Fluid management in clinical practice part 5

 Fluid in clinical practice

Fluid: part 5

  A Fluid may be resuscitative fluid, maintenance fluid or both. Resuscitative fluid criteria are described before. Maintenance fluid must have water and electrolytes in a balance, that can replace daily requirements and ongoing loss. During resuscitation, fluids electrolyte components must be kept in mind. As in case of potassium, it is not advised to infuse >>10mmol/hour. Before prescribing fluid for maintenance, please keep in mind the composition and pH of body fluids in different parts of GIT. Have a look at the Diagram below. Fluids containing lactate and citrate are converted by liver to bicarbonate and become more alkaline . So, for replacement of bicarbonate , these fluids can be used.

    Replacement and Redistribution ::::

       Check for: vomiting and nasogastric tube loss biliary drainage loss high/low volume ileal stoma loss diarrhoea/excess colostomy loss ongoing blood loss, e.g. melena sweating/fever/dehydration pancreatic/jejunal fistula/stoma loss urinary loss, e.g. post AKI polyuria.

     Check for: dehydration ,fluid overload, hyper/hypokalaemia

Assessing fluid balance::

Overfilled: • raised JVP

• Pitting oedema of the sacrum, ankles, or even legs and abdomen • Tachypnoea

• Bibasal crepitations

• Pulmonary oedema on CXR

 Underfilled:

• Tachycardia

• Postural drop in BP (low BP is a late sign of hypovolaemia) • decreased capillary refill time • decreased urine output

• Cool peripheries • Dry mucous membranes • decreased skin turgor • Sunken eyes.

   Q1:: Are there existing fluid and/or electrolyte deficits or excesses?

🌀 If yes,then---

    Estimate deficits or excesses and add to or subtract from normal daily maintenance requirements.

   Now:;: Are there any ongoing abnormal fluid or electrolyte losses?

     💣 If yes,then---

Prescribe for routine maintenance requirement plus additional fluid and electrolyte supplements to replace the

‘measured’ abnormal ‘ongoing’ losses.

Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring.

 🌀 If not,then----

      Are there other complex issues? 

Check if allowance required for: gross oedema severe, sepsis , hyper/hyponatraemia , renal, liver and/or cardiac impairment.

    If yes, seek expert advice.

    

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

By: Dr. Manilal Biswas

SSMC (2012-13)