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Fluid & Electrolyte

TherapyDr.Waskito SpAnK.IC

Departement Anesthesiology and Intensive CareSaiful Anwar Hospital, Malang


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Purposes of fluid administrationduring the perianesthetic period:

replace insensible fluid losses during theanesthetic period,for example : (evaporation, diffusion)

replace sensible fluid losses (blood loss, sweating)during the anesthetic period

maintain an adequate and effective blood volume maintain cardiac output and tissue

perfusion maintain patency of an intravenous route of drug

administration


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Normal body water distribution:

1 gm = 1 ml; 1 kg = 1 liter; 1 kg = 2.2 lbs

total body water : 60% of body weight intracellular water : 40% of body weight extracellular water : 20% of body weight

(intravascular water + Interstitial water)

a. interstitial water : 15 % of body weightb. intravascular water : 5 % of body weight

A REVIEW


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intercompartmental distribution of water maintained by

hydrostatic, oncotic, and osmotic forces daily water requirement;up to 10 kg, 4ml/kgbw/hour or 100ml/kg/24hours

11-20kg, 2ml/kgbw/hour or 50ml/kg/24 hours

>21kg, 1ml/kgbw/hour or 20ml/kg/24 hours50 ml x body weight (kg) provides rough estimate for dailyrequirement

requirements vary with age, environment, disease, etc


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Fluid movement across capillarymembranes

Filtration is governed by Starlings equation Net driving pressure into the capillary =

[(Pc Pi) (p i)]

Abbreviation :Pc = capillary hydrostatic pressure (varies from artery to vein)Pi = interstitial hydrostatic pressure (0)p = plasma oncotic pressure (28 mmHg) i = interstitial oncotic pressure (3 mmHg) If COP in the capillaries decreases lower than the COP in the interstitium,fluid will move out of the vessels and edema will develop.


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Plasma colloid osmotic pressurePlasma proteins are primary determinant for

the plasma colloid osmotic (oncotic)pressureOne gram of albumin exerts twice the colloid

osmotic pressure of a gram of globulin

Because there is about twice as much albuminas globulin in the plasma, about 70 % of the totalcolloid osmotic pressure results from albumin.


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What happens if man BW 50kg losses 1000 ml of blood?The capillary hydrostatic pressure (Pc) dropsespecially at the venous end.

The net pressure into capillary increases and thebalance is no longer maintained so fluid is retrievedinto the circulation from the interstitium until Pc isrestored.


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Review normal electrolyte distributionSodium: The major component of ECF osmotic concentration is regulated by maintaining

sodium balance and provides osmotic forces to maintainwater balance in interstitial fluid compartment

generally, water and sodium disturbances occur simultaneously

sodium levels indicate overall fluid balance

sodium levels are regulated by the kidney, throughaldosterone & other related factors


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Potassium: The major component of ICF 98% of total body potassium is located intracellularly provides osmotic forces to maintain water balance in intracellular fluid

compartment plasma potassium levels may not reflect total body potassium levels!

Because it is indirect measure of intracellular K+ potassium imbalances result in altered function of excitable membranes

(eg heart, CNS) normal renal function is required to prevent hyperkalemia hypokalemia should be treated slowly: do no t exceed 0.5- 1 mEq

K+/kg/hr, a lso maxim um con centrat ion 40 mEq/L.


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Calcium: vital ion in normal neuromuscular activity, cardiac rhythm and

contractility, cell membrane function, and coagulation highly protein bound; total plasma calcium levels vary with

plasma albumin levels, however ionized calcium levels mayremain constant


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Chloride: The major component of ECF renal regulation of electroneutrality usually results in

an inverse relationship between Cl- and HCO3- Tends to follow Na+, so chloride deranges, in general,

do not need to be directly corrected

Bicarbonate: part of the major buffer system in the body discussed previously

Other Anions: plasma proteins, organic acids, sulphates not routinely measured constitute the "anion gap"


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Changes in fluid and electrolyte balance in response to disease processes:

may vary widely hypovolemia is common! electrolyte changes are variable goal i s to correct f luid and electrolyte imbalances before anesthesia , i f

poss ib le

Changes in fluid and electrolyte balance in response to anesthesia:

many anesthetic agents produce vasod i lat ion and hyp otension re la t ive hypovolemia!

results in alterations in sympathetic nervous system activity and the endocrinesystem

redistribution of blood flow with changes in vascular resistance reduction in urinary flow rate, renal blood flow, and glomerular filtration rate

seen with withholding water (fasting), anesthetic drug effects, and increased ADH levels these effects can b e el iminated or reduced by " f i l l ing th e tank" with

crysta l loids


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Maintenance vs. replacement therapy :

m aintenanc e fluid th erapy (plasmalyte 56, 0.45 NaCL with d extros e etc) is design ed to meet the pat ient 's on go ing sensib le and insensib le f luid losses wi th norm al f lu id vo lume over 1 2 days ; in the no rmal human this is pr im ari ly w ater loss , wi th a lesser degree of e lectrolyte loss .

replacem ent f lu id th erapy (LRS, Plasmalyte A , Norm os ol, 0.9 NaCL, etc) is designed to replace exis t ing f luid def ic i ts ; th is usual ly requires replacement o f bo th w ater and electrolytes

The opt imal f luid type for each of the abo ve set t ings d epend up on serum electrolytes , acid-base s ta tus , and con current adm inis t ra t ion of d rug s and b lood p roduc t s .

