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Fluid Management in Adults

2009/8/19 ⼩小港外科 Intern teaching

R2 ⿈黃昱豪
Surgeon’s Maintenance Fluid
Human beings are
built by water......
⼥女⼈人是⽔水作的??

Male (60%) > female (50%)
Biomedical Importance of Water
Homeostasis (CES)
Water distribution
PH maintenance
Maintain Electrolyte Concentration
Set ...
Body Fluid Compartments:

2/3

X 50~70%
lean body weight

TBW

3/4

Male (60%) > female (50%)
TBW(Total Body Water)=0.6xBW...
Mr.Iron, 60-Kg male, he has......IVW
Ans:
60Kg x 60%(man) x
1/3(ECF) x 1/4(IV) =
3kg intravascular water
(about 3000 ml pl...
Composition of Body Fluids:
Cations

150

Anions

100
50
0

ECF

Na+
ClHCO3Ca 2+
Mg 2+

Protein

50

ICF

K+

PO43Organic
...
Regulation of Fluids:

Hydrostatic pressure v.s. Oncotic pressure
à Albumin is the major determining oncotic pressure
Regulation of Fluids:
Renal sympathetic nerves
Renin-angiotensinaldosterone system
Atrial natriuretic peptide (ANP)
Fluid management
output, loss

intake, produce
FLUID REQUIREMENTS
Sources

Losses (35ml/kg/day)
Urine

Water

1500 ml

Food

800 ml

Stool

200 ml

Oxidation

300 ml

Sk...
Fluid Management
Maintenance
Ongoing loss

Deficit

lMaintenance+Deficit+Ongoing loss
Maintenance fluid
Maintenance Fluid:
Water require, Rule:
100-50-20(60kg=2300ml/day)
100ml/kg/d(for 1st 10kg) +50ml/kg/d(for 2nd 10kg)+20ml/...
Mr.Iron, 60-Kg male, NPO

Maintenance Fluid......
1. Daily Na Requirement=3meq/kg ×60kg=180meq
Daily K Requirement=1meq/kg...
MAINTENANCE vs. REPLACEMENT
n Maintenance:
• Provide normal daily requirements:	
• Water: 2.5 L
• Sodium ½ or ¼ NS
• KCl ...
Intravenous Fluids:
• Crystalloids
• Colloids
• Blood/blood products and blood
substitutes
Parenteral Fluid Therapy:
Crystalloids:
- contain Na as the main osmotically
active particle
- useful for volume expansion...
Crystalloids:
Isotonic crystalloids
- Lactated Ringer’s, 0.9% NaCl
- only 25% remain intravascularly
Hypertonic saline sol...
Colloid Solutions:
Contain high molecular weight
substancesàdo not readily migrate across
capillary walls
Preparations
- ...
Common parenteral fluid therapy-Crystalloid
Solutions

Volumes

Cl-

HCO3-

5

103

27

280-310

3

109

28

273

K+

Ca2+...
Common parenteral fluid therapy-Colloid
Solutions

Volumes

K+

Ca2+

142

ECF

Na+

4

5

6%
Hetastarch

500

154

5% Alb...
The Influence of Colloid & Crystalloid on
Blood Volume:
Blood volume
Infusion
volume

200

1000cc

500cc

500cc

500cc

60...
Deficits fluid
NPO and other deficits
• NPO deficit =number of hours NPO x
maintenance fluid requirement.
• Bowel prep may result in up to 1...
Third Space Losses
• Isotonic transfer of ECF from functional body
fluid compartments to non-functional
compartments.
• Dep...
Replacing Third Space Losses
• Superficial surgical trauma: 1-2 ml/kg/hr
• Minimal Surgical Trauma: 3-4 ml/kg/hr
- head and...
Ongoing loss fluid
• Measurable fluid losses:
• Foley tube

• Unmeasurable fluid
losses:

• ostomy output

• Fever(Temp of
38.3C~39.4C, >24hr
=...
Composition of GI Secretions:
Source

Volume (ml/24h)

Na+*

K+

Cl-

HCO3-

Salivary

1500 (500~2000)

10 (2~10)

