Fluid therapy for surgical post graduates

1. Fluid therapy-
pros and cons
Dr. Rohit Gupta
PG General Surgery
AIIMS Patna

2. Overview
• History of fluid therapy
• Physiology
• Types of iv fluids
• Perioperative fluid therapy
• Fluid therapy in burns
• Take home messages
• References

3. History of fluids
• The first record – ambroise pare use of clysters (enema)
• 1830 – Thomas latta , O’ shaughnessy, herman treated
cholera patient – water and salt solution intravenously.
• Hartog jakob in 1882 – 0.9 % Nacl.
• 1883 Sydney Ringer- ringer solution
• Alex Hartmann modified ringers solution by adding sodium
lactate- lactated ringer’s

4. Physiology

6. •

7. Types of iv fluids
• Crystalloid
isotonic – 0.9% NS, ringer lactate
hypotonic- 0.45% Nacl, D5W
hypertonic- 3% Nacl
• Colloids – albumin 5 %, albumin 25%, dextran 40,
dextran 70, Hetastarch, gelatins.
• Bloods products –PRBC, FFP , PRP, Cryoprecipitate

9. Isotonic saline (0.9%)
• Neither normal nor physiological
• Composition -154 mEq Na+ 154 mEq Cl-
Advantages/uses -
1. Hypovolemic shock.
2. Ideal fluid – volume deficit with metabolic alkalosis
3. Correction of hyponatremia
4. Fluid challenge .
5. Vehicle for various drugs and blood products.
6. Irrigation of wounds and dressings.

10. Disadvantages-
1. Pulmonary edema and interstitial edema.
2. Decrease in renal perfusion.
3. Hyperchloremic metabolic acidosis.
4. Cautious use – hypertensive or preeclampsia,
congestive cardiac failure , pre existing renal disease.

11. The effects of isotonic saline (0.9% NaCL) versus lactated Ringer’s solution
on the pH of blood in patients undergoing elective surgery
- Rapid saline infusion produces acidosis in patients undergoing gynecologic surgery.
Anesthesiology 1999; 90:1265–1270. by Scheingraber S et al

12. •
-Nor’azim Mohd Yunos, MD Rinaldo Bellomo, MD, FCICM et al
JAMA, October 17, 2012—Vol 308, No. 15
Objective To assess the association of a chloride-restrictive (vs chloride-liberal)
intravenous fluid strategy with AKI in critically ill patients.
Design, Setting, and Patients Prospective, open-label, sequential period pilot study
of 760 patients admitted consecutively to the intensive care unit (ICU) during the
control period (February 18 to August 17, 2008) compared with 773 patients
admitted consecutively during the intervention period (February 18 to August 17,
2009) at a university-affiliated hospital in Melbourne, Australia.
Conclusion ;The implementation of a chloride-restrictive strategy in a tertiary ICU
was associated with a significant decrease in the incidence of AKI and use of RRT.

13. Ringer lactate
• Hartmann added sodium lactate to Ringer’s solution –RL
Advantages-
1. Lack of significant acid – base imbalance.
2. Fluid of choice -diarrhea induced dehydration.
3. Replacing fluid in post operative patients.
4. Crystalloid of choice - burns.
5. Diabetic ketoacidosis.

14. Disadvantages-
1. lactic acidosis.
2. May worsen metabolic acidosis
3. Hypovolemia with metabolic alkalosis .
4. Contraindicated - diluent of blood products
5. Reduces bioavailability of certain drugs e.g.
amphotericin, ampicillin etc.

15. 5 % dextrose
• One liter of fluid contains 50 gm glucose = 170 k cal /liter
Advantages-
1. correct intracellular dehydration.
2. Cheap fluid to provide calories(protein sparing effect).
2. pre and post operative fluid replacement.
3. Prevention of ketosis
5. Correction of hypernatremia due to excessive electrolyte
solution use.

16. Disadvantages-
1. Cerebral edema – can aggravate the condition.
2. Increases intracranial pressure.
3. Acute ischemic stroke – hyperglycemia aggravates
ischemic brain damage.
4. Not indicated in hypovolemic shock
5. Can worsen hyponatremia, hyperglycemia.
6. Hemolysis and clumping of rbcs
7. Lactate production - tissue hypo perfusion.

17. The effect of intravenous fluid therapy with and without dextrose on blood lactate
levels in patients undergoing abdominal aortic aneurysm repair.
-DeGoute CS, Ray MJ, Manchon M, et al. Intraoperative glucose infusion and blood lactate:
during abdominal aortic surgery. Anesthesiology 1989; 71;355–361.

18. Dextrose saline (DNS)
• Contain 50 gm glucose, Sodium154 mEq , chloride154
mEq.
Advantages-
1. Correction of hypovolemia.
2. Correction of alkalosis and hypochloremia.
3. Provide calories along with electrolyte correction.
4. Unlike D-5 , compatible with blood products.

