Critical Care Mailbag - IV Fluids

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MD Commentary

Mizuho Spangler, DO, Scott Weingart, MD, Lisa Chavez, RN, and Kathy Garvin, RN
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Seth -

when adding 3 amps bicarb to a litre of D5 (which has a total volume of 150 mL), do you need to withdraw 150 mL of D5 before hand or just add the 3 amps giving the bag a total volume of 1,150 mL?

brendanC -

Since most patients with DKA have vomiting, strong consideration to using NS rather than LR as the initial fluid of choice. I have always used NS but not with the large volume that is typically used for DKA. The physiologic basis for this is that (with high volume NS) as urine output increases, the acetone is excreted and the body no longer has the acetone to use as the substrate to regenerate CO2, resulting in the hyperchloremic, non-gap acidosis. Lower volumes of NS (in a non-shock pt) will resus the patient without this pitfall.
JAMA. 1989;262(15):2108-2113. doi:10.1001/jama.1989.03430150076029.
Having said that, I love LR for everything else.

c. berg -

Scott,

We've switched to LR in our sepsis resuscitation algorithm, and the performance looks great. We also use lactate clearance (in a limited capacity). We are not seeing any impairment in clearance across >1,000 patients. Do you genuinely believe that LR may cause a spurious elevated in laboratory lactic acid levels during serial measurements?

Best,
Cameron

Michelle S. PA-C -

I second Cam's question. Thanks!

Michelle

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