DEPARTMENT OF

ORAL & MAXILLOFACIAL SURGERYRUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCH

KOHKA, BHILAI

PRESENTED BY –

DR. SHEETAL KAPSE

2nd YEAR, P.G. STUDENT

MODERATORS -

DR. SUNIL DUTT C.

DR. M. SATISH

DR. DEEPAK THAKUR

DR. MANISH PANDIT

FLUID & ELECTROLYTE BALANCE

CONTENTS

1. Introduction

2. Basic physiology

3. Body fluid electrolytes disturbances

4. Parenteral fluid therapy

5. Basic principles

6. I.V. fluids

7. Methods of calculation of fluid transfusion rate

8. Fluid therapy in surgical patients

9. Volume resuscitation – end parameters & goals

10. Conclusion

11. References

Total body water Distribution CompositionNormal exchange of fluidsSalt intake & output

Introduction

• Body is formed with solids & fluids.

• In human body water content is 45-75% of body weight.

• Importance :

1. In homeostasis

2. In transport Mechanism

3. In metabolic reactions

4. In maintenance of tissue texture

5. In temperature regulation

BASIC PHYSIOLOGY

Total body water (TBW)

• TBW varies with age, gender and body habitus .

• In adult males= 60-65% of body weight, average = 60%

• In adult female=45-50% of body weight, average = 50%

• In infant = 80% of body weight

• Obese patients have less TBW per Kg than lean body adult.

1= Intracellular fluid (ICF)= 70% TBW or 30%(F) - 40% (M) BW

2= Extracellular fluid (ECF) = 30%TBW or 20% BW

Interstitial fluid = 7.5% of body weight ( 15%)

Intravascular fluid or plasma volume = 4% of body weight ( 5%)

Transcellular fluid = 3.5 % of body weight

Body compartment fluid

Distribution

CompositionOrganic Inorganic

Glucose

Amino acids

Proteins

Fatty acid

Lipid

Hormones

Enzymes

Oxygen

electrolytes

Some important terminologies

Osmolarity :• It is fluid’s capability to create osmotic pressure.• It is concentration of osmotically active substances in solution.

Osmolality :• It is no. of particles / L of solution.

Tonicity :• Way of expressing effective osmolarity.

10

Same effective osmolarity as body fluid Greater effective osmolarity than body fluid less effective osmolarity than body fluid

Cell in a hypertonic solution

Cell in a hypotonic solution

Cell Membrane

ICF

Cell Membrane

Na+

K+

Interstitial

H2O

H2O

Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient!

Na+= 10

Urea

glucose

Normal exchange of fluidsWater Gain route Average

Daily vol. (ml)Minimum

(ml)Maximum

(ml)

sensible Oral fluids 800 - 1500 0 1500/h

Solid food 500 – 700 0 1500

insensible Water of oxidation

250 125 800

Water of solution

0 0 500

Water loss route averageDaily vol. (ml)

Minimum(ml)

Maximum(ml)

sensible Urine 800 - 1500 500 1400 / h

Intestine 0 – 250 0 2500 / h

sweat 0 0 4000 / h

insensible Lungs 400600 1500

Skin 500 - 1000

13

Daily fluid replacement = 700 + urine output

Excess water loss 1. fever : 100 ml / degree fever / day2. Tracheostomy (unhumidified air) : >1.5 L / day

Salt intake & output

• Daily salt intake varies 3-5 gm as NaCl

• Kidneys excretes excess salt: can vary from < 1 to > 200

mEq/day

• Volume and composition of various types of gastrointestinal

secretions

• Gastrointestinal losses usually are isotonic or slightly hypotonic

• Should replace by isotonic salt solution

Body fluid & electrolytes disturbances

• Volume Changes :

• Concentration Changes :

• Composition Changes : Acid/Base Balance

Potassium Abnormalities

Calcium Abnormalities

Magnesium Abnormalities

Hypovolemia

Hypervolemia

Hyponatremia

Hypernatremia

Volume ChangesHypovolemia

Hypervolemia

Hypovolemia

• ECF volume deficit is most common fluid loss in surgical patients, and aggravated by General Anesthesia.

• Most common causes of ECF volume deficit are: GI losses from vomiting, nasogastric suction, diarrhoea, and fistular drainage

• Other common causes: soft-tissue injuries and infections, peritonitis, obstruction and burns.