General pr inc ip les o f f lu id adm inis t ra tion:


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Crystalloid = a solution of crystalline solid dissolved inwater

Colloids = a suspension of particles in a liquid ie, does notcross a semipermeable membrane, so exerts a colloidoncotic pressure

Types of fluids available and general indicationsfor their use:


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Crystalloids: Replacement fluids generally are polyionic isotonic fluids Ringer's, Lactated Ringer's (LRS), PlasmaLyte148, PlasmaLyte A are all polyionic isotoniccrystalloid fluids that closely mimic plasma electrolyte concentrations (with or withoutbicarbonate precursors)

0.9% NaCl (normal saline) is an isotonic solutionof Na, Cl, and water


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commonly administered during generalanesthesia to diminish the cardiovasculareffects of anesthetic drugs and replaceongoing fluid lossesreplace acute blood loss by administering 3 volumes of crystalloid solution for each 1 volume of blood lost


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Crystalloids: Maintenance fluids Are hypotonic crystalloids that are low in sodium,chloride, and osmolality, but high in potassium comparedto normal plasma compositions.eg, 0.45 % sodium chloride, 2.5 % dextrose with 0.45% saline, 2.5 % dextrose with half strength LRS,Normosol M, Normosol M in 5 % dextrose, PlasmaLyte56 in 5% dextrose, and Plasmalyte 56.generally polyionic isotonic or hypotonic fluidsused for long term fluid therapy , such as the ICUsetting; not generally used during anesthesia generally are low in Na and Cl, and high in K may or may not contain dextrose


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Crystalloids: Hypertonic fluids hypertonic saline (7.5% NaCl) has been indicated in someshock states to maintain cardiovascular function; pulls fluidinto intravascular space by osmosis by creating transienthypernatremia.usually must be given cautiously


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ions are presented as mEq/l

*M = Maintenance; R = Replacement


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Colloids: Synthetic colloids are polydisperse (various molecularweight) and do not readily cross semipermeablemembrane.Hypertonicity pulls fluids into the vascular space and

increase blood volume which effect is longer lastingcompared to crystalloid therapy.solutions of starch or dextrans (of various molecularweights)smaller volumes of colloids are as effective as larger

volumes of crystalloids in maintaining intravascular fluidvolume


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historically have had a number of problemsassociated with their use, including allergicreactions, impaired coagulation, and renaldamage; solutions available now have lessproblems associated with their useexpensive compared to crystalloids


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Whole blood:contains it all: colloids (plasma proteins), clottingfactors including platelets, red blood cells foroxygen carrying capacityrelatively easy to collect and store indications : acute blood loss, concurrent anemiaand hypoproteinemia, clotting defectsstored blood is not quite as useful as freshblood: reduced oxygen carrying capacity (review2,3-DPG), platelets are inactive, clotting factorsmay be degraded

Blood and blood components


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A blood filter must be always used to sieve

microthrombi from the blood product.In massive transfusion, defined as bloodvolume replacement greater than 1.5

times the recipient volume, abnormalbleeding may occur.This homeostatic defects is characterizedby oozing from the operative wound,mucous membranes, and intravenouspuncture sites.


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Blood Types and crossmatching Crossmatching between donor and recipient

will minimize a fatal outcome. Always administer slowly in the beginning so

as to allowing adequate time to detect anyadverse reactions, such as rashes, edema,vomiting, fever, DIC, dyspnea, hypotension,unconsciousness and tachycardia


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Packed red blood cells: red cell fraction of separating plasma from

whole blood

usually has a PCV of 70% useful in treating anemia reduces risk of fluid overload reconstitute with equal volumes of 0.9%

saline


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Plasma: two types: fresh or frozen

fresh plasma contains colloids, activeplatelets, and clotting factorsuseful in treating coagulation defects

frozen plasma can be stored for periodsup to a year; serve as a source of colloids(plasma proteins); often collected fromstored whole blood when the red cell

fraction is no longer viableuseful in treating hypoproteinemia and

maintaining normal colloidal osmoticpressure


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Complications of blood and plasma

transfusions: immune response to red cell antigens immune response to white cell antigens

in vitro (storage) changes coagulation defects citrate intoxication hyperkalemia hypothermia sepsis


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