fluids veerendra

8/2/2019 Fluids Veerendra

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FLUID MANAGEMENTFLUID MANAGEMENTSPECIAL SITUATIONSSPECIAL SITUATIONS


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Water :63%Water :63%

Protein :17%Protein :17%

Fat :12%Fat :12%

Minerals :7%Minerals :7%

Carbohydrates :1%Carbohydrates :1%


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SUMMARY OF FLUID INTAKE AND OUTPUT PER

DAY UNDER NORMAL CONDITIONS IN ADULTIN ADULT

MANMAN

INTAKE(mL) OUTPUT(mL)

Ingested liquidsIngested liquids 16001600KidneysKidneys 15001500

Ingested foodsIngested foods 700700SkinSkinEvaporationEvaporation

PerspirationPerspiration

400400Metabolic waterMetabolic water 200200

Total 2500Total 2500

100100

LungsLungs 300300

GI TractGI Tract 200200

TotalTotal 25002500


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TTOTALOTAL BBODYODYFFLUIDSLUIDS

Dissolved substancesDissolved substances

Decreases with ageDecreases with age Lean body massLean body mass Fat free tissueFat free tissue Stored fat :waterfreeStored fat :waterfree

Electrolyte balanceElectrolyte balance

Total Body WaterTotal Body Water

AverageAverage

ValueValue

RangeRange

MenMen 62%62% 54-70%54-70%

WomenWomen 51%51% 45-60%45-60%

InfantsInfants 65-75%65-75%


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MOVEMENTOF BODYFLUIDS

Between plasma and interstitial compartments:Between p

lasma and interstitial compartments:

Four principal pressures :Four principal pressures :

1) BHP, Pc 2) IFHP, Pt 3)BOP,1) BHP, Pc 2) IFHP, Pt 3)BOP, c 4) IFOP,c 4) IFOP, tt

Effective filtration pressure (PEffective filtration pressure (Peffeff))

Arterial end = 8mm HgArterial end = 8mm HgVenous end = -7mm HgVenous end = -7mm Hg

Unde r no rm a l c ond i t io n s , t h e r e i s a s t a t e o f n ea r e qu i l ib r i umnde r no rm a l c ond i t io n s , t h e r e i s a s t a t e o f n ea r e qu i l ib r i uma t t he a r t e r ia l e nd and v enous end s o f a c ap i l l a r y w i t ht th e a r t e r ia l e nd and v enous end s o f a c ap i l l a r y w i t hf i l t e re d f l u i d a nd a b so r bed f lu i d a s w e l l a s t h a t p i c k ed upi lt e r e d f l u id a n d ab so r bed f l u i d a s w e l l a s t h a t p i c k ed upby t he l ymph a t i c s y s tem be i ng nea r l y e qua l .y t h e l ympha t ic s y s t em be i ng nea r l y e qua l .

Starlings law of the capillaries.Starlings law of the capillaries.

Transcapillary fluid flux (Jv) = Lp [(Pc Pt) - [(Transcapillary fluid flux (Jv) = Lp [(Pc Pt) - [(c -c - t)]t)]Lp = average transcapillary hydraulic conductivityLp = average transcapillary hydraulic conductivity

= average colloid osmotic reflection coefficient.= average colloid osmotic reflection coefficient.


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MMOVEMENTOVEMENTOFOF BBODYODYFFLUIDSLUIDS

Between interstitial& intracellularBetween interstitial& intracellular

compartments :comp

artments :

Equal osmotic pressuresEqual osmotic pressuresinside the cell : Kinside the cell : K++

out side the cell :Naout side the cell :Na++

ADH:ADH: ECF electrolyte concentrationECF electrolyte concentration

Aldosterone:Aldosterone: Regulates ECF volumeRegulates ECF volume


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REGULATION OF FLUID VOLUME BY ADJUSTING

INTAKE TO OUTPUT

Dehydration

Decreased flow of sal iva

Dry mouth and throat

Increased osmotic pressure ofbloodStimulates osmoreceptors inhypothalamus

Th i r s tIncreased fluid intake

Increases total volume of body fluid

OUT

PUT

INP

UT

RETURN TO


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Excessive sweating or vomiting, diarrhoea + plain waterintake[Na+] in ISF ISF oncoticpressure

