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Pharmacology > Fluid Therapy > Flashcards

Fluid Therapy Flashcards

1
Q

What questions do you ask before prescribing fluid

A

What is my patients volume status - ABCDE
Does my patient need IV fluid
How much fluid do they need
What type of fluid do they need
What is cause of deficit / surplus and Rx this! e.g AKI / sepsis

When examining for fluid status

  • Are they thirsty / check tongue
  • Pulse, BP, CRT, JVP
  • Oedema - look peripheral and listen to lungs for peripheral
  • Look at U+E
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2
Q

What are the signs of hypovolaemia

A 
Nausea
Thirsty
Flat veins
Cool periphery
No sweat
Low or postural BP 
High HR
Conc oliguria
Responds to SLR
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3
Q

What do people with hypovolaemia need

A

Resuscitation fluid if low BP
Rehydration fluid
Need to work out cause of fluid loss and stop the leak

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4
Q

What are the signs of euvolaemia

A 
Feel well, not thirsty
Filled veins
Warm extremities
Mild sweat
Normal BP and HR
Normal urine
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5
Q

What do euvolaemic people need

A

No fluids unless electrolyte deplete or low BP

Can be in this state as fluids are maintaining

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6
Q

What are the signs of hypervolaemia

A 
SOB
Not thirsty
Warm and oedematous 
Distended vein 
Sweaty
High BP and HR
Dilute urine 
Oliguric or polyuric
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7
Q

What do hypervolaemic people need

A

No more fluids
Diuretics possibly if respiratory compromise
Haemofiltration if anuric

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8
Q

How do you work out fluid deficit

A 
Catheter 
Chest drains 
Fluid balance chart
Weight 
Vomit bowl / sputum pot / stool chart + stoma 
U+E's
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9
Q

What are the insensible that cannot be measured

A 
Transepidermal diffusion
Sepsis sweat
Ventilation 
Open wound
Burns
Blood loss
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10
Q

How much water is lost through transepidermal diffusion

A

400-800ml per day

NO SOLUTE LOSS

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11
Q

What are fluids given for

A 
IV vs oral vs NG 
Resuscitation
Routine maintenance
Replacement
Redistribution
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12
Q

What type of fluid are there

A

Dextrose
Crystalloids
Colloids - Plasma expanders
All go into different areas of body

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13
Q

When do you give resuscitation fluids

A

Hypovolaemic shock

Cannot perfuse organs

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14
Q

What fluid do you give in hypovolaemic shock

A

Rapid bolus to increase intravascular space

500ml over 15 minutes CRYSTALLOID with 130 mmol of Na (saline)
- 0.9% saline = hypercholaraemic acidosis risk
- Hartman’s / PlasmaLyte but caution if hyperkalaemia
Can give further bolus up to 2000ml then senior

Colloid only if haemorrhagic or blood on BTS chart

250ml if HF/ renal / elderly as less strain

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15
Q

How do you check that resuscitation fluids have worked

A

REASSESS
Check BP
Give another 250-500ml if respond
May require vasopressors if in shock

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16
Q

When do you give routine maintenance fluids

A

Fasted patients >8 hours or after surgery

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17
Q

What type of fluid is given as routine maintenance

A

Crystalloid
Look in guidelines to find out what is needed
If >3 days then enteral feeding is preferred

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18
Q

When do you give replacement fluids

A

To replace electrolytes that have been lost - Mg, K, Po4

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19
Q

How do you check that replacement fluids have worked

A

Take blood

Check electrolytes

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20
Q

What is dextrose useful in

A

Chronic dehydration

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21
Q

What is dextrose not useful in

A

Resuscitation

Low albumin

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22
Q

Why is dextrose not useful as resuscitation

A

Isotonic so moves through all compartments and won’t expand blood to fill up BP

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23
Q

What are most fluids

A

Crystalloids

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24
Q

What are crystalloids useful in

A 
Dehydration
AKI
Sepsis
SHock
Resuscitation
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25
Q

What are cryalloids not useful for

A

Long term maintenance as puts strain on the heart
Hypernatraemia as contains Na
Hyperchloraemic metabolic acidosis

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26
Q

How do crystalloids work

A

Come in various combinations and remain in ECF

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27
Q

What is a common crystalloid

A

0.9% saline
Contains a lot of sodium - risk of hyperchloraemic metabolic acidosis
Plasma Lyte - preferred now post-op as more balanced

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28
Q

What are plasma expanders

A

Colloids

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29
Q

What are examples of colloid

A

Blood
TPN
IV albumin - used in Burns

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30
Q

What do colloids do

A

Stay exclusively in IVS so give if bleeding

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31
Q

When are colloids used

A

Liver patients as have low albumin - post paracentesis
Selected intra-op
NOT commonly prescribed

32
Q

When do you get specialist help

A 
Low oncotic pressure
CCF 
Renal or live failure 
Obstetrics
Head injury 
Children
33
Q

Does a euvolemic patient with low urine output need fluids after surgery?

