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SEPTIC SHOCK

By: Amy Barboza

Melissa Sanchez

Justin Therrien

Stefanie Lavalle-Fontaine

Alysse Connors

35.8 mL/hr

We will not perform live saving intervention we will

provide comfort care for your mother.

Mrs. B.s daughter is aware of her mother’s deteriorating condition and requests a team meeting.

Mrs. B. has an advance directive and designated her daughter as Power of Attorney. She asks what will change in her mother’s care if the status is changed to Comfort Measures/DNR. The medical resident looks to you to answer the question.

What is your response?

Signs and symptoms;

Lungs show dysfunction of normal exchange of gas,

normally in arterial hypoxemia

Kidneys show oliguria despite fluid resuscitation as evidenced by rising creatinine and serum electrolyte levels.

Cardiac - impaired delivery of O2 to other organs

Hepatic – excess bilirubin in blood as lack of bile flowing from the liver

Hematologic- thrombocytopenia

Neuro - Altered LOC, Reduction in Glasgow

Question

What are the other clinical manifestations of this syndrome?

Prediagnosis of sepsis

Change in mental status

Increase in temperature, pulse,

respirations and WBC.

Question

Over the next week, Ms. B’s condition continues to deteriorate.

She is determined to be experiencing Multiple Organ Dysfunction Syndrome (MODS).

What nursing actions are needed prior to administering the blood?

  • Type and cross
  • 2 RN check
  • Priming tubing with NS
  • Verify order
  • Type of blood
  • Expiration date
  • 2 patient identifiers
  • Informed consent
  • Back-up NS in case of a reaction

What are the early

warning signs of MODS?

Question

The LPN can….

The one that has not been accessed.

Document the NG drainage and urinary output on the ICU flowsheet

and administering insulin.

What is the rate of administration

of the Packed RBCs?

There is also an experienced LPN on the unit.

Which nursing activities should be delegated to the LPN? (Select all that apply)

  • Document the nasogastric tube drainage and urinary output on the ICU flowsheet
  • Notify the laboratory after giving gentamycin to that peak and trough levels can be drawn
  • Monitor the dopamine infusion site for signs of extravasation
  • Administer sliding-scale insulin lispro subcutaneously every 6 hours
  • Complete and document a head-to-toe assessment every 4 hours
  • Monitor blood pressure and titrate dopamine to keep systolic pressure at 100 mm Hg

It is change of shift at 7 am the next morning.

Which of the following RNs in the

ICU is best prepared to care for this patient?

Ms. B. is also to receive 2 units of packed red blood cells (PRBCs). 275 mls are in each unit and the order says to administer them over a total of 3 hours.

The patient has the triple lumen catheter. TPN is running in one lumen, dopamine is in the other, and the other one is heparinized but not accessed.

183.3mL/hr

  • A “traveler” with 5 years of ICU experience who has been working in this unit for 4 months.
  • A new graduate RN who worked on the unit as a CNI and has just completed orientation.
  • An experienced ICU nurse who has been called in from his day off to work the first four hours of the shift.
  • A “float” RN from PACU.

Into which lumen should the blood product be administered?

The traveler nurse because she has 5 years experience in the ICU

  • Make sure the port is patent.
  • It is not being used for anything else beside TPN
  • You have a 2 nurse check
  • Compatibility with medications
  • Being administered through central venous catheter only
  • Blood sugar and urine acetone monitoring
  • Watch for Refeeding syndrome
  • Explain to patient
  • I and O monitoring
  • Redress the site according to agency
  • Use aseptic technique
  • Monitor electrolytes
  • Daily weights.

Question

Based on your analysis, which collaborative action do you anticipate happening next?

  • Administer a sodium bicarbonate (NaHCO3) bolus IV
  • Insert an endotracheal tube and initiate mechanical ventilation
  • Continuous monitoring of Ms. B’s respiratory status
  • A nebulized albuterol (Proventil) treatment

Ms. B. is ordered to begin TPN via a triple lumen central venous catheter (TLCVC).

Question

What are the major nursing responsibilities/actions

in initiating and administering TPN to this patient?

