This document provides an overview of fluid therapy and electrolyte disturbances. It discusses the basic physiology of body fluids, including total body water content and distribution. It then covers various electrolyte abnormalities like hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also addresses acid-base balance disturbances and different intravenous fluid options for fluid resuscitation and maintenance.

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 bodyweight.
• Importance :
1. In homeostasis
2. In transport Mechanism
3. In metabolic reactions
4. In maintenance of tissue texture
5. In temperature regulation

5. • 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.

6. 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

8. Organic Inorganic
Glucose Oxygen
Amino acids electrolytes
Proteins
Fatty acid
Lipid
Hormones
Enzymes

9. Osmolarity :
• It is fluid’s capability to create osmoticpressure.
• 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

10. Cell Membrane
ICF
Cell Membrane
Interstitial
H2O
Cell membrane is freely permeable to H20 but Na and K are pumped across
this membrane to maintain a gradient!
Na+= 10
Urea
H2O
Na+
K+
glucose

11. 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

12. 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

13. 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

14. • Volume Changes :
• Composition Changes : Acid/Base Balance
Potassium Abnormalities
Calcium Abnormalities
MagnesiumAbnormalities
Hypovolemia
Hypervolemia
• Concentration Changes : Hyponatremia
Hypernatremia

15. Hypovolemia
Hypervolemia

16. Hypovolemia
• ECF volume deficit is most common fluid loss in surgical
patients, and aggravated by GeneralAnesthesia.
• 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.

17. 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

18. 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

19. 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

20. Hyponatremia <135 mEq/l.
Hypernatremia > 145 mEq/l.

21. 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.
Signs & symptoms
• Sign & symptoms : <120 mEq/l.
• CNS:
confusion, lethargy, stupor,headache,
seizure, coma
• GI: nausea, vomiting

22. Etiology & treatment of hyponatremia

23. • Asymptomatic
• Symptomatic (Na>160 meq/L)
Hypernatremia
>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

24. Etiology & treatment
of hypernatremia
Aggressive correction :
central pontine
myelinolysis

25. Acid/Base Balance
Potassium Abnormalities
Calcium Abnormalities
MagnesiumAbnormalities

26. 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.

27. 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

28. 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

29. Hyperkalemia
Serum K+ > 5.1 mEq /L
Etiology :
1. Increased intake : Potassium supplementation & Bloodtransfusions
2. Endogenous load/destruction: hemolysis, rhabdomyolysis, crush injury,
gastrointestinal hemorrhage
3. Increased release :Acidosis
4. Rapid rise of extracellure osmolality (hyperglycemia or mannitol) : Impaired
excretion of potassium & Renal insufficiency/failure.

30. 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

31. Calcium Abnormalities
• Majority of the 1000 to 1200g of calcium in the average-sized adultis
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 neuromuscularstability
• Most is excreted via the GI tract
Corrected calcium = 4 – albumin x 0.8 + serum calcium

32. 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

33. 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

34. 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+

35. Hypomagnesemia
• causes:
– starvation, malabsorption syndromes, GI losses, prolonged
IV or TPN with magnesium-free solutions
• signs & symptoms:
– similar to those of calcium deficiency

36. 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

37. 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

38. • Oral route is always preferred.
• Intravenous therapy should be started in criticalsituations.
indications
Oral intake is not possible
Severe vomiting, diarrhoea,
Dehydration & shock
hypoglycemia
Vehicle for some medication contraindications
Nutrition Ability to take oral fluid
Treatment of critical problems
(poisoning)
Avoid in CHF & volume overload

39. 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

40. • Para = other than , enteron (Gk) = intestine
• Ways to approach i.v. route –
venepuncture venesection

41. Median
cubital vein
Long
Saphenous
vein
In obese, female & infants
Risk of
thrombophlebitis &
pulmonary
embolism
Rare in infants / children
1. Cephalic vein in deltopectoral
groove
2. Subclavian vein
3. Internal jugular vein
4. External jugular vein
Neonates /
small children

42. I.V. fluids
Based on use
Maintenance fluids Replacement fluids Special fluids
5% D NS, Inj. Sod.bicarbonate,
5% D with 0.45% NaCl DNS, mannitol,
RL, NS 1.6%, 3%, 5%
ISOLYTE -G, Inj. KCl
ISOLYTE-E, 25% Dextrose
ISOLYTE-M,
ISOLYTE-P

43. I.V. fluids
Based on property
Crystalloids
(solution of large molecules)
Colloids
(solution of electrolytes)
Life saving
RL 5% Albumin
NS 25% Albumin
DNS 10% Pentastarch
D-5% 10% Dextran -40
ISOLYTES 6% Dextran -70
10% Hetastarch

44. 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 againsttoxic
substances
• Correction of hypernatremia

45. 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

46. 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

47. 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.

48. 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

49. 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

50. 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 operativeperiods
• Treatment of hypernatremia
• Compatible with blood transfusion
Contra indications :
• hyponatremia
• Severe dehydration

51. 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.

