Resus and Fluid prescribing Flashcards
What are indications for IV fluids?
when needs cannot be met by oral or enteral routes. e.g:
* A patient is nil by mouth (NBM) for medical/surgical reasons (e.g. bowel obstruction, ileus, pre-operatively)
* A patient is vomiting or has severe diarrhoea
* A patient is hypovolaemic as a result of blood loss (blood products will likely be required in addition to IV fluid)
How would you assess a patient to see if they needed fluids?
Mention what you would do/look for in:
1. history?
2. clincial examination?
3. clinal monitoring (e.g. charts available around bed)?
4. lab results?
- History - previous limited intake, thirst, abnormal losses, any co-morbidities
- Clincial examination - pulse, BP, Cap refill, JVP, odema (peripheral/pulmonary), postural hypotension
- Clinical monitoring - NEWS, fluid balance charts, weight
- Lab assessments - FBC, urea, creatinine, electrolytes
AR some reasons why a patient may have ongoing abnormal fluid or electrolyte losses?
- vomiting
- biliary drainage loss
- ileal stoma loss
- diarrhoea /colostomy losses
- ongoing blood loss - e.g. melaena
- sweating/fever/dehydration
- urinary loss - e.g. post AKI polyuria
What are symptoms suggestive of dehydration?
- thirst
- dizziness/syncope
Before starting fluids for a patient, what co-morbidities should you be aware of?
renal failure
heart failure
For maintenance IV fluids, what are normal daily fluid and electrolyte requiremenets?
Normal daily fluid and electrolyte requirements:
* 25–30 ml/kg/d water
* 1 mmol/kg/day sodium, potassium, chloride
* 50–100 g/day glucose (e.g. glucose 5% contains 5 g/100ml)
What are resuscitation fluids you can prescribe?
(AR algorithm for resus fluids if you can - pic in answer)
500ml bolus 0.9% sodium chloride /hartmann’s over 15 mins
then reassess the patient !
In what 3 patient groups should you consider prescribing less fluid in a bolus?
- elderly
- renal impairment or heart failure
- malnourished patients at risk of refeeding
What are risks of inappropriate use of fluids?
- inadequate resuscitation or rehydration leading to tissue hypoperfusion
- excessive fluid infusion leading to tissue oedema and severe electrolyte derangement.
- morbidity and mortality
- longer hospital stays
- fluid overload
- organ damage or failure (to the lungs, brain and kidneys),
- hyponatraemia and hypernatraemia,
- hyperchloraemic metabolic acidosis due to excess chloride administration
- coagulation abnormalities
- increased need for transfusion with blood products
What are some ethical considerations for resuscitations and DNAR orders?
The main idea = doing things in pt’s best interests
- decisions to withold or withdraw treatement - can only be made by the pt unless they have LPA. Family are invited to share views when pt lack’s capacity about pt’s previous wishes, views and values.
- advance directives - these are advance refusals of treatment. This is legally binding. If there is a disagreement in the validity of the advance refusal, need to presume to favour of providing treatment, if it has a chance of prolonging life, improving patient’s condition or managing symptoms.
- DNAR orders- need to ask qu: is CPR in pt’s best interest to prolong treatment where it is futile to do so? CPR can cause harm to patients - so DNAR is discussed with patients and relatives.
- What are some legally binding documents regarding CPR?
- What documents are not legally binding?
- Advance decision to refuse treatment (ADRT)
- DNACPR, ReSPECT
What factors influence decisions regarding resuscitation?
- how well the pt is - is the pt unlikely to survive even with resuscitation attempts?
- patient wishes
- co-morbidities e.g. advanced cancer, HF, COPD
- quality of life before and after a previous resuscitation
- cultural factors - race/ethnicity, marital status, religion
- views of healthcare team
- in an emergency - where you do not know pt views and there is no previous DNACPR in place = need to attempt CPR un;ess you think it won’t be successful in restarting pt’s breathing and circulation.
