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what you're eating. Everyone. I think that's that's going live now Welcome to today's mind. The bleed webinar on prescribing fluids s a two day. We have Lizzie and Anna here with us. Lazy is an anesthetic straining, so it's very well placed to talk to us about fluids on. She's going to take us through this really important topic. You can also read the article on the MINDEDLY website, and I put the link to that in the video description. So do you take it out? Just a reminder that we're gonna be recording this session and we'll be up to view on the Facebook page, and we'll send out all of the materials if you sign up at mine. Oblique dot com forward slash webinar dash registration Again, I'll put the link in the comments. Remember to ask you lots of questions. We'll try to get to a Semenya's possible, but if we can't get to all of them, we will answer them after the webinar. In the comment, we've also got a short feedback for me at the end is really helpful for us to to find out how these webinars are doing. So please do fill it out, and you will also get a certificate of attendance, which is great for your poor failure as well on. So let's see, we could just go on to the next life briefly. Thank you. So before hand over properly to Lizzie. Just a quick shout out to our sponsors, the Medical Defense Union. It's really important not to forget to sort out your N D. You foundation membership before you start your shadowing period. Because unless you filled in a foundation application for your student membership will cease in the summer. And obviously, as you know, it's essential that you do have indemnity cover. So I'm gonna put a link in the comments again so you can join at the MD you dot com for special Osanai. But that link or Morong you wrecked with on with any questions? So that's all for me. Over to your busy. Great. Thank you so much. Neurology. We've also got under here who's on F four company local man. She's gonna be chipping in a swell, uh, with the comments, etcetera. So a snorer says I'm dizzy. I'm an ST one on static training currently working in a on today. We're going to tackle in fluid prescription, so hopefully this will be helpful for you all. So we're just gonna think about why fluid restriction is important. I'm sure you'll know already we gave you thinking about fluid status examination and how toe approach. A patient who you need to prescribe flu. It's full well, then move onto looking at different types of IV fluids and when you might use thumb on the different ones available and then we'll go through two different scenarios. So resuscitation, fluids, lots of maintenance. Florence. So first of all, Oh, that's Megan. So why is three description important? Well, firstly, it's one of the most common prescriptions are going to do both in ours and out of hours. I think even now is Ah, trainee as next H 01 of most common things get us to do is can you prescribe some fluids, or could you do a fluid balance on one of my patients? So it's something you're going to do it a little time on. It's good to get a bit of a background. I've been bit more confident with them as you go into F one practice. The other reason it's important is that it's a drug, so there's a reason we prescribe that as much as it has benefit for patients that can also be could be harmful. So it's important to think about what fluid you're prescribing, how quickly going to prescribe them on how you're going to reassess to patient as you go through. I mean, a third thing is that three prescription was always a bit tricky. I think all of us have kind of rules of thumb is that we use to try and kind of get through and describe the correct fluids. But there's always going to patients who are a bit more complicated. Have multiple comorbid Iti's when you're sitting there scratching your head, thinking, I'm not really sure what to do in this situation. I was always that's always gonna happen on gets good, to have a bit of a background, to think. How can I approach this? What do I need to think about was I go forwards but also asking for help when you need to. So let's start with the fluid status examination. So you're on call and you've been asked her review a patient who the the necessary or could you give some fluids? But they're not really eating or drinking. So whenever I approach a patient, first thing is, is this person sick? Or they well, they stand at the end of the bed on examine from a fall. The other things think about that I find helpful both in clinical practice and simulations. Is, Is this person compensating or decompensated? So is this person unwell? But they're observations are holding on their clinically stable. Or have I got a patient here who is has an infection and it's decompensated, or perhaps has a background of cardiac issues, and it's now in decompensated heart failure to try to distinguish sick, big zit little sick is almost thinking about it compensated and decompensated and then at the end of your fluid status. The purpose of the examination is, is the person in front of me hypoglycemic, even limit or hyperbole? Mch and each part of your examination is trying to address that so you can come to an answer at the end of your examination. So things to think about just going to move to say this, I can see why put so again start the end of the bed. Have a look around? Can I see any vomit balls? NGOs, catheters, anything distinct that's going to tell me if this patient is technically dry, has lots of fluid losses. Or maybe they got big Lupus, a two lemonades exception that they're charging on on a drinking really well. And then with all the examinations and ascended and 80 approach is, I start peripherally. So what's the peripheral cap? Refill? Was the central cap refill our They clinic, you know, clinically a pretty shot down. Then I moved to the post. So what's the character of the post? The right, the rhythm, then moving on to the BP so hopefully that would be available to you. Or you can look at the trend. But also, ideally, trying to get a line standing can also be helpful with blood pressures. What I would say with pulse and BP is also take into account the patient in front of you. But they might be on beat a blockade because of cardiac arrhythmias or whatever they may have. Multiple anti hypertensive agents or their baseline BP may be much higher than the average taking the elderly population, so not just looking at the discrete numbers themselves were also thinking about for my patient. Is this a low BP for my patient? Would I expect them to mount a tachycardia if they're significantly fluid deplete? Are they on Passat Pelo atenolol? That might be more skin a tachycardia. So once it done post blood pressure moving onto, let's get in to stick the tongue out. Are they really crispy? Have they got more to mucous membranes? Quickly looking at the JVP doing me to put pressure on the right upper quadrant revealed the JVP or is it up to their ear and suggestive of heart failure? I have a quick listen to the heart. Sounds kind of hear any murmurs? Potentially any new murmurs from the last examination Is there a Gallup within that might be suggested of heart failure And then I get in sit forwards If I can listen at the basis for any crap stations that might be suggestive of palm Redeemer What's it In four days I have a look