fluid management

1. FLUID
MANAGEMENT

2. Aim of fluid resuscitation
 Correct Pre-existing Deficiencies
 Restoration of a Normal Circulating Blood Volume
 Maintenance of Adequate Urine Output
 Maintenance of a Normal Hydration and Electrolyte
Composition of the Plasma is Essential
 Replace Losses

3. NORMAL BODY COMPOSTION
IC F
4 0 % B O D Y W T
K : 1 5 0 m E q /L
N a : 1 0 m E q /L
IN T R A V A S C U A R
5 % B O D Y W T
IN T E R S T IT IA L
1 5 % B O D Y W T
E C F
2 0 % B O D Y W T
K : 4 m E q /L
N a : 1 4 0 m E q /L
T O T A L B O D Y F L U ID
6 0 % b o d y w t

4. Total Body Water (TBW)
• Varies with age, gender, body habits
• 55% body weight in males
• 45% body weight in females
• 80% body weight in infants
• Less in obese: fat contains little water

5. Body Water Compartments
• Intracellular water: 2/3 of TBW
• Extracellular water: 1/3 TBW
- Extra vascular water: 3/4 of extra cellular
water
- Intravascular water: 1/4 of extra cellular water

6. CONTENTS OF IV FLUIDS
Solutions Glucose
Gm/L
Na
mEq/L
Cl
mEq/L
K
mEq/L
Ca
mEq/L
Lactate
mEq/L
2.5% Dextrose 25
5% Dextrose 50
10% Dextrose 100
0.45% Nacl 77 77
0.9% Nacl 154 154
5% Dextrose + 0.45% Nacl 50 77 77
Ringer’s 147 155 4 4
Lactate Ringer’s 130 109 4 3 28
5% Sodium Bicarbonate 595 595
0.15% Potassium Chloride 20 20
0.30% Potassium Chloride 40 40

7. EVALUATION OF FLUID VOLUME
pulse – rate
- volume
 BP
 Urinary flow rate
 Skin turgor and hydration of mucous
membrane

8. Signs of Fluid Loss
5%
Mild
10%
Moderate
15%
Severe
Mucous membrane Dry Very dry Parched
Sensorium Normal Lethargic Obstunded
Orthostatic changes
heart rate
BP
Absent
No change
No change
Present
No change
No change
Marked
>15
<10
Urinary flow rate Mild
decreased
Moderately
decreased
Marked
decreased

9. Intra Operative Management
Intra Operative MUST Replace both
Preoperative Deficit and Intra operative
Hypotonic and Isotonic Deficits

10. Routine Intraoperative Fluid
Administration
Maintenance fluid requirement
Deficit replacement (NPO)
Third space losses
Replacement of blood losses
Special additional losses

11. Maintenance Fluid
Requirements
• Insensible losses such as evaporation of
water from respiratory tract, sweat, feces,
urinary excretion. Occurs continually.
• Adults: approximately 1.5 ml/kg/hr
• “4-2-1 Rule”
- 4 ml/kg/hr for the first 10 kg of body weight
- 2 ml/kg/hr for the second 10 kg body weight
- 1 ml/kg/hr subsequent kg body weight
- Extra fluid for fever, tracheotomy, denuded
surfaces

12. Maintenance Fluid
Estimating maintenance fluid requirements
• Weight Rate
For the 1st10kg 4ml/kg/hr
For the next 10-20kg 2ml/kg/hr
For each kg above 20kg 1ml/kg/hr
Example: The maintenance fluid requirement for
45kg adult,
1st 10kg : 10kg * 4ml/kg/hr = 40ml/hr
2nd 10kg: 10kg * 2ml/kg/hr = 20ml/hr
remaining 25kg:25kg * 1ml/kg/hr = 25ml/hr
Total = 85ml/hr

13. NPO and other deficit
NPO deficit = number of hours NPO x
maintenance fluid requirement.
Bowel prep may result in up to 1 L fluid
loss.
Measurable fluid losses, e.g. NG
suctioning, vomiting .
Eg; For average 45kg man fasting for
10hrs amounts to
( 40+20+25)ml/hr *10Hrs=850 ml

14. Surgical Fluid Loss :
• Other fluid losses:
evaporation from exposed wound & viscera
• directly proportional to the surface area &
• duration of surgical period,
internal redistribution (third space loss),
• related to trauma,
• inflammation,
• infected tissues (burns, surgical dissections etc)

15. Third Space Losses
• Isotonic transfer of ECF from functional
body fluid compartments to non-functional
compartments.
• Depends on location and duration of
surgical procedure, amount of tissue
trauma, ambient temperature, room
ventilation.

