Makindo Medical Notes.com

Always make an individualised assessment if the patient is over or under filled based on situation, postural BP, HR, JVP, thirst, oedema, mucous membranes and skin turgor and fluid balance chart

About

• Use an ABCDE approach: Airway, Breathing, Circulation, Disability, Exposure approach
• Assess whether the patient is hypovolaemic and needs fluid resuscitation.
• Assess volume status using clinical examination, trends and context.

Indicators suggesting Underfilled - may need fluid resuscitation

• Low volume pulse
• Low JVP
• Low systolic BP <100 mmHg
• Heart rate >90 bpm
• Capillary refill >2s
• Cool peripheries
• Postural - sitting BP drop
• Respiratory rate >20 breaths per min
• NEWS >= 5
• CXR - no pulmonary oedema
• Weight loss due to fluid loss
• 45-degree passive leg raising suggests fluid responsiveness.

Indicators suggesting Overfilled - avoid fluid resuscitation

• Raised JVP or high central venous pressure
• Hypertensive
• Good volume pulse
• Basal crackles
• Tachycardia
• Peripheral dependent oedema
• Ascites
• Pulmonary oedema on CXR
• Weight gain

Cautions

• Avoid overloading the frail and elderly with fluids unless clearly dry and then do it slowly
• Avoid IV fluids if the patient can be encouraged to drink to replace deficit
• Give IV dextrose with those with acute stroke as it can worsen cerebral oedema in theory
• Give 3 L/day to a small and frail elderly lady who has undiagnosed diastolic heart failure who will soon develop pulmonary oedema.

Fluid challenge

• Give a 250 ml bolus of N-Saline and assess response
• If physiology improves then consider ongoing IV fluids

Give maintenance IV fluids (NICE)

• Normal daily fluid and electrolyte requirements:25-30 ml/kg/d water
• 1 mmol/kg/day sodium , potassium, chloride
• 50-100 g/day glucose (e.g. 1 L 5% Glucose = 50 g Glucose).

Daily Intake

• Typical Daily Intake for 70 Kg person with normal cardiac/renal function is
  • 1 L N Saline + 20 mmol KCL
  • 1 L 5% Dextrose + 20 mol KCL
  • 1 L 5% Dextrose + 20 mol KCL
• For older or low weight patients consider
  • 1 L N Saline + 20 mmol KCL
  • 1 L 5% Dextrose + 20 mol KCL

Reassess and monitor the patient

• Postoperative patients have raised ADH and so prone to hyponatraemia so avoid excess dextrose.
• May need more Saline e.g. 2 L of 0.9% saline to 1 L of 5%dextrose depending on hydration and Na levels.
• Replacement fluids for drains and drips generally need to be 0.9% saline, as losses tend to have a high sodium concentration, e.g. drain fluid, blood, vomit, diarrhoea.
• Fluids should always be prescribed knowing fluid balance, cardiac and renal status and clinical state.
• Stop IV fluids when no longer needed. Nasogastric fluids or enteral feeding are preferable when maintenance needs are more than 3 days