secretly. Is there any pitting edema that I can pick up and then move periphery to look at there Any pitting edema in the legs Jesus is also helpful. So is this a patient you know who now has a deterioration in the GCS? Could this be someone who's delirious or has a cognitive impairment where trying to get an accurate fluid balance or history is difficult? And then, ideally, one of the best things to get is a urine output. So they're bottles. Is there a catheter? Can we work out what the, uh, earlier and output is? And if know, is this something I need to consider? Is a capital going to be helpful? So as you're going through a reminds to think, is this person decompensated or compensate in? And is this person hypoglycemic, euvolemic or hyperpoly make on each point? You should be thinking, How does this abscess the picture of the patient in front of me? It's by the time he gets the end. You can hopefully answer that question. You going to change? So once you discussed your patient and you've answered your question, this is a hypovolemia patient or whatever you come to. You don't need to think about what fluids. Um I going to give this patient So the two main ways you think about it is your question. Lloyd's in your keloids, so we start with Keloids. These are fluids for fluid products that have large proteins or large molecules in on the general eating. Some Teo address the oncotic pressure within the system. So Jennifer Hudson is an old example, which is already used. Animal. I don't think I've seen it in practice that used to use, but there was a high risk of allergy and anaphylaxis, so that's kind of got a trend. Human album insulation is another keloids that it's sometimes use can be using resuscitation. Purpose is the most common reason I've seen it is for patients who have never cirrhosis. You have a set, it drains in situ, and he may require a bonuses of human albumin. Generally, you're given it to patients who may be intravascularly depleted that you may be fluid or salt restricted because of multiple different point abilities. Again, it's not gonna be a solution that you're going to use without senior or specialist input, so I have left that for. For that, the other colleagues to remember is blood products. It's important to think about blood products as fluids because your increase in the interest of space, um, again can be used for resuscitation purposes. So for patients who are got oxygen, I believed, or major hemorrhages or patients trauma patients who may be using blood products as resuscitation purposes. But generally, we use that for, uh, dick your own awards that beef patients who are compensated with anemias etcetera that require still have a product transfusion. The other side is your crystalloid see of crystalloids off fluids that have smaller kind of sorts him on. Generally, they affect the hydrostatic pressure in the intravascular system, so there's lots of different crystalloids lots of different isotonic hypotonic hypotonic solutions, the most common that you're going to use once you provides DHA or more independently, let's say it's gonna be your normal saline, So 0.9% Hartmann's or plasmalyte, depending on the trust and wipes of dextrous. Why I forgot to mention is that this is a fluid lectured, just the adults I'm not a pediatrician on. I would not be in the position to teach about pediatric flu prescription even in any pediatric departments. I don't really go in their fluids without pediatric support, so this is primarily for adults, so now we have thoughts about our different types of fluid. I hate that makes sense. Let's think about what's in them. I'm sorry. It's probably edited. Slide it to me a long time to work out. Help her a table into this, so I don't by any means expect you to remember this table. This is Joe just to have an idea of what you prescribed him with any other drug that you prescribed. You have an idea of the pharmacology of side effects, etcetera off the drug, so it's important to understand what's on your fluids. So if we take the three main fluid types of picked, Hartmann's just for ease of a possible right, so your sodium chloride is just salt water. It's gotten much high portion of sodium in Croydon than your heartburn's. Hartmann's has got a smidge of potassium in a smidge of bicarbonate, and arguably more physiological on the next race is just sugar, so they're that in mind. We'll come back to it later side, So let's we want to resuscitation. So the people you're going to be doing resuscitation fluids are going to be your unwell patients. So you're hypertensive until tachycardia patients patient to have potentially septic on patients who may be bleeding. So hypoglycemic patients again. The main things we give our crystalloids a Z, I said before that, maybe purpose for blood products as a recess. It a shin resource again, it's important to think about that that is still a fluid. So if you're given fluids side by side, it's resuscitation scenario. It may mean that you need to get both at the same time, depending on on what's available. But generally, if I was on the ward, if I was in resource, I generally be going for crystalloids so even have stayed in Croydon. The normal saline or your heart is a possible line. UH, it was a state of Florida are a bit easier to get a head around. So generally you're gonna do bonuses and you going to be pickin to 50 or 500 mils pentin on the patient in front of you. It's a well patient who's a young patient, minimal cardiac or little background or no cardiac little background. Who's a good BM I reasonable size. You're not concerned about overload in? Then I would go to 500 mil if you've got someone who's maybe bit frail has a poor functional or physiological reserve has cardiorenal background know get to 50 and you're gonna bolus that even 15 to 20 minutes off each British we're going to reassess on. The point of the reassessment is to repeat the fluid status, but water to think about is this person respond in Are the transient responding to the pickup and then they go down again or they're not responding to all. The reason for that is to judge the next step. So I am I going to get another fluid bolus they picked up. I'm gonna keep going and give him another bonus before reassess. Are they transient? You respond in, Say, I need to be keeping on them and give them another Botox. And you know, we may need to go down a different room or they're not responding at all. Maybe because I'm not keeping up. The fluid loss is there's a bleed that I'm not picking up. Um or, you know, this is a person who was so sick we might need to get intensive care involved to review them basic price of support, etcetera. Now, generally, with bonuses, you tend to go for up to full bonuses before you get stiff on the maximum point, we think, Well, you know, it is not working me to think of a different route, and then you go into a middle ground off dumber bonuses. They've had a liter, two liters. Now I need to give them. I called in the middle ground of resuscitation and maintenance. The do it so someone who was septic was no, had a bleed. You stabilize the movie resuscitation fluids, then you're gonna think about giving them. You know, maybe a six hour to four hours is exactly a totally back, depending on what they look like. Anything with fluid is that it's a bit of an art, and it's based on experience. On confidence