By: Iis Martilopa (04104705051)Olia Indri Saktianingsih (04104705085) Yarah Azzilzah (04104705264) Advisor:Dr. Endang Melati Maas, Sp. An, KIC. KAP
Fluid is the largest part in body. The total amount of body fluid volume and solute, as well as concentration are relatively constant during steady-state condition. Disturbances of composition and volume of body fluid is one of the most common clinical problems and important. Large disturbances of fluid and electrolyte balance may quickly lead to changes in cardiovascular function, neurological, and neuromuscular
Fluidis the largest part in body. TBW (Total Body Water) may change, depending on age, gender, & degree of obesity Age Percentage of TBW Depending on Body weightInfant 75%Male(20-40 years old) 60%Female(20-40 years old) 50%Geriatrics(> 60 tahun) 45-50%
Fluid intake comes from: Oral Fluid, Solid Foods & Oxidative Metabolism. Fluid loss Insensible Water Loss Fluid loss through skin Fluid loss through GI tract Fluid loss through kidney
Fluid Intakes Fluid LosesOxidative Metabolism 300 ml Kidney 1200-1500 mlOral Fluid 1100-1400 ml Skin 500-600 mlSolid Foods 800-1000 ml Lungs 400 ml GI tract 100-200 mlTotal 2200-2700 ml Total 2200-2700 ml
Compartment Fluid as Total Body Fluid percent body Water (%) Volume (L) weight (%)Intracellular 40 67 28Extracellular Interstitial 15 25 10,5 Intravascular 5 8 3,5Total 60 100 42
WATER ELECTROLYTE Na+ K+BODY FLUID PO4 - Cl- dll SOLUTE NON ELECTROLYTE Protein Urea Kreatinin Glukosa
ECF, including plasma & interstitial fluid, contain sodium & chloride ions in large amount, bicarbonate ions are also in large enough quantities, but only a few ions of potassium, calcium, magnesium, phosphate, and organic acids. ICF only contains a few amount of sodium and chloride ions and almost no calcium ion. In fact, this fluid contains a large amount of potassium ions, phosphate, and proteins.
Osmosis is the net movement of water across a semipermeable membrane as a result of difference in non diffusible solute concentration between the two side. Osmotic pressure is the pressure that must be applied to the side with more solute to prevent a net movement of water across the membrane to dilute the solute. Osmotic pressure is generally dependent only on the number of nondiffusible solute particles.
The osmolarity of the solution is equal to the number of osmoles per liter of solution. The osmolality equals the the number of osmoles per kilogram of solvent. Tonicity refers to the effect a solution has on cell voluume. An isotonic solution has no effect on cell volume, whereas hypotonic and hypertonic solution increase and decrease cell volume respectively.
The condition that is caused by depletion of extracellular fluid. The most common cause of volume depletion is diarrhea or vomiting. The other causes include trauma, infection, inflamation, bleeding, burns, etc. Volume depletion is devided into 3 types based on the blood sodium level: - Isonatremic (normal blood sodium levels) - Hyponatremic (abnormally low blood sodium levels) - Hypernatremic (abnormally high blood sodium levels)
Volume overload is the condition that can be caused by iatrogenic or secondary of renal insuffiency, sirosis or congestive heart failure. Edema is the indication of volume overload in tissues. Classification of edema : Intracelullar Edema & Extracelullar Edema
1. Sodium DisturbanceHyperosmolality & Hypernatremia Hypernatremia is nearly always the result of either a loss of water in excess of sodium or retention of large quantities of sodium Clinical Manifestation: restless, lethargy, and hyperreflexia can progresss to seizures, coma, and ultimately death. Treatment of hypernatremia is aimed at restoring plasma osmolality to normal as well as correcting the underlying problem.
Water deficit should generally be corrected over 48 h with hypotonic solution such as D5W. Hypernatremic patients with decreased total body sodium should be given isotonic fluids to restore plasma volume. Hypernatremic patients with increased total body sodium should be treated with loop diuretic along with intravenous D5W.
Hypoosmolality & Hyponatremia Hyponatremia invariably reflects water retention from either an absolute increase in TBW or loss of sodium in excess of water. Clinical Manifestation : anorexia, nausea, weakness. Progressive cerebral edema, however result in lethargy, confusion, seizures, coma and finally death. Treatment of hyponatremia: Na+ Deficit = TBW x (desired Na [Na+] – present [Na+]) Very rapid correction of hyponatremia has been associated with demyelinating lesion in pons. The correction rate : :0,5 meq/L/horless (mild symptom); 1 meq/L/h or less (moderate symptom); and 1,5 meq/L/h or less (severe symptom).
2. Potassium DisturbanceHyperkalemia Hyperkalemia exsists when plasma [K] exceeds 5,5 meq/L Hypercalemia can result from (1) an intercompartmental shift of potassium ions (2) decreased urinary excretion of potassium or rarely (3) an increased potassium intake. Clincal manifestation involves CNS (paraesthesia, skeletal weakness) and cardiovascular system (dysrhytmia, ECG changes).
Treatment of hyperkalemia: Treatment is directed at reversing cardiac manifestation, anda skeletal muscle weakness and restoring of plasma K to normal calcium 95-10 ml of 10% calcium gluconate or 3-5 ml of 10% calcium chloride) partially antagonizes the cardiac effects of hyperkalemia and is useful in patients with marked hyperkalemia.
