Concept of I/V fluid &

its updates on surgical practice

Dr. MD. Majedul Islam EmonRegistrar

Department of Surgery

Enam Medical College Hospital

In 2013 NICE(National Institute for health and care excellence) reported that:

Majority of I/V fluid prescriber(Surgeon/Assisstant surgeon/Trainee) –

1. know neither the fluid and electrolyte needs for the patients

2. nor the specific composition of the fluid

Why this is essential ?

1. Inadequate I/V fluid2. Excess I/V Fluid

Effect/Outcome of lack of knowledge:3. Increase morbidity and mortality4. Prolong hospital stay5. Increase cost6. Ultimately death…………..

Result of lack of knowledge:

1. Emergency Department2. Acute admission Unit3. General Ward

Place of Good I/V fluid Practice4. Operation Theatre5. Intensive care unit(ICU)6. High dependency unit(HDU)7. Dialysis Unit

Place of Poor I/V fluid Practice

To prescribe, following are recommendated :

Knowledge of Physiology or principle of body fluid balance

Knowledge of Electrolyte physiology Knowledge of Type of I/V fluid and its composition Knowledge of Selection of I/V fluid for the patient Knowlede of Monitoring Knowledge of I/V fluid related events

How to prescribe a best fluid prescription

The average 70-kg male can be considered to consist:

fat(13 kg) and fat-free mass (or lean body mass: 57 kg)

composed primarily of – 1. protein(12 kg),

2. Water (42 kg) and 3. minerals (3 kg)

BODY COMPOSITION

Infant 90% of body weight

Children 70-80% of body weight

Male(Ault) 60% of body weight

Female(Adult) 55% of Body wight

Distribution of Body Water

◦ Transport nutrients to the cells and carries waste products away from the cells

◦ Maintains blood volume ◦ Regulates body temperature ◦ Serves as aqueous medium for cellular metabolism ◦ Assists in digestion of food through hydrolysis ◦ Acts as solvents in which solutes are available for cell

function ◦ Serves as medium for the excretion of waste products

Function of Body Water

A. Intracellular fluid(ICF) – 28 litresB. Extracellular Fluid(ECF) – 14 litres

Distribution of extracellular fluid(ECF) Interstitial fluid(fluid between cells in tissues) – 11 litres Plasma – 3litre Transcellular fluid – 1 litre

N.B Transcellular fluid Examples 1. cerebrospinal fluid, 2. ocular fluid and3. joint fluid

Total body water is 42 litres

Composition of ECF and ICF

Plasma > ISF > ICF Plasma and ISF seperated by capillary membrane ISF and ICF separated by cell membrane 2 pressure COP(Colloidal osmotic pressure) and Hydrostatic

pressure(HP) also play a part in fluid movement COP tendency to keep/ draw fluid inside the vessels but HP

tends to push fluid out

Movement of fluid

Movement of fluid Contd.

Between Plasma and ISF: H2O and electrolyte freely mobile Protein cant move

Between ISF and ICF H2O freely mobile Electrolyte restrictly permeable(Move in fluid imbalance)

Intake Volume(ML) Output Volume(ml)

Drink 1500 Urine 1500

Water from food 700 Insensible loss 1000

Metabolic 359 Faeces 100

Total 2600 Total 2600

Daily water Balance in a 70kg healthy adult in a teperate climate

Adult 30-40 ml/kg/day or

1st 10 kg 100 ml/kg/day 2nd 10 kg 50 ml/kg/day After each/1 kg 20 ml/kg/day

Example 60 kg male would require 10 x 100 = 1000 ml 10 x 50 = 500 ml 40 x 20 = 800 ml Total = 2300 ml/day

Fluid requirement (Daily)

1st 10 kg = 4 ml/kg/ hour 2nd 10 kg = 2 ml/kg/ hour After 20 kg = 1 ml/kg/hour

Example 60 kg male would require 10 x 4 = 40 ml 10 x 2 = 20 ml 40 x 1 = 40 mlTotal 100 ml/hour (2400 ml/day)

Fluid requirement (Hourly)

Daily requirements of major electrolytes: Sodium 1 mmol /kg/ day Potassium 1 mmol/kg/ day Chloride 1 mmol/kg/ day Calcium 2 g/ day Magnesium 20 mEq / day Glucose 100gm/day

