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MODULE 16 - Alimentary Tract Disease > PATIENT SUPPORT - Advanced Fluid Therapy > Flashcards

PATIENT SUPPORT - Advanced Fluid Therapy Flashcards

1
Q

What are the indicators for fluid therapy?

A

Dehydration
Shock
Correct electrolyte abnormalities
Maintain oncotic pressure
Provide maintenance fluids
Diuresis

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2
Q

What is dehydration?

A

Dehydration is a deficit of total body water

Dehydration results in a decreased volume within the interstitial space. As dehydration worsens, it can affect the vascular and intracellular compartments as well, leading to dehydration with concurrent hypovolemia

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3
Q

What are the general causes of dehydration?

A

Decreased fluid intake
Increased pathological fluid loss

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4
Q

What can cause decreased fluid consumption?

A

Anorexia
Starvation

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5
Q

What are some of the causes of pathological fluid loss?

A

Vomiting
Diarrhoea
Renal disease
Panting (i.e. secondary to pyrexia)
Wound exudation
Third space fluid loss

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6
Q

What are the clinical signs of dehydration?

A

Skin tenting
Dry mucous membranes
Sunken eyes

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7
Q

What are the clinical signs of a patient less than 5% dehydrated?

A

Not clinically detectable

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8
Q

What are the clinical signs of a patient 5 - 6% dehydrated?

A

Subtle skin tent

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9
Q

What are the clinical signs of a patient 6 - 10% dehydrated?

A

Moderate skin tent
Tacky mucous membranes
Possibly sunken eyes

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10
Q

What are the clinical signs of a patient 10 -12% dehydrated?

A

Marked skin tent
Dry mucous membranes
Sunken eyes

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11
Q

What are the clinical signs of a patient 12 - 15% dehydrated?

A

Marked skin tent
Dry mucous membranes
Sunken eyes
Clinical signs of hypovolaemia

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12
Q

What are some other indicators of dehydration other than clinical signs?

A

Increased PCV/TS
Weight loss

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13
Q

What are your aims when treating dehydration?

A

When treating dehydration your aims are to replace the fluid deficit over 24 hours as well as provide maintainence fluids and account for ongoing losses. It is also important to assess patient parameters (improved clinical signs) throughout the fluid therapy process with the goal of correcting the full fluid deficit within 24 hours

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14
Q

How do you treat dehydration?

A

Fluid therapy with isotonic crystalloid fluids

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15
Q

What are isotonic crystalloid fluids?

A

Isotonic crystalloid fluids are fluids containing water and electrolytes in a similar composition of extracellular fluid (ECF)

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16
Q

What are four examples of isotonic crystalloid fluids?

A

0.9% NaCl
Ringer’s solution
Hartmann’s (also known as lactated ringers)
Plasmalyte 148

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17
Q

What is the composition of 0.9% NaCL?

A

Water
Sodium
Chloride

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18
Q

What is the composition of Ringer’s solution?

A

Water
Sodium
Chloride
Potassium
Calcium

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19
Q

What is the composition of Hartmann’s?

A

Water
Sodium
Chloride
Potassium
Calcium
Lactate

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20
Q

What is lactate?

A

Lactate is a bicarbonate precursor which is metabolised by the liver into bicarbonate

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21
Q

What is the composition of plasmalyte 148?

A

Water
Sodium
Chloride
Potassium
Calcium
Acetate

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22
Q

What is acetate?

A

Acetate is a bicarbonate precursor which is metabolised by the muscle into bicarbonate

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23
Q

What is the most common route of administration for fluid therapy?

A

Intravenous fluid administration

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24
Q

When is oral and subcutaneous fluid administration indicated?

