JAMIA ISLAMIA ISHATUL ULOOMS

INDIAN INSTITUTE OF MEDICAL SCIENCE AND RESEARCH

PG ACTIVITY PRESENTATION

DEPT OF ANESTHESIA

 FLUID MANAGEMENT

BY DR SHAHAB SHAIKH
ASSISTANT PROFESSOR DEPT OF PHYSIOLOGY

BODY FLUIDS
Total Body Water (TBW):

Varies with age, gender, body habitus

55 - 60% body weight in males 45 - 50% body weight in females 80% body weight in infants Less in obese: fat contains little water

BODY FLUIDS
Body Water Compartments:

Intracellular fluid: 2/3 of TBW

Extracellular fluid: 1/3 TBW
Extravascular fluid: 3/4 of extracellular fluid
Intravascular fluid: 1/4 of extracellular fluid

BODY FLUIDS
Body Water Compartments

BODY FLUIDS
Body Fluid Electroytes:
ELECTROLYTE ECF (mEq/L) ICF (mEq/L)

Na
K Cl Hco3 Ca

142
4.3 104 24 5

10
150 2 6 0.01

Mg

40

BODY FLUIDS
Body Fluid Electrolyte:

BODY FLUIDS
Non Electrolytes of Plasma:

BODY FLUIDS
Tonicity of Fluids:

BODY FLUIDS
Daily Intake and Output of Water:

BODY FLUIDS
Daily Intake and Output of Water:

I V FLUIDS
Classification:

CRYSTALLOIDS
COLLOIDS BLOOD PRODUCTS

I V FLUIDS
Crystalloids:
Clear solutions made up of water & electrolytes.

These fluids are good for volume expansion.

Both water & electrolytes will cross membrane

and achieve equilibrium in 2-3 hours.

3mL of isotonic crystalloid solution are needed to replace 1mL of patient blood.

CRYSTALLOIDS I V FLUIDS

I V FLUIDS
Colloids:
Colloids are large molecular weight solutions

Do NOT readily cross semi-permeable

membranes or form sediments.

Because of their high osmolarity, these are

important in capillary fluid dynamics

These fluids stay almost entirely in the IV space.

COLLOIDS I V FLUIDS

COLLOIDS I V FLUIDS
Na Gelofusin Elohaes, Voluven Volplex Haesteril Albumin Haemacell Geloplasma Volulyte 150 Cl 120150 K Lactate Ca Mg Other

145 150 137

145 100

5 5 4 30

6 1-1.5 110 1.5 Acetate 34

DEPARTMENT OF ANESTHESIA INDIAN INSTITUTE OF MEDICAL SCIENCE AND RESEARCH

I V FLUIDS: 5% Dextrose
Contains 50 gm Glucose/L Used for Rx of dehydration, Pre & Post-Op fluid replacement, IV drugs administration, etc. Contraindicated in Cerebral Edema, Neurosurgical procedures, Ac Stroke, Hypovolemic shock, Hyponatremia Blood transfusion through the same IV line as Dextrose should not be done. Can be given @ 0.5gm / Kg body Wt. / Hour

I V FLUIDS: 0.9% saline

Contains 9.0 gm NaCl/L (Na: 154 mEq, Cl: 154 mEq) Used for Rx of water & salt depletion states like Vomiting, Diarrhoea, Exc sweating, etc. Rx of Hypovolemic Shock, Hyponatremia, IV drugs administration, etc. Contraindicated in Hypertensive pts, preeclamptic pts, Used Cautiously in pts with CCF, Renal disease & cirrhosis, very young or old pts.

I V FLUIDS: RINGER LACTATE

Contains Na: 130, Cl: 109, K: 4, Ca: 3, HCO3: 28 mEq/L. . . . . Most Physiological fluid ! Used for Rx of Hypovolemia, Metabolic Acidosis etc. For fluid replacement in Pre. Intra & Post-Op pts, Burns, #s, Peritoneal Irrigation, DKA etc. Contraindicated in Liver Disease, severe Hypoxia & Shock pts, Met Alk due to Vomiting or NG Aspiration, Simultaneous infusion of RL and Blood product. Ca in RL binds with certain drugs and reduce their bioavailability and efficiency.

