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Quiz: Contemporary Fluid Strategies in the ICU

Amy Butler, DVM, MS, DACVECC, Critical Consults, Clarks Summit, Pennsylvania

Emergency Medicine & Critical Care

|June 2017|Peer Reviewed|Web-Exclusive

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Quiz: Contemporary Fluid Strategies in the ICU
7  Questions
Multiple Choice Questions
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Quiz: Contemporary Fluid Strategies in the ICU

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A 1-year-old intact male Labrador retriever weighing 81.5 lb (37 kg) is presented about 30 minutes after being hit by a car. The owners witnessed the accident and reported that the car had struck their dog on his left side, after which he was thrown. Initially he was able to stand and run on three limbs, but then he collapsed. 

On initial presentation, the dog is laterally recumbent and depressed but responsive. His body temperature is 99.9°F (37.2°C) (normal, 101.1 + 1.2°F [38.4 +/- 0.7°C]),4 heart rate 196 bpm (normal, 87 ± 22 bpm),5 and respiratory rate 80 breaths/min (normal, 18-34 breaths/min),5 with shallow, rapid respirations. Lung sounds are decreased bilaterally and femoral pulses are weak, but his pupils are of normal size and reactive. 

Abdominal palpation elicits a painful response; and marked crepitus, pain, swelling and bruising are present over the left femur. Deep pain is intact in the left pelvic limb, but withdrawal is decreased. Superficial abrasions are present over the left thigh, inguinal region, and top of the head. Doppler blood pressure is decreased at 70 mm Hg (normal, 80-120 mm Hg). An IV catheter is placed, and nurses prepare to administer fluids. 

Which of the following choices regarding fluid therapy is most correct?

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Quiz: Contemporary Fluid Strategies in the ICU
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Which of the following describes resuscitation injury?

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The patient’s intravascular volume status, hydration, and fluid balance all must be taken into consideration when discussing fluid therapy.

Which of the following statements best summarizes one or more of these terms?

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A 6-year-old female intact yellow Labrador retriever is presented to a local emergency hospital with a 4-day history of vomiting, anorexia, polyuria, and polydipsia. Initial physical examination reveals depressed mentation, bounding femoral pulses, tachycardia with a heart rate of 186 bpm (normal, 87 ± 22 bpm),5 painful abdomen on palpation, and small amount of purulent vulvar discharge. The dog weighs 55.1 lb (25 kg), and is estimated to be 8% dehydrated. 

Abdominal ultrasonography shows a fluid-distended uterus and peritoneal effusion. Emergency surgery confirms pyometra. A small perforation in a necrotic area of the uterus is noted, with scant purulent abdominal effusion in that region. Ovariohysterectomy is performed and an indwelling Jackson-Pratt drain placed. 

The patient is transferred back to the attending veterinarian’s hospital the following morning. Over the course of initial and intraoperative fluid resuscitation, the patient had received 3L of lactated Ringer’s solution (LRS), which has been continued at a rate of 100 mL/hr since surgery. On physical examination the following morning, the patient’s body temperature is 102.9°F (39.4°C) (normal, 101.1 + 1.2°F [38.4 +/- 0.7°C]),4 heart rate is 172 bpm (normal, 87 ± 22 bpm),5 respiratory rate is 50 breaths/min (normal, 18-34 breaths/min),5 and mean blood pressure is 50 mm Hg (oscillimetric; normal, 103 ± 15 mm Hg).4 The dog is recumbent and depressed, with red mucous membranes and skin. Capillary refill time (CRT) is <1 second. Femoral pulses are weak. The abdomen is soft on gentle palpation. The Jackson-Pratt drain has been producing about 200 mL q4h. Mild pitting edema of all four limbs and the face is noted. The dog has not urinated since admission, and her urinary bladder is small. Her current body weight is 62.4 lb (28.3 kg). 

What is this patient’s fluid compartment status?

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Regarding the dog described in question 4, which of the following would be the most appropriate tool to monitor overall (ie, all fluid compartments) volume status?

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A 3-year-old castrated domestic short-haired cat is presented with a 24-hour history of straining to urinate but failing to produce urine. Physical examination reveals a depressed but responsive cat with a large, firm, painful, inexpressible urinary bladder. The cat’s body temperature is 99.5°F (37.5°C) (normal 101.5 ± 1°F [38.6 +/- 0.6°C]),5 heart rate is 140 bpm (normal, 182 ± 20 bpm),21 and respiratory rate is 60 breaths/min (normal, 16-40 breaths/min).5 Presenting body weight is 9.9 lb (4.5 kg); the cat is an estimated 7% dehydrated.  

Blood work shows marked azotemia, with BUN of 210 mg/dL (75 mmol/L) (normal, 13-30 mg/dL [4.6-10.7 mmol/L])22 and serum creatinine concentration of 6.8 mg/dL (601 μmol/L) (normal, 0.9-2.1 mg/dL [80-186 μmol/L]).22 Potassium is elevated at 8.3 mEq/L (8.3 mmol/L) (normal, 3.2-5.5 mEq/L [3.2-5.5 mmol/L]).22 Sodium is within normal range. An ECG reveals absent P waves and bradycardia.

The heart rate returned to normal after slow administration of a bolus of 45 mL Normosol-R and calcium gluconate at 50 mg/kg IV. Cystocentesis is performed, and an indwelling urinary catheter with a closed collection system is placed. Recovery from the procedure is uneventful. 

The veterinarian plans to rehydrate the patient over a 12-hour period. 

Using a daily maintenance rate of 60 mL/kg, what should be the anticipated weight gain, preferred initial fluid selection, and starting fluid rate?

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As established in question 6, the cat was started on Normosol-R at an initial total fluid rate of 38 mL/hr. Four hours later, the patient is awake but remains depressed. His body temperature is 100.3°F (37.9°C) (normal 101.5 ± 1°F [38.6 +/- 0.6°C]),5 heart rate is 186 bpm (normal, 182 ± 20 bpm),21 and respiratory rate is 30 breaths/min (normal, 16-40 breaths/min).5 Doppler blood pressure is 100 mm Hg (normal, 134 ± 16 mm Hg).21

During the past 4 hours, the cat has produced 120 mL of dark red urine (measured via collection bag). His current body weight is 9.7 lb (4.4 kg, weight of 9.9 lb [4.5 kg] at presentation).

Should the fluid rate be adjusted?

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Quiz: Contemporary Fluid Strategies in the ICU

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