52. Indications
• Correction in severe hypovolemia
• Replacing fluid in post op patients, burns
• Diarrhoea induced hypokalemic metabolic acidosis
• Fluid of choice in diarrhoea induced dehydration inpaediatrics
• DKA , provides water, correct metabolic acidosis and suppliespotassium
• 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

53. Isolyte fluids
Isolyte G Isolyte M Isolyte P Isolyte E
dextrose 50 50 50 50
Na 63 40 25 140
K 17 35 20 10
Cl 150 40 22 103
Acetate --- 20 23 47
Lactate --- --- --- ---
NH4Cl 70 --- --- ---
Ca --- --- --- 5
Mg --- --- --- 3
HPO4 --- 15 3 ---
Citrate --- --- 3 8
Mosm/L 580 410 368 595

54. 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, metabolicacidosis
Isolyte M
• Richest source of potassium (35 mEq)
• Ideal fluid for maintenance
• Correction of hypokalemia
• Contraindications : Renal failure, burns,adrenocortical insufficiency

55. 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

56. • 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

57. Crystalloids …

58. 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

59. colloids…

60. 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

61. 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

62. Indications :
• Plasma volume expansion in acute hypovolemic shock, burns, severe
hypoalbuminemia
• Hypo proteinemia – liver disease, Diuretic resistant in nephroticsyndrome
• Oligourea
• In therapeutic plasmapheresis , as an exchange fluid
Contra indications :
• Severe anaemia, cardiac failure
• Hypersensitive reaction

63. Dextran
• Dextran are glucose polymers produced by bacteria (leuconostoc
mesenteroides)
2 forms : dextran 70(MW 70,000) and dextran40(40,000)
Pharmacological basis :
• Effectively expand iv volume, but not suitable for bloodtransfusion.
• Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapidrenal
excretion
• Anti thrombotic , inhibits plateletaggregation
• Improves micro circulatory flow as preventing thromboimbolism.

64. Indications :
• Hypovolemia correction
• Prophylaxis of DVT and post operative thromboembolism
• Improves blood flow and micro circulation in threatenedvascular
gangrene
• Myocardial ischemia, cerebral ischemia as maintaining vascular
graft patency
Adverse effects
• Acute renal failure
• Interfere with blood grouping and crossmatching
• Hypersensitivity reaction

65. 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 exceed20ml/kg
• Next 5 days – 10 ml/kg/ day

66. 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

67. Advantages :
• Does not interfere with coagulation, bloodgrouping
• 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

68. 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

69. 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 , factorVIII

70. 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

71. 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

72. 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

73. 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)

74. 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

75. 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 )

76. • 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.

77. • 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

81. 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

82. 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.

83. 1. Acute stress : sympathetic stimuli, tachycardia & vasoconstriction.
2. Stress : corticosteroids secretion (up to 48 hrs)
Na+ retention, K+ depletion Intracellular K+ depletion  hyperkalemia
3. Stress : ADH (up to 2-3 post op days)  water retention
Requirement of maintenance fluid is less on1st post op day.
4. NPO require consideration & replacement.
5. Pre, intra & post operative blood / fluid loss require consideration&
replacement.

84. 6. Hypovolemia should be corrected preoperatively  hypotension intraoperatively
7. Surgical stress / direct damage to kidney, brain, lungs, skin, GIT shouldbe
considered as they play important role in fluid & electrolytebalance.

85. 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)

86. Intraoperative fluid therapy
• Volume to be replaced –
1. Correction of fluid deficit due to starvation:
2. Maintenance volume for intraop period :
Duration of starvation (in hr) x 2 ml / kg ; 5% D
Duration of surgery (in hr) x 2 ml / kg ; 5% D
3. Correction of intra op loss :
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

87. Postoperative fluid therapy
1. First 24 hrs of surgery (total = 2L)
2. 2nd post op day (total = 3L)
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

88. 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

89. • ‘Fluid therapy should
be directed not only to
effective volume
expansion of a leaky
circulation but also to
micro vascular
protection’.

90. BOOKS
1. H E L E N G I A N N A K O P O U L O S , LEE C A R R A S C O , J ASON
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 AND E L E C T R O L Y T E M A N A G E
M E N T AND 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 AM 18 ( 2 0 0 6 ) 7 – 17 .
2. GYTO N & HALL TE XTB O O K O F M E D I CAL PHYS I O LO GY, 1 0 TH
E D ITI 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 RD ED
References

91. Others
 Ruttmann TG, James MF. Effects on coagulation due to
intravenous cry stalloid or colloid in patients undergoing v
ascular surgery. Br J Anesth 2002 ; 89 : 999 – 1003.
 Svensen C, Ponzer S. Volume kinetics of Ringer solution after sur
gery for hip fracture. Canadian journal of anesthesia 1999
; 4 6 : 1 3 3 – 141.
 Roberts I, Alderson P, Bunn F et al : Colloids versus
cry stalloids for fluid resuscitation in critically ill patients.. C
ochrane Database Syst Rev(4) : CD 000567, 2004
 C ommittee on Trauma. Advanc ed Trauma Life Support St
u d e n t ma n ual. 6th ed. Chicago. American College of Surg
eons. 2001: 87 -107
References

92. Thank you