Fluid Maintenance

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Fluid Maintenance

• CPT James R. Rice, PA-C
• Program Manager
• Tactical Combat Medical Care

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COMBAT FLUID RESUCITATION

• On todays battlefield medical providers will be
  required to manage their patients fluid
  resuscitation from point of wounding until their
  arrival at the FST or CSH.
• CASEVAC/MEDEVAC assets may be delayed or mission
  may require patient hold on the battlefield or in
  the BAS for hours to days.
• Hypotensive resuscitation initially
• Maintenance protocols
• IO monitoring

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HYPOTENSIVE RESUSCITATION

• IV access must be gained. The use of a single 18
  gauge catheter is recommended.
• A heparin, saline lock-type access tubing,
  extension set, or 3 way stop-cock should be used
  unless the patient needs immediate resuscitation.
• Insure the IV site isnt established distal to a
  significant wound.

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HYPOTENSIVE RESUSCITATION

• Splint if the site is over a joint to prevent
  dislodgement during transport.
• If unable to start an IV consider starting a
  sternal Inter-Osseous line to provide fluids. A
  caveat-If you do this insure the skin is prepped
  well. Osteomyelitis in the manubrium is VERY
  BAD!!!

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FLUID RESUSCITATION

• After initial resuscitation if CASEVAC/MEDEVAC is
  impossible or delayed for any reason fluid
  maintenance must be recalculated based on the
  patients condition, supplies, and time available.
• Maintenance rate calculation when NPO (Weight in
  Kg) 40 ml per hour of infusion rate.

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FLUID RESUSCITATION

• End Points of resuscitation for controlled
  hemorrhage and dehydration
• Normal BP
• Pulse
• Urine output (0.5-1 ml/kg/hr)
• Normal capillary refill
• Good mentation

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FLUID RESUSCITATION

• If patient can accept p.o fluids begin Oral
  Rehydration Salts (ORS) , water, and other
  fluids as tolerated.
• Pre-packaged ORS are very prevalent Downrange,
  but patients for the most part, hate the taste
  and will require some encouragement. Gatorade
  though not quite as good has better compliance.
• ORS Recipe- 4 tsp sugar, ½-1 tsp salt, 1L water

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BURN RESUSCITATION

• Adults 2-4 cc LR x Kg body weight x BSA burn.
• Children 3-4 cc LR x kg body weight x BSA burn.

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BURN RESUSCITATION

• The infusion rate is regulated so that ½ the
  estimated volume will be administered in the
  first 8 hours post burn-the time when capillary
  permeability and intra-vascular volume loss are
  greatest.
• The remaining half of the estimated resuscitation
  volume should be administered over the subsequent
  16 hours of the the first post burn day.

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BURN RESUSCITATION

• The burn victim requires fluid maintenance in
  addition to the initial resuscitation!

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IV DRIP RATE CALCULATION

• Macro Drip Delivers rates greater than 100
  ml/hr (Drip factor is 10 to 15 gtt/ml depending
  on equipment used. Drop Factor is printed on the
  box.
• Micro Drip Delivers rates less than 100 ml/hr.
  Most commonly 60 gtt/ml.

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CALCULATING FLOW RATE

• Flow Rate (ml/hr) Total Infusion (Vol in ml)
• 
  Hours of Infusion Time
• gtt factor x Flow Rate Drop Rate
• 60 1
• Example Infuse 120ml/hr via 10gtt/ml Drop
  Factor

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ALTERNATE METHOD FOR CALCULATION

• If drop factor is 10 gtt/ml, take ordered rate
  per hour and divide by 6.
• If drop factor is 15 gtt/ml, take ordered rate
  per hour and divide by 4.
• If drop factor is 20 gtt/ml, take ordered rate
  per hour and divide by 3.
• If drop factor is 60 gtt/ml, take ordered rate
  per hour and divider by 1.

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MONITORING I O

• Appropriate for patients that for whatever reason
  are in a hold status, and their condition
  requires close monitoring to maintain hemostasis.
• Anticipate, and bring graduated containers.
• Normally calculated q 8 hrs.
• Compare 24 hr totals over several days.
• Utilize resuscitation endpoints and UOP to help
  in making a CLINICAL DECISION
• Increase or decrease the fluid maintenance based
  on your CLINICL DECISION

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QUESTIONS???