Fluids - General Advice?

[KLPM]

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The more I read about fluids and the literature surrounding it, the more confused I am. Just wondering if I can get some general advice on:

- Commonly used fluids?
- How you determine how much fluids to give?

There seems to be a lot of stuff on goal-directed fluid therapy except I am not really sure which "goals" are good to look at. Cardiac output? Pulse pressure variation? Urine output? Guess?

 

[2ndyear]

In what setting? The OR for an elective case is much different from a dead bowel case, or a new sepsis in the ICU, burns are a whole other story. I actually think a nice intro to fluids is to start reading pediatric fluid guidelines. Maintenance fluids. Deficit fluids. How to replace them. It's not hard to 'scale up' to adults but not as clear if you were to try to apply it the other way. Once you have a handle on this you can get into goal directed therapy.

 

[WholeLottaGame7]

The more I read about fluids and the literature surrounding it, the more confused I am. Just wondering if I can get some general advice on:

- Commonly used fluids?
- How you determine how much fluids to give?

There seems to be a lot of stuff on goal-directed fluid therapy except I am not really sure which "goals" are good to look at. Cardiac output? Pulse pressure variation? Urine output? Guess?

This is too broad a question, and I'm sure there are plenty of debates on the forum if you search for it.

In general, treat fluids like you would any other med. Put some thought into the type and amount that you're going to use. I will say that the vast majority of the time the answer is LR. If you want to use a colloid, albumin is basically the only choice left.

Same goes for blood products, make sure you have a plan and a goal when using them.

"Goal"-wise, I typically use PPV or SVV, keeping in mind you need a ventilated patient.

 

[urge]

Why do I feel like we are doing his assignments?

 

[dhb]

"Fluids - General Advice?"
Give some - Take some 😉

Seriously the most important thing is to build a clinical sense of the patients volume status.
What do i do:
-ask the patient if extubated he can tell you if he's thirsty
-look at mucous membranes (tongue generally)
-look at urine density/quantity
-look at BUN & creatinine (more in the icu)
-passive leg raise
if after all thi you still haven't got a clue or for a confirmation of your impression look at heart chambers, IVC, lungs with a TTE.

Intra-op management is pretty strait forward: replace what's lost from npo, give a little for maintenance and replace blood loss.
I use 99% cristalloids...

 

[dhb]

I actually think a nice intro to fluids is to start reading pediatric fluid guidelines. Maintenance fluids. Deficit fluids. How to replace them. It's not hard to 'scale up' to adults but not as clear if you were to try to apply it the other way. Once you have a handle on this you can get into goal directed therapy.

A lot of what's been written is BS

 

[nap$ter]

Why do I feel like we are doing his assignments?

the OP has had a cuppla posts recently fishing for help with homework...

it's great when students have a specific question - that's what this forum is for.

but cmon, klpm, you want "general advice" on fluid therapy, preload assessment? if a medical student asked me this in the OR i would puke in my mask a little and tell him/her to go read and then tell ME about it. you shouldn't start a discussion in medical education with fishing. that's weak.

it should go more along the lines of, "so, i was reading about x,y, and z for preload assessment in pt type a in the clinical setting of q, and my interpretation is blah, blah, blah. what do you guys think about that? ie is my interpretation of my reading true to clinical practice according to your (vast) experience?"

 

[JoBreeze]

What IS the deal with fluids anyway??

 

[painmd87]

Can I tack a legitimate question onto this thread?

This came up yesterday because of the "nationwide saline shortage" that the hospital pharmacy was warning everyone about. There were no strong advocates for NS (mainly docs/residents/nurses who preferred it by default) but there were very loud voices that LR should be used for intraop maintenance for most patients (except in the case of AKI/with PRBC/other specific contraindications).

Published evidence seems to point toward LR having somewhat better results, so the ambivalence among the NS crowd surprised me.

In the absence of a specific indication/CI, do you prefer LR or NS intraoperatively? Post-op?

 

[deleted171991]

It doesn't matter for 1-2L. Above that, NS alone tends to give hyperchloremic metabolic acidosis. The sicker the patient, the greater the impact. It's already clear that LR is the fluid with better outcomes. A compromise for shortage situations would be NS alternating with LR.

Potential theoretical hyperkalemia (renal disease) is not a contraindication to LR. The amount of potassium in a few liters of LR is nothing compared to the intracellular compartment. A banana has 1 mEq of K per inch of length. 😉

The main contraindication to LR is blood transfusion on the same line.

 

[urge]

very loud voices that LR should be used for intraop maintenance for most patients (except in the case of AKI/with PRBC/other specific contraindications).

AKI/ESRD not a contraindication to LR. In fact LR is indicated. NS was shown, quite a few years ago, to be dangerous for these patients.

 

[Mapleson D]

NS is horribly unphysiologic and I prefer to avoid it if possible. LR is fine, but I like Plasmalyte. I really wished we had some at my current hospital yesterday.

But I agree that for 1-2 L it doesn't matter either way.

 

[Laryngophed]

NS is horribly unphysiologic and I prefer to avoid it if possible. LR is fine, but I like Plasmalyte. I really wished we had some at my current hospital yesterday.

But I agree that for 1-2 L it doesn't matter either way.

Isn't plasmalyte 4-5x the cost of NS liter for liter? We are still talking under $10, but in an era where cost measures are becoming a huge focus for providers and hospitals, 4-5x for every liter of saline or LR that you run will add up, particularly in bundled payments.

 

[Mapleson D]

I thought Plasmalyte cost about the same as LR and NS. I'll have to look into it.

 

[deleted171991]

I thought Plasmalyte cost about the same as LR and NS. I'll have to look into it.

Google seems to indicate you are right.

 

[Mapleson D]

Two studies worth reading:

A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation.
http://www.ncbi.nlm.nih.gov/pubmed/15845718

The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation.
http://www.ncbi.nlm.nih.gov/pubmed/18635497

 

[Mapleson D]

Finally got some numbers. Where I work, the acquisition cost for a bag of LR or NS is about $3, give or take a few cents. Plasmalyte is $5.30. So it's more expensive, but certainly not multiple times more expensive.

 

[shift_roro]

A Rational Approach to Perioperative Fluid Management
http://journals.lww.com/anesthesiol...=2008&issue=10000&article=00021&type=abstract

 

[Random Anesthesiologist]

I use LR too, except with blood products. I've spent much more time in the ICU than the OR this year. Fluid goals really depend on what kind of patient I have. Is it a postop open hernia or bowel resection that was hours long? I'd be looking at CVP, arterial pressure, heart rate, UOP and if I've given 4-5L already and still with decreased UOP (given they're not 80 and/or with preexisting renal failure), I might look at Bun/Cr and FeNa +/- lactate. Or is this patient 2-3 days postop after a similar case and third-spacing? Do they need colloid over crystalloid? Or is this a bleeder who needs volume and product? Then I'd be worried about UOP and Hct.

I guess for me it's a big-picture thing, although with experience, some things become intuitive when you know your patient.