Intravenous Fluids In Surgical Patients

1. Intravenous Fluids In Surgical Patients
Dr Lalit K Shah
Resident General Surgery
Mentor- Asso Prof Dr Tanka Prasad Bohara

2. Introduction
• Water constitutes approximately 50% to 60% of total body
weight
• The relationship between total body weight and total body
water (TBW) is relatively constant for an individual and is
primarily a reflection of body fat
• Lean tissues such as muscle and solid organs have
higher water content than fat and bone

4. Fluids Component

8. Types
• Crystalloids
• Colloids

9. CRYSTALLOID COLLOID
aqueous solution of low molecular weight electrolyte aqueous solution of high molecular weight substance
replacement ratio of crystalloid for blood loss is 3:1
(1/3rd remains in intravascular, 2/3rd remains in
interstitial)
replacement ratio of colloid is 1:1 (as all remains in
intravascular space)
T 1/2= 15-20 mins T1/2= 3-4 hrs
Cheap Costly
3 types 1. Hypotonic (5% dextrose)
2. Isotonic (NS, RL)
3. Hypertonic (3% NS, 6% NS
always isotonic

11. Plasmalyte
140 mEq sodium, 5 mEq potassium, 3 mEq
magnesium, 98 mEq chloride, 27 mEq acetate,
and 23 mEq gluconate

12. Curran JD, Major P, Tang K, et al. Comparison of Balanced Crystalloid Solutions: A Systematic Review
and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor. 2021;3(5):e0398. Published 2021
May 14. doi:10.1097/CCE.0000000000000398

17. Goal Directed Fluid Therapy
• Based on physiologic variables related to CO, oxygen
delivery and administering of fluids and possibly
inotropes, vasopressors, vasodilators and RBC to
improve tissue perfusion and clinical outcome
• Used both in perioperative and critical care settings
• Survivor values undergoing major surgery
- Cardiac index >4.5L.min/m2
- O2 delivery index ( DO2I) > 600ml/min/m2
- O2 consumption of index > 170 ml/min/m2

20. Approach to GDF
• Rapidly administer 250ml of boluses of colloid or
crystalloid
• Aim to increase SV by 10% or more each time
• Continued until there is no further rise in SV
• GDF extrapolates a patient’s fluid responsiveness from
measurable hemodynamic changes according to the
Frank–Starling curve.

21. Appropriate Fluid Selection
• Crystalloids :
- evaporative losses,
- maintenance fluid requirements
- expansion of the entire extracellular fluid volume
• Colloids :
- intravascular volume expansion

23. Preoperative Fluid Therapy
• Elective
Oral clear fluid intake should continue until 2 hours
preoperatively
Longer fasting discouraged
Crystalloid with K+ supplementation should be given in
the preoperative period.

24. • Emergency
require timely resuscitation guided by rational physiologic
endpoints such as trends in blood pressure and heart
rate, lactate, urine output, and mixed or central venous
O2 saturations.

25. • The administration of maintenance fluids should be all
that is required in an otherwise healthy individual who
may be under orders to receive nothing by mouth for
some period before the time of surgery
• This does not, however include replenishment of a
preexisting deficit or ongoing fluid losses

26. • The following is a frequently used formula for calculating
the volume of maintenance fluids in the absence of
preexisting abnormalities
• For example, a 60-kg female would receive a total of 2300
mL of fluid daily:
- 1000 mL for the first 10 kg of body (10 kg × 100 mL/kg per day),
- 500 mL for the next 20 kg (10 kg × 50 mL/kg per day), and
- 800 mL for the last 40 kg (40 kg × 20 mL/kg per day)

27. Intraoperative
• Maintenance - infusion of balanced crystalloid ( 1-1.5 ml/kg/hr )
• Hypovolemia due to GA / RA : unless hypovolemia, treat small doses of
vasopressors or iontropes
• High risk patient
- Invasive BP monitoring
- CO optimized by titrating boluses of colloid or balanced crystalloids
- Blood loss should be replaced with colloid or blood products
• Goal – achieve euvolemia by end of surgery or the early postoperative
period

28. • Maintenance Fluid Requirements
4-2-1 Rule
- 4ml/kg/hr for the first 10 kg of body weight
- 2ml/kg/hr for the second 10 kg of body weight
- 1ml/kg/hr for subsequent kg body weight
Eg: 70 Kg
Maintenance Fluid: 40+20+50 ml/hr

29. • Deficit
number of hours NPO X maintenance fluid requirement
measurable fluid losses e.g NG suctioning, vomiting,
stoma output
Eg: 70 kg patient fasting for 8 hours
Deficit: 8 X 110= 880 ml
Half given in first hour, one fourth each in next two hour

30. • Third Spaces 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

31. • Replacing third space losses
minimal surgical trauma: 0-2 ml/kg/hr (eg herniorrhaphy)
moderate surgical trauma: 2-4 ml/kg/hr (eg cholecystectomy)
severe surgical trauma: 4-6 ml/kg/hr (eg major bowel resection)

32. • Blood Loss
 Replace 4 cc 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

33. • clot size of a clenched fist
is 500ml
• weighing the swab before
and after use
• Rains Fcator

34. Enhanced Recovery After Surgery (ERAS)
• As pioneered by the Danish surgeon Henrik Kehlet, ERAS
pathways have been designed to guide the perioperative
management of various types of surgical procedures
• Fluid management within ERAS should be viewed as a continuum
through the preoperative, intraoperative, and postoperative
phases

35. • The 2011 European Society of Anaesthesiology guidelines were
among the first formal recommendations to alter standard
recommendations for preoperative enteral intake
• These recommendations include allowance of clear liquids up to 2
hours prior to surgery
• Many ERAS protocols include the use of carbohydrate and
electrolyte-rich fluids to enhance hydration and metabolic
response to surgery

36. • In addition to preoperative enteral hydration, a major focus of
ERAS protocols is the restriction of intra- and postoperative
sodium and intravenous fluids
• Fluid overload has been associated with prolonged ileus and
coagulation abnormalities

38. References
• Schwartz’s Principles Of Surgery
• Sabiston Textbook Of Surgery 21st edition
• Bailey & Love 27th edition
• Pubmed

39. THANK YOU