a short and precise presentation on Fluids, Nutrition and Blood Transfusion by Dr. Habibur Rahman Bhuiyan, at 2014 at Dhaka Medical College Hospital.

1. Dr. Habibur Rahman Bhuiyan
Intern Doctor
DMCH

3. Importance of Body fluid
Management
• To make a decision about patients
management.
• Loss of more than 10% of total body
fluids can shut one’s vital systems
down!!!
• Can be life-saving in certain conditions.

4. Abdus Subhan, A 35 years Old day laborer
admitted in DMCH with severe abdominal pain
with a history of ingestion of NSAID
one day back. On examination he is
restless, his BP is unrecordable and
his pulse is 120 b/min. his abdomen is
tender and rigid. What may be the first
step of management?

5. WATER BALANCE
•Daily Turn over 2500ml
•Daily Water input:
–Ingested water: 1500mL
–Water content in food: 800mL
–Water from oxidation : 300ml
–TOTAL: 2500mL

6. •Daily water output:
 Urine: 1500mL
 Skin: 500mL
 Respiratory tract: 300mL
 Stool: 200mL
TOTAL: 2500ml

7. Daily GIT Fluid secretion
 Saliva- 1000-2000 ml
 Gastric juice- 1000-2000 ml
 Bile- 500-1000 ml
 Pancreatic juice- 1000-2000 ml
 Intestinal secretions- 1000-2000 ml

8. When its IMBALANCE?
Excessive Fluid Loss –
Dehydration
Excessive fluid administration-
Fluid Overload

9. Cause of Dehydration
Intestinal obstruction
Diarrhoea
Blood loss
Fistulae
Burn
Sepsis
RTA

10. Dehydration: clinical assessment
 Appearance
 Respiration
 Mucous membrane
 Eyes
 Capillary filling
 Pulse
 Urine flow
 Weight loss

11. Maintenance Requirements
IV fluid -2500ml/Day
- NS- 500ml
- 5% Da – 2000ml
Easy Tips!!!
1500ml for first 20kg then 2oml for rest
per kg/day.
Don’t forget to add 1mp k+ in each litre of
5% DA solution if patient is in NPO. (add
it after 24 hour of Surgery.)

12. Maintenance Pathological losses
 ml for ml Replacement with Normal Saline
in case of
 Vomiting
 Diarrhoea
 Fistula
 in case of ileostomy fistula-
• Hartmann’s solution
• h2 receptor Blocker
• Somatostatin

13. Be careful about…
 Vitals of the Body
 Urine Output
 Respiratory distress
 Any Cardiac Insufficiency

14. Hypervolemia
 Excessive administration of IV fluid (
commonest)
 Renal Failure
 Cardiac Failure

15. IV FLUIDS
According to Osmolarity:
 Colloid solution
 Crystalloid solution
 According to tonicity:
 isotonic solution
Hypotonic solution
Hypertonic solution

16. Commonly available fluids
 0.9% NaCL solution
 5% DA
 5% DNS
 Hartmann’s solution
 Cholera Saline
 Ringer Lactate solution

17. Available Fluids at a glance
Na+
mEq/L
K+
mEq/
L
Cl-
mEq/L
HCO3
-
mEq/
L
Dextrose
gm/L
mOsm/
L
Ca++
mEq/
L
Lactat
e
mEq/
L
NS 154 154 286
5% DA 50 278
5% DNS 154 154 50 564
Ringers
Lactate
130 4 109 28 50 272
Hartman
Solution
133 5
111
3 4 29

18. Indication of Fluid adminstration
 Three seperate aspects need to be
considered.
i. Mainetenance requirements
ii. Replacement of ongoing
pathological losses
iii. Repair of deficits

19. Important Electrolytes in ECF
Cations
Na+ 135-145 mEq/L
K+ 3.5-5 mEq/L
Ca++ (Ionized) 2.2-2.8 98-106 mEq/L
Mg++ 1.5-1.9 mEq/L
Anions
Cl- 98-106 mEq/L
HCO3- 21-30 mEq/L

20. Hypokalaemia
 Clinical Feauture
(Specially muscular manifestation)
 Muscular weakness
 Depressed Reflex
 Drowsiness
 gasping Respiration
 paralytic ileus

21. Investigation (HypoK+)
 S. electrolytes
 ECG
ECG Findings: when k is below 2.7 mEq/L
 T wave inversion.
 Prominent U waves.

