Tue28September1204PM 10

A 63-year-old man is admitted to the critical care unit following a laparotomy for faecal peritonitis.

He is sedated and ventilated. His haemodynamic parameters are as follows, pulse 120 beats per minute, blood pressure 80/40 mmHg and CVP 4 mmHg. His urine output is less than 10 ml/hour and temperature 38°C. Haemofiltration is being considered.

The following biochemistry haematology results are obtained:

Na 155 mmol/L (135-145)

K 5.8 mmol/L (3.5-5.1)

Cl 116 mmol/L (99-101)

Bic 8 mmo/L (22-29)

Urea 10.4 mmol/L (1.7-8.3)

Creat 101 µmol/L (44-80)

pH 7.21 (7.35-7.45)

PaCO2 31 mmHg (38-42)

PaO2 98 mmHg (75-100)

BE -12 (-3 to +3)

Bicarbonate 17 mEq/L (22-28)

SpO2 98% -

Lactate 2.1 mmol/L (0.3-1.3)

Glucose 15.4 mmol/L (3.5-5.5)

Hb 98 g/L (115-145)

WBC 17.3 ×109/L (4-11)

The patient requires fluid resuscitation whilst the haemofiltration system is being assembled.

Which one of the following options is the most appropriate fluid for resuscitation?

(Please select 1 option)

Hetastarch

0.9% N saline

Hartmann's Correct

0.45% dextrose/saline

Blood

Explanation

Both Hartmann's and 0.9% N saline are crystalloids that are first choice for fluid resuscitation.

0.9% N saline given in large volumes is associated with a hyperchloraemic acidosis. The patient is already hypernatraemic, hyperchloraemic and acidodic and therefore it would not be first choice fluid.

Hartmann's solution, whilst containing a small amount of K+ (5 mmol/L) and lactate (27 mmol/L), on balance would remain the fluid of choice despite the patient's high potassium and slightly raised lactate.

One could argue the case for 0.45% dextrose/saline as it contains less Na+ and Cl- (70 mmol/L) but remains a fluid for maintenance therapy and not resuscitation. Hyperglycaemia may also preclude its administration.

There is no indication for the administration of allogeneic blood as the haemoglobin concentration is satisfactory. The starches are associated with the development of acute kidney injury and are therefore contraindicated.

Answer Statistics

1

1%

2

13%

3

75%

4

10%

5

4%

Times answered: 300