FLUID THERAPY

Ahmed A Shorrab; MD.

Professor of Anesthesia & ICU
Mansoura Faculty of Medicine
 Goals
 Fluidhomeostasis
 Consider the volume status

 Be able to recognize hypovolemia

and formulate a treatment
 Know when and which IV fluids to
use

Shorrab AA; May 2009

 Body Water and Fluid
Compartments
 TBW = 0.6 x kg
 TBW = ECF + ICF

(1/3) (2/3)
ECF = extracellular, ICF = intracellular

 ECF = Interstitial + Plasma

(1/3) (1/4)
 Fluid spaces are iso-osmolar due to water
movement
Shorrab AA; May 2009
 Body Fluid Compartments

2/3
ICF:
55%~75%

X 50~70% TBW
lean body weight

3/4 Extravascular
Interstitial
fluid
 Male (60%) > female (50%)
Most concentrated in skeletal muscle 1/3
ECF

 TBW=0.6xBW
 ICF=0.4xBW
 ECF=0.2xBW

Intravascular
1/4 plasma
Shorrab AA; May 2009
 Regulation of Fluids
Renal sympathetic nerves
Renin-angiotensin-
aldosterone system
Atrial natriuretic peptide
(ANP)

Shorrab AA; May 2009

Forces acting on the fluid in blood
vessels

 Oncotic

 Hydrostatic

 These
are closely balanced in a well
human body.

Shorrab AA; May 2009

Regulation of Fluids

Hydrostatic pressure v.s. Oncotic pressure

 Albumin is the major determining
oncotic pressure
Shorrab AA; May 2009
Shorrab AA; May 2009
Terminology
 Osmolality: a measure of the number of particles
dissolved in solution
 Tonicity: a measure of the number of “effective”
osmoles in solution (for practical purposes, the
sodium plus potassium concentration)
 Plasma osmolality=2(Na+K)+Gl/18+U/2.4
280-310 mOsmol/L

Shorrab AA; May 2009

Terminology
 Dehydration

Depleted of electrolyte-free water

Diagnosis is simple – a high serum sodium
concentration
 Volume depletion

Depleted of isotonic saline

Diagnosis by history, physical, and assessment
of the patient’s response to therapy

Shorrab AA; May 2009

 Signs of Hypovolemia
 Diminished skin turgor
 Dry oral mucus membrane
 Altered mental status
 Oliguria
- <500ml/day
- normal: 0.5~1ml/kg/h
 Tachycardia
 Hypotension
 Hypoperfusioncyanosis

Shorrab AA; May 2009

 Vital Signs are Vital
 Urine
output is the most sensitive (first to
change) sign of volume contraction
 Poor urine output can be nonspecific
 Be aware of causes besides volume
depletion
 Heart rate changes second
 Blood pressure changes late

Shorrab AA; May 2009

Urine output
 0.5-1 mL/kg
 May be deceptive
 Oliguria in renal impairment
 Polyuria in DKA
 Polyuria in early uraemia

Osmotic diuresis

Plasma osmolality=2(Na+K)+Gl/18+U/2.4
Shorrab AA; May 2009
 Clinical Diagnosis of Hypovolemia

 Thorough history taking: poor intake, GI

bleeding…etc
 BUN : Creatinine > 20 : 1
- BUN↑: hyperalimentation, glucocorticoid
therapy, UGI bleeding
 Increased specific gravity
 Increased hematocrit
 Electrolytes imbalance
 Acid-base disorder

Shorrab AA; May 2009

Shorrab AA; May 2009
 Fluid Therapy

Replacement

Maintenance

Repair deficit

Shorrab AA; May 2009

 FLUID THERAPY

RESUSCITATION MAINTENANCE

Crystalloid Colloid ELECTROLYTES NUTRITION

1. Replace acute loss 1. Replace normal loss

(hemorrhage, GI loss, (IWL + urine+ faecal)
3rd space etc) 2. Nutrition support
Shorrab AA; May 2009
Ions in Fluid Compartments