26 (20~...
Other factors
• Ongoing fluid losses from other sites:
- gastric drainage
- ostomy output
- diarrhea
- PTGBD, T-tube
• Repl...
Blood Loss
• Replace 3 cc of crystalloid solution per cc of blood
loss (crystalloid solutions leave the intravascular
spac...
Example
• Mr.Michelin, 62 y/o male, 80 kg, for hemicolectomy
• NPO after 2200, surgery at 0800, received bowel prep
• 3 hr...
Example (cont.)
• Ans:
• Fluid deficit: 1.5 ml/kg/hr x 10 hrs = 1200 ml + 1000
ml for bowel prep = 2200 ml
• Maintenance: 1...
Monitor
Hypovolemia
Signs of Hypovolemia:
Diminished skin turgor
Dry oral mucus membrane
Oliguria
- <500ml/day
- normal: 0.5~1ml/kg/hr
Tachyca...
Orthostatic Hypotension
• Systolic blood pressure decrease of greater than
20mmHg from supine to standing
• Indicates fluid...
Clinical Diagnosis of Hypovolemia:
Thorough history taking: poor intake, GI
bleeding…etc
BUN : Creatinine > 20 : 1
- BUN↑:...
Hypervolemia
Signs of Hypervolemia:
Hypertension
Polyuria
Peripheral edema
Wet lung
Jugular vein engorgement

Especially when
hypo-albu...
Management of Hypervolemia:
Prevention is the best way
Guide fluid therapy with CVP level or
pulmonary wedge pressure
Diur...
Summary
• Fluid therapy is critically important during the
perioperative period.
• The most important goal is to maintain ...
歡迎加⼊入外科的⾏行列
General Surgery ~~ Fluid management in Adults
General Surgery ~~ Fluid management in Adults
General Surgery ~~ Fluid management in Adults
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General Surgery ~~ Fluid management in Adults

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General Surgery ~~ Fluid management in Adults
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General Surgery ~~ Fluid management in Adults

