3rd Year Revision Day

23 May 2015

Fluids Worksheet

Fluids
Number one question-Can your patient drink?????
IV fluids are not without complications and require more frequent monitoring of
patients-in any fluids OSCE station, always mention you would consider if the patient
can take fluids orally

Shock
Acute circulatory failure leading to inadequate tissue perfusion
Tachycardia, Hypotension, Cool Peripheries, Increased CRT, Altered Mental State
500ml boluses of 0.9% saline/Hartmann’s, with reassessment of obs
Up to a max of 2L-then needs senior review
DO NOT EVER USE 5% DEXTROSE AS A RESUS FLUID-serum
hypoosmolality/hyponatraemia , drawing fluid extravascularly by osmosis and
leading to cerebral oedema and death

Deficit
Based on the previous days fluid balance in most cases. However, patients can come
in ‘dry’ and have a clinically apparent deficit (e.g. dry mucous membranes, sunken
eyes, decreased skin turgor, thirst, decreased CRT) following, for example, an
episode of severe diarrhoea, or malnourished elderly patients.
These patients have an increased fluid requirement over and above the normal daily
maintenance

Maintenance
30ml/kg/day of water-up to a max of 2.5L for men, and 2L for women
2mmol/kg/day of Na+
1mmol/kg/day of K+
The above figures are not absolutes-don’t be worried about 5-10 mmol either side
In most patients, include 1L of dextrose-the sugar in this prevents fasting patients
from entering ketosis

Ongoing Losses
Most common examples include a high output stoma, or fluid loss through
vomiting/NG tube aspirate.
Replace Upper GI losses with Saline with additional K+
Replace lower GI losses with Hartmann’s
Golden Rules of Fluids
Never, ever use 5% dextrose as a resus fluid. Leads to plasma hypoosmolality,
cerebral oedema and death. Saline or Hartmann’s
Max infusion rate of K+ is 10mmol/h
Maximum of 40mmol/L of K+
Never add potassium to Hartmann’s

Assessment of fluid Status

Heart rate
Examine for postural hypotension
JVP
Mucous Membranes
Skin Turgor
CRT
Yesterdays fluid balance-are they in a deficit? With particular reference to their
urine output
Recent U&E
Are they thirsty/have a dry mouth?
Have they had vomiting/diarrhoea?

Monitoring
Daily U&E
Clinical Assessment-are they in fluid overload/deficit (check the fluid balance chart
every day)
Do they still need fluids-can your patient drink?
Example Scenario
Scenario 1
(a) You are called to the surgical ward to see a patient you have never met before,
and the nurse asks you to prescribe him some IV fluids, as he has been vomiting and
now has an NG tube in situ, and can no longer take in any fluids orally. How would
you asses this mans fluid status?

(b) Following your assessment of the patient, you feel that he is in deficit. What fluid
would you use to replace the lost volume?

(c) What are the complications associated with use of 5% dextrose as a resuscitation
fluid?

Scenario 2
(a) You admit a 45 year old man with no-comorbidites for a routine repair of an
inguinal hernia. The patient is to be fasted from midnight. It is now 2330 and the
ward sister asks you to prescribe fluids for the patient for the next 12 hours. What
fluids will you prescribe?