Dr. N.K. Agrawal

Professor,

JNMC, Sawangi

HOW MUCH IS WATER ON EARTH?

HOW IS COMPOSITION OF FLUID IN HUMAN

BODY?

60% of the body is FLUID

40% of the body is SOLID

HOW IT VARIES WITH SEX AND AGE?

Total body water :

HOW THE FLUID IS DISTRIBUTED IN BODY?

The body fluid is mainly having

Intra cellular compartment (ICF)

Extra cellular compartment (ECF)

Electrolytes(mEq/L) ECF ICF

Sodium 142 10

Potassium 4.3 150

Chloride 104 2

Biocarbonate 24 6

Calcium 5 0.01

Magnesium 3 40

Phosphate & Sulphate 8 150

HOW THE BODY LOOSES WATER?

INSENSIBLE

AND

SENSIBLE loss of water

Oral or IV fluid intake and urine output are important

parameters of body fluid balance

Normal daily insensible fluid loss:

Fluid loss – Fluid input = 1000-300 = 700 ml.

Daily fluid requirement = urine output + insensible loss

Insensible fluid input Insensible fluid loss

300 ml water due to oxidation 500 ml through skin

400ml through lung

100 ml through stool

URINE OUT PUT IS

=1.5ml/kg/hr

For a person of 70kg

Urine out put=70 x 1.5x24=2.5lit/day

For a normal adult fluid requirement is

Urine out put +insensible loses

2.5 lit + 0.7 lit= 3.2 lit/day

THIS IS THE REQUIREMENT OF AN

INDIVIDUAL DAILY

For an adult- 2ml/kg/hr

Children - 4ml/kg/hr

To maintain normal body fluid balance one must take

this much minimum water

Whether a person is fasting or for surgery

One must be given fluid to keep the fluid compartment

hydrated this is—

Maintenance fluid therapy

Osmolarity is determined by amount of solute

dissolved in a solvent measured in volume(lt).

Osmolality of any solution is measured by measurment

of its freezing point.

Plasma Osmolality =

2 x Na + Glucose(mg/dl)/ 18 + BUN(mg/dl)/2.8.

A VERY IMPORTANT ASPECT

ONE ML OF FLUID CONTAIN HOW MANY

DROPS?

NORMAL IV SET 1ML= 15 drops

PAEDIATRIC IV SET 1ML= 60 drops

Crystalloids:

hypotonic- 5% dextrose ,D5 1/2 NS OR 1/4NS

Isotonic- 0.9%Nacl, ringer lactate, ringer acetate

Hypertonic- 3%,5%, 7.5% Nacl.

Colloids:

Hydroxyethyl starches

Gelatins

Dextran

Albumin.

Crystalloids are aqueous solutions of inorganic and

small organic molecules, the main solute being either

normal saline or glucose. Depending on the

concentration of the solute, crystalloid solutions are

isotonic, hypotonic, and hypertonic.

Colloids, in contrast, are homogeneous noncrystalline

substances containing large molecules.

Colloids have much greater capacity to remain within

the intravascular space.

Distribution of

1,000 mL of fluid

given IV

Intracel

lular

Fluid

Interstit

ial Fluid

Intravas

cular

Fluid

5% Dextrose 666 249 83

Crystalloid 0 750 250

Colloid

Immedi

ate0 0 1,000

After 4

hours0 750 250

Blood 0 0 1,000

Composition

One liter contains 50 grams.

Pharmacological Basis

Corrects dehydration and supplies energy.

After consumption of glucose remaining water is distributed in all compartments so it is best to correct intracellular dehydration.

D5% provides 170 Kcal/L

Composition

One liter contains :

Glucose 50 gm, Chloride 154 mEq,

Sodium 154 mEq

Each 100 ml contains 5 gm glucose

and 0.90 gm NaCl.

Composition

One liter fluid supplies

Sodium 130 mEq, Potassium 4

mEq,

Calcium 3mEq, Bicarbonate 28mEq,

Chloride 109mEq

Each 100 ml contains Sodium Lactate

320 md, sodium chloride 600 mg,

Potassium chloride 40 mg, calcium

chloride 27 mg

Hydroxyethyl starches are

modified natural

polysaccharides similar to

glycogen.

They are derived from

amylopectin, a highly branched

corn or potato starch.

Produced by degradation of bovine collagen and

chemical modifications, gelatins are polydispersed

colloidal solutions.

Three types

1. oxy-crosslinked,

2. urea-crosslinked,

3. and succinylated gelatins.

Molecular weight (average 30-35 kD), concentrations

(3.5%-5.5%) and volume-restoring efficacy (volume

effect 70%-100%).

500ml, 3.5% solution

100ml- 3.5 gms of gelatin

Stable for 3years

Mw wt- 30000-350000

Half life- 2-4 hours

a) Uses- a) hypovolemia

b) Pre loading

c)haemo dilution

Dextrans are polydispersed colloids -synthesized from

sucrose by the bacterium Leuconostoc mesenteroides.

The formulations most frequently selected are dextran

40 and dextran 70, with molecular weights of 40 and

70 kD, respectively.

After intravenous administration, small dextran

molecules less than 50 kD are rapidly eliminated by the

kidneys (filtration). All other molecules are being

metabolized to carbon dioxide and water by cell-bound

enzymes in the kidneys, liver, and spleen.

