Fluid and electrolytes

Fluid and electrolytes

1. 1. Introduction Basic physiology Body fluid electrolytes disturbances Parenteral fluid therapy Basic principles I.V. fluids Methods of calculation of fluid transfusion rate Fluid therapy in surgical patients Volume resuscitation – end parameters & goals Conclusion References Total body water Distribution Composition Normal exchange of fluids Salt intake & output

2. Body is formed with solids & fluids. In human body water content is 45-75% of body weight. Importance : In homeostasis In transport Mechanism In metabolic reactions In maintenance of tissue texture In temperature regulation

3. 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.

4. 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

5. Organic Inorganic Glucose Oxygen Amino acids electrolytes Proteins Fatty acid Lipid Hormones Enzymes

6. 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 h y per t o nic solution Cell in a h y po t onic solution

7. Cell Membrane ICF Cell Membrane Interstitial H 2 O Cell membrane is freely permeable to H 2 but Na and K are pumped across this membrane to maintain a gradient! Na + = 10 Urea H 2 O Na + K + glucose

8. Water Gain route Average Daily vol. (ml) Minim u m (ml) Maximum (ml) sensible Oral fluids 800 - 1500 1500/h Solid food 500 – 700 1500 insensible Water of o x idat i on 250 125 800 Water of solution 500 Water loss route average Daily vol. (ml) Minim u m (ml) Maximum (ml) sensible Urine 800 - 1500 500 1400 / h Intestine 0 – 250 2500 / h sweat 4000 / h insensible Lungs 400 600 1500 Skin 500 - 1000

9. 13 Daily fluid replacement = 700 + urine output Excess water loss fever : 100 ml / degree fever / day Tracheostomy (unhumidified air) : >1.5 L / day

10. 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

11. Volume Changes : Composition Changes : Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities Hypovolemia H y pervol e m ia Concentration Changes : Hyponatremia H y perna t re m ia

12. Hypovolemia H y pervol e m ia

13. 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.

14. 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

15. Hy p ervolemia 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

16. 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

17. Hyponatremia <135 mEq/l. Hypernatremia > 145 mEq/l.

18. 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. Signs & symptoms Sign & symptoms : <120 mEq/l. CNS: confusion, lethargy, stupor, headache, seizure, coma GI: nausea, vomiting Skeletal system : muscle twiches

19. Etiology & treatment of hyponatremia

20. Asymptomatic Symptomatic (Na>160 meq/L ) Hypernatremia >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

21. Etiology & treatment of hypernatremia Aggressive correction : central pontine myelinolysis

22. Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities

23. 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.

24. 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

25. 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

26. Hyperk a lemia Serum K + > 5.1 mEq /L Etiology : Increased intake : Potassium supplementation & Blood transfusions Endogenous load/destruction: hemolysis, rhabdomyolysis, cru s h injury, gastrointestinal hemorrhage Increased release : Acidosis Rapid rise of extracellure osmolality (hyperglycemia or mannitol) : Impaired excretion of potassium & Renal insufficiency/failure.

27. 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

28. 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

29. 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

30. Hypocalcemia S/S Hypercalcemia S/S Hypotension Anxiety Psychosis Paresthesia Laryngeal spasm Numbness and tingling of the circumoral region and the tips of the fingers and toes tetany with carpopedal spasm, convulsions (with severe deficit), Chvosteck & trousseau’s signs Hypertension Bradycardia Constipation Anorexia nausea, vomiting Nephrolithiasis Pain Psychosis Pruritis weight loss, thirst, polydipsia, and polyuria easy fatigue, weakness, stupor, and coma Treatment : IV calcium for acute -1gm in D5 or NS Oral calcium and vitamin D for chronic

31. 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+

32. Hypomagnesemia causes: starvation, malabsorption syndromes, GI losses, prolonged IV or TPN with magnesium-free solutions signs & symptoms: similar to those of calcium deficiency

33. 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

34. Basic principle Should have knowledge of 1. Etiology of fluid deficit 2. Type of electrolyte deficit 3. Associated illness 4. Clinical status Rationale 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

35. 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 contraindications Nutrition Ability to take oral fluid Treatment of critical problems (poisoning) Avoid in CHF & volume overload

36. 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

37. Para = other than , enteron (Gk) = intestine Ways to approach i.v. route – ve n e p u n cture venesection

38. Median cubital vein Long Saph e no u s vein In obese, female & infants Risk of thrombophlebitis & pulmonary e mbolism Rare in infants / children Cephalic vein in deltop e ctoral groove Subclavian vein Internal jugular vein External jugular vein Neonates / small children

39. I.V. fluids Based on use Maintenance fluids Replacement fluids Special fluids 5% D NS, Inj. Sod.bicarbonate, 5% D with 0.45% NaCl DNS, mannitol, RL, NS 1.6%, 3%, 5% ISOLYTE -G, Inj. KCl ISOLYTE-E, 25% Dextrose ISOLYTE-M, ISOLYTE-P

40. I.V. fluids Based on property Crystalloids (solution of large molecules) Colloids (solution of electrolytes) Life saving RL 5% Albumin NS 25% Albumin DNS 10% Pentastarch D-5% 10% Dextran -40 ISOLYTES 6% Dextran -70 10% Hetastarch

41. 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

42. 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

43. 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 : Lactic acidosis Hyperurecemia hypophosphatemia Contra indications hereditory fructose intolerance Caution in renal & hepatic impairment >25gm fructose should be avoided more expansive

44. 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.

