INTRAVENOUS FLUID (CRYSTALLOIDS )by Dr Deepak kalyani hospital

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intravenous fluid therapy by- dr deepak nirwal kalyani hospital kiratpur bijnor up

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INTRAVENOUS FLUID (CRYSTALLOIDS ):

INTRAVENOUS FLUID (CRYSTALLOIDS ) Presented By:- DR. DEEPAK KR. NIRWAL Moderator:- Dr. R. Subhedar Guided by Dr. Joshi Dept Of Anaesthesia ,GMC, DHULE Monday, November 25, 2013 1

Why do we need IV fluids?:

Why do we need IV fluids? Maintenance therapy - Supply the water, electrolytes and calories Restore previous body fluid losses Replace present body fluid losses To administer medications Nutrition in patients who do not tolerate enteral feeds. Monday, November 25, 2013 2

QUE ….?:

QUE ….? When to give fluid & when avoid ? Which fluid to give & why ? How much to give and how to calculate ? Rate of fluid ? C/I of different type of fluid & why ? How to correct electrolyte imbalance ? AFTER ALL THIS EVALUATION WE PLANED AND ORDER FOR FLUID THERAPY…..!!!!! Monday, November 25, 2013 3

BASIC PHYSIOLOGY OF BODY FLUID:

BASIC PHYSIOLOGY OF BODY FLUID T.B.W(total body water ) 80% of body weight of new born 60% of body weight of young adult male 50 % of body weight of young adult female Becoz fat contain less water. ( obese < lean ) T.B.W. ↓ with age Monday, November 25, 2013 4

Compartmental Distribution of Total Body Water :

Compartmental Distribution of Total Body Water Plasma 3L (5%) Interstitial fluid 11L (15%) Intracellular fluid 28L( 40%) 66% ICF (2/3) OF TBW 33% ECF (1/3) OF TBW Total body water 70 kg male TBW 42 L Monday, November 25, 2013 5

TOTAL BLOOD VOLUME :

TOTAL BLOOD VOLUME The blood volume is 60 to 65 mL/kg, and is distributed as 15% in the arteries and 85% in the venous system. The major components of the extracellular compartment are the plasma volume (30 to 35 mL/kg) and the interstitial fluid (120 to 165 mL/kg). Other constituents of the ECF include pleural fluid, peritoneal fluid, aqueous humor, sweat, urine, lymph, and cerebrospinal fluid. Monday, November 25, 2013 6

BASIC PHYSIOLOGY OF BODY FLUID:

BASIC PHYSIOLOGY OF BODY FLUID NORMAL WATER BALANCE :- Water balance =( total input – total output ) Consider insensible input and output also Insensible fluid input = 300 ml of water due to oxidation Insensible fluid loss = 500 ml through skin + 400 ml through lungs +100 ml through stool = 1000ml Total balance = 300 – 1000 = ( - 700 ml ) fluid deficit Monday, November 25, 2013 7

BASIC PHYSIOLOGY OF BODY FLUID:

BASIC PHYSIOLOGY OF BODY FLUID NORMAL PERSON DAILY REQUIRMENT = URINE OUTPUT + 700 ML Insensible loss ↑ 500 ml in moderate sweating 1.0-1.5 lit in sever sweating / high fever 0.5-3.0 lit through expose wound surface ( burns) and laparotomy Water needs increase by 15% for every 1 degree C rise in temp Monday, November 25, 2013 8

Daily water balance:

Daily water balance ICF ECF WATER INTAKE Fluids 1300ml approx Solid food 800ml 2400ml Metabolic water 300ml approx WATER LOSS Urine 1300ml Feces 100ml 2400ml Insensible loss 1000ml (skin and lungs) Monday, November 25, 2013 9

Electrolyte Physiology :

Electrolyte Physiology Primary ECF/ intravascular cation is Na + Primary ICF cation is K + & Mg 2+ Primary ECF/ intravascular anion is Cl - Primary anion in ICF is PO 4 3- ,SO 4 3- , protein. Monday, November 25, 2013 10

Solute composition of body fluid compartments:

Solute composition of body fluid compartments Cation Na + 10 Na + 142 (meq/L) K + 150 200 K + 4 153 Mg +2 40 Mg +2 2 Ca +2 4.5 Anion Cl - 102 (meq/L) PO4 - 10 PO4 - 2 SO4 - 30 153 SO4 - 1 200 HCO3 - 10 HCO3 - 27 Protein 40 Protein 16 Organic acids 5 water water ICF ECF 275-290 mOsm/L Monday, November 25, 2013 11

All specialty need to give I.V. fluid :

All specialty need to give I.V. fluid For proper fluid therapy we must know ? Etiology of fluid deficit & type of electrolyte imbalance . Associated illness ( DM, HT , IHD , RENAL & HEPATIC illness , valvular disease ) Clinical status ( hydration , vitals , urine output.) Monday, November 25, 2013 12

Why IV FLUID ?:

Why IV FLUID ? Although oral therapy always preffered over iv . but iv has great imp in various clinical problems . ADVANTAGE:- Accurate , controlled, predictable , Immediate response due to direct infusion to intravascular compartment . Prompt correction of serious fluid & electrolyte disturbances. DISADVANTAGE:- Risk of sepsis ,need hospitalization , improper fluid used can lead to serious problem. Improper volume and rate lead to life threatening Monday, November 25, 2013 13