is well. But whatever you prescribed, the key is always to reassess and see what the fluid doing and how the patients responding the beauty of fluids. You can adjust them as you go. You can go fasting. Gross number. But the main things about think take away from assasination is bolus reassess, bolus, reassess. I'm thinking about how your patient is responding. Stop. So let's do Okay, so we've got a lovely little the lady from Google here, here is 84 lives in a nursing home on has come into any You're the F one called him with two days of confusion a temperature, um, allergy issues. So just looking ahead. Examination. Just have a quick read three. Um, and see what you think. Appreciate I'm I don't know. He's watching this. I hate to be born in this, but you have a quick reason. And so we think. And whether you think this is a patient who is gonna need resuscitation or maintenance fluids But the clue in that we have just a research station, that's it's an 84 year old female from a nursing home. So from a nursing home nursing home to me suggest someone here is potentially frail with the poor, functional or physiological reserve. We've got two days of confusion temperature, smelly urine. So UTI delirium. Something to think about. Why would it do that? Examination. So we've got someone who is tachycardia, hypertensive, uh, several. That periphery shut down clinically dry with no signs off clear overload. And this lady particular, let's say this is a lady just, you know, frail in from the nursing home you know that her reserve is gonna be cool. We don't anything about her background still waiting for blood. Six, actually. So I think this lady, she's first. You gonna need resuscitation in the bonuses because she's hypertensive tachycardia. So but this lady, I go who to 50 mL. Bonus of normal saline. I prefer normal saline because there's no potassium in it. And it is a new smidge from what I've seen, but without knowing what they're they're based on potassium is I prefer normal saline. But it's up to the individual on our bolus this over 15 20 minutes, and I would reassess where we're not bolus. Um, the other point of this is that her urine output is unknown. So the next week with this electron AKI on banishing that but first he was in a sec. Take patient. So you're gonna be fun on your sepsis. Six and catheterize on. When was helpful? Ways to know is this person respond in toe? My fluid bolus is is that observations and also the urine output trying to get an idea of what their Parsons important. So that is to take your example I would do for teeth of the mill of Sodium thyroid don't want 9% over 15 20 minutes and reassess. I probably do two or three bonuses. It is responsive and then move on with your six or eight hour drug. So do employed or personal I dependent on her response. Hi, Leslie. Just ask a quick question here a few people and asking whether you would give the fluid over 15 minutes or whether you would give it. It's just that, you know, So people are wondering about the cup. Refill is the cut we felt under two seconds. Or is it over? And just that influence and the fluids? Fine. Let's say first thing was, uh, stopped versus 15. 20 minutes, Um, have been 15. 20 minutes is a ball park. It's, I think if you try to run fluid starts without a pressure bag, it probably would be just in the time frame. Anyway, um, pressure bags completely must faster. So in this lady, I promise to 2 50 mill on full flow on. It's about 15 20 minutes if you've seen the devices that you use, so you've either got one. That's the turns negative. You calculate mill per hour meal per minute. I think on you can do it more accurately, or you have the ones which just a roly on you put it on. I just tend to put on opens and I'm and let it go. Three. The pressure bags You can put fluid in and pump it up. So it was a BP cuff on that. We'll go much through much faster, so I think it depends on If I had a young patient in front of many who was deteriorating and had a little pressure like this, I I probably even put 500 mil or even a liter. I'm putting the pressure back to you quickly. I think it's important to think about patient in front of you, the risk of overload. But Germany for satar, a nurse can get like 15, 20 minutes. They're going to put it on like a flow, so it's not really about time in it. It's, um I mean, I think it's variable. Depending on first, you can only have got in the abscess. You've got the type of kid that you're using, um, on how false Little gray three. So I wouldn't get too hung up on 15 to 20 minutes start 15 minutes is basically the same. And then the other thing you said wasa about cut refill, right? Yes. Um, although that's a guy. What was the question in town and table? Just wondering whether this improvement is your decision. If the copy fellas over under two minutes, what kind of fluids to use then? So I think with the country for the things that again, you're not looking at one isolated Think so you're billed using it to build up a picture of the patient. His own has got a powerful cut. Rethought off more than two seconds if you took it for 56 seconds. This 80 skull, a peripheral cut refill, say, from her fingers or four seconds. Blood is being diverted away from the periphery. So to go, essentially because they started to compensate. So I think what peripheral, central cut refill tell you is house because the patient in front of me Now let's see if you've got someone who's got rain, order is cold or whatever, that's gonna affect the pap refill, so I wouldn't never take any of this really in isolation. You think about whole picture But what peripheral fat refill on Central partners will tell you is, what's the distribution of blood in the body, and are they starting to probably shut down? So if you've got someone who has the heart rate's fine, the blood pressure's fine. They got big. They're drinking some water. They've got no peripheral state Dema, but the cap refill. It's more than a couple of 345 seconds. I'm not necessarily going to Russian with fluid bonuses, because the clinical picture is not telling me that's a high privilege indication. If I've got something in front of me here, yes, has a perfect heart. Refill off. Four seconds is dry. Is hypertensive talking politic? I'm drowsy. Then that's pushing me towards a high privilege and a picture. So you're not taking things in isolation. As with anything in medicine, you're taking each part and put it as an argument towards your favorite wanted to question is, Does that help? Yes, that's great. Thank you. Perfect. So hopefully we have that case presentation has been helpful again. It's a one off presentation. What? I'm happy to go through other scenarios if you need to, but this is a scenario where you might adjust and go for a lower volume for your bolus. Let me get into maintenance foods, which we were discussing just before this talk. Come be quite tricky on, but, as I said with fluid description, Is it a science on an art? And a lot of experience in confidence can help with prescription. So the people giving maintenance fluids to are people who are in your mouth so they may have a reduced use. Yes, they may have their weight of the sort assessment because their risk aspirate in they may be for elective surgery, they have reduced oral intake. So I have a bit of gastroenteritis, said driving drunk commuted bit, but