45. Ind i ca t i o ns 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

46. DNS Pharmacological 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

47. DNS with half 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

48. Ring e r’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.

49. 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

50. Isolyte fluids Isolyte G Isolyte M Isolyte P Isolyte E dextrose 50 50 50 50 Na 63 40 25 140 K 17 35 20 10 Cl 150 40 22 103 Acetate --- 20 23 47 Lactate --- --- --- --- NH4Cl 70 --- --- --- Ca --- --- --- 5 Mg --- --- --- 3 HPO4 --- 15 3 --- Citrate --- --- 3 8 Mosm/L 580 410 368 595

51. 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 i nsu f fic i ency

52. 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

53. 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

54. Crystalloids …

55. Coll o ids 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

56. colloids…

57. Type of fluid Effective plasma volume ex pan s ion/ 100m l 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

58. Album i n 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

59. 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

60. 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.

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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)

71. 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

72. 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 )

73. AMERICAN COLLEGE OF SURGEONS (2001), Classification of acute hemorrhage Committee on Trauma. Advanced Trauma Life Support Student manual. 6 th ed. Chicago. American College of Surgeons. 2001: 87-107.

74. Transfusion with whole blood is indicated very rarely. Advantages : Preservation of remaining whole blood components Longer storage Decreases the risk of transfusion reaction

75. Holiday Segar Method 4 ml/kg/hr = 4x10/hr = 40 ml/hr 2ml/kg/hr = 2x20/hr = 40 ml/hr So, for > 20 kg patient = body wt + 40 ml Eg. For 70 kg. pt = 70+40 = 110 ml

76. 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.

77. 1. Acute stress : sympathetic stimuli, tachycardia & vasoconstriction. Stress : corticosteroids secretion (up to 48 hrs) Na + retention, K + depletion Intracellular K + depletion  hyperkalemia Stress : ADH (up to 2-3 post op days)  water retention Requirement of maintenance fluid is less on1 st post op day. NPO require consideration & replacement. Pre, intra & post operative blood / fluid loss require consideration & replacement.

78. Hypovolemia should be corrected preoperatively  hypotension intraoperatively Surgical stress / direct damage to kidney, brain, lungs, skin, GIT should be considered as they play important role in fluid & electrolyte balance.

79. Preoperative fluid therapy Very important for better outcome in surgical patients. 3 parameter are important Correction of hypovolemia (GA diminishes the compensatory reflexes ) Correction of anemia (48 hours prior to surgery) Correction of other disorders (eg. hypo & hyperkalemia)

80. Intraoperative fluid therapy Volume to be replaced – 1. Correction of fluid deficit due to starvation : 2. Maintenance volume for intraop period : Duration of starvation (in hr) x 2 ml / kg ; 5% D Duration of surgery (in hr) x 2 ml / kg ; 5% D Correction of intra op loss : Suction container Surgical sponge 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

81. Postoperative fluid therapy 1. First 24 hrs of surgery (total = 2 L) 2. 2 nd post op day (total = 3 L) 3. 3 rd 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

82. End parameters Goals Achieve primary goal (0xygen supply) Good level of Hb% & cardiac output Test for – ABG CVP Pulmonary pressure BP heart rate Urine output > 1ml/kg/hr CVP = 15 mmHg Pulmonary capillary wedge pressure 10-12 mmHg Cardiac index >3L/min/sq meter Oxygen uptake >100 ml /min/sq meter Blood lactate < 4 mmol/l Basic deficit

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

84. B O O K S 1. H E L E N G I A N N A K O 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 K O F F , P E T E R D . Q U I N N . F L U I D AND E L E C T R O L Y T E M A N A G E M E N T AND 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 F A C I A L S U R G C L I N N AM 18 ( 2 6 ) 7 – 17 . \ 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 TH E D I T I O N . S E M B U L I N G A M K. S E M B U L I N G A M P R E M A . K S E M B U L I N G A M - E S S E N T I A L S O F M E D I C A L P H Y S I O L O G Y , 6 T H E D I T I O N C O N C I S E T E X T B O O K O F S U R G E R Y – D A S S . 3 RD ED References

85. O t h e r s 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 r g o i n g v a s c u l a r s u r g e r y. B r J A n e s t h 2 2 ; 8 9 : 9 9 9 – 1003. S v e n s e n C , P o n z e r S . Vo l u m e k i n e t i c s o f R i n g e r s o l u t i o n a f t e r s u r g e r y f o r h i p f r a c t u r e . C a n a d i a n j o u r n a l o f a n e s t h e s i a 1 9 9 9 ; 4 6 : 1 3 3 – 141. R o b e r t s I , A l d e r s o n P, B u n n F e t a l : C o l l o i d s v e r s u s c r y s t a l l o i d s f o r f l u i d r e s u s c i t a t i o n i n c r i t i c a l l y i l l p a t i e n t s . . C o c h r a n e D a t a b a s e S y s t R e v ( 4 ) : C D 5 6 7 , 2 4 C o m m i t t e e o n T r a u m a . A d v a n c e d T r a u m a L i f e S u p p o r t S t u d e n t m a n u a l . 6 t h e d . C h i c a g o . A m e r i c a n C o l l e g e o f S u r g e o n s . 2 1 : 8 7 - 107 References

86. Thank you