do it, that is less than a 12oz can of Coke).

Overall, in the adult patient that has normal glucose values and can potentially take PO, then using NS is gonna be fine. Chosing a value of 125cc MIVF and then titrating to appropiate condition and urinary output is the key.
Pediatrics is different, as 20cc/kg boluses is the rule and then I use the 4,2,1/10,20,30 rule for MIVF.