2. TOTAL BODY WATER
Approx. 60% Body weight
Varies with age, gender and body habitus
50% BW in females
80% BW in infants
Less in obese : fat contain little water
3. Body Water Compartments
Intracellular volume : 2/3 of TBW
Extracellular volume : 1/3 of TBW
- Intravascular : Plasma volume (1/4)
- Extravascular: Interstitial fluid and others(3/4)
4. Preoperative Evaluation of Fluid Status
- Mental status
- H/O intake and output
- Blood pressure: supine and standing
- Heart rate
- Skin turgor
- Urinary output
- CVP
5. 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
6. Osmoles :unit for conc. Of osmotically active particles
Osmolality: osmotic active solute per volume of solution
( mOsm/L)
Osmolarity : mOsm/Kg
Plasma osmolarity : 290 mOsm/kg
Tonicity ( relative osmotic activity )
Isotonic/ hypotonic/hypertonic
BASICS
7. Intravenous Fluids Therapy
Intravenous fluid therapy may consist of infusions ofIntravenous fluid therapy may consist of infusions of
crystalloids, colloids, or a combination of both.crystalloids, colloids, or a combination of both.
IndicationsIndications
Volume resuscitationVolume resuscitation
Vehicle for i/v drugsVehicle for i/v drugs
KVOKVO
9. Crystalloids
Clear fluids made up of water and electrolyte solutions; Will
cross a semi-permeable membrane
Grouped as isotonic, hypertonic, and hypotonic
Eg:
Normal saline 0.9%,3 %
Dextrose solutions 5 %,10%,20%,25%
DNS
Ringer’s lactate
Isolyte P
10. Crystalloids
0.9% Normal Saline
Contains: Na+ 154 mmol/l, Cl-
- 154 mmol/l
Osm : 308mosm/l, pH 6.0
IsoOsmolar compared to normal plasma.
Indication :
Intravascular resuscitation and replacement of salt loss
e.g. diarrhoea and vomiting.
Also for diluting packed RBCs prior to transfusion
Used for diluting Drugs
11. Distribution:
Stays almost entirely in the extracellular space.
Of 1 litre - 750ml extra vascular fluid; 250ml intravascular fluid.
100ml blood loss – need to give 400ml N. saline [only 25%
remains intravascular
Complications:
When given in large volume can produces
Hyperchloremic metabolic acidosis because of high
Na+ and Cl- content.
12. 0.45% Normal saline = ‘Half’ Normal Saline
= HYPOtonic saline
Na+ 77mmol/l, Cl- 77mmol/l,
Osmo 154mOsm/l
Indications :
Fluid therapy for paediatric pt
Maintenance fluid therapy
Complications :
Leads to HYPOnatraemia if plasma sodium is normal
May cause rapid reduction in serum sodium if used in excess or infused
too rapidly. This may lead to cerebral oedema and rarely, central
pontine demyelinosis ; Use with caution!
13. 3.0 % Saline = HYPERtonic
saline
3% contain 513 mmol/l of Na+ and Cl- each,
osmol of 1026 mOsm/l; pH 5.0
Indications :
Treatment of severe symptomatic hyponatremia
(coma, seizure)
To resuscitate hypovolemic shock
14. Leads to an osmotic gradient between the ECF and
ICF, causing passage of fluid into the EC space.
Must be administered slowly and preferably with
CV line because it carries risk of causing phlebitis,
necrosis, hemolysis.
Complications :
Precaution in pt. with CHF
severe renal insufficiency, edema with sod. retention.
15. Dextrose
5% Dextrose (often written D5W)
50g/l of glucose, 252mOsm/l, pH 4.5
Regarded as ‘electrolyte free’ – contains NO Sodium, Potassium,
Chloride or Calcium
Indication :
Primarily used to maintain water balance in patients who are not able to
take anything by mouth;
Commonly used post-operatively in conjunction with salt retaining fluids
ie saline
Hypernatremia treatment
16. When infused is rapidly redistributed into the
intracellular space; Less than 10% stays in the
intravascular space therefore it is of limited
use in fluid resuscitation.
Side effects:
Iatrogenic hyponatraemia in surgical patient
Hyperglycemia
Not compatible with blood ,cause hemolysis
conc 5% 10% 20% 25% plasma
Osmolarity 252 505 1010 1262 290
17. Ringer Lactate
Most physiological solution
Electrolyte composition similar to ECF
One litre of lactated Ringer's solution contains:
Sodium ion= 130 mmol/L.
Chloride ion = 109 mmol/L.
Lactate = 28 mmol/L.
