Introduction
You will need to be competent in all areas pertaining to the prescription of intravenous fluids and infusions prior to becoming a PRHO; This module will direct your learning but it is up to you to put the knowledge and skills into practice. The skills included in this module should be attempted in a skills centre before being practiced in the clinical setting.
Colloids and Crystalloids - What Surgeons and Anaesthetists talk about over coffee Intravenous fluids may be divided into
Saline Solutions
(1) 0.9% Normal Saline Think of it as Salt and water
Principal fluid used for intravascular resuscitation and replacement of salt loss e.g diarrhoea and vomiting Contains: Na+ 154 mmol/l, K+ - Nil, Cl- - 154 mmol/l; But K+ is often added IsoOsmolar compared to normal plasma Distribution: Stays almost entirely in the Extracellular space Of 1 litre 750ml Extra cellular fluid; 250ml intravacular fluid So for 100ml blood loss need to give 400ml N.saline [only 25% remains intravascular]
(3) 1.8, 3.0, 7.0, 7.5 and 10% Saline = HYPERtonic saline
Reserved for plasma expansion with colloids In practice rarely used in general wards; Reserved for high dependency, specialist areas Distributed almost entirely in the ECF and intravascular space. This leads to an osmotic gradient between the ECF and ICF, causing passage of fluid into the EC space. This fluid distributes itself evenly across the ECF and intravascualr space, in turn leading to intravascular repletion. Large volumes will cause HYPERnatraemia and IC dehydration.
Dextrose solutions
(1) 5% Dextrose (often written D5W) Think of it as Sugar and Water
Primarily used to maintain water balance in patients who are not able to take anything by mouth; Commonly used post-operatively in conjuction with salt retaining fluids ie saline; Often prescribed as 2L D5W: 1L N.Saline [Physiological replacement of water and Na+ losses] Provides some calories [ approximately 10% of daily requirements] Regarded as electrolyte free contains NO Sodium, Potassium, Chloride or Calcium Distribution: <10% Intravascular; > 66% intracellular When infused is rapidly redistributed into the intracellular space; Less than 10% stays in the intravascular space therefore it is of limited use in fluid resuscitation. For every 100ml blood loss need 1000ml dextrose replacement [10% retained in intravascular space Common cause of iatrogenic hyponatraemia in surgical patient
Colloid solutions
The colloid solutions contain particles which do not readily cross semi-permeable membranes such as the capillary membrane Thus the volume infused stays (initially) almost entirely within the intravascular space Stay intravascular for a prolonged period compared to crystalloids However they leak out of the intravascular space when the capillary permeability significantly changes e.g. Severe trauma or sepsis Until recently they were regarded as the gold standard for intravascular resuscitation (see next slide) Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) thus they can cause significant coagulopathy in large volumes.
The Colloid / Crystalloid debate An interesting night out with Surgeons and Anaesthetists
Until recently the use of colloid or crystalloid in acute resuscitation was a point of heated debate between surgeons and anaesthetists Through their redistribution after infusion it takes approximately 2- 3 x volume of crystalloid to cause the same intravascular expansion as a single volume of colloid Thus in unstable patients, with hypotension and tachycardia, colloid, often in large volumes (3 4 units) were immediately infused in preference to crystalloid However in the last 5 - 10 years there have been several meta-analyses of the literature around this subject Results suggest (a) No short or long term benefits of the use of colloid in the resuscitation of patients with severe sepsis, trauma, haemorrhage, burns or coronary artery by-pass. In severely ill patients with sepsis and trauma there was in fact a significant rise in mortality compared to the use of crystalloid (b) However, in patients undergoing elective surgery there was a rise in mortality using crystalloid compared to colloid when used for restoring the intravascular volume.