A

Oral and subcutaneous fluid administration is indicated for mild dehydration

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25
What can cause patients to remain clinically dehydrated even with fluid therapy?
Technical issues with fluid administration Incorrect estimation of dehydration Ongoing fluid losses
26
How do you estimate ongoing fluid losses?
You have to reassess your patient every 4 hours and if possible measure the ongoing losses and account for these losses when calculating/altering your fluid rate
27
What are some of the clinical signs of hypokalaemia?
Asymptomatic Muscle weakness Polyuria, polydipsia (PUPD)
28
What are the general causes of hypokalaemia?
Decreased intake of potassium Translocation of potassium Increased loss of potassium
29
What are some of the gastrointestinal causes of hypokalaemia?
Vomiting Diarrhoea
30
How do you correct hypokalaemia?
Fluid therapy using an isotonic crystalloid fluid spiked with potassium
31
What are some of the main causes of hypernatraemia?
Diabetes insipidus Neurological disease
32
How do you correct hypernatraemia?
Bespoke fluid therapy where the change in serum sodium levels is less than 0.5mmol/l/hr
33
Why should you correct hypernatraemia with a fluid rate of less than 5mmol/l/hr?
In response to hypernatraemia the brain cells produce idiogenic osmoles as a protective mechanism from the high osmolality in the plasma which could draw fluid from the brain cells causing the brain to become dehydrated. Idiogenic osmoles increase the intracellular osmolality to minimise the loss of intracellular water in the brain. However, becaused of these idiopathic osmoles, rapid correction of hypernateaemia can be fatal as a rapid decrease in serum sodium levels will rapidly decrease the osmolality of the blood relative to the cells, causing fluid to move into the brain cells and cause swelling of the brain
34
How do you correct hyponatraemia?
Fluid therapy using an isotonic crystalloid fluid at a rate of less than 5mmol/l/hr
35
Why should you correct hyponatraemia with a fluid rate of less than 5mmol/l/hr?
There is a risk of myelinolysis
36
What is one of the main functions of albumin?
Albumin is a plasma protein which generates oncotic pressure which is a pressure gradient that pulls fluid into the vasculature
37
What are the general causes of hypoalbuminaemia?
Decreased production of albumin Increased loss of albumin
38
What can cause decreased production of albumin?
Hepatic disease
39
What can cause an increased loss of albumin?
Protein-losing enteropathy Protein-losing nephropathy Negative acute phase protein (decreases with inflammation) Third space losses
40
When are serum albumin levels classified as critically low?
Serum albumin levels of less than 15g/l is classified as critically low
41
How do you correct hypoalbuminaemia?
Correcting hypoalbuminaemia is challenging and often requires treatment of the underlying disease which is causing the hypoalbuminaemia, however, synthetic colloids can be used to try and help maintain oncotic pressure. This should be done in addition to isotonic crystalloid fluid therapy
42
Which rate of synthetic colloids can be used to attempt to maintain oncotic pressure due to hypoalbuminaemia?
20ml/kg/day
43
What are synthetic colloids?
Synthetic colloids are fluids containing large molecular weight particles *(such as starch or gelatin)* which cause rapid expansion of the intravascular volume and cannot easily diffuse out of the intravascular space
44
What are the potential side effects of synthetic colloids?
Dilutional coagulopathy Renal failure Anaphylaxis
45
What is the most common synthetic colloid available for use in the UK?
Haemaccel *(gelatin based colloid)*
46
Other than synthetic colloids, what else can be used to correct hypoalbuminaemia?
Fresh frozen plasma Human serum albumin
47
What are the limitations of fresh frozen plasma for correcting hypoalbuminaemia?
Fresh frozen plasma is expensive and not very effective at correcting hypoalbuminaemia
48
What are the benefits and limitations of human serum plasma for correcting hypoalbuminaemia?
Human serum plasma is very effective at correcting hypoalbuminaemia however there is a risk of anaphylaxis due to an autoimmune response against the human plasma
49
Which electrolyte and acid base imbalances can be seen with diarrhoea and vomiting?
Hypokalaemia Metabolic acidosis
50
How do you correct the electrolyte and acid base imbalances seen in patients with diarrhoea and vomiting?
Hartmann's spiked with potassium. The hartmann's spiked with potassium will correct the fluid deficit and hypokalaemia as well as provide lactate which will be converted into bicarbonate and correct the metabolic acidosis
51
What is pre-pyloric vomiting?
Pre-pyloric vomiting is the evacuation of gastric contents before the pylorus
52
Which electrolyte and acid base imbalances can be seen with pre-pyloric vomiting?
Hypokalaemia Hyponatraemia Hypochloraemia Hypochloraemic metabolic alkalosis
53
How does the body self-perpetuate states of metabolic alkalosis?
The body will prioritise correcting volume loss over correcting the metabolic alkalosis through increasing renal reabsorption of water and bicarbonate into the blood and secreting chloride into the urine which will help to correct volume loss however will exacerbate the metabolic alkalosis. A chloride (Cl-) depletion stimulates the kidneys to resorb bicarbonate ions (HCO3-) to maintain electroneutrality. The HCO3- ions would bind to H+ in the blood, further increasing the pH and maintaining the alkalosis. This will also result in paradoxical aciduria due to the increased secretion of chloride into the urine
54
How do you correct the electrolyte and acid base imbalances seen in patients with pre-pyloric vomiting?
Fluid therapy with chloride containing fluids such as 0.9% NaCl to correct the alkalosis. You may also have to spike these fluids with potassium
55
How can you use fluids in the management of intestinal obstructions?
Fluid therapy can be used to correct any dehydration, electrolyte and acid base imbalances seen with intestinal obstructions, especially as these cases are often surgical and these factors need to be corrected prior to anaesthesia. Generally these patients will have diarrhoea so will be hypokalaemia and acidotic (so give fluids appropriately)
56
Which features of liver disease can affect fluid choice for fluid therapy?
Hypoalbuminaemia Hypoglycaemia Hypokalaemia Coagulopathy Acid/base imbalances Hepatic encephalopathy Ascites
57
Why should hartmann's ideally not be used in patients with severe hepatic dysfunction?
Hartmann's contains lactate which needs to be metabolised into bicarbonate by the liver. Thus if you are trying to correct acidosis, this will not be achieved as the lactate will not be converted to bicarbonate by the liver
58
What is the difference between replacement fluids and maintenance fluids?
Replacement fluids are are intended to correct fluid deficits and replace lost body fluids and electrolytes. Maintenance fluids are used to maintain normal hydration and electrolyte balance for a long period of time in patients unable to intake oral fluids
59
How does the composition of replacement and maintenance fluids differ?
Replacement fluids have a higher sodium content to restore the sodium lost in excess with fluid deficits. However, maintenance fluids have a lower sodium content compared to replacement fluids, as the primary goal is to maintain normal hydration. Maintenance fluids also typically have higher potassium levels to replace the daily potassium losses, as potassium is usually lost in small amounts daily through urine
60
What are the potential complications of fluid therapy?
Iatrogenic electrolyte disturbances Catheter complications Volume overload
61
What are the clinical signs of fluid overload?
Chemosis Serous nasal discharge Increased respiratory, rate and effort (due to pleural effusion) Restlessness Peripheral oedema Polyuria | Due to venous congesion secondary to fluid overload
62
What is chemosis?
Chemosis is swelling of the conjunctiva
63
Which patients are predisposed to fluid overload?
Renal disease patients Cardiac disease patients Hypoalbuminaemia patients Pulmonary contusion patients

MODULE 16 - Alimentary Tract Disease (23 decks)

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