Fluid Balance

1. Why – Outreach - Education – Critical Care Without Walls Critical Illness starts in general ward areas and if correctly managed admission to ICU can be avoided. Introduction to Speakers - all work in practice within Critical Care or Critical Care OutreachWhy – Outreach - Education – Critical Care Without Walls Critical Illness starts in general ward areas and if correctly managed admission to ICU can be avoided. Introduction to Speakers - all work in practice within Critical Care or Critical Care Outreach

2. By the end of the session you should be able to: A. Discuss the importance of fluid balance B. Highlight causes & symptoms of fluid loss/overload C. List key factors important to carrying out fluid balance D. Explain insensible loss and its role in fluid balance E. Identify common problems with fluid balance F. Discuss completion & review of fluid balance - Discuss key points in management

3. Fluid balance is an essential tool in determining hydration If there are problems with fluid balance then it may indicate warning signs that the patient is actually or potentially acutely ill If fluid balance is not done correctly then, such signs can be missed resulting in: Late referral & missed opportunities Unexpected deterioration Prolonged stay In some cases - Death

4. The acutely ill competencies put forward by NICE (2008) cite fluid balance as a key requirement for staff to demonstrate skill All health care staff have to assume the relevant responsibility to ensure that they are competent and that they are meeting national and local guidelines regarding this

5. This is an important part of ABCDE assessment. Without this you are missing key information. Do you give fluids or with-hold? Inaccurate fluid balance can mean problems can be overlooked for a very long time resulting in disastrous scenarios. Therefore, some problems can be prevented by careful assessment of fluid balance If problems do occur they can be rectified by simple interventions and careful fluid balance

6. Some specific examples where fluid balance is important include:

7. Secretions Your patient has an increased risk of consolidating chest secretions and getting a chest infection if they are dry Such patients do not need less - they need more! (providing there is no cardiac history -where a more careful assessment needs to be done)

10. Weight loss Weakness Fatigue Confusion Dry/flaking skin Dry/coated tongue Dry oral membranes Thirst Low CVP Cool peripheries Pale skin Higher resp. rate Lower Oxygen sats Tachycardia Lower blood pressure Reduced urine output Negative fluid balance Dark urine output Causes include: GI tract Diarrhoea, vomiting, nasogastric Polyuria Diabetes insipidus, head injury Sepsis/fever Excessive ‘insensible’ loss Respiratory loss Higher respiratory rate Diuretics Drugs to promote urination Surgical: Bleeding Fluid loss during the operation Evaporation from the peritoneum Inhalation of dry aneasethetic gasses Uncorrected pre-operative loss Third space loss due to surgical site Third Space Loss Protein normally functions to support the cell membrane The cell membrane promotes good fluid balance between the cell and interstitial spaces around the cell If the membrane does not function well, (e.g. if the patient has low protein) fluids may prefer interstitial space rather than intra-vascular space Patient may seem swollen/odematous and overloaded but in fact their circulating volume is poor and they need fluids Causes include: GI tract Diarrhoea, vomiting, nasogastric Polyuria Diabetes insipidus, head injury Sepsis/fever Excessive ‘insensible’ loss Respiratory loss Higher respiratory rate Diuretics Drugs to promote urination Surgical: Bleeding Fluid loss during the operation Evaporation from the peritoneum Inhalation of dry aneasethetic gasses Uncorrected pre-operative loss Third space loss due to surgical site Third Space Loss Protein normally functions to support the cell membrane The cell membrane promotes good fluid balance between the cell and interstitial spaces around the cell If the membrane does not function well, (e.g. if the patient has low protein) fluids may prefer interstitial space rather than intra-vascular space Patient may seem swollen/odematous and overloaded but in fact their circulating volume is poor and they need fluids

11. Bloods: Urea Increased urea is usually an early sign of dehydration Createnine An increase in createnine occurs as a prelude to Pre-Renal Failure - which may result in increased sodium and potassium that can (unchecked) be lethal

12. Peripheral oedema Disorientation Confusion Decreased responsiveness Breathlessness Frothy/watery sputum Tachycardia Low O2 sats +ve fluid balance Raised CVP Causes include: Over administration of IV fluids Renal failure (cannot excrete) Heart failure (cannot transport) High dietary sodium intake) - causes fluid retention Cirrhosis of the liver Causes include: Over administration of IV fluids Renal failure (cannot excrete) Heart failure (cannot transport) High dietary sodium intake) - causes fluid retention Cirrhosis of the liver

13. The kidneys need a high percentage of the blood pressure to filter the urine In the fluid depleted patient - there is little urine to filter and the kidneys being to fail If blood pressure is also low due to fluid depletion, the kidneys have less pressure to filter what little urine there is This combination can accelerate renal failure

14. Timely and appropriate rational for starting and stopping One set method for recording detailed and accurate input/output Insensible loss (part of output) Appropriate application/use of the fluid balance monitoring

15. Actual or potential dehydration Nil by mouth Diarrhoea Excessive vomiting Excessive surgical loss Excessive wound exudate

16. Commencing IV fluid Actual or potential acute illness Risk of level 2 or 3 care Sepsis EWS triggered/patient unstable

17. Routine post op management Fluid restriction Unstable cardiac failure Liver failure Acute renal failure Doubt over fluid status

18. Reason for commencement resolved End of life care Stopping fluid balance is the decision of a senior clinician or sister/charge nurse only Patients must be assessed thoroughly before making such a decision

19. The process whereby fluids are lost through sweating, breathing and so on This can add up to a surprising amount Take the example of a 100kg man…

20. 100kg man Divide the figure in half This is what he is losing PER HOUR Multiply this by 24 and you get: 1200ml lost Just from normal sweating & breathing!

