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OSCEs > Fluid prescribing (children & adults) > Flashcards

Fluid prescribing (children & adults) Flashcards

1
Q

What is the normal urine output for a child <2 years old?

A

> 2ml/kg/h

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2
Q

What is the normal urine output for a child >2 years old?

A

> 1 ml/kg/h

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3
Q

What are the total daily fluid requirements for a child? (not neonates)

A
  1. 100 mL/kg/day for the 1st 10kg
  2. 50 mL/kg/day for the 2nd 10kg
  3. 20 mL/kg/day for the remainder of bodyweight
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4
Q

What electrolytes does a child also need and in how much(in mmol/kg/day)?

A

Sodium:
- 2-4 mmol/kg/day (based on a study involving obese American children with high-salt diets, so this is generally ignored)

Potassium:
- 1-2 mmol/kg/day (500ml bags come with 10 mmol KCl)

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5
Q

What fluid type is usually prescribed for maintenance in children?

A

500 mL of 0.9% saline + 5% dextrose with 10 mmol KCl

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6
Q

Define mild dehydration in children.

A
  • 50ml/kg deficit

- 5% body weight

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7
Q

What are the clinical features of mild dehydration?

A
  • Slightly dry mucous membranes
  • Increased thirst
  • Decreased urine output
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8
Q

What is the management of mild dehydration in children?

A
  • Oral/NG rehydration solution (1-1.5x maintenance) OR

- IV maintenance

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9
Q

Define moderate dehydration in children.

A
  • 100ml/kg deficit

- 10% body weight

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10
Q

What are the clinical features of moderate dehydration?

A
  • Dry mucous membranes
  • Tachycardia
  • Reduced urine output
  • Loss of skin turgor
  • Sunken eyes/fontanelles
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11
Q

What is the management of moderate dehydration in children?

A
  • IV bolus OR

- NG fluids at 25ml/kg/h for first 4h; ORS

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12
Q

Define severe dehydration in children.

A
  • 150ml/kg deficit

- 15% body weight

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13
Q

What are the clinical features of severe dehydration?

A
  • Same as in moderate and:
  • Pronounced tachycardia
  • Weak pulse
  • Hypotension
  • Delayed cap refill
  • Mottled skin/cyanosis
  • Dyspnoea
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14
Q

What is the management of severe dehydration in children?

A
  • IV fluid bolus (may require multiple boluses)
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15
Q

How much of a fluid bolus is appropriate to give to a child? And what solution do you give?

A

10-20 ml/kg of 0.9% saline

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16
Q

How much fluids should be given for an oral rehydration solution fluid challenge?

A

1-2 mL/kg of ORS every 10 mins

20 ml/kg of oral fluid in 2 hours should be adequate, if not child may need admission

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17
Q

When is an oral rehydration solution fluid challenge indicated?

A

Mild-moderate gastroenteritis

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18
Q

How much water (ml/kg/day) does an adult require?

A

25-30 ml/kg/day

19
Q

How much potassium, sodium, and chloride (mmol/kg/day) does an adult require?

A

1 mmol/kg/day

20
Q

How much glucose (g/day) does an adult require?

A

50-100g/day

21
Q

How should you adjust fluid prescribing for obese patients?

A

Adjust prescription according to their ideal body weight - patients rarely need >3L per day

22
Q

In which groups should you consider prescribing less fluid (i.e., 20-25 ml/kg/day)?

A
  • Elderly patients
  • Patients with renal impairment or cardiac failure
  • Malnourished patients at risk of refeeding syndrome
23
Q

How do you choose the most appropriate maintenance fluid for an adult?

A

Calculate the patients daily requirements based on their weight and then choose fluids which match these requirements closest.

24
Q

What is maximum rate at which potassium can be given at?

A

10 mmol/h (any more than this is very dangerous)

25
Q

Describe the use of 5% dextrose, and its possible advantages and disadvantages.

A
  • Given instead of pure water
  • Glucose is present to maintain initial osmolality but is quickly used up
  • Used as part of maintenance fluid regimen, when water is required without electrolytes
  • Is of no use in treating hypovolaemia when it is not physiological and distributes widely across all fluid compartments
  • Administering too much, too quickly can cause hyponatraemia
26
Q

Describe the use of dextrose-saline, and its possible advantages and disadvantages.

A
  • Good choice for maintenance fluids, when given alone at the correct maintenance rate it will provide approximately the correct sodium replacement requirement over 24h
  • The sodium content is much lower than that of plasma, therefore it is of no use in treating hypovolaemia
  • Administering too much, too quickly can cause hyponatraemia
27
Q

Describe the use of Hartmann’s solution, and its possible advantages and disadvantages.

