RESOURCES NHS Lothian Guidelines for basic IV fluid and electrolyte - PowerPoint PPT Presentation

IV F LUID P RESCRIBING Year 4 Prescribing Tutorial 2019 – 2020 Disclaimer: All cases are fictional for teaching purposes

RESOURCES NHS Lothian Guidelines for basic IV fluid and electrolyte prescription in adults http://intranet.lothian.scot.nhs.uk/Directory/IVFluids/Pages/Intravenous%20Fluids.aspx NHS Lothian Adult Fluid Prescribing Chart https://policyonline.nhslothian.scot/Policies/Documentation/Fluid%20Prescription%20and%20Bala nce%20Chart.pdf Golden rules of prescription writing http://intranet.lothian.scot.nhs.uk/Directory/MedicinesManagement/Documents/Golden%20rules% 20for%20prescribing%20V%203.1.pdf BNF http://www.bnf.org/ Lothian Joint Formulary http://www.ljf.scot.nhs.uk/LothianJointFormularies/Adult/Pages/default.aspx

G OLDEN R ULES OF P RESCRIBING  Select correct prescription chart (14 day ± warfarin chart)  Write clearly in block CAPITALS using a black ballpoint pen  Complete all the required patient details on the front  Use generic names for drugs where possible and appropriate  Write drug dose clearly; remember only g, mg and ml are acceptable abbreviations  Select route of administration

G OLDEN R ULES OF P RESCRIBING  Enter correct start date (use original start date when rewriting)  Remember the once only section  Sign and print your name  Enter supplementary charts in use  Never alter prescriptions (cancel and rewrite)  Discontinue prescriptions correctly

LEARNING OUTCOMES  Describe the physiological principles that underpin IV fluid prescribing  List the different types of IV fluids  Explain indications for IV fluids  Describe the assessment of fluid status  List the factors to consider when prescribing IV fluids

F LUID C OMPARTMENTS  Rule of thirds:  Roughly 2/3 rd of body weight is water  For a 70kg person, this is approximately 42L  Of this, 2/3 rd is intracellular, 1/3 rd extra-cellular

Reference: BMJ 2015; 350 Intravenous fluid therapy in adult inpatients

N ORMAL FLUID REQUIREMENTS  Depends on expected losses and gains, but in a fit and healthy fasting patient for instance:  Fluid required: 30 ml /kg/day. Usually works out as around 2 – 2.5 litres per day  Sodium – approximately 1 mmol/kg/day  Potassium – approximately 1 mmol/kg/day

F ACTORS AFFECTING FLUID REQUIREMENTS  Bleeding  Vomiting  Diarrhoea  Infection  Pyrexia  Heart failure  Renal failure  Chronic liver disease  Burns

T HINK D RINK !!  Think…can your patient drink?  Do they actually NEED fluid therapy?  This is the first essential of IV fluid management

A SSESSING FLUID STATUS  Airway  Breathing:  Oxygen saturations  Respiratory rate and effort  Chest auscultation – any bibasal crepitations

A SSESSING FLUID STATUS  Circulation  Pulse  Blood pressure – any postural drop?  Urine output  Capillary refill time  Mucous membranes  Skin turgor  Peripheral oedema  JVP  Thirst

 D – Disability  GCS  Temperature  Investigations: Blood results, CXR, urine…  Medications: Beta-blockers, diuretics…  Think about where fluid is – consider third space losses.  Consider any excess fluid losses – vomiting, diarrhoea….

A SSESSING FLUID STATUS  ABC approach to determine fluid status  Euvolaemia  Hypovolaemia  Hypervolaemia

Prescribing IV Fluids

W HICH FLUID , IF ANY , IS REQUIRED ? 1. What is their fluid status? 2. What are you trying to achieve? - Resuscitation - Replacement - Maintenance 3. Which IV fluids required? 4. Recent biochemistry, do they need K+ supplementation?

F LUID TYPES  Crystalloid  Sodium Chloride 0.18%/glucose 4%  Sodium Chloride 0.9% (‘Normal’ Saline)  Glucose 5%  Plasmalyte 148  Colloid  Human Albumin Solution  Gelofusine  Blood Products  RCC, FFP, Platelets

Reference: BMJ 2015; 350 Intravenous fluid therapy in adult inpatients

SODIUM CHLORIDE 0.18% & GLUCOSE 4%  Standard maintenance fluid  More physiological than alternating 0.9% saline & glucose 5%  Contains 30 mmol of sodium in 1000 ml  Maximum rate of 100 ml/hr  Caution in hyponatraemia (Na <132 mmol/L)