I.V FLUID THERAPY CHARACTERSTIC :

I.V FLUID THERAPY CHARACTERSTIC Ringer lactate is most physiological I.V.F . Because constituent similar to ECF, and additional adv in correction of acidosis. RL, Iso- E , P , M directly correct acidosis because Iso- E , P , M contain acetate , acetate converts to bicarbonate in liver and correct acidosis . In case of liver impairment RL may lead to lactic acidosis . so RL is avoided. Monday, November 25, 2013 14

I.V FLUID THERAPY CHARACTERSTIC :

I.V FLUID THERAPY CHARACTERSTIC only Iso- G , directly correct metabolic alkalosis becoz it contain NH 4 Cl, it gets convert to H + and urea in liver. Iso- G ,M ,E , P , RL should be avoided in renal failure , Becoz risk of developing hyperkalemia. NH 4 Cl in Iso – G gets converted into H + and urea and therefore may aggravate uremic acidosis. Monday, November 25, 2013 15

CLASSIFICATION OF I.V. FLUID :

CLASSIFICATION OF I.V. FLUID I.V FLUID DIVIDED INTO THREE GROUPS:- Maintenance Fluid:- replaces fluid loss from lungs , skin , urine , faeces ,these losses are poor in salt so this maintenance fluid should be hypotonic to plasma sodium . eg – 5 % dextrose , dextrose with 0.45 % NaCl solution . Replacement Fluid :- it correct body fluid deficit caused by losses such as gastric drainage , vomiting , diarrhoea , oozing from wound , infection , burns , intestinal edema , eg – isotonic saline , DNS , RL, Iso – M P G Special Fluid :- used for special indication such as hypoglycemia , hypokalemia , metabolic acidosis . Monday, November 25, 2013 16

GOAL OF FLUID THERAPY :

GOAL OF FLUID THERAPY Maintain normovolemia Hemodynamic stability Maintain electrolytemia Maintain tissue perfusion Maintain adequate urine output Avoid fluid overload and deficit Monday, November 25, 2013 17

PALSMA OSMOLALITY :

PALSMA OSMOLALITY Serum osmolality = 2Na + + Glucose + BUN 18 2.8 Normal plasma osmolality is 285 ( 275-295) Isotonic fluid – ( 250-375) Hypotonic - < 250 Hypertonic > 375 Monday, November 25, 2013 18

CRYSTALLOIDS :

CRYSTALLOIDS Crystalloids are fluids that contain water and electrolytes. May be isotonic, hypertonic, and hypotonic salt solutions. Crystalloid solutions are used to provide maintenance water and electrolytes and to maintain intravascular fluid volume. The replacement requirement is threefold or fourfold the volume of blood lost because administered crystalloid is distributed in a ratio 1 : 4 similar to ECF, which is composed of about 3 L intravascularly (plasma) and about 12 L extravascularly(interstitial). Monday, November 25, 2013 19

PowerPoint Presentation:

Monday, November 25, 2013 20

Crystalloids:

Crystalloids Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Plasma 7.4 140 4.5 100 2.3 290 0.9 % NS 5 154 154 308 0.45 % NS 5 77 77 154 3% NS 513 513 1026 0.45%DNS 77 77 50g/L 350 5%DNS 154 154 50g/L 564 RL 6.5 130 4 109 3 28 274 5%D 4.2 50g/L 253 Iso -G 63 17 150 50g/L 70 274 Iso -M 40 35 40 50g/L 20 580 Iso -P 25 20 22 50g/L 23 410 Iso - E 140 10 103 5 3 50g/L 47 368 Monday, November 25, 2013 21

RINGER’S LACTATE :

RINGER’S LACTATE Physiological basis:- because of high Na + , ringer lactate rapidly expands intravascular volume. And so its very effective in treatment of severe hypovolemia . Ringer lactate is most physiological fluid as its electrolyte conc. And Osmolarity is near to plasma, so even in larger amount of RL can be infused without or minimal electrolyte imbalance. It is also useful in correction of metabolic acidosis . Lactate is used instead of bicarb as in stored solution lactate is more stable . OSMOLARITY – 274 mOsm/L Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L RL 6.5 130 4 109 3 28 274 Monday, November 25, 2013 22

RINGER LACTATE :

RINGER LACTATE INDICATION Severe hypovolemia Replacement fluid in post op, burn, #, Diarrhoea induced hypovolemia with hypokalemic met. Acidosis. For maintaining normal ECF and electrolyte during and after surgery. CONTRAINDICATION liver disease , severe hypoxia and shock , lactate metabolism is severely impaired. RL infusion can lead to lactic acidosis in such patients. In CHF lactic acidosis takes place , which is more in heart tissue. Lactate given can’t be utilized, so it ppt condition . vomiting or continuous NG aspiration – here hypovolemia is associated with met alkalosis , as RL provide bicarb so its worsen alkalosis.. Calcium in RL binds with citrate (CPDA) in blood transfusion .this can inactivate the anticoagulant and promote the formation of clot in donor blood .so simultaneous BT and RL infusion through one I.V. line c/ i . Calcium in RL binds with certain drugs ( thiopental, doxycycline, ampicillin,) and reduce their bioavailability and efficiency . Monday, November 25, 2013 23

ISOTONIC SALINE (0.9% NaCl):