Signs• Diminished skin turgor• Dry oral mucus membrane• Dry axilla• Oliguria - <500ml/day (normal: 0.5~1ml/kg/h)• Flat neck veins • Tachycardia• Orthostatic Hypotension• Hypoperfusion cyanosis

(hypothermia)• Sunken eye• Altered mental status

Clinical Diagnosis

• Thorough history taking: poor

intake, GI bleeding…etc

• glucocorticoid therapy

• BUN : Creatinine > 20 : 1

• Increased specific gravity

• Increased hematocrit

• Electrolytes imbalance

• Acid-base disorder

Hypervolemia • Iatrogenic or Secondary to renal

insufficiency, cirrhosis, or CHF.

Signs

• CNS: none

• CVS: elevated JVP, venous distension

– pulmonary edema, S3,

• Respiratory : shortness of breath even

in rest.

• GI: edema of bowel

• Tissue: pitting edema – anasarca,

ascites, weight gain

Clinical Diagnosis • Electrolytes imbalance

• Decreased specific gravity

• Decreased hematocrit

• Cholesterol

• Liver enzymes

• Bilirubin

• Creatinin clearance

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

Concentration Changes

Hyponatremia <135 mEq/l.

Hypernatremia > 145 mEq/l.

Hyponatremia

• Na+ is the most abundant positive ion of ECF compartment

and is critical in determining the ECF and ICF osmolality.

• Normal amount 135-145 mEq/l.

• Sign & symptoms : <120 mEq/l.Signs & symptoms

• CNS: confusion, lethargy, stupor,

headache, seizure, coma

• GI: nausea, vomiting

• Skeletal system : muscle twiches

Etiology & treatment of hyponatremia

Hypernatremia• Asymptomatic • Symptomatic (Na>160 meq/L)

>145 mEq/l.

CNS manifestations : due to dehydration of brain cells

Body system Signs & symptoms

Central nervous system Restlessness, lethargy, ataxia, irritability, tonic spasms, delirium, seizures, coma

Musculoskeletal Weakness

Cardiovascular Tachycardia, hypotension, syncope

Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears

Renal Oliguria

Metabolic Fever

Etiology & treatment of hypernatremia

Aggressive correction : central pontine myelinolysis

Composition Changes

Acid/Base Balance

Potassium Abnormalities

Calcium Abnormalities

Magnesium Abnormalities

Potassium Abnormalities

• Normal daily dietary intake of K+ is approx. 50 to 100 mEq/day, & The normal range of serum potassium: 3.5-5.1 meq/L.

• Majority of K+ is excreted in the urine (0-700 meq/day).

• 98% of the potassium in the body is located in ICF at 150 mEq/L and it is the major cation of intracellular water.

• Intracellular K+ is released into the extracellular space in response to severe injury or surgical stress, acidosis, and the catabolic state.

• K+ has an important role in the regulation of acid-base balance.

Hypokalemia

Etiology : • Inadequate intake• Dietary, potassium-free intravenous fluids, potassium-deficient • Total parenteral nutrition • Excessive potassium excretion • Hyperaldosteronism • Medications• Gastrointestinal losses• Direct loss of potassium from gastrointestinal fluid (diarrhea), (gastric fluid,

either as vomiting or high nasogastric output)• Renal loss of potassium• Intracellular-shift (metabolic alkalosis or insulin therapy) • Potassium decrease by 0.3 meq/L for every 0.1 increase in pH above normal

Serum K+ < 3.5 mEq /L

Treatment : • KCl 10 mEq/L/hr IV - pripherally• KC1 20 mEq/L/hr IV - centrally

Body system Signs & symptoms

Gastrointestinal Paralytic Ileus, constipation

Neuromuscular Decreased reflexes, fatigue, weakness, paralysis, rhabdomyolysis, hyporeflexia

Cardiovascular U-waves T-wave flattening ST-segment changes Arrhythmias

Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears

Renal Polyuria & polydypsia

HyperkalemiaSerum K+ > 5.1 mEq /L

Etiology :

1. Increased intake : Potassium supplementation & Blood transfusions

2. Endogenous load/destruction: hemolysis, rhabdomyolysis, cruch injury,

gastrointestinal hemorrhage

3. Increased release : Acidosis

4. Rapid rise of extracellure osmolality (hyperglycemia or mannitol) : Impaired

excretion of potassium & Renal insufficiency/failure.

