1. Fluid Management

2. The 60-40-20 rule:  60% total body weight is water  40% of total body weight is intracellular fluids  20% of body weight is extracellular fluids

3. Guidelines you need to know!  NICE 2013 - http://www.nice.org.uk/guidance/cg174/chapter/1- recommendations

4. Inappropriate fluid management!  Pulmonary oedema  Peripheral oedema  Volume depletion and shock

5. Fluid management principles – the 5 Rs  Resuscitation  Routine maintenance  Replacement  Redistribution  Reassessment

6. Assessment  ABCDE approach  NEWS score  Urine output  Does the patient need resuscitation?

8. 1. Resuscitation  Identify cause of deficit and respond  Give 500ml bolus of crystalloid  Reassess – does the patient still need resuscitation?  Continue giving boluses of 250-500ml and reassess after each  Up to a maximum of 2000ml - seek expert help

10. 2. Routine maintenance If no abnormal losses:  25-30mls/kg/day (usually around 2-3 litres)  1mmol/kg/day sodium, potassium, chloride  50-100g/day glucose  Remember to adjust for other sources of fluids e.g. drugs, any oral intake

11. 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?

12. 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!

13. 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

14. 5. Reassess  Go back to the start  History, examination, observations, blood parameters  Has anything changed?

15. 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

16. Fluid choice Contents of crystalloids in mmol-1 NaKClBicarbLactate Plasma135-1453.5-5.395-10522-25<1 0.9% saline 153015300 Hartmann’s 1304110028

17. 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

18. 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

19. 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

20. 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?

21. Options:  A) 500ml gelofusine stat B) 1000ml Hartmann’s over 1 hour C) 500ml gelofusine over 30 minutes D) 500ml Hartmann’s stat

22. Options:  A) 500ml gelofusine stat B) 1000ml Hartmann’s over 1 hour C) 500ml gelofusine over 30 minutes D) 500ml Hartmann’s stat

23. 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?

24. Options:  A) Further 500ml bolus Hartmann’s B) 2 units blood C) 500ml bolus gelofusine D) 1 unit blood, 1 unit platelets

25. Options:  A) Further 500ml bolus Hartmann’s B) 2 units blood C) 500ml bolus gelofusine D) 1 unit blood, 1 unit platelets

26. 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?

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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?

33. Options:  A) 1700mls B) 2000mls C) 3000mls D) 1500mls

34. Options:  A) 1700mls B) 2000mls C) 3000mls D) 1500mls