Normal Values

PaCO2: 35-45

PaO2: 80-100

HCO3-: 22-26 (21-28 hesi)

O2 saturation: 92-100%

pH: 7.35-7.45

ABG state:

Respiratory acidosis uncompensated

Hbg 9.9 because HGB is needed for oxygenation

An arterial blood gas (ABG) sample is obtained by

the physician. The results are as follows:

PaCO2: 62 mm Hg

PaO2: 50 mm Hg

HCO3-: 22 mEq/L

O2 saturation: 87%

pH: 7.23

The results from initial lab work are:

Na 130 mEq/L Cl 95 mEq/L Glucose 190 mg/dL

BUN 38 mg/dL Creatinine 1.6 mg/dL

WBC 17,000 mm3 Hct 29% Hgb 9.9 g/dL

Platelets 120,000

Question

WHICH ONES ARE ABNORMAL?

What laboratory value requires immediate attention? Why?

What values are high? Low?

What are the normal values?

What state is she in?

Question

Altered Tissue perfusion related to hypotension and hypoxemia

What actions can you suggest to Ms. B.’s daughter to

comfort her mother in the dying phase?

Providing O2, monitoring central arterial pressure for hemodynamic support.

Monitor mental status for changes

b/p and pulse within normal range.

O2 with in normal limits

Urine output at least 30 mL/hr

No significant change in LOC

Metoprolol – beta blocker

Amiodarone – antidysrrythmic

They help maintain the heart rate in case it was to increase.

Question

Be there for her, hold her hand, rub her head, talk to her and reminisce about the past.

Utilizing the data,

develop a priority nursing

diagnosis, an expected outcome, and three interventions for Ms. B.

Question

The cardiac monitor shows the following rhythm. Analyze the pattern and name the dysrhythmia.

Communication between family, patient,

and doctor to keep them up to date.

Atrial Fibrillation

Some signs are;

  • Mottling (bluish tone) of hands, mouth, and knees
  • Rattling breathing sounds
  • Decreased respirations
  • Decreased LOC
  • Hallucinations
  • Urinary and stool incontinence
  • Jaw drop
  • Rigid position of her body

What characteristics make this rhythm A-fib?

Question

What else could the doctor have ordered?

References

What are other nursing responsibilities in caring for a

patient with septic shock?

 

Ahsan, I. (1997). Textbook of surgery (2nd ed.). Australia: Harwood Academic.

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., & ...

Webb, S. A. (2013). Surviving sepsis campaign: international guidelines for

management of severe sepsis and septic shock: 2012. Critical Care Medicine,

41(2), 580-637 58p. doi:10.1097/CCM.0b013e31827e83af

HESI Comprehensive Review for the NCLEX-RN Examination, 4e. St. Louis, MO:

Elsevier.

Koh, G. C. K. W., Peacock, S. J., van der Poll, T., & Wiersinga, W. J. (2012). The impact

of diabetes on the pathogenesis of sepsis. European Journal of Clinical

Microbiology & Infectious Diseases, 31(4), 379–388

http://doi.org/10.1007/s10096-011-1337-4

LaCharity, L.; Kumagai, C. & Bartz, B. (2013). Prioritization, delegation, and

assignment. 3ed. St. Louis, MO: Mosby.Resolving Diabetes-Related

Bladder Problems - Diabetes Self-Management. (2013, December 16).

Retrieved October 19, 2015, from http://www.diabetesselfmanagement.com/managing-

diabetes/complications-prevention/resolving-diabetes-related-bladder-problems/

Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., & ... Tomlanovich, M. (2001).

Early goal-directed therapy in the treatment of severe sepsis and septic shock.

New England Journal Of Medicine, 345(19), 1368-1377 10p.

What You Need to Know About UTIs - Diabetes Self-Management. (2014, March 24).

Retrieved October 19, 2015, from http://www.diabetesselfmanagement.com/

blog/what-you-need-to-know-about-utis

Irregular R-R, no true P-wave, no PR interval, normal QRS

What size IV should we use?

How often should we check Orientation and alertness?

Should we get a 12 lead EKG before attaching the telemetry?

