Seminar on fluids and electrolyte imbalance

Moderator : Dr. (Mrs.) H.P. Saikia Dept. of ENT AMCH, Dibrugarh Presented by : Dr. Shib Shankar Roy 1ST yr. PGT, Dept. of ENT, AMCH, Dibrugarh

Basic physiology :
 Total body water :  Total body water content is about 60% of body weight in an young adult male and about 50% in an young adult female. Since fat contains less water, an obese person will have proportionately less body water as compared to lean person.

 Distribution of body fluid :  Out of total body water two third (40% of body weight) is intracellular fluid & one third (20% of body weight) is extracellular fluid.  Extracellular fluid is further divided into interstitial fluid (3/4 of ECF or 15% of total body weight) and plasma or intravascular volume (1/4 of ECF, 1/12 of total body water or 5% of total body weight).

For better understanding, distribution of fluid volume in a 70kg man is summarized below : Fluid type % of body weight Vol. for 70kg weight Total 60% ICF 40% ECF 20% Interstitial Plasma 15% 5%

42L

28L

14L

10.5L

3.5L

Normal water balance :

 Oral (or I.V.) fluid intake and urine output are important measurable parameters of body fluid balance. To determine daily fluid requirement of body we need to know insensible fluid input and loss as summarized on next page :

Insensible fluid input = 300 ml water due to oxidation. Insensible fluid loss = 500ml through skin = 400ml through lung =100ml through stool Fluid loss fluid input = 1000ml 300ml = 700ml NORMAL DAILY INSENSIBLE FLUID LOSS = 700ml Fluid loss = 500ml through moderate sweating(abnormal) = 1 to 1.5 L through severe sweating/high fever = 0.5 to 3L through exposed wound surface (burns) and body cavity (laparotomy). (laparotomy).

 So higher amt. of water is lost during exercise, abnormal perspiration, pyrexia, burns and surgery. This basic information is needed to calculate daily fluid requirements in patients on I.V. fluids.  In a normal person daily fluid requirement is the sum of urine output and insensible losses. In normal person daily insensible loss is 700ml. So daily fluid requirement = urine output + 700ml. After water distribution, we will see distribution of electrolytes. Major cation is sodium in ECF and potassium and magnesium in ICF, while major anion is chloride in ECF and phosphate, sulphate and proteins in ICF.

The electrolyte concentration of body fluids (mEq/L) Electrolytes (mEq/L) ECF (mEq/L) Sodium Potassium Chloride Bicarbonate Calcium Magnesium Phosphate & sulphate 142 4.3 104 24 5 3 8 ICF 10 150 2 6 0.01 40 150

Fluids :
 Fluid intake :  Fluid intake is derived from two sources : exogenous; and endogenous.  Exogenous water is either drunk or ingested in solid food. The quantities vary within wide limits, but average 223L/day, of which nearly half is contained in solid food.  Endogenous water is released during the oxidation of ingested food; the amt is normally less than 500ml/day. However, during starvation, this amt is supplemented by water released from the breakdown of tissues.

 Fluid output :  Water is lost from the body by 4 routes viz :  By the lungs About 400ml of water is lost in expired air per day. In a dry atmosphere, and when the respiratory rate is increased, the loss is correspondingly greater(as found in tracheal intubation).  By the skin When the body becomes overheated, there is visible perspiration, but throughout life invisible perspiration is always occurring. The cutaneous fluid loss varies within wide limits in accordance with atmospheric temperature and humidity, muscular activity and body temperature. In a temperate climate the average loss is between 600ml and 1000ml/day.  Faeces Between 60 and 150ml of water are lost by this route daily. In diarrhea this amt is greatly multiplied.

 Urine The output of urine is under the control of multiple influences, such as blood volume, hormonal and nervous influences, among which the antidiuretic hormone plays a major role controlling tonicity of the body fluids, a function that it performs by stimulating the reabsorption of water from the renal tubules. The normal urinary output is approximately 1500ml/day, and provided that the kidneys are healthy, the specific gravity of the urine bears a direct relationship to the volume. A minimum urinary output of approximately 400ml/day is required to excrete the end products of protein metabolism.