Potassium ion = 4 mmol/L.
Calcium ion = 1.5 mmol/L
Osmolarity of 273 , pH of 6.5
18. Lactate is converted to bicarbonate in liver
Indications :
Deficit ,Intraoperative fluid loss
Severe hypovolemia
Precautions:
Severe metabolic acidosis ( impaired lactate conversion)
Don’t give with blood product ( Ca bind with citrate
reduced anticoagulant activity )
19. DNS
0.9% saline & 5% dextrose
Na+ 154, Cl- 154, 5 gm. Glucose
Osm : 432 mosm/L
Indication :
Maintenance solution
Correction of fluid deficit with supply
of energy
Compatible with blood
21. Colloids
The colloid solutions contain particles which do not readily
cross semi-permeable membranes such as the capillary
membrane.
Thus the volume infused stays (initially) almost entirely within
the intravascular space .
Stay intravascular for a prolonged period compared to
crystalloids.
However they leak out of the intravascular space when the
capillary permeability significantly changes e.g. Severe trauma
or sepsis.
22. Because of their gelatinous properties they cause
platelet dysfunction and interfere with fibrinolysis
and coagulation factors (factor VIII) – thus they can
cause significant coagulopathy in large volumes.
Natural : Albumin
Artificial : Gelatin and Dextran , HES
23. ALBUMIN
Principal natural colloid comprising of 50-60% of all plasma
proteins.
Synthesized only in liver and has a half life of app. 20 days.
5% soln is iso oncotic and leads to 80% initial vol expansion
25% soln leads to 200-400% increase in vol.
Used
For emergency treatment of shock especially due to loss of plasma,
acute management of burns
fluid resuscitation in ICU
Hypoalbumineamia.
24. Side effects :
pruritis, anaphylactoid reactions and coagulation
abnormalities as compared to synthetic colloids.
Disadvantages
cost effectiveness
volume overload (in septic shock pt albumin add to
interstitial edema)
25. DEXTRAN
Highly branched polysaccharide molecules
Produced by synthesis using the bacterial enzyme dextran
sucrase from the bacterium Leuconostoc mesenteroids.
Most widely used are 6%(dextran 70) and 10%(dextran 40)
soln.
Excreted via kidney primarily.
Both lead to a higher vol expansion as compared to HES and
5% albumin.
26. Used mainly to improve microcirculatory flow in
microsurgical re-implantation .
Also used in extracorporeal circulation during cardiopulmnary
bypass.
Side effects: Anaphylactic reactions, Coagulation abn,
Interference with cross match, Ppt of ARF.
27. GELATINS
Large mol. wt. proteins formed from
hydrolysis of collagen.
Produced by thermal degradation of cattle-
bone gelatin.
3 types of gelatin soln currently in use are;
1. Succynylated or modified fluid
gelatin(e.g. Gelofusine, Plasmagel)
2. Urea crosslinked gelatins(e.g. Polygeline)
3. Oxypolygelatins(e.g. Gelifundol)
28. Gelatins lead to 70-80% of vol expansion
Indication :
Rapid expansion of intravascular volume and correction of
hypotension
Advantage :
cost effectiveness and no effect of renal impairment ,does not
affect coagulation
Disadvantage :
Hypersenstivity
Anaphylactoid reactions
29. HYDROXYETHYL
STARCHES
Derivatives of amylopectin, which is a highly
branched compound of starch.
6% HES soln are isooncotic
10% soln are hyper oncotic , with a vol effect
exceeding the infused vol .(about 145%)
Duration of vol expansion is usually 8-12 H.
30. Advantage
Cost effective: cheaper and comparable vol of expansion to albumin.
Disadvantage: assoc. with 1st
& 2nd
generation HES
- Coagulation abn
- Accumulation
- Anaphylactoid reactions
- Renal impairment
- Increase in amylase level
31. TETRASTARCH:3RD
GEN. HES
Newer starch based plasma expander
Improved safety and pharmacological prop
Minimal effect on coagulation process and platelet
function
Less accumulation and tissue storage
No effects on renal function
Positive effects on tissue oxygenation and
microcirculation
32. Colloid or Crystalloid Resuscitation
Recommendations:
Colloid should NOT be used as the sole fluid replacement in
resuscitation ,volumes infused should be limited because of
side effects and lack of evidence for their continued use in the
acutely ill.
In severely ill patients – principally use crystalloid and
blood products; Colloid may be used in limited volume to
reduce volume of fluids required or until blood products are
available.
33. In elective surgical patients
Replace fluid loss with ‘physiological Ringer’s solutions.