Net osmosis from ISF ICF

Ce l l u l a rOve rhyd ra t i on

ISF hydrostatic pressureWater moves from plasma ISF Blood volume

C i r cu l a to ry shock

INTERRELATIONS BETWEEN FLUID AND

ELECTROLYTE IMBALANCE


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Maintenance fluid : 4-2-1 ruleMaintenance fluid : 4-2-1 rule

Weight in kgWeight in kgFluid requirement in mL/kg/hrFluid requirement in mL/kg/hrNewborns to 10kgNewborns to 10kg 44mLmL

1020 kg1020 kg 40mL(10X4mL) +40mL(10X4mL) + 22mL for each kg >10 kgmL for each kg >10 kg

>20 kg>20 kg 60mL(10X4mL+10X2mL) +60mL(10X4mL+10X2mL) + 11mL for each kg >20mL for each kg >20kgkg

Daily requirementsDaily requirements

NaNa++

(0.7 to 1.4 mmol/kg)(0.7 to 1.4 mmol/kg) KK++(0.8 to 1.4 mmol/kg)(0.8 to 1.4 mmol/kg)

Water: 20-25 mL/kg/dayWater: 20-25 mL/kg/day

2 mg/kg/min of glucose2 mg/kg/min of glucose

Additional lossesAdditional losses replacementreplacement


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Loss Result

10-15% fluid10-15% fluid SympatheticSympatheticstimulationstimulation

25-30%25-30%

bloodblood

Circulatory shockCirculatory shock

Fluid LossFluid Loss ClinicalClinicalExamplesExamples HaematocritHaematocrit

Plasma(100Plasma(100mL)mL)

Burns,Burns,pancreatitis,pancreatitis,

peritonitisperitonitis

1 %1 %

ECF(500mL)ECF(500mL) GI lossesGI losses 1 %1 %

Pure waterPure water EvaporationEvaporation

from lungsfrom lungs

Clinical Guides


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PPRODUCTSRODUCTSFORFOR VVOLUMEOLUMERRESUSCITATIONESUSCITATION

ColloidsColloids IdealIdealcolloidcolloid::

-Natural -sustained-Natural -sustained

iv OP.iv OP.

-Synthetic-Synthetic --nono Natural colloidsNatural colloids

-infection risks-infection risks

-Plasma -allergic-Plasma -allergic

reactionsreactions-Albumin -cross--Albumin -cross-

matchingmatching

- Inexpensive- Inexpensive

PlasmaPlasma


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CCOMPARISON OFOMPARISON OF CCRYSTALLOIDSRYSTALLOIDS

ANDAND CCOLLOIDSOLLOIDSCrystallo

idColloid

Intravascularpersistence Poor Good

Haemodynamicstabilization

Transient Prolonged

Volumerequired Large Moderate

Plasmacolloidosmoticpressure

Reduced Maintained

Riskofoverhydration Obvious InsignificantEnhancementofcapillary

perfusionPoor Good

Riskofanaphylactoid

reactions

Non-

existent

Low to

moderateCost Inex ensiv Ex ensive


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HEART FAILUREHEART FAILURE

LIVER DISEASELIVER DISEASE

CEREBRAL EDEMACEREBRAL EDEMA

RENAL FAILURERENAL FAILURE

INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION

BURNSBURNS

TRAUMATRAUMA


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FLUID MANAGEMENT IN HEART FAILUREFLUID MANAGEMENT IN HEART FAILURE

Pathophysiology :Pathophysiology :

1. Inadequate cardiac output.,1. Inadequate cardiac output.,

2. Elevated filling pressures.,2. Elevated filling pressures.,

3. Systemic & pulmonary fluid overload.,3. Systemic & pulmonary fluid overload.,

4. Renin- angiotensin- aldosterone system and4. Renin- angiotensin- aldosterone system and

sympathetic system activation andsympathetic system activation and

5. Electrolyte abnormalities .5. Electrolyte abnormalities .


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GoalsGoals

Optimization of preloadOptimization of preload :: Facilitated by preloadFacilitated by preloadmeasurement (CVP, PAOP.)measurement (CVP, PAOP.)

Contractile function assessment.Contractile function assessment.

Judicious fluid challenge preop to identify the optimalJudicious fluid challenge preop to identify the optimal

preload.preload.

Reducing the oedema.Reducing the oedema.

Judicious sodium administration.Judicious sodium administration.