Using one of the blank charts supplied - Please write up 3 x 1litre of normal saline with 20 mmol/l of KCl in each litre to run at 1litre/ 8 hourly; Patient is Mr Ali Khan Number 326587, DOB 13/09/81, weight 81Kg. Consultant Ms Cuttem; Ward B3
Your fluid chart should look something like this. (I have written it out twice as I was unconvinced of my first attempt)
So now youre experts and all aglow, Have a go, at the examples below (Dr Zeus and the IV calculations)
Using the fluid charts provided please prescribe intravenous fluids for the following patients for the next 24 hours. You may wish to ask a friendly PRHO or SHO for advice with regard the correct fluid regimes. (a) (b) (c) (d) (e) A 29 yo man who is nil by mouth awaiting an OGD for a small upper GI bleed. He is haemodynamically stable and well. A 74 yo woman who is 24 hours post laparotomy. The drains contain 180mls of blood stained fluid. She is NBM; BP 105 /70, Pulse 96 bpm. A 17 yo man admitted with suspected salmonella gastroenteritis. He is passing frequent fluid like stools and vomiting hourly. Urea 9.6mmol/l; BP 110/70, Pulse 100 bpm A 34 yo Type 1 Diabetic man who is admitted with DKA secondary to urinary sepsis; BP = 90/60, Pulse 120 bpm; Urea 38.9mmol/l Creatinine 231 mol/l. A 91 yo man who is admitted with severe dehydration, left sided hemiparesis and carpet burns. He is confused but it is estimated he has been on the floor of his bedroom for 72 hours. BP = 100/70, Pulse 120 bpm, Urea 42.6mmol/l , Creatinine 311 mol/l, CK 12,098 iu/l
E.g. What is the transfusion rate in ml /hour of a blood transfusion being run at 40 drops / minute through a giving set with drop factor of 20 gtt / ml? If there are 40 drops in one minute then in 1 hour 40 drops = X drops thus X = 40 x 60 = 2400 drops / hour 1 minute 60 minutes If the giving set has drop factor of 20 drops/ 1 ml 20 drops = 2400 drops thus Xml = 2400 = 120 ml / hour 1 ml X ml 20 Therefore one could set an infusion pump to deliver this volume or it can be factored into the fluid input /hour.
(2)
(1)
You are asked to run an intravenous infusion of 1litre of D5W over 6 hours. What drop rate will you set the infusion at if the giving set has a drop factor of 10 gtt/ml? Drops = 1000ml x 1 hour x 10 gtt Minute 6 hours 60 mins 1ml = 1000 = 27.8 drops / min 36 Since we always round up or down to the nearest drop the actual rate will be 28 drops / minute
You are asked to set up a 1litre normal saline infusion to run over 10 hours. The giving set has a drop factor of 20 gtt / ml. what rate will you set the drip at in drops/minute? Drops = 1000ml x 1 hour x 20 gtt minute 10 hr 60 min 1 ml = 100 = 33 drops / minute 3
A 91 yo woman is receiving intravenous fluids for dehydration. The SHO asks you to make sure her drip is running at the correct rate as he is concerned she may rapidly go into heart failure if it is infused too quickly. There are 350ml remaining of a 1000ml bag which has been running for 6 hours. It is prescribed to run through in 12 hours. The drop rate is 25 drops /minute and the giving set has a drop factor of 20gtt/ml. How long will the present drip take to run through? What adjustments (if any) will you need to make to ensure the drip runs through in 12 hours as prescribed?
Present Rate 650 ml = 1000ml Thus X = 6000 = 9.2 hours 6 hours X hours 650
To Run in 12 hours X drops = 350ml x 1 hr x 20 drops pm minute 6 hr 60 min 1ml = 350 = 19 drops / minute 18
Thus you will have to change the rate of the drip to run at 19 drops / minute ie reduce the rate by 6 drops/ minute
(2)
(3)
A 750ml infusion of 5% dextrose is infusing at 65gtt/min. The drop factor of the giving set is 60 gtt/ml. How long will the infusion take?
A litre of normal saline is meant to be running over 8 hours. The drip is set at 83gtt/min,the giving set has a drop factor of 20gtt/ml.
A litre of 5% dextrose is running at 80 gtt/min. The drop factor is 60 gtt/ml. What will the pump be set at in ml/Hr.