Body system Signs & symptoms

Gastrointestinal Nausea/vomiting ,colic diarrhea

Neuromuscular weakness, paralysis, respiratory failure

Cardiovascular Arrhythmia, arrest

ECG changes Peaked T waves (early change)Flattened P wave Prolonged PR interval (first-degree block) Widened QRS complex Sine wave formation Ventricular fibrillation

Treatment of hyperkalemia

Calcium Abnormalities

• Majority of the 1000 to 1200g of calcium in the average-sized adult is

found in the bone .

• Normal daily intake of calcium is 1 to 3 gm.

• Normal serum level = 8.8-10.5 mg/dl

• Albumin Bound = 40-60%

• Ionized portion (1.2 mg/dl) is responsible for neuromuscular stability

• Most is excreted via the GI tract

Corrected calcium = 4 – albumin x 0.8 + serum calcium

Hypocalcemia Hypercalcemia

• Serum calcium level <8.8 mg/dl

• Causes:

acute pancreatitis,

massive soft-tissue infections

(necrotizing fasciitis),

acute and chronic renal failure,

pancreatic and small-bowel fistulas,

hypoparathyroidism

• Serum calcium level >10.5 mg/dl

• Causes:

hyperparathyroidism

cancer PTH-like peptide in malignancies

Hypocalcemia S/S Hypercalcemia S/S

1. Hypotension2. Anxiety3. Psychosis4. Paresthesia5. Laryngeal spasm6. Numbness and tingling of the

circumoral region and the tips of the fingers and toes

7. tetany with carpopedal spasm, convulsions (with severe deficit),

8. Chvosteck & trousseau’s signs

1. Hypertension2. Bradycardia3. Constipation4. Anorexia5. nausea, vomiting6. Nephrolithiasis7. Pain8. Psychosis9. Pruritis10. weight loss, thirst, polydipsia, and

polyuria11. easy fatigue, weakness, stupor, and

coma

Treatment : IV calcium for acute -1gm in D5 or NS

Oral calcium and vitamin D for chronic

Magnesium Abnormalities

• Total body content of magnesium 2000 mEq, about half of which is

incorporated in bone.

• Normal daily dietary intake of magnesium is approximately 240 mg

• Normal serum level = 1.5- 2.4 mg/dl

• Deficiency causes impaired repletion of Na+ & Ca 2+

Hypomagnesemia

• causes:

– starvation, malabsorption syndromes, GI losses, prolonged

IV or TPN with magnesium-free solutions

• signs & symptoms:

– similar to those of calcium deficiency

Hypermagnesemia

• Symptomatic hypermagnesemia, although rare, is most

commonly seen with severe renal insufficiency

• signs & symptoms:

CNS: lethargy and weakness with progressive loss of DTR’s –

somnolence, coma, death

CVS: increased P-R interval, widened QRS complex, and

elevated T waves (resemble hyperkalemia) – cardiac arrest

Basic principleShould have knowledge of

1. Etiology of fluid deficit

2. Type of electrolyte deficit

3. Associated illness

4. Clinical statusRationale

1. When to give or avoid

2. Which fluid

3. How much

4. Drop rate

5. Contraindication of specific fluid

6. How to correct the imbalance

7. How & when to use specific fluids

• Oral route is always preferred.• Intravenous therapy should be started in critical situations.

indications

Oral intake is not possible

Severe vomiting, diarrhoea,Dehydration & shock

hypoglycemia

Vehicle for some medication

Nutrition

Treatment of critical problems (poisoning)

contraindications

Ability to take oral fluid

Avoid in CHF & volume overload

Advantages

Acute, controlled, predictable way

Immediate response

Prompt correction

Disadvantages

Require strict asepsis

Skilled supervision

Improper selection of fluid - dangerous

Improper volume – life threatening

Improper technique - complications

complications

Local : hematoma, infusion phlebitis, infiltration

Systemic : circulation overload, rigors, septicemia, air embolism

Others : fluid contamination, I.V. set & catheter problem

Human error

Parenteral fluid therapy

• Para = other than , enteron (Gk) = intestine• Ways to approach i.v. route –

venepuncture venesection

Sites for venepuncture -

Median cubital vein

Long Saphenous

vein

In obese, female & infants

Risk of thrombophlebitis &

pulmonary imbolism

Rare in infants / children

1. Cephalic vein in deltopactoral

groove

2. Subclavian vein

3. Internal jugular vein

4. External jugular vein

Neonates / small children

I.V. fluidsBased on use

Maintenance fluids Replacement fluids Special fluids

5% D5% D with 0.45% NaCl

NS,DNS, RL, ISOLYTE -G, ISOLYTE-E, ISOLYTE-M, ISOLYTE-P

Inj. Sod.bicarbonate, mannitol, NS 1.6%, 3%, 5%Inj. KCl25% Dextrose

I.V. fluids

Based on property

Crystalloids(solution of large molecules)