  1. 1. Fluid Management in Adults 2009/8/19 ⼩小港外科 Intern teaching R2 ⿈黃昱豪
  2. 2. Surgeon’s Maintenance Fluid
  3. 3. Human beings are built by water......
  4. 4. ⼥女⼈人是⽔水作的?? Male (60%) > female (50%)
  5. 5. Biomedical Importance of Water Homeostasis (CES) Water distribution PH maintenance Maintain Electrolyte Concentration Set of Fluid Balance Depletion (dehydration) Intoxication (over-hydration) Osmotic & non osmotic mechanism
  6. 6. Body Fluid Compartments: 2/3 X 50~70% lean body weight TBW 3/4 Male (60%) > female (50%) TBW(Total Body Water)=0.6xBW ICF: 55%~75% 1/3 ECF ICF=0.4xBW ECF=0.2xBW 1/4 Extravascular àInterstitial fluid Intravascular àplasma
  7. 7. Mr.Iron, 60-Kg male, he has......IVW Ans: 60Kg x 60%(man) x 1/3(ECF) x 1/4(IV) = 3kg intravascular water (about 3000 ml plasma)
  8. 8. Composition of Body Fluids: Cations 150 Anions 100 50 0 ECF Na+ ClHCO3Ca 2+ Mg 2+ Protein 50 ICF K+ PO43Organic anion 100 150 Osmolarity = solute/(solute+solvent) Osmolality = solute/solvent (290~310mOsm/L) Tonicity = effective osmolality Plasma osmolility = 2 x (Na) + (Glucose/18) + (Urea/2.8) Plasma tonicity = 2 x (Na) + (Glucose/18)
  9. 9. Regulation of Fluids: Hydrostatic pressure v.s. Oncotic pressure à Albumin is the major determining oncotic pressure
  10. 10. Regulation of Fluids: Renal sympathetic nerves Renin-angiotensinaldosterone system Atrial natriuretic peptide (ANP)
  11. 11. Fluid management output, loss intake, produce
  12. 12. FLUID REQUIREMENTS Sources Losses (35ml/kg/day) Urine Water 1500 ml Food 800 ml Stool 200 ml Oxidation 300 ml Skin 500 ml (0.5~1ml/kg/hr) (12ml/kg/day) 1500 ml Resp. Tract Total 2600 ml 400 ml Total 2600 ml Practically Daily Input/Output balance = +500ml
  13. 13. Fluid Management Maintenance Ongoing loss Deficit lMaintenance+Deficit+Ongoing loss
  14. 14. Maintenance fluid
  15. 15. Maintenance Fluid: Water require, Rule: 100-50-20(60kg=2300ml/day) 100ml/kg/d(for 1st 10kg) +50ml/kg/d(for 2nd 10kg)+20ml/kg/d(per add 1 kg) 4-2-1(60kg=100ml/hr=2400ml/day) 4ml/kg/hr(for 1st 10kg) +2ml/kg/hr(for 2nd 10kg)+1ml/kg/hr(per add 1 kg) 1.5ml/kg/hr(60kg=90ml/hr=2160ml/day) Electrolytes require: - Na+: 2-3mmol/kg/day - K+: 1~2mmol/kg/day Glucose supplement(if NPO): 100~150g dextrose/per day "Two stereoisomers (isomeric molecules whose atomic connectivity is the same but whose atomic arrangement in space is different.) of the aldohexose sugars are known as glucose, only one of which (Dglucose) is biologically active. This form (D-glucose) is often referred to as dextrose monohydrate, or, especially in the food industry, simply dextrose (from dextrorotatory glucose).
  16. 16. Mr.Iron, 60-Kg male, NPO Maintenance Fluid...... 1. Daily Na Requirement=3meq/kg ×60kg=180meq Daily K Requirement=1meq/kg ×60kg=60meq 2. Maintenance water=2300ml=2.3L 3. 【Na】of fluid=180meq÷2.3L= 78meq/L≒1/2 normal saline 4. 0.9%NaCl=154meq/L
  17. 17. MAINTENANCE vs. REPLACEMENT n Maintenance: • Provide normal daily requirements: • Water: 2.5 L • Sodium ½ or ¼ NS • KCl 40-60 meq n Example: D5 ½ NS with KCL 20 meq/L running at 100 ml/hr
  18. 18. Intravenous Fluids: • Crystalloids • Colloids • Blood/blood products and blood substitutes
  19. 19. Parenteral Fluid Therapy: Crystalloids: - contain Na as the main osmotically active particle - useful for volume expansion (mainly interstitial space) - for maintenance infusion - correction of electrolyte abnormality
  20. 20. Crystalloids: Isotonic crystalloids - Lactated Ringer’s, 0.9% NaCl - only 25% remain intravascularly Hypertonic saline solutions - 3% NaCl Hypotonic solutions - D5W, 0.45% NaCl - less than 10% remain intravascularly, inadequate for fluid resuscitation
  21. 21. Colloid Solutions: Contain high molecular weight substancesàdo not readily migrate across capillary walls Preparations - Albumin: 5%, 25% - Dextran - Gelofusine - Voluven
  22. 22. Common parenteral fluid therapy-Crystalloid Solutions Volumes Cl- HCO3- 5 103 27 280-310 3 109 28 273 K+ Ca2+ 142 ECF Na+ 4 4 Mg2+ Dextrose mOsm/L Lactated Ringer’s 500 130 0.9% NaCl 500 154 154 308 0.45% NaCl 500 77 77 154 D5W/D10W D2.5/0.45% NaCl 50/100 500 3% NaCl 77 513 Taita No.3 500 75 12 Taita No.4 500 110 20 Taita No.5 400 36 18 77 Acetate:20 Phosphate:6 Acetate:16 Phosphate:12 Acetate:28 Phosphate:12 3 25 513 406 1026 26 20 285 102 8 300 17 100 669