If 80 drops = X drops minute 60minutes X = 60 x 80 = 4800 drops / Hr If 60 drops = 4800 drops 1ml Xml Xml = 4800 = 80mls / Hr 60
(3) (4)
(5)
(6)
A heparin infusion is prescribed to run at 5000 units / Hr. The infusion is made up of 25,000 units in 500ml 5% dextrose. What rate in ml/hr will you set the pump?
An aminophylline infusion is running at 30ml/hr. There is 0.5g / 500ml. It should be running @ 12mg / hour. What is the infusion rate and what will you do to ensure it runs at the correct rate?
30 ml = Xmg x 500ml x 1g 1 hour Hour 0.5g 1000mg X = 30 mg / hr The drip should be running at 12 mg/hr Thus need to reduce the rate to 12 ml/hr (30mg: 12mg = 30ml:12ml)
2g of Kilabug is mixed up in 500ml of 5% dextrose. It is set to run at 5mg / min. What rate in ml/hr will you set the infusion pump?
Rate Xml = 5mg x 60 min x 500ml x 1g Hr min 1 hr 2g 1000mg Rate = 75ml /Hr
A patient is on a GTN infusion for pulmonary oedema. The infusion is made up of 50mg in 250ml 5% dextrose. It is presently running at 20ml/hr. How many mcg / minute is the patient receiving?
20 ml = X mcg x 250 ml x 60 min x 1mg Hr min 50mg 1 hr 1000 mcg = 66.7 mcg / min
A patient is started on an inotrope infusion for cardiogenic shock. The infusion is 750mg in 250ml N. saline. It is running at 5 ml/hr. The patient becomes increasingly hypotensive and his urine output is dropping off. The infusion rate is increased to 12ml/hr. The patient is 70Kg. What dose in mcg / Kg/ min is the patient now receiving?
12ml = X mcg x 250ml x 70Kg x 60 min x 1mg Hr min.Kg 750mg 1hr 1000 mcg X = 8.6 mcg / Kg / min
A second patient who weighs 100Kg is on an inotrope infusion running at 10mcg/kg/min. You receive a pharmacy prepared bag with 1g in 500ml. At what rate (ml/hr) will you set the pump? Rate ml = 10 mcg x 500 ml x 100Kg x 60 min x 1g x 1mg Hr Kg.min 1g 1 hr 1000mg 1000mcg
= 30 ml / hr
Mr Jones in extremis
Mr Jones is a 60 year old man with known IHD. He is brought to A&E in extemis (makes a change from an ambulance) after suddenly becoming short of breath whilst watching television. He is clinically and radiologically in severe pulmonary oedema. He is electively ventilated and sent to ITU. He is started on Frusemide 50mg/ml running at 5mg/hr Dobutamine 500mg in 250ml running at 8mcg / Kg.min GTN 100mg in 500ml running at 20 mcg / Kg.min He weighs 80 Kg. After one hour he is haemodynamically stable and his urine output is satisfactory.
(1)What rate is the GTN infusion running at in ml /hr? (2)What rate is the dobutamine infusion running at in ml /hr?
Overnight he goes into fast AF and is started on an Amiodarone infusion. After the loading dose, he is started on 5mcg/kg/min. The infusion is 500mg in 50ml. (3) What rate in ml/hr is the pump set out?
You will need to show the workings for each calculation. The answers are shown overleaf.
Learning outcomes
At the end of this module you should now:Be aware of The difference between crystalloids and colloids The clinical indications for the different fluids The steps required in setting up an intravenous infusion Be able to Prescribe fluids on a fluid chart Calculate the rate of a drip Calculate the rates and dosage of infusions
Recommended websites
www.wine1.sb.fsu.edu/chm1045/notes/Intro/Dimanal/Dimanal.html www.-isu.indstate.edu/nurs/mary/mathprac.html www.classes.kumc.edu/son/nurs420/CalculatingDrugDosages.html www.cs.jcu.edu.au/~michael/web/Sections6.html