After her mother’s death, her daughter thanks you and the ICU team for your help and support in making the difficult time a little easier.

Cardio version is the best option with these options to hopefully shock the rhythm back into a normal pace, monitoring cardiac rhythm is necessary to make sure the cadioversion has been completed .

According to the david manual for ECG cardioversion, this is indicated for unstable tachy with an altered LOC, dizziness, chest pain or hypotension.

Question

Ms. B.’s daughter also asks how she will know

when her mother’s death is imminent.

The following bags of fluid are in the med room:

500 ml of 0.45 NaCl

1000 ml of 0.45 NaCl

1000 ml of 0.9 NaCl

500 ml of D5.45 NaCl

What action should you prepare to take?

Question

What is your response?

Continue to monitor the cardiac rhythm

Administer lidocaine (Xylocaine) 1 mg/kg IV push

Prepare to perform cardioversion at 50 Joules

Administer adenosine (Adenocard) 6 mg IV push

Which do you select and why?

Question

Monitoring central arterial pressure through central line for hemodynamic support.

Obtain cultures of blood, urine and any relevant specimen.

Monitor O2 saturation constantly, while Providing O2

Do you have any questions about the above orders?

What are they?

Question

She should tell her mother that she is dying but she should ensure her mother that we will stay with her as long as possible. This will help the family and patient be prepared for the impending death.

The nurse needs to provide honest information to maintain the credibility of our profession.

What are expected nursing interventions for each goal?

Infuse 1 Liter of normal saline over 30 minutes

Start a dopamine (Intropin) drip at 15 mcg/kg/min

Draw blood for cultures from three separate sites

Administer gentamycin (Gentacidin) 60 mg IV

Acetaminophen (Tylenol) 650 mg rectally

 

Fluid infusion because of decrease urine volume and history of not taking in fluid, in addition sepsis is associated with massive vasodilation resulting in hypotension and decrease tissue perfusion so increase the circulation volume.

Dopamine is used next for cardiac stimulation and renal perfusion.

Blood draws to figure out invading organism to specifically treat the infection.

Gentamycin is a broad spectrum antibiotic. Acetaminophen to reduce the fever.

Take vital signs every 15 minutes

Monitor urine output hourly

Some UAP are trained to start cardiac monitoring but it is in the discretion of the nurse

Mrs. B.’s daughter asks if she should

tell her mother that she is dying.

What is your response?

The Orders

Peak levels – 30 minutes after infusion (4-12mcg/ml)

Trough level should be drawn just before the next given dose (0.5-2mcg/ml)

Used to determine whether an IV administered medication is consistently with in therapeutic range

At 11 pm In the ICU, new orders are written.

They are as follows:

Acetaminophen (Tylenol) 650 mg rectally

Draw blood for cultures from three separate sites

Infuse 1 Liter of normal saline over 30 minutes

Start a dopamine (Intropin) drip at 15 mcg/kg/min

Administer gentamycin (Gentacidin) 60 mg IV

Question

Available staffing in the ED includes you and an experienced CNA. Which of the following activities can be delegated to the nursing assistant? Select all that apply.

Number the above actions in the order in which they should be implemented and explain your rationale.

If the medication is to be administered every 8 hours and the first dose was administered at 6 am today, when should the blood specimens for peak and trough be drawn? Why?

  • Take vital signs every 15 minutes
  • Attach the patient to the cardiac monitor
  • Document a head-to-toe assessment
  • Check orientation and alertness
  • Insert an IV
  • Monitor urine output hourly

Ms. B.’s medical diagnosis is septic shock.

Ototoxicity

Nephrotoxicity

Vertigo

Muscle paralysis

Hypersensitivity

Identify the three major goals in treating septic shock

Question

Recommendations:

Elevate her blood pressure so she has adequately perfusion.

Monitoring respiratory status and sedation.

Start to treat her infection.

Treat pain if needed.

Maintain adequate oxygenation.

Stablize blood pressure.

Resolve the infection.

What symptoms do you monitor for that

can indicate a potentially serious side effect

of the medication?