I V FLUIDS: The Isolytes

ISOLYTE G: is Gastric replacement solution
Only IV Fluid which directly corrects any Met. Alkalosis

ISOLYTE M: is Maintenance solution

Richest source of K+ (35 mEq/L)

ISOLYTE E: is Extracellular replacement Solution

Only IV fluid which corrects Magnesium deficiency Provides maximum HCO3 among all IV fluids

ISOLYTE P: is Pediatric maintenance solution

Has half concn. of electrolytes as compared to Isolyte-M

I V FLUIDS

I V FLUIDS

Assessment of volume status

Mild:
Thirst Concentrated Urine

Severe:
Confusion, Stupor Systolic BP < 100 mmHg Tachycardia, Low Pulse Volume Cold Extremities, Poor Capillary filling Reduced skin turgor

Moderate:
Dizziness, Weakness Oliguria Postural Hypotension Low JVP

Assessment of volume status

A more invasive approach:
Urine output Central venous line Arterial line PAWP catheter

FLUID MANAGEMENT
OK, so the patient needs fluid How much . . . ?

FLUID MANAGEMENT
Deficits

Maintenance
3rd Space loss Blood loss

FLUID MANAGEMENT
Deficit:
Estimate
Preop NPO (hourly maintenance x duration) Preop bowel preparation (1-1.5L) Preop blood loss (trauma) or fluid loss (burns)

Typically replaced over first 2-4 hours

FLUID MANAGEMENT
Maintenance: (4-2-1 rule)
4 ml/kg/hr for first 10 kg of body weight 2 ml/kg/hr for 2nd 10 kg of body weight 1 ml/kg/hr for each kg of body weight above 20 kg

Example: 70 kg adult = 40 cc/hr for 1st 10 kg BW + 20 cc/hr for 2nd 10 kg BW + 50 cc/hr for remaining 50 kg BW = 110 cc/hr

FLUID MANAGEMENT
Third Space Losses:
Isotonic transfer of ECF from functional body fluid compartments to non-functional compartments. Depends on location and duration of surgical procedure, amount of tissue trauma, ambient temperature, room ventilation.

FLUID MANAGEMENT
Replacing Third Space Losses:
Superficial surgical trauma: 1-2 ml/kg/hr

Minimal Surgical Trauma: 3-4 ml/kg/hr

head and neck, hernia, knee surgery

Moderate Surgical Trauma: 5-6 ml/kg/hr

hysterectomy, chest surgery

Severe surgical trauma: 8-10 ml/kg/hr (or more)

AAA repair, nephrectomy

FLUID MANAGEMENT
Replacing Blood Losses:
3 to 1 ratio of crystalloid

1 to 1 for colloid or blood

FLUID MANAGEMENT
TIME TO PUT IT ALL TOGETHER:

Deficits

Maintenance

3rd Space loss

Blood loss

FLUID MANAGEMENT
Calculating Rate of Fluid Infusion:
For routine I.V set 15 drops = 1 ml

Rule of Ten for infusion rate in 24 hrs.

I.V fluid in litre/24 hrs X 10 = Drop rate / min

Rule of Four for infusion rate in 1 hr.

I.V fluid in ml/ hour 4 = Drop rate / min

FLUID MANAGEMENT
Risks of Excess Fluid:
Interstitial edema Impaired cellular metabolism Poor wound healing Decreased pulmonary compliance Heart failure overload Delayed return of bowel function Hemodilution

FLUID ANYWAYS . . . !!!

A DEPT OF ANESTHESIA PRESENTATION

THANK

YOU

Daily Requirements
The normal electrolyte requirements are:

Na+ 1-2 mmol/kg/24 h K+ 0.5-1 mmol/kg/24 h.

Sodium imbalance s Hyponatr -aemia

Definiti on

Risk factors/ etiology

Clinical manifestation

Laboratory findings

management

Kidney diseases
It is defined as a plasma sodium level below 135 mEq/ L Adrenal insufficiency

Gastrointestinal losses
Use of diuretics (especially with along with low sodium diet) Metabolic acidosis

Weak rapid pulse Hypotension Dizziness Apprehension and anxiety Abdominal cramps Nausea and vomiting Diarrhea Coma and convulsion Cold clammy skin Finger print impression on the sternum after palpation Personality

Serum sodium less than 135mEq/ L

serum osmolality less than 280mOsm/kg urine specific gravity less than 1.010

Identify the cause and treat

*Administration of sodium orally, by NG tube or parenterally *For patients who are able to eat & drink, sodium is easily accomplished through normal diet *For those unable to eat,Ringers lactate solution or isotonic saline

Sodium imbalan -ce Hypernat -remia

Definiti on It is define d as plasm a sodiu m level greate r than 145m E q/L

causes

Clinical manifestation Low grade fever Postural hypertension Dry tongue & mucous membrane Agitation Convulsion Restlessne

Lab findings

management

*Ingestion of large amount of concentrated salts *Iatrogenic administratio n of hypertonic saline IV *Excess alderosterone secretion