A

No
Most likely physiological post-op stress response
Possible AKI

34
Q

When do you not give Hartmann’s / Plasma Lyte

A

If hyperkalaemia

35
Q

What do NICE recommend as maintenance

A

25-30ml/kg/24 hours water
1mmol/kg/day K,Cl, Na
50-100g glucose to limit starvation ketosis

e. g. 25-30ml/kg NaCl 0.18% in 4% dextrose with 27mmol of K of maintenance
- Never give mixed back >100ml / hr due to risk of hyponatraemia and central pontine demyelination

If Na <132 the us PlasmaLyt

To work out find how much needed in 24 hours then / 24 to see the rate you should give / hour

36
Q

What to think

A

If post op major loss = more needed
HF = less needed as pulmonary oedema
If elderly / malnourished or renal may need less

If obese

  • Adjust to idea body weight
  • A patient will rarely need >3L
  • Expert help if BMI >40
37
Q

What are most commonly used fluid

A

PlasmaLyte (NaCL + HCO3 + K)
0.9% saline - NaCl (more than 0.18%)
5% glucose
0.18% saline + 4% glucose

38
Q

What are risks of fluid

A 
Acute LVF 
Hyponatraemia
Hyponatraemic encephalopathy 
Electrolyte imbalance - hyperkalaemia
Cerebral oedema
39
Q

Paediatric fluid

A

HARD
0.45% NaCl + 5% dextrose
Risk of hyponatraemia and cerebral oedema if use 0.18% saline

40
Q

What is ABCDE when assessing fluid balance

A

A
B = any HF?
C = JVP, BP, HR, CRT, FBC / U+E
D = dry membrane / turgor / oedema

41
Q

What does plasma have in regards to Na, K, Cl, bicarb, lactate -

A

Na - 137
K - 4
Cl - 95
Bicarb - 22

42
Q

What does 0.9% saline have

A

H20 = 1L
Na - 154
Cl - 154
No K or glucose

43
Q

What is risk if give too much 0.9% saline

A

Hypercholarmic acidosis
More Na and CL in one bag than is required in 24 hours
so monitor Cl levels daily

44
Q

What does 5% Dextrose have

A 
1l - H20 
Glucose - 50g 
Essentially water as no Na / K / Cl 
Na - 30.6
Cl - 30.6
45
Q

What does PlasmaLyte have have

A

Na - 130
K - 4 - risk of hyperkalameia so CI
Cl - 110
Lactate- 0

46
Q

What is given as bolus to see if low BP due to hypovolaemia

A

0.9% saline 500 ml over 15 minutes

47
Q

How does hyponatraemic encephalopathy present

A

Gait
Headache
Confusion
Low BP

48
Q

What causes

A

Hypotonic solution - 0.45% NaCL
Paeds at risk
Also SIADH after surgery. / stress

49
Q

If on maintenance fluid what should happen

A

Monitor U+E

Even if good fluids can still get hypontraemia e.g. if on diuretic increasing Na

50
Q

Why do you avoid 0.45% NaCl as resus

A

Hypotonic so won’t expand plasma

Also risk of cerebral oedema

51
Q

Paeds fluid bolus

A

20ml / kg 0.9% saline
Repeat 10ml/kg up to 40
If circulation not restored = senior

52
Q

Paeds maintenance

A 
0.9% saline + 5% dextrose +-KCL
4,2,1 rule or 
First 10kg = 100ml / kg
Next 10kg = 50ml / kg
Next 10kg = 20ml / kg
53
Q

What should you do if risk of cerebral oedema

A

Go slower

Use 10ml/kg 0.9% saline if DM

54
Q

When is Hartmann’s CI

A

Hyperkalaemia as contains potassium

55
Q

What is max speed K can be infused peripherally

A

10mmol / h

If >20 needs cardiac monitor as risk of arrhythmia

56
Q

How do you assess fluid status

A

ABCDE approach

57
Q

What suggests patient needs fluid resus

A 
BP <100
HR >90
CRT >2s
Cold periphery to touch
RR >20
NEWS >5
58
Q

What do you give as resus

A

500ml crystalloid over <15 minutes (Na 130-150)

59
Q

What else

A

Identify cause of deficit

60
Q

What do you do after

A

Reassess using ABCDE to see if needs resus
Senior help if unsure
If better = see algorithm for non-resus fluid
If <2000ml given can give another bolus of 250-500ml
If still signs of shock = senior help

61
Q

How do you assess fluid and electrolyte needs in patient who does not require resus

A

Examination

  • Pulse
  • BP
  • CRT
  • RR
  • JVP
  • Oedema
  • Postural hypo

Monitoring

  • NEWS
  • Fluid balance
  • Weight

Lab

  • FBC
  • U+E
62
Q

If patient can meet needs oral

A

OK

63
Q

If patient cannot meet needs through oral but no complex issues

A

Routine

64
Q

If complex

A

Replacement and redistribution algorithm

65
Q

What is routine maintenance

A

25-30ml/kg/day water
1mmol / kg / day Na, K, Cl
50-100g glucose

66
Q

When do you stop

A

When no longer needed

67
Q

If >3 days

A

NG or enteral feeding preferred

68
Q

Redistribution and replacement

A

Add or subtract according to deficit

69
Q

What is average needs in 70kg adult

A 
1.75-2.1l water
70-140 Na
35-70K
70Cl 
50-100g glucose
70
Q

How can you meet this

A

Mixed bag of NaCll 0.18% + 4% glucose with 27mmol KCl on day 1
Prescribe 2 1L bags + 1 500ml

71
Q

What increases risk of hyponatraemia

A

> 2.5l

72
Q

If don’t have mixed bag what can you do

A

Use a mix of single bads
2 bags of 5% dextrose with KCl
1 bag of 0.9% saline 500ml with potassium
Makes up 2.5L

73
Q

If prescribed 3x 8 hourly bag of Hartmann what is risk

A

Giving 3l of H20
Giving way to much Na and Cl
Not enough K
Not enough glucose

74
Q

Wha is Hartmann’s good for

A

Resus but not maintenance

75
Q

If patient is hyper-volaemic what do you do

A

Restrict
Consider diresis
Consult senior

Pharmacology (5 decks)

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