1. Fluid Balance
Daniel Jones

2. 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

3. 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

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

5. 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

6. 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

7. 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?

8. 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

9. 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

10. 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+
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

11. 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