Dehydration and Fluid management Flashcards

Question

How is the location of fluids relevant depending on purpose?

Answer 1

General maintenance of hydration - fluid must distribute into all compartments Resuscitation - fluid must stay in intravascular space

Answer 2

- In septic patients, the tight junctions between the capillary endothelial cells break down and vascular permeability increases. - As a result, increasing hydrostatic pressures and reducing oncotic pressure lead to fluid leaving the vasculature and entering the tissue. - It is often therefore necessary to give relatively large volumes of IV fluid to maintain the intra-vascular volume, even though the total body water may be high. C - lose monitoring of the fluid balance will be required.

Answer 3

3/5th of fluid input comes through fluids via the enteric route Remainder comes from both food and metabolic processes. When a patient is nil by mouth (NBM), it is important that all sources are replaced via the parenteral route.

Answer 4

Losses from non-urine sources These rise in unwell patients who may be febrile, tachypnoeic, or having increased bowel output Need to take this into account when replacing

Answer 5

When patients start to clinically improve, their vascular permeability returns to baseline state. They therefore often “correct themselves” and urinate out the excess fluid that was previously required to maintain their intravascular volume and tissue perfusion. In such patent, monitor the electrolytes and allow this correction to occur, as this is normal and is to be expected (rarely will supplementary IV fluids will be warranted in such cases).

Answer 6

Dry mucous membranes and reduced skin turgor Decreasing urine output (should target >0.5 ml/kg/hr) Orthostatic hypotension In worsening stages: - Increased capillary refill time - Tachycardia Low BP

Answer 7

Raised JVP Peripheral or sacral oedema Pulmonary oedema

Answer 8

fluid input-output chart daily weight chart U&E's for evidence of dehydration, renal hypo perfusion or electrolyte abnormalities

Answer 9

Water Sodium Potassium Glucose

Answer 10

Water: 25-30 mL/kg/day Na+: 1.0 mmol/kg/day K+: 1.0 mmol/kg/day Chloride: 1.0 mmol/kg/day Glucose: 50-100g/day to limit starvation ketosis

Answer 11

2 litres of water 80mmol potassium

Answer 12

Resuscitation Routine maintenance Replacement Redistribution Reassessment

Answer 13

Crystalloids and Colloids

Answer 14

- Solutions of small molecules in water - More used in acute settings, theatres, for maintenance fluids - Neither crystalloid or colloid is better in replenishing volume in resuscitation - Crystalloids cheaper

Answer 15

- High osmotic pressure - Raise intravascular volume faster than crystalloids (in theory) - Solutions of larger organic molecules - Used less than crystalloids as they carry a risk of anaphylaxis

Answer 16

0.9% Saline 5% Dextrose Hartmann's Solution

Answer 17

- Sodium Chloride 0.9% - Isotonic - Used for resuscitation/maintenance

Answer 18

Isotonic Used for resuscitation/maintenance

Answer 19

Hypotonic Used for resuscitation/maintenance

Answer 20

Hypotonic Used for maintenance

Answer 21

Albumin Gelofusine Dextran Volplex

Answer 22

if large volumes are used there is an increased risk of hyperchloraemic metabolic acidosis

Answer 23

contains potassium and therefore should not be used in patients with hyperkalaemia

Answer 24

Correct the deficit AND the fluids prescribed for maintenance

Answer 25

- Reduced urine output <0.5 ml/ kg/ hr) - Manage aggressively - Give fluid challenge - Then re-check clinical parameters (incl. urine output)

Answer 26

either 250ml or 500ml over 15-30 mins Depending on pt size and co-morbidities

Answer 27

1. Are there any third spaces? 2. Is there a diuresis? 3. Is the patient tachypnoeic or febrile? 4. Is the patient passing more stool than usual (high stoma output)? 5. Are they losing electrolyte-rich fluid?

Answer 28

1. Dehydration - (high urea:creatinine ratio and high PCV) 2. Vomiting - (low K+, low Cl–, and alkalosis) 3. Diarrhoea - (low K+ and acidosis)

Answer 29

Regularly assess fluid status Check what pt is managing orally and amend fluid prescription accordingly Use clinical assessment, nursing charts (fluid input-output charts ± daily weights) and U&Es to guide this.