ISOTONIC SALINE (0.9% NaCl) PHARMACOLOGICAL BASIS:- NaCl present chiefly in ECF maintaining osmolality of ECF. So isotonic saline is used to provide major EC electrolytes. As isotonic saline is distributed chiefly in ECF , it will increase the intravascular volume substantially. Therefore isotonic saline is very useful I.V. fluid to raise BP in patient with Hypovolemic shock . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L 0.9 % NS 5 154 154 308 Monday, November 25, 2013 24

NaCl :

NaCl Indication Water and salt depletion as in diarrhoea , vomiting , excessive diuresis and perspiration. Hypovolemic shock Tt of alkalosis ( vomiting) with dehydration . In hyponatremia when rapid correction required. Initial fluid therapy in DKA . Tt of hypercalcemia Fluid challenge in prerenal ARF Irrigation for washing of body fluid and cavity . contraindication Caution use or avoid in hypertensive or preeclamptic patients and in patients with edema due to CHF , renal Ds , cirrhosis. Dehydration with severe hypokalemia :- with severe hypokalemia there is deficit of even ICF potassium so infusion of NaCl , without additional Potassium supplement ,will aggravate electrolyte imbalance of ICF. Monday, November 25, 2013 25

DEXTROSE - 5%:

DEXTROSE - 5% PHARMACOLOGICAL BASIS:- it correct dehydration and supplies energy. After consumption of dextrose , remaining water distributed in all compartment of body proportionately . Therefore D-5% is best agent to correct intracellular dehydration . So D-5 % is selected when there is need of water but not electrolyte . 1 gm dextrose provide 3.4 kcal energy. And D- 5% provide 170 kcal/ L. PRECAUTIONS:- I.V. administration of dextrose solution may cause local pain (especially hypertonic), vein irritation . Prolonged I.V. administration can cause hypokalemia , hypomagnesaemia, hypophosphatemia. Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L 5%D 4.2 50g/L 253 Monday, November 25, 2013 26

DEXTROSE – 5% :

DEXTROSE – 5% INDICATIONS:- Widely used fluid for prevention and treatment of dehydration. For I.V administration of various drugs . For treatment of ketosis in starvation , diarrhoea , vomiting , high grade fever. Adequate glucose infusion protects the liver against toxic substances. Correction of hypernatremia due to pure water loss ( eg DI ). CONTRAINDICATION Cerebral edema : because of its hypotonic nature which aggravate cerebral edema. Neurosurgical procedure :- as D-5 % increases intracranial pressure. It cause damage during neurosurgery. Acute ischaemic stroke :- as hyperglycemia aggravates cerebral ischaemic brain damage. Hypovolemic shock :-as it doesn’t substantially increase intravascular volume .moreover fast replacement can lead to hyperglycemia and osmotic diuresis. Hyponatremia and water intoxication. Avoid with oxytocin . Blood transfusion :-not given with same I.V line as hemolysis and clumping can occur. Fetal distress :- in large amount cause fluid overload in mother lead to breathing problem, and fluid also increase insulin level in maternal blood and cause hyperglycemia in fetus and lead to acidosis in fetus which ppt distress. Monday, November 25, 2013 27

PowerPoint Presentation:

Effects of maternal glucose infusion on fetal acid-base status in human pregnancy. Philipson EH ,  Kalhan SC ,  Riha MM ,  Pimentel R . Source Department of Obstetrics, Case Western Reserve University School of Medicine, Cleveland Metropolitan General Hospital, OH 44109. Abstract The maternal and fetal metabolic effects of three commonly used intravenous fluids administered before regional anesthesia were studied in 32 gravid women undergoing elective cesarean section at term. Patients were randomized into one of three groups to receive 1 L of either 5% dextrose (50 gm of glucose) or Ringer's lactate or isotonic saline solution before epidural anesthesia. Acute glucose infusion resulted in maternal hyperglycemia, hyperinsulinemia, and an increase in the blood lactate level. Cord blood glucose, insulin, and lactate levels were also increased in this group. The key finding of this study was the significant lowering of pH in the umbilical cord vein (7.31 +/- 0.04) and artery (7.21 +/- 0.06) in the glucose-infused group when compared with the non-glucose infusion groups (p less than 0.05). Confounding perinatal factors such as maternal position, maternal hypotension, and prolonged time of surgery did not influence the fetal acid-base status. Thus acute maternal glucose infusion in normal patients can cause fetal hyperglycemia, metabolic acidosis, and neonatal hypoglycemia. These findings may be of particular clinical importance when fetal distress or fetal hypoxemia is due to other perinatal events. Under these circumstances, acute maternal glucose infusion may further contribute to fetal metabolic acidosis. Monday, November 25, 2013 28

PowerPoint Presentation:

Water intoxication:- Because oxytocin possesses slight antidiuretic activity, its prolonged i.v. administration at high doses in conjunction with large volumes of fluid, as may be the case in the treatment of inevitable or missed abortion or in the management of postpartum haemorrhage, may cause water intoxication associated with hyponatraemia . The combined antidiuretic effect of oxytocin and the i.v. fluid administration may cause fluid overload leading to a haemodynamic form of acute pulmonary oedema without hyponatraemia . To avoid these rare complications, the following precautions must be observed whenever high doses of oxytocin are administered over a long time: an electrolyte-containing diluent must be used (not dextrose) ; the volume of infused fluid should be kept low (by infusing oxytocin at a higher concentration than recommended for the induction or enhancement of labour at term); fluid intake by mouth must be restricted; a fluid balance chart should be kept, and serum electrolytes should be measured when electrolyte imbalance is suspected. Caution should be exercised in patients with severe renal impairment because of possible water retention and possible accumulation of oxytocin  Monday, November 25, 2013 29