Colloids (solution of electrolytes)

Life saving

RLNS

DNSD-5%

ISOLYTES

5% Albumin25% Albumin

10% Pentastarch10% Dextran -406% Dextran -7010% Hetastarch

5 % dextrose

Composition : Glucose 50 gms

Pharmacological basis :

Corrects dehydration and supplies energy( 170Kcal/L)

Indications : • Prevention and treatment of dehydration• Pre and post op fluid replacement• IV administration of various drugs• Prevention of ketosis in starvation, vomiting, diarrhea• Adequate glucose infusion protects liver against toxic

substances• Correction of hypernatremia

Contra indications• Cerebral edema, neuro surgical procedures• Acute ischaemic stroke• Hypovolemic shock • Hyponatremia , water intoxication• Same iv line blood transfusion – hemolysis , clumping occurs• Uncontrolled DM , severe hyperglycemia

Rate of adminstration – 0.5 gm/kgBW/hr or 666ml/hr 5 % D or 333ml/hr 10 %D

INVERTED SUGAR SOLUTION

Composition : inverted sugar 100 gms

Pharmacological basis :

half dextrose + half fructose

Indications : • Prevention and treatment of dehydration (specially pregnancy)• Liver diseases (prevents glycogen depletion)

Adverse effects :

1. Lactic acidosis

2. Hyperurecemia

3. hypophosphatemia

Contra indications• hereditory fructose intolerance• Caution in renal & hepatic impairment• >25gm fructose should be avoided• more expansive

Isotonic saline(0.9 % NS)

• Composition : Na+ 154 mEq, Cl- 154 meq

• Pharmacological basis : provide major ECF electrolytes..

corrects both water and electrolyte deficit.

increase the iv volume substantially

Contra indications• Avoid in pre eclamptic patients, CHF, renal disease and cirrhosis• Dehydration with severe hypokalemia – deficit of ICF potassium• Large volume may lead to hyperchloremic acidosis.

Indications

• Water and salt depletion – diarrhoea, vomiting, excessive diuresis

• Hypovolemic shock

• Alkalosis with dehydration

• Severe salt depletion and hyponatremia

• Initial fluid therapy in DKA

• Hypercalcemia

• Fluid challenge in prerenal ARF

• Irrigation – washing of body fluids

• Vehicle for certain drugs

DNSPharmacological basis :

• Supply major EC electrolytes, energy and fluid to correct dehydration

Indications :• Conditions with salt depletion ,hypovolemia• Correction of vomiting or NGT aspiration induced alkalosis and

hypochloremia• Compatible with blood transfusion

Contra indications :• Anasarca – cardiac, hepatic or renal• Severe hypovolemic shock (osmotic diuresis)• >25gm/hr should be avoided

DNS withhalf strength saline

Pharmacological basis : • Supply major EC electrolytes, energy and fluid to correct dehydration• more water with less salt.

Indications :• paediatric & very elderly• Maintenance fluid in early post operative periods• Treatment of hypernatremia• Compatible with blood transfusion

Contra indications :• hyponatremia • Severe dehydration

Ringer’s lactate

Pharmacological basis :• Most physiological fluid , rapidly expand s iv volume.. • Lactate metabolised in liver to bicarbonate providing buffering capacity• Acetate instead of lactate advantageous in severe shock.

