Intern Content: Approach to IV Fluids – OnlineMedEd



a lot of people feel very strongly about fluids and if you talk to someone who really cares there's going to be a lot of differences in tonicity in which body cavity they're gonna stay in how much stays in the bloodstream how much thirdspace is what one don't what make it easy for yourself when it comes to IV fluids there's very few things you need to know you can do one of three things you are either going to give volume resuscitation you're going to give maintenance fluid or you're going to give free water if your goal is to give volume you think their volume deplete you have two choices you either have lactated ringers or normal saline there is a theoretical risk with each one it turns out that in general normal saline is equal to Lafayette ringers for all intents and purposes let's talk about those theoretical differences that you know about them but also know that chances are it doesn't matter lactated ringers are consider the surgeon's fluid the reason being that surgeons especially during long procedures where the belly is open they're losing a lot of fluid or they're bleeding will need large volume resuscitation in lactated ringers there is potassium in fact every leader has four milli equivalents now as an intern on medicine you will be constantly repeating patients potassium 3.5 given 40 ml equivalents 3.2 Jim 80 ml equivalents barely gets them to where you need to be so feel this we hand out 40 mil equivalents like it's candy there's four millions on lactated ringers that means you have to give someone ten liters of lactated ringers which is a lot in order to give out that dose we give out like candy point is even if they're end-stage renal disease don't worry about the potassium in lactated ringers it's good for volume expansion now the reason why it's the surgeon's fluid is because quite often when they go to surgery patients are otherwise well they don't have kidney disease and so you don't have to worry about the potassium and they're going to give large volume that large volume thing comes into play when we talk about normal saline normal saline is a strong and ion gradient and if you give a lot of it you can induce an acidosis normal saline is consider the internists fluid there's no potassium to worry about and most of the time we have CHF or in stage renal disease patients who can't tolerate a lot of volume so there won't be large volume resuscitation that is enough to induce acidosis however they are both equal no study has separated the two for anyone can I'll make the argument that it is worth always using lactated ringers if you're going to give volume resuscitation the reason being the two times that as an internist you're going to give large volume resuscitation is going to be in septic shock and hemorrhagic shock now there's debate and how much fluid we should give before we start pressors in septic shock but if you're going to give three four or five liters of fluid it should be lactated ringers and here's the theoretical justification if you're bleeding and you induce an acidosis you will worsen coagulopathy in septic shock you're already acidotic worsening the acidosis will make your pressors work less well theoretically will act eita ringers is better and personally I use lactated ringers I don't even use normal saline all right Vaughn resuscitation lactated ringers normal saline they are essentially equal to each other and how you give it doesn't matter some people like 500 CC bolus and then you check the lungs some people do a thousand some people do 2,000 at once it depends what the underlying condition is if they have CHF and you're not sure that they're very volume down you give a little bit of a fluid and then you check them if you've diagnosed sepsis you know their volume down give them two liters if you've diagnosed DKA accept an ncage renal disease patients because they can't diurese to their urine give them a lot of fluid how much do you give 250 300 333 cc's an hour 400 CCS an hour there's no real math behind it you just have to give a lot of volume but be cognizant of the fact that if you give someone a lot of volume you should be assessing for volume overload in particular pulmonary edema and jvd all right volume expansion you have two options take your pick for maintenance fluid what you're trying to do is say okay this person is euvolemic but they're gonna be NPO and so I want them to not get dried out so I need to give them their daily requirements they're insensible losses just replete it back to them you have a couple of options and it doesn't matter which one you pick quarter normal saline quarter normal saline with d5 half-normal saline half-normal saline define it doesn't matter they are equal to each other the way you'd calculate what the maintenance fluid is and I'm just going to give you the equation rather than actually derive it for you it's going to be 1,500 cc's plus in parentheses the current kilogram body weight minus 20 all of that times 20 to put brackets so you can see the math this fifteen hundred CCS comes from the first twenty kilos so every kilo after that first twenty gets multiplied by 20 this is the total daily fluid requirement you then divide that by 24 and you get your cc's per hour in general this is going to be between 75 and 150 CCS per hour so feel that this is going to be maintenance rate obviously if they're small like only a 50 kilo woman they might be closer to 60 if it's a 500-pound dude it's probably gonna be more towards 200 but the idea is that their maintenance fluid somewhere exists somewhere in here so when you put someone at 120 100 CC's per hour you are not resuscitating them you are simply giving them the maintenance fluid they need to account for their insensible losses when their NPO pick one it doesn't matter which and again personally I like to use half normal saline it's just what I use and so that's what I use again some people feel very strongly about this especially in the pediatric population when it comes down to it there's not a whole lot of difference all right the last thing is free water how do we give free water there's two ways you give free water which is the best way you tell them to drink it if they can't drink it you give them an NG tube and do free water flushes a PEG tube free water flushes you put pure water into their stomach if that doesn't work or they can't tolerate that then you give them d5w this is the best way free water P o ng e o peg and how much you give is sort of ballpark you have to check their sodium because what you're doing is trying to replace free water sodium is a measurement of how much water they have in their body not salt and so it's generally around 250 CCS free water flushes q6 hours sometimes it's two four sometimes it's 300 it depends where they're at especially if you're trying to correct the sodium we're not d5w is the closest thing to free water through the IV so you do this if free water fails then you give to you 5w what do you set it at you set it at some rate 70 100 whatever it might be a maintenance rate and then you check the sodium to make sure that it's not correcting too quickly the sodium correction that you want when you replace free water should increase by 0.25 that's 0.25 milik Whillans per hour or about two militants every four hours which is just about when you want the nurse to draw the next lab and finally if you need calories do not use d5 do not use d-10 d5 has about 150 calories in it not sufficient to sustain someone's life if you need calories you have to go for TPN or ppm don't worry about the details in here basically you're gonna order it and someone's gonna send you a form and say hey I checked it off for you I'm the nutritionist sign here and boom get your TPN alright so there's a lot of discussion a lot of little nuances in there but what I want you to take away if you walk out of here knowing nothing else I need volume resuscitation bolus ringers I need maintenance fluid half-normal saline at some rate around 100 to 125 i need free water to be replaced i should use the oral round but if I can't then I'll use d5w and if I'm going to be NPO for a long time what I want is calories to the Ivy via TPN and that's fluids you