22. Management Of Hypokalaemia
 Oral 15 ml KCl – 6 hourly
or
 I/V KCl -40mmol/L in 0.9% NS slowly
Caution:
Don’t give > 20 mmol/L/Hour
Don’t give >40 mmol/L

23. Hyper kalemia
Causes
Renal Failure
I/V fluid containing K+
Transfusion of stored blood
Massive tissue destruction

24. Hyperkalaemia Cont.
Dangers Of Hyperkalaemia
 Cardiac Arrest
 Cardiac arrythmia
ECG change:
 high peaked T wave
 Wide QRS Complex
 ST depression

25. Treatment Of Hyperkalaemia
 Infusion of 10% Ca-Gluconate
 50 ml 50% Glucose with 10 IU Insulin – I/V
slowly
 I/V Frusemide
 I/V NaHCO3
 Calcium Resonium

26. Other important E. imbalance
 Hyponatremia
 Hypernatremia
 Hypocalcemia
 Hypercalcemia etc

27. Nutrition

28. Case scenario…
Doyal munshi a 65 year muslim male
admitted in DMCH 1 week back with
the complain of inability to pass
stool and abdominal swelling for
3days. Now he is getting just IV
fluids as his nutritional suppliment.
Is it enough for him?

29. Importance of nutrition
Patients with severe malnutrition have
greater incidence of postoperative
complications such as
 Pneumonia
 Wound infection
 Prolonged hospital stay

30. Nutritional assesment
 History Taking: Diet & weight loss.
 Physical Examination:
General appearance
Body fat stores assessment
Protein stores assessment
 Biochemical Indicators:
Serum albumin
Hb%

31. Daily Requirements…
 Water: 30-70 ml/kg/d
 Calories: 30-50 kcal/kg/d
 Protein: 1.5-2.0 g/kg/d
 Electrolytes-
○ Na+ - o.9-1.2 mmlo/kg
○ K+ - 0.7-0.9 mmol/kg
In addition Mg++, Ca++, Chloride, Phosphate, Zinc,
Trace elements and Vitamins are also required
in different interval.

32. Types of nutrition
2 ways
 Enteral nutrition
 Parenteral nutrition

33. Entral Nutrition
Routes
Oral feeding
NG feeding
Feeding gastrostomy
Feeding jejunostomy

34. Total Parenteral Nutrition
 Indication: :( Where Enteral feeding is
impossible)
 Gut short: Volvulus with
infarction
 Gut blocked: Anastomotic edema
 Gut unable to cope: Radiation
enteritis
 Gut fistulated: Crohn’s disease

35. TPN regimen (In a 55kg pt)
Nutrition Amount/daily
50% Dextrose 550ml
20% lipid Solution 550 ml
Amino Acid solution 1000ml
Free Water 400ml
Total volume 2500ml
Volume For Electrolytes 200ml
Trace element Solution 10ml/day
Extra Zinc 10ml/day
Multivit Infusion 10ml/day
Folic Acid 1mg/day

36. Follow up of TPN
 Tube Dressing – 3 times in a week
 S. Electrolytes and glucose daily until
pt is stable. If stable then 3 Times in
a week.
 Zinc, Mg, Hb – weekly
 weight monitoring - Daily

37. Complication of PN
 Mechanical: thrombosis, embolism, skin slough.
 Infectious: particularly staph epidermidis,
candida.
 Metabolic: hypoglycaemia, hyperglycaemia,
cholestasis.

38. BLOOD TRANSFUTION

39. Case Scenario…
 Mr. Jashim Uddin is admitted in
DMCH for last 1 month. He has
undergone several episode of
laparotomy. He has h/o fever fpr last
2 days. Suddenly a rush of fresh
blood started to come from his
ileostomy bag. To manage it Which
component of blood he need?

40. Indication of BT
Acute blood loss
 Major surgical operations
 Road traffic accident
 Hematemesis & melena
 perioperative anemia
 Severe burn victims
 DIC
 Hematological disorders etc.

41. Blood components
 Whole blood
 Packed red cell
 Fresh frozen plasma
 Platelet concentrate
 Cryoprecipitate
 Factor VIII
 Factor IX

42. Transfusion Hazards
 Hemolytic transfusion reaction
 Allergic reaction
 Febrile reaction
 Transmission of diseases.
 Transfusion related acute lung injury (TRALI)
 DIC
 Citrate toxicity
 Metabolic acidosis.

43. Complications of massive BT
 Coagulopathy
 Volume overload
 Hypothermia
 Hyperkalemia
 Metabolic acidosis
 Hypocalcemia

44. Hemolytic Transfusion Reaction :
 Sign & Symptoms :
 Fever
 Chest tightness
 Flank pain
 Nausea
 pruritus

45. Management of HTR…
 STOP THE TRANSFUSION.
 Maintain the urine output at a minimum of
75 to 100 ml/hour.
 Alkalinize the urine
 Determine platelet count, partial
thromboplastin time, and serum fibrinogen
level.
 Return unused blood to blood bank for
repeat crossmatch.
 Prevent hypotension to ensure adequate
renal blood flow.

46.  “Its not merely a mercy to the
patient to maintain the proper
supplementation of nutrients. it’s
essential to save life. If I miss it
then it will be just Miss-
magement…”