ITU (Fluids, blood products and nutrition) Flashcards by Iona Donnelly

In what ways are fluid lost from the body?

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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What is normal urine output?

1500ml/ day

0.5ml/kg/hr minimum

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What is good output from a catheter?

35-70ml/ hr

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How much are insensible losses?

500ml/ day

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

2500ml per day

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

1mmol/kg/hr

specifically
100mmol

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

1mmol/kg/hr

specifically 70mmol

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

1mmol/kg/hr

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What is the physiological requirement for glucose in a day?

50-100g glucose

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How much glucose is in 5% dextrose?

5g/100ml

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

10mmol/hr

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

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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What are the signs that a patient is fluid overloaded?

Raised JVP
Pitting oedema
Tachypnoea
Basal crepitations
Pulmonary oedema on CXR

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How is fluid balance formally assessed?

Catheterising the patient and closely recording their output and input

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What are crystalloid fluids and give some examples

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

5% or 10% dextrose

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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

0.9% Saline

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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

Hartmann’s solution

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What are colloid solutions? and give some examples

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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What are some of the issues with synthetic colloids?

Anaphylaxis
Anti-thrombotic effects
Pruritis
Impaired renal function

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What are typical fluid maintenance requirements for adults?

30ml/kg/day

equating to 2-2.5L/ day

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What are compensation fluids and when are they needed?

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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What are replacement fluids?

Fluids for correcting the fluid deficit that the patient already has

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Ideally how would fluid be prescribed?

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

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

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

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

0.9% saline or Hartmann's solution The volume and rate should be titrated to maintain neutral fluid balance

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

Sodium restricted diet | Fluid restriction of 1.5L/ day (including both PO and IV fluids

What is given as resuscitation fluids?

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

How fast should red cells be transfused?

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

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

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

When are Red cells used for transfusion?

Anaemia, Haemorrhage

When are platelets used for transfusion?

Active bleeding (or prevention)

What is the target Hb level when transfusing Red cells?

Target is Hb of 90

What do you aim for when transfusing platelets?

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

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

To increase clotting | Target PT and APTT less than 1.5 x normal

When is human albumin solution used?

Hypoalbuminaemia

When is cryoprecipitate used?

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

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

Less than 30 mins

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

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

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

The transfusion can continue

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

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

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

Acute Haemolysis (ABO incompatibility)

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

- Stop the transfusion - Resuscitate using ABC approach - Check the blood against the patient ID and documentation - Give IV saline

What complication of a blood transfusion is this: Within minutes - bronchospasm - cyanosis - hypotension and tachycardia - swelling and rash

Anaphylaxis

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

- Stop transfusion - Resuscitate using ABC approach - Adrenaline 0.5ml - Chlorphenamine 10mg - Hydrocortisone 200mg - IV saline

What complication of a blood transfusion is this: Slow rising temp 60 mins after onset of infusion

Non haemolytic febrile reaction

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

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

What complication of a blood transfusion is this: After 30-60 mins - SOB - Hypoxia and bibasal creps - Tachycardia - Raised JVP

Fluid overload

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

- Slow or stop transfusion - Oxygen - IV furosemide

What complication of a blood transfusion is this: Rash

Urticarial reaction

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

- Stop transfusion - Re-check blood - Flush cannula with saline - Chlorphenamine 10mg

What is Mean arterial pressure (MAP)?

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

What is BP determined by?

BP = CO x SVR

What is cardiac output determined by?

CO = HR x SV

What is stroke volume?

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

What is systemic vascular resistance (SVR)?

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)

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

1. MAP less than 65 | 2. SBP less than 90 (or more than 40 lower than normal)

What is normal central venous pressure?

3-8 mmHg

What are the problems with non invasive BP monitoring?

- 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

When are arterial lines indicated?

1. continuous BP measurement | 2. Frequent ABG analysis

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

Radial artery as associated with lowest complication rates Others = femoral, brachial, post tibial, dorsalis pedis

What is done to prevent clotting of arterial lines?

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

What are the complications of arterial line insertion?

- 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)

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

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

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

- Narrow waveform - Low dicrotic notch - Pressure varying with inspiration

What are the advantages of invasive blood pressure monitoring?

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