the edited version of my previous upload

1. PRESENTED BY –
DR. SHEETAL KAPSE
2nd YEAR, P.G. STUDENT
MODERATORS -
DR. SUNIL DUTT C.
DR. M. SATISH
DR. DEEPAK THAKUR
DR. MANISH PANDIT

3. 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
Composition
Normal exchange of fluids
Salt intake & output

4. • 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

6. • 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.

7. 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

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

10. 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

11. 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

12. Water 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 average
Daily 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 400
600 1500
Skin 500 - 1000

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

14. 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

15. • Volume Changes :
• Concentration Changes :
• Composition Changes : Acid/Base Balance
Potassium Abnormalities
Calcium Abnormalities
Magnesium Abnormalities
Hypovolemia
Hypervolemia
Hyponatremia
Hypernatremia

16. Hypovolemia
Hypervolemia

17. 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.

18. 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

19. 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

20. 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

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

22. 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

23. Etiology & treatment of hyponatremia

24. 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

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

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

27. 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.

28. 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

29. 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

30. Hyperkalemia
Serum 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.

31. 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

32. 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

33. 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

34. Hypocalcemia S/S Hypercalcemia S/S
1. Hypotension
2. Anxiety
3. Psychosis
4. Paresthesia
5. Laryngeal spasm
6. 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. Hypertension
2. Bradycardia
3. Constipation
4. Anorexia
5. nausea, vomiting
6. Nephrolithiasis
7. Pain
8. Psychosis
9. Pruritis
10. weight loss, thirst, polydipsia, and
polyuria
11. easy fatigue, weakness, stupor, and
coma
Treatment :
IV calcium for acute -1gm in D5 or NS
Oral calcium and vitamin D for chronic

35. 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+

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

37. 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

38. 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

39. • 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

40. 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

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

42. 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

43. I.V. fluids
Based on use
Maintenance fluids Replacement fluids Special fluids
5% D
5% 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. KCl
25% Dextrose

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

45. 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

46. 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

47. 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

48. 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.

49. 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

50. 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

51. 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

52. 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.

53. 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

54. 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
Acetate
Lactate
NH4Cl
---
---
70
20
---
---
23
---
---
47
---
---
Ca
Mg
---
---
---
---
---
---
5
3
HPO4 --- 15 3 ---
Citrate --- --- 3 8
Mosm/L 580 410 368 595

55. 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

56. 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

57. • 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

58. Crystalloids …

59. 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

60. colloids…

61. 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

62. Albumin
• Maintain plasma oncotic pressure – 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
Rate of infusion :
• Adults – initial infusion of 25 gm
• 1 to 2 ml/min – 5% albumin
• 1 ml/min - 25% albumin

63. Indications :
• Plasma volume expansion in acute hypovolemic shock, burns, severe hypo
albuminemia
• Hypo proteinemia – liver disease, Diuretic resistant nephrotic syndrome
• In therapeutic plasmapheresis , as an exchange fluid
Contra indications :
• Severe anaemia, cardiac failure
• Hypersensitive reaction

64. 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
• Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapid renal
excretion
• Anti thrombotic , inhibits platelet aggregation
• Improves micro circulatory flow

65. Indications :
• Hypovolemia correction
• Prophylaxis of DVT and post operative thromboembolism
• Improves blood flow and micro circulation in threatened vascular
gangrene
• Myocardial ischemia, cerebral ischemia, PVD and maintaining
vacular graft patency
• Priming in ECC
Adverse effects
• Acute renal failure
• Interfere with blood grouping and cross matching
• Hypersensitive reaction

66. 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

67. Gelatin polymers( haemaccel)
• 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 Cl 145 mEq, Ca 12.5 mEq,
potassium 5.1 mEq
Indications :
• Rapid plasma volume expansion in hypovolemia
• Volume pre loading in regional anesthesia
• Priming of heart lung machines

68. Advantages :
• Does not interfere with coagulation, blood grouping
• Remains in blood for 4 to 5 hrs
• Infusion of 1000ml expands plasma volume by 300 to 350 ml
Side effects :
• Hypersensitivity reaction
• Should not be mixed with citrated blood

69. 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

70. Physiochemical characteristics :
• Substitution of hydroxy ethyl groups at C2, C3 and C6
• Concentration : low( 6%), high(10%)
• MW : Low( <70kDa), med and high(>450kDa)
• Degree of substitution : low(0.45 – 0.58),
high( 0.62 – 0.70)
• C2/C6 : low(<8) , high(>8)
Metabolism :
Rapid amylase dependent breakdown and renal excretion upto 50% in 24 hrs

71. 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

72. 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

73. 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

74. Special fluids
• Inj KCl 10 ml amp – 20mEq
• 25%D (25 mi 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

75. 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)

76. 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

77. 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 ongoin blood loss >100ml/min
6. Acute blood loss > 40% (2L crystalloid 3:1 ---
 colloid 1:1 )

78. • 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.

79. • 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

83. 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

84. 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.

85. 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.

86. 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.

87. 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)

88. Intraoperative fluid therapy
• Volume to be replaced –
1. Correction of fluid deficit due to starvation :
2. Maintenance volume for intraop period :
3. Correction of intraop 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 container
b. Surgical sponge
c. 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

89. 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

90. 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

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

92. BOOKS
1 . G Y TO N & H A L L T E XT 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 .
2 . 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
3 . 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 R D E D
References

93. Others
 Ruttmann TG, James MF. Effects on coagulation due to
intravenous cry stalloid or colloid in patients undergoing
vascular surgery. Br J Anesth 2002 ; 89 : 999 – 1003.
 Svensen C, Ponzer S. Volume kinetics of Ringer solution after
surgery for hip fracture. Canadian journal of anesthesia 1999
; 46 : 133 – 141.
 Roberts I, Alderson P, Bunn F et al : Colloids versus
cry stalloids for fluid resuscitation in critically ill patients..
Cochrane Database Sy st Rev(4) : CD 000567, 2004
 Committee on Trauma. Advanced Trauma Life Support
Student manual. 6th ed. Chicago. American College of
Surgeons. 2001: 87-107
References

94. Thank you