MedicinePowder

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any article or chapter anyone recommends on IV hydration in ED patients? when do you bolus or what rate to give IV fluids for old people, young people etc etc.

this is another subject where i have been unable to get practical information (e.g. in tintinali, treatment of vasoocclusive crisis include "i.v. hydration". also, in hypoglycemia, give "dextrose 10% IV" there is no mention of what rate you write the fluids for.

anyone care to point me at an article or chapter that provide practical information on how much fluids to give and at what rate for certain patients/conditions, e.g. those with diarrhea x2days, or old people with signs of dehydration, or possible bowel obstruction etc etc.

thanx
 

BKN

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MedicinePowder said:
any article or chapter anyone recommends on IV hydration in ED patients? when do you bolus or what rate to give IV fluids for old people, young people etc etc.

this is another subject where i have been unable to get practical information (e.g. in tintinali, treatment of vasoocclusive crisis include "i.v. hydration". also, in hypoglycemia, give "dextrose 10% IV" there is no mention of what rate you write the fluids for.

anyone care to point me at an article or chapter that provide practical information on how much fluids to give and at what rate for certain patients/conditions, e.g. those with diarrhea x2days, or old people with signs of dehydration, or possible bowel obstruction etc etc.

thanx
Can't do it. It's not a cookbook. You estimate the degree of dehydration and follow the patient's response to hydration (urine output, mental status, resolution of tachycardia, sudden onset of pulmonary edema :oops: ).

My initial doses: child 20 cc/kg may repeat once. Adult with normal heart, lungs, kidneys 1 liter. fragile adults 250 cc boluses. very fragile adults 100 cc boluses.

cheers.
 

southerndoc

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Agree with what BKN states. Here are some numbers to keep in mind:

Maintenance Rates:
4 mL/kg/hr for the first 10 kg +
2 mL/kg/hr for kilos 11-20 +
1 mL/kg/hr for >20 kg

Add all those together to get an estimated maintenance fluid rate. However, that's more applicable in kids. With some of our "endowed" adult population, you may end up with a calculation for 180 mL/hr easily.

One final comment: remember, 250 mL is basically a cup of water (an 8 ounce cup is 240 mL). A can of soda is about 350 mL.

So when you write for that 250 mL bolus, ask yourself if they can handle more than a cup of water. Granted some delicate CHF'ers can easily be thrown out of balance with 500 mL of fluid, and it's better to be cautious, give a little, and reassess before giving more.

I usually try to rehydrate people with 8 cups... 2 liters of fluids. If you're giving D5 solution, remember to make it D5 1/2 NS or better yet D5 + 150 of sodium bicarb. D5NS is very hypertonic. (Our surgeons are very keen on fluid management here, and any rotation in our SICU will get anyone up to speed on fluids.)
 
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Homunculus

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MedicinePowder said:
any article or chapter anyone recommends on IV hydration in ED patients? when do you bolus or what rate to give IV fluids for old people, young people etc etc.

this is another subject where i have been unable to get practical information (e.g. in tintinali, treatment of vasoocclusive crisis include "i.v. hydration". also, in hypoglycemia, give "dextrose 10% IV" there is no mention of what rate you write the fluids for.

anyone care to point me at an article or chapter that provide practical information on how much fluids to give and at what rate for certain patients/conditions, e.g. those with diarrhea x2days, or old people with signs of dehydration, or possible bowel obstruction etc etc.

thanx
for kids i bolus with normal saline. don't bolus with hypotonic fluids or you could lyse RBC's (a generally bad thing to do). 20cc/kg up to 3x, however the correct answer in how many you can give according to our PICU folks is "as much as it takes". ultimately, at least for me, it's about perfusion. the brain and bean like blood flow and oxygen.

BKN is correct (i feel silly even having to say that, lol). there are general guidelines, but the art is in figuring out what your patient needs. "dehydration" comes in many flavors, whether it's simply a clinical appearance that "looks like" dehydration or hypo/iso/hypernatremic and other dehydrations. you also need to consider the cause of the dehydration-- DKA? vomiting? poor intake? diarrhea (cha cha cha)? third spacing? that infant who for the life of you you thought was "dehydrated" due to poor feeding from a respiratory infection who now has a big liver and pulmonary edema from his myocarditis probably didn't need fluids to begin with. IVF are a bandaid for you to figure out wtf is going on. or, in the case of the ED, to stabilize the gomer so IM can take them away and argue the finer points of sodium and potassium regulation in the kidney and RAA axis.

maintenence fluids for kids were extrapolated from adult data. google holliday-segar and see what pops up. eventually you'll just use what you've used before, or even practice a bit of "eminence" based medicine and do what your attendings do, but it's fun to work through the fluid and electrolyte requirements with students from time to time just to see that what you are doing has some basis on data.

