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Acutely Ill Patient > ITU (Fluids, blood products and nutrition) > Flashcards

ITU (Fluids, blood products and nutrition) Flashcards

1
Q

In what ways are fluid lost from the body?

A
  • Urine
  • Insensible losses e.g. sweating and breathing (increase in burns/ tachypnoea)
  • Third space losses (due to inflammation and injury causing increased capillary permeability)
  • Also consider diarrhoea/ vomit/ stoma/ drains/ fever etc.
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2
Q

What is normal urine output?

A

1500ml/ day

0.5ml/kg/hr minimum

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3
Q

What is good output from a catheter?

A

35-70ml/ hr

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4
Q

How much are insensible losses?

A

500ml/ day

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5
Q

To cover for losses, how much fluid will a normal person require in a day?

A

2500ml per day

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6
Q

What is the physiological requirement for Na+ in a day?

A

1mmol/kg/hr

specifically
100mmol

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7
Q

What is the physiological requirement for K+ in a day?

A

1mmol/kg/hr

specifically 70mmol

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8
Q

What is the physiological requirement for Cl- in a day?

A

1mmol/kg/hr

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9
Q

What is the physiological requirement for glucose in a day?

A

50-100g glucose

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10
Q

How much glucose is in 5% dextrose?

A

5g/100ml

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11
Q

What is the maximum safe rate for potassium administration outside of ITU?

A

10mmol/hr

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12
Q

What are the signs that a patient is “dry”/ fluid depleted?

A
  • Tachycardic
  • Postural hypotension
  • Dec cap refill time
  • Dec urine output (less than 0.5ml/kg/hr)
  • Cool peripheries
  • Dry mucous membranes
  • Dec skin turgor
  • Sunken eyes
  • Raised urea and haematocrit
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13
Q

What are the signs that a patient is fluid overloaded?

A
  • Raised JVP
  • Pitting oedema
  • Tachypnoea
  • Basal crepitations
  • Pulmonary oedema on CXR
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14
Q

How is fluid balance formally assessed?

A

Catheterising the patient and closely recording their output and input

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15
Q

What are crystalloid fluids and give some examples

A 
They are isotonic fluids. They are sterile, cheap and safe that have a short intravascular half life.
Examples:
- 5% or 10% dextrose 
- 0.9% saline
- Hartmann's solution
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16
Q

Which type of fluid is this describing:
Normally used in resuscitation
20 or 40mmol KCl can be added

A

5% or 10% dextrose

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17
Q

Which type of fluid is this describing:
Normally used for fluid resuscitation or rehydration. Contains 150mmol of Na
20 or 40mmol KCl can be added

A

0.9% Saline

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18
Q

Which type of fluid is this describing:
Given for fluid resuscitation or rehydration.
Its components are very physiological. It contains Na, Cl, Lactate, K, bicarb and Ca

A

Hartmann’s solution

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19
Q

What are colloid solutions? and give some examples

A

They are large molecular weight compounds e.g. albumin, dextrin, gelatin and starch.
They have long intravascular half-life.
They can be used for fluid resuscitation.

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20
Q

What are some of the issues with synthetic colloids?

A
  • Anaphylaxis
  • Anti-thrombotic effects
  • Pruritis
  • Impaired renal function
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21
Q

What are typical fluid maintenance requirements for adults?

A

30ml/kg/day

equating to 2-2.5L/ day

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22
Q

What are compensation fluids and when are they needed?

A

fluid that covers additional fluid losses on top of maintenance fluids, dependent on the clinical status of the patient.

For example from diarrhoea/ vomiting/ sepsis/ post-op/ polyuria/ pyrexia/ burns/ wounds

This is usually an extra 0.5-1.5L/ day

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23
Q

What are replacement fluids?

A

Fluids for correcting the fluid deficit that the patient already has

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24
Q

Ideally how would fluid be prescribed?

A

On the basis of a fluid balance chart, estimating requirements over 24 hours

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25
Q

In a NBM patient who is otherwise well how much fluid is appropriate and what types of fluid?

A

2.5L of fluid is appropriate
A normal schedule would be 2 sweet, 1 salty:

  • 1L 5% glucose over 10 hours with 20mmol added KCL x2
  • 500ml 0.9% saline over 4 hours with 20mmol added KCL
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26
Q

What type of fluid is usually given to correct fluid deficit on top of maintenance? and how is it given?

A

0.9% saline or Hartmann’s solution

The volume and rate should be titrated to maintain neutral fluid balance

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27
Q

If a patient is fluid overloaded, how should they be treated and what fluids should be prescribed?

A

Sodium restricted diet

Fluid restriction of 1.5L/ day (including both PO and IV fluids

28
Q

What is given as resuscitation fluids?

A

500ml/ 250ml (in frail or heart problems) crystalloid STAT (over less than 15 mins)

10ml/kg in children
Raising the patients legs can also help to increase BP

29
Q

How fast should red cells be transfused?

A

250ml over 2-4 hours (unless haemorrhagic shock)

30
Q

How many units of red cells can be given without FFP/ platelets?

A

No more than 4 units of red cells should be transfused without FFP/ platelets

31
Q

When are Red cells used for transfusion?

A

Anaemia, Haemorrhage

32
Q

When are platelets used for transfusion?

A

Active bleeding (or prevention)

33
Q

What is the target Hb level when transfusing Red cells?

A

Target is Hb of 90

34
Q

What do you aim for when transfusing platelets?