Shorrab AA; May 2009

 Electrolyte solutions

Plasma Isotonic Hypotonic solutions

solutions
308 273 278 290

290

278

Normal Ringer’s
saline acetate/ lactate
D5 KAEN 3B*

Shorrab AA; May 2009

Normal saline
 Na Cl 0.9%
 0.9 gm of Na Cl in 100 mL

 900 mg in 100 mL
23
Na11
 9000 mg in 1L

 1mmol = 23 + 35 =58 mg
35
Cl17
 1L = 9000 / 58 = 154 mmol

 Osmolarity 308 mosmol/L

 = plasma osmolarity

Shorrab AA; May 2009

 Types of IV Fluid solutions
 Hypotonic - 1/2NS
 Isotonic - NS, LR, albumen

 Hypertonic – Hypertonic saline 2.7%

 Crystalloid

 Colloid

Shorrab AA; May 2009

The Influence of Colloid & Crystalloid on
:Blood Volume

Blood volume
Infusion 20 60 100
volume 0 0 0

1000 Lactated
cc Ringers

500c 5% Albumin
c

500c 6% Hetastarch
c

500c Whole blood

c
Shorrab AA; May 2009
 Crystalloids Colloids
 Isotonic crystalloids  Contain high molecular
- Lactated Ringer’s, 0.9% weight
NaCl
- only 25% remain
substancesdo not
intravascularly readily migrate across
 Hypertonic saline solutions capillary walls
- 3% NaCl  Preparations
 Hypotonic solutions - Albumin: 5%, 25%
- D5W, 0.45% NaCl
- Dextran
- less than 10% remain intra-
vascularly, inadequate for - Gelifundol
fluid resuscitation - Haes-steril 10%

Shorrab AA; May 2009

 Fluid Management

Goal:
 to maintain urine output of
0.5~1.0mg/kg/h
 to keep CVP~ 8-12 mmHg
 to keep mean BP > 70 mmHg
 To keep SpvO2 > 70%

GDT, no liberal fluids

Shorrab AA; May 2009
 Fluid Management
Aim
 To replace normal losses
 500cc urine
 Stool
 Evaporative
 Respiratory
 Maintenance for losses
 Replace abnormal losses, blood

Shorrab AA; May 2009

 FLUID SELECTION
 Replace : RA, RL, NS

 Maintain: N/2 + D (adult) + K+ 20 mEq

N/4 + D (chlldren) + K+ 20 mEq

 Repair : NaHCO3 8,4%

KCl 25 mEq/25 ml
NaCl 3%
Shorrab AA; May 2009
For normal losses

 Adds up to 2000-2500cc/day in well adult

human; 1-2 ml/kg/h
 Can be calculated for a child with formula:

4, 2,1 rule
 First 10kg@ 4mL/kg
 Second 10kg@ 2mL/kg

 More kg@ 1 mL/kg

 The sum is multiplied by 24 hrs

Shorrab AA; May 2009

Example
A child weighing 28 kg needs maintenance
fluids over 24 hours as follows
 First 10 kg, 10x4= 40 mL
 Second 10 kg, 10x2= 20 mL

 Remaining 8 kg, 8x1= 8 mL

 Total = 68x24 = 1660 mL

1/3 D5 + 2/3 crystalloids

Shorrab AA; May 2009

 Hypotonic
infusion
• 5%
dextrose

Replace Normal
increases ICF > ECF loss (IWL + urine)

ICF ISF Plasma

660 ml 255 mlShorrab 85 ml

AA; May 2009
 ?D5 or not
 Not for volume resuscitation
 Safe at concentration of 5% (D5).

 If brittle DM, don’t add it, unless treating

DKA
 Otherwise, it provides a few extra
calories
 0.05*1000=50 g dextrose*4kcal/g=200
cal/liter*2L=400 kcal/day in maint fluids.
 Obviously, this is not enough calories to
heal yourself
Shorrab AA; May 2009
Abnormal losses& repair
 Blood
 Crystalloids, 1ml blood by 3 ml
 Colloids volume by volume
 Blood 1ml by 1ml
 Electrolytes
 Na, 1-2 mmol/kg
 K, 0.5-1 mmol/kg

Shorrab AA; May 2009

 Case 1
 Healthy 38 yo man in farm accident avulsed his R arm at
elbow and bled profusely at the scene. His brother
tourniqueted the stump and controlled bleeding after
significant blood loss. “Blood everywhere.”
 VS 96.0 100/60 124 22
 Anxious, pale, man acutely ill. Missing R hand,
tourniquet in place, cool extremities.
 What should you do for his fluid status?