Correction of electrolyteCorrection of electrolyte abnormalities .abnormalities .


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Pre-operative periodPre-operative period:: Infusion ratesInfusion ratesat the lower ranges of estimates.at the lower ranges of estimates.

Hypovolemia treated with colloid infusions.Hypovolemia treated with colloid infusions.

Post-operative periodPost-operative period :Impaired ability to excrete:Impaired ability to excreteduring fluid mobilization..during fluid mobilization..

Maintenance fluid stopped as soon as either theMaintenance fluid stopped as soon as either thefilling pressures or the urine output increases .filling pressures or the urine output increases .

Electrolyte abnormalitiesElectrolyte abnormalities:: DilutionalDilutionalhyponatremia is common - Rhyponatremia is common - RXX Diuretics .Diuretics .

Hypocalcemia,Hypocalcemia,hypokalemia & hypomagnesemia.hypokalemia & hypomagnesemia.


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THE PATIENT WITH LIVER DISEASETHE PATIENT WITH LIVER DISEASE

PathophysiologyPathophysiology:: Functionally hypovolemic despiteFunctionally hypovolemic despiteelevated blood volume.elevated blood volume.

Under fill, overflowUnder fill, overflow, hypothesis along with abnormalities, hypothesis along with abnormalities

ininANPANP secretion .secretion . Hepato-renal syndromeHepato-renal syndrome: Ascites and vascular under filling: Ascites and vascular under filling

result in reduced renal perfusion pressure.result in reduced renal perfusion pressure.

Diuretics and dopamine help to improve urine output butDiuretics and dopamine help to improve urine output but

do little to reverse renal failure.do little to reverse renal failure.

Hypoalbuminemia:Hypoalbuminemia: low colloid oncotic pressure low colloid oncotic pressure interstitial volume expansion & intravascular volumeinterstitial volume expansion & intravascular volumedepletion .depletion .


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Goals of fluid managementGoals of fluid management

Maintenance of intra vascular volume.Maintenance of intra vascular volume.

Prevention of rise in interstitial volume .Prevention of rise in interstitial volume .

Normal electrolyte concentration.Normal electrolyte concentration.

Colloid oncotic pressureColloid oncotic pressure salt poorsalt poor albuminalbumin

solution pre-operatively.solution pre-operatively.

ParacentesisParacentesis : Replace each litre of ascitic fluid: Replace each litre of ascitic fluid


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Intra operative management :Intra operative management : crystalloids are used withcrystalloids are used with

close monitoring of CVP & electrolytes to meetclose monitoring of CVP & electrolytes to meet

maintenance requirements.maintenance requirements.

Acute hypovolemia can beAcute hypovolemia can be treated with 5% albumintreated with 5% albumin

solutions( salt poor).solutions( salt poor).

Dextrose infused judiciously to avoid hypoglycemia.Dextrose infused judiciously to avoid hypoglycemia.

Hypotension along with a reduced SVR should be treatedHypotension along with a reduced SVR should be treated

with inotropes to improve renal perfusion pressure.with inotropes to improve renal perfusion pressure.


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THE PATIENT WITH CEREBRAL OEDEMTHE PATIENT WITH CEREBRAL OEDEM

Determinants of cerebral oedemaDeterminants of cerebral oedema

Capillary pressure.Capillary pressure. Serum osmolarity and colloid oncotic pressure .Serum osmolarity and colloid oncotic pressure .

PermeabilityPermeability..

Goals of fluid managementGoals of fluid management

Maintenance of cerebral perfusion pressure.Maintenance of cerebral perfusion pressure. Prevention of rise in cerebral venous pressure.Prevention of rise in cerebral venous pressure.

Prevention of hypertension.Prevention of hypertension.

Avoidance of changes in plasma osmolarity.Avoidance of changes in plasma osmolarity.


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THE PATIENT WITH CEREBRAL OEDEMTHE PATIENT WITH CEREBRAL OEDEM

A degree of dehydration without hypovolemia is desired.A degree of dehydration without hypovolemia is desired.

Plasma NaPlasma Na++ concentration : 142-148 mEq/ L.concentration : 142-148 mEq/ L.

Using isotonic saline or Ringers lactate only 75% to 90%Using isotonic saline or Ringers lactate only 75% to 90%of maintenance fluid should be infused.of maintenance fluid should be infused.

