A3- Intravenous Fluid

Question 1

WHat are the three things to think for patients fluid status?

Answer 1

Physiology of water and electrolytes

Composition of IV fluids

Fluid and electrolyte disturbances in acute illness

Question 2

What % of our body is made up of water

Answer 2

60%

Question 3

What is the main extracellular cation in our body?

Answer 3

Sodium

Question 4

How much Na and water is reabsorbed in the PCT

Answer 4

60-70%

Question 5

RECAP of RAAS system

Answer 5

• drop in bp
• kidney release renin
• renin converts angiotensiongen in the liver into angiotensin I
• angiotensin I is converted to angiotensin II
• acts on the adrenal glands
• releases aldosterone
• increases bp

Question 6

How does ADH control osmolarity?

Answer 6

Two ways

Osmotic control: more salt, less water so reduce ADH,

Non osmotic control: reduction in ECF volume, hypoT, Nausea so increase in ADH

Question 7

What happens to sodium and water retention in unwell patients?

Answer 7

• Physiological stress increases RAAS
• Kidney: ability to dilute and concentrate urine is impaired
• Raised urea production: reduces ability to concentrate urine
• Acute Kidney Injury: reduced GFR
• Hypokalaemia
• Increased capillary permeability : albumin leak

Question 8

Name different types of solutions

Answer 8

Crystalloid Solution

Colloid Solution

Question 9

compare

Crystalloid Solution

Colloid Solution

Answer 9

Question 10

Type of FLUIDs in Crystalloid solutions ?

Answer 10

Question 11

Types of fluids in colloid solutions?

Answer 11

Question 12

What are the dangers of excess sodium?

Answer 12

High sodium means high osmolaluty and so stimulates ADH more and reabsorb loads of water.

This will reduced excretion of soidum which can lead to AKI

Question 13

What are the dangers of excess chloride?

Answer 13

Causes renal vasoconstriction which reduced eGFR and affects the kidney function

That then increases morbidity and leads to AKI/Acute illness

Question 14

Principles of IV Fluid therapy?

Answer 14

➢Review/ Assessment

➢Routine maintenance

➢Resuscitation fluid

➢Replacement of abnormal losses

➢Redistribution

Question 15

What are the Indicators for Resuscitation IV Fluid Therapy?

Answer 15

•Hypovolaemia

➢systolic blood pressure is less than 100 mmHg

➢heart rate is more than 90 beats per minute

➢capillary refill time is more than 2 seconds or peripheries are cold to touch

➢respiratory rate is more than 20 breaths per minute

➢National Early Warning Score (NEWS) is 5 or more

➢passive leg raising suggests fluid responsiveness

Question 16

What is the ideal IV fluid that you would want for Resuscutation?

Answer 16

◆Produces a predictable and sustained increase in intravascular volume

◆Chemical composition as close as possible to that of extracellular fluid

◆Metabolized and completely excreted without accumulation in tissues

◆Does not produce adverse metabolic or systemic effects

◆Cost-effective in terms of improving patient outcomes

Question 17

Compare and contrast colloids and crystalloids (eg expense etc)

Answer 17

Question 18

What are the three main types of colloids?

Answer 18

ALbumin

Gelatin

HES

Question 19

COmpare the different types of colloids?

Answer 19

Question 20

Albumin versus Crystalloids

Answer 20

• Albumin versus crystalloid solutions in patients wit hypovolemia, burns, or hypoalbuminemia • Albumin was associated with a significant increase in the rate of death
• A comparison of albumin and saline for fluid resuscitation in the ITU • Albumin was associated with a significant increase in the rate of death at 2 years among patients with traumatic brain injury

No clear evidence on efficacy of Albumin as resuscitation fluid

Question 21

HES versus Crystalloids

Answer 21

• Hydroxyethyl starch versus Ringer’s acetate in severe sepsis • HES had an increased risk of death at day 90 and were more likely to require renal-replacement therapy
• A comparison of 6% HES (130/0.4), as compared with saline, in the intensive care unit • HES was associated with a significant 21% relative increase in the rate of renal replacement therapy

Question 22

What are the two types of isotonic IV fluids?

And what are there adverse effects?

Answer 22

Question 23

What are the hypotonic IV fluids

Answer 23

Question 24

DO you use HES for fluid resuscitation

Answer 24

NO

COnsider human albumin solution 4-5% for fluid reesus only in patients with severe sepsis

Question 25

What is the Preferred IV replacement

Answer 25

• Hartmann’s solution should be used rather than normal saline when the plasma chloride is >108 mmol/l
• If plasma chloride is <98 mmol/L e.g. vomiting or gastric drainage, normal saline is more appropriate than Hartmann’s

Question 26

Hartmans is preferable to normal saline except in?

Answer 26

Question 27

How do you monitor IV fluid therapy?

Answer 27

Patients should have an IV fluid management plan, which should include details of fluid and electrolyte prescription over the next 24 hours

Daily reassessments of clinical fluid status, U&E and fluid balance charts, along with weight measurement twice weekly

IV fluid prescriptions should be reviewed on the consultant post take round and on each senior doctor ward round during the patient’s hospital stay

Clear incidents of fluid mismanagement should be reported through standard critical incident reporting

Question 28

Answer 28