Example of a 60 kg woman - 60 mmol needed for Na, K, Cl

Daily electrolyte requirement

A. CrystalloidB. ColloidC. Blood products

On the basis of tonicity1. Isotonic2. Hypertonic3. Hypotonic

Type of I/V fluid and its composition

1. Isotonic(tonicity similar to plasma) solution

5% DA 0.9% NaCl(Normal Saline) Hartman solution Ringers Lactate solution

NB. Normal plasma osmolality 280-295 mOsm

Crystalloid solution

Hypotonic Solution(plasma osmolality is more than that of solution)

0.45% NaCl, 0.33% sodium chloride, 0.2% sodium chloride, and 2.5% dextrose in water

Crystalloid solution contd.

2. Hypertonic solution(plasma osmolality is less than that of solution)

5% DNS 3% NaCl

Crystalloid solution contd.

Solutions containing high-molecular weight substances such

as proteins or large glucose polymers.

Types of Colloids

Blood derived Human albumin. Synthetic * Hydroxyethyl Starches(Hespan) * Gelatins(Haemaccel) * Dextrans.

Function: Plasma expanders by increasing plasma oncotic pressure moving fluids from IS to IV spaces i. e. Abnormal protein loss. e.g peritonitis & Severe burns.

Colloids

Differences between colloids and crystalloids

Colloids stay more in IV space (3-6 h.) but Crystalloids (20-30 m.)

Colloids 3 times potent than crystalloids. Severe IV fluid deficits can be more rapidly corrected using

colloids. Colloid resuscitation more expensive. Rapid administration of large amounts of crystalloids (>4-

5L) is more frequently associated with significant tissue edema.

Colloids contd.

1. In practical terms, operative blood loss up to 500 ml can be replaced with saline(Colloid or crystalloid)

Only if >1 L of blood has been lost in a healthy adult

should you consider giving blood.

For the majority of patients undergoing elective or emergency surgery a transfusion trigger of 8 g dl"1 is appropriate.

A pt undergoing operation with a normal Hb of approximately 14 g dl"1 can afford to lose 1.5 litres of blood before red cell transfusion becomes necessary.

Recent RCT showed A trigger haemoglobin of 7-8 g dl-1 is therefore appropriate even in the critically ill.

critical level of of Hb is 4-5 g dl"1. because at this level, oxygen consumption begins to be limited .

Red cell transfusion

Pre-Operative:1. Pt is symptomatically anemic2. Hb< 6gm/dl3. HCT < 21%4. Bone marrow failure resulting from drug or RT or CTPer operative/post operative: Blood loss> 1-1.5 litreN.B: One unit of red cells raises the haemoglobin by 1 g

dH. Transfusion may correct a severely low haemoglobin

but not correct iron deficiency So Oral iron replacement therapy is required for 4-6

months. Alternatively, give a total dose infusion of iron.

Who need Red cell transfusion:

Requirement 15ml/kg/day One unit contain 150ml FFP Frozen at -30°C. stored upto 12 months. Once thawed it should be used within 2 h because

degradation of the clotting factors at room temperature.

FFP contains coagulation factors, including the labile factors V and VIII and the vitamin K-dependent factors II, VII, IX and X.

Indication: To correct abnormal coagulation in patients with liver disease. To reverse oral anticoagulation as from, for example, over

warfarinization. DIC Massive BT

Fresh frozen Plasma

1. Normal Saline2. 5% DA3. 5% DNS4. Hartman solution5. Rigers Lactate

Common IV fluid in Surgical practice:

Contaion : Na+ 154 mmol/L, Cl+ 154 mmol/L Isotonic(308 mOsm/L)Indication:1. Correction of volume in shocked pt due to Hge, burn,

dehydration2. Peritoneal wash(lavage), stomach Wash, 3. Syringe wash, injured area, wound burn, ulcer4. Dressing purpose5. Dilution of drug6. Preservative

Normal Saline(Sodium chloride 0.9%)

Contaion – 50 gm Glucose(dextrose)/L Isotonic(280 mOsm/L)

Indication:1. Posotoperative Patient(When kept NPO)2. Post head injury Pt3. Channel maintainence for emergency

medication

5% DA(dextrose in aqua)

Contaion : Na+ 154 mmol/L, Cl+ 154 mmol/L 50 gm Glucose(dextrose)/L Hypertonic(320mOsm/L)Indication: Intraoperative fluid Post operative fluid Resuscitation