Question

Nonrebreather mask because it

gives you a fraction of inspired O2 of close to 100% . This patient is severely hypoxic therefore needing this device.

What do you think about the orders?

Monitor kidney functioning

Situation

166.7mL/hr

Could be more;

  • CHEM 7
  • CBC
  • ABG’s
  • Type and cross of blood
  • Type of O2 administration
  • X-ray to further assess abdomen/back pain

Question

Assessment

EB. Is a 54 year old female who came into the ED with Nausea, vomiting, back and abdominal pain, and a decrease in level of consciousness. Vitals were done showing significant hypoxemia where O2 was applied, UA and ABG’s were obtained, Telemetry monitoring was conducted. Upon telemetry monitoring pt. was in A-fib and shocked at 50 joules to return the rhythm into normal sinus. ABG’s showed patient was in severe uncompensated respiratory acidosis therefore pt was intubated and PEEP was applied to ventilation. As a result of using PEEP, blood pressure dropped to 86/40, HR 112, O2 – 93%. Patient is now adequately oxygenated but blood pressure is dropping. We are still waiting on results from the UA but the patient has a temp. of 103, urine is cloudy and dark amber with red streaks showing signs of possible infection.

 

PMH: Hypertension, peripheral arterial disease, diabetes mellitus type 2

Medications: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.

Vitals: 86/40 BP, HR 112, 32 Respirations, 93% O2 and 103 temp.

 

Heart sounds irregular and distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with crackles present in left lung base. Grimaces with light abdominal palpation above pelvic bone. Urine is amber and cloudy with red streaks. 100 ml urine output when Foley catheter inserted. Opens eyes and moves to command. Pupils equal, round, and reactive to light.

Background

Which method of oxygen administration will best increase Ms. B.’s oxygen saturation?

THE ORDERS

Recommendations??

Nasal cannula

Nonrebreather mask

Venturi mask

Face mask

Insert a Foley catheter and send a urine specimen for C&S

Start oxygen and titrate to maintain oxygen saturation at 90% or higher

Place the patient on telemetry

Check the blood glucose level

 

Question

What is another important reason why the Foley was inserted so early?

You are preparing to administer 60 mg of gentamycin IV. The bag has been delivered from the pharmacy:

60 mg in 250 ml of NS to run in over 1 ½ hours.

Based on the history and assessment, in which order should you implement the physician orders? And Why?

Question

What are the volume and rate settings?

At 10 pm the patient is to be transferred to the ICU.

Prepare an SBAR to give a verbal report to the nurse in the ICU.

What are the priorities?

Oxygen, telemetry, glucose, foley

O2 first – because of ABC’s and because the patient is severely hypoxic and needs additional O2 to prevent damage to organs. Telemetry to monitor cardiac status, Glucose because she has a history of diabetes and not eating today.

What we think...

Atrial fibrillation –

What are some characteristics of A-fib.

  • CBC
  • Foley
  • fluids
  • type and cross
  • X-ray

Cardiac monitor indicates a heart rate of 156 bpm.

High doses of dopamine are sympathomimetic and increase cardiac conduction and automaticity.

This increases the cardiac workload and can damage the heart.

  • 12-lead EKG
  • oxygen
  • ABG’s
  • Glucose
  • Chem 7

  • Hyperglycemia decreases the patient’s humoral immunity leaving the patient more susceptible to infections.
  • Poor circulation is associated with diabetes and it reduces the ability of WBC’s to travel throughout the body.
  • Diabetic neuropathy cause the bladder to loose sensation when it is full therefore resulting in stagnant urine.

Question

How does diabetes contribute to her risk?

After successful intubation, you perform a focused assessment of Ms.B.

What is your priority focus? Why?

Which patient finding is most important to report to the physician regarding the error in dopamine infusion?

  • First thing to do is assess the patient for signs and symptoms of toxicity;
  • Interventions may be needed to correct these.
  • Notify the physician of the error afterwards.

-The noninvasive BP monitor shows a BP of 102/48 mm Hg

-The data screen on the ventilator indicates a respiratory rate of 44 breaths/min

-Pulse oximitry is 90%

-The cardiac monitor indicates a heart rate of 156 beats/min.