GLUCOSE 5%  Crystalloid fluid  Will stay in the intravascular space for a very short period of time compared to other crystalloids of higher osmolarity; metabolised quickly to water  Only 1/9 th of volume will remain intravascularly  Not useful for resuscitation  Good for maintenance fluid therapy

PLASMALYTE 148  Balanced crystalloid  Designed to resemble plasma - contains 140 mmol/L of sodium, 5 mmol/L of potassium, 1.5 mmol/L of magnesium  Isotonic with plasma remains in the extracellular fluid proportional distribution between the plasma and interstital fluid  First line resuscitation fluid

SODIUM CHLORIDE 0.9% ( Normal Saline)  Crystalloid  Contains 154 mmol/L of sodium  Will stay in the intravascular space for a reasonable period of time due to a higher osmolarity than other crystalloids, but will eventually distribute between all the fluid compartments.  Can therefore be used for both maintenance fluid therapy and some forms of resuscitation.

HUMAN ALBUMIN SOLUTION  Colloid  Good at expanding intravascular space  Mainly used with senior advice in replacing ascitic fluid lost in liver disease  Comes in 500ml 5% or 100ml 20%  Needs to be given in less than 3 hours.

RED CELL CONCENTRATE  Blood product  Best fluid to give in major haemorrhage  Expands intravascular volume, but also replaces lost red bloods cell – this is important for oxygenation  Blood transfusion protocols ensure that the right product is given to the right patient, at the right time

Reference: BMJ 2015; 350 Intravenous fluid therapy in adult inpatients

C ASE DISCUSSION 1  You are an FY1 in General Surgery  You are clerking a 25 year old male who has presented with presumed appendicitis  No significant past medical history  No known drug adverse drug reactions  Observations:  T 38.5, HR 130, BP 88/54, RR 24, SpO2 97% on air  Weight 68 kg  What would you do?

C ASE DISCUSSION 1  ABC approach and assess fluid status  Observations suggest he is hypovolaemic – secondary to sepsis  What fluids would you prescribe for him?  Prescribe these now

C ASE DISCUSSION 1

C ASE DISCUSSION 1  Keep accurate fluid balance  Review fluid status after fluids given  Likely to require further fluids after bolus  Consider requirement for a urinary catheter

C ASE DISCUSSION 2  You are an FY2 in Medicine of the Elderly  Nursing staff ask you to prescribe more fluids for a 78 year old lady who was admitted with community acquired pneumonia – on IV Clarithromycin and Amoxicillin  She is eating and drinking  Past medical history:  MI – 2011  Multiple medications, including furosemide

C ASE DISCUSSION 2  Observation chart:  T 37.2  HR 94  BP 154/88  SpO2 88% on 2 L/min O2  RR 26  She has been given Glucose 5% at 125ml/hour since admission 24 hours ago  What should you do?

C ASE DISCUSSION 2  Review the patient: A – Maintaining own  B – Increased respiratory effort, bibasal creps (R>L)  C – HS I+II+ESM, peripherally warm, moist mucous membranes, CRT <2s,  JVP raised 4cm, peripheral oedema to knees, urine output 40ml/hr. D – GCS 15   What fluid would you like to prescribe?

C ASE DISCUSSION 3  You are an FY2 in Orthopaedics  You are asked to see a 45 year old man who has been admitted with a distal radius fracture  He is fasting pre-operatively  Weight is 83 kg  He has no past medical history of note and does not normally take any medications.  What would you like to do?

C ASE DISCUSSION 3  ABC approach to assess fluid status  His observations are:  T 36.5, HR 76, BP 128/64, SpO2 98% air, RR 16  K 4.2mmol/l, Na 140 mmol/l  Systemic examination is unremarkable  What fluids would you like to prescribe?

C ASE DISCUSSION 3

I F THE PATIENTS POTASSIUM WAS 5.1 WHAT REGIMEN WOULD YOU PRESCRIBE ?

C ASE DISCUSSION 4  You are an FY1 in Gastroenterology  You are called to see a 37 year old lady who has been admitted with decompensated alcoholic liver disease  The nursing staff have just witnessed a small haematemesis of around 100mls of fresh red blood  As you walk in to see the patient, she suddenly vomits another 1000mls of fresh blood. She looks pale and clammy  What would you do?

C ASE DISCUSSION 4  ABC approach  Get help  Observations:  T 37.6, HR 130, BP 80/58, SpO2 95% air, RR 28  On examination:  A – Maintaining own, not compromised  B – Increased respiratory effort, chest clear  C – Cool peripherally, CRT ~ 4s. HS I+II+0, JVP not visible. Mild peripheral oedema.  D – GCS15, but very anxious

C ASE DISCUSSION 4  What do you need to do?  Oxygen  Wide bore IV access x 2  Bloods including G+S  Fluids… Prescribe the fluid you would like to give in this clinical situation.