19. Disadvantages-
1. Large infusion can cause hyperglycemia
2. Osmotic diuresis.
3. Avoided in patients with partially treated shock.
4. Contraindicated in patients with interstitial edema
5. DNS for fluid correction for shock and providing
energy simultaneously is not correct .

20. 5 % Dextrose with 0.45% Nacl
Composition- glucose 50 gm, sodium 77 mEq, chloride 77mEq
Advantages-
1. Maintenance therapy – pre and post op periods.
2. Treatment of severe hypernatremia.
3. Fluid therapy in pediatric patients.
Disadvantages-
1. Contraindicated in hyponatremia.
2. Severe dehydration - larger salt replacement.

21. •

22. • Isolyte- P
- maintenance fluid in children
- Diabetes Insipidus.
• Isolyte – E
- ECF volume replacement.
- Metabolic acidosis.
• Isolyte – M
- maintenance fluid,
- correction of hypokalemia.
• Isolyte – G
- Gastric replacement fluid.
- treatment of metabolic alkalosis .

23. Colloids

24. ALBUMIN
• Versatile plasma protein – principal determinant of
plasma colloid osmotic pressure.
• Available as 5% and 25% solution.
.
• 5 % solution cop 20 mm hg and 100% plasma increment
• 25 % solution is hypertonic – 70 mm hg cop with 3 to 4
times increment..

25. Advantages –
1. Rapid plasma volume expansion – acute hypovolemic
shock.
2. Patients with hypovolemia with hypoalbuminemia
3. In therapeutic plasmaphersis - exchange fluid in place
of plasma.
4. Patients with hypoproteinemia – liver disease,
malnutrition, nephrotic syndrome.

26. Disadvantages-
1. Fast infusion - circulatory overload-
2. 25 % albumin - volume resuscitation .
3. Higher mortality rates in patients with head injury.
4. High cost limits use in low resource settings.
5. Contraindicated in patient with septic shock.

27. Background - The Saline versus Albumin Fluid Evaluation study suggested that patients
with traumatic brain injury resuscitated with albumin had a higher mortality rate than
those resuscitated with saline.
Methods For patients with traumatic brain injury (i.e., a history of trauma, evidence of
head trauma on a computed tomographic [CT] scan, and a score of ≤13 on the Glasgow
Coma Scale [GCS]), we recorded baseline characteristics from case-report forms, clinical
records, and CT scans and determined vital status and functional neurologic outcomes 24
months after randomization.
Conclusions In this post hoc study of critically ill patients with traumatic brain injury,
fluid resuscitation with albumin was associated with higher mortality rates than was
resuscitation with saline
N Engl J Med 2007;357:874-84

28. Objective-This study assessed the risk of renal adverse events in patients with
shock resuscitated using hypo-oncotic colloids, artificial hyperoncotic colloids,
hyperoncotic albumin or crystalloids, according to physician's choice.
Participants and setting: International prospective cohort study including 1,013
ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis
or receiving plasma were excluded
Conclusions: This study suggests that harmful effects on renal function and
outcome of hyperoncotic colloids may exist. Although an improper usage of these
compounds and confounding factors cannot be ruled out, their use should be
regarded with caution, especially because suitable alternatives exist
Intensive Care Med. 2008 Dec;34(12):2157-68. doi: 10.1007/s00134-008-1225-2.

29. Dextran
• Glucose polymers produced by bacteria (Leuconostoc)
• Available as dextran 40 and dextran 70.
Advantages-
1. Expansion of plasma volume.
2. Improve microcirculation.
Disadvantages-
1. Oliguria and renal failure.
2. Hypersentivity reaction.
3. Interfere with blood grouping , cross matching
4. Dose related bleeding tendency.

30. Hydroxyethyl Starch
Synthetic colloid formed by hydroxylation of glucose poylmers,
Advantages-
1. Volume expansion higher than 5 % albumin.
2. Non antigenic, no hindrance with blood grouping.
3. Prolonged effect upto 24 hrs.
Disadvantages-
1. Altered Hemostasis.
2. Nephrotoxicity.
3. Hyperamylasemia.

31. The effects of selected colloid and crystalloid fluids on the plasma volume
and interstitial fluid volume.
I
- Imm A, Carlson RW. Fluid resuscitation in circulatory shock. Crit Care Clin 1993; 9:313–333.