Shorrab AA; May 2009

 Case 1- Basic trauma patient
 He needs 2 large bore
IVs
 Give 2L wide open
NS/LR
 His history is enough
to know he can handle
a lot of fluid
 His HCT/Hb will be
normal acutely
Shorrab AA; May 2009
 Use VS and U/O to
gauge volume status
 Follow CK since he
has a crush injury
from the tourniquet
 He will need blood,
so start early blood
resuscitation on him
 Case 2
 70 yo woman who has hx of CHF and
CRI with several days of changed
mental status and poor PO
 VS 36.5, 155/88 92 16

 Thin, elderly, confused. Lungs:

crackles both bases. CV: 3/6 and
irreg irreg. No peripheral edema.
 What is appropriate from here?

Shorrab AA; May 2009

Case 2-unclear volume
status
 Not obvious whether she’s wet or dry
from the story—CHF + poor PO intake
 Be cautious—do further investigation

 Use labs, serial exams, chest film

 Either try fluids or try diuretics

 Adjust your treatment

Shorrab AA; May 2009

 Hemotherapy
 Oxygen delivery and oxygen consumption
 Compensatory mechanisms during anemia

 ↑ cardiac output

 changes in oxygen-hgb affinity

 Oxygen-hemoglobin dissociation curve

Shorrab AA; May 2009

Average Blood Volumes
 Neonates

 Premature 95 ml/kg
 Full-term 85 ml/kg
 Infants 80 ml/kg
 Adults

 Men 75 ml/kg
 Women 67 ml/kg

Shorrab AA; May 2009

Maximum allowable blood loss
 MABL = EBV x (starting Hct – target Hct) / start Hct

Example
 Adult 70kg, Hct 45 allowed to reach 33

EBV = 70 x 70 = 4900 mL = 5L
 MABL = 5 x (45 -33) / 45 = 1300 mL

Shorrab AA; May 2009

Transfusion Threshold

 According to volume
 15 20% tolerable
 > 20 % needs trasfusion
 According to Hct
 Hct > 30 no transfusion
 Hct < 30 needs infusion

Shorrab AA; May 2009

Blood typing
 Type & screen
 Predicts compatible transfusion 99.9%
 Cross-matching
 Additional 1% for compatibility
 EMERGENCY – (pt blood type unknown) give un-
cross-matched type O-
 (if 2 or more units transfused then pt should not receive
type specific blood later due to risk of hemolysis)

Shorrab AA; May 2009

 ABO and Rh compatibility
Blood Group Antigen on Antibodies in Blood group
RBC serum compatibility

A A Anti-B A, O
B B Anti-A B, O
AB A and B none AB,A,B,O
O none Anti-A and O only
Anti-B
Rh + D none Rh+ and Rh-

Rh - none Anti –D if Rh -
sensitized
Shorrab AA; May 2009
Blood components
 Whole blood
 Hct 40%
 Use primarily in hemorrhagic shock

 Packed red blood cells (PRBCs)

 Hct 70-80%
 Volume 250-350 ml

 Increase adult hemoglobin about 1g/dl

Shorrab AA; May 2009

Blood components
 Fresh frozen plasma (FFP)
 Contains all coagulation factors except platelets
 Reversal of warfarin effects, coagulopathy,
correct microvascular bleeding
 Platelets
 Treat thrombocytopenia and abnormal function plt
 Cryoprecipitate
 Treat von Willebrand, treat fibrinogen deficits
Shorrab AA; May 2009
Risk of blood transfusion
 Citrate intoxication
 Acid-base change

 Decrease 2,3 –DPG

 Hyperkalemia

 Dilutional coagulopathy

 Volume overload

 Hypothermia

 Transmission of infection

Shorrab AA; May 2009

Immune complication
 Hemolytic Reactions
 Acute hemolytic reaction
 Delayed hemolytic reaction
 Non-Hemolytic Reactions
 Febrile reaction
 Anaphylaxis, Urticarial reaction
 Graft vs. Host disease
 Immune suppression
 Infectious complications
 Coagulopathy
 Citrate toxicity

Shorrab AA; May 2009

Types of transfusion
 Donor, with compatible blood
 Autologous, own blood withdrawn weeks
before re-infusion
 Blood salvage, by cell saver devices
 RBCs centrifuged, separated, washed with saline
and infused at Hct 40-60
 Contraindicated in malignancy.

Shorrab AA; May 2009

 Thanks very much

Shorrab AA; May 2009