it's by no means much in the overall targets, or they may have electrolyte abnormalities. So you need to replace potassium or magnesium and did a bit faster than a lutes, for example, if their losses of greater than their intake, or perhaps they're not, absorb it so you don't give them or successively before I leave again, we're gonna get down the crystalloid rate, Um, your maintenance. So it's just aging chloride, Hartmann's or 5% dextrous, and then we get into a bitch I think people find difficult on. I still find difficult even today. I'm sitting there in a debating with myself for maintenance foods to give, and there's no right or wrong answer again. The most important thing is whatever you prescribe, you are reassess in on what your patient's response to it. So this is when we got into the formula. So the nice guideline state that this is the 24 hour requirements for maintenance, though it's so healthy individual who's not to drink. So we're aiming for 25 to 30 mill per kilogram per day or fluids and water. So you packed up your potassium sodium employed. It's one minimal per kilogram per day. It is easy to calculate at a nuclear cause. You're aiming to 50 to 100 g today of glucose. The day gets you worried about this. I can even sense using that this in public, Maybe panic. So let's take a Nexium pulse. But it's much easier to do it in practice. So you're the surgical F one you're out of hours on. A 36 year old lady has come in and she's got an elective cholecystectomy, um, over you've been told by your rights that Oh, she's got, you know, one month from tomorrow night, can you prescribe some limits? Just clinically. Well, her opposite lying just even a Mexican. Your fluid status examination. And she weighs about 80 g. So let's apply that to our, um, formula. Say, if we look at what her recommendations for water, we're talking about 2 to 2.5 liters of water a day. About 18 minimally off the potassium sodium a Kreutz on again, 5200 g per day of your notes Point. Let's apply that to work. Um, I was in, uh, Florence, so I think it'll about this before the lecture start is this is a rough guide, but I think it's helpful in terms of understanding. What quantity? What? Williams of Fluid. You're gonna give you a patient to be this lady to 2.5 liters a day. That's a helpful guide. I think they're helpful in terms of making you recognize that you think about a taxi, and I think about glucose not just given some to water, but if you look at the graph so you can see from the stadium for it in the heart mons. There's an awful off sodium in there so that this may do it for 18 holes of sodium. Well, unless you're gonna give her those dextrose, you always gonna He's a noxious agent. Um, in terms of potassium, you've got a smidgen your heart mons, but there's no, you know, it's five moles. You can't add potassium to that. So your options to provide potassium is to give the task employees and add it to box of either you can add it to a surgeon cores or two dextrous. With your potassium, you can are 20 to 40 minimums. Um, now your main routes of the widen by the potassium again, you can get Hartmann's, but cut Nizam, that is, then you're gonna be a smidge of the potassium requirements for 24 hours. And then, in terms of your blue coasts, s 01 lead to a brief hosts gives you 50. So your liver end of normal being requirements, as I said, is a bit complicated. So let's apply this for your back. This so what we'll do is just have a quick thing. There's no whatever months to this, but just for a minute. Having think of what Would you describe this patient? So some of you may have heard of the soul to sleep, etcetera. But try and think about how my gonna get 22, 2.5 liters of fluid inside. Um, either by a surgeon for it. Apartments or dexterous. How am I going to match the potassiums? They were as a general poured needs again. Sodium chloride. You probably gonna eat the egg. That home. I didn't get that potassium in them on how my gonna balance giving him since, uh, sugar results. So if you if you want to, you feel free to write them in the comments. I can't see them. The other will be keeping belly if you don't want to. That's fine. Just just have a little thing about what you would do on again. No. Right or wrong answers to thinking about what sedation you get. How are you gonna get the past even how you gonna get the new place in? And then how far are you gonna get those limits? It's tricky because have a guy you gonna get nine o'clock and to be in the nose. It is any questions. In the meantime, well, it's just a quick question. That's come three on the chat on that. Actually, I've always wondered about you said Somebody's just asked about 4% on about 4% on glucose know, 18% sodium chloride, something that's called dextrose a line, isn't it? Yeah, so I think the difficult do those always thinking about your it isotonic like metallic etcetera. Generally, though, I wouldn't prescribe those without seen this advice just because it's also complicated in there. So join the potassium. You need to think about what they're baseline sodium sassiness, so about you on it. But I've never prescribed anything other than 0.9%. Hartmann's of 5% dexterous. The only times I prescribe maybe hypotonic or hypertonics 89 is in the context of hypo hyper Nutri Mia, and that's generally under the advice of endocrine and lie to you. Yes, I agree. I don't even think the normal ward would have it. Like, readily available. You'd have to go looking for. It would be something you could find quickly and again. I think when you're thinking about when you're prescribing fluids are gonna think that's hypodense hyperness tree talks as part of my sleep, but you need to be aware off what? You're not only print because you're putting sodium chloride in what ships that's gonna have your potassium and your sodium except her, and how that's gonna factual results of the next couple of days. So I would even here I I certainly wouldn't be comfortable prescribing anything other than these three. Sh purely. Because of predicting the response. Those fluids No, only in terms of fluid balance, but in your ships of fluid from one compartments, the other based on the sodium potassium. So in theory, yes. But in practice, I think if you ask the nurse to find you a different 1% or whatever, they would be Bunkley on after you describe something else, basically, maybe an intensive Cats essence, except for that may be a different story. So, uh, let's have a look in this world example. So I'm giving a suggestion is not right. It's not wrong. This is something that I came up with. So I'm gonna get to one liter box and then consider giving a half for later. Um, I'm going to Dom spread my potassium in one bag of sodium chloride on one bag of dextrose. So Medex Trace, one need to is gonna give my 50 g new case. My sodium chloride is gonna get me more than nothing. My Did you employed loss? I'm gonna add in some potassium chlorate over my teabags. They get in their mind, I'll be a bit more keloids burning a swell. So this patient, she's young. I'd probably give over eight hours. Doesn't matter which back you start with. It's up to you. Um and then depending on her response, you can speed up, slow down fluids as you need to based on what you're looking like about her opposite urine. Um, I need more. Say he wanted to talk up to the two half liters on