--your friendly neighborhood fluid shifting caveman
 

BKN

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maintenence fluids for kids were extrapolated from adult data.
--your friendly neighborhood fluid shifting caveman
Were they? I thought originally they were done at JHH in the Lane clinic in the 30s. MP, if you get a Harriet Lane Handbook, you'll probably still find all that stuff about doing it in kids by body surface area, adjusting for fever and so on. Homunculus is right too of course. They made it us do it that way, as soon as I got out, I went back to Baylor's 1000 cc/24 hrs for first 10 kg, 500 cc/24 hrs for second 10 kg, 100 cc/24 hrs for each 10 kg above that. When you do it both ways it's always within 10%. And when you use Southerndocs formula, it looks pretty close too.

cheers, bkn
 

12R34Y

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We use D5NS all of the time. Great for those folks with a little ketons in their urine from not eating (homeless etc..).

Last night we gave a 50 y/o lady a couple of liters bolus of D5NS who hadn't eaten in a while (ketones in urine, BS 68, pscyh patient).

Anybody else using D5NS? We use it for all of our banana bags for alcoholics as well.

haven't heard/seen anything bad about it yet.

later
 

Homunculus

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BKN said:
Were they? I thought originally they were done at JHH in the Lane clinic in the 30s. MP, if you get a Harriet Lane Handbook, you'll probably still find all that stuff about doing it in kids by body surface area, adjusting for fever and so on. Homunculus is right too of course. They made it us do it that way, as soon as I got out, I went back to Baylor's 1000 cc/24 hrs for first 10 kg, 500 cc/24 hrs for second 10 kg, 100 cc/24 hrs for each 10 kg above that. When you do it both ways it's always within 10%. And when you use Southerndocs formula, it looks pretty close too.

cheers, bkn
one of our peds nephrologists said it was from adult data . . i think, lol. it may have been a different fluid/electrolyte thing. or maybe the adult data is extrapolated from peds. . ped leads the way!! :thumbup:

--your friendly neighborhood fuzzy recall caveman
 

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12R34Y said:
Anybody else using D5NS? We use it for all of our banana bags for alcoholics as well.
What are the chances of throwing an alcoholic into Wernicke's by administering glucose in the banana bag with the thiamine, folate, and mvi? I know the classical teaching point is to administer the thiamine before the glucose, but does co-administration via a banana bag with D5 affect the occurence of Wernicke's?
 

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fuegofrio17 said:
What are the chances of throwing an alcoholic into Wernicke's by administering glucose in the banana bag with the thiamine, folate, and mvi? I know the classical teaching point is to administer the thiamine before the glucose, but does co-administration via a banana bag with D5 affect the occurence of Wernicke's?
The problem is the bolus effect of the D50 on the rapid depletion of thiamine in the pentose phosphate pathway (as the thiamine is consumed due to the big influx of glucose, the remaining glucose - which can't now be immediately metabolized - hits the brain in a bolus and dehydrates it, causing the Wernicke's). You won't get the bolus effect with IV fluids (no matter how fast you flow it in), since it's not hitting it all at once.
 

southerndoc

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12R34Y said:
Anybody else using D5NS? We use it for all of our banana bags for alcoholics as well.
Our banana bag:

2 grams magnesium +
10 mL multivitamin +
15 mg zinc sulfate +
100 mg thiamine +
1 mg folic acid,
all bundled in a liter of D5W and infused over 1 hour.

I couldn't even imagine how hypertonic that would be in a liter of D5NS.
 

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Most ED patients do not need IV fluids.

The ones that do, we usually undertreat in the ED. The whole take-home point of the Rivers sepsis trials is that we greatly underestimate fluid requirements in sepsis. Even 50 kg little old ladies can frequently benefit from 4-6 liters when they're septic.

IMHO, anyone can take 250 cc of IV fluids except for someone who is already in chf. I don't think anyone's ever gone into pulmonary edema after a 250 cc bolus, or even 500. Anyone under 50 with good kidneys and a good heart can take 2 liters straight up.

This being said, I just resuscitated a guy who was hypotensive and in failure in an outside ED and got 4 L IVF before arriving to our ED in florid failure coughing up frothy pink sputum.

The trick is bolus, reassess, bolus, reassess. Some people say just throw a CVP monitor in them but in my experience these frequently get disconnected, are usually miscalibrated, and are constant sources of frustration.