Because she was unable to oxygenate herself independently we had to insert the ETT to help her breathe.

Peep will help with the exchange of oxygen in her body by opening up her lungs more.

Question

Respiratory status and making sure the patient is adequately sedated.

She had ETT inserted and because she was in resp. acidosis therefore we are making sure that our interventions are doing what we want them to do.

Diabetes, peripheral artery disease, and HTN

Question

What do you expect the

physician to order?

When you recheck the dopamine drip, you notice that you have miscalculated the dopamine dose

and have set the rate too high.

How would you explain PEEP to Ms. B. and her daughter?

Question

What do you do?

List the nursing actions in priority order.

Update

Question

You document the assessment findings as follows:

“Heart sounds irregular and distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses nonpalpable. Denies chest pain. Breath sounds audible bilaterally with crackles present in left lung base. Grimaces with light abdominal palpation above pelvic bone. Urine is amber and cloudy with red streaks. 100 ml urine output when Foley catheter inserted. Opens eyes and moves to command. Pupils equal, round, and reactive to light”

The current vital signs are as follows:

Blood pressure: 86/40 Heart rate: 112 bpm

O2 saturation: 93%

Respiratory rate: 32 breaths per minutes

Temperature: 103° F (39.4° C)

What other PMH increase

her risk of sepsis?

What we said we were missing...

Question

Hemodynamic changes

Decrease CO and

Venous return.

What is your interpretation of the patient’s current status?

  • Vital signs
  • Last time meds were taken
  • Allergies
  • Check sugar
  • Code status

If the patient weighs 140 lbs., and you decide to use the premixed solution of dopamine, what are the pump volume and rate settings?

Some one come to the board to do it!

  • Blood pressure is dropping and heart is trying to make up for it, as a result of the ETT and PEEP.
  • Possible infection because of her high temp, possible UTI/pyelonephritis evidenced by amber color, cloudy appearance with red streaks and pain above pelvic bone.
  • Fluid is backing up into lungs related PEEP and possible trauma from ETT.

Using the form on which you recorded the patient’s information, prepare and give a report in SBAR format to your partner. Critique each other’s reports

  • Decrease blood pressure and increase HR are indicators of shock,
  • Elevation in temperature is indicative of Sepsis
  • Cloudiness and blood in urine, back/abdominal pain can indicate UTI or Pyelonephritis.

Question

It is used when the patient is on mechanical ventilation and cannot adequately oxygenate their body by themself.

It is a method of holding alveoli opening during expiration allowing for more adequate arterial oxygenation.

Question

WHAT ARE WE MISSING IN OUR PREVOUS SBAR FOR RECOMMENDATIONS?

Question

  • Syringe
  • Filter needle
  • Normal needle
  • Gauze
  • Gloves
  • Sharps receptacle

What to watch for?

Major side effects of PEEP

Answer

Which information in your assessment requires the most immediate action?

Question

  • Elevate HOB
  • Apply o2 because of hypoxemia
  • Get 2 IV’s running
  • EKG
  • Turn on her side in case she vomits so she does not aspirate
  • Glasgow Coma scale
  • Check sugar
  • Draw Blood lab values
  • Obtain a weight/height
  • Assessing pain with FLACC

Which data from the health history and physical assessment are significant in developing and confirming the diagnosis?

Question

Our diagnosis

You are preparing to administer the dopamine (Intropin) drip as ordered at 15 mcg/kg/min.

The medication is available in an ampule containing 40 mg/ml or premixed 400 mg/250 ml NaCl.

Question

What do you think the probable

medical diagnosis is?

Question

Shock and possible septic shock related to UTI/pyelonephritis as evidenced by Increased WBC, decrease BP, Increase HR, RR and Temperature

The blood pressure needs to improve in order to promote adequate perfusion.

The interventions for the PEEP are working but it is affecting the hemodynamics of Ms. B.

Question

When is it used and what is its benefit?

What are the priority

nursing actions?

If you were to use the ampule,

what equipment do you need?

Question

When you are infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid infusion of fluid?

