Case 1: fluid resuscitation

Clinical case:

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.

Examination shows:

  • 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? 

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates.

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

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