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ESA 5 - Integrative > Fluid Prescribing > Flashcards

Fluid Prescribing Flashcards

1
Q

Who should be prescribed IV fluids?

A

Patients whose needs cannot be met by oral or enteral routes

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2
Q

What should be done with fluids when possible?

A

Oral fluid intake should be maximised, and IV fluid only used to supplement the defecit

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3
Q

Give three examples of when fluids might be required

A
  • Nil by mouth
  • Patient vomiting or has severe diarrhoea
  • Patient is hypovolaemia as a result of severe blood loss
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4
Q

Why might a patient be nil by mouth?

A
  • Bowel obstruction
  • Ileus
  • Pre-surgery
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5
Q

What is likely to be needed when a patient is hypovolaemic as a result of severe blood loss?

A

Blood products in addition to IV fluid

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6
Q

What two major groups are fluids categorised into?

A
  • Crystalloids
  • Colloids
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7
Q

What are crystalloid fluids?

A

Solutions of small molecules in water

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8
Q

Give three examples of crystalliod fluids

A
  • Sodium chloride
  • Hartmann’s
  • Dextrose
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9
Q

What are colloid fluids?

A

Solutions of larger organic molecules

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10
Q

Give two examples of colloid solutions

A
  • Albumin
  • Gelofusinine
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11
Q

Why are colloids used less often than crystalloids?

A
  • Carry a risk of anaphylaxis
  • Research has shown crystalloids are superior in initial fluid resuscitation
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12
Q

What is the ionic composition of human plasma?

A
  • Na+ 135-145 mmol/L
  • K+ 3.5-5.0 mmol/L
  • Cl- 100-110 mmol/L
  • HCO3- 22-26 mmol/L
  • 3.5 - 7.8 mmol/L
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13
Q

What is the tonicity of sodium chloride 0.9% fluid?

A

Isotonic

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14
Q

What is the ionic composition of sodium chloride 0.9%?

A
  • Na+ - 154 mmol/L
  • K+ - 0
  • Cl- - 154 mmol/L
  • HCO3- - 0
  • Glucose - 0
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15
Q

What is the tonicity of Hartmann’s solution?

A

Isotonic

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16
Q

What is the ionic composition of Hartmann’s solution?

A
  • Na+ - 131 mmol/L
  • K+ - 5 mmol/L
  • Cl- - 111mmol/L
  • HCO3- - 29mmol/L
  • Glucose - 0
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17
Q

What is the tonicity of sodium chloride 0.18%/ glucose 4%?

A

Hypotonic

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18
Q

What is the ionic composition of sodium chloride 0.18%/glucose 4%?

A
  • Na+ - 30mmol/L
  • K+ - 0
  • Cl- - 30mmol/L
  • HCO3- - 0
  • Glucose - 40g/L
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19
Q

What is the tonicity of 5% dextrose?

A

Hypotonic

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20
Q

What is the ionic composition of 5% dextrose?

A
  • Na+ - 0
  • K+ - 0
  • Cl- - 0
  • HCO3- - 0
  • Glucose 50g/L
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21
Q

What are isotonic solutions used for?

A

Resuscitation and maintenance

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22
Q

What are hypotonic solutions used for?

A

Maintenance

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23
Q

What are the 5 R’s of fluid prescribing?

A
  • Resuscitation
  • Routine maintenance
  • Replacement
  • Redistribution
  • Reassessment
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24
Q

What does the initial fluid asessement involve?

A

Assessing the patients likely fluid and electrolytes needs from;

  • History
  • Clinical examination
  • Available clinical monitoring
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25
Q

What should be considered in the history when making a fluid assessment?

A
  • Fluid intake
  • Thirst
  • Dizziness/syncope
  • Abnormal fluid loss
  • Co-morbidities
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26
Q

What are the potential causes of abnormal fluid loss?

A
  • Vomiting
  • Diarrhoea
  • Polyuria
  • Fever
  • Hyperventilation
  • Increased drain output, e.g. biliary drain, pancreatic drain
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27
Q

What co-morbidities are significant when considering patients fluids?

A
  • Heart failure
  • Renal failure
28
Q

What approach should be taken in the clinical examination when considering fluids?

A

ABCDE

29
Q

What should be considered about the airways when assessing a patient for fluids?

A

Is the airway patent

30
Q

What should be done when considering breathing when assessing a patients fluids?

A
  • RR
  • Oxygen saturations
  • Auscultate lung fields
31
Q

What should be done when considering the circulation when assessing a patients fluids?

A
  • Pulse
  • BP
  • Capillary refill
  • JVP
  • Peripheral oedema
32
Q

What ‘exposure’ factors should be considered when assessing a patients fluids?

A
  • Wounds
  • Drains
  • Catheter output
  • Abdominal distention
  • Peripheral oedema
  • Fluid balance/weight charts
  • Other losses
33
Q

What should be done if, after your initial assessment, you feel there is evidence of hypovolaemia?

A

Your next step would be to initiate fluid resuscitation

34
Q

What should be done if, after your initial assessment, the patient appears stable and normovolaemic?

A

Calculate maintenance fluids

35
Q

What should be done if, after your intial assessment, the patient is hypervolaemic?