  23. 23. Common parenteral fluid therapy-Colloid Solutions Volumes K+ Ca2+ 142 ECF Na+ 4 5 6% Hetastarch 500 154 5% Albumin 250,500 130-16 0 25% Albumin 20,50,100 130-16 0 Mg2+ Cl- HCO3- 103 27 Dextrose mOsm/L 280-310 154 310 <2.5 130-16 0 330 <2.5 130-16 0 330
  24. 24. The Influence of Colloid & Crystalloid on Blood Volume: Blood volume Infusion volume 200 1000cc 500cc 500cc 500cc 600 1000 Lactated Ringers 5% Albumin 6% Hetastarch Whole blood
  25. 25. Deficits fluid
  26. 26. NPO and other deficits • NPO deficit =number of hours NPO x maintenance fluid requirement. • Bowel prep may result in up to 1 L fluid loss.
  27. 27. Third Space 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. Department of Anesthesiology Uniformed Services University of the Health Sciences
  28. 28. Replacing Third Space Losses • Superficial surgical trauma: 1-2 ml/kg/hr • Minimal Surgical Trauma: 3-4 ml/kg/hr - head and neck, hernia, knee surgery • Moderate Surgical Trauma: 5-6 ml/kg/hr - hysterectomy, chest surgery • Severe surgical trauma: 8-10 ml/kg/hr (or more) - AAA repair, nehprectomy Department of Anesthesiology Uniformed Services University of the Health Sciences
  29. 29. Ongoing loss fluid
  30. 30. • Measurable fluid losses: • Foley tube • Unmeasurable fluid losses: • ostomy output • Fever(Temp of 38.3C~39.4C, >24hr ==>500ml ;>37C, 100~150ml/C) • PTGBD, T-tube • Ventilator • Bleeding • Bleeding • NG suctioning/ vomiting ! ! !
  31. 31. Composition of GI Secretions: Source Volume (ml/24h) Na+* K+ Cl- HCO3- Salivary 1500 (500~2000) 10 (2~10) 26 (20~30) 10 (8~18) 30 Stomach 1500 (100~4000) 60 (9~116) 10 (0~32) 130 (8~154) 0 Duodenum 100~2000 140 5 80 0 Ileum 3000 140 (80~150) 5 (2~8) 104 (43~137) 30 Colon 100-9000 60 30 40 0 Pancreas 100-800 140 (113~185) 5 (3~7) 75 (54~95) 115 Bile 50-800 145 (131~164) 5 (3~12) 100 (89~180) 35 * Average concentration: mmol/L
  32. 32. Other factors • Ongoing fluid losses from other sites: - gastric drainage - ostomy output - diarrhea - PTGBD, T-tube • Replace volume per volume with crystalloid solutions
  33. 33. Blood Loss • Replace 3 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
  34. 34. Example • Mr.Michelin, 62 y/o male, 80 kg, for hemicolectomy • NPO after 2200, surgery at 0800, received bowel prep • 3 hr. procedure, 500 cc blood loss • What are his estimated intraoperative fluid requirements?
  35. 35. Example (cont.) • Ans: • Fluid deficit: 1.5 ml/kg/hr x 10 hrs = 1200 ml + 1000 ml for bowel prep = 2200 ml • Maintenance: 1.5 ml/kg/hr x 3hrs = 360mls • Third Space Losses: 6 ml/kg/hr x 3 hrs =1440 mls • Blood Loss: 500ml x 3 = 1500ml • Total = 2200+360+1440+1500=5500mls
  36. 36. Monitor
  37. 37. Hypovolemia
  38. 38. Signs of Hypovolemia: Diminished skin turgor Dry oral mucus membrane Oliguria - <500ml/day - normal: 0.5~1ml/kg/hr Tachycardia Orthostatic hypotension/Hypotension Hypoperfusionàcyanosis Altered mental status
  39. 39. Orthostatic Hypotension • Systolic blood pressure decrease of greater than 20mmHg from supine to standing • Indicates fluid deficit of 6-8% body weight - Heart rate should increase as a compensatory measure - If no increase in heart rate, may indicate autonomic dysfunction or antihypertensive drug therapy
  40. 40. Clinical Diagnosis of Hypovolemia: Thorough history taking: poor intake, GI bleeding…etc BUN : Creatinine > 20 : 1 - BUN↑: hyperalimentation, glucocorticoid therapy, UGI bleeding Increased specific gravity Increased hematocrit Electrolytes imbalance Acid-base disorder
  41. 41. Hypervolemia
  42. 42. Signs of Hypervolemia: Hypertension Polyuria Peripheral edema Wet lung Jugular vein engorgement Especially when hypo-albuminemia
  43. 43. 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
  44. 44. Summary • Fluid therapy is critically important during the perioperative period. • The most important goal is to maintain hemodynamic stability and protect vital organs from hypoperfusion (heart, liver, brain, kidneys). • All sources of fluid losses must be accounted for. • Good fluid management goes a long way toward preventing problems.
  45. 45. 歡迎加⼊入外科的⾏行列

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