the options. I thought we did either talk about that. Employed a half about dextrous. Um, I know that in the 500 million avoided at any potassium, you can't have potassium. Probably either maximum 20 mil a minimal. But generally I find it easier to put the test employed in the on one knee to box. So that's one option. I'm happy I can look through the other suggestions later then I'll see anything there. Not right it. Well, as I said, I think this formula is helpful. Am thinking about the volume you're gonna be given. So this lady, you know, your only prescribing 22 bags. You know we'll be going, you know, when it's not pumping her with 42 hour before Lasix probably boxes too much. It also doesn't make anything which you think it's gotten. Sometimes is that they will have tassan be post requirements as well. Now I say to cover, Yeah, that's all. Firstly, that this is a lady who's coming in for elective cholecystectomy. She's probably not be in your bladder after 24 hours. So, actually, do you need to be prescribing box? There's always I'm set, its complications, things that delay lists. It's important to think of you know what you would give, and you may want to prescribe him in the background. If she's going to be a tissue may have fluids down there as well, which will not prescribe them. So this is when the formula is perhaps less helpful in real life, because unless someone is going to be completely healed by mouth with 234 days, Um, which they shouldn't really be without. Think about the nutrition personally. Not necessary Going to prescribe you this lab supplier it. The other caveat is again you're gonna be excess off each bag on. So if you're honest, normal aorta you prescribed about fluid I would at least halfway through or tools into shift. I bought the patient having the ob just to make sure that you're providing a lot of fluids on that. The other thing to think about is if we go on Teo, Uh, the more challenging patient. So the ugly as always, gonna be a bit more. You wouldn't worry about what you prescribed him. Equally as the patients got higher abortion off body fat to muscle, then you don't want to stop. You don't go just on there after weight. You want to think about that? I do. Would you like to someone who's going over 100 110 kg? There's four minutes to counter the ideal body weight, and I'd go buy that in there. Oh, the weight on the scales. Nothing's think about renal impairment and heart failure. So even someone who is perhaps dehydrated or into bust really deplete they have a background of renal impairment, heart failure, then just need to be a bit more cautious or bit more wary of how you're prescribing it. I would tend to go a bit slower, but maintenance. So no resuscitation for maintenance, side of things and assess more frequently. I'm again you're assessing by doing your fluid status. What's the observations doing? How much you know the Parkinson and this is when communicate with the nurses. It's important because you need to have good input output charts to make sure that what you're doing is on what patient is responding to his reflective of actually was happening and then your doesn't think about is actually with the potassium. Take it, Adam Test. Um, and you need to be keeping an eye on what to do and you don't want to. Over. I get with Tussin, Germany, for adding potassium. Then it's not gonna she particularly tickets, and I want you to drink. But you do need to keep an eye on her. The reasons you may need to increase in the testing you give him or think about other sorts that magnesium, calcium or think about giving you It's a little bit faster is they got ongoing electrolyte loss is or fluid losses. There is this person having ongoing diarrhea and vomiting. If you think you think briefly about task in someone's got testing lives 3 to 3.5 Germany, I'll give a little place in. You got somebody front of you who has vomited and potassium 33.13 point two. My intonation would be start going down the IV fluid route to patient potassium because that's the main way. First, we're gonna keep up with their losses off both fluids, unless lights were also absorption or all supplements. And that may not be optimal. They haven't not in the back of your mind of Do I need to increase the speed or the volume of warmer place in? Does this person have becoming bowel obstruction that God rose cheap in and they've got high output from the street? They got a stammer that having high output losses or is this person being mg cheap? That on actually, the dietician is as what's helped the rebel appointments, and they're having flashes potentially medication that I ain't in court. Brayton's my maintenance. Remember as an F one I had a patient. He was not eating or drinking or eating. Um, was having anything and enjoy each IV. Um uh, nd chief is actually in for medications on the resulting to think about and you to feed in, um on. It was a tricky balance between think about maintenance fluid in that bridge, also remembering that they're having brushes. So whatever medications being put in that having 5100, 200 no flushes that are going through on is a consideration of actually, because I get that Could I increase their fluids by increasing the amount of fluid with brushes? Well, good idea. They enjoy chiefs. Awesome. Think that to think about having discussion with dieticians and nurses about what's actually going into the entry tube is really helpful. Other things that may require foster electrolyte replacement. Why the fluid is things like pancreatitis, where they have high amounts of third space in and then you lots of fluids, and they may need to have a quicker hemorrhage. Sorry, Do I need to think about giving blood products on, like a lot of sense that DKA So they're strict Brooklier guidelines in your trust about DKA replacement on. But in certain cohorts say example, younger patients who need to be cautious about fluid balance a typical cerebral edema again, if any doubt. And these complex patients always ask. I still ask. Forget stuff, Um, but it's just, uh, the old of a picture of the patient in front of you and how the maintenance was making more complicated so you can see how, although that formula is helpful, it has a lot of caveats, and you need to make sure you're thinking, you know, that's all skeletal. What you're aiming for is anything that's affecting it and anything that might mean that I give more fluent or need to tweak up. Why would say the elderly patients is a thing if you ask a box? Um, so, uh, we've said 25 to 30. Nope. Kilogram per day of water for the complicated patients of the patients who have risk of overload of frail elderly party real backgrounds? Probably. I think the recommendation is 2025 mil around today, but I still the same, but I was just very light. The other main since there is it's tricky now, Uh, this is the nice guideline, which I don't need any of you can read. I can't read it, But this is what to look for when you Google. This is the flow chart. What is recommended to evidence based. It tapped into fluid resuscitation, so giving Botox is on that also goes down the root off routine maintenance. You know, my mouth and they're over requirements. But then also caveats to that. I want you to think you're not. Now when you go to the wolves, I can guarantee that if you also blocks from ST Changes vegetables, they may not be calculated