Where is the Fluid Going?:

Where is the Fluid Going? Monday, November 25, 2013 30

DNS (5% dextrose with 0.9 % NaCl ):

DNS (5% dextrose with 0.9 % NaCl ) PHARMACOLOGICAL BASIS :- DNS has advantage of providing both 5% dextrose ( for energy ) and NaCl (for salt ). So DNS is useful to supply major E.C. electrolyte and energy along with fluid to correct dehydration . Like 0.9 % NaCl it rapidly correct NaCl deficit of ECF ,as DNS is distributed chiefly in ECF compartment, unlike D-5 % it doesn’t correct intracellular dehydration . As DNS increase only ECF volume , it can be consider in treatment of dehydration with hypovolemic shock . But like D-5 % , faster infusion of larger volume of DNS will lead to large glucose load (> 25 gm / hr), leading to hyperglycemia induced osmotic diuresis. So in presence of incompletely or partially corrected shock patient will have increased urine output . Unlike D-5 % DNS is not hypotonic ( due to NaCl) and hence it is compatible with blood transfusion . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L 5%DNS 154 154 50g/L 564 Monday, November 25, 2013 31

DNS:

DNS INDICATION Correction of salt depletion and hypovolemia with supply of energy . Correction of vomiting or NG aspiration induced alkalosis and hypochloremia along with supply of calories. Fluid compatible with blood product. CONTRAINDICATION Caution use in cardiac , hepatic , renal disease . Hypovolemic shock :- not preffered in severe hypovolemic shock , when rapid replacement with larger volume of fluid is required . Rapid infusion of DNS can cause hyperglycemia and osmotic diuresis even in presence of fluid deficit. Monday, November 25, 2013 32

ISO – P :

ISO – P PHARMACOLOGICAL BASIS:- I.V. fluid which fulfill maintenance requirement of children. As compare to adult , children need more water and same electrolyte . So it contain double water but same electrolyte as ISO-M. so it has half concentration of electrolyte as compare to ISO-M. so ISO-P can be used in adult when there is chiefly water loss and only small loss of electrolyte ( hypernatremia) Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso -P 25 20 22 50g/L 23 410 Monday, November 25, 2013 33

ISO- P :

ISO- P INDICATION Chiefly used as maintenance fluid in infant and children to provide daily water and electrolyte . Excessive water loss or inability to concentrate urine ( DI) CONTRAINDICATION HYPONATREMIA ( low Na+) RENAL FAILURE ( high K+) HYPOVOLEMIC SHOCK :-isolyte –P is not suitable to correct hypovolemic shock (diarrhoea, vomiting) because low Na+ , high K+ in oliguric state in not safe . And rapid infusion of large ISO-P can cause hyperglycemia and osmotic diuresis. Monday, November 25, 2013 34

ISO - E:

ISO - E PHARMACOLOGICAL BASIS:- ISO-E is extracellular replacement solution. Electrolyte are similar to ECF except that it has double the concentration of K+ and acetate. Patient on long term fluid therapy may develop Mg+ deficiency . but ISO-E is only fluid which will correct magnesium deficiency . So this fluid provide all ECF electrolyte , additional advantage to correct metabolic acidosis , supply energy , replace water deficit . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso - E 140 10 103 5 3 50g/L 47 368 Monday, November 25, 2013 35

ISO – E :

ISO – E INDICATION Diarrhoea Metabolic acidosis In maintenance of ECF volume preoperatively CONTRAINDICATION Vomiting or continuous NG aspiration :- this is metabolic alkalosis state and ISO-E contain acetate which convert to bicarb so it further ppt the condition . Monday, November 25, 2013 36

ISO – M :

ISO – M PHARMACOLOGICAL BASIS:-ISO- M is richest source of K+ . So very useful to treat hypokalemia .before adm ensure good urine output and renal function . Proportion of electrolyte is almost similar to maintenance requirements of body . Additionally ,it correct acidosis and supply energy . So this fluid fulfills the needs of body electrolytes, pH maintenance , caloric supply and water replacement and , so it’s the ideal fluid for maintenance fluid therapy . As it contain low Na+( 40 mEq/L) ,so should be avoided in hyponatremia . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso -M 40 35 40 50g/L 20 580 Monday, November 25, 2013 37

ISO – M :

ISO – M INDICATION For parenteral fluid therapy , it is the ideal maintenance fluid. To correct hypokalemia secondary to diarrhoea , bilious vomiting , prolonged infusion of potassium free I.V. fluid. CONTRAINDICATION RENAL FAILURE :- due to risk of hyperkalemia . HYPONATREMIA AND WATER INTOXICATION :-because low concentration of Na+ in fluid. ADRENOCORTICAL INSUFFICIENCY :- these patient have abnormally high K+ . BURNS:-in burn patient K+ concentration may be abnormally high due to tissue destruction and acidosis. Monday, November 25, 2013 38

