Fluid Balance Daniel Jones

Learning Objectives To cover the format of the fluid balance station To develop an approach to that station To learn how to carry out a fluid status exam To go through some worked examples

The Station You will be given a clinical vignette: You will be asked to go through a fluid status exam You will then give your impression and management

Scenarios Normal fluid status Hypovolaemia V + D Blood loss Dehydration Sepsis Fluid overload

Approach Start with an ABCDE assessment When assessing C, state you would do a fluid status exam Fluid status exam: Patient examination Basic Observations Review fluid balance chart

Patient examination Component Hypovolaemic Hypervolaemic Sepsis Inspection Dry membranes, pallor, reduced skin turgor, sunken eyes, drowsy Peripheral oedema Unwell, flushed, oedema Cardiovascular Thready pulse, non-visible JVP Elevated JVP, 3rd heart sound, rales Thready pulse Observations Tachycardic, delayed CRT, hypotensive Tachypnoeic Tachycardic, tachypnoeic, hyperthermic, delayed CRT

Fluid Balance Check the chart Balance = Input-Output Inputs Outputs Oral fluids IV fluids Water content of food Urine output Vomiting NG tube aspirate Drain output Stoma output Check the chart Balance = Input-Output Account for daily insensible losses (bowel, sweat, respiration). Usually 500 ml but can be higher. Is it deficit or surplus?

Impression What is the patient’s volume status? Hypo/hyper/euvolaemic What is the patient’s urine output like? Oliguria is <0.5 ml/kg/hr Anuria is usually due to an obstruction Is the patient in fluid deficit or surplus? What clinical scenario fits best? Hypovolaemic and in deficit = Fluid loss (Dehydration) Hypovolaemic but not in deficit = Third space loss Hypervolaemic and in surplus = Fluid overload

Management Identify and treat cause: Fluid loss = Identify source Third space loss = Find bleed/Sepsis 6 protocol Fluid overload = IV furosemide Resuscitation with IV access: Use in severe hypovolaemia or sepsis IV 500 ml 0.9% saline in under 15 mins (250 ml if older or signs of heart failure) Replacement, ideally oral: Replace the fluid deficit over several hours Get U & E’s and add in any depleted electrolytes

Maintenance If a patient is eating and drinking normally then you don’t need to worry If not then every 24h they need: 25-30 ml/kg of water plus insensible losses 1 mmol/kg of Na+, K+, Cl+ 50-100 g of glucose Typical regimen (for 70 kg person) would be: 1 L of 5% glucose with 40 mmol KCl over 10h 0.5 L of 0.9% saline over 4h 1 L of 5% glucose with 30 mmol KCl over 10h

Recap Listen to the vignette ABCDE Fluid status exam with obs and fluid balance Impression re: volume, fluid balance, urine output Management- ?Cause, ?Resus, ?Replacement, Maintenance requirements