Indications• Correction in severe hypovolemia• Replacing fluid in post op patients, burns• Diarrhoea induced hypokalemic metabolic acidosis• Fluid of choice in diarrhoea induced dehydration in paediatrics• DKA , provides water, correct metabolic acidosis and supplies potassium• Maintaining normal ECF fluid and electrolyte balance

Contra indications• Liver disease, severe hypoxia and shock• Severe CHF , lactic acidosis takes place• Addison’s disease• Vomiting or NGT induced alkalosis• Simultaneous infusion of RL and blood• Certain drugs – amphotericin, thiopental, ampicillin,

doxycycline

Isolyte fluids Isolyte G Isolyte M Isolyte P Isolyte E

dextrose 50 50 50 50

Na K Cl

63 17 150

40 35 40

25 20 22

140 10 103

AcetateLactate NH4Cl

--- --- 70

20 --- ---

23 --- ---

47 --- ---

CaMg

--- ---

--- ---

--- ---

5 3

HPO4 --- 15 3 ---

Citrate --- --- 3 8

Mosm/L 580 410 368 595

Isolyte G : • Vomiting or NGT induced hypochloremic, hypokalemic metabolic alkalosis• NH4 gets converted to H+ and urea in liver• Treatment of metabolic alkalosis• Contraindications : Hepatic failure, renal failure, metabolic acidosis

Isolyte M• Richest source of potassium (35 mEq)• Ideal fluid for maintenance• Correction of hypokalemia• Contraindications : Renal failure, burns, adrenocortical insufficiency

Isolyte P• Maintenance fluid for children – as they require less electrolytes and more

water• Excessive water loss or inability to concentrate urine• Contraindications : hyponatremia, renal failure

Isolyte E• Extracellular replacement solution, additional K and acetate (47mEq)• Only iv fluid to correct Mg deficiency • Treatment of diarrhoea, metabolic acidosis• Contraindications – metabolic alkalosis

Effects of large volume crystalloid infusion.

• Extravascular accumulation in skin, connective tissue , lungs and kidney

• Inhibition of GI motility

• Delayed healing of anastomosis

• Large volume ,rapid infusion crystalloids causes hypercoagulability..

Ruttmann TG, James MF. Effects on coagulation due to intravenous crystalloid or colloid in

patients undergoing vascular surgery.

Br J Anesth 2002 ; 89 : 999 - 1003

Crystalloids …

Colloids

Colloids : large molecular wt substances that largely remains in

the intravascular compartment thereby generating oncotic

pressure

• 3 times more potent

• 1 ml blood loss = 1ml colloid = 3ml crystalloids

colloids…

Type of fluid Effective plasma volume expansion/100ml

duration

5% albumin 70 – 130 ml 16 hrs

25% albumin 400 – 500 ml 16 hrs

6% hetastarch 100 – 130 ml 24 hrs

10% pentastarch 150 ml 8 hrs

10% dextran 40 100 – 150 ml 6 hrs

6% dextran 70 80 ml 12 hrs

Albumin • Maintain plasma oncotic pressure – 75-80 %• Heat treated preparation of albumin – 5%, 20% and 25%

commercially available

Pharmacalogical basis :• 5% albumin – COP of 20 mmHg• 25% albumin – COP of 70mmHg ,expands plasma volume to 4-5

times the volume infused within 4-5 min.

Rate of infusion :• Adults – initial infusion of 25 gm• 1 to 2 ml/min – 5% albumin• 1 ml/min - 25% albumin

Indications :• Plasma volume expansion in acute hypovolemic shock, burns, severe

hypoalbuminemia• Hypo proteinemia – liver disease, Diuretic resistant in nephrotic syndrome• Oligourea • In therapeutic plasmapheresis , as an exchange fluid

Contra indications :• Severe anaemia, cardiac failure• Hypersensitive reaction

Dextran • Dextran are glucose polymers produced by bacteria (leuconostoc

mesenteroides)

2 forms : dextran 70(MW 70,000) and dextran 40(40,000)

Pharmacological basis :• Effectively expand iv volume, but not suitable for blood transfusion.• Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapid renal

excretion• Anti thrombotic , inhibits platelet aggregation• Improves micro circulatory flow as preventing thromboimbolism.