Blood products and colloid may be needed to replace
intravascular volume acutely.
34. Peri- operative Fluid Requirements
• The following factors must be taken into account:
• C V E
• Maintenance fluid
• Deficit
• Third space losses
• Replacement of loss
35. COMPENSATORY INTRAVASCULAR VOLUME
EXPANSION
Most gen and regional anaesthetics cause arteriolar and
venous dilatation, expanding the vascular capacity, which
reduces the peripheral venous pressure, venous return, and
cardiac output.
Fluid must be adm. to expand the blood vol to compensate for
venodilation .
Expansion with 5-7ml/kg of BSS must occur before or
simultaneous with the onset of anaesthesia .
36. Maintenance Fluid Requirements
• “4-2-1 Rule”
- 4 ml/kg/hr for the first 10 kg of body weight
- 2 ml/kg/hr for the second 10 kg body weight
- 1 ml/kg/hr subsequent kg body weight
Eg : 70 Kg pt
Maintenance fluid : 40+20+50= 110 ml/hr
37. Deficit
• Deficit = number of hours NPO x maintenance fluid
requirement.
• Measurable fluid losses, e.g. NG suctioning, vomiting, stoma
output.
70 kg pt fasting for 8 hrs
Deficit : 8 X 110 = 880 ml
Half in first hr
One fourth each in next two hr .
38. 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.
39. Replacing Third Space Losses
Minimal Surgical Trauma: 0-2 ml/kg/hr
- e.g. herniorrhaphy
Moderate Surgical Trauma: 2-4 ml/kg/hr
- e.g. cholecystectomy
Severe surgical trauma: 4-6 ml/kg/hr (or even more)
- e.g. major bowel resection
40. 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.
41. Fluid management, starting with a hemoglobin level of
15 g/dL, for a 70-kg patient undergoing gastrectomy
who has been fasting for 8 hours.
Maintenance rate is 110 mL/hr,
Deficit of 880 mL
First hr = CVE+ Half of deficit + maintenance + loss+ third space loss
350+440+110+50 + 420
Second hr = one fourth of deficit + maintenance + loss+ third space loss
220+ 110+ 250 + 420
Third hr = one fourth of deficit + maintenance + loss+ third space loss
220+ 110+ 250 + 420
Fourth hr = Maintenance + loss+ third space loss
110+ 50 + 420
42. Summary
Most physiological :RL
Rich in sodium : NS,DNS
Rich in potassium :ISo –p
Glucose free: RL,NS,3% saline
Sodium free: Dextrose
Potassium free: NS,DNS,Dextrose
Can correct acidosis directly : RL,ISo-p
When two solutions are separated by a membrane that allows the passage of water butnot solutes, the water passes from the solution with the lower osmotic activity to thesolution with the higher osmotic activity. The relative osmotic activity in the two solutionsis called the effective osmolality, or tonicity. The solution with the higher osmolality isdescribed as hypertonic, and the solution with the lower osmolality is described ashypotonic. Thus, the tendency for water to move into and out of cells is determined by therelative osmolality (tonicity) of the intracellular and extracellular fluids.
Crystalloids are fluids that contain water and electrolytes. They are grouped as isotonic, hypertonic, and hypotonic salt solutions. Crystalloid solutions are used to provide maintenance water and electrolytes and to expand intravascular fluid. The replacement requirement is threefold or fourfold the volume of blood lost because administered crystalloid is distributed in a ratio 1 : 4 similar to ECF, which is composed of about 3 L intravascularly (plasma) and about 12 L extravascularl
Hypertonic Salt Solutions
Hypertonic salt solutions are less commonly used, and their sodium concentrations range from 250 to 1200 mEq/L. The greater the sodium concentration, the less the total volume is required for satisfactory resuscitation. This difference reflects the movement owing to osmotic forces of water from the intracellular space into the extracellular space. The reduced volume of water injected may reduce edema formation; this could be crucial in patients predisposed to tissue edema (e.g., prolonged bowel surgery, burns, brain injuries). Clinical studies have confirmed that a moderately hypertonic solution (250 mEq/L of sodium) can produce lower muscle interstitial pressure than lactated Ringer’s solution. Bowel function returned earlier, although the pulmonary shunt fraction was no different.[94] Experimental studies have shown decreased intracranial pressures in animals receiving hypertonic solutions. The intravascular half-life of hypertonic solutions is no longer, however, than isotonic solutions of an equivalent sodium load. In most studies, sustained plasma volume expansion was achieved only when colloid was present in the resuscitation solution. The osmolality of these solutions can cause hemolysis at the point of injection.[95]