5% DNS (Dextrose in normal saline)

Contaion : Na+ 130 mmol/L, Cl- 130 mmol/L K+ 5 mmol/L Lactate 29 mmol/L Isotonic(280 mOsm/L)Indication: Correction of volume in shocked pt due to Hge, burn,

dehydration Intraoperative fluid Post operative fluid

Hartman solution

Contaion : Na+ 131 mmol/L, Cl- 111 mmol/L K+ 5 mmol/L Ca+ 2 mmol/L HCO3 29 mmol/L Isotonic(280 mOsm/L)Indication: Correction of volume in shocked pt due to Hge, burn,

dehydration Intraoperative fluid Post operative fluid

Ringer’s Lactate

How to calculate infusion rate.Here the, drop factor for blood is 15 drops/ml drop factor for solution is 20 drops/ml

Tired ??????

Problem:1. Lack of evidence of study2. Problem with salt and water overload: Renin anigiotensin, aldosterone, ADH system Provision of high inappropriate I/V fluid Misinterpretation of postop dilutional hyponataremia Misconception of body potassium Malnutrition

3. Problem in making accurate assessment of abnormal fluid and electrolyte loss

4. Problem from internal fluid redistribution.5. Problem of organ dysfunction.6. Problem of poor record keeping.

Prescribing I/V fluid in Surgery:

NICE designated 4 R for prescribing fluid along with 5th R for reassessment :

1. Resuscitation2. Routine maintainence3. Replacement4. Redistribution

All are depend on : History General Examination CVP Electrolyte measurement Urine output External loss Weight chart

Indication of fluid:

Who need? Acute multi system trauma Acute post operative haemorrhage SepsisWhy need?To restore intravascular fluidWhat type of fluid?Normal Saline, Hartman, Ringers lactate, Albumin, HaemaccelHow ?Initial – 500ml bolus over < 15 min then reassess, if still need resuscitation then give another 250

ml bolus no response >2000ml over 2 hour already given but no response-> seek expert help

Resuscitation

It provide daily physiological fluid and electrolyte requirements

How much Normal Requirements:

Fluid 30-40 ml kg/kg/day Na+ and K+, 1 mmol/kg/day Glucose 100gm/day

What type of fluid? 5% DA Normal Saline Hartman

Routine Maintainence

This fluid prescribing is wrong.

If the Pt Wt is 60 kg then he need 2400ml fluid

So , 5% glucose 2000ml 0.9% saline 500ml Is appropriate for Postop

order

Routine Maintainence contd.

Provision of fluid for ongoing fluid and elctrolyte loss , previous deficit with daily maintenance fluid

When to give: Electrolyte imbalance(detected by daily electrolyte measurement) Fistula(ECF), Ileostomy, NG aspiration or drainge, vomiting, diarrhoea, abdominal drain tube collection.

What type of fluid? Normal Saline with added potassium Riger’s Lactate Hartman

Replacement

A 60 kg Pt with abdominal surgery on 1st post operative day, with NG collection 300 ml and drain tube collection 200 ml, prescribe his fluid regime:

His daily requirement is 2400mlToday Ongoing loss is 500 ml(Total 2900ml)

So fluid therapy should be 5% glucose 1400ml 5% DNS 500ml Rigers lactate 1000ml

Replacement fluid contd

calculate the deficit: Formula

For Na deficit = (Normal Na level- Measured plasma level of Na)X Wt in KgX0.6

For K deficit = (Normal K level- Measured plasma level of K)X Wt in KgX0.2

Replacement fluid contd

Na K Cl HCO3

Saliva 10 25 10 30

Stomach 50 15 110

Duodenum 140 5 100

Ileum 140 5 100 30

Pancrease 140 5 75 1115

Bile 140 5 100 35

Composition of gastrointestinal secretions (mmol/L).

Nature of abnormal external loss

Despite fluid therapy they are not remain in the circulation and not participate in normal exchange mechanism(third space fluid loss)

Check for edema, ascities, renal failure, liver failure, post operative fluid retention

Best fluid therpay is difficult, too little- to hypovolumia - too more , fluid overload

So it is best to reduce overall fluid and electrolyte provision to permit a negative sodium and water balance to aid edema resolution.