Indications :• Hypovolemia correction• Prophylaxis of DVT and post operative thromboembolism• Improves blood flow and micro circulation in threatened vascular

gangrene• Myocardial ischemia, cerebral ischemia as maintaining vascular

graft patency

Adverse effects• Acute renal failure • Interfere with blood grouping and cross matching • Hypersensitivity reaction

Precautions/CI :• Severe oligo-anuria• CHF, circulatory overload• Bleeding disorders like thrombocytopenia.• Severe dehydration• Anticoagulant effect of heparin enhanced• Hypersensitive to dextran

Administration :• Adult patient in shock – rapid 500 ml iv infusion• First 24 hrs – dose should not exceed 20ml/kg• Next 5 days – 10 ml/kg/ day

Gelatin polymers( haemaccel)• 500 ml Sterile, pyrogen free 3.5 % solution• Polymer of degraded gelatin with electrolytes• 2 types • Succinylated gelatin (modified fluid gelatin)• Urea cross linked gelatin ( polygeline)

Composition : Na 145 mEq, Cl 145 mEq, Ca 12.5 mEq,

potassium 5.1 mEq

Indications :• Rapid plasma volume expansion in hypovolemia• Volume pre loading in general anesthesia• Priming of heart lung machines

Advantages :• Does not interfere with coagulation, blood grouping • Remains in blood for 4 to 5 hrs• Infusion of 1000ml expands plasma volume by 50%

Side effects :• Hypersensitivity reaction• Bronchospasm, hypotension• Should not be mixed with citrated blood

Hydroxyethyl starch

Hetastarch : • It is composed of more than 90% esterified amylopectine.• Esterification retards degradation leading to longer plasma expansion • 6% starch - MW 4,50,000

Pharmacological basis :• Osmolality – 310 mosm/L• Higher colloidal osmotic pressure • LMW substances excreted in urine in 24 hrs

Advantages :• Non antigenic• Does not interfere with blood grouping• Greater plasma volume expansion• Preserve intestinal micro vascular perfusion in endotoxaemia• Duration – 24 hrs

Disadvantages :• Increase in S amylase concentration upto 5 days after

discontinuation• Affects coagulation by prolonging PTT, PT and bleeding time

by lowering fibrinogen • Decrease platelet aggregation , VWF , factor VIII

Contra indications :• Bleeding disorders , CHF• Impaired renal function

Administration :• Adult dose 6% solution – 500ml to 1 lit• Total daily dose should not exceed 20ml/kg

Pentastarch :

• LMW derivative (2,64,000) 3%, 6% and 10% solution• Lower degree of esterification• Lesser effect on coagulation• 10% solution can increase plasma volume 1.5 times of infused volume

Special fluids

• Inj KCl 10 ml amp – 20mEq

• 25%D (25 ml amp or 100 ml infusion bottle)– in hypoglycemic shock

• Inj. Sodium bicarbonate (25 ml amp. 22.5mEq Na+ & 22.5mEq HCO3-)

dose = 10-15 mEq/L : in metabolic acidosis

• Mannitol 10% & 20% : osmotic diuretic

Goals

• Maintenance of normovolemia and hemodynamic stability

• Acceptable plasma colloid osmotic pressure

• Correction of electrolyte imbalance

• Correction of acid base imbalance

• Adequate urine output( 0.5 to 1 ml/kg/hr)

Crystalloids or colloids…???

• Crystalloids – recommended as the initial fluid of choice in resuscitating patients from hemorrhagic shock

Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 - 141

• COCHRANE Collaboration in critically ill patients –

“ No evidence from RCT that resuscitation with colloids reduces the risk of death, compared with crystalloids in patients with trauma or burns after surgery”

Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD 000567, 2004

Indication of blood therapy

Goal : the oxygen carrying capacity of blood.

Indications

1. Hb <6 gm% (normal =10 gm%)

2. age

3. Medical status

4. Major surgical procedure

5. Anticipation of ongoing blood loss >100ml/min

6. Acute blood loss > 40% (2L crystalloid 3:1 --- colloid 1:1 )

• AMERICAN COLLEGE OF SURGEONS (2001),• Classification of acute hemorrhage

Committee on Trauma. Advanced Trauma Life Support Student manual. 6th ed. Chicago. American College of Surgeons. 2001: 87-107.

Blood component therapy

• Transfusion with whole blood is indicated very rarely.

• Advantages :

1. Preservation of remaining whole blood components

2. Longer storage

3. Decreases the risk of transfusion reaction

Methods of calculation of fluid transfusion rate

Holiday Segar Method

4 ml/kg/hr = 4x10/hr = 40 ml/hr2ml/kg/hr = 2x20/hr = 40 ml/hr

So, for > 20 kg patient = body wt + 40 mlEg. For 70 kg. pt = 70+40 = 110 ml

Fluid therapy in surgical patients

• Fluid and electrolyte management are paramount to the care of the surgical

patient. Changes in both fluid volume and electrolyte composition occur

preoperatively, intraoperatively, and post operatively, as well as in response

to trauma and sepsis.

