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181121 Selecting Iv Fluids to Manage Fluid Loss in Critically Ill Patients

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181121 Selecting Iv Fluids to Manage Fluid Loss in Critically Ill Patients Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice Keywords Crystalloid/Colloid/Blood products/Osmolarity Review This article has been Fluid therapy double-blind peer reviewed In this article... ● Causes of insensitive and sensitive fluid loss in critically ill patients ● Different types of intravenous fluids, their indications and side-effects ● Guidance on the treatment of fluid loss and fluid resuscitation algorithm Selecting IV fluids to manage fluid loss in critically ill patients Key points Authors Xabi Cathala is a lecturer in vocational learning, Institute of Vocational Intravenous fluid Learning; Calvin R Moorley is an associate professor in adult nursing, Faculty of therapy is one of Health and Social Care; both at London South Bank University. the most common treatments in Abstract Critically ill patients admitted to intensive care settings may need to be intensive care administered intravenous fluids – for example, to restore their blood pressure or replace lost blood. A crucial question arising in the management of these patients Fluid loss leads to is which type of fluid to use. To decide which fluid is most appropriate and safest, hypovolaemia and, nurses working in critical care need to understand how the different types of fluids if left untreated, act on the human body. This article describes the three main types of fluids to death (crystalloids, colloids and blood products), their composition, mode of action, indications and side-effects. Crystalloids vary in their osmolarity Citation Cathala X, Moorley C (2018) Selecting IV fluids to manage fluid loss in and so have critically ill patients Nursing Times [online]; 114: 12, 41-44. different indications Colloids contain ntravenous (IV) fluid replacement is Sensible fluid loss, which can be seen macromolecules one the most common treatments and measured, can be due to diarrhoea, that increase administered in intensive care and vomiting, haemorrhage, high output from vascular pressure, Iother critical care areas (Myburgh and drains or stomas, wounds or excessive diu- resulting in plasma Mythen, 2013). Three types of fluids are retic therapy. Sepsis is another cause of volume expansion used: crystalloids, colloids and blood prod- fluid loss, as it causes an intravascular ucts; in our experience, their use varies fluid deficit due to vasodilatation, venous There is a lack of between hospitals and practitioners. It is pooling and capillary leakage (Marx, 2003). conclusive evidence important that nurses understand the dif- on which fluid to use ferent types of fluids, their mechanisms of Treatment of fluid loss for treating fluid loss action and side-effects. This article pro- Acutely ill patients who experience fluid vides essential information on fluid resus- loss will need to be administered IV fluids. ciation in critical care. Where fluid loss is significant, replace- ment is urgent and this is known as fluid Fluid loss resuscitation. As with all drug treatments, Fluid loss can lead to hypovolaemia and, if IV fluids must be correctly prescribed by a left untreated, to death. In acutely ill doctor or a non-medical prescriber. One of patients, fluid loss can occur from insen- the roles of nurses is to ensure this is done sible and/or sensible loss. according to organisational policies. How- Insensible fluid loss cannot always be ever, if the patient’s condition is life- seen and measured; examples include threatening, the National Institute for sweating, fluid loss from the gastrointes- Health and Care Excellence advocates that tinal tract (for example, via reabsorption) nurses should be able to start IV fluids and fluid loss from the lungs (loss of H2O according to organisational policy until via respiration), which can be up to 800ml they are prescribed by a relevant practi- ALAMY in 24 hours (El-Sharkawy et al, 2017). tioner (NICE, 2013). Nursing Times [online] December 2018 / Vol 114 Issue 12 41 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice Review Indications for fluid resuscitation Fig 1. Fluid resuscitation algorithm in adults In its guidance on IV fluid therapy in adults in hospital, the NICE (2013) lists the fol- Step 1: Using the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) lowing criteria for fluid resuscitation: approach, assess whether the patient is hypovolaemic and needs fluid resuscitation ● Systolic blood pressure <100mmHg; Assess fluid volume considering clinical examination, trends, context and indicators ● Heart rate >90 beats per minute; that a patient may need fluid resuscitation (see text) ● Capillary