48 thoughts on “Intern Content: Approach to IV Fluids – OnlineMedEd

  1. Is anyone watching this becoming a nurse? Im a student nurse and trying to get a clear picture of IV fluids.

  2. Wow! You are very great lecturer. Actually I was explained once my classroom instructor but I was yet satisfied even up to now. But after all I watch your education video, it really opened up my knowledge broader and easy to understand more. I am so glad for you for being such a wonderful and educated speaker. I have little a bit problem with 4-2-1 rule. How 75kg or 70kg as an example? Thanks

  3. 4-2-1 rule very helpful for maintenance rate fluid rate: 4ml/kg/hr for first 10kg + 2ml/kg/hr for next 10kg + 1ml/kg/hr for everything over 20gm.
    i.e. for me, I weigh 88kg, thus:
    40 (for first 10kg) + 20 (for the 10-20kg) + 68 (every kg over 20lg) = 128 ml/kg/hr

  4. I like the no-nonsense teaching style. For those in the UK – lactated ringers is Hartmann’s and D5W is Dex 5%. Also cc=ml!

  5. Dr. Williams, I am so grateful for your amazing labor and the effort that you put doing these videos, especially for free! I am from a developing country, and your classes really help me a lot in my academic and professional environment. With your humble labor, you are saving millions of lives through students and professionals like me all over the world. Thank you, and I am 100% sure that God will reward your special labor in this world and beyond it. Greetings from Venezuela!

  6. O.25 mEq//hr = 1.0 mEq/4 hr. Not 2.0 mEq/4 hr mais no? I'm just sayin… anyway, thanks for the clear cut lecture

  7. i have studied, read, and asked many times about IV fluid giving, only got unapplicable ways(calculating about quarters of hours to prepare the fluid!) thanks alot for this simple applicable way

  8. This is the bread and butter of fluid resuscitation no one told me when I was a student  because no one knew  how to explain it and because  ….   this video did not exist .

  9. Give us some real case examples with real cases, e.g. a person with severe gastroeteritis comes dehydrated which that is analogous to a 10% dehydration. If the guys weight is around 50kilos then you replace the 50 x 0.1= 5L as replacing initialy fluid loss…then we maintain, but what is this free water??!

  10. i have a problem understanding his language….and these solutions which vary in Europe from the US. I think it could have been explained easier. When we replace fluids where i work we estimate first fluid loss according to the persons weight and then maintain it. what is this free water thing?i dont get it.

  11. When discussing the maintenance fluids you mentioned it would be for insensible losses. Wouldn't that be sensible losses if they are NPO? As far as I understood it the insensible losses are above and beyond the normal sensible losses such as if they have a j-tube for example. Thanks for any clarification.

  12. I have literally asked my teachers to explain me properly but i never get satisfied but i watched this video two times and made notes and now i dont think i will ever forget this. Like a rule of three. I am so thankful to you.

  13. Don't understand something. You said that sodium is an indication of water – but which way round? High sodium = low water or low sodium = low water? Also you said give free water D5W and watch the sodium correct slowly – increase sodium by 2mmol every 4 hours… but how does giving free water increase sodium content? I thought you give sodium to increase sodium and water to decrease sodium? Confused!

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