和信內科clerk rotation時報的mini-topic，做PPT也是個重整知識的功課

1. IV
Fluid
Gem Wu

2. Abstract
1. Requirements (fluid distribution + electrolyte)
2. Distribution
3. Products (crystalloid)
4. Application
 Shock resuscitation
 Electrolyte imbalance
 Maintenance (in various situations)

3. Fluid Requirements
2/3
1/4
1/12
Ingestion (1.5L)
Food (0.7L)
Respiration (0.3)
Input Output
Urine (0.8~1.5L)
Stool (0.2L)
Insensible (0.6~0.9L)
If fever+1℃, +0.1~0.15L
1500+[(Kg-20)*20]
Fluid for Maintenance

4. Electrolyte Requirements
½ NS + 20 KCl mEq
LR + 20 KCl mEq
Glucose 100~150 g

5. Distribution D5W
= free water
Hypernatremia
Hypoglycemia
Maintenance
Resuscitation
Resuscitation
Resuscitation
Volume Maintenance Free
Water
LR
NS
1/4 NS
1/4 NS DS
1/2 NS
1/2 NS DS
Water
D5W
Hypo-
volemia
Oral intake ↓

6. Crystalloids
全塩
半塩
三倍塩
半塩+鉀
糖水
Hypotonic D5W, ½ Saline
Isotonic NS, LR, Taita No. 1~4
Hypertonic 3% Saline, D5S, D10W, Taita No. 5

7. Colloids
• natural (e.g.
albumin, FFP)
• synthetic (e.g.
dextrans,
hydroxyethyl
starch, gelatins)
• Use:
resuscitation in
severe
hypovolemia,
cirrhosis SBP
and renal failure

8. Shock -1
量CVP沒差
Fluid responsiveness
Spontaneously breathing
Ventilator
Inspiration LV SV
– expiration LV SV

9. Shock -2
1. LR或NS?
2. 量：in boluses, not via “maintenance fluids”
 w/o CHF or ESRD: 1-2L at a time
 w/ mild-mod CHF or ESRD: 0.5-1.0L at a time
 w/ severe CHF or ESRD: 0.25L at a time
3. 測：每次給完IVF都要再評估
4. 直到：
 MAP>=65 mmHg
 CVP 8~12 mmHg
 SCVO2 >= 70%
 Urine output >= 0.5 ml/kg/hr
 Normalized lactate, mental status

10. Electrolyte Imbalance
Hypo-
natremia
Hyper-
natremia
Hypo-
kalemia
Hyper-
kalemia
Hypo-
calcemia
Hyper-
calcemia
Hypo-
volemic
Eu-
volemic
Hyper-
volemic
0.9%
NS
3% NS
+ lasix
Limit
water
w/o SSx: <0.5 mEq/L/h
w/ SSx: <2.0 mEq/L/h (3h)
<0.5 mEq/L/h
Hypo-
volemic
Central
DI Hyper-
volemic
0.45%
NS
DDAVP
D5W
+ lasix
peripheral
DI
Limit water
+ thiazide
IV: 10-20 mEq 500ml
(MAX: 400 mEq)
PO: 40 mEq/dose Q4H
(MAX)
Ca gluconate
bicarbonate
Insulin
Klimate
Furosemide
Hemodialysis
<40 mEq/L/2h
P↑ hemodialysis or lower P
P - give Ca
NS + lasix

11. Maintenance -1
1. NPO?
 <7D: Dextrose + H2O + Electrolyte
 >7D: PPN or TPN
 If not, consider fluid status, electrolyte and appetite
2. Volume?
 Holiday-Segar method: 100ml/kg/d (first 10kg) + 50ml/kg/d (second
10kg) + 20ml/kg/d (other kg) *elders 10ml/kg/d
 Normally 1.5~3.0L; Elders 1.0~1.5L per day
3. Loss?
 Loss : crystalloids = 1 : 3 ; loss : colloids = 1 : 1
 3rd space loss: superficial (1-2 ml/kg/h), hernia (3-4 ml/kg/h),
hysterectomy (5-6 ml/kg/h), nephrectomy (8-10 ml/kg/h), colon prep
1000ml

12. Maintenance -2
• 70 kg man: D5 ½ NS w/ KCl 125 ml/h
• D5S → Osmo too high → Vessel rupture
• D5 ¼ NS → Sodium 77 (2L) → hyponatremia