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Module 4 : Case Scenarios

 

 

Case 3 : Fluid overload

 

While on-call, you are bleeped to see an 82 year old man with known ischaemic heart disease, who was admitted a few hours ago with an episode of chest pain. The nurses looking after him tell you that he has been eating and drinking normally while in hospital, but they are concerned that he has dropped his blood pressure and become increasingly confused in the past 30 minutes.

 

On assessment you find him to be quite confused, with a blood pressure of 83/72 (baseline 115/90). He does not have a catheter in situ and his bed pad is dry.

 

 

  Test Yourself !  
   
  How will you manage this situation?

How did you do?
 

Increasing confusion and a fall in blood pressure is potentially serious. You should recognise that this patient needs attention. In any such situation you should manage the patient following an ABC algorithm, involving senior help early if you feel you are out of your depth! In this case the patient's airway and breathing are normal, but on examination he looks dry...

 
 

 

 

 

You decide that the patient may benefit from a fluid challenge, to see if his blood pressure picks up with fluid repletion.

 

 

  Test Yourself !  
   
  Which of the following would you give him:
That's correct, well done!
 

250-500ml Normal Saline STAT or 250-500ml Volplex STAT - Either of these would make for a reasonable fluid challenge. The idea is to watch for a response while the fluid remains intravascular, and so it does not matter greatly weather colloid or crystalloid is used (although glucose is best avoided as it redistributes very quickly). Fluid challenge should be given as a stat dose rather than a slow infusion. NB : 'STAT' comes from the Latin 'statim', meaning 'immediately' .

 

1000ml Normal Saline over 2hrs and 1000ml Volplex over 2hrs - A fluid challenge is a quick bolus of a small amount of fluid to encourage a physiological response. This is too much fluid, given over too long. 500-1000ml Normal Saline over 1hr and 500-1000ml Volplex over 1hr in an unknown patient is likely to be too much fluid still. Only small amounts of fluid should be needed to lift the blood pressure. Using large amounts can lead to problems…

 

Sorry, that's incorrect!
 

250-500ml Normal Saline STAT or 250-500ml Volplex STAT - Either of these would make for a reasonable fluid challenge. The idea is to watch for a response while the fluid remains intravascular, and so it does not matter greatly weather colloid or crystalloid is used (although glucose is best avoided as it redistributes very quickly). Fluid challenge should be given as a stat dose rather than a slow infusion. NB : 'STAT' comes from the Latin 'statim', meaning 'immediately' .

 

1000ml Normal Saline over 2hrs and 1000ml Volplex over 2hrs - A fluid challenge is a quick bolus of a small amount of fluid to encourage a physiological response. This is too much fluid, given over too long. 500-1000ml Normal Saline over 1hr or 500-1000ml Volplex over 1hr in an unknown patient is likely to be too much fluid still. Only small amounts of fluid should be needed to lift the blood pressure. Using large amounts can lead to problems…

 

 

 

 

Before you can prescribe the fluids, your well-meaning SHO (who unfortunately had not read this tutorial) has given the patient a stat dose of 2L Volplex. The patient quickly becomes more unwell.

 

On examination he is now short of breath, with a respiratory rate of 35 and crackles are heard bi-basally. The oxygen saturation is 90 on 2L oxygen via nasal specs (baseline 98% on air) and his lips are slightly blue.

 

 

  Test Yourself !  
   
  What has happened to the patient? How would you go about managing this acute situation? Write down what you would do, and what order you would do it in. Then click the button to reveal the answer.

How did you do?
 

The patient has known ischaemic heart disease which may predispose to heart failure. Large intravenous boluses are dangerous in these patients, as they often lead to fluid overload and pulmonary oedema, as has happened here. Acute heart failure with pulmonary oedema is an emergency. These patients will be very unwell. The patient should again be managed by an ABC algorithm. Turn the oxygen up to 15L, and switch to a non-rebreathing mask. Stop the fluids! (don't forget to do this!) Call for help. The patient will need to be cared for in a monitored bed or transferred to HDU/ITU.

 
 

 

 

 

You bleep your registrar, who quickly arrives to help stabilise the patient. The registrar asks you to prescribe the ‘acute heart failure drugs’ on the chart, and asks you to keep a close eye on the patient's cardiac function.

 

 

  Test Yourself !  
   
  Make a list of 4 drugs you might need to prescribe for this patient, and the ways in which you can further monitor the patient's cardiac function on the ward.

How did you do?
 

The exact drugs that are used to treat heart failure may vary from case to case. However, most patients in acute heart failure will require:

 

Oxygen – remember this needs to be prescribed on the drug chart!

 

Diamorphine – not all patients will need this, but it acts as a pulmonary venodilator and relieves some of the backpressure from the heart.

 

Nitrates – are also vasodilators, although they work more by reducing the arterial tone so that the heart has to work less hard to pump blood forward.

 

Furosemide – This is a powerful and fast-acting loop diuretic which helps to remove the excess fluid by diuresis.

 

Although HDU/ITU is the ideal place to monitor cardiac function, some simple monitoring can be set up on the ward : Continuous or regular ECG monitoring. Regular blood pressure and heart rate monitoring. Catheterise the patient. Urine output is a good indicator of cardiac output. The patient should have a fluid balance chart started, if they do not already have one. Frequent weighing – Patients' weights should not fluctuate much day-to-day. If a patient gains a lot of weight over the course of the day or night, this may suggest that they are retaining fluid.

 
 

 

 

 

After a few hours, you manage to stabilise the patient and the registrar heads back to theatre. The nursing staff are very busy on a drug round, and sister asks if you could help out by replacing a cannula that has tissued and starting some maintenance fluids for a different patient. You haven't set up a drip for a while, so you nip to the doctors office to remind yourself of how to do it, by watching Module 5 of this tutorial.

 

 

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