A

Do not administer IV fluids, and manage as appropriate

36
Q

What should be done in addition to prescribing resuscitation fluid if a patient is hypovolaemic?

A

Start considering the cause of the deficit, and take appropriate action to treat it

37
Q

What are the steps in the administration of resuscitation fluids?

A
  1. Initial fluid bolus
  2. Reassess the patient
  3. Second bolus
38
Q

What should be done in the ‘initial fluid bolus’ stage of fluid resuscitation?

A

Give an initial 500ml bolus of crystalliod solution over less than 15 minutes

39
Q

What should be done in the ‘reassess the patient’ stage of fluid resuscitation?

A

Use ABCDE approach, looking for evidence of ongoing hypovolaemia

40
Q

What should be done in the ‘second bolus’ stage of fluid resuscitation?

A

If the patient still has clinical evidence of ongoing hypovolaemia, give a further 250-500ml bolus of crystalliod solution, then reassess using the ABCDE approach

41
Q

When should the fluid resuscitation process be repated until?

A

Until there is no longer clinical evidence suggestive of need for fluid resuscitation, or when given a total of 2000ml of fluid

42
Q

What should be done if you administer 2000ml of fluid and there is still ongoing need for fluid resuscitation?

A

Seek expert help

43
Q

When should a more cautious approach to fluid resuscitation be taken?

A
  • if the patient has complex medical co-morbidities, e.g. heart failure or renal failure
  • If the patient is elderly
44
Q

What should be done differently when taking a cautious approach to fluid resuscitation?

A
  • Only give boluses of 250ml
  • Seek expert help earlier
45
Q

What should be done if the patient appears normovolaemic, but has signs of shock?

A

You should seek expert help immediately

46
Q

What can be considered once a patient is haemodyanmically stable?

A

Their daily fluid and electrolyte requirements can be considered

47
Q

What should you consider when reviewing a patients daily fluid requirements?

A
  • History
  • Clinical examination
  • Clinical monitoring
  • Laboratory monitoring - electrolytes, renal function, haemoglobin
48
Q

What do you need to decide once you have reviewed a patients fluid requirements?

A

If they can meet their fluid and/or electrolyte needs orally and enterally

49
Q

What do you need to consider if a patient is unable to meet their fluid and/or electrolyte needs orally/enterally?

A

If they have;

  • Complex fluid issues
  • Electrolyte replacement issues
  • Abnormal fluid distribution issues
50
Q

Why should it be considered if a patient has complex fluid issues, electrolyte replacement issues, or abnormal fluid distribution when considering daily fluid requirements?

A

Patients who have any of these issues will probably require fluid replacement and/or redistribution. Patients who do not have these issues, but are unable to meet their fluid requirements, should receive routine maintenance IV fluids

51
Q

At what time of day should routine maintenance fluids be prescribed to patients?

A

If possible, during daytime hours to prevent sleep disturbance

52
Q

What are the daily fluid requirements for an average patient?

A
  • 25-30ml/kg/day of water
  • Approx 1mmol/kg/day of potassium, sodium, and chloride
  • Approx 50-100mg/day of glucose
53
Q

What should be done to weight based potassium prescriptions?

A

They should be rounded to the nearest common fluids available

54
Q

Why does the patient need 50-100mg/day of glucose in their fluids?

A

To limit starvation ketosis, this will not address their nutritional needs

55
Q

What should be done when prescribing fluids for obese patients?

A

You should adjust the prescription to their ideal body weight, and use the lower range for volume per kg

56
Q

What groups require a more cautious approach to fluid prescribing?

A
  • Elderly
  • Renal impairment
  • Cardiac failure
  • Malnourished
57
Q

When should intravenous fluids be stopped?

A

When they are no longer required

58
Q

What should be done when the maintenance needs are more than 3 days?

A

Nasogastric fluids or enteral feeding

59
Q

What patients will require a slightly different appraoch to routine fluid maintenance?

A
  • Those with existing fluid or electrolytes deficits or excess
  • Those with ongoing abnormal fluid or electrolyte losses
  • Those with redistribution or other complex issues
60
Q

What will patients with dehydration require?

A

More fluid than routine maintenance

61
Q

What will patients with fluid overload require?

A

Less fluid than routine maintenance

62
Q

What will patients with hyperkalaemia require?

A
63
Q

What will patients with hypokalaemia require?

A

More potassium

64
Q

How should modifications in fluid requirements due to existing fluid or electrolyte losses be calculated?

A

Add or subtract their abnormality from standard routine maintenance fluids

65
Q

What are the potential sources of fluid/electrolyte loss?

A
  • Vomiting/NG tube loss
  • Diarrhoea
  • Stoma output
  • Biliary drainage loss
  • Blood loss
  • Sweating/fever/dehydration
  • Urinary loss
66
Q

What can cause excessive fluid loss in urine?

A
  • Diabetes insipidus
  • Post AKI polyuria
67
Q

What complex issues should be considered when prescribing fluids?

A
  • Gross oedema
  • Severe sepsis
  • Hypernatraemia/hyponatraemia
  • Renal, liver, and/or cardiac impairment
  • Post-operative fluid retention and redistribution
  • Malnourishment and refeeding issues

ESA 5 - Integrative (10 decks)

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