Mr Philip Watson, a 68 year old man, arrives in hospital via ambulance after the warden at his warden-controlled flat finds him unwell. He has hypertension and diabetes, and performs intermittent self catheterisation for prostatic hypertrophy. He lives alone and is usually independent. He is a retired paper mill foreman, a non-smoker and does not drink alcohol. He has no allergies. His medications include atenolol, perindopril, metformin, gliclazide, simvastation, aspirin and quinine sulphate.
His observations are:
- Temperature: 38.4 C, HR 105bpm, RR 22, GCS 14/15, BP 90/60mmHg, BM 7.1mmol/L, Sats 91% on air.
- A: airway clear
- B: tachypneoic, air entry bilaterally, no crepitations or wheeze
- C: thready pulse, cool peripherally, prolonged capillary refill time of 3 seconds, tachycardic, but heart sounds normal
- D: confused, GCS E3 V4 M6, pupils equal and reactive, no neck stiffness
- E: abdomen soft, no masses, suprapubic tenderness, but no guarding or rebound, bowel sounds present
His VBG shows:
- pH 7.34, pO2 5.4kPa, pCO2 5.6kPa, HCO3 24mEq/L, Lactate 3.7
Other investigations reveal:
- CXR: no focal consolidation
- Urine dip: leucocytes +++ nitrites ++ blood –
- Bloods: Haemoglobin 11.5g/dL, WCC 22, Potassium 4.7mmol/L Sodium 138mmol/L, Urea 14mmol/L, Creatinine 180mmol/L, Platelets 150×10^9, CRP 280
Question: What is the most appropriate fluid regimen for this patient?
Question setter: Dr Laura-Jane Smith, Medical Registrar and Clinical Teaching Fellow at UCL medical school
Expert: Prof Mervyn Singer, Professor of Intensive Care Medicine, UCL