Fluid Management
The rule: 60% total body weight is water 40% of total body weight is intracellular fluids 20% of body weight is extracellular fluids
Guidelines you need to know! NICE recommendations
Inappropriate fluid management! Pulmonary oedema Peripheral oedema Volume depletion and shock
Fluid management principles – the 5 Rs Resuscitation Routine maintenance Replacement Redistribution Reassessment
Assessment ABCDE approach NEWS score Urine output Does the patient need resuscitation?
1. Resuscitation Identify cause of deficit and respond Give 500ml bolus of crystalloid Reassess – does the patient still need resuscitation? Continue giving boluses of ml and reassess after each Up to a maximum of 2000ml - seek expert help
2. Routine maintenance If no abnormal losses: 25-30mls/kg/day (usually around 2-3 litres) 1mmol/kg/day sodium, potassium, chloride g/day glucose Remember to adjust for other sources of fluids e.g. drugs, any oral intake
Assessment for maintenance Consider maintenance requirements for fluid and electrolytes Consider history, examination, observations and blood parameters Can they meet their needs enterally? Do they have any abnormal losses?
3. Replacement Existing fluid / electrolyte deficits Ongoing fluid / electrolyte losses Vomiting / gastric aspirate Stomas Diarrhoea Biliary drains Sweating Fistulas Urinary losses Add to maintenance fluids!
4. Redistribution Consider third space redistribution and other complex issues – seek expert help! Cardiac / renal / liver failure Malnutrition (low albumin) Post-operative fluid retention Severe sepsis
5. Reassess Go back to the start History, examination, observations, blood parameters Has anything changed?
Fluids for resuscitation Crystalloids – water soluble substances pass freely between intravascular and interstitial compartments Colloids – larger molecular weight substances that do not dissolve completely and remain in intravascular compartment for longer (must give sufficient water to avoid hyperoncotic state – AKI) Replace blood with blood
Fluid choice Contents of crystalloids in mmol-1 NaKClBicarbLactate Plasma <1 0.9% saline Hartmann’s
Paediatric fluids Fluid requirements in a 24 hour period: 100ml/kg for 1st 10kg 50ml/kg for 2nd 10kg 20ml/kg for every kg above this
Burns fluids Fluid requirements in 24 hours (Parkland formula) = Total body surface area burned (%) x Weight (kg) x 4mL Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours
ERAS concepts Reduction in the amount of peri-operative fluid given Patients for elective surgery should not be nil by mouth for more than 2 hours Concurrent administration of Hartmann’s should be considered if using bowel prep Administration of carbohydrate rich drinks 2 hours pre-operatively Goal-directed fluid management intra- operatively to avoid unnecessary fluid overload
Scenario 1 50 year old female with jaundice, RUQ pain, fever and rigors PMH: Hypercholesterolaemia 500ml bolus Hartmann’s given Obs following the fluid bolus: BP 95/50, HR 120, temp 38.1 What is the most appropriate fluid to prescribe next?
Options: A) 500ml gelofusine stat B) 1000ml Hartmann’s over 1 hour C) 500ml gelofusine over 30 minutes D) 500ml Hartmann’s stat
Options: A) 500ml gelofusine stat B) 1000ml Hartmann’s over 1 hour C) 500ml gelofusine over 30 minutes D) 500ml Hartmann’s stat
Scenario 2 70 year old male 1/7 post partial hepatectomy for colorectal metastases PMH: Hypertension, MI 5 years ago ATSP due to high NEWS score. BP 90/55, HR130, RR30, looks pale and clammy Chart says abdominal drain drained 50ml over past 24 hours but now has 600ml in it. Abdo distended and tender Hb last night 98. Hb now 69 500ml bolus Hartmann’s given with some improvement What is the most appropriate fluid to prescribe next?
Options: A) Further 500ml bolus Hartmann’s B) 2 units blood C) 500ml bolus gelofusine D) 1 unit blood, 1 unit platelets
Options: A) Further 500ml bolus Hartmann’s B) 2 units blood C) 500ml bolus gelofusine D) 1 unit blood, 1 unit platelets
Scenario 3 50 year old 70kg male 6/7 post resection of SCC tonsil, soft palate and lateral pharyngeal wall, awaiting radiotherapy PEG fed as currently unable to swallow Pt c/o nausea so PEG feeds slowed down to 50ml/hr for 12 hours overnight. What fluid should you prescribe for maintenance over 24 hours?
Options: A) 1500ml of water given through the PEG B) 2 bags of dextrose C) 2 bags dextrose and one bag 0.9% saline with 40mmol K+ D) 3 litres of Hartmann’s IV
Options: A) 1500ml of water given through the PEG B) 2 bags of dextrose C) 1 bag of 0.9% saline with 40mmol potassium IV with an extra 500ml water flushed through the PEG D) 1.5 litres of Hartmann’s IV
Scenario 4 69 yr old gentleman admitted with a community acquired pneumonia. Bx of AF, IHD(triple vessel disease), HTN, COPD Is on clarithromycin, amox, furosemide, Ramipril, warfarin, bisoprolol, tiotropium and salbutamol inhalers Na 140Urea 12.2 K 2.7Creat 150
Options A) Encourage oral fluids B) 2 bags of dextrose C) 2 bags of 0.9% saline + 40 mmol K+ added D) 2 bags of dextrose +40 mmol K+ added
Options A) Encourage oral fluids B) 2 bags of dextrose C) 2 bags of 0.9 % saline + 40mmol K+ added D) 2 bags of dextrose +40 mmol K+ added
Scenario 5 8 year old child NBM for tonsillectomy PMH: Nil Weight: 30kg What is the most appropriate fluid volume to prescribe for maintenance fluids in 24 hours?
Options: A) 1700mls B) 2000mls C) 3000mls D) 1500mls
Options: A) 1700mls B) 2000mls C) 3000mls D) 1500mls