Answer 30

1. Treat reversible causes

Answer 31

- Oral rehydration solution or IV fluids. - All patients: fluid balance charts to assess fluid input, ongoing losses and urine output. Oral rehydration solution: - Small volumes at frequent intervals. - Regular reassessment to determine effectiveness. If child clinically dehydrated but able to tolerate enteral fluids (PO/NG): - 50mL/kg fluid deficit is calculated. - This is given orally, along with maintenance fluids, over 4 hours as oral rehydration solution. - For example, a child who weighs 10kg will require 500mL AND maintenance fluid over 4 hours.

Answer 32

- Shock: suspected or confirmed - A child with red flag symptoms or signs - shows clinical evidence of deterioration despite oral rehydration therapy - A child persistently vomits the oral rehydration solution, given orally or via a nasogastric tube.

Answer 33

- Give a rapid 20ml/kg bolus 0.9% sodium chloride - Call for senior help - Reassess the patient - (Caution advised in DKA or underlying heart condition when 10mL/kg bolus should be considered) If inadequate or no response: - Give another rapid 20ml/kg sodium chloride bolus and consider other causes of shock. If a third bolus is required, consider input from paediatric intensive care Once an adequate response to bolus therapy has been achieved (i.e. the patient is no longer clinically in shock) start IV fluid deficit correction

Answer 34

- If there is a recent weight done prior to admission, the fluid deficit can be taken as the weight loss compared to current weight. - For example, if weight done 2 days ago was 15.5 kg and current weight is 15 kg, the fluid deficit can be taken as 500 ml (500 gram lost) However, if there are signs of clinical dehydration, and there is no recent weight, the fluid deficit is calculated as: weight (kg) x % replacement x 10. - This is given over 48 hours. - The % replacement (also known as % dehydration) should be assumed to be 10%, if dehydrated. For example, a child who weighs 12 kg will require 1200 ml (12 x 10 x 10) over 48 hours, or 600 ml each day in addition to their maintenance. Aim to correct fluid deficit over 48 hours with 0.9% sodium chloride and 5% dextrose

Answer 35

U+Es and plasma glucose - Measure before starting deficit correction and regularly over the 48 hour period. - Electrolyte imbalances and/or hypoglycaemia may require alterations to the type of fluid used. Significant ongoing losses (eg. through Vomiting + diarrhoea) - documented on the patient’s fluid balance chart and replaced in addition to fluid deficit correction.

Answer 36

- Call senior paediatric help - Replace fluid slowly over 48 hours in order to avoid cerebral oedema. - Regular monitoring of U+Es should be done to ensure plasma sodium does not fall by a rate greater than 0.5mmol/L/hour.

Answer 37

Encourage breastfeeding and other milk feeds Encourage fluid intake Discourage fruit juices and carbonated drinks

Answer 38

- < 1 y/o, esp those < 6 months - Infants who were of low birth weight - Children who have passed > 5 diarrhoeal stools in the previous 24 hours - Children who have vomited >2 times in previous 24 hours.

Answer 39

Over a 24hr period using 0.9% NaCl and 5% Dextrose 100ml/kg for first 10kg bodyweight 50ml/kg for second 10kg bodyweight 20ml/kg for every kg above 20kg bodyweight For example, a 25kg child would require the following: - First 10 kg = 1000ml (10 x 100mL) - Second 10kg = 500ml (10 x 50mL) - Last 5kg = 100ml (5 x 20mL) - Total 1600ml over 24 hours (1600/24: rate = 67ml/hr) Remember to monitor electrolytes to determine if anything such as potassium should be added to the fluids.

Answer 40

Over 24 hours, males rarely need more than 2500mL and females rarely need more than 2000mL

Answer 41

Obese - When prescribing routine maintenance fluids for obese patients you should adjust the prescription to their ideal body weight. You should use the lower range for volume per kg (e.g. 25 ml/kg rather than 30 ml/kg) as patients rarely need more than 3 litres of fluid per day. Elderly Renal impairment or cardiac failure patients Malnourished patients at risk of refeeding syndrome

Answer 42

Because of understanding of complication re. hypercholeraemic acidosis Before, many oliguric postoperative patients received enormous quantities of IV fluids.

Answer 43

5% dextrose and dextrose/saline combinations

Answer 44

- Fluids given should be documented clearly and easily available - Assess the patient's fluid status when they leave theatre - f a patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible - Review patients whose urinary sodium is < 20 - If a patient is oedematous, hypovolaemia if present should be treated first. This should then be followed by a negative balance of sodium and water, monitored using urine Na excretion levels. - Solutions such as Dextran 70 should be used in caution in patients with sepsis as there is a risk of developing acute renal injury.