Fluid management in clinical practice part 4

 Fluid in clinical practice

Fluid :: part 4

Please see the diagram for better understanding

   💉⏩ Starting fluid therapy::

Initial assessment :

   Assess whether the patient is hypovolaemic and needs IV fluid resuscitation. Indicators of urgent resuscitation include:

®systolic blood pressure is less than 100 mmHg ®heart rate is more than 90 beats per minute ®capillary refill time is more than 2 seconds or peripheries are cold to touch ®respiratory rate is more than 20 breaths per minute ®National Early Warning Score (NEWS) is 5 or more passive® leg raising test is positive.

If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/l, with a bolus of 500 ml over less than 15 minutes. Use human albumin 4-5% only in severe sepsis resuscitation.

Initiate treatment ::

•Give high-flow oxygen. • Secure large bore IV access. •Identify cause of deficit and respond.•

•Give a fluid bolus of 500 ml of crystalloid

Reassess the patient using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure)

 Does the patient still need fluid resuscitation?

  If needed, Repeat with 250- 500mL solution and reassessment. Repeat upto total 2000 mL fluid.

If improved, asses for maintenance fluid.

If> 2000 mL given, without improvement,seek expert

 help.

Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues? Look for existing deficits or excesses, ongoing losses, abnormal distribution or other complex issues.

Give maintenance IV fluids Normal daily fluid and electrolyte requirements:

•• Water- 25–30 ml/kg/d water•• Na,K,Cl---1 mmol/kg/day sodium,potassium,chloride •• Glucose- 50–100 g/day glucose (e.g. glucose 5% contains 5 g/100ml).

Reassess and monitor the patient. 

Stop IV fluids when no longer needed. Nasogastric fluids or enteral feeding are preferable when maintenance needs are more than 3 days.

If patients have received IV fluids containing chloride concentrations greater than 120 mmol/l (for example, sodium chloride 0.9%), monitor their serum chloride concentration daily. If patients develop hyperchloraemia or acidaemia, reassess their IV fluid prescription and assess their acid–base status. Consider less frequent monitoring for patients who are stable.

For patients who are obese, adjust the IV fluid prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of 3 litres of fluid per day) and seek expert help if their BMI is more than 40 kg/m2.

Do not exceed 30 ml/kg/day for routine fluid maintenance, and consider prescribing less fluid (for example, 25 ml/kg/day fluid) for patients who:

are older or frail have renal impairment or cardiac failure.

When prescribing for routine maintenance alone, consider using 25–30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 (there are other regimens to achieve this). Prescribing more than 2.5 litres per day increases the risk of hyponatraemia. Further prescriptions should be guided by monitoring.

Source: NICE guidance

By: Dr. Manilal Biswas

SSMC (2012-13)