Water imbalance :
 Water depletion :  Pure water depletion is usually due to diminished intake. This may be due to lack of availability, difficulty or inability to swallow because of painful conditions of the mouth and pharynx, or obstruction in the oesophagus. Exhaustion and oesophagus. paresis of the pharyngeal muscles will produce a similar picture. Pure water depletion may also follow the increased loss from the lungs after tracheostomy. This loss may be tracheostomy. as much as 500ml in excess of the normal insensible loss. After tracheostomy, humidification of the inspired air is an tracheostomy, important preventive measure.

 Clinical features :  The main symptoms are weakness and intense thirst. The urinary output is diminished and its specific gravity increased. The increased serum osmotic pressure causes water to leave the cells (intracellular dehydration), and thus delays the onset of overt compensated hypovolemia. hypovolemia.

 Water intoxication :  This can occur when excessive amts of water, low sodium or hypotonic solutions are taken or given by any route. The commonest cause on surgical wards is the overprescribing of IV 5% dextrose solutions to post operative patiens. patiens.  Similarly, water intoxication can occur if the body retains water in excess to plasma solutes. This can be seen in SIADH secretion which is most commonly associated with lung conditions such as lobar pneumonia, empyema and Oat cell Ca of bronchus, as well as head injury.

 Clinical features:  Drowsiness, weakness, sometimes convulsions and coma. Nausea, vomiting of clear fluid are common. Lab. invstn. may show a falling hematocrit, serum sodium invstn. hematocrit, and electrolyte concentrations.  Treatment :  Water is to be restricted. The administration of diuretics or hypertonic saline should not be undertaken lightly as rapid changes in serum sodium concentration may result in neuronal demyelination and a fatal outcome.

Electrolyte balance :
 Sodium balance :  Sodium is principal cation content of ECF. The total body sodium amounts to approximately 5000mmol, of which 44% is in ECF, 9% in the ICF and the remaining 47% in bone.  Na, with its equivalent anions, accounts for about 90% of the osmotic pr. of the plasma. The serum Na value is normally b/w 137 & 147 mmol/L. mmol/L.  Thus there is a large storehouse ready to compensate abnormal loss from the body.  Daily intake of sodium is 1mmol/kg NaCl or 500ml of isotonic 0.9% saline soln. An equivalent amount is excreted daily, mainly in the urine and some in the faeces. faeces. The loss in perspiration normally is negligible; however people not acclimatized to tropical heat may have considerable loss of sodium as much as 85mmol/hr. If water alone is given to counter balance the fluid loss, serious sodium depletion can occur from excessive sweating.

Factors controlling the balance :

 Control by adrenal corticoids : The output of sodium, governed by the variation in the avidity with which the renal tubules reabsorb sodium excreted from the glomerular filtrate and the amt of Na excreted by the sweat glands, is under the control of adrenal corticoids, the most powerful conservator of Na being aldosterone. aldosterone.  The Na excretion shut down in trauma : Following trauma/surgery there is a variable period of reduced excretion of Na. For this reason it may be inadvisable to administer large quantities of isotonic (0.9%) saline solution after an operation. This period of Na excretion shut down can last for upto 48hrs & is due to increased adrenocortical activity.

 Sodium depletion (hyponatreamia) : (hyponatreamia)  Causes : Small bowel obstruction, vomiting, aspiration. Severe diarrhoea due to dysentery, cholera, UC (alongwith acidosis).  C/f : It is mainly due to extracellular dehydration.  Sunken eyes, drawn face, coated & dry tongue in advanced cases it is brown in colour, thirst is absent. colour,  Dry & wrinkled skin ----- pat. looks aged.  Sub cut. tissue feels lax.  Art blood pr is likely to be below normal.  Scanty dark colour urine of high specific gravity.

