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(BQ) Part 1 book Making sense of fluids and electrolytes has contents: Fluid assessment; keeping the balance - physiology, electrolytes and intravenous fluids, cardiac arrest and shock.
A hands-on guide Zoja Milovanovic and Abisola Adeleye CRC Press • Toylor &.fnncll Cn>up MAKING SENSE of Fluids and Electrolytes MAKING SENSE of Fluids and Electrolytes A hands-on guide Zoja Milovanovic Anaesthetic Clinical Fellow, Homerton Hospital London, UK Abisola Adeleye Junior doctor training in Obstetrics and Gynaecology in the East of England, UK CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2017 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4987-4719-6 (Paperback) This book contains information obtained from authentic and highly regarded sources While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and not necessarily reflect the views/opinions of the publishers The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www copyright.com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-7508400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Contents Acknowledgements List of abbreviations How to use this book vii ix xiii Fluid assessment Fluid assessment – format History Examination Investigations A systematic approach to fluid management Special considerations Further reading 1 11 12 12 Keeping the balance: physiology, electrolytes and intravenous fluids Introduction Human body fluid compartments Renal physiology Intravenous fluids Electrolyte abnormalities Definitions of essential concepts Conclusion References Further reading 13 13 13 19 23 31 45 46 47 47 Cardiac arrest and shock Introduction Assessment Cardiac arrest Severe sepsis and septic shock Anaphylactic shock Hypovolaemic shock Conclusion Further reading 49 49 49 56 59 61 63 65 70 v vi Contents Intravenous fluid therapy in medical patients Introduction Medical considerations in fluid assessment and management IVF therapy in the context of specific medical presentations Fluid depletion Fluid overload Complex fluid states Other important presentations Conclusion Further reading 76 78 93 102 107 107 111 Fluid therapy management in surgical patients Introduction Pre-operative fluid status management Intra-operative fluid balance Post-operative fluid status management Conclusion Further reading 113 113 114 124 125 132 137 Blood products and transfusion Introduction Assessment History Blood components Blood products Transfusion regimes Review the implemented treatment Conclusion Further reading 139 139 140 140 150 155 156 159 160 164 Index 73 73 74 167 Acknowledgements We have a number of people to thank for this book, without whom realisation of our idea would not have been possible The Royal Society of Medicine for awarding us the young author’s prize in 2013 and Dr Harpreet Gill for her collaboration in this Dr Douglas Corrigall, for his contribution to the design and content of the book, especially the medical chapter Our editorial advisors Dr Thomas Gilkes, Dr Stefanie Robert and Dr Shilpa Reddy for their clinical experience and for sharing our vision We are also deeply grateful to our families for their unwavering support and endurance during the writing of this book, and we would especially like to thank Mr Alex Hayes for his help and patience with proofreading our final copy vii List of abbreviations A&E AAA ABG ACE ADH AF AKI ALP ALS ALT APTT AST ATP AVPU AXR BE BMI BNF BNP BP BSA CCF CK CKD CMV COPD CPAP CRP CRT CT CVP CXR Da DI accident and emergency abdominal aortic aneurysm arterial blood gas angiotensin converting enzyme antidiuretic hormone atrial fibrillation acute kidney injury alkaline phosphatase advanced life support alanine aminotransferase activated partial thromboplastin time aspartate aminotransferase adenosine triphosphate alert, responsive to voice, responsive to pain, unresponsive abdominal x-ray base excess body mass index British National formulary brain natriuretic peptide blood pressure burn surface area congestive cardiac failure creatinine kinase chronic kidney disease cytomegalovirus chronic obstructive pulmonary disease continuous positive airway pressure c-reactive protein capillary refill time computed tomography central venous pressure chest x-ray daltons diabetes insipidus ix x List of abbreviations DIC DKA GCS EBV ECF ECG ECHO EF eGFR ERCP FBC FFP G&S GI GORD GP GTN Hb HCl HDU HES HF HLA HPA HR HRS HTN ICF ICU IHD IM INR ITU IU IVF JVP KDIGO HIV LFTs LVEF MAP disseminated intravascular coagulation diabetic ketoacidosis Glasgow Coma Scale Epstein-Barr virus extracellular fluid electrocardiogram echocardiogram ejection fraction estimated glomerular filtration rate endoscopic retrograde