IV fluid prescribing

Question 1

the 5 R’s

Answer 1

1. Rescucitation
2. Replacement
3. routine maintenance
4. Redistribution
5. Re-assessment

Question 2

what fluids should be used for initial resucitation

Answer 2

crystalloid fluids

Question 3

which crystalloid fluid should be used for initial rescuctiation

Answer 3

balanced crystalloid fluid (haramtns solution or ringers lactate)

Question 4

why is a balance crystalloid fluid used

Answer 4

because if you use 0.9% NaCl there is a risk of hyperchloraemic metabolic alkalosis

Question 5

when should you use 0.9% NaCl in rescuctiaiton

Answer 5

in patients with rhabdomyolysis, acute kidney injury or chronic kidney disease due to the risk of hyperkalaemia

Question 6

fluid resuscitation definition

Answer 6

re-establishing haemodynamic stability by restoring intra-vascular volume

Question 7

fluids used in resuscitation

Answer 7

balanced crystalloid (hart mans solution or ringers lactate) or crystalloid solution (0.9% NaCl)

Question 8

fluid replacement definition

Answer 8

provides daily maintenance and replaces any on-going losses

Question 9

fluids used for fluid replacement

Answer 9

balances crystalloid or crystalloid

Question 10

routine maintenance definition

Answer 10

provides daily maintenance requirements

Question 11

fluids used for routine maintenance

Answer 11

0.18% NaCl/ 4% dextrose, 5% dextrose, 0.45% NaCl

Question 12

Vomiting and nasogastric tube loss can cause

Answer 12

a hypochloraemic (hypokalaemic) metabolic alkalosis which requires potassium and chloride replacement

Question 13

pure water loss

Answer 13

fevered dehydration can cause a potential hypernatramia

Question 14

hartmans solution

Answer 14

contains mostly sodium and chloride contains small amount of potassium, bicarbonate pre-curse (lactate) and calcium

Question 15

lactated ringers

Answer 15

contains sodium, chloride small amount of potassium, calcium and bicarbonate precursor (lactate)

Question 16

0.9% NaCl

Answer 16

contains only sodium and chloride (154mmol/litre of each)

Question 17

0.45% NaCl

Answer 17

Contains only sodium and chloride (77mmol/litre of each)

Question 18

0.18% NaCl/ 5% dextrose

Answer 18

contains 31mmol/litre of sodium and chloride in 222 mol/litre of glucose

Question 19

5% dextrose contains only

Answer 19

277mmol/litre of glucose only

Question 20

colloid fluids

Answer 20

consider human albumin solution (4-5%) only in patients with severe sepsis

Question 21

20% albumin is

Answer 21

hyperoncoct,100ml will expand to approximately 400ml in 25 minutes

Question 22

20% albumin is used in

Answer 22

large volume paracentesis

• 100ml every 3litres if normal renal function
• 100ml every 2 litre if renal dysfunction

Question 23

blood producrs

Answer 23

• FFP
• red blood cells
• platelets
• cryoprecipitate

Question 24

massive haemorrhage protocol

Answer 24

send urgent blood samples (FBC, coagulation scree, cross match, fibrinogen, U+E, calcium) blood bank will send 4 units of red cells, 4 units of FFP, 1 unit of plasma

Question 25

specific scenarios: hyponatraemia if the patient is dry

Answer 25

give 0.9% NaCl carefully monitoring there U’s and E’s

Question 26

if hyponatraemic but euvolaemic

Answer 26

consider SIADH as the diagnosis and do a paired serum and urine osmolarity

Question 27

if SIADH is the correct diagnosis

Answer 27

restrict water to less than one litre a day and treat underlying cause

Question 28

if hyponatrameic and fluid overloaded

Answer 28

water restriction and consider diuretic use if symptomatically overloaded with monitoring of Us and Es

Question 29

correct of hyponatramaeia goal of treatment

Answer 29

is to raise the sodium concentration by 4-6 mEq/litre in a 24 hour period

Question 30

in patients who require emergency theory for hyponatraemia

Answer 30

the goal of raising sodium concncetration by 4-6mEq/litre should be achieved within 6 hours or less and then after this sodium levels should be kept constant

Question 31

in the treatment of hyponatraemia every effort should be made to ensure that

Answer 31

the rise in serum sodium is less than 9mEq/litre within any 24 hour period due to the risk of a devastating osmotic demyelination condition occurring called central pointing myelinolysis

Question 32

patients who are at the highest risk of osmotic demyelination

Answer 32

those with serum sodium concentration of less than 105mEq/litre, those with hypokalaemia,alcoholism, malnutrition and liver disease

Question 33

severe hyponatramia

Answer 33

sodium less than 120mmol/litre requires emergency therapy with hypertonic saline

Question 34

hypertonic saline is indicated in the following situations

Answer 34

• patients with symptomatic hyponatramia such as seizures and altered conscious level
• patients with acute hyponatrameia even with mild symptoms due to the risk of osmotically drive water flow across the blood brain barrier causing life-threatening cerebral oedema which causes brain herniation
• symptomatic patients with post-operative hyponatramia or hyponatramia cause by an intra-cranial pathology as brain herniation can occur

Question 35

emergency treatment of hyponatraemia

Answer 35

100ml of 3% NaCL over 10-15 minutes