• Proper fluid & electrolyte state is helpful in reducing morbidity & mortality in certain surgical procedures, hence it is important.

Need for correction

1. Acute stress : sympathetic stimuli, tachycardia & vasoconstriction.

2. Stress : corticosteroids secretion (up to 48 hrs)

3. Stress : ADH (up to 2-3 post op days) water retention

4. NPO require consideration & replacement.

5. Pre, intra & post operative blood / fluid loss require consideration & replacement.

Na+ retention, K+ depletion Intracellular K+ depletion hyperkalemia

Requirement of maintenance fluid is less on1st post op day.

6. Hypovolemia should be corrected preoperatively hypotension intraoperatively

7. Surgical stress / direct damage to kidney, brain, lungs, skin, GIT should be considered as they play important role in fluid & electrolyte balance.

Preoperative fluid therapy

• Very important for better outcome in surgical patients.

• 3 parameter are important

1. Correction of hypovolemia (GA diminishes the compensatory reflexes )

2. Correction of anemia (48 hours prior to surgery)

3. Correction of other disorders (eg. hypo & hyperkalemia)

Intraoperative fluid therapy

• Volume to be replaced –

1. Correction of fluid deficit due to starvation :

2. Maintenance volume for intraop period :

3. Correction of intra op loss :

Duration of starvation (in hr) x 2 ml / kg ; 5% D

Duration of surgery (in hr) x 2 ml / kg ; 5% D

a. Suction containerb. Surgical spongec. Third space

• Blood loss =3/1 with crystalloid• Blood / blood products if indicated• Decrease in Hb by 2gm% can be tolerated by patient with pre op Hb = 10gm%

Type of trauma Requirement of fluid

Least trauma nil

Minimal trauma 4 ml /kg / hr

Moderate trauma 6 ml /kg / hr

severetrauma 10 ml /kg / hr

Postoperative fluid therapy

1. First 24 hrs of surgery (total = 2 L)

2. 2nd post op day (total = 3 L)

3. 3rd post op day (total = 3 L)

2L 5% D or 1.5 L 5% D + 500ml 0.9% NS

2L 5% D + 1L 0.9% NS

2L 5% D + 1L 0.9% NS + 40-60 mEq K+ / day

Volume resuscitation – end parameters & goals

End parameters Goals

1. Achieve primary goal (0xygen supply)

2. Good level of Hb% & cardiac output

3. Test for –

ABG

CVP

Pulmonary pressure

BP

heart rate

Urine output > 1ml/kg/hr

1. CVP = 15 mmHg

2. Pulmonary capillary wedge pressure

10-12 mmHg

3. Cardiac index >3L/min/sq meter

4. Oxygen uptake >100 ml /min/sq meter

5. Blood lactate < 4 mmol/l

6. Basic deficit

Conclusion

• ‘Fluid therapy should be directed not only to effective volume expansion of a leaky circulation but also to micro vascular protection’.

BOOKS

1. H E L E N G I A N N A KO P O U L O S, L E E C A R R A S C O, J A S O N A L A B A KO F F, P E T E R D. Q U I N N. F LU I D A N D E L E C T R O LY T E M A N A G E M E N T A N D B L O O D P R O D U C T U S A G E . O R A L M A X I L L O FA C I A L S U R G C L I N N A M 1 8 ( 2 0 0 6 ) 7 – 1 7 . \

2. G Y T O N & H A L L T E X T B O O K O F M E D I C A L P H Y S I O L O G Y, 1 0 T H E D I T I O N .

3. SEM BULI NGA M   K .   SEM BULI NGA M P R E M A . K S E M B U L I N G A M - E SS E N T I A L S O F M E D I C A L P H Y S I O L O GY, 6 T H E D I T I O N  

4. C O N C I S E T E X T B O O K O F S U R G E RY – D A S S . 3 R D E D

References

Others R u t t m a n n T G , J a m e s M F. E f f e c t s o n c o a g u l a t i o n d u e t o

i n t r a v e n o u s c r y s t a l l o i d o r c o l l o i d i n p a t i e n t s u n d e rg o i n g v a s c u l a r s u rg e r y. B r J A n e s t h 2 0 0 2 ; 8 9 : 9 9 9 – 1 0 0 3 .

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