A
  • This is the most physiological fluid and so is very good for replacing plasma loss (e.g. GI losses or during surgery)
  • Not v good for maintenance fluids as 3L of Hartmann’s solution over 24h would 3x too much Na+ and not enough K+
28
Q

Describe the use of 0.9% saline, and its possible advantages and disadvantages.

A
  • More physiological than dextrose as it contains NaCl
  • Not as physiological as Hartmann’s solution because it contains a greater concentration than plasma
  • Too much chloride can cause a hyperchloraemic metabolic acidosis
  • Can cause renal afferent arteriole vasoconstriction (increases risk of AKI)
29
Q

What is the approximate loss of electrolytes (mmol/L) through vomiting/NG tube loss?

A

Na+: 20-40 mmol/L
K+: 14 mmol/L
Cl-: 140 mmol/L
H+: 60-80 mmol/L

30
Q

What is the approximate loss of electrolytes (mmol/L) through diarrhoea/excess colostomy loss?

A

Na+: 30-140 mmol/L
K+: 30-70 mmol/L
HCO3-: 20-80 mmol/L

31
Q

What is the approximate loss of electrolytes (mmol/L) through jejunal loss (stoma/fisutla)?

A

Na+: 140 mmol/L
K+: 5 mmol/L
Cl-: 135 mmol/L
HCO3-: 8 mmol/L

32
Q

What is the approximate loss of electrolytes (mmol/L) through high volume ileal loss (new stoma, high stoma, or fistula)?

A

Na+: 100-140 mmol/L
K+: 4-5 mmol/L
Cl-: 75-125 mmol/L
HCO3-: 0-30 mmol/L

33
Q

What is the approximate loss of electrolytes (mmol/L) through lower volume ileal loss (established stoma or fistula)?

A

Na+: 50-100 mmol/L
K+: 4-5 mmol/L
Cl-: 25-75 mmol/L
HCO3-: 0-30 mmol/L

34
Q

What is the approximate loss of electrolytes (mmol/L) through pancreatic drain or fistula loss?

A

Na+: 125-138 mmol/L
K+: 8 mmol/L
Cl-: 56 mmol/L
HCO3-: 85 mmol/L

35
Q

What is the approximate loss of electrolytes (mmol/L) through biliary drainage loss?

A

Na+: 145 mmol/L
K+: 5 mmol/L
Cl-: 105 mmol/L
HCO3-: 30 mmol/L

36
Q

How might fluid prescriptions be adjusted post-surgery?

A
  • K+ stores are mostly intracellular and serum levels can increase due to cell lysis during surgery
  • If K+ is >4.5 mmol/L post-operatively, omit from the fluid prescription for 24h
  • If K+ is normal/low, you can given some (e.g. 40 mmol in 24h)
  • 0.9% saline tends to be avoided as surgery triggers RAAS which causes Na+ and fluid retention and reduced urine output
  • Dextrose-saline is preferred for maintenance
37
Q

How might fluid prescriptions be adjusted in sepsis?

A
  • Sepsis causes intravascular depletion due to plasma loss through leaky capillaries and vasodilation
  • Replace fluid with Hartmann’s/plasmalyte or 0.9% saline, but avoid too much chloride if large quantities of fluid are required
  • Monitor response carefully
38
Q

How might fluid prescriptions be adjusted in heart failure?

A
  • These patients are prone to fluid overload and pulmonary oedema
  • They many run normally hypotensive
  • If overload develops, start fluid restriction, furosemide, low sodium diet, and record daily weights
39
Q

How might fluid prescriptions be adjusted in liver disease?

A
  • Excess Na+ may worsen ascites
  • Human albumin solution is a good alternative volume expander (e.g. 100mL 20% HAS)
  • Too much dextrose can also be problematic as it can worsen hyponatraemia
40
Q

How might fluid prescriptions be adjusted in AKI?

A

Be cautious with potassium because they are at risk of hyperkalaemia

41
Q

How might fluid prescriptions be adjusted in severe CKD?

A

Avoid excess fluid, Na+, and K+ as the kidneys may not be able to excrete them

42
Q

How might fluid prescriptions be adjusted in alcohol abuse/risk of refeeding syndrome?

A
  • Avoid dextrose where possible because it can precipitate refeeding syndrome
  • If you need to give dextrose, give Pabrinex first because dextrose can precipitate Korsakoff syndrome
43
Q

How might fluid prescriptions be adjusted in brain haemorrhage/stroke?

A
  • Avoid dextrose as this can cause osmotic haematoma swelling
  • Dextrose destroys the brain if there’s a bleed
  • Saline is best

OSCEs (45 decks)

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