32. COLLOID-CRYSTALLOID CONUNDRUM
Problem
• Early focus – replacement of interstitial fluid
Crystalloids useful – expands interstitial fluid.
• Recent concerns – promoting cardiac output and oxygen
delivery.
colloids superior than crystalloid
still preferred – crystalloids. Why?
• Large volume crystalloid resuscitation – edema formation

33. Solution-
1. Life threatening hypovolemia due to blood loss-
- Iso oncotic Colloid > crystalloids
2. Hypovolemia secondary to dehydration (ECF) loss-
- crystalloid therapy.
3. Hypovolemia with hypoalbuminemia
- hyper oncotic colloid

34. Perioperative fluid therapy

35. Elective surgeries
• Maintenance fluid is all what is required in an otherwise
healthy person under NPO.
• Pre- existing deficit and ongoing losses should be
considered.
• For 0 – 10 kg Give 100 ml/kg per day
next 10-20 kg Give additional 50 ml/kg per day
> 20 kg Give additional 20 ml/ kg per day

36. • Alternate approach – replace calculated daily water
losses
• Preferred fluid- 5 % dextrose in 0.45% nacl with
potassium supplementation at 80 to 100 ml/hr

37. •
Methods - This crossover study consisted of two 48h study periods, during which 12 fasting
healthy adults were treated with a frequently prescribed solution (NaCl 0.9% in glucose 5%
supplemented by 40mmol litre1 of potassium chloride) and a premixed hypotonic fluid (NaCl
0.32% in glucose 5% containing 26mmol litre1 of potassium) . The primary end point was
cumulative urine volume; fluid balance was thus calculated.
Results. After 48h, 595ml (95% CI: 454–735) less urine was voided with isotonic fluids than
hypotonic fluids (P<0.001), The isotonic treatment was characterized by a significant
decrease in aldosterone (P<0.001). Sodium concentrations were higher in the isotonic
arm(P<0.001), but all measurements remained within the normal range. Potassium
concentrations did not differ between the two solutions (P¼0.45). Chloride concentrations
were higher with the isotonic treatment (P<0.001), even causing hyperchloraemia.
Conclusions. Even at maintenance rate, isotonic solutions caused lower urine output,
characterized by decreased aldosterone concentrations indicating (unintentional) volume
expansion, were associated with hyperchloraemia.
Despite their lower sodium and potassium content, hypotonic fluids were not associated
with hyponatraemia or hypokalaemia.
N. Van Regenmortel, T. De Weerdt et al British Journal of Anaesthesia, 118 (6): 892–900 (2017)

38. Emergency surgeries
• Rule out acute volume deficit.
• Cardio vascular signs and fluid challenge test.
• Visible sign of hypovolemia- 1 to 2 l bolus.
• End point of resuscitation
• Intensive monitoring for non responders and elderly.

40. Assessment of fluid status
• Static parameters
Central venous pressure
Pulmonary artery occlusion pressure
Inferior vena cava (IVC) diameter
• Dynamic parameters
Pulse pressure variation
Stroke volume variation
Plethysmographic variability index
• Modified fluid challenge

42. Intra operative fluid therapy
• Goal – maintain tissue perfusion and oxygenation.
• Crystalloid v/s colloid – debatable.
Crystalloid- interstitial dehydration
1. Ringer lactate – most commonly used.
2. Isotonic Saline – hypovolemic shock.
3. 5% Dextrose- insensible losses and maintenance fluid
4. Pediatric patients- Isolyte P is preferred.

43. Colloids-
Advantages
1. Rapid restoration of plasma.
2. Prolonged effect.
3. Low volume required
Disadvantages
1. More expensive .
2. Risk of hypersensitivity.
3. May increase bleeding tendency.
4. May cause renal injury.
Indications- sudden hypotension , blood product awaited.

44. How to calculate?
1. Correction of fluid deficit due to starvation .
duration of starvation (hours) x 2ml/kg body wt.
2.Maintenance requirement for period of surgery
duration of surgery(hours) x 2 ml/ kg body weight
3. Loss due to tissue dissection/ hemorrhage.
minor - 4ml/kg + 2 ml/kg
moderate - 6 ml/kg + 2 ml/kg
Severe – 10 ml/kg + 2 ml/kg.

45. Post operative fluid therapy
• Goals-
- Maintain bp > 100/70 mm of hg
- Pulse < 100 bpm
- Urine output 30 to 50 ml/kg
- Normal skin temperature and sensorium
• depend on the type and nature of surgery .
1.Short operative procedure ( no involvement of intestine
and viscera)- maintenance fluid for 5 – 6 hours

46. 2.Surgery involving intestine – post operative fluid therapy
for few days.
3. Major surgeries without intestine involvement- fluid
therapy for 24 to 48 hours.
Maintenance fluid in post op period.
Day 1 – 2 L of 5% dextrose + 500 ml of isotonic saline
Day 2 – 2 L of 5 % dextrose + 1 L of isotonic saline
Day 3 – add 40-60 mEq of potassium per day .