A

Aim to increase platelet count by 20-40 or stop bleeding

35
Q

When do you use FFP? and what are the target levels?

A

To increase clotting

Target PT and APTT less than 1.5 x normal

36
Q

When is human albumin solution used?

A

Hypoalbuminaemia

37
Q

When is cryoprecipitate used?

A

Significant bleeding in trauma to keep fibrinogen more than 1.5g/L

38
Q

How long can blood be out of the refrigerator before it is transfused?

A

Less than 30 mins

39
Q

When monitoring a patient who is having a blood transfusion how often should baseline observations be taken?

A

at 0, 15, 30 and 60 mins from onset of transfusion then hourly until transfusion has finished

40
Q

If a patient who has been started on a blood transfusion becomes feverish but systemically well what action should be taken?

A

The transfusion can continue

41
Q

If there is evidence of transfusion reaction what action should be taken?

A

It is essential to disconnect the blood before any further investigations/ management
Then use ABC to assess and manage according to complication that has occurred

42
Q

What complication of a blood transfusion is this:

Within minutes

  • spike in temp (above 40)
  • hypotensive and tachycardic
  • agitated, flushed
  • pain
  • bleeding from cannula site
A

Acute Haemolysis (ABO incompatibility)

43
Q

What action should you take if there is ABO incompatibility causing acute haemolysis?

A
  • Stop the transfusion
  • Resuscitate using ABC approach
  • Check the blood against the patient ID and documentation
  • Give IV saline
44
Q

What complication of a blood transfusion is this:

Within minutes

  • bronchospasm
  • cyanosis
  • hypotension and tachycardia
  • swelling and rash
A

Anaphylaxis

45
Q

What action should be taken if a blood transfusion causes anaphylaxis?

A
  • Stop transfusion
  • Resuscitate using ABC approach
  • Adrenaline 0.5ml
  • Chlorphenamine 10mg
  • Hydrocortisone 200mg
  • IV saline
46
Q

What complication of a blood transfusion is this:

Slow rising temp 60 mins after onset of infusion

A

Non haemolytic febrile reaction

47
Q

What action should be taken if the patient has a non haemolytic febrile reaction to a blood transfusion?

A
  • Slow or stop transfusion
  • Resuscitate using ABC approach
  • Check the correct blood has been given
  • 1g paracetamol
  • IV fluids
48
Q

What complication of a blood transfusion is this:

After 30-60 mins

  • SOB
  • Hypoxia and bibasal creps
  • Tachycardia
  • Raised JVP
A

Fluid overload

49
Q

How should fluid overload as a result of a blood transfusion be managed?

A
  • Slow or stop transfusion
  • Oxygen
  • IV furosemide
50
Q

What complication of a blood transfusion is this:

Rash

A

Urticarial reaction

51
Q

What action should be taken if a blood transfusion causes an urticarial reaction?

A
  • Stop transfusion
  • Re-check blood
  • Flush cannula with saline
  • Chlorphenamine 10mg
52
Q

What is Mean arterial pressure (MAP)?

A

(cardiac output x systemic vascular resistance) + central venous pressure

53
Q

What is BP determined by?

A

BP = CO x SVR

54
Q

What is cardiac output determined by?

A

CO = HR x SV

55
Q

What is stroke volume?

A

SV = the volume of blood ejected by the left ventricle in one contraction
(end diastolic volume - end systolic volume)

56
Q

What is systemic vascular resistance (SVR)?

A

SVR = the resistance the left ventricle has to overcome to pump blood through the systemic circulation
(i.e. the resistance to blood flow offered by the vasculature excluding the pulmonary vasculature)

57
Q

What are the two main ways that hypotension can be defined?

A
  1. MAP less than 65

2. SBP less than 90 (or more than 40 lower than normal)

58
Q

What is normal central venous pressure?

59
Q

What are the problems with non invasive BP monitoring?

A
  • Automated machines can’t estimate the pressure where the envelope of oscillations is not uniform e.g. in AF
  • The cuff must be the right size and the right position, for example if the cuff is too small it will over read
  • The machine must be accurately calibrated
60
Q

When are arterial lines indicated?

A
  1. continuous BP measurement

2. Frequent ABG analysis

61
Q

What artery is most often used for insertion of arterial lines? and what are some other options?

A

Radial artery as associated with lowest complication rates

Others = femoral, brachial, post tibial, dorsalis pedis

62
Q

What is done to prevent clotting of arterial lines?

A

Continuous flush of 3-4ml/hr. This must be via a pressurised bag of normal saline.

63
Q

What are the complications of arterial line insertion?

A
  • Haemorrhage can occur if there are leaks in the system
  • Thrombosis, particularly if the lie has been in situ for a long time. The risk of total occlusion increases in pre-existing arterial disease, hypotension and use of vasopressors
  • Infection
  • Emboli
  • Accidental drug injection. (drugs should never be injected into an arterial line - it should be labelled red to prevent this)
64
Q

What 3 bits of information are given from the waveform seen with invasive blood pressure monitoring?

A
  1. BP
  2. Myocardial contractility (rate of change of pressure)
  3. Circulating volume
65
Q

What does the waveform of invasive blood pressure monitoring look like in hypovolaemia?

A
  • Narrow waveform
  • Low dicrotic notch
  • Pressure varying with inspiration
66
Q

What are the advantages of invasive blood pressure monitoring?

A
  • Continuous blood pressure recording
  • Accurate BP even when patients are profoundly hypotensive
  • Other information can be gathered from the arterial trace

Acutely Ill Patient (8 decks)

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