Plastic Cases-IV Fluids

brownbook · Mar 5, 2014

WOW...I love your question. I have no idea as to the answer? We do a wide variety of surgeries so i am not a plastics expert.

Our plastic patients rarely get more than 1500 ml of crystalloids even in long procedures. In PACU we rarely give more than 500 to 1 liter. We sometimes accommodate overnight patients when pre-scheduled by the MD, then the IV rate is ordered by the surgeon, usually 75 to 100 ml per hours.

I hope someone answers, but it is above my pay grade...ha ha., kind of joking. But I do think an anesthesiologists would have the best answer. We do get really good replies from CRNA's here.

Goose Xx, MSN, RN, EMT-P, CRNA · Mar 5, 2014

Fluid requirements are based on a couple of things. I can give a quick example.

1) Fluid Deficit. (NPO time - calculated from night before)

2) Hourly maintenance fluid rate

3) Anticipated 3rd space loss (Determined by procedure and is variable to what provider feels appropriate)

4) Actual blood loss (Not tissue loss)

Example:

30 y/o patient 100 kg, NPO 10 hours, for Bilateral breast reduction planned for 3 hours.

In anesthesia we use the 4-2-1 rule to calculate hourly fluid rates.

4 ml per hour for 1st 10 kg = 40 ml

2 ml per hour for 2nd 10 kg = 20 ml

1 ml per hour for each kg > 20 = 80 ml

Hourly rate for = 140 ml / hour

Or for adults take weight in kg's and add 40: 100 kg + 40 = 140 ml / hour

The hard part is over.

1) Fluid deficit: 10 hours x 140 ml / hour = 1400 ml

2) Hourly rate: 3 hours x 140 ml / hour = 420 ml

3) 3rd space: (4 ml / kg / hour) 4 ml x 100 kg x 3 hr = 1200 ml

4) Minimal blood loss. Replace blood loss with crystalloid at 3:1 ratio. For every 1 cc blood loss give 3 cc crystalloid. So if Estimated Blood Loss is 100 cc, then give 300 ml fluid.

Total fluid in = 3320 (Textbook healthy patient without any significant comorbidites.

Hope that helps.

kngl · Mar 6, 2014

Thanks Goose, this is very helpful! Our surgeons do not order a post-op fluid rate. Some CRNAs clamp the fluids coming out of the OR and some have them wide open. This way I have a clearer picture of where those longer recovery patients should be.

Goose Xx, MSN, RN, EMT-P, CRNA · Mar 6, 2014

Thanks Goose this is very helpful! Our surgeons do not order a post-op fluid rate. Some CRNAs clamp the fluids coming out of the OR and some have them wide open. This way I have a clearer picture of where those longer recovery patients should be.[/quote']
I don't always reach the fluid goal. It is more of a guideline. Other factors way in also. Urine output if foley. Stroke volume variation if there is an art line and monitoring. CVP. There are also instances were I end up giving more fluids than anticipated. But if you can use the above calculations it gives you a ballpark.
When in doubt ask how much more fluid they should get. I try to get the patients fluid optimized prior to leaving the OR and leave the IV at tko in PACU unless they are going straight to the ICU and staying intubated. Otherwise, the goal is to get them taking PO to ensure there is no PONV to get them home.

brownbook · Mar 6, 2014

I knew a CRNA would come to the rescue. You guys are wonderful. I would take a CRNA anytime over an anesthesiologist.

I know it is a guideline. But in PACU, out patient surgery, textbook healthy patients going home in 2 - 3 hours, since they start taking juice, water, etc., soon after arrival. I'm just not seeing if PO intake enters into the equation.

It seems like "DUH!" of course, but then there are no stupid questions.