9. GIFTASUP

Question 1

Initial management of hypovolaemia / Oliguric patient

Answer 1

Structured approach assessing abc

To asses filling status

• Fluid balance (including intraop)
• Skin turgor
• CVP trend (?controversial)
• Peripheral CRT
• HR & BP

Information about periop KFT (Kidney Fxn Test)
renal reserve

ABG
Metabolic & electrolyte rapd assesment

Question 2

Assessing fluid status

Hypovol

Answer 2

Hypovolaemia

• Pre renal failure 2nd to depletion
• Assess & review response to bolus crystalloid
• Straight leg raise test
• Continue boli until euvolemia and U/O improved

Question 3

Assess fluid status

Euvolaemic team

Answer 3

Intrinsic AKI / Obstruction

Stop nephrotoxic drugs (aminoglycosides / NSAIDs)

U/S rule out post renal obstruction
- info size kidney / indicate chronic renal disease

If remain anuric -> perfusion pressure
- low augment with pressors/tropes in CC setting

May need HF & renal

Question 4

Fluid Resus Gift a sup

Scenarios suggesting one fluid has advantage over other

1. Saline
   Advantages

Answer 4

Advantages

Crystalloid
rehydrates all spaces well

Low allergy / anaphylaxis

High Na load
Na deplete patients
free water clearance impair/hypona

Chloride load for gastric fluid replacement
Vomiting

** only true role for saline is in head injured patients to prevent cerebral oedema

Question 5

1. Saline

b disadvantages

Answer 5

Excess infusion of Chloride
a/w metabolic acidosis

Risk of HyperNa in patients w/ impair sodium clearance

Low pH
‘normal saline’ - Fallacy

Question 6

2. CSL

advantages

Answer 6

Crystalloid
rehydrates all spaces well

Low allergy / anaphylaxis

Less acidotic

Balanced salt solution for better rehydration of ICF & ECF

Less electrolyte disturb compared to other

Less Na & Cl load
for patients with impair Na clearance post op
d/t acute phase response

Question 7

2. CSL

Disadvantages

Answer 7

Lactate accum in liver failure

Hypergly diabetic?

Caution with AKI - K accumulation possible
evidence base justifies safety profile

** can safely be used in diabetics as per the AAGBI guideline on managing peri-op diabetes

** lactate accumulation is theoretical but is officially a C/I on the SPC

Question 8

3. Dextrose

advantages

Answer 8

Acts source free water for water deplete patient
HyperNa

Distribution to all compartments
expansion of Intracellular compartment >crystalloid

Question 9

3. Dextrose

Disadvantage

Answer 9

Poor for Intravascular expansion

a/w deranged cell fxn
oedema
bgl
hypona
fluid overload

** absolutely C/I in TBI

Question 10

4. Colloid

Advantage

Answer 10

Theoretical advantage of plasma expansion
longer than crystalloid - circ & perfusion

Reduced oedema risk
smaller equivalent volume of fluid required for BP

Question 11

4. Colloid

Disadvantage

Answer 11

Poor for hypovolaemia fluid deplete

Allergy / anaphylactic risk higher

Large molecule starches - aki in oliguric patient

plasma expansion can be short lived

cost

** Starches have been taken off the market due to renal injury and platelet dysfunction (although 8.4% hepastarch is still available in the Coombe)