refill time >2 seconds or peripheries cold to touch; Yes ● Respiratory rate >20 breaths per minute; Fluid resuscitation ● National Early Warning Score ≥5 Step 2: Initiate treatment or more; • Identify cause of fluid deficit and respond ● Passive leg raising suggesting fluid • Give a fluid bolus of 500ml of crystalloid (containing sodium responsiveness (Box 1). in the range of 130-154mmol/L) over less than 15 minutes To help health professionals in their decision-making, the NICE guideline includes algorithms for IV fluid therapy Step 3: Reassess the patient using the ABCDE approach (Bit.ly/NICEFluidAlgorithms). The algo- Does the patient still need fluid resuscitation? Seek expert help if unsure rithm for fluid resuscitation (Fig 1) fea- No tures three steps: ● Step 1: ABCDE (Airway, Breathing, Yes Does the patient have signs of shock? Circulation, Disability, Exposure) Yes No Assess the patient’s assessment; likely fluid and ● Step 2: initiating treatment – the electrolyte needs algorithm indicates how much fluid to Yes give over a specific period; timing is >2,000ml given? Seek expert help important: if given too slowly, resuscitation will be less effective; No ● Step 3: reassessment. It is important to monitor patients Give a further fluid bolus of 250-500ml of crystalloid during fluid resuscitation. Systemic obser- vations should be undertaken frequently Adapted from NICE (2013) according to organisational policy. It is good practice to assign the monitoring to a Nurses need to be able to identify the side- dextrose saline, 0.33% NaCl (sodium specific nurse. Haemodynamic observa- effects of IV fluids, which include fluid chloride), 0.45% NaCl, 2.5% dextrose, tions should include blood pressure (BP), overload, oedema and anaphylactic reac- 5% dextrose and 5% glucose (an heart rate, heart rhythm, oxygen satura- tion. Early recognition of complications isotonic fluid, which is quickly tion and capillary refill time. If the patient and side-effects is essential to preserve metabolised, leaving free water that has a central venous catheter in situ, cen- patients’ safety. is hypotonic). tral venous pressure should be measured. ● Hypertonic crystalloids, which include Respiratory rate and urine output also Crystalloids 3% NaCl, 5% NaCl, 7% NaCl, 10% need to be assessed and recorded. Fluid Crystalloid solutions contain electrolytes dextrose, 20% dextrose and 50% dextrose balance should be maintained or com- and glucose. Osmolarity (Box 2) is an (Lira and Pinsky, 2014; Gan 2011). menced and accurately recorded. important property of crystalloids, which The observations will show trends in can be classified into four subgroups: Properties and indications the patient’s status and how the patient ● Isotonic crystalloids – the most Different types of crystalloids have dif- reacts to the treatment that you initiated. commonly used is sodium chloride ferent properties and will, therefore, be They also will allow early recognition of 0.9% (normal saline); appropriate in different situations possible complications such as shock. ● Balanced isotonic crystalloids – the according to the cause of fluid loss and the most commonly used are Ringer’s patient’s condition. Box 1. How to ascertain fluid lactate and Hartmann’s solution; Isotonic crystalloids have a sodium and responsiveness ● Hypotonic crystalloids, which include a chloride concentration of 154mmol/L and To ascertain a patient’s responsiveness Box 2. What is osmolarity? to fluid therapy, lay them down horizontally and raise their legs 45 Osmolarity measures the number of osmoles of solute particles per unit volume of degrees so the blood returns to the solution. It is defined as the number of osmoles (Osm) of solute per litre (L) of central circulation. If the blood pressure solution and expressed as Osm/L (pronounced ‘osmolar’). This value allows us to increases within 30-90 seconds, the measure the osmotic pressure of a solution and determine how its particles will patient is likely to be responsive to fluid diffuse across a semi-permeable membrane separating two solutions of different therapy to restore blood pressure. osmotic concentrations (osmosis). Nursing Times [online] December 2018 / Vol 114 Issue 12 42 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice Review a similar electrolyte concentration to Box 3. Case scenario plasma. With isotonic infusions, there is no significant fluid shift across cellular or Tom Stevens* is admitted to the ● Capillary refill time >3 seconds vascular membrane for a normally intensive care unit (ICU) via accident As per national guidance (NICE, 2013), hydrated patient (Lira and Pinsky, 2014; and emergency (A&E) for optimisation Mr Stevens would be initially treated Gan, 2011). These fluids are usually used to
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