ISO – G :

ISO – G PHARMACOLOGICAL BASIS :- during vomiting or continuous NG aspiration there is loss of gastric juice . Which lead to hypochloraemic , hypokalemic metabolic acidosis. ISO-G is gastric replacement solution . It provide all electrolytes lost by gastric juice, corrects alkalosis and provides calories. Ammonium ions in ISO-G are converted into urea and hydrogen ion in liver. So ISO-G only fluid which directly correct metabolic alkalosis if any nature . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso -G 63 17 150 50g/L 70 274 Monday, November 25, 2013 39

ISO-G :

ISO-G INDICATION In vomiting and continuous gastric aspiration to replace loss of gastric juice. In treatment of metabolic alkalosis due to excessive administration of bicarb or aggressive diuretic therapy . CONTRAINDICATION HEPATIC FAILURE :-because ammonium ion will not be converted into H+ ion .and accumulation of unchanged ammonium ion may ppt hepatic precoma in severe liver disease. RENAL FAILURE :-may aggravate uremic acidosis, hyperkalemia , METABOLIC ACIDOSIS:- H+ will ppt . Monday, November 25, 2013 40

Fluid therapy why needed preoperatively?:

Fluid therapy why needed preoperatively? It is an imp. Aspect to ↓ morbidity and mortality . In surgical patient multiple factor modify the normal physiology of fluid and electrolyte balance in body . ACUTE STRESS :- physical or mental stress .( before ,during, after) surgery. Due to stress reflex sympathetic response leads to tachycardia and vasoconstriction. In surgical patient ↑ secretion of ACTH .which ↑Hydrocortisone (to fight with ac .stress ) and ↑ Aldosterone ( cause Na + and H 2 O retention) Preop. evaluation and correction of existing fluid and electrolyte imbalance in very imp. Monday, November 25, 2013 41

Fluid therapy why needed preoperatively?:

Fluid therapy why needed preoperatively? Hypovolemia need to be corrected prior to surgery . Because Hypovolemia compensation reflex tachycardia and ↑vascular resistance ( d/t baroreceptor reflex ), lost on induction , as reflexes are interrupted and compensation lost , and lead to severe hypotension & ARF. 3 rd space loss:- 3 rd spacing is internal redistribution of ECF due to sequestration of fluid in body. This fluid loss ↓ circulating volume and produce hypotension. Rough guidelines of volume deficit Mild dehydration – 4% Moderate dehydration – 6-8% Severe dehydration -10% liter fluid Shock -> 15 % Monday, November 25, 2013 42

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY . Fluid balance is an important area of perioperative medicine. If managed incorrectly it is a significant cause of morbidity and mortality. AIMS OF FLUID THERAPY Perioperative fluids are required to maintain adequate: Correction of hydration and hypovolemia. Correction of anaemia ,blood volume and oxygen delivery renal function electrolyte balance . Monday, November 25, 2013 43

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY FASTING POLICY:- Current preoperative fasting guidelines for elective surgical patients state that elective patients may take clear oral fluids until two hours prior to the anaesthetic and surgery. Oral fluids alone are suitable for many patients undergoing anaesthesia and surgery. The Association of Anaesthetists of Great Britain and Ireland recommends these minimum fasting periods based on the American society of Anaesthesiologists (ASA) guidelines: 6 hours for solid food, infant formula, or other milk. 4 hours for breast milk 2 hours for clear (non particulate) and non-carbonated fluids. Monday, November 25, 2013 44

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY INTRAVENOUS FLUID :- Perioperative fluid therapy is divided into replacement of pre-existing losses, provision of maintenance fluids and replacement of intraoperative and postoperative losses. Many factors alter the amount of fluid required in the perioperative period. Wide variations in the impact of these factors exist between individuals. Fluid regimes must therefore be individualised for each patient. Monday, November 25, 2013 45

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY REPLACEMENT OF PRE-EXISTING LOSSES:- The fluid deficit to be replaced is the maintenance fluid requirement (multiplied by the hours since last oral intake) added to preoperative external and third space losses. Normal maintenance requirement of fluid and electrolyte can be estimated at 1.5ml/kg/hr and is usually replaced with normal saline or RL. Abnormal insensible losses must be included. Pyrexia increases insensible loss by 20% per degree Celsius rise in body temperature. Note normal insensible loss for an adult in a temperate climate is 1000ml/day. Abnormal preoperative external losses are often from the gastrointestinal tract. It is best replaced with crystalloid of similar composition, either normal saline or Hartmann’s. Diarrhoeal losses may contain high concentrations of potassium. Monday, November 25, 2013 46

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY THIRD SPACE LOSSES:- It is loss of fluid from the intravascular compartment secondary to increased capillary permeability found in conditions such as sepsis and trauma. Some of this fluid forms oedema in the surgical field, some is lost into the bowel lumen and some into the peritoneal cavity. These losses contain equivalent electrolyte concentrations but a lower protein concentration compared to extracellular fluid. These losses are best replaced during resuscitation by a combination of normal saline or Hartmann’s and colloids. The fluid volume required to replace pre-existing losses is difficult to estimate as the losses are hard to measure accurately. Third space losses are notoriously difficult to assess and may continue to increase until the patient starts improving. Therefore fluid replacement must be dynamic, based on the patient’s response, and not simply based on one set of observations or predictions. Monday, November 25, 2013 47