from this. They may be going from experience, they may be saying, even a hourly tonality accepts again. That's not wrong. And it may be that it that's coming from seeing lots of patients prescribing fluid. I'm kind of subliminally coming up, you know, in the back of their mind what patients require some people people prefer just giving plasma, like particularly it's a short period time. Any maintenance fluids, um, and again, that's not wrong. It's just that when you're doing a prescription, make sure that you are reassess in understanding what your patients needs are so that you can keep up the Germany marble of thumb. And this is not something to necessarily follow. Is that even doing maintenance fluids, elderly patients I would tend to gain 8 10, 12 hours tend to normal ago. Bit slow 10 12 hours on and reassess more frequently. The younger patients in maintenance, um, might be 68 10 Ali, but again that is very bold. On it is based off of squabbles limits on again. I would not be prescribing out looking at my patient. I born in them. I'm thinking about Won't have the outset. I lost that. So, ultimately maintenance, though it's wide, say is you're stuck. Use the formula and think about what's this person's normal requirements. If they were well and it cetera all there, any caveats to go? Do I need to be fasting or slower because of their background? And is there any electrolyte abnormalities that we need to think about bloody to think about their magnesium and place that before the potassium on I was 86 monitors ago. The maintenance is more difficult, and again it's always going to be a science and the art on your as the more you do, the more confident that they don't. That confidence turning to complacency must always resuscitation and make sure that they're responding. How you anticipate? So I've had about 50,000 times this talk. Always reassess recess, reassess, reassess. If in doubt, recess the more frequently it's time conceiving, it doesn't have to be more. You do it too quick you that that it will be more confidence that what you're doing, it's working. You can tweak things that you go Remember that the nurses of your assets that your eyes and your ears you can't be sitting there in extra patient watching the year and you're into the bag. You need to be relying on them. Teo alert was a problem. Um, so making sure your doctor Minton, please. We have accurate input output monitoring. This is what my target saw on it is. Any problems do you eat? So what I recommend is doing your regular with assessments looking at so utilizing bloods. So particularly do electrolyte replacements. Make sure that you are doing I would say, daily blood particular tasi Um, um, I'm making sure you know what their baseline is, so efficacy could be helpful over the CRP for infectious markers after markers. Also, hematocrit could be helpful to see if they drive the dilution. Doctors. Delusional effects. Bone profile. So again, it's more to do with that in the nutritional status and also a lot to do with thinking about potassium, etcetera. So do I need to play something else before the place? Taxing more me like medium and your allergies are helpful again more. Most of the nutritional status and the album year and output, the former pretend to say, Is there a 0.5 mils per kilogram per hour? So now 80 to the ground was suspecting patient laying 40 Nolan hour in our little fair lady before Okay, Jay in for 21. Again, this is a guide. So I tend to write is we are aiming first urine output monitoring on hourly, aiming for 40 minute hour if less than this, the two consecutive hours lately, because they're gonna be some hardly and dips and drops. I'm looking at the average able. Remember to have caution in complex patients and patients who, particularly elderly aunt having a look at on No. Is this patient a higher risk of pushing to overload? Way to think about electrolyte loss is. And is that something that might be tricking me? Are they on multiple anti hypertensives? Be two blockade? That might be complicated. Picture in front of me the most important thing goddess of your state of training. If you're allied health professional, if you're f, one will resolve and it doesn't matter if you're in doubt. Arts. We all have periods where, particularly fatigued is that you just call me. You can come in. Answer on this, taking times his next one more sat there and I sat there and I sat there and I tried to work it. Our and actually, if I just ask my Reg, you could have had I had learned a bit from that much quicker. Um, I can always reassess it today, so see what you call you. Say, see what the nurses thing. Have a conversation and look at the whole picture and come up with a management on on whatever you do, just make sure your reassessing a patient as you build up, but I hope that's helpful. If there's anything that was clearest model or you want me to go over, just let me know. Departments on hand 82. Yeah, high. Lazy was great. Thank you. Very great. And then a lot. Just go A few questions, if that's all right. So one of them, which is a very good question for Mohammed early on Waas. If a patient's quite a well, how do you do a lying and standing BP on wood? It actually added it into the clinical kitchen. So I know I would in that situation of the Alliance. And the pressure is helpful as a helpful adjuvant to your benefits and nation. So the reason I'll use it is from a knee. Is a patient in the waiting room who's describing some diarrhea bombs and symptoms on actually observations. Okay, I would ask Reliance on your BP because sometimes that can reveal dehydration. No, if I've got again, how about patient from me to you? Is hypertensive talking colitic on but probably shut down, not passing urine alliance and pressure. First, it's probably dangerous. You don't want to do it. It's time to look for more than about two years, and it's not going to change. A month doesn't help or adjuvant to what we're doing, but it's by no means again on isolated thing that you've been a reliable young thing. You can do a PSA spirit response, so example, if you need to, a sexy attention needs fill in. So who could bonuses? Etcetera, is that you can take them so if their legs up or talk about. And if there's a response in the BP, the heart rate, then it's suggested that there they would benefit from it again. I don't recommend going in and taking a vacation upside down, but sometimes if they every hypertensive that can go, I just it is that they're gonna be very responsive on. Maybe go get the BP up and helping Cerebrate walks. You're trying to assess it a thumb, but I think it and the next question I had that was just a few people was what's the maximum amount of potassium that you could give her an hour? Questions? I think, um, on the ward. It's 20 mil on our know 10 minutes on our in I t. I'm central lines. 