Fluid management in clinical practice part 6

 Fluid in clinical practice

Fluid

Part 6

Special cases::

Acute blood loss: 

Resuscitate with colloid or 0.9% saline via large-bore cannulae until blood is available. 

Children: Use glucose with sodium chloride for fl uid maintenance: 100mL/kg for the fi rst 10kg, 50mL/kg for the next 10kg, and 20mL/kg thereafter—all per 24h. 

Elderly: May be more prone to fl uid overload, so use IV fl uids with care (smaller fluid bolus).

 GI losses: (Diarrhoea, vomiting, NG tubes, etc.) Replace lost K+ as well as lost fluid volume. 

Heart failure: Use IV fl uids with care to avoid fl uid overload.

 Liver failure: Patients often have a raised total body sodium, so use salt-poor albumin or blood for resuscitation, and avoid 0.9% saline for maintenance.

 Acute pancreatitis: Aggressive fl uid resuscitation is required due to large amounts of sequestered ‘third-space’ fl uid.

      Poor urine output: Aim for >1 mL/kg/h; the minimum is >0. 5mL/kg/h. Give a fl uid challenge, eg 500mL 0.9% saline over 1h (or half this volume in heart failure or the elderly), and recheck the urine output. If not catheterized, exclude retention; if catheterized, ensure the catheter is not blocked!

 Post-operative: Check the operation notes for intraoperative losses, and ensure you chart and replace added losses from drains, etc.

 Shock: Resuscitate with colloid or 0.9% saline via large-bore cannulae. Identify the type of shock .

 Transpiration losses: (Fever, burns.) Beware the large amounts of fluid that can be lost unseen through transpiration. Severe burns in particular may require aggressive fluid resuscitation.

Problems with fluid mismanagement::

      Dehydration:

 Identifying features---

Patient’s fluid needs not met by oral or enteral intake and

o Features of dehydration on clinical examination

o Low urine output or concentrated urine

o Biochemical indicators, such as more than 50% increase in urea or creatinine with no other identifiable cause

Timeframe of identification--

Before and during IV fluid therapy

Pulmonary oedema:

(breathlessness during infusion)

No other obvious cause identified (for example, pneumonia, pulmonary embolus or asthma). Features of pulmonary oedema on clinical examination.Features of pulmonary oedema on X-ray.

Timeframe of identification--

During IV fluid therapy or within 6 hours of stopping IV fluids

Hypernatraemia :

Serum sodium less than 130 mmol.No other likely cause of hyponatraemia identified

Serum sodium 155 mmol/l or more. Baseline sodium normal or low. IV fluid regimen included 0.9% sodium chloride. No other likely cause of hypernatraemia identified.

Timeframe of identification--

During IV fluid therapy or within 24 hours of stopping IV fluids.

Hyponatremia:

Hperkalemia:

Hypokalemia:

Peripheral Edema:

Source: NICE guidance, Oxford handbook of clinical medicine, 10th Ed.

By: Dr. Manilal Biswas

SSMC (2013-14)