- Fluid therapy
Link:www.nice.org.uk/nicemedia/live/13298/63880/63880.pdf
- Key problems
- Errors in fluid management common in A&E, acute admissions and general medical & surgical wards
- Standards of monitoring input and output generally poor
- Poor knowledge of fluid composition
- Often prescribed by most junior medical staff
- Poor training related to fluids
- Patients dying as a result of too much/too little fluid
- Debate about the best fluids to use
- Trials are difficult to interpret
- Recommendations
- 5 'R's
- Resuscitation
- Routine maintenance
- Replacement
- Redistribution
- Reassessment
- Algorithm based approach based around the 5 'R's
- Training and education
- Training for all healthcare professionals
- IV fluid lead clinician
- Ongoing audit of IV prescribing
- Routine maintenance
- 25-30ml/kg/day water, consider lesser amounts for cardiac and renal patients
- 1 mmol/kg/day of potassium, sodium and chloride
- 50-100g/day glucose to limit ketosis
- Resuscitation
- Use crystalloids that contain sodium in the range of 130-154 mmol/l, 500ml over <15 mins
- Do not use starches for resuscitation
- Consider HAS 4-5% only in patients with severe sepsis
- Adjust IV fluid prescriptions for IBW in the obese
- Assessment and monitoring
- Document likely fluid and electrolyte needs from history and examination, monitoring and lab investigations
- All patients receiving IV fluids should be weighed 2x/wk, have daily review and bloods daily
- Incidents of fluid mismanagement should be reported through standard clinical incident reporting