 T/t :  It must be individualized considering the etiology, the rate of development (acute vs chronic), severity & clinical signs & symptoms.  Dictum : Na, which develops quickly should be treated rapidly, whereas, which develops slowly should be corrected slowly.  Goal of therapy : To raise the plasma Na conc. at a safe rate. To replace Na deficit or K deficit or both. To correct underlying etiology.  In general Na is corrected acutely by giving Na to pats. who are vol. depleted and by restricting water intake in pats. who are normovolemic & oedematous. oedematous.

 Specific t/t :  Removal of the drugs responsible for it, like diuretics, clorpropamide, i.v. cyclophosphamide. clorpropamide, i.v. cyclophosphamide.  Management of physical stress, P.O. pain.  Specific t/t for adrenal insufficiency, hypothyroidism, uncontrolled diabetes & ketoacidosis. ketoacidosis.

   

Hypernatraemia : Causes : Excess water loss : heat exposure, severe burns, severe exercise, pat. on mechanical ventilator. Water deficit due to impaired thirst : comatose pat. Na retention : excessive I/V hypertonic NaCl. NaCl.

 C/f : slight puffiness of the face is the only early sign.  Pitting oedema should be sought, esp. in the sacral region.  But for pitting oedema to be present at least 4.5L of excess fluid must have accumulated in tissue spaces.  C/f is mainly neurological, this is the only state in which dry sticky mucous membrane is characteristic & body temp is generally elevated. Major neurological symptoms include nausea, ms weakness, altered mental status, neuromuscular irritability, focal neurological deficit and occasionally coma or seizures.

 T/t :  Therapeutic goals are :  To stop ongoing fluid loss by treating the underlying causes.  To correct water deficit.  Two important factors to decide t/t plan are : ECF vol. status rate of development of Na. The imp t/t aspects are :  To diagnose and treat specific etiology.  Rate of correction : in acute Na the water deficit can be replaced relatively rapidly, without increasing the risk of cerebral oedema. In acute Na targeted rate of correction oedema. of Na is 1mEq/L/hr. Rapid correction of chr. Na is chr. dangerous. It may lead to cerebral oedema. oedema.  Goal of treatment : the goal is to reduce serum Na conc to 145mEq/L.  T/t of Na is water, safest route of administration of water is by mouth or via a nasogastric tube.

 Potassium balance :  K is almost entirely intracellular, only 2% is present in ECF. th of the total body K (approx 3500mmol) is found in skeletal ms. When the body needs endogenous protein as a source of energy, K as well as nitrogen is mobilized.  The normal range of K is 3.5 5mmol/L. K deficiency is present, if the serum K value is less than 3.5mmol/L.  Each day a normal adult ingests approx 1mmol/kg of K in food; Fruit, milk & honey are rich in this cation. cation.

 K:  Following trauma, including operation trauma, there is a spell, varying directly with the degree tissue damage, of increased excretion by the kidneys. So great are the bodys reserves of K that, unless the pat was severely depleted at the time of the operation, K may not reveal itself for 48hrs. However, K is such a key IC cation that carefully monitored replacement should start early in the P.O period in all pats, with the exception of those that have evidence of renal dysfunction.

 C/f :  Listlessness and slurred speech, muscular hypotonia, hypotonia, depressed reflexes and abdominal distension as a result of paralytic ileus. ileus.  Weakness of the respiratory ms may result in rapid, shallow, gasping respirations; these are conducive to PO pulmonary complications. The diagnosis is supported by ECG, which may show a prolonged QT interval, depression of the ST segment and flattening or inversion of the TTwave.

 T/t :  Oral K : It can be given in the form of milk, meat extracts, fruit juices and honey. Potassium chloride 2g can be given per mouth 6hrly.  I/V K : Rapid intravenous supplementation carries the risk of dysrrhythmias and cardiac arrest if the serum conc. rises to a dangerous level.  When theres no associated alkalosis, the K deficit can be restored by adding 40mmol KCl to each litre of 5% D, 0.9% saline soln., which is given 6-8 6hrly. hrly.