20. So if you're given a fasting replacement, firstly, you never given Testim replacement as a resuscitation measures. If you're given IV potassium, it's 10 minimal in our. So if you want to be 40 minimal the birth since you could give them four hours Onda again. If you have an unwell patient informed to be, I would not be used in add in sodium potassium chloride to anything to Mississippi, abusing my heart burns or my surgeon choroid to increase the intravascular volume. And then, um, doing you can do quick maintenance for it. If you need to replace potassium relatively quickly, you consolidate them. But your worries. They got ongoing lawsuits you could do for our six about testicle. That's fine, but making sure the reason for that was that you don't trigger with me is you know you can get extra visitation schools irritation to the skin except you from Adam Test Lord. So 10 minutes, one hour on the ward is the bastard chicken bass guitar. See, um, I don't use it. The process station measures if you need it faster than it's disgusting discussions and seniors for potential central lines to you, A can't perfect, and one person that was a little bit tricky is what's that idea? Recess station fluid for a hypertensive, chronic liver disease patients so good. So your liver. Your cirrhotic of the patients are the reason that they're the complex patients. They're one of the complex patients because I like to have a low albumin. So without having albumin in your intravesical system, whatever you put in is likely to leak into third stage, which is why you get the ascites. So again, if you have a six cirrhotic patients who never patients and sick really sick on bacon go quite quickly. I read Go for T 15 or Minuses of sodium chloride. What Escalated Senior? Because again, it may be that they need to pass or they knew sections intervention. So in because whatever with cirrhotic patients, wherever you're putting in, if they have a low albumin, the third space on the main intravascular. So in those situations, sometimes hostages. But again, it's, uh, just, uh, artificially the place in the abdomen that been office in that if you make him the patients independent, the decompensated, it's meant to get it early. Senior advice in because they become unstable quickly. So again, if you had someone who's at risk of heart failure, you is intensive on. Do you think it's dry? I'm still grateful to 15 more bonus is because the problem is fun to use that in past you need to eat. But there's always gonna be tricky thing of condition. It's a good overloaded any point, and you can start in a simple measures by doing small bonuses and seeing how that responds, bring a lease. Complex patients. I would escalate early. I can't pass that. And we had a question with the gods describing prescribing and fluids and when he would go for it. I work six hourly bags. I know there's not much difference between the two. I don't know if you found any difference in your experience. I think what I found helpful sometimes it's to calculate. How much do you give him? Our So, for example, if you think, Oh, if you're giving someone to 50 well, listen, 500 a bonus. It's a young person, so really over an hour by Tell me, get set up and contribute and you've given me to re run out. So if you think about a four already bag, that's only 2 15 or per hour, so you're going into smaller bonuses. So if you try and break it down, so what is your post post. Nice. So is you. So you did not say six bags. 166 months for Albert, A whole bag to be 100 25 million. Our they're actually, There's not a whole lot of difference between that again. You don't need to want to stick to your resuscitation. You don't need to never touch it again. You can speed up, slow it down, work up the urine output is I tend to just go tend to get the kind of 68 hours in younger patients, depending how dry. Now there's no right answer to that. I wouldn't I would slow it down much more. In the elderly who are stable, you need to meet with fluids. But again, if you think about six a Ali or 8 to 10 hours, there's not a whole lot of difference over and hour. Which is why we reassess in means that you know, he resist up to three hours know a whole lot of difference is gonna have gone three. By that point, we have time to just I find it more reassuring if you calculated per hour just because then if you think about kind of coax 230 mill, 600 bucks, 166 meals. If you think of actually help just going in, it does make me feel a bit better. Um, technically, it's 12 14 hours. Bob's etcetera on the but again, you know there's no real difference. It's all about the reassessment and how your patient is responding. You made your a only bag you sleep before, but you may do a six hourly bag and slow it down to 10 on bag again. It's finding a starting point, being safe in your practice and reassess in it. You go definitely, and another question. My heart. It waas with regards how often you would need to take bloods certain person who's receiving maintenance fluids. So I think that is more to do with why they require maintenance fluids the more you give them. So if you have someone who is no by mouth in elective surgery, it's probably gonna be your routine bloods that you gonna do preoperatively even someone who needs maintenance periods because, uh, they, uh, aspiration risk, and they just come in on you have a decision about you, too? Then you're also thinking about what's their renal function? Was the potassium doing? What's their nutritional status from the potassium that the calcium magnesium except on? So I think we'll be more frequently equally if you've got someone who came in with an infection that accepting were given some maintenance fluid to try and, you know, support the mosque getting through there on infection, perhaps because they're slight in the losing fluids. That way you're, uh, blood is more in response to what they do with their infection rather than most likely it's doing, I would say the cabinets, that is, if someone's one a k I, or if they have a background of CKD and you worry about calcium again, it's almost got a potassium of Morton five as a baseline probably wouldn't be adding much. Potassium in particularly got a background of CKD. Um, so I think my answer would be depends on what the cause of the maintenance medicines foods is. It is that you're particularly worried about in terms of most like it's been the electrolytes that your you know a place in, they note someone. Here's a low sodium, ah, high sodium, a low potassium high potassium. Do it least want to twice a day, particularly high. That's the most so patient and low, so no high sodium. I get it probably over protective. Often I do twice a day, sometimes if I'm worried about overcorrected. But that's more of a lecture on sorts and electrolyte replacements than general fluids, Uh, so that there's no correct answer to it. Be guided by a team. And what would your consultants practices that? It's more relation of why you're getting fluids with filling himself? Did you, Brianna? Yes. So it's just a few more quick questions with God. Do you calculate replacement fluids in dehydration on the diligence? So I guess if someone is clinically dehydrated, first you do any resuscitation. So do you think are given? Let's give him some bonuses and see how they respond to it. Um, I would tend Teo. I think if they are, they're dry. Then you're thinking about what the losses are. So this is not The formula we've got is the patients who haven't got extra losses. So why they dehydrated if it's because they're not eating or drinking, and we have a place that fluid sufficiently, that's one reason Are they dehydrated? Because they have profuse diarrhea and vomit in I'm not There for It's going to be beyond what the calculation is. So I don't think the formula for the maintenance fluid it's helped to think because person was well, in 