In my book septic little old people get a liter per hour and a reassessment after each one. By the time your lactate level comes back you've gotten 2-3 liters in and you're not behind the game. If you just write for a liter an hour you'll turn around and they're in failure.
 

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Has anyone else been given too much fluid before? I woke up in the hospital and could feel my veins distending. Twas very strange...

beyond all hope said:
Most ED patients do not need IV fluids.

The ones that do, we usually undertreat in the ED. The whole take-home point of the Rivers sepsis trials is that we greatly underestimate fluid requirements in sepsis. Even 50 kg little old ladies can frequently benefit from 4-6 liters when they're septic.

IMHO, anyone can take 250 cc of IV fluids except for someone who is already in chf. I don't think anyone's ever gone into pulmonary edema after a 250 cc bolus, or even 500. Anyone under 50 with good kidneys and a good heart can take 2 liters straight up.

This being said, I just resuscitated a guy who was hypotensive and in failure in an outside ED and got 4 L IVF before arriving to our ED in florid failure coughing up frothy pink sputum.

The trick is bolus, reassess, bolus, reassess. Some people say just throw a CVP monitor in them but in my experience these frequently get disconnected, are usually miscalibrated, and are constant sources of frustration.

In my book septic little old people get a liter per hour and a reassessment after each one. By the time your lactate level comes back you've gotten 2-3 liters in and you're not behind the game. If you just write for a liter an hour you'll turn around and they're in failure.
 

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I'm with beyond all hope - I never give less than 500cc and that almost never. I haven't seen anyone yet (EF 15% ers not withstanding) who was hurting after a liter.
 

BKN

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Seaglass said:
I'm with beyond all hope - I never give less than 500cc and that almost never. I haven't seen anyone yet (EF 15% ers not withstanding) who was hurting after a liter.
I have.;)
 

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A 250 cc bolus isn't a bolus... It's more like high maintenance fluids. Our ICU attendings have chewed out numerous interns for stating they "gave a 250 cc bolus". As a rule, we never keep people on maintenance fluids in our hospital or ICU. We administer fluids as needed according to UOP, HR, I/O's, BP, and other markers for fluid status. The only exceptions are generally DKA, Hyponatremia, Burns, Dehydration in peds, or NPO for surgery. Leaving maintenance fluids running is a good way to put someone inadvertently into pulmonary edema.

Hard24Get said:
Has anyone else been given too much fluid before?
I had a lady signed out to me who develolped pulmonary edema and respiratory failure after receiving 1500 cc of NS over 12 hrs. It was a HONC patient w/ lung CA s/p L pneumonectomy and a large compressive R sided effusion. She was essentially functioning off of about one half of one lung. She got a 1 Liter bolus on arrival for a boarderline BP (although it was later determined she lived there). When the nurses changed shifts, the new nurse saw a SBP of 85 and asked if we could give a small bolus. I okayed 500 cc more. 4 hrs later she coded. Her repeat CXR for tube placement was basically whited out.
 

militarymd

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southerndoc said:
.........
Maintenance Rates:
4 mL/kg/hr for the first 10 kg +
2 mL/kg/hr for kilos 11-20 +
1 mL/kg/hr for >20 kg

.........
One final comment: remember, 250 mL is basically a cup of water (an 8 ounce cup is 240 mL). A can of soda is about 350 mL.

So when you write for that 250 mL bolus, ask yourself if they can handle more than a cup of water. Granted some delicate CHF'ers can easily be thrown out of balance with 500 mL of fluid, and it's better to be cautious, give a little, and reassess before giving more.

.......
Ahhh ...Fluid metabolism....One of my favorite topics.

When you talk fluids....you really need to talk about Sodium content and metabolism also.

That 500 ml of fluids will rarely throw any CHF patient "out of balance" if there is no sodium in it.....however...as you increase the sodium content of that "fluid"....You will very likely cause some "decompensation".

When you assess a patient, you need to assess for 2 differen things:
1) water deficit
2) sodium deficit

And replace both.....

Remember that 24 hour sodium requirements is no more than 2 grams....and there is about 4 grams of sodium in 1 liter of NS.
 

southerndoc

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Someone mentioned volume resuscitation in sepsis and measuring CVP measurements.

Is anyone aware of the literature of using IVC measurements with ultrasound in determining CVP? Supposedly the French are doing this. I do it as a quick gage to see how they are doing (does the IVC collapse with each breath, does it collapse with a strong negative inspiratory force, or does it even collapse at all)? It provides a rough estimate, but in my experience has not been completely accurate when a central line is thrown in and a CVP is measured. However, I've heard other residents and our ultrasound gurus talk about research supporting it. I've yet to read the article that shows a strong correlation.
 
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