 K:  Causes :  intake : - I/V fluid containing K - high K containing foods. - K containing drugs.  Tissue breakdown : Bleeding into the soft tissue, GI tract or body cavities. Hemolysis, rhabdomyolysis. Hemolysis, rhabdomyolysis.  Shift of K out of the cell : tissue damage, severe exercise, uncontrolled DM  Impaired excretion : ARF or CRF.

 C/f :

K is often asymptomatic until plasma K conc is above 6.5 7 mEq/L and may lead to fatal cardiac arrhythmia mEq/L hence it is called silent killer.  Vague muscular weakness, hyporeflexia, gradual hyporeflexia, paralysis affecting initially legs, then trunk and arms, and at last face & respiratory muscles & later on ultimately cardiac arrest and death occurs.  T/t : Principle for the treatment of K : Antagonism of membrane effects : Inj. Calcium gluconate. gluconate. K movt. into the cells : insulin & glucose, 2 agonist : movt. salbutamol. salbutamol. Removal of K from the body : cation exchange resin, hemodialysis or peritoneal dialysis, loop or thiazide diuretics.


 Calcium :  Ca is an EC cation with a plasma conc. of 2.2 2.5mmol/L. It exists in 3 forms : bound to protein, free non-ionised, free non-ionised, ionized the last form being the component necessary for blood coagulation & affecting neuromuscular excitability. The ionized proportion falls with increasing pH; thus in respiratory alkalosis due to hyperventilation there may be tetany with an apparently normal total serum Ca level.  The serum level of Ca is under the control of : factors like vit. vit. D and phytic acid, parathormone & calcitonin. calcitonin.  The management of abnormal Ca blood levels depends, where possible, on removal of the cause, for e.g. removal of a parathyroid tumour or in the coagulation disorder due to massive transfusion of blood containing acid citrate dextrose, 10ml of 10% of Ca gluconate may be injected slowly intravenously.

 Magnesium : Mg is an IC cation which shares some of the properties of K & some of Ca. The normal Mg conc. is 0.7 0.9mmol/L. The avg. daily intake is approx. 10mmol. Mg deficiency occur due very prolonged administration of I/V fluids without Mg supplements.  The clinical picture of Mg def. is marked by CNS irritability, ECG changes, lowered BP and lowered protein synthesis. P.O. cardiac arrythmias are commonly associated with both K & Mg.  T/t : For the t/t of mild Mg 20mmol as MgSO4 can be added to 5% D or NS over 24 hr period.

 Acid base balance :  In health, the blood H+ ion conc. lies within range pH 7.36 7.44. In acidosis, theres accumulation of acid or a loss of a base causing a fall in pH. The pH of the blood is regulated & controlled by various buffering systems, of which the most important is the HCO3 - : H2CO3 ratio. It is also regulated by the removal of CO2 by the lungs and by the excretion of both acids & bases by the kidneys.  The ratio of HCO3 - : H2CO3 is normally 20:1. A decrease in the ratio leads to increased acidity and vice versa.  The bicarbonate level can be altered by metabolic factors, while the carbonic acid level is subject to alteration by respiratory factors.

 Measurement of acid base disturbances :  These measurements are normally made on arterial or arterial capillary blood. pCO2 is a measurement of the tension or partial pressure of carbon dioxide in the blood. The normal arterial pCO2 is 4.1 5.6 kPa (31 42 mmHg). pO2 is a measurement of the tension or partial pressure of oxygen in blood. The normal value is 10.5 14.5 kPa (80 110 mmHg).  Standard bicarbonate is the conc. of the serum bicarbonate after fully oygeneted blood has been equilibrated with CO2 at 40mmHg at 38 C. This eliminates respiratory causes & respiratory compensation for altered bicarbonate levels. Normal levels are 22 25 mmol/L. mmol/L.