24 hour period, what would they need? So it's a two to a half liters. Okay, this person's now got profuse diarrhea, vomiting, and I know that they're losing 500 military fluid you're probably gonna be aiming for want to have 3, 3.5 liters. But again, I wouldn't never prescribed 2.5 liters and walk away. I'd probably get faster back. So say you've got young patient diary in Vomitin can keep dehydrated, but I'm stable ish. I'd give us 46 allergy bag. I would reassess. What's that lives going to make sure they don't burn. This is a lost A limit and then see where you are at the end of the bag house. When you get an antiemetics to be worked up because of the diarrhea, have you managed to slow things down and do I need to with another fast by what's a urine output? Actually, their parts and loads of fluid to the possible those of urine that's scale back and maybe given a only bag 10. You know, a movie from that again, there's no strict measurements. I think you calculate what your maintenance of what your goals are. And then what about your losses are in for is you can kind of make balance, but again, after each bag, you just need to keep reassessing because you when you're prescribing and trying to predict your post it response. But then you need to make sure that that is much in their actual response. You agree? Yes, definitely. I would be very nervous. The skies opened three leaders and then walk you with degree out. There's a temptation of the weekends, a thing for to just try and help the ankle team out and just describe your fluids. Um, I would do that cautiously. If you're going to do that, I would put him on the handover. For someone to check that that is appropriate. Um, particularly if it's a you know, it could be 48 72 hours between you seeing a patient next. I would be very cautious about scribing multiple bags of fluid without reassessment yourself or someone else. We just have a quick question on. But what is the usual fluid to given sepsis? So if someone has septic it, then you're thinking so. Sepsis is an abnormal response to an infection, so you're going down the steps of six protocol so they'll remember them. A. So you didn't fluids. It's given fluids given oxygen, uh, given antibiotics and you're taken blood lactate on urine. Think so in someone who is septic. By definition, they are on, well, another. They are decompensated by definition, so I would go down the resuscitation stage. So if they are hypertensive tachycardia that brought, I would go down the fluid bonuses. Remember, someone can have an infection and not accept it. Eso again was if your balance on eating, drinking except if I realistically, if someone who's hypertensive logic you given them the bolus is is firstly required and seconds ago whole whole or problems because they're intravascularly depleted, you can't ask for it, and then would it be possible just to go back to the worked example that we had? And it's just a few questions wondering if would be given the patient a little bit too much potassium, uh, interest, I think if you go to the example the even for $18 per day. Um, so if we go to the No, I think I mean, that's 18 animals over, what, 16, 72 hours? I think I think also, the question was a bit about. If you want to get the apartment, you you load them with potassium. I actually answered it in the comments, but we wanted to double check with you that if you get people, if you give Hartmann's as a maintenance fluid, you can't add any potassium to camp. No, it might not be giving, you know? So I mean, if you look here, the on Hartmann's, it's it's five minimal. Police don't want to. You're not going to meet in their potassium requirements. I used to love given help. Plasmalyte. Um, I still do. You go down that route if I've got someone who is eating and drinking, and it's just to give them a bit of a boost on top of things. But if I call someone who's nearby mouth, he is no, you know, there's no they're not get any sorts, and I don't think the Hartmann's is mapping. Imagine a requirements it will match them for the sodium potassium. Be fine, Um, but this hard. Although there is potassium in it, does know. Sure. And there's also some lactate in there is. What is it that Yeah, I think heart wise, there is the date. I think it's just kind of is that relevant in the context of sepsis? And with that, with the question that we just heard about fluids and sepsis way not that way. Okay, Do you think so? I think it's I would say, if you think about what's in a liter of fluid, I would say it would be negligible. I don't know took my head, but I've certainly wouldn't not give if I dissected patient in front of a Only had Hartmann's gives Hartmann's I'm again. The the counter argument is, if you have someone who is dehydration from to be, would you give them a couple of 70? We'll just a jug probably know diet. Rely isn't just don't want to. It's got some potassium stuff in it. So the counter argument is, you know, with you giving someone papers amounts of a normal saline, you can push him to metabolic acidosis because your shift in there and I and up. So the counter argument is also true of you don't want to keep throwing loads of surgeon cord at them and sometimes give him some dextrose is an alternative. I'm probably a hardness is gonna have the same effect to still call a significant of staging and Croydon that, um, sometimes particular for, um, patients who have been quite low fluids too particular that I can end it kind backgrounds, the DKA hatred chair. Sometimes with the insulin in the background. You constriction. Want to, Dexter. It's just because you're avoiding the yeah, nine shifts with the sodium chloride. But again, don't get to book down in that. You you'll never I can tell. I can tell you two anesthetics you spoke earlier. Loose? Never much, actually. About a six year. So actually, on the very interesting physiology that, uh, yeah. So, yeah. And, uh, if there are no more questions coming through on the chat Yeah, anything to add to, um please. He said, I don't think so. I think just that did a really good job. Covered everything really a little lot. I agree. I learned so much as well. Thank you so much. Yeah. So everyone who's still watching the vaccine is still got quite a few people watching. If you do have any more questions than I do, feel free. Just comment on Facebook. I'm Lizzy or one of the team will get back to you on with with some answers. But thank you so much for watching. I think we had about 400 people. Um, at the peak, there's 404 101 people prescribing fluids. Very well, Thank you so much, Louisiana. You both did a really good job on everybody else. We've got an A k i webinar coming up next week. I know some of you were asking about make a I and obviously it ties in very nicely with this topic. Oh, you're doing that one too. If you want to see more of lazy next week, then, uh, a friend of mine on. Do you want to come? Come by for the achy I talk on. So just go to our Facebook page and take events. Just a reminder this is available to you again on so our our previous elections. So if you want to teach electrolyte abnormalities and things like that. Do you have a look on day? Take a look at the associates. Starts good as well. I've put the link in the description. So that's all from everybody. Should we call it a day? All right. Thanks, everyone. See you next week.