Albumin is purified from human plasma and is commercially available as a

1. 5% (iso-oncotic), 2. 20%, or 25% (hyperoncotic)

solution. Because albumin is heated and sterilized by ultrafiltration, the risk of bacterial or viral disease transmission should be eliminated.

Albumin is the most abundant plasma protein.

• Crystalloids are

1. inexpensive

2. adverse effects are

rare or absent

3. There is no renal

impairment,

4. minimal interaction

with coagulation

5. no tissue

accumulation,

6. and no allergic

reactions

• Colloids are

1. better volume-

expanding

properties,

2. minor edema

formation

3. improved

microcirculation.

4. Improve tissue

oxygenation.

5. expensive

Pre operative

Intra operative

Post operative

Aims

Correction of Hypovolemia

Correction of Anemia

Correction of Other Disorders.

Hypovolemia jeopardizes O2 transport and increase the

risk of hypoxia & development of organ failure.

Uncorrected hypovolemia is compensated by increased

vascular resistance and heart rate due to normal

baroreceptor reflex but these are lost during induction

of anesthesia.

Causes : vomiting, nasogastric suction, blood loss, third

space loss, diuretic therapy etc

Estimation severity of dehydration.

Mild= 4% body weight fluid deficit.

Moderate = 6-8 % body weight fluid deficit.

Severe = 10 % body weight fluid deficit.

Choice of fluid depends on nature of loss and

haemodynamic status,compositional abnormality.

NS, RL , colloids & Whole blood are most widely used

fluids

It is the space which normally dose not exist in body

It is created due to some complications like Hydro

Thorax,Acsities

Rate of fluid administration varies depending on

severity of fluid disturbance, presence of continuing

losses and haemodynamic and cardiac status.

In severe deficit FT may be started at 1000ml/hr

,gradually reducing the rate as the fluid status

improves.

Elderly require slow and careful correction.

Monitoring :Improvement in tachycardia and blood

pressure, absence of orthostatic hypotension and

achieving urine output of > 30-50 ml/hr (in absence of

diuretics) suggests correction of fluid deficit.

Intraoperative volume can be calculated as-

1. MAINTANACE-Correction of fluid deficit due to

fasting

2. REPLACEMENT- Replace the lost components

3. SPECIFIC-Loss due to tissue dissection/ hemorrhage

Volume to be replaced for starvation=

Duration of starvation(hrs) x2ml/kg body weight

1st hour = 50%

2nd hour = 25%

3rd hour = 25%

Maintenance volume for intra-op: 2ml/kg/hours

(fasting should never be more than 4-6 hrs, if so we

recommend to start iv fluids pre operatively)

Fluid loss is calculated as-Type of surgery Fluid volume(ml/kg/hr)

Least trauma Nil

Minimal trauma 4

Moderate trauma 6

Severe trauma 8

List trauma : cataract, sebaceous cyst , surgery etc

Minimum : appendix, hernia, surgery etc

Moderate : laparotomy , hysterectomy etc

Severe : THR, bowel resection, etc

intra-op blood loss calculation

MABL= EBV x (sHct-tHct)/ sHct

Methods of estimation-

Weight the sponges before and after use.

The difference in gm = volume in ml of blood they have

absorbed

This has to be added to suction bottle blood.

Then increase the total by 50 %.

Result will give you the actual blood loss.

If blood loss is more than 20% of blood volume, give BT

Total fluid would be

1st hr = 50 % of deficit+ maintenance + Fluid loss

according to surgery

2nd hr = 25 % of deficit+ maintenance + Fluid loss

according to surgery

3rd hr = 25 % of deficit+ maintenance + Fluid loss

according to surgery

4th hr onwards = Maintenance + Fluid loss according to

surgery.

AIM

BP > 100/70 mm of Hg or MAP >60 mm Hg

HR < 120/min

Urine output = 0.5 -1 ml/kg/hr along with normal

temperature , warm skin , normal respiration and

senses.

How long to give fluids?--- it depends upon the type

and nature of surgery.

If minor surgery - maintain fluid till NBM period

Major surgery- fluids can be required till 24-48hrs.

Fluid requirement = 2ml/kg/hr with isotonic

crystalloids

Take into consideration Blood loss , urine output, blood

glucose levels, insensible fluid loss and titrate fluid

intake accordingly.

Avoid glucose containing solutions in neurosurgical

patients, severely dehydrated patients & cautious use in

diabetic patients.

WHAT HAPPENS IF FLUID IS EXCESS?

So to avoid complications

we have to monitor FLUID

Hemodynamic monitoring:

◦ Heart rate, Blood pressure

Urine output monitoring

Temperature & Sensorium

Invasive monitoring

◦ CVP monitoring , Invasive BP, PCWP

Echo

Serum Electolytes

Fluid overload

◦ Rise in BP, Tissue edema

◦ pulmonary edema

◦ poor wound healing

hyperglycemia - Osmotic diuresis-

Dehydration

Electrolyte imbalance

◦ Hypo/ Hypernatremia ,

◦ Hypo/ Hyperkalemia

60% body weight is fluid

40% is ICF,15% intertitial,5% intra vascular

One requires 2ml/kg/hr water daily

Intra operative 4ml,6ml,8ml /kg/hr as per type of

surgery

Always consider total circulating volume

1ml have 15 or 60 drops

Never over infuse

SAVE WATER ,

SAVE EARTH ,

GIVE WATER,

GIVE LIFE