Redistribution

Why? To altered or stop the fluid therapy How: 1. Daily reassessment of clinical fluid status2. Daily Fluid balance chart(Input/Output)3. Measurement of CVP, PAWP4. Wt measurement twice weekly

Laboratory:5. Daily measurement of Urea, creatinine, electrolyte, Hb%,

Albumin6. Urinary Na+, K+, Albumin

Reassessment

Fluid requirement Increased in:

Fever(if 101 add 7% extra fluid)

Hyperthyroidism Hyperventilation Abnormal fluid loss, etc

Fluid requirement decreased in:

Hypothermia Raised humidity Hypothyroidism Immobilise pt Uncoscious Pt Cerebral edema: Meningitis, stroke Fluid retention Oliguria CCF, etc

Essential to know

Cause: Excess infusion of 5%

DA/Hypotonic saline Misinterpretation of fluid regime in

Pt with CRF, Head injury Pt, cerebral infection Pt

Excess irrigation during prostatectomy.

C/F:A. Peripheral edema(if >2L): Puffy face, ankle edema, ascities,

pleural effusionB. Raised JVP, BP may raisedC. Urine out put> 2ml/kg/hourD. Cerebral edema, confusion,

convulsion , coma

Investigation:S. Na+, Hb%, PCV,

Albumin(all are decreased)

Treatment:Its an emergency

1. Stop all fluid therapy

2. Mannitol diuretis(not by frusemide because which causes both water and Na+ loss)

3. Monitoring the Patient.

H2O/Water Excess/Intoxication

The patient is starved for 6-12 h, there may be blood loss, plasma loss, ECF loss and evaporation of water from exposed bowel -> As part of the stress response to surgery the patient retains water and sodium.

What Fluid to give ? Hartmann's solution 5 ml/kg/h.

Intra operative Fluid therapy

5 % DA = 1600 ml 0.9% NaCl = 500 ml Ringer lactate = 500 ml

Monitoring: patients thirst, puffiness of face, CVP, peripheral perfusions, leg

edema, chest, urine output Daily: elctrolytes, CBC

Fluid plan: POD #0

Total Fluid: 30-35 ml / kg body-wt (60 kg)

Maintenance fluid 60 x 35 = 2100 mlBlood loss = 500 ml

total = 2600 ml

5 % DA = 1600 ml 5% DNS = 500 ml Ringer lactate = 1000 ml

Monitoring: patients thirst, CVP, peripheral perfusions, leg edema, chest, urine

output Daily: elctrolytes, CBC

Fluid plan: POD #1

Total Fluid: 30-35 ml / kg body-wt (60 kg)

Maintenance fluid 60 x 35 = 2100 mlDrain out put = 500 mlNG out put = 500 ml

total = 3100 ml

5 % DA = 1600 ml 5% DNS = 500 ml Ringer lactate = 500 ml

Monitoring: patients thirst, CVP, peripheral perfusions, leg edema, chest, urine

output Daily: elctrolytes, CBC

Fluid plan: POD #2

Total Fluid: 30-35 ml / kg body-wt (60 kg)

Maintenance fluid 60 x 35 = 2100 mlDrain out put = 300 mlNG out put = 200 ml

total = 2600 ml

5 % DA = 1100 ml 5% DNS = 1000 ml Ringer lactate = 500 ml 60 mmol KT/day

Monitoring: patients thirst, CVP, peripheral perfusions, leg edema, chest,

urine output Daily: elctrolytes, CBC

Fluid plan: POD #3

Total Fluid: 30-35 ml / kg body-wt (60 kg)

Maintenance fluid 60 x 35 = 2100 mlDrain out put = 300 mlNG out put = 200 ml

total = 2600 ml

TPN(Total Parenteral nutrition)

Consider If Patient is NPO more than 5 Days.

Principle: intensive monitoring and aggressive management of perioperative Hemodynamics in high risk patients to optimize oxygen delivery or manipulate a patient’s physiology to achieve targets that are associated with an improved outcome

Aim: The right fluid, for the right patient, at the right time

What Goal we can target:1. Stroke volume2. Oxygen Delivery or consumptionHow to achieve: By measurements of cardiac output (CO) which direct the use of

I/V fluid and ionotrpes.

What operations? Which patients? expected blood loss >500 mL( major abdominal general surgical, orthopedics,

urological, gynae) Trauma, pt with sepsis, burn

Goal-directed therapy