Hypokalemia Is defined as plasma [K+] less than 3,5 mEq/l. Hypokalemia can occur as result of (1) intercompartmental shift of K+ (2) increased potassium loss or (3) an inadequate potassium intake. Clinical Manifestation : abnormality of ECG, sketetal muscle weakness, muscle cramping, tetany, and rarely rhabdomyolisis. Treatment of hypokalemia: - oral replacement with potassium chloride solution is generally safest (60-80 mEq/d). - intravenous replacement of potassium chloride should usually reserved for patient with or risk for serious cardiac manifestation or muscle weakness
Fluid management is aimed to replacement of water and electrolyte depletion, shock therapy, and solves another abnormalities that occur because of therapy.Intravenous fluid management, consists of:- Crystalloid Fluid- Colloid Fluid- Combination both of them
This fluid has composition that is similar to ECF. Crystalloid solutions are aqueous solutions of low molecular-weight ion (salts) with or without glucose.. Half time of crystalloid solution in intravascular is about 20-30 minutes. Crystalloid should be considered as resuscitation fluid in patients with hemorrhagic and septic shock, in burn patients, in patients with head injury to maintain cerebral perfusion pressure, and in patients undergoing plasmapharesis and hepatic resection.
If 3-4 l of crystalloid has given, and hemodynamic responses inadequate, colloid may be added. Solution are chosen according to the type of fluid loss being replaced. For loses primarily involving water hypotonic solution maintenance type solution If loses involve both water and electrolyte isotonic solution replacement type solution.
The most commonly used fluid is lactated Ringer’s solution. When NS is given in large volume, can produces a dilutional hyperchloremic acidosis because of its high sodium and chloride (154 mEq/l). NS is the preferred solution for hypochloremic metabolic alkalosis and for diluting PRC prior to transfusion. D5W is used for replacement of pure water deficits and as a maintenance fluid for patients on sodium restriction. Hypertonic 3% saline is employed in therapy of severe symptomatic hyponatremia.
Colloid is called as plasma replacement fluid or usually called “plasma substitute” or “plasma expander” The osmotic activity of high molecular weight substances in colloid tends to maintain these solution intravascularly. Most colloid solutions have intravascular half- lives between 3-6 h.
Generally accepted indicatons for colloid include:1.Fluid resusitation in patients with severe intravascular fluid deficit (eg. Hemorrhagic shock) prior to the arrival of blood transfusion.2.Fluid resusitation in the presence of severe hypoalbuminemia or condition associated with large protein losses such as burns.
Perioperative fluid therapy includes replacement of preexisting fluid deficits of normal losses (maintenance requirements), and surgical wound losses including blood loss.
Normal Maintenance Requirementsin the absence of oral intake, fluid & electrolyte deficits can rapidly develop as result of continued urine formation, gastrointestinal secretions, sweating and insensible loses from skin and lung. Weight Rate For the first 10 kg 4 ml/kg/h For the next 10-20 kg add 2 ml/kg/h For each kg > 20 kg add 1 ml/kg/hEg: what are the maintenance fluid requirements for 25 kg child? 40 + 20 + 5 = 65 ml/h
Preexisting deficit Patients presenting for surgery after an overnight fast without any fluid intake will have a preexisting deficit proportionate to the duration of the fast. Preexisting deficit = normal maintenance rate x length of the fast Eg : for average 70 kg, fasting for 8 h, this amounts to (40+20+50)ml/h x 8 h = 880 ml Fluid is given ½ part for the first hour, ¼ part for the next second hour, and ¼ part for the next third hour.
Intraoperative Fluid ReplacementIntraoperative fluid therapy should include supplying basic fluid requirements and replacing residual preoperative deficit as well as intraoperative losses (blood, fluid redistribution, and evaporation)
1. Replacing Blood LossIdeally, blood loss should be replaced with crystalloid or colloid to maintain vascular volume until the danger of anemia outweighs the risk of transfusion.The transfusion point can be determined preoperatively from the hematocrit and by estimating blood volume. Age Blood Volume Neonates - Premature 95 mL/kg - Full-term 85 mL/kg Infants 80 mL/kg Adults - Men 75 mL/kg - Woman 65 mL/kg
Patientswith normal hematocrit should generally be transfused only after losses greater than 10-20 % of their blood volume.
2. Replacing Redistributive & Evaporative LossesBecause these losses are primarily related to wound size and the extent of surgical dissection and manipulation procedures can be classified according to the degree of tissue traumaDegree of Tissue Tauma Additional Fluid RequirementMinimal (eg hernioraphy) 0 – 2 ML/KGModerate ( eg cholecystectomy) 2 – 4 ML/KGSevere(eg bowel resection) 4 – 8 ML/KG
Perioperative Fluid Therapy: 1. Maintenance = (4 x the first 10 kg) + (2 x the next 10-20 kg) + (1 x each kg > 20 kg) 2. Preexisting deficit = Maintenance x length of fasting 3. Redistributive & Evaporation (IWL) = degree of tissue trauma x BBThe first hour = ½ part = (½ P) + M + IWLThe second hour = ¼ part = (¼ P) + M + IWLThe third hour = ¼ part = (¼ P) + M + IWL