*high serum sodium 135mEq/L

*Administration of hypotonic sodium solution [0.3 or 0.45%]

s ss

*high serum osmolality295 mO sm/kg

*high urine specificity 1.030

*Rapid lowering of sodium can cause cerebral edema

*Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes

Excitability Oliguria or anuria Thirst Dry &flushed skin

Potassium imbalances Hypokalemi a

Definitio n It is defined as plasma potassiu m level of less than 3.0 mEq/L

Causes *Use of potassium wasting diuretic *diarrhea, vomiting or other GI losses *Alkalosis *Cushings syndrome

Clinical manifestation *weak irregular pulse *shallow respiration *hypotesion *weakness, decreased bowel sounds, heart blocks , paresthesia, fatigue, decreased muscle tone intestinal obstruction

Lab findings * K less than 3mEq/L results in ST depression , flat T wave, taller U wave * K less than 2mEq/L cause widened QRS, depressed ST, inverted T wave

Management Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement Moderate hypokalemia *K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/

*Polyuria
*Extreme sweating

*excessive

Severe hypokalemia Kless than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625

Definition

Causes

Clinical manifestation Irregular slow pulse, hypotension, anxiety,

Lab findings

Management

Hyperkal emia

It is defined as the elevation of potassiu m level above 5.0mEq/L

Renal failure , Hypertonic dehydration, Burns& trauma

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad Pwave *serum potassium levels of 8mEq/L

*Dietary restriction of potassium for potassium less than 5.5 mEq/L *Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics *Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium 2.infusion of insulin and

Large amount of IV administration of potassium,

Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of

irritability,
paresthesia, weakness

Calcium imbalan ces

Definitio n

Causes

Clinical manifestation

Lab finding s

Management

hypocal cemia

It is a plasma calcium level below 8.5 mg/dl

Rapid administration of blood containing citrate, hypoalbuminemi a, Hypothyroidism , Vitamin deficiency, neoplastic diseases, pancreatitis

Numbness and tingling sensation of fingers, hyperactive reflexes, Positve Trousseaus sign, positive chvosteks sign , muscle cramps, pathological fractures,

Serum calciu m less than 4.3 mEq/L and ECG change s

1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

Calcium imbalanc e

Definition

Causes

Clinical manifestation

Lab findings

Management

Hypercal cemia

It is calcium plasma level over 5.5 mEq/l or 11mg/dl

Hyperthyro idism, Metastatic bone tumors, pagets disease, osteoporosis , prolonged immobalisatio n

Decreased muscle tone, anorexia, nausea, vomiting, weakness , lethargy, low back pain from kidney stones, decreased level of consciousness & cardiac

High serum calcium level 5.5mEq/L,

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium 2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive

x- ray showing generalized osteoporosis,

widened bone cavitation, urinary stones, elevated BUN 25mg/100ml,

Acid-Base imbalance Respiratory acidosis

Definition

Causes

Clinical manifestation

Lab findings

Management

Hypoventilatio n & excessive CO2 production

Respiratory Alkalosis
Hyperventilation

It is a clinical disorder in which the pH is less than 7.35 and the paCO2 is greater than 42mmHg It is a clinical condition in which the arterial Ph is greater than7.45

COPD, neuromuscular disorder, Guillian-Barre syndrome, Myssthenia gravis, Respiratory center depression, Drugs, late ARDS, Hypoxemia, impaired lung expansion, thickened alveolar capillary membrane, Chemical stimulation of

Dyspnea ,
disorientation , coma

PH lesser than 7.35, Paco2 greater than 45mmHg, Hyperkalemia, Hypoxemia

1.Treat underlying cause

2.Support ventilation
3.Correct electrolyte imbalance 4.Intravenous NaHCO3 Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation

Tachypnea, giddiness, dizziness, syncope, convulsions , coma, weakness, paresthesia , tetany

PH greater than 7.35 PaCO2 lesser than 35 mmHg, Hypokalemia, Hypocalcemia

Definition

causes

Clinical manifestation

Lab findings

Management

Metabolic Acidosis

It is a clinical condition in which the HCO3 & pH is decreased

Renal failure, Diabetic ketoacidosis, Lactic acidosis, ingested toxins, renal tubular acidosis

Hyperventilatio n confusion, drowsiness, coma, headache

PH< 7.35, HCO3< 22mEq/L

1.Treat the underlying cause 2.Intravenous NaHCO3 3.correct electrolyte imbalance

Metabolic Alkalosis

It is a clinical condition in which PH is raised

Hypokalemia, gatric fluid loss, massive correction of whole blood, Overcorrection of acidosis with NaCO3

Hypoventilation Dysrythmias

PH >7.45 Hypokalemia Hypocalcemi a PaCO2 normal or increased

1.Treat the underlying cause 2.Administer KCL 3.intravenous acidifying salts[NH4CL]