Fluid balance in times of stress

Question 1

What does the mnemonic BUFALO relate to in treatment of sepsis?

Answer 1

B = blood cultures
U = urine measurement
F = fluid challenge
A = antibiotics
L = lactate
O = oxygen

Question 2

In the sepsis 6 is antibiotics. Should patients be given broad or narrow spectrum IV antibiotics?

Answer 2

• broad spectrum

Question 3

When performing a fluid challenge in a patient with sepsis, how much fluid should they be challenged with?

1 - 10mg/kg
2 - 30ml/kg
3 - 3ml/kg
4 - 50ml/kg

Answer 3

2 - 30ml/kg

• purpose is to increase intravascular pressure

Question 4

When performing a fluid challenge in a patient with sepsis, they should be challenged with 30ml/kg of fluids. Generally, how quickly should this be delivered?

1 - 500ml over 15-20 minutes
2 - 500ml/10 minutes
3 - 3L/hour
4 - 1L over 15-20 minutes

Answer 4

1 - 500ml over 15-20 minutes

• 250ml over 30minutes if patient is frail

Question 5

There are 2 types of fluids patients can be given, colloids and crystalloids. Which of the 2 will remain in the vasculature of the patient?

Answer 5

• colloids due to large molecular weight particles
• too big to diffuse across normal endothelium so they remain in the blood

Question 6

Colloids are IV fluids where almost 100% remains in the intravascular space. Although not given very often, they can be prescribed for high protein losses. They generally contain albumin (20 or 4.5%) or dextrose. Of the conditions below, which would generally receive colloids?

1 - mother giving birth
2 - burn victim
3 - internal haemorrhage
4 - transplant

Answer 6

2 - burn victim

• the body loses skin, connective tissue and even muscle containing high protein
• the body tries to compensate and therefore needs a lot of protein to heal

Question 7

What is a crystalloid solution?

1 - aqueous solution alone
2 - aqueous solution containing mineral salts and small molecules
3 - aqueous solution containing proteins
4 - aqueous solution containing dextrose

Answer 7

2 - aqueous solution containing mineral salts and small molecules

Question 8

Crystalloid fluid is used as normal saline, which is the most common fluid given to patients. Normal saline contains Na+ and Cl-. What are the normal concentrations of Na+ and Cl- in normal saline?

1 - Na+ = 154 mmol/L and Cl- = 54 mmol/L
2 - Na+ = 124 mmol/L and Cl- = 104 mmol/L
3 - Na+ = 54 mmol/L and Cl- = 154 mmol/L
4 - Na+ = 154 mmol/L and Cl- = 154 mmol/L

Answer 8

4 - Na+ = 154 mmol/L and Cl- = 154 mmol/L

• normal Na+ in blood = 154 mmol/L
• normal Na+ in blood = 96-106 mmol/L

Question 9

When prescribing a patient a crystalloid solution roughly how much of the fluid will remain in the intravascular and interstitial fluids?

1 - intravascular = 25% and interstitial = 75%
2 - intravascular = 75% and interstitial = 25%
3 - intravascular = 50% and interstitial = 50%
4 - intravascular = 80% and interstitial = 20%

Answer 9

1 - intravascular = 25% and interstitial = 75%

• due to small molecular size the fluid moves across endothelium and into the interstitial space

Question 10

Why is taking a detailed history important in a patient who is suspected of being hypovolemic?

Answer 10

• ask them about normal fluid intake

Question 11

Which of the following is not a measure of outgoing fluid?

1 - urine measurement
2 - stool output
3 - vomiting
4 - tears
5 - sweat

Answer 11

4 - tears

Question 12

In relation to recording fluid levels, why is it important that medication is recorded accurately?

Answer 12

• often given as an IV so will be contained in saline
• diuretics are important for fluid output

Question 13

In cases of shock and/or dehydration what happens to capillary refill time?

Answer 13

• becomes slower
• not as much blood flow and cold so takes longer

Question 14

In cases of shock and/or dehydration what happens to skin turgor (skins elasticity)?

Answer 14

• decreases
• does not return to normal as quickly

Question 15

In cases of shock and/or dehydration what happens to mucus membranes?

Answer 15

• become dry
• can see this in tongue and eyes

Question 16

In cases of shock and/or dehydration are patients likely to experience oedema?

Answer 16

• yes
• generally in ankles and sacrum due to gravity and bed rest

Question 17

In cases of shock and/or dehydration what can happen to a patients pulse rate and volume?

