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

IV FLUID PRESCRIBING

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

GOLDEN RULES OF PRESCRIBING

 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

GOLDEN RULES OF PRESCRIBING

 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

FLUID COMPARTMENTS

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

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

NORMAL 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

FACTORS AFFECTING FLUID REQUIREMENTS

 Bleeding  Vomiting  Diarrhoea  Infection  Pyrexia  Heart failure  Renal failure  Chronic liver disease  Burns

THINK DRINK!!

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

ASSESSING FLUID STATUS

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

ASSESSING 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….

ASSESSING FLUID STATUS

 ABC approach to determine fluid status  Euvolaemia  Hypovolaemia  Hypervolaemia

Prescribing IV Fluids

WHICH 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?

FLUID 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 1/9th 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

• smolarity 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

• xygenation

 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

CASE 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?

CASE 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

CASE DISCUSSION 1

CASE 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

CASE 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

CASE 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?

CASE 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?

CASE 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?

CASE 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?

CASE DISCUSSION 3

IF THE PATIENTS POTASSIUM WAS 5.1

WHAT REGIMEN WOULD YOU PRESCRIBE?

CASE 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?

CASE 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

CASE 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.

CASE DISCUSSION 4

 Activate major haemorrhage protocol  Resuscitation fluids until blood products arrive  Continue to reassess the patient

SUMMARY

 The keys to appropriate fluid prescribing are:

 Understand fluid compartments  Know the different types of fluids available and when to prescribe them  Always assess a patient’s fluid status  Always check U&Es  Select the appropriate type of fluids – maintenance, versus replacement,

versus resuscitation

 Maintenance fluids – try and use 1 litre bags and don’t forget to

prescribe potassium

 Reassess the patient after IV fluids given

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 %20Balance%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 NICE IV fluid guidance https://www.nice.org.uk/guidance/cg174 BMJ 2015;350 Intravenous fluid therapy in adult inpatients (Published 06 Jan 2015) http://dx.doi.org/10.1136/bmj.g7620

THE END

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