16. Fluid management for 3rd space loss &
insensible loss
 Minimal (small incision) 0-2 ml/kg/hr
Moderate (medium incision) 2-4 ml/kg/hr
Severe (large incision) 4-8 ml/kg/hr

17. Third space loss = weight of the patient * 3rd
space loss * OT duration
Therefore ; total intraoperative fluid given in the
patient = Fluid Maintenance + deficit + surgical
wound loss + Blood loss

18. Average blood volume
neonates : premature 95ml/kg
full-term 85ml/kg
infants : 80ml/kg
adults : men 75ml/kg
women 65ml/kg

19. Blood loss estimation
• surgical suction container,
• wound soaked surgical sponges and lap pads,
• occult bleeding into the wound or under surgical
drapes,
• serial hb or hct is more useful,

20. When to transfuse blood?
Acceptable blood loss (ABL)
= [Hb (current) – Hb (target)] / Hb (current)
*Expected blood volume
For eg : For an adult men weighing 45kg with Hb
11gm% and we allow the Hb drop to 9gm%
ABL=(11gm% - 9gm%) / 11gm% * (75ml *
45kg)
= 607.5 ml

21. Blood loss
• Replace 1.3cc of crystalloid solution per
cc of blood loss (crystalloid solutions leave
the intravascular space)
• When using blood products or colloids
replace blood loss volume per volume

22. Example
• 23 y/o male, 45 kg, for hemicolectomy
• NPO after 12am, surgery at 10am,
• 3 hr. procedure, with hemoglobin of
11gm%
• What are his estimated intraoperative fluid
requirements?

23. Maintenance Fluid : (40+20+25)ml/hr *
3hrs = 255ml
Fluid Deficit : (40+20+25)ml/hr * 10hr
=850ml
Third space loss = 45kg * 8ml/kg/hr * 3hrs
=1080ml
Blood loss = 607.5ml
Total = 255ml + 850ml + 1080 ml +
607.5ml =2792.5ml
Example( contd.)

24. 1st hour: 1/2 total deficit + maintenance,
2nd hour: 1/4 total deficit + maintenance,
3rd hour: 1/4 total deficit + maintenance

25. Choice of fluids
There are Three Types of Intravenous
Fluids
-Crystalloid
-Colloid
-Blood
(Dextrose 5% is not Effective in the
Treatment of Shock as it Leaves the
Circulation Rapidly)

26. Fluid ????
Crystalloid Colloid Blood
products
Ringer lactate
0.9% saline
Dextrose Haemaccel
Hetastarch
Albumin solution Whole blood
Packed red cells
Plasma
FFP

27. Crystalloids
 Replaces interstitial loss
 Three times the amount
will be needed and acts
slowly
 Cheaper
 Overdose causes
respiratory failure
 Overdose results in
dramatic peripheral
oedema
Colloids
 Replaces plasma volume
 Acts faster and lasts
longer
 More expensive
 Overdose causes
respiratory failure
 Restoration of blood
volume, cardiac output
and tissue perfusion

28. Choice of Fluid : Isotonic Fluid (Ringer
Lactate) is Ideal Choice
 Blood Loss : By Same Amt. Of Colloid or
Blood or 3 Times Crystalloid, depending
upon pre-op Hb

29. Ringer lactate
It is closest in electrolyte composition with that
of plasma and interstitial fluid
It has a pH of 6.7
It is more physiological
Electrolytes contents are sodium, chloride,
lactate, potassium and calcium

30. Close Monitoring is Important In
Regards to Fluid Overload

31. Monitoring During Fluid Therapy
Pulse Rate
Blood Pressure
Urine Output (at least 1.0ml/kg/hr)
Chest Auscultation (Pulmonary Edema)
Monitor FBC & U/E
CVP Monitoring

32. Choice and Quantity of Intraoperative Fluids.
 In the ideal world, perhaps one would start two I.V., one with
maintenance fluids at a set rate and the other replacement
fluids.
 However, this is both burdensome and unnecessary.
 The choice is rather simple, whether or not to give a
hypotonic solution such as maintenance fluids and hope
that the kidney can excrete the extra water or
 the administration of a balanced salt solution where the
kidney excretes any extra sodium and water.
 The latter is by far the best choice since expected or
unexpected fluid losses will be appropriately replaced.

33. Summary
• Fluid therapy is critically important
during the preoperative period.
• The most important goal is to maintain
homodynamic stability and protect vital
organs from hypo perfusion (heart, liver,
brain, kidneys).
• All sources of fluid losses must be
accounted for.
• Good fluid management goes a long
way toward preventing problems.

34. Thank you

35. When to transfuse blood?
Calculate allowable blood loss:
 
hb
curren
eth
t
curren
EBV arg

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