Answer 17

• pulse rate increases as less blood
• pulse volume will be reduced as less blood

Question 18

Haematocrit is a measure of the blood. What is haematocrit?

1 - volume of blood volume made up of WBCs
2 - protein in the RBCs
3 - protein in the WBCs
4 - volume of blood volume made up of RBCs

Answer 18

4 - volume of blood volume made up of RBCs

Question 19

Haemoglobin is a measure of the blood. What is haemoglobin?

1 - volume of blood volume made up of WBCs
2 - protein in the RBCs
3 - protein in the WBCs
4 - volume of blood volume made up of RBCs

Answer 19

2 - protein in the RBCs

• carries O2 to tissues

Question 20

What happens to the urea:creatanine ratio during times of stress and/or dehydration?

Answer 20

• increases
• may be increased levels but kidney should filter them out of the body
• sign kidneys are not working properly

Question 21

What is the formula for calculating serum osmolality?

1 - (2xNa) + (2xK) + Glucose + Urea
2 - (Na) + (2xK) + Glucose
3 - (2xNa) + (K) + Glucose + Urea
4 - (2xNa) + (2xK) + Urea

Answer 21

1 - (2xNa) + (2xK) + Glucose + Urea

Question 22

We can calculate serum osmolality using the following equation: (2xNa) + (2xK) + Glucose + Urea. What happens to osmolality during stress and/or dehydration?

Answer 22

• increases
• fluid levels drop and electrolyte content increases

Question 23

In a patient who is dehydrated and/or who’s body is under stress, why can a chest X-ray be useful?

Answer 23

• respiratory and cardiac defects are often the primary site of inflammation and sepsis
• fluid leaks through endothelium into the lungs

Question 24

Normal saline is a fluid given to patients when they need to increase their fluid levels. What does it mean for it to be normal saline?

1 - composition is the same as plasma fluids
2 - osmolality is the same as the human plasma
3 - when given IV it will not cause RBCs to rupture

Answer 24

3 - when given IV it will not cause RBCs to rupture

Question 25

Normal saline is a fluid given to patients when they need to increase their fluid levels. It is 0.9% saline including which of the following?

1 - Na+ and Cl- = both 154mmol/L
2 - Na+ = 154mmol/L and glucose 277mmol/L
3 - Na+ and K+ = both 154mmol/L
4 - Na+ = 131 and K+ = 5mmol/L

Answer 25

1 - Na+ and Cl- = both 154mmol/L

• Na+

Question 26

Normal saline is a fluid given to patients when they need to increase their fluid levels. It is 0.9% saline including Na+ and Cl- both at 154mmol/L. What can happen if a patient is given too much of the normal saline alone?

1 - become hyponatremic, hyperchloremia and metabolic acidosis follows
2 - can become hyponatremic and metabolic alkalosis follows
3 - can become hypernatremic and metabolic alkalosis follows
4 - can become hypernatremic, hyperchloremia and metabolic acidosis follows

Answer 26

4 - can become hypernatremic, hyperchloremia and metabolic acidosis follows

• pH of normal saline is 3.5-6.5

Question 27

Normal saline is a fluid given to patients when they need to increase their fluid levels. It is 0.9% saline including Na+ and Cl- both at 154mmol/L. If a patient is given too much of the normal saline alone they can develop hypernatremic and metabolic acidosis follows. To stop this from happening patients are given 2L of normal saline with 1L of 5% glucose. Why is the glucose given alongside?

1 - glucose neutralises Na+ and Cl-
2 - glucose provides calories
3 - glucose provides calories and is metabolised into H2O
4 - glucose is metabolised into H2O

Answer 27

3 - glucose provides calories and is metabolised into H2O

• the H2O neutralises the acidity of the normal saline

Question 28

Patients who need a fluid resuscitation will generally be given 2L of normal saline and 1L of 5% glucose. However, they will also need what else to be added?

1 - Ca2+
2 - K+
3 - HCO3-
4 - Mg+

Answer 28

2 - K+

• varies depending on the trust protocol, but generally 20-40mmol/L

Question 29

In the picture is a case study of a patient who is presenting with right iliac pain. There are some things highlighted in red. What do the things in red indicate that the patient has?

1 - infection
2 - sepsis
3 - systemic inflammatory response (SIRS)
4 - septic shock

Answer 29

3 - systemic inflammatory response (SIRS)