cholangiopancreatography full blood count fresh frozen plasma group and save gastrointestinal gastro-oesophageal reflux disease general practitioner glyceryl trinitrate haemoglobin hydrochloric acid high dependency unit hydroxyethyl starch heart failure human leucocyte antigen human platelet antigen heart rate hepatorenal syndrome hypertension intracellular fluid intensive care unit ischaemic heart disease intramuscular international normalised ratio intensive therapy unit international units intravenous fluids jugular venous pressure kidney disease improving global outcomes human immunodeficiency virus liver function tests left ventricular ejection fraction mean arterial pressure List of abbreviations MI MONAC MRCP MRI NBM NGT NIV NJT NICE NSAIDs PCR PEA PEG PMH PND PT RAS RAAS RBC RMP RR SBP SBP SIADH SIRS SNS SOB SSRIs TCRE TEN TIPSS TRALI TURP U&Es USS VBG VF VT vWF WBC myocardial infarction morphine, oxygen, nitroglycerine, aspirin, clopidogrel magnetic retrograde cholangiopancreatography magnetic resonance imaging nil by mouth nasogastric tube non-invasive ventilation nasojejunal tube National Institute for Health and Clinical Excellence non-steroidal anti-inflammatory drugs protein:creatinine ratio pulseless electrical activity percutaneous endoscopic gastrostomy past/previous medical history paroxysmal nocturnal dyspnoea prothrombin time reticular activating system renin-angiotensin-aldosterone system red blood cell resting membrane potential respiratory rate systolic blood pressure spontaneous bacterial peritonitis syndrome of inappropriate antidiuretic hormone secretion severe inflammatory response syndrome sympathetic nervous system shortness of breath selective serotonin reuptake inhibitors transcervical resection of the endometrium toxic epidermal necrolysis transjugular intrahepatic portosystemic shunt transfusion-associated lung injury transurethral resection of the prostate urea and electrolytes ultrasound scan venous blood gas ventricular fibrillation ventricular tachycardia von Willebrand factor white blood cell count xi 58 Making Sense of Fluids and Electrolytes and one in whom cardiac arrest has been identified If resuscitation is successful, the most immediate threat is haemodynamic collapse The circulatory system attempts to restore perfusion to vital organs, but in this fragile state, hypotension and circulatory failure can develop Aim to maintain a balance between restoring intravascular volume, perfusing vital organs and avoiding excess strain on the heart Balanced crystalloids are preferred in the initial stage, but the risk of ensuing cerebral or pulmonary oedema with large volumes may indicate an early switch to a colloid infusion instead Aim for a mean arterial pressure (MAP) of 80–100 mmHg, CVP of 8–12 mmHg and urine output of ≥0.5 mL/kg/hr The inflammatory response to cardiac arrest often leads to peripheral vasodilatation severe enough to require treatment with vasopressors and inotropes Vasopressors like noradrenaline work predominantly by increasing peripheral vasoconstriction and thus peripheral vascular resistance to maintain cardiac output and circulation An inotrope like dobutamine acts on β1 receptors to increase the force of cardiac contractility and therefore cardiac output and circulation Other factors to consider post–cardiac arrest are oxygenation, ventilation, correction of electrolyte disturbances and therapeutic cooling (to help minimise hypoxic-ischaemic brain injury) Note that decisions to use inotropes or vasopressors or therapeutic cooling are universally expected to be made by senior clinicians with the involvement of the high dependency/intensive care team The patient is going to require close monitoring and is therefore often nursed in a high dependency, critical or intensive care setting anyway REMEMBER IVF for initial resuscitation in a patient surviving cardiac arrest Balanced crystalloids are preferred in the initial stage, but monitor the patient’s response closely and alter the volume and type of administered fluid as necessary Aim for a mean arterial pressure (MAP) of 80–100 mmHg and urine output of ≥0.5 mL/kg/hr Some clinicians still aim for central venous pressure (CVP) of 8–12 mmHg Cardiac arrest and shock 59 SEVERE SEPSIS AND SEPTIC SHOCK Sepsis features systemic inflammation secondary to infection, the severity of which varies and can be fatal Septic shock is a form of distributive shock whereby peripheral vasodilatation is impaired by the inflammatory process The following criteria help to identify these conditions: • Severe inflammatory response syndrome (SIRS) criteria: • • • • • • • • Temperature >38°C or 90 bpm RR >20 breaths/min or PaCO2 12,000/mm3 or 20 or PaCO2 12,000/mm3 or