Fluids + Nutrition

Question 1

What are the 5Rs of Fluid prescribing?

Answer 1

Resuscitation
Routine maintenance
Replacement
Redistribution
Reassessment

Question 2

How would you give resus fluids and who needs them?

Answer 2

Patient showing signs of hypovolaemia
Give initial Crystalloid fluid bolus of 500ml in 15mins
Then re-assess the patient’s response.
If euvolaemia not achieved repeat this up to 2Ls over approx an hour.
If still not euvolaemic + stable then seek senior help.

Question 3

What are maintenance fluids?

Answer 3

Adult needs 30ml/kg/day of water
and 1-2mmol Na and Cl per Kg per day
and 0.5-1mmol K per kg per day

Question 4

How can you be sure that a patient is receiving sufficient fluids?

Answer 4

Insert a urinary catheter for accurate measurements

Enough fluid is being given in the patient’s urine output is at least 0.5ml/kg/hr

Question 5

What is a colloid?

Answer 5

Colloids are gelatinous solutions that maintain a high osmotic pressure e.g. Gelofusion

Question 6

Give examples of crystalloid fluids

Answer 6

0.9% NaCl = normal saline
Hartmann’s soln = Compound lactate
5% Dextrose

Question 7

Why is K added separately?

Answer 7

Patient K needs vary greatly and mistakes in K levels can have serious consequences.
Hartmann’s only has 5mmol/L of K, the rest have no K. Most patients get K from diet but consider K if patient is NPO

Question 8

What is contained in a litre of Hartman’s soln?

Answer 8

1L water
131 Na
111 Cl
5 K
29 Bicarb

Question 9

Are all colloids isotonic?

Answer 9

No, dextrose is hypotonic.

Hartmann’s and normal saline are isotonic.

Question 10

What is in a litre of normal saline?

Answer 10

1L water

154 Na and 154 Cl

Question 11

What is in 5% dextrose?

Answer 11

1L water and 50g of glucose

Question 12

What are the clinical signs of dehydration?

Answer 12

Dry mucous membranes
Skin turgor
Prolonged capillary refill time

Vital signs - tacky and low systolic BP
urinary output below 0.5ml/kg/hr = oliguric
below 10ml urine per hour is anuric

Question 13

What do we not give pure H2O?

Answer 13

Would cause cell lysis and hyperkalaemia

Question 14

What are the indications for providing nutritional support for a patient?

Answer 14

Pre existing malnutrition
Anticipated or actual inadequate intake by mouth e.g. dysphagia / pancreatic cancer, Neo-adj chemo radio
Multiple comorbidities - stroke patient
Early enteral feeding post op e.g. after upper GI sx
Parental feeding will be unable to receive adequate enteral nutrition by post op days 10-14

Question 15

What is the best way to assess nutrition?

Answer 15

MUST score
universal screening tool for malnutrition
1. Current BMI
2. Weight 3 months ago
3. Acute disease effect score
Based on MUST score, a dietician may need to be consulted.

Question 16

What is Enteral feeding?

Answer 16

• Delivered straight to gut
• Should be used if the gut can be used
• 3 Route Options
  ○ Oral
  ○ Feeding tube NG/NJ
  ○ Gastrostomy ( PEG tube) or Jejunostomy

Question 17

What is parenteral nutrition?

Answer 17

• Can be given peripherally or centrally ( better central)
• Peripheral parenteral nutrition should be given via a large diameter venous catheter
  ○ Can cause phlebitis in peripheral veins
  Used in patients where the bowel needs to rest e.g. bowel resection, fistula that needs to dry out

Question 18

What is a PICC line?

Answer 18

Peripherally inserted central catheter
- A long catheter placed through a peripheral vein that end up actually entering a central vein
○ Used for TPN and chemo
○ Can be used long term and the patient can go home with it
○ Lower risk of line sepsis

Question 19

What is TPN?

Answer 19

TPN is entire daily nutritional needs, macronutrient needs in their smaller components, also contains fluid so will be included in someone’s daily fluid plan, dieticians can add vitamins and minerals also.

Question 20

What is important about the storage of TPN?

Answer 20

Covered by the green bag because it needs to be protected from sunlight which would denature the amino acids

Question 21

What is in the bag of yellow fluid? Why would the patient be on it?

Answer 21

B complex vitamins - mainly thiamine b12
Given to patients with hx of alcohol dependence or long hx of vomiting
Used to prevent Wernicke’s encephalopathy

Question 22

What are the complications of TPN?

Answer 22

• Hyperglycaemia
• Serum electrolyte abnormalities
• Refeeding syndrome
○ K, Mg, and Phosphate can be imbalanced and cause trouble quickly
• Wernicke’s encephaopathy
• Bacteraemia
• Complications secondary ot central venous catheterisation
Fatty liver - could lead to liver failure ( 2 most common cause of death in patient on long term TPN)

Question 23

What should be monitored in a patient on TPN?

Answer 23

• Daily glucose, urea and electrolytes until stabilised
• Twice weekly LFTs
  Weekly copper, magnesium, phosphate and manganese