 Alkalosis :  Metabolic alkalosis : Metabolic alkalosis, a condn. of base excess or a deficit of condn. any acid other than H2CO3, can be caused by: Excessive ingestion of absorbable alkali. Loss of acid from stomach by repeated vomiting or aspiration. Cortisone excess  Compensation is effected by : retention of CO2 by lungs; and excretion of bicarbonate base by kidneys.  C/f : Most striking feature is Cheyne Stokes respiration with period of apnoea lasting from 5 to 30s. Tetany sometimes occur. Severe alkalosis may result in renal epithelial damage and consequent renal insufficiency.

 T/t :  Metabolic alkalosis without hypokalemia seldom requires direct treatment. The cause of the alkalosis should be removed where possible and a high urinary output is encouraged.

 Hypokalemic alkalosis :  Hypokalemic alkalosis is seen in patients who have lost K and acid owing to repeated vomiting (from P. stenosis). stenosis). The low serum K causes K to leave the cell and be replaced by Na+ & H+ ions. The shift of H+ ion into the cell causes IC acidosis and increases the cellular acidosis of the kidney cells.  T/t : When hypokalemia is sufficient to cause a metabolic alkalosis, the losses can be massive (>1000 mmol). mmol). Replacement is a serious undertaking. It can be achieved gradually and relatively safely by supplementing I/V fluids with 40mmol/L of KCl if the urine output is adequate. More rapid replacement will require intensive monitoring & supervision with continuous ECG monitoring in a high dependency or ICU.

 Respiratory alkalosis :  Causes : excessive pulmonary ventilation in anaesthesised pat. which is accompanied by pallor and fall in BP, hyperventilation occasioned by high altitudes, hyperpyrexia, a lesion of the hypothalamus & hysteria.  T/t :  Respiratory suppression due to alkalosis is rectified by insufflation of CO2.

Acidosis
 Metabolic acidosis :  Metabolic acidosis, a condition where there is a deficit of base or an excess of any acid other than H2CO3, occurs as a result of :  Increase in fixed acids due to formation of ketone bodies as in DM or starvation, the retention of metabolites in renal insufficiency.  Loss of bases such as occurs in sustained diarrhea, UC, gastrocolic fistula, or prolonged intestinal aspiration.

 C/f :  Rapid deep noisy breathing.  The hyperpnoea is due to over stimulation of the respiratory centre by the reduction in pH of the blood, and the physiological purpose of overbreathing is to eliminate as much as possible of the acid substance.  T/t :  The commonest cause of an acute preoperative metabolic acidosis is tissue hypoxia and the correct t/t is restoration of adequate tissue perfusion.  The acute acidosis seen in prolonged cardiac arrest may require the infusion of 50mmol of 8.4% NaHCO3 soln.

 Respiratory acidosis : Respiratory acidosis, a condition where the pCO2 is above the normal range, is caused by impaired alveolar ventilation. Most commonly occurs when theres inadequate ventilation of the anaesthesised pat., or when the effects of MRs have not worn off or been fully reversed at the end of the anaesthetic. anaesthetic. Theres also a risk of respiratory acidosis when the pat. undergoing surgery already has pre existing pulmonary ds. ds.  The anion gap This is a calculated estimation of the undetermined or unmeasured anions in blood.  Anion gap = (Na + K) (HCO3 + Cl) Cl)  The normal anion gap is 10 to 16mmol/L.  The increased anion gap is seen in metabolic acidosis due to ketoacidosis, lactic acidosis, poisoning and renal failure. ketoacidosis,

 Fluid therapy in surgical patients :  Fluid and electrolyte management is an imp. aspect for the care of surgical patients.  Proper fluid and electrolyte state is helpful in reducing morbidity and mortality in certain surgical patients.

 Q. Why fluid therapy in surgical patients needs special consideration?  A. In surgical patients, multiple factors modify the normal physiology of fluid and electrolyte balance of body and, therefore, need special consideration. Important factors to be considered are :  Acute stress : physical and mental stress which occurs before, during and after surgery leads to sympathetic stimuli, which leads to tachycardia, vasoconstriction, and stress.

 In surgical patients secretion of ACTH is increased. Increased ACTH stimulates adrenal glands to secrete hydrocortisone to fight with acute stress and aldosterone which leads to Na retention and urinary loss of K.  During major surgery hypovolemia also leads to increased aldosterone secretion. This increased secretion for the first 2 3 P.O. days leads to decreased Na requirements. This should be kept in mind.