47. How to give –
within 8 to 12 hours
steady rate over 18 to 24 hours.
Guidelines-additional losses.
1. Prolonged vomiting/ nasogastric suction- normal saline
if urine output adequate – add k+
2. Loss of blood- blood is ideal replacement.
3. Other GI losses – ringer lactate is preferred

48. Complications-
1. volume excess
• Avoid excess isotonic fluid administration.
• Monitor signs of volume overload.
• Restrict fluid and look for other abnormalities.
2. Electrolyte imbalance-
• hyponatremia/ hypernatremia.
• hypokalemia/ hyperkalemia
3. Postoperative oliguria – many etiologies.

49. Fluid therapy in burns
Principle- To maintain intravascular volume in order to perfuse
both the visceral organs and peripheral tissue – skin.
Indications-
1. Adults with more than 15 %TBSA.
2. Children with more than 10 % TBSA.
3. Electric burns.

50. Steps of follow
1. evaluation of TBSA burnt-
• Wallace rule of nine
• Lund and browders chart
• 1% hand method
2. Calculation of fluid-
• Parkland formula for crystalloids-
TBSA X weight (kg) x 4 = volume(ml)
half in first 8 hours and second half in next 16 hours.
• Ringer lactate is the fluid to choice .

51. • Muir and Barclay formula for colloids,
0.5 x TBSA x weight(kg) = one portion
periods of 4/4/4 , 6/6 , 12 hours are made
one portion to be given in each period.
• colloids to be avoided in initial 12 hours of burns –
protein leak out .
3. Monitoring of resuscitation-
• Urine output
• Vital parameter – HR , BP
• Hematocrit
• Urine sodium >20 meq indicates improvement

52. Take home messages
1. Isotonic saline – treat shock and salt depletion.
Large volume resuscitation – complications.
2. 5% dextrose – maintenance fluid and correct
intracellular dehydration.
can cause lactate accumulation.
3. Ringer lactate – choice in burn and diarrhea induced
dehydration.
4. 5% albumin – acute hypotension and blood loss .
Colloids – avoid in sepsis, brain injury

53. HEMORRHAGE AND HYPOVOLEMIA

54. Assessment of blood volume
• clinical evaluation is flawed – called a “comedy of errors”
1. Vital signs – supine tachycardia , supine hypotension,
postural pulse increment, postural hypotension.

55. • vitals sign provide little benefit in evaluation of
hypovolemia – excluding the diagnosis.
2. Hematocrit –
• changes in hematocrit shows poor correlation with blood
volume deficits in acute hemorrhage.
• Hematocrit is a reflection of resuscitation effort ( type
and volume of fluid infused )

56. •
Influence of acute hemorrhage and fluid resuscitation on blood
volume and hematocrit.

57. 3. Cardiac filling pressures-
• include central venous pressure and pulmonary artery
occlusion pressure.
• role is not justified – poor correlation of between
cardiac filling pressure and VEDV and circulating blood
volume

58. 4. Chemical markers of Dysoxia-
• Serum lactate- lactate levels of >= 4 mM/L is predictive of
increased mortality – used to identify life threatening
condition.
• Lactate clearance- normalization of lactate within 24 hrs is
used as end point of resuscitation .
• Arterial Base deficit- surrogate marker of lactic acidosis in
form of metabolic acidosis.
5. Fluid responsiveness- attempt to limit volume therapy
to those likely to respond.
• Fluid challenge
• Passive leg raising.
6. Measuring blood volume

59. Resuscitation strategies
• Immediate goal –support oxygen delivery to vital organs.
• Two components – cardiac output and hemoglobin
concentration.
1. Promoting cardiac output-
colloid fluid is most effective for augmenting cardiac
output , crystalloid is only 25 % as effective despite twice
volume

60. •
Change in cardiac index after a one-hour infusion of different resuscitation fluids.
The infusion volumes are roughly equivalent (500 mL), except for Ringers lactate
(1 liter)

61. The preferred fluid –
Despite the superiority of colloid over crystalloid, latter are
the preferred choice becoz-
• Low cost of crystalloids
• Lack of documented survival benefit with colloid resuscitation.
preferred crystalloid – Ringer lactate
Standard regimen-
1. Any patient with active bleeding/ hypotension – infuse 2
liters of crystalloid over 15 mins
2. If hypotension or bleeding continue ,packed RBCs
infused to maintain mean bp > 65 mm hg
3. When bleeding is controlled threshold for Rbc transfusion is
hb.> 7 g/dl

62. •

63. End points

64. References
1. The ICU Book – 4 th edition by Paul L Marino.
2. Practical guidelines on fluid therapy – Dr. sajay Panday
3. Sabiston textbook of surgery.
4. Schwartz principles of surgery.
5. Bailey and Love – short practice of surgery
6. Clinical and experimental emergency medicine.
7. British journal of anesthesia.
8. Anesthesiology – journal.