21. It is unrealistic to expect staff to work out this calculation for every patient although it is important for severely under or overweight patients Some fluid balance charts will have an averaged amount stencilled into the output Insensible loss is added to the patients output So, if the patient’s output is 1500ml and insensible loss is 600ml – overall output is 2100ml

22. We all know there are practical issues of difficulty with fluid balance There are serious problems with maintaining fluid balance charts in practice Given the importance of fluid balance does that mean we just give up? Or we do tackle the problems?

23. ‘He goes to the toilet & doesn’t tell me’

24. ‘He goes to the toilet & doesn’t tell me’ Give the patient something to take & put his name on it for starters?

25. ‘He goes to the toilet & doesn’t tell me’ ‘The relatives keep giving her drinks so I don’t have a clue what is going in’

26. ‘The relatives keep giving her drinks so I don’t have a clue what is going in’ Give the relatives a sheet with the amounts on. Get them to document the amounts on fluid balance. This works for some patients too

28. ‘He goes to the toilet & doesn’t tell me’ ‘The relatives keep giving her drinks so I don’t have a clue what is going in’ ‘How do I know what is in a pad if its wet?’

29. ‘How do I know what is in a pad if its wet?’ We recommend that if the patient is incontinent of urine or diarrhoea you consider weighing as a means of getting the amount - especially in severely fluid deprived patients or…

30. Try this technique: Pick two incontinence pads Pour in 200mls in one Pour in 600mls in the other Get someone to estimate It sounds ridiculous, but staff get expert really quickly

32. ‘He goes to the toilet & doesn’t tell me’ ‘The relatives keep giving her drinks so I don’t have a clue what is going in’ ‘How do I know what is in a pad if its wet?’ ‘Well, if he’s been incontinent all over the bed I can only put that he’s passed urine’

33. ‘Well, if he’s been incontinent all over the bed I can only put that he’s passed urine’ If weighing the sheet is an impractical proposition, (and most often it is), try estimating. Is this so impossible?

34. Wet on the bed?

35. Wet on the bed?

36. These tell you NOTHING: “Wet +++” “Pad changed” ‘Pu’d’ So how can you do an accurate ABCDE?

37. ‘He goes to the toilet & doesn’t tell me’ ‘The relatives keep giving her drinks so I don’t have a clue what is going in’ ‘How do I know what is in a pad if its wet?’ ‘Well, if he’s been incontinent all over the bed I can only put that he’s passed urine’ ‘The pump keeps alarming so I don’t know if the hourly input is accurate’

38. ‘The pump keeps alarming so I don’t know if the hourly input is accurate’ The pump tells you how much has gone in

39. ‘We just don’t have time’

43. In a complaint about patient care, poor recording of fluid balance was cited as a contributing factor This was upheld by the Health Service Ombudsman The nurse was held accountable by NMC She was struck of the register

44. The nurse completing the chart and working out the balance has to sign for completion at the end of the 24 hour period – this is usually night staff If night staff have not done this it falls to the next shift

46. Routinely Emergencies EWS Triggers Concern

47. Routinely review yesterdays balance at the start of the shift Review new fluid balance during the middle of the shift or as often as required Review immediately if the patient develops an emergency, EWS trigger or if you have concerns

48. Immediately refer to the doctor if: Concern over fluid balance Poor oral intake Poor urine output (less than 30mls for three hours in a row). If this occurs – also call Critical Care Outreach if available Greater than 150ml hour for three hours in a row and no diuretics have been given No IV present and patient is nil orally

49. Routinely review yesterdays balance during routine review and/or ward round Review immediately if the patient develops an emergency, EWS trigger or if you have concerns

50. On shift handover nursing staff must ensure that they clearly indicate which patients are on fluid balance and which present concern When patients are transferred between wards and departments – verbal and written documentation must include fluid balance and any concerns F1 doctors must alert an F2 doctor immediately if there are concerns about fluid balance which cannot be resolved

51. If fluid balance omissions lead to deterioration of the patient, this requires an incident report and consideration as a serious untoward incident Areas should arrange regular audits of fluid balance

52. Thoroughly evaluate priorities in your area If increasing performance on fluid balance causes a decreased performance on other aspects of care, then report it appropriately Set up meetings and awareness sessions Identify ward champions to re-train staff using this tool and the guideline Accountability is with individuals and personal responsibility framework should be considered for persistent non compliance

53. Any Questions? Tees Valley and South Durham Critical Care Network

54. - Identify ‘at risk’ patients - Monitor fluid balance - Check previous fluid balance status - Increase observations if fluid balance is dire - Inform doctor/Critical Care Outreach if problems occur - Investigations (bloods) if fluid balance is dire - Maintain adequate oxygen saturation if fluid balance is dire - Maintain adequate circulation to keep the kidneys perfused - Evaluate/review the effectiveness of interventions

55. By the end of the session you should be able to: A. Discuss the importance of fluid balance B. Highlight causes & symptoms of fluid loss/overload C. List key factors important to carrying out fluid balance D. Explain insensible loss and its role in fluid balance E. Identify common problems with fluid balance F. Discuss completion & review of fluid balance - Discuss key points in management