Colloids - hypovolemia.Colloids - hypovolemia.

Fluid administration should aim to maintain the osmolarityFluid administration should aim to maintain the osmolarityand prevent reduction in COP.and prevent reduction in COP.

Good glycemic controlGood glycemic control


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THE PATIENT WITH RENAL FAILURETHE PATIENT WITH RENAL FAILURE

The patients not requiring dialysisThe patients not requiring dialysis

Pre operatively these patients may benefit from volumePre operatively these patients may benefit from volumeloading.loading.

Volume preloading - Balanced salt solutions 10-20 ml /kg.Volume preloading - Balanced salt solutions 10-20 ml /kg.

Hypovolemia rapid infusion of crystalloid solutions.Hypovolemia rapid infusion of crystalloid solutions.

Diuretics used only if intravascular volume is adequate.Diuretics used only if intravascular volume is adequate.


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THE PATIENT WITH RENAL FAILURETHE PATIENT WITH RENAL FAILURE

Patients requiring dialysisPatients requiring dialysis

DialysisDialysis- acute electrolyte shifts , hypovolemia & acidosis.- acute electrolyte shifts , hypovolemia & acidosis.To be done 12-24 hours prior to surgeryTo be done 12-24 hours prior to surgery

Minor surgeries insensible losses with 5% DW and urineMinor surgeries insensible losses with 5% DW and urineoutput if any with 0. 45% saline.output if any with 0. 45% saline.

Thoracic, abdominal and other major surgeries:Thoracic, abdominal and other major surgeries:

Significant interstitial losses - balanced salt solutions orSignificant interstitial losses - balanced salt solutions or5% albumin.5% albumin.

Maintenance requirement : 30% is metMaintenance requirement : 30% is met.. NaNa++, K, K++, pH, HCO3, pH, HCO3-- and blood glucose should beand blood glucose should be

monitored and abnormalities correctedmonitored and abnormalities corrected


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THE PATIENT WITH INTESTINAL OBSTRUCTIOTHE PATIENT WITH INTESTINAL OBSTRUCTIO

PathophysiologyPathophysiology

Immeasurable fluid and electrolyte losses into the bowelImmeasurable fluid and electrolyte losses into the bowel& peritoneum.& peritoneum.

Slow volume deficit giving enough time for theSlow volume deficit giving enough time for thecompensation.compensation.

Vomiting & lack of oral intake.Vomiting & lack of oral intake.

Protein losses which exacerbate intravascular losses.Protein losses which exacerbate intravascular losses. ECF volume is depleted.ECF volume is depleted.

A state of ongoing fluid requirement in the absence ofA state of ongoing fluid requirement in the absence ofexternal losses external losses third spacingthird spacing


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THE PATIENT WITH INTESTINALTHE PATIENT WITH INTESTINAL

OBSTRUCTIONOBSTRUCTION

Goals of managementGoals of management

Restoration of ECF volume.Restoration of ECF volume.

Correction of acidosis & electrolytes.Correction of acidosis & electrolytes.

Correction of B.P. to the normal range.Correction of B.P. to the normal range.

Optimization of oxygen delivery & utilization.Optimization of oxygen delivery & utilization.

The management is guided by frequent monitoring ofThe management is guided by frequent monitoring of

B.P., CVP, pulse pressure, urine output , electrolytesB.P., CVP, pulse pressure, urine output , electrolytes

along with Hb% and hematocritalong with Hb% and hematocrit

A rising Hb% indicates ongoing loss of plasma waterA rising Hb% indicates ongoing loss of plasma water



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OBSTRUCTIONOBSTRUCTION Maintenance fluid - 5% dextrose + 0.45% saline + KCL.Maintenance fluid - 5% dextrose + 0.45% saline + KCL.

Fluid lost to the bowel : balanced salt solution,Fluid lost to the bowel : balanced salt solution, ColloidColloid

In pa t i en t s w i t h h aem odynam i c i n s t ab il it yn pa t i en t s w i t h hae m odynam i c in s t ab i li ty

CVPCVP CVPCVP CVPCVP

3 ml/kg/h 2 ml/kg/h 0.5 2 ml/kg3 ml/kg/h 2 ml/kg/h 0.5 2 ml/kg

UOPUOP

1.5 ml/kg/h1.5 ml/kg/h

glycosuriaglycosuria

infusion rate by 0.5 ml/kg/hinfusion rate by 0.5 ml/kg/h


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THE PATIENT WITHTHE PATIENT WITH BURNSBURNS Tissue injury disruption of capillary bedTissue injury disruption of capillary bed

Protein, electrolyte & fluid enter the burnt tissueProtein, electrolyte & fluid enter the burnt tissue Fluid mobilization & evaporation.Fluid mobilization & evaporation.

