Fluid Management

Question 1

Distribution of fluid within compartments

3 layers of fluid compartment %

• 2 (rich in…)
• 2

-

Answer 1

67% body weight is water

67% ICF rich in K+
33% ECF rich in Na+

ECF: 80% Interstital fluid, 20% Blood plasma

Starling Forces

• Hydrostatic pressure PUSHES out
• Oncotic pressure SUCKS in

Question 2

Types of IV fluid

1)
- Contains
3 eg’s

2)
- Contain… therefore….
2 eg’s

Answer 2

Crystalloids
- contain simple ions which are permeable across semi-permeable membrane from plasma to interstitium

eg. 0.9% Sodium Chloride, Hartmann’s (Na + lactate), 5% Dextrose

Colloids
- Contain larger molecules eg proteins which can’t cross semi-permeable membrane (inc oncotic pressure in plasma and expand plasma vol)

eg. Human Albumin, Blood products

Question 3

Fluid Balance

Intake 2 and their % and daily requirements L/day

Output controlled/ uncontrolled loss aka…
3 and daily requirements L/day

in surgery….

Daily Fluid Requirements and for a 70kg individual
Water
Glucose
Na, K, Cl

Why would you have change to intake?
3
Why would you have change to output?
3

Answer 3

IN
Oral - 60% (2.2 L/day)
Food + Metabolism - 40% (0.3 L/day)

OUT 40% insensible and 60% sensible
Resp + Persp. (0.9 L/day)
Faeces (0.1 L/day)
Urinate (1.5 L/day)

In surgery: Inc bowel out, Tachypnoea, inc persperation via pyrexia
Avg 70kg:
Water 25- 30ml/ kg/ day 1750-2100ml
Glucose 50-100 g/ kg/ day 50-100g
Na, K, Cl 1mmol/ kg/ day 70mmol

Intake changes:

• NBM
• Poor oral intake
• Dec consciousness

Output changes:

• GI losses (usually high K+)
• Third space losses eg. bowel obstruction, acute pancreatitis
• Intra-operative blood losses

Question 4

Hypovolamic shock signs 8

Fluid over-load signs 6

Fluid Assessment steps 
1) .... ( + 6 Red Flags)
2) 3 Qs to ask
3) Go through all the steps 
4) Charts (5) 
5) Bloods + Imaging
FBC and U+E:
-Dehydration: 4
- Volume: 3
- Diarrhoea: 2
-  
-

Answer 4

Hypo

• Sunken eye
• Dry mucous membrane
• Tachycardia
• Hypotensive
• Palor
• Cold peripherally
• > 2s Cap refill
• Dec urine ouput

Over-load

• Inc. JVP
• Bilateral basal crackles
• Third heart sound
• Displaced apex beat
• Peripheral/ sacral odema
• Ascites

Fluid Assessment
1) Quick A-E
Red Flags: Cap Refill > 2s, Systolic BP< 100 mmHg, HR > 90bpm, RR> 20bpm, Cool peripherally, NEWS >/ 5
2) History: Managing to drink/ eat, Dry mouth, Feel thirsty?
3) Examination
General inspection
- Patient: alertness, tachypnoea, pryrexia, wounds, drains
- Bed: IV fluid, catheter, Stoma, NG tube, Vom/Sputum bowl
Hand/ Arm
- Pulse (rate, rhythm, vol), Cap refill, Tugor of skin
Head+ Neck
- Sunken eyes, mucous membrane, JVP
Chest
- Apex beat, heart sounds, lung base
Abdo
- Ascities
Legs/ Sacrum
- Peripheral oedema
4) Charts
-Obs (NEWS - Temp, HR, BP, O2 sats, RR)
- Stool chart ( Diarr or Constipation
- Fluid balance chart (input and output
- Drains chart
- Drug charts (IV fluids, diuretics, Oral electrolyte replacement
5) Bloods and Imaging
FBC and U+E:
-Dehydration: high urea, high urea: creatinine ration, high PVC (Packed Cell Vol.)
- Volume: Low K, Low Cl- and Metabolic llkalosis
- Diarrhoe: Low K and metabolic acidosis
- Acute Kidney Injury
CXR- pulmonary overload

Question 5

Name the 5R’s in Fluid therapy (one isn’t an R)

Shock def
4 Types and why

Answer 5

• Resuscitation- Hypovolaemic
• Routine Management- NBM
• Replace- excessive loss due to 3rd space, bleeding, vom, diarrhoea
• Redistribute- Gross oedema, sepsis, hypo/ hypernaturaemia, renal/liver, post-op fluid retention
• Re-assess- malnutrition or re feeding issues

Shock- poor tissue perfusion -> ishcaemia -> organ failure

• Hypovolaemic - Haemorrhagic shock
• Distributive- Pathological redistribution of blood due to sepsis, (vol shift due to vasoconstriction) 2) Neurogenic (Loss of vascular tone) 3) Anaphylaxsis/ Anaphylactoid (huge vasodilation)
• Cardiogenic - Primary cardiogenic dysfunction
• Obstruction - Blockage in circulation

Question 6

R1 
Inidcations: 6 
Aim:
Prescribe: .... in HF or elderly 
max...
if no improvement 

R2
Inidcations: 2
Calculate….
All the classics!

R3
Indications: 1
Prescribe: 1
Urine output to aim for?

Answer 6

Resuscitation
Indications: Cap Refill > 2s, Systolic BP< 100 mmHg, HR > 90bpm, RR> 20bpm, Cool peripherally, NEWS >/ 5
Aim; Inc Blood volume to maintain BP therefore tissue perfusion
Prescribe: STAT (over 15 mins) 500ml bolus of crystalloid, if HF reduce to 250ml. Reassess via A-E
Max: 2000ml
If no improvement seek support as may need inotropes/ vasopressors

Routine maintenance
Indications: NBM or cant reach requirement orally
Calculate requirements per 24hrs
Water 25- 30ml/ kg/ day (20–25ml in HF/ frail)
Glucose 50-100 g/ kg/ day
Na, K, Cl 1mmol/ kg/ day

Replacement
Indication; ongoing losses
Prescribing; replace losses ontop of fluid requirements
Urine output < 0.5 ml/kg/hr (aim for this! )

Question 7

8 Potential Complications of IV fluid

Answer 7

• Hypovolaemia
• Pulmonary Oedema
• Hyponaturaemia
• Hypernaturaemia
• Peripheral Oedema
• Hyperkalaemia
• Hypokalaemia
• Cannula assoc. compliction eg. phlebitits