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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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FLUID MANAGEMENT IN HEART FAILUREFLUID MANAGEMENT IN HEART FAILURE
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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FLUID MANAGEMENT IN HEART FAILUREFLUID MANAGEMENT IN HEART FAILURE
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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THE PATIENT WITH LIVER DISEASETHE PATIENT WITH LIVER DISEASE
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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THE PATIENT WITH LIVER DISEASETHE PATIENT WITH LIVER DISEASE
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
THE PATIENT WITH INTESTINALTHE PATIENT WITH INTESTINAL
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THE PATIENT WITH INTESTINALTHE PATIENT WITH INTESTINAL
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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