The speaker is Mr. Deepak Vijayan, ST8 Specialist Registrar at Queen Elizabeth Hospital, Birmingham, UK, with an interest in General and Colorectal Surgery, Intestinal Failure and Abdominal Wall Reconstruction. Honorary Clinical Lecturer, Institute of Clinical Sciences, University of Birmingham, Project Lead and Steering Committee for National Open Abdomen Audit (NOAA). He graduated in 2006, after completing his Foundation years, then joined the Royal Navy as a Submarine Medical Officer. He served on HMS Vigilant and HMS Victorious and undertook NATO/UK Trident deterrent patrols. Following that, he served as the Military Registrar at the Royal Centre for Defence Medicine, receiving all UK casualties during the Afghan war. Subsequently, he started Specialist Training in General and Colorectal Surgery. His special interest is Intestinal Failure and Abdominal Wall Reconstruction. He is currently the Project Lead for the National Open Abdomen Audit, funded by Bowel Research UK.
Fluid and Electrolyte Management for the Surgical Patient
Summary
This on-demand teaching session is relevant to medical professionals and will focus on the management of intravenous fluid therapy in adults. Expert speaker Mr Deepak Vijayan (Surgeon Lieutenant Commander, Royal Navy) will provide a quick refresher on body water composition and movement before discussing the types of fluids prescribed, the effects of chloride ions, the myth buster and STOP sign related to using 0.9% NaCl, and NICE Clinical Guideline 174 (2013). He will also cover audit standards for fluid prescription, fluid resuscitation, routine maintenance, the NICE algorithm and reference important research materials. As well as this, there will be a discussion on the implications of the SALD-ED trial.
Description
Learning objectives
Learning Objectives:
- To understand the importance of fluid and electrolyte balance in adult patients, and how to properly assess a patient's needs in this regard.
- To understand how to create a comprehensive intravenous (IV) fluid management plan.
- To understand the appropriate use of crystalloid and colloid fluids in fluid resuscitation and routine maintenance settings.
- To know Clinical Guideline 174 (2013) and the auditing standards associated with it.
- To understand the NICE algorithm, dangers of chloride ions, and pertinent evidence from the Shaw et al, Annals of Surgery (2012) and Lobo, D Physiological Aspects of Fluid and Electrolyte Balance (2003) studies.
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The management of intravenous fluid therapy in adults NICE Guideline CG174 Mr Deepak Vijayan Surgeon Lieutenant Commander, Royal Navy (rtd) 1982 Patientsaredyingduetoinfusionof toomuchortoolittlefluidsby inexperiencedstaff Fluidprescriptionshouldbegiven samestatusasdrugprescriptionFluid Homeostasis A quick refresherBodywatercomprises60%of bodyweightand73%oflean mass. EquilibriummaintainedbyStarlings law.What happens to the fluids? Capillary Permeability .What are we prescribing? The effect of Chloride ions…Chloride and the Kidney The effect of 0.9% Saline and balanced fluids. Major Complications, Mortality, and Resource Utilization After Open Abdominal Surgery: 0.9% Saline Compared to Plasma-Lyte Shaw et al, Annals of Surgery 2012The Myth BusterThe effect of 0.9% NaCl STOP USING 0.9% NaCl There is nothing normal about it!! NICE Clinical Guideline 174 (2013) § Audit standards 1 - 4 (IV fluid prescription) 1. The patient's fluid and electrolyte needs are assessed as part of every ward review. 2. The following information is included in the intravenous (IV) fluid prescription: • the type of fluid to be administered • the rate of fluid to be administered NICE • the volume of fluid to be administered GUIDELINE 3. Patients have an IV fluid management plan. 4. The IV fluid management plan includes the following: • details of the fluid and electrolyte prescription over the next 24 hours • details of the assessment • details of the monitoring plan NICE Clinical Guideline 174 (2017) § Audit standards 5 - 9 (IV fluid resuscitation) 5. For patients in need of fluid resuscitation: • the cause of the fluid deficit is identified • a fluid bolus of 500 ml of crystalloids is given 6. Patients who have received initial fluid resuscitation are reassessed using the ABCDE approach. NICE 7. Patients who have already been given >2000 ml of crystalloids and still need fluid resuscitation after GUIDELINE reassessment receive expert help. 8. Patients who have not had >2000 ml of crystalloids and who still need fluid resuscitation after reassessment receive 250–500 ml of crystalloids and have a further reassessment using the ABCDE approach. 9. Patients who are showing signs of shock but do not need fluid resuscitation after reassessment receive expert help NICE Clinical Guideline 174 (2013) §Audit standards 10 (IV routine maintenance) 10. If patients need IV fluids for routine maintenance NICE alone, the initial prescription is restricted to: • 30 ml/kg/day of water and GUIDELINE • 1 mmol/kg/day of potassium, sodium and chloride and • approximately 50–100 g/day of glucose to limit starvation ketosis.NICE AlgorithmNICE AlgorithmNICE AlgorithmNICE AlgorithmParenteral fluid therapy triad Blood Products Hartmann’s PlasmaLyte Parenteral fluid therapy triad Hartmann’ 4% DEXTROSE s 0.18% NaCl + K+ PlasmaLyt 20- e 30mls/Kg/day 1mmol/kg/day Na, K 50-100g/day of glucose § Lobo, D. Physiological aspects of fluid and electrolyte balance. 2003. DM Thesis § Shaw, A D et al, Major Complications, Mortality, and Resource Utilization After Open Abdominal Surgery: 0.9% Saline Compared to Plasma-Lyte § Liu, K. Fluid overload and AKI. Presentation § Lobo, D. Basic Concepts of Fluid and Electrolyte Therapy. Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen 2013 § Lobo,D. Choice of fluids in the perioperative setting. 2017, IFAD Presentation References § Lobo, D. Fluids beyond resuscitation: Maintenance and replacement. 2017, IFAD Presentation § Lobo, D et al. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr. 2001 Apr;20(2):125-30. § Saline versus Lactated Ringer’s (LR) in ED (SALD- ED Trial) § Pragmatic , unblinded single centre study over 16 months Study § Each month all patient’s received either LR or saline § Jan 2016 – April 2017 § <18yrs of age who received >500mls of IV fluids AND were subsequently hospitalised § Patients not admitted to ICU § Not having ESRD and receiving RRT Inclusion criteria § ITT analysis of all randomized patients § Primary outcome -Number of hospital free days within first 28 days of initial presentation to ED § Secondary outcome – Major adverse kidney events Outcome within 30days, death from any cause, new RRT, persistent renal dysfunction (elevation of creatinine levels >200% of baseline) § 13,347 patients -Results Blood Products Hartmann’s PlasmaLyte IV fluid therapy Hartmann’ 4% DEXTROSE s 0.18% NaCl + K+ PlasmaLyt 20- e 30mls/Kg/day 1mmol/kg/day Na, K 50-100g/day of glucose § Questions? THE END