Acid-Base Balance and Electrolyte Management

Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy. This review contains 12 figures, 7 tables, and 38 references Keywords: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

EP.TU.364Intravenous fluid prescribing – common pitfalls and suggestions for improvement

Aim Intravenous fluids are no doubt most prescribed treatments in surgical practice. It is also an area where junior doctors’ performance is commonly found deficient. There appeared to be a gap in general knowledge of fluid and electrolyte management. Our audit aims to assess the competency of surgical juniors in fluid prescribing as compared to recommendations set out by GIFTASUP 2011. FY1s have also been asked to complete a survey on fluid and electrolyte management. Method We included all adult surgical inpatients (28) admitted over one week to our DGH who were started on IV fluids for maintenance only. We retrospectively audited their prescription charts and medical notes. FY1's in the department have been also asked to fill out a short survey testing their knowledge on fluid and electrolyte requirements. Following this, we held a tutorial on fluid management of surgical inpatients for FY1's. We also made fluid management algorithm available in SAU for reference. Results Data was tabulated and outcomes compared with CG174 guidance. Cycle 1 showed poor compliance with only about 50% patients being prescribed appropriate intravenous fluid volumes. FY1’s completing the survey scored 54% on average. Often previous fluid prescription was copied. Cycle 2 showed some improvement in appropriate volumes and choice of maintenance fluids prescribed, and better survey score of 64%. There was also improvement on the understanding of daily fluid and electrolyte requirement from the FY1 cohort. Conclusions We suggest implementing varied educational approach to improve on fluid prescribing and patient outcomes in hospital.

Altered Mental Status

Altered mental status in a child is a common presenting complaint. One of the more common causes of altered mental status is diabetic ketoacidosis. The change in mental status from this metabolic disorder is thought to be secondary to the cerebral fluid shifts from the underlying hyperglycemia and metabolic acidosis. The only way to correct diabetic ketoacidosis and its associated symptoms like altered mental status is with intravenous fluids, insulin, and electrolyte management. This case describes the care of a child presenting with diabetic ketoacidosis and explains the testing, diagnosis, and key management points focused on subsequent fluid and electrolyte management.

Acid-Base Balance and Electrolyte Management

Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy. This review contains 12 figures, 2 tables, and 34 references. Key words: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology