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Fluid & electrolyte balance in surgical patients

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  • 1. PRESENTED BY – DR. SHEETAL KAPSE 2nd YEAR, P.G. STUDENT MODERATORS - DR. SUNIL DUTT C. DR. M. SATISH DR. DEEPAK THAKUR DR. MANISH PANDIT
  • 2. 1. Introduction 2. Basic physiology 3. Body fluid electrolytes disturbances 4. Parenteral fluid therapy 5. Basic principles 6. I.V. fluids 7. Methods of calculation of fluid transfusion rate 8. Fluid therapy in surgical patients 9. Volume resuscitation – end parameters & goals 10. Conclusion 11. References Total body water Distribution Composition Normal exchange of fluids Salt intake & output
  • 3. • Body is formed with solids & fluids. • In human body water content is 45-75% of body weight. • Importance : 1. In homeostasis 2. In transport Mechanism 3. In metabolic reactions 4. In maintenance of tissue texture 5. In temperature regulation
  • 4. • TBW varies with age, gender and body habitus . • In adult males= 60-65% of body weight, average = 60% • In adult female=45-50% of body weight, average = 50% • In infant = 80% of body weight • Obese patients have less TBW per Kg than lean body adult.
  • 5. 1= Intracellular fluid (ICF)= 70% TBW or 30%(F) - 40% (M) BW 2= Extracellular fluid (ECF) = 30%TBW or 20% BW  Interstitial fluid = 7.5% of body weight ( 15%)  Intravascular fluid or plasma volume = 4% of body weight ( 5%)  Transcellular fluid = 3.5 % of body weight Body compartment fluid
  • 6. Organic Inorganic Glucose Amino acids Proteins Fatty acid Lipid Hormones Enzymes Oxygen electrolytes
  • 7. Osmolarity : • It is fluid’s capability to create osmotic pressure. • It is concentration of osmotically active substances in solution. Osmolality : • It is no. of particles / L of solution. Tonicity : • Way of expressing effective osmolarity. 10 Same effective osmolarity as body fluid Greater effective osmolarity than body fluid less effective osmolarity than body fluid Cell in a hypertonic solution Cell in a hypotonic solution
  • 8. Cell Membrane ICF Cell Membrane Na+ K+ Interstitial H2O H2O Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient! Na+= 10 Urea glucose
  • 9. Water Gain route Average Daily vol. (ml) Minimum (ml) Maximum (ml) sensible Oral fluids 800 - 1500 0 1500/h Solid food 500 – 700 0 1500 insensible Water of oxidation 250 125 800 Water of solution 0 0 500 Water loss route average Daily vol. (ml) Minimum (ml) Maximum (ml) sensible Urine 800 - 1500 500 1400 / h Intestine 0 – 250 0 2500 / h sweat 0 0 4000 / h insensible Lungs 400 600 1500 Skin 500 - 1000
  • 10. 13 Daily fluid replacement = 700 + urine output Excess water loss 1. fever : 100 ml / degree fever / day 2. Tracheostomy (unhumidified air) : >1.5 L / day
  • 11. Salt intake & output • Daily salt intake varies 3-5 gm as NaCl • Kidneys excretes excess salt: can vary from < 1 to > 200 mEq/day • Volume and composition of various types of gastrointestinal secretions • Gastrointestinal losses usually are isotonic or slightly hypotonic • Should replace by isotonic salt solution
  • 12. • Volume Changes : • Concentration Changes : • Composition Changes : Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities Hypovolemia Hypervolemia Hyponatremia Hypernatremia
  • 13. Hypovolemia Hypervolemia
  • 14. Hypovolemia • ECF volume deficit is most common fluid loss in surgical patients, and aggravated by General Anesthesia. • Most common causes of ECF volume deficit are: GI losses from vomiting, nasogastric suction, diarrhoea, and fistular drainage • Other common causes: soft-tissue injuries and infections, peritonitis, obstruction and burns.
  • 15. Signs • Diminished skin turgor • Dry oral mucus membrane • Dry axilla • Oliguria - <500ml/day (normal: 0.5~1ml/kg/h) • Flat neck veins • Tachycardia • Orthostatic Hypotension • Hypoperfusion  cyanosis (hypothermia) • Sunken eye • Altered mental status Clinical Diagnosis • Thorough history taking: poor intake, GI bleeding…etc • glucocorticoid therapy • BUN : Creatinine > 20 : 1 • Increased specific gravity • Increased hematocrit • Electrolytes imbalance • Acid-base disorder
  • 16. Hypervolemia • Iatrogenic or Secondary to renal insufficiency, cirrhosis, or CHF. Signs • CNS: none • CVS: elevated JVP, venous distension – pulmonary edema, S3, • Respiratory : shortness of breath even in rest. • GI: edema of bowel • Tissue: pitting edema – anasarca, ascites, weight gain Clinical Diagnosis • Electrolytes imbalance • Decreased specific gravity • Decreased hematocrit • Cholesterol • Liver enzymes • Bilirubin • Creatinin clearance
  • 17. Management of Hypervolemia: • Prevention is the best way • Guide fluid therapy with CVP level or pulmonary wedge pressure • Diuretics • Increase oncotic pressure: FFP or albumin infusion (may followed by diuretics) • Dialysis
  • 18. Hyponatremia <135 mEq/l. Hypernatremia > 145 mEq/l.
  • 19. Hyponatremia • Na+ is the most abundant positive ion of ECF compartment and is critical in determining the ECF and ICF osmolality. • Normal amount 135-145 mEq/l. • Sign & symptoms : <120 mEq/l. Signs & symptoms • CNS: confusion, lethargy, stupor, headache, seizure, coma • GI: nausea, vomiting • Skeletal system : muscle twiches
  • 20. Etiology & treatment of hyponatremia
  • 21. Hypernatremia • Asymptomatic • Symptomatic (Na>160 meq/L) >145 mEq/l. CNS manifestations : due to dehydration of brain cells Body system Signs & symptoms Central nervous system Restlessness, lethargy, ataxia, irritability, tonic spasms, delirium, seizures, coma Musculoskeletal Weakness Cardiovascular Tachycardia, hypotension, syncope Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears Renal Oliguria Metabolic Fever
  • 22. Etiology & treatment of hypernatremia Aggressive correction : central pontine myelinolysis
  • 23. Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities
  • 24. Potassium Abnormalities • Normal daily dietary intake of K+ is approx. 50 to 100 mEq/day, & The normal range of serum potassium: 3.5-5.1 meq/L. • Majority of K+ is excreted in the urine (0-700 meq/day). • 98% of the potassium in the body is located in ICF at 150 mEq/L and it is the major cation of intracellular water. • Intracellular K+ is released into the extracellular space in response to severe injury or surgical stress, acidosis, and the catabolic state. • K+ has an important role in the regulation of acid-base balance.
  • 25. Hypokalemia Etiology : • Inadequate intake • Dietary, potassium-free intravenous fluids, potassium-deficient • Total parenteral nutrition • Excessive potassium excretion • Hyperaldosteronism • Medications • Gastrointestinal losses • Direct loss of potassium from gastrointestinal fluid (diarrhea), (gastric fluid, either as vomiting or high nasogastric output) • Renal loss of potassium • Intracellular-shift (metabolic alkalosis or insulin therapy) • Potassium decrease by 0.3 meq/L for every 0.1 increase in pH above normal Serum K+ < 3.5 mEq /L
  • 26. Treatment : • KCl 10 mEq/L/hr IV - pripherally • KC1 20 mEq/L/hr IV - centrally Body system Signs & symptoms Gastrointestinal Paralytic Ileus, constipation Neuromuscular Decreased reflexes, fatigue, weakness, paralysis, rhabdomyolysis, hyporeflexia Cardiovascular U-waves T-wave flattening ST-segment changes Arrhythmias Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears Renal Polyuria & polydypsia
  • 27. Hyperkalemia Serum K+ > 5.1 mEq /L Etiology : 1. Increased intake : Potassium supplementation & Blood transfusions 2. Endogenous load/destruction: hemolysis, rhabdomyolysis, cruch injury, gastrointestinal hemorrhage 3. Increased release : Acidosis 4. Rapid rise of extracellure osmolality (hyperglycemia or mannitol) : Impaired excretion of potassium & Renal insufficiency/failure.
  • 28. Body system Signs & symptoms Gastrointestinal Nausea/vomiting ,colic diarrhea Neuromuscular weakness, paralysis, respiratory failure Cardiovascular Arrhythmia, arrest ECG changes Peaked T waves (early change) Flattened P wave Prolonged PR interval (first-degree block) Widened QRS complex Sine wave formation Ventricular fibrillation Treatment of hyperkalemia
  • 29. Calcium Abnormalities • Majority of the 1000 to 1200g of calcium in the average-sized adult is found in the bone . • Normal daily intake of calcium is 1 to 3 gm. • Normal serum level = 8.8-10.5 mg/dl • Albumin Bound = 40-60% • Ionized portion (1.2 mg/dl) is responsible for neuromuscular stability • Most is excreted via the GI tract Corrected calcium = 4 – albumin x 0.8 + serum calcium
  • 30. Hypocalcemia Hypercalcemia • Serum calcium level <8.8 mg/dl • Causes: acute pancreatitis, massive soft-tissue infections (necrotizing fasciitis), acute and chronic renal failure, pancreatic and small-bowel fistulas, hypoparathyroidism • Serum calcium level >10.5 mg/dl • Causes: hyperparathyroidism cancer PTH-like peptide in malignancies
  • 31. Hypocalcemia S/S Hypercalcemia S/S 1. Hypotension 2. Anxiety 3. Psychosis 4. Paresthesia 5. Laryngeal spasm 6. Numbness and tingling of the circumoral region and the tips of the fingers and toes 7. tetany with carpopedal spasm, convulsions (with severe deficit), 8. Chvosteck & trousseau’s signs 1. Hypertension 2. Bradycardia 3. Constipation 4. Anorexia 5. nausea, vomiting 6. Nephrolithiasis 7. Pain 8. Psychosis 9. Pruritis 10. weight loss, thirst, polydipsia, and polyuria 11. easy fatigue, weakness, stupor, and coma Treatment : IV calcium for acute -1gm in D5 or NS Oral calcium and vitamin D for chronic
  • 32. Magnesium Abnormalities • Total body content of magnesium 2000 mEq, about half of which is incorporated in bone. • Normal daily dietary intake of magnesium is approximately 240 mg • Normal serum level = 1.5- 2.4 mg/dl • Deficiency causes impaired repletion of Na+ & Ca 2+
  • 33. Hypomagnesemia • causes: – starvation, malabsorption syndromes, GI losses, prolonged IV or TPN with magnesium-free solutions • signs & symptoms: – similar to those of calcium deficiency
  • 34. Hypermagnesemia • Symptomatic hypermagnesemia, although rare, is most commonly seen with severe renal insufficiency • signs & symptoms: CNS: lethargy and weakness with progressive loss of DTR’s – somnolence, coma, death CVS: increased P-R interval, widened QRS complex, and elevated T waves (resemble hyperkalemia) – cardiac arrest
  • 35. Basic principle Should have knowledge of 1. Etiology of fluid deficit 2. Type of electrolyte deficit 3. Associated illness 4. Clinical status Rationale 1. When to give or avoid 2. Which fluid 3. How much 4. Drop rate 5. Contraindication of specific fluid 6. How to correct the imbalance 7. How & when to use specific fluids
  • 36. • Oral route is always preferred. • Intravenous therapy should be started in critical situations. indications Oral intake is not possible Severe vomiting, diarrhoea, Dehydration & shock hypoglycemia Vehicle for some medication Nutrition Treatment of critical problems (poisoning) contraindications Ability to take oral fluid Avoid in CHF & volume overload
  • 37. Advantages Acute, controlled, predictable way Immediate response Prompt correction Disadvantages Require strict asepsis Skilled supervision Improper selection of fluid - dangerous Improper volume – life threatening Improper technique - complications complications Local : hematoma, infusion phlebitis, infiltration Systemic : circulation overload, rigors, septicemia, air embolism Others : fluid contamination, I.V. set & catheter problem Human error
  • 38. • Para = other than , enteron (Gk) = intestine • Ways to approach i.v. route – venepuncture venesection
  • 39. Median cubital vein Long Saphenous vein In obese, female & infants Risk of thrombophlebitis & pulmonary imbolism Rare in infants / children 1. Cephalic vein in deltopactoral groove 2. Subclavian vein 3. Internal jugular vein 4. External jugular vein Neonates / small children
  • 40. I.V. fluids Based on use Maintenance fluids Replacement fluids Special fluids 5% D 5% D with 0.45% NaCl NS, DNS, RL, ISOLYTE -G, ISOLYTE-E, ISOLYTE-M, ISOLYTE-P Inj. Sod.bicarbonate, mannitol, NS 1.6%, 3%, 5% Inj. KCl 25% Dextrose
  • 41. I.V. fluids Based on property Crystalloids (solution of large molecules) Colloids (solution of electrolytes) Life saving RL NS DNS D-5% ISOLYTES 5% Albumin 25% Albumin 10% Pentastarch 10% Dextran -40 6% Dextran -70 10% Hetastarch
  • 42. 5 % dextrose Composition : Glucose 50 gms Pharmacological basis : Corrects dehydration and supplies energy( 170Kcal/L) Indications : • Prevention and treatment of dehydration • Pre and post op fluid replacement • IV administration of various drugs • Prevention of ketosis in starvation, vomiting, diarrhea • Adequate glucose infusion protects liver against toxic substances • Correction of hypernatremia
  • 43. Contra indications • Cerebral edema, neuro surgical procedures • Acute ischaemic stroke • Hypovolemic shock • Hyponatremia , water intoxication • Same iv line blood transfusion – hemolysis , clumping occurs • Uncontrolled DM , severe hyperglycemia Rate of adminstration – 0.5 gm/kgBW/hr or 666ml/hr 5 % D or 333ml/hr 10 %D
  • 44. INVERTED SUGAR SOLUTION Composition : inverted sugar 100 gms Pharmacological basis : half dextrose + half fructose Indications : • Prevention and treatment of dehydration (specially pregnancy) • Liver diseases (prevents glycogen depletion) Adverse effects : 1. Lactic acidosis 2. Hyperurecemia 3. hypophosphatemia Contra indications • hereditory fructose intolerance • Caution in renal & hepatic impairment • >25gm fructose should be avoided • more expansive
  • 45. Isotonic saline(0.9 % NS) • Composition : Na+ 154 mEq, Cl- 154 meq • Pharmacological basis : provide major ECF electrolytes.. corrects both water and electrolyte deficit. increase the iv volume substantially Contra indications • Avoid in pre eclamptic patients, CHF, renal disease and cirrhosis • Dehydration with severe hypokalemia – deficit of ICF potassium • Large volume may lead to hyperchloremic acidosis.
  • 46. Indications • Water and salt depletion – diarrhoea, vomiting, excessive diuresis • Hypovolemic shock • Alkalosis with dehydration • Severe salt depletion and hyponatremia • Initial fluid therapy in DKA • Hypercalcemia • Fluid challenge in prerenal ARF • Irrigation – washing of body fluids • Vehicle for certain drugs
  • 47. DNS Pharmacological basis : • Supply major EC electrolytes, energy and fluid to correct dehydration Indications : • Conditions with salt depletion ,hypovolemia • Correction of vomiting or NGT aspiration induced alkalosis and hypochloremia • Compatible with blood transfusion Contra indications : • Anasarca – cardiac, hepatic or renal • Severe hypovolemic shock (osmotic diuresis) • >25gm/hr should be avoided
  • 48. DNS with half strength saline Pharmacological basis : • Supply major EC electrolytes, energy and fluid to correct dehydration • more water with less salt. Indications : • paediatric & very elderly • Maintenance fluid in early post operative periods • Treatment of hypernatremia • Compatible with blood transfusion Contra indications : • hyponatremia • Severe dehydration
  • 49. Ringer’s lactate Pharmacological basis : • Most physiological fluid , rapidly expand s iv volume.. • Lactate metabolised in liver to bicarbonate providing buffering capacity • Acetate instead of lactate advantageous in severe shock.
  • 50. Indications • Correction in severe hypovolemia • Replacing fluid in post op patients, burns • Diarrhoea induced hypokalemic metabolic acidosis • Fluid of choice in diarrhoea induced dehydration in paediatrics • DKA , provides water, correct metabolic acidosis and supplies potassium • Maintaining normal ECF fluid and electrolyte balance Contra indications • Liver disease, severe hypoxia and shock • Severe CHF , lactic acidosis takes place • Addison’s disease • Vomiting or NGT induced alkalosis • Simultaneous infusion of RL and blood • Certain drugs – amphotericin, thiopental, ampicillin, doxycycline
  • 51. Isolyte fluids Isolyte G Isolyte M Isolyte P Isolyte E dextrose 50 50 50 50 Na K Cl 63 17 150 40 35 40 25 20 22 140 10 103 Acetate Lactate NH4Cl --- --- 70 20 --- --- 23 --- --- 47 --- --- Ca Mg --- --- --- --- --- --- 5 3 HPO4 --- 15 3 --- Citrate --- --- 3 8 Mosm/L 580 410 368 595
  • 52. Isolyte G : • Vomiting or NGT induced hypochloremic, hypokalemic metabolic alkalosis • NH4 gets converted to H+ and urea in liver • Treatment of metabolic alkalosis • Contraindications : Hepatic failure, renal failure, metabolic acidosis Isolyte M • Richest source of potassium (35 mEq) • Ideal fluid for maintenance • Correction of hypokalemia • Contraindications : Renal failure, burns, adrenocortical insufficiency
  • 53. Isolyte P • Maintenance fluid for children – as they require less electrolytes and more water • Excessive water loss or inability to concentrate urine • Contraindications : hyponatremia, renal failure Isolyte E • Extracellular replacement solution, additional K and acetate (47mEq) • Only iv fluid to correct Mg deficiency • Treatment of diarrhoea, metabolic acidosis • Contraindications – metabolic alkalosis
  • 54. • Extravascular accumulation in skin, connective tissue , lungs and kidney • Inhibition of GI motility • Delayed healing of anastomosis • Large volume ,rapid infusion crystalloids causes hypercoagulability.. Ruttmann TG, James MF. Effects on coagulation due to intravenous crystalloid or colloid in patients undergoing vascular surgery. Br J Anesth 2002 ; 89 : 999 - 1003
  • 55. Crystalloids …
  • 56. Colloids Colloids : large molecular wt substances that largely remains in the intravascular compartment thereby generating oncotic pressure • 3 times more potent • 1 ml blood loss = 1ml colloid = 3ml crystalloids
  • 57. colloids…
  • 58. Type of fluid Effective plasma volume expansion/100ml duration 5% albumin 70 – 130 ml 16 hrs 25% albumin 400 – 500 ml 16 hrs 6% hetastarch 100 – 130 ml 24 hrs 10% pentastarch 150 ml 8 hrs 10% dextran 40 100 – 150 ml 6 hrs 6% dextran 70 80 ml 12 hrs
  • 59. Albumin • Maintain plasma oncotic pressure – 75-80 % • Heat treated preparation of albumin – 5%, 20% and 25% commercially available Pharmacalogical basis : • 5% albumin – COP of 20 mmHg • 25% albumin – COP of 70mmHg ,expands plasma volume to 4-5 times the volume infused within 4-5 min. Rate of infusion : • Adults – initial infusion of 25 gm • 1 to 2 ml/min – 5% albumin • 1 ml/min - 25% albumin
  • 60. Indications : • Plasma volume expansion in acute hypovolemic shock, burns, severe hypoalbuminemia • Hypo proteinemia – liver disease, Diuretic resistant in nephrotic syndrome • Oligourea • In therapeutic plasmapheresis , as an exchange fluid Contra indications : • Severe anaemia, cardiac failure • Hypersensitive reaction
  • 61. Dextran • Dextran are glucose polymers produced by bacteria (leuconostoc mesenteroides) 2 forms : dextran 70(MW 70,000) and dextran 40(40,000) Pharmacological basis : • Effectively expand iv volume, but not suitable for blood transfusion. • Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapid renal excretion • Anti thrombotic , inhibits platelet aggregation • Improves micro circulatory flow as preventing thromboimbolism.
  • 62. Indications : • Hypovolemia correction • Prophylaxis of DVT and post operative thromboembolism • Improves blood flow and micro circulation in threatened vascular gangrene • Myocardial ischemia, cerebral ischemia as maintaining vascular graft patency Adverse effects • Acute renal failure • Interfere with blood grouping and cross matching • Hypersensitivity reaction
  • 63. Precautions/CI : • Severe oligo-anuria • CHF, circulatory overload • Bleeding disorders like thrombocytopenia. • Severe dehydration • Anticoagulant effect of heparin enhanced • Hypersensitive to dextran Administration : • Adult patient in shock – rapid 500 ml iv infusion • First 24 hrs – dose should not exceed 20ml/kg • Next 5 days – 10 ml/kg/ day
  • 64. Gelatin polymers( haemaccel) • 500 ml Sterile, pyrogen free 3.5 % solution • Polymer of degraded gelatin with electrolytes • 2 types • Succinylated gelatin (modified fluid gelatin) • Urea cross linked gelatin ( polygeline) Composition : Na 145 mEq, Cl 145 mEq, Ca 12.5 mEq, potassium 5.1 mEq Indications : • Rapid plasma volume expansion in hypovolemia • Volume pre loading in general anesthesia • Priming of heart lung machines
  • 65. Advantages : • Does not interfere with coagulation, blood grouping • Remains in blood for 4 to 5 hrs • Infusion of 1000ml expands plasma volume by 50% Side effects : • Hypersensitivity reaction • Bronchospasm, hypotension • Should not be mixed with citrated blood
  • 66. Hydroxyethyl starch Hetastarch : • It is composed of more than 90% esterified amylopectine. • Esterification retards degradation leading to longer plasma expansion • 6% starch - MW 4,50,000 Pharmacological basis : • Osmolality – 310 mosm/L • Higher colloidal osmotic pressure • LMW substances excreted in urine in 24 hrs
  • 67. Advantages : • Non antigenic • Does not interfere with blood grouping • Greater plasma volume expansion • Preserve intestinal micro vascular perfusion in endotoxaemia • Duration – 24 hrs Disadvantages : • Increase in S amylase concentration upto 5 days after discontinuation • Affects coagulation by prolonging PTT, PT and bleeding time by lowering fibrinogen • Decrease platelet aggregation , VWF , factor VIII
  • 68. Contra indications : • Bleeding disorders , CHF • Impaired renal function Administration : • Adult dose 6% solution – 500ml to 1 lit • Total daily dose should not exceed 20ml/kg
  • 69. Pentastarch : • LMW derivative (2,64,000) 3%, 6% and 10% solution • Lower degree of esterification • Lesser effect on coagulation • 10% solution can increase plasma volume 1.5 times of infused volume
  • 70. Special fluids • Inj KCl 10 ml amp – 20mEq • 25%D (25 ml amp or 100 ml infusion bottle)– in hypoglycemic shock • Inj. Sodium bicarbonate (25 ml amp. 22.5mEq Na+ & 22.5mEq HCO3-) dose = 10-15 mEq/L : in metabolic acidosis • Mannitol 10% & 20% : osmotic diuretic
  • 71. Goals • Maintenance of normovolemia and hemodynamic stability • Acceptable plasma colloid osmotic pressure • Correction of electrolyte imbalance • Correction of acid base imbalance • Adequate urine output( 0.5 to 1 ml/kg/hr)
  • 72. Crystalloids or colloids…??? • Crystalloids – recommended as the initial fluid of choice in resuscitating patients from hemorrhagic shock Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 - 141 • COCHRANE Collaboration in critically ill patients – “ No evidence from RCT that resuscitation with colloids reduces the risk of death, compared with crystalloids in patients with trauma or burns after surgery” Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD 000567, 2004
  • 73. Goal : the oxygen carrying capacity of blood. Indications 1. Hb <6 gm% (normal =10 gm%) 2. age 3. Medical status 4. Major surgical procedure 5. Anticipation of ongoing blood loss >100ml/min 6. Acute blood loss > 40% (2L crystalloid 3:1 ---  colloid 1:1 )
  • 74. • AMERICAN COLLEGE OF SURGEONS (2001), • Classification of acute hemorrhage Committee on Trauma. Advanced Trauma Life Support Student manual. 6th ed. Chicago. American College of Surgeons. 2001: 87-107.
  • 75. • Transfusion with whole blood is indicated very rarely. • Advantages : 1. Preservation of remaining whole blood components 2. Longer storage 3. Decreases the risk of transfusion reaction
  • 76. Holiday Segar Method 4 ml/kg/hr = 4x10/hr = 40 ml/hr 2ml/kg/hr = 2x20/hr = 40 ml/hr So, for > 20 kg patient = body wt + 40 ml Eg. For 70 kg. pt = 70+40 = 110 ml
  • 77. Fluid therapy in surgical patients • Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively, and post operatively, as well as in response to trauma and sepsis. • Proper fluid & electrolyte state is helpful in reducing morbidity & mortality in certain surgical procedures, hence it is important.
  • 78. 1. Acute stress : sympathetic stimuli, tachycardia & vasoconstriction. 2. Stress : corticosteroids secretion (up to 48 hrs) 3. Stress : ADH (up to 2-3 post op days)  water retention 4. NPO require consideration & replacement. 5. Pre, intra & post operative blood / fluid loss require consideration & replacement. Na+ retention, K+ depletion Intracellular K+ depletion  hyperkalemia Requirement of maintenance fluid is less on1st post op day.
  • 79. 6. Hypovolemia should be corrected preoperatively  hypotension intraoperatively 7. Surgical stress / direct damage to kidney, brain, lungs, skin, GIT should be considered as they play important role in fluid & electrolyte balance.
  • 80. Preoperative fluid therapy • Very important for better outcome in surgical patients. • 3 parameter are important 1. Correction of hypovolemia (GA diminishes the compensatory reflexes ) 2. Correction of anemia (48 hours prior to surgery) 3. Correction of other disorders (eg. hypo & hyperkalemia)
  • 81. Intraoperative fluid therapy • Volume to be replaced – 1. Correction of fluid deficit due to starvation : 2. Maintenance volume for intraop period : 3. Correction of intra op loss : Duration of starvation (in hr) x 2 ml / kg ; 5% D Duration of surgery (in hr) x 2 ml / kg ; 5% D a. Suction container b. Surgical sponge c. Third space • Blood loss =3/1 with crystalloid • Blood / blood products if indicated • Decrease in Hb by 2gm% can be tolerated by patient with pre op Hb = 10gm% Type of trauma Requirement of fluid Least trauma nil Minimal trauma 4 ml /kg / hr Moderate trauma 6 ml /kg / hr severetrauma 10 ml /kg / hr
  • 82. Postoperative fluid therapy 1. First 24 hrs of surgery (total = 2 L) 2. 2nd post op day (total = 3 L) 3. 3rd post op day (total = 3 L) 2L 5% D or 1.5 L 5% D + 500ml 0.9% NS 2L 5% D + 1L 0.9% NS 2L 5% D + 1L 0.9% NS + 40-60 mEq K+ / day
  • 83. End parameters Goals 1. Achieve primary goal (0xygen supply) 2. Good level of Hb% & cardiac output 3. Test for – ABG CVP Pulmonary pressure BP heart rate Urine output > 1ml/kg/hr 1. CVP = 15 mmHg 2. Pulmonary capillary wedge pressure 10-12 mmHg 3. Cardiac index >3L/min/sq meter 4. Oxygen uptake >100 ml /min/sq meter 5. Blood lactate < 4 mmol/l 6. Basic deficit
  • 84. • ‘Fluid therapy should be directed not only to effective volume expansion of a leaky circulation but also to micro vascular protection’.
  • 85. BOOKS 1 . H E L E N G I A N N A K O P O U L O S , L E E C A R R A S C O , J A S O N A L A B A K O F F , P E T E R D . Q U I N N . F L U I D A N D E L E C T R O L Y T E M A N A G E M E N T A N D B L O O D P R O D U C T U S A G E . O R A L M A X I L L O F A C I A L S U R G C L I N N A M 1 8 ( 2 0 0 6 ) 7 – 1 7 . 2 . G Y TO N & H A L L T E X T B O O K O F M E D I C A L P H Y S I O L O G Y, 1 0 T H E D I T I O N . 3 . S E M B U L I N G A M K . S E M B U L I N G A M P R E M A . K S E M B U L I N G A M - E S S E N T I A L S O F M E D I C A L P H Y S I O L O G Y , 6 T H E D I T I O N 4 . C O N C I S E T E X T B O O K O F S U R G E R Y – D A S S . 3 R D E D References
  • 86. Others  Ruttmann TG, James MF. Effects on coagulation due to intravenous cry stalloid or colloid in patients undergoing vascular surgery. Br J Anesth 2002 ; 89 : 999 – 1003.  Svensen C, Ponzer S. Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 – 141.  Roberts I, Alderson P, Bunn F et al : Colloids versus cry stalloids for fluid resuscitation in critically ill patients.. Cochrane Database Sy st Rev(4) : CD 000567, 2004  Committee on Trauma. Advanced Trauma Life Support Student manual. 6th ed. Chicago. American College of Surgeons. 2001: 87 -107 References
  • 87. Thank you