Listen to Ms. B’s lung sounds. The most common complication to rapid infusion of fluid is fluid overload which leads to heart failure,

although peripheral edema, decreased urine output and JVD are indicative of HF, crackles occur much more rapidly.

PEEP

  • Palpate Ms. B. for peripheral edema
  • Monitor Ms. B’s urine output
  • Listen to Ms. B’s lung sounds
  • Check for JVD

– positive end-expiratory pressure

2000mL/hr

Her presentation could be showing;

  • Shock
  • Hypoxic
  • Lethargic
  • Hypoglycemic
  • HHNS,DKA
  • Hearing issues
  • Hypokalemia
  • Hypercalcemia

Question

There is discussion about adding PEEP.

What is the meaning of this acronym?

Question

Question

What is your

initial assessment?

How many ml/hr would that be if you set the pump?

Briefly explain the intubation procedure to the patient and her daughter

Place the patient in supine position

Pre-oxygenate with bag valve mask at 100% oxygen

Insert the ETT orally through the vocal cords

Inflate the ETT cuff

Check end-tidal CO2 level

Auscultate breath sounds bilaterally

Tape the ETT in place

Obtain a chest X-ray

Vitals

Blood pressure: 102/38

Heart rate: 102 beats/minute

Oxygen saturation: 76%

Respiratory rate: 40 bpm Temperature: 102.4 ° F (39.1° C) oral

Question

Through the IV that you had already placed in ED.

It should be the primary fluid bag.

According to the order it says to run a full liter in 30 minutes.

Check with daughter about any other information related to health status. Surgeries, if she knew how long the symptoms were going on for, hearing issues, and recent falls. Doing a Glascow coma scale, FLACC pain scale. Blood electrolyte levels, 12-lead EKG, start 2 IVs.

Question

SBAR

What are you thinking as you are about to enter

the patient’s area and what do you plan to do?

What are your initial RECOMMENDATIONS?

You are preparing to assist the ED physician initiate endotracheal intubation of Ms. B. In which order will the following actions be accomplished?

Number each appropriate action in its order of occurrence.

  • Check end-tidal CO2 level
  • Tape the ETT in place
  • Pre-oxygenate with bag valve mask at 100% oxygen
  • Place the patient in supine position
  • Briefly explain the intubation procedure to the patient and her daughter
  • Inflate the ETT cuff
  • Auscultate breath sounds bilaterally
  • Obtain a chest Xray
  • Insert the ETT orally through the vocal cords

Situation

At 11 am, Ms. E.B. a 54 year old female, is brought to the Emergency Department of the hospital by her daughter because of weakness and a decreasing level of consciousness. Ms. B. was complaining about abdominal and back pain. She also reported nausea and had vomited twice. Because of her lethargy and nausea, she has not had anything to eat or drink today.

Background:

PMH: Hypertension, peripheral arterial disease, diabetes mellitus type 2

Medications: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.

 

Assessment

E.B. responds to brief commands to open her eyes and move her arms and legs, but she does not answer your questions. She is lethargic and sleepy.

Question

How do you administer the IV fluid?

What are the volume and rate?

Scenario

At 11 am, Ms. E.B. a 54 year old female, is brought to the Emergency Department of the hospital by her daughter because of weakness and a decreasing level of consciousness. E.B. responds to brief commands to open her eyes and move her arms and legs, but she does not answer your questions. The daughter tells you that when she stopped at her mother’s house today for a visit, Ms. B. was complaining about abdominal and back pain. She also reported nausea and had vomited twice. She is lethargic and sleepy. Because of her lethargy and nausea, she has not had anything to eat or drink today.

Her medical history includes: Hypertension, peripheral arterial disease, diabetes mellitus type 2. Her daughter gives you a list of Ms. B’s medications which include: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.

Insert an endotracheal tube and initiate mechanical ventilation

She is unable to maintain adequate oxygenation and ventilation independently.

Sodium bicarb – is for metabolic acidosis

Ongoing respiratory monitoring and Proventil maybe use but not indicated for severe ABG’s

1000 ml of 0.9 NaCl

It decreases the risk of fluid

shift in the body.

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