IV Fluids

Bindu Swaroop, MD
Inpatient Medicine Core Curriculum
VA Long Beach Health Care System
Objectives
Understand daily fluid and electrolyte
requirements for an average adult

Understand the major components of
replacement fluid

Maintenance versus Resuscitation

Complications of fluid therapy

Input and Output
of the Normal Adult
Minimal Obligatory Daily input:
Ingested water: 500mL
Water content in food: 800mL
Water from oxidation : 300mL
TOTAL: 1600mL
Minimal Obligatory Daily water output:
Urine: 500mL
Skin: 500mL
Respiratory tract: 400mL
Stool: 200mL
TOTAL: 1600mL

On average, an adult input and output is 30-35mL/kg/day (about
2.4L/day)
Electrolyte Requirements
Sodium: 100-250meq (western diet)
mostly excreted in urine

Potassium: 50-100meq
mostly excreted in urine, 5% in feces

Chloride: 60-150meq

Bicarb: 1-3meq/kg/day
Contents of IV Fluid Preparations
Na
(mEq/L)

K
(mEq/L)
Cl
(mEq/L)
HCO3
(mEq/L)
Dextrose
(gm/L)
mOsm/L
D5W 50 278
NS 77 77 143
NS 154 154 286
D51/2NS 77 77 50 350
D5NS 154 154 50 564
Ringers
Lactate
(RL)
130 4 109 28 50 272
Case Vignette
58 y/o male with h/o HTN, dyslipidemia, admitted for cough
and atypical chest pain. Found to have abnormal CXR and CT
Thorax concerning for malignancy . Kept NPO overnight for
possible bronchoscopy with biopsy in the morning. He is
placed on NS @ 75cc/hr.
1. Was the right solution picked?
2. Is the rate correct?
Maintenance Therapy
Replaces the ongoing losses of water and
electrolytes under NORMAL physiological
conditions
Used when the patient is not expected to eat
or drink normally for prolonged period of time
Patients who are afebrile, not eating, not
physically active require less that 1 L of
electrolyte free water per day
Maintenance Therapy
Initial approach:

2-3L/day (30-35cc/kg/day) of D51/2NS with 20meq of KCL
averages to 90-125mL/hr
This provides 3.4 g of sodium (similar to a hospital diet)

Dextrose containing solution should be used in patients
with hypoglycemia or ketoacidosis; avoid in patients with
uncontrolled DM or hypokalemia

There is not much data to suggest addition of D5 is
beneficial, however can be added to prevent catabolism



Maintenance Therapy
Alternative Approaches:
4/2/1 rule
-4 ml/kg/hr for the first 10 kg2ml/kg/hr for the next 10kg then 1
ml/kg/hr for remaining weight
OR
Weight in kg + 40
For the Clinical Vignette:
Pt weight 85kg
85kg x 35cc/kg/24hr= 3L / 24 hr= 125cc/hr
40+20+65=125cc/hr (using 4/2/1)
85+40=125cc/hr
-Fluid choices: 1/2NS or D51/2NS would be appropriate
choices
Fluid Resucitation
Correct existing abnormalities in volume
status or serum electrolytes
Parameters used to assess volume deficit:
Blood pressure
Jugular venous pressure
Urine sodium concentration
Urine output
Pre and post deficit body weight
Rate of Repletion
Severe volume depletion or hypovolemic shock: rapid
infusion of 1-2L isotonic saline (NS)
Mild to moderate hypovolemia:
Choose a rate that is 50-100mL/h greater than estimated
fluid losses
urine output 50ml/h
insensible losses = 30ml/h
additional loss such as GI, high fever (additional
100ml/day for each degree of temp >37C, etc)
Choice of fluid: based on type of fluid that has been lost
and any co-existing electrolyte disorders
Clinical Vignette
86y/o female admitted with nausea and vomiting and c/o
rectal bleeding. She has a history of recent admission for
CHF exacerbation. Weight 45kg. SBP 80s in the ED. She is
started on IV pantoprazole.
1. What is your initial choice of fluids?
-Normal Saline
She is kept NPO for EGD and colonoscopy the next morning.
After receiving 2u PRBC and normal saline you decide to start
maintenance fluids. What rate and type of fluid do you
choose?
-D51/2NS
-45kg x 35cc/kg/24hr= 67cc/hr
-4/2/1= 40+20+25=85cc/hr
-45kg +40= 85cc/hr



Complications of IVF
The team decides to put her on D51/2NS @ 125cc/hr. Her repeat
serum sodium level is 130 the next morning and she is
complaining of some SOB. She is thought to have an infiltrate on
CXR and started on IV Zosyn and Vancomycin for hospital
acquired pneumonia.
3. What could be contributing to the hyponatremia?
-think about composition of IV fluids

4. What is likely contributing to the SOB?
-fluid overload (too high rate of fluids, composition type)
-additional fluids from IV Abx and PPI (50-100cc per medication,
either D5W or NS)
Understanding Salt and Water
ICF
2/3
Osmolality: determined
primarily by potassium salts
and phosphate esters
ICF volume excess usually due
to:
-primary water gain (primary
polydypsia)
or
-sodium loss (SIADH)
ICF volume contraction usually
secondary to :
-primary sodium gain (usually
secondary to administration
of hypertonic saline)
or
-water deficit (diarrhea, DI)
ECF
1/3
Intravascular & Interstitial
1:3 ratio
Osmolality: determined
primarily by sodium
ECF volume losses are usually secondary to:
renal loss, GI loss, hemorrhage

Treatment: blood transfusion, normal saline

When associated with hyponatremia, usually
secondary to electrolyte free water retention

ECF volume excess usually secondary to
interstitial edema
(secondary to renal sodium retention:
examples include renal failure, heart failure,
cirrhosis)
Treatment: targeted to underlying disorder
Normal saline has
no free water and is
confined to ECF
space
Where is the Fluid Going?
D5W
1L TBW
2/3 of ECF
Interstitial
220cc
1/3 of ECF
Intravascular
110cc
1/3 of TBW
ECF
340cc
2/3 of TBW
ICF
660cc
Where is the Fluid Going?
Free water
content
ICF ECF Interstitial Intravascular
D5W 1000cc 660cc 340cc 226cc 114cc (11%)
NS 500cc 500cc 500 330cc
+ 55cc from
free water
content
170cc + 55cc
=225cc (22%)
NS 0 0 1000cc 660cc 330cc (33%)
Summary

Treat IV fluids as prescription like any other medication
Determine if patient needs maintenance or resuscitation
Choose fluid type based on co-existing electrolyte
disturbances
Dont forget about additional IV medications patient is
receiving
Choose rate of fluid administration based on weight and
minimal daily requirements
Avoid fluids in patients with ECF volume excess
Always reassess whether the patient continues to require IVF