 P.O. pain and stress leads to increased ADH secretion from posterior pituitary gland in first 2 3 P.O. days. Ultimately leads to decreased urine output. Therefore, it is imp. to remember that maintenance fluid required on the 1st P.O. day is lesser.  Fluid deficit, which occurs due to preoperative oral fluid restriction (NPO), needs consideration and replacement pre or intra operatively.  Abnormal blood as well as fluid loss which occurs before, during and after various surgery needs proper attention and careful calculation to decide type, volume and rate of fluid to be infused.

 Pat. who is hypovolemic prior to surgery is very likely to become hypotensive during surgery and anaesthesia. anaesthesia. Hence hypovolemia should preferably be corrected prior to surgery.  Surgical stress or direct damage can affect kidney, brain, lung, skin or GI tract. These organs are very useful in maintaining normal fluid, electrolytes and acid base balance. So fluid therapy in such surgical pats. needs special consideration.  Fluid therapy in surgical pats. can be discussed under 3 headings :  Pre operative  Intra operative  Post operative

 Preoperative fluid therapy :  Preoperative evaluation and correction of existing fluid and electrolytes disorder is very imp. for better outcome in surgical pats.  It can be discussed under 3 headings :  Correction of hypovolemia  Correction of anaemia  Correction of other disorders.

 Correction of hypovolemia :  Q. Why to correct hypovolemia preoperatively ?  A. Any degree of hypovolemia jeopardizes O2 transport and increases the risk of tissue hypoxia and the development of organ failure.  Causes :  Vomiting, NG suction, blood loss, third space loss, fever, hyperventilation, diuretic therapy, diarrhoea or preoperative bowel preparation.

 Q. How to decide the vol. of fluid deficit pre operatively ?  A. It is impossible to decide the fluid deficit exactly, but roughly it can be  Mild dehydration = 4% body wt. fluid deficit.  Moderate = 6 8% body wt. fluid deficit.  Severe = 10% body wt. fluid deficit.  The fluid of choice :  Depending on nature of loss, hemodynamic status and conc. abnormality.  It can be 0.9% saline, Ringers lactate, colloids and whole blood.

 Q. How to monitor fluid therapy ?  A. Improvement in tachycardia and BP, absence of orthostatic hypotension and achieving urine output > 30 50 ml/hr suggest correction of fluid deficit.  Correction of anaemia :  Q. Why to correct anaemia in surgical pats. ? A. Correction is imp. :  To establish haemodynamic stability in surgical pat. with blood loss.  For proper tissue oxygenation in intra & post operative period.  To cope up with possible operative blood loss.  For early recovery and quick healing.

 Q. When to correct anaemia ?  A. In elective surgery correction of anaemia by blood transfusion should be done 48 to 72 hrs prior to surgery.  Q. How to correct anaemia ?  A. Packed cell is always preferred to correct anaemia, as it anaemia, avoids vol. overload. If whole blood needs to be given, it is safer to give slowly and along with diuretics.

 Intraoperative fluid therapy :  Proper fluid therapy intraoperatively will avoid hypovolemia and hypotension. It also maintains proper tissue perfusion and oxygenation.  Important causes where we need intraoperative fluid therapy are loss of blood, fluid depletion, third space losses, evaporative losses from viscera or wound itself, hypoxia, vasodilatory effect of anaesthetic agents.  Q. Which fluid to give crystalloid or colloid ?  A. Its a matter of dispute.  For rapid restoration of haemodynamic function a colloid does the job more effectively than a crystalloid.

 Crystalloid :  Advantage :  Most commonly used agent because it is least expensive, readily available and reaction free.  Disadvantage :  Since it passes readily through semipermeable membrane, it cannot remain confined to the intravascular compartment so it has short lived heamodynamic improvement effect. Larger vol. of crystalloid is needed for correction of hypotension, which can leads to excess salt and