Management :Management : Restoration of plasma volume andRestoration of plasma volume andreplacement of the massive losses.replacement of the massive losses.

Parklands formula :Parklands formula :2 ml RL/kg/% of burnt BSA 12 ml RL/kg/% of burnt BSA 1stst 8 hours8 hours

2 ml RL/kg/% of burnt BSA next 16 hours.2 ml RL/kg/% of burnt BSA next 16 hours.

5% DW 0.2ml/kg/ + 5% albumin 0.015 ml/kg/%BSA5% DW 0.2ml/kg/ + 5% albumin 0.015 ml/kg/%BSA

per hourper hour

Next 24 hours.Next 24 hours.


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OTHER FORMULAEOTHER FORMULAE

Evans formulaEvans formula : 1ml crystalloid + 1 ml colloid /: 1ml crystalloid + 1 ml colloid /kg /% burnt BSA + 2000 ml 5% DW / 24 h.kg /% burnt BSA + 2000 ml 5% DW / 24 h.

Brooke formulaBrooke formula : 1.5 ml crystalloid + 0.5 ml: 1.5 ml crystalloid + 0.5 mlcolloid / kg / % burnt BSA + 2000 ml 5% DW /colloid / kg / % burnt BSA + 2000 ml 5% DW /24 h.24 h.

Modified Brooke formulaModified Brooke formula : 2.0 ml / kg / % burnt: 2.0 ml / kg / % burntBSA of RL / 24 h.BSA of RL / 24 h.


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THE TRAUMA PATIENTTHE TRAUMA PATIENT

Restoration of blood volumeRestoration of blood volume,, Hb concentrationHb concentrationand finally coagulationand finally coagulation

Crystalloid or colloid - restore volume.Crystalloid or colloid - restore volume.

Mixtures of 7.5% saline and dextran .Mixtures of 7.5% saline and dextran .

Haematocrits - 18 - 22 % as against 28 - 30 %Haematocrits - 18 - 22 % as against 28 - 30 % Losses > 30% , transfuse blood. >40% type 0Losses > 30% , transfuse blood. >40% type 0

packed cells.packed cells.

Permissive hypotensionPermissive hypotension: (SBP 70 - 80 mm Hg): (SBP 70 - 80 mm Hg)evolving in penetrating torso injuries , avoid inevolving in penetrating torso injuries , avoid inhead injurieshead injuries


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TTHEHE PPOSTOPERATIVEOSTOPERATIVE PPERIODERIOD

Vasodilator effect ofVasodilator effect ofanaesthesia Vsanaesthesia Vs

vasoconstrictor effect ofvasoconstrictor effect ofhypothermiahypothermia

IntravascularIntravascular re-accumulationre-accumulation

ininthe face of high ADH andthe face of high ADH and

AldosteroneAldosterone

NaNa++

and water retention.and water retention.


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FluidFluid in the postoperativein the postoperative

periodperiod(5% dextrose + KCl 30 mmol/L);(5% dextrose + KCl 30 mmol/L);

amounting to 30 mL/kg/day. Naamounting to 30 mL/kg/day. Na++

after 2 daysafter 2 days

HYPONATREMIC ENCEPHALOPATHYYPONATREMIC ENCEPHALOPATHY Balanced salt solutionBalanced salt solution andand normal salinenormal saline


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Blood loss Haemoglobin levelBlood loss Haemoglobin level

Specific lossesSpecific losses

Urine to be maintained >0.5Urine to be maintained >0.5mL/kg/hrmL/kg/hr

Daily plasma urea andDaily plasma urea andelectrolyteselectrolytes

Potassium levelPotassium level


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CONCLUSIONCONCLUSION

The discretion of the treating clinician mayThe discretion of the treating clinician may

well be used alongwith the strategieswell be used alongwith the strategiesdescribed above in the management ofdescribed above in the management of

these situations .these situations .


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