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY PERIOPERATIVE LOSSES General anaesthesia causes significant vasodilatation and varying degrees of myocardial suppression. Positive pressure ventilation will reduce venous return and cardiac output. Vasodilatation produced by sympathetic blockade following spinal and epidural anaesthesia will also reduce preload and blood pressure. Surgery has a number of influences on intraoperative and postoperative fluid balance. These include bleeding, third space losses, evaporative losses from exposed surfaces, fluid sequestration in obstructed or adynamic bowel, patient positioning, and the neuro -hormonal or stress response. The physiological stress response to surgery or trauma causes a rise in the levels of circulating catecholamines, aldosterone , cortisol and antidiuretic hormone (ADH). This catecholamine and steroid release results in water and sodium retention post-operatively. Because relatively more water is retained than sodium there is a risk of post-operative hyponatraemia , particularly if an excess of non-sodium containing fluids are given. Monday, November 25, 2013 48

PERIOPERATIVE FLUID THERAPY :

PERIOPERATIVE FLUID THERAPY Factors affecting perioperative fluid requirements Patient size, weight, body composition Preoperative fluid losses, hydration and volume status Co-morbid diseases, particularly sepsis, renal, cardiac and hepatic impairment Normal maintenance requirements Fever Temperature of environment Anaesthetic technique Type of operation Duration of operation Operative losses Neuro-hormonal stress response Postoperative losses Speed of return to oral intake Monday, November 25, 2013 49

PHYSICAL SIGNS OF DEHYDRATION :

PHYSICAL SIGNS OF DEHYDRATION Monday, November 25, 2013 50

HYPOVOLAEMIC SHOCK GRADES:

HYPOVOLAEMIC SHOCK GRADES Monday, November 25, 2013 51

Which fluid to give and how fast ?:

Which fluid to give and how fast ? Fluid depends on nature of loss , hemodynamics & electrolyte and underlying disease. Fluid should be which correct volume and abnormality. Elderly and anemic patient require slower and more careful correction and monitoring. Monday, November 25, 2013 52

ECF VOLUME DEFICIT :

ECF VOLUME DEFICIT 1. Thirst is an early symptom of ECFVD or dehydration. Encourage fluid intake. 2. The serum osmolality is one method to detect dehydration. A serum osmolality of 300 mOsm/kg indicates dehydration. 3. Decreased skin turgor, dry mucous membranes, an increased pulse rate, and a systolic blood pressure (while standing) 10–15 mm Hg of the regular blood pressure are some signs and symptoms of dehydration. 4. Urine output less than 30 mL/hr or 720 mL/day should be reported. A decrease in urine output can indicate insufficient fluid intake, hypovolemia, or renal dysfunction. 5. A quick assessment of hypovolemia or dehydration can be accomplished by checking the peripheral veins in the hand. First hold the hand above the heart level for 10 seconds and then lower the hand below the heart level. The peripheral veins in the hand below the heart level become engorged within 5–10 seconds with a normal blood volume. If the peripheral veins are not engorged, hypovolemia or dehydration is present. Monday, November 25, 2013 53

ECF VOLUME DEFICIT :

ECF VOLUME DEFICIT Check blood pressure while the patient is sitting and again if the patient is able to stand without difficulty (a fall of 10–15 mm Hg in systolic pressure can indicate marked ECFVD). A narrow pulse pressure of less than 20 mm Hg can indicate severe hypovolemia. Check laboratory results of BUN and hematocrit. Elevated levels might indicate fluid loss. Monday, November 25, 2013 54

Volume Control:

Volume Control Volume changes sensed by Baroreceptor Osmoreceptors Modulate Vol. Sensors located in Aortic arch and carotid sinsuses Detect changes in fluid osmolality through osmoreceptors changes in thirst & diuresis through kidney

Routine Intraoperative Fluid Administration :

Routine Intraoperative Fluid Administration The goals of intraoperative fluid administration are to maintain adequate oxygen delivery, normal electrolyte concentrations, and normoglycemia. The total fluid requirement is composed of compensatory intravascular volume expansion (CVE), deficit replacement, maintenance fluids, restoration of losses, and substitution for fluid redistribution (i.e., third space fluids): RATE OF FLUID= CVE + DEFICIT + Mx FLUID+LOSSES+THIRD SPACE Monday, November 25, 2013 56

PowerPoint Presentation:

Monday, November 25, 2013 57

PowerPoint Presentation:

Monday, November 25, 2013 58

RATE AND DROP CALCULATION :

RATE AND DROP CALCULATION When using IV infusion sets for IV therapy administration first check the drop factor or drip rate that is printed on the manufacturer’s box or package. The number of drops per ml (gtt/ml) varies with each manufacturer. Drop factors range from 10–20 gtt/ml for the macrodrip chambers and 60 gtt/ml for microdrip chambers. Monday, November 25, 2013 59

Fluid management for an elective laparoscopic cholecystectomy :

Fluid management for an elective laparoscopic cholecystectomy Fit 43 year old female, weighing 80kg. Clear oral fluids until 2 hours preoperatively. Total blood loss approximately 30mls. Operation duration 1 hour. Fluid regime During surgery there was no significant blood loss and tissue oedema and third space losses are minimal. Therefore fluid replacement only needs to cover pre-operative deficit and maintenance requirements. These are approximately: Normal hourly maintenance = 1.5ml/kg/hr = 120 mL/hr Pre-operative deficit =2 hours x 120 mL = 240 mL Maintenance fluid during operation = 1 hour = 120mls Allowance for third space loss / evaporation 5mls/kg = 400mls Total: maintenance + replacement = 760mls Hartmann’s Ongoing postoperative maintenance fluids (until tolerating oral fluids) = 120mls/hour. Monday, November 25, 2013 60

Fluid management for an elective bowel resection :

Fluid management for an elective bowel resection Fit 70 year old man, weight 80kgs Preoperative Hb 12g/dl Has been nauseated overnight and had no oral intake for 8 hours. Received enema to prepare bowel resulting in diarrhoea overnight. Total blood loss: 1000mls Operation duration 3hours. Fluid regime Preoperative deficits and maintenance fluids need replacing, but in addition there has been significant blood loss and third space losses. As only one third of infused crytalloids remain in the intravascular compartment, crystalloid replacement volume should be 3 times the blood volume lost. This patient would have a blood volume of around (70mls X 80kg = 5600mls). Measured blood lost is around 20% of the blood volume and so the postoperative Hb will be around 9 - 9.5g/dl which is acceptable. Monday, November 25, 2013 61

Fluid management for an elective bowel resection :

Fluid management for an elective bowel resection Normal maintenance rate = 80kg x 1.5ml/hr = 120ml/hr Pre-operative deficit = 8 hours x 120mls = 960mls Maintenance fluid during operation = 120mls x 3 hours = 360mls Other losses include diarrhoea of an unknown amount - estimate 1000mls. Replacement of 1000mls blood loss can be with 1000mls of colloid or 3000mls of Hartmann’s. Third space losses estimated = 10ml/kg/hr for first hour then reducing to 5mls/kg/hr thereafter = 1600mls Total - approximately 6000mls over 3 hours Postoperatively the patient will require higher that normal fluid volumes as fluid will tend to gather in the bowel which will not function, and oedema in the area of surgery will sequester fluid. Fluid replacement should be primarily with Hartmann’s or saline 0.9% during the first 24 hours and K+ should be added on the following day. Fluid replacement should be reassessed every 4 hours using the clinical signs. Monday, November 25, 2013 62

Fluid management for an emergency laparotomy :

Fluid management for an emergency laparotomy 65 year old female with occasional angina weighing 70kgs Pain for 24 hours, no oral intake during this time Pulse 120/min, BP 90/60, poor capillary refill Preoperative Hb: 16g/dl, Na 143, K5.4, creatinine 153, Urea 10.4 Scheduled operation: laparotomy and bowel resection for faecal peritonitis. This patient is very complex and fluid management will be difficult. Estimating preoperative losses is difficult as she has had no fluid for 24 hours and also will have a lot of intra-abdominal fluid due to her faecal peritonitis. Her Hb and urea are raised with her existing fluid deficit. Fluid replacement will be based on her clinical signs, invasive monitoring and the response to volume loading. Preoperative intervention: 1 litre colloid and 2 litres crystalloid over 2 hours. Intraoperative blood loss: 700mls Operation duration 2 hours Monday, November 25, 2013 63

FLUID MANAGEMENT IN PIH AND ECLAMPSIA:

FLUID MANAGEMENT IN PIH AND ECLAMPSIA Fluid restriction unless there is associated maternal hemorrhage, to reduce the chance of fluid overload and pulmonary edema Strict intake-output chart should be maintained As per NICE guidelines, total fluids should be limited to 80ml/hr i n women with severe eclampsia until post partum diuresis commences Cardiogenic - due to impaired LV systolic or diastolic dysfunction Non- Cardiogenic – due to  Capillary permeability  Colloid Osmotic Pressure Fluid overload Monday, November 25, 2013 64

Daily electrolyte requirement:

Daily electrolyte requirement Sodium – 1-1.5mEq/kg/day Potassium – 1mEq/kg/day Chloride – 1.5mEq/kg/day Phosphate – 0.2-0.5mmol/kg/day Calcium – 0.1-0.2mmol/kg/day Magnesium – 0.1-0.2mmol/kg/day 70kg male – 2400ml/day, Na + - 70-100 mEq/day, K + - 70 mEq/day In the nonstressed, fasting state, the 150g per day can provide enough carbohydrate to limit proteolysis. 1L 0.45% NS, 500ml 0.45%DNS, 1L 5%D with 20mEq/L of KCL and 2 gm MgSO4. Monday, November 25, 2013 65

TARGET OF POST OPERATIVE FLUID THERAPY :

TARGET OF POST OPERATIVE FLUID THERAPY Maintain B.P. Maintain adequate urine output ( > 0.5 ml/kg /hr ) Replace fluid loss in post op period ( drain, soakage, NG aspiration) Provide energy and maintain electrolyte . Post op NPO status subjected to operative procedure Procedure which don’t require handling of intestine or viscera ( like in hernia , minor orthopedic op on limbs ) will require only maintenance I.V. fluid to correct deficit due to preop NPO state. Surgery like intestinal R&A , or total colostomy , where intestinal viscera need rest, require postop I.V. fluid for few days ,after ensuring normal movement of intestine oral intake is restarted. Monday, November 25, 2013 66

FACTOR CONSIDERATION FOR POSTOP I.V. FLUID RX :

FACTOR CONSIDERATION FOR POSTOP I.V. FLUID R X Age , weight , vitals ,hydration , urine output Preop diagnosis, nature of surgery and blood loss Nature and volume of fluid and blood intraop. Drain output, NG aspiration , soakage , oozing , Associated illness like ( renal , DM ,IHD, HT,) and electrolyte illness Consider insensible loss due to atmospheric temp, pyrexia Monday, November 25, 2013 67

Post operative patient fluid :

Post operative patient fluid For maintenance fluids adhere to the 4/2/1 rule for water balance. Require 1-2 mmol/kg of Na+ per day Require 0.5-1 mmol/kg of K+ per day So for a usual sized, euvolemic person a rate of approx 125 ml per hour of 0.45%DNS with 20 mEq of KCl per litre per day will give approx 100 meq of Na+ and 60 meq of K+ per day. Provides free water for insensible losses Dextrose prevents catabolism and proteolysis Monday, November 25, 2013 68

Renal failure and liver failure:

Renal failure and liver failure Prevention of contrast induced nephropathy – Hydration with normal saline at 100-150ml/hr. Reduce intake in patients who are oliguric Avoid K containing solution Use hypertonic solutions with caution. In polyuric phase – replacement with NS. Rate equal to previous hours urine output. Monitor electrolytes. Liver failure - use dextrose, avoid RL Monday, November 25, 2013 69

Trauma patients with head injury:

Trauma patients with head injury Resuscitate with isotonic fluids preferably NS. Avoid synthetic colloid in patients with head injury or intracranial bleeding. ESICM task force guidelines. Intensive Care Med 2012;38:368-83 Avoid dextrose containing solutions Avoid hypotonic solutions There is no advantage in hypertonic fluids with brain injury JAMA 2004 Mar 17; 291(11):1350-7 Mannitol effective only if BBB intact Electrolyte disturbances Monday, November 25, 2013 70

Burns:

Burns Loss of Na and water in first 6-8hrs and continues for 48hrs Initial resuscitation –Parkland formula First 24 h: RL at 4ml/kg/% TBSA; give half in first 8 h & the remaining over next 16 h Second 24 h: colloid at 20-60% of calculated plasma volume to maintain adequate urinary output After initial resuscitation use a combination fluid infusion of albumin and 5%D. From 3 rd day reduce intake as there is sodium and water reabsorption. Monday, November 25, 2013 71

Diabetic ketoacidosis:

Diabetic ketoacidosis Water and electrolyte loss due to osmotic diuresis Hyperkalemia due to acidosis. However there is total body potassium deficit Initial resuscitation with 1sotonic saline or RL along with IV insulin 0.1units/kg/hr After 3-4L of NS give 0.45%NS to avoid hyperchloremic acidosis. Give 0.45%DNS when blood sugar is <200mg/dl 20-30mEq/L K + to be added if Sr K + <5.3 and patient has good urine output Monday, November 25, 2013 72

Choice of fluids:

Choice of fluids Hypotonic fluids (0.45%ns,0.33%NS,5%D) Maintenance, intracellular dehydration Avoid –head injury, trauma, burns Isotonic fluids (RL, 0.9%NS) Hypovolemic patients Hypertonic fluids (3%NS, 5%DNS,10%D) Nutrition, electrolyte disturbances Use with caution- impaired renal and cardiac function Avoid in cellular dehydration Monday, November 25, 2013 73

MINIMIZE HYPOTHERMIA DUE TO IVF:

MINIMIZE HYPOTHERMIA DUE TO IVF Hypothermia in Labor & Delivery Patients Studies have shown that anesthesia delivered during surgical procedures reduces patient core temperature by provoking a core-to-peripheral redistribution of body heat. Factors such as chilled IV solutions, cold OR environments and surgical procedure length further impact the body temperature of patients. Unfortunately, core temperature loss is often unexpressed by the patient and unforeseen in neuraxial anesthesia. Thus accidental hypothermia often accompanies spinal/epidural anesthesia for cesarean delivery. Monday, November 25, 2013 74

Complications of Hypothermia :

Complications of Hypothermia Mild hypothermia has been linked to various complications and discomforts for patients, including:- severe shivering impairment of blood clotting inhibited coagulation, which can increase the chance of postpartum haemorrhage. prolonged postoperative recovery. reduced resistance to surgical wound. infections reduced drug metabolism decreased circulation and cardiac function Monday, November 25, 2013 75

CLINICAL BENEFIT OF WARMING :

CLINICAL BENEFIT OF WARMING Clinical Benefits of Warming Studies looking at the impact of perioperative warming on women undergoing cesarean delivery with epidural anesthesia found that: maternal and fetal hypothermia were prevented maternal shivering was reduced umbilical vein pH was improved lack of warming inhibits coagulation and can worsen postpartum haemorrhage for mothers. Monday, November 25, 2013 76

Summary:

Summary Treat IV fluids as “prescription” like any other medication Determine if patient needs maintenance or resuscitation Choose fluid type based on co-existing and anticipated electrolyte disturbances Choose rate of fluid administration based on weight and minimal daily requirements Monitor electrolytes Always reassess whether the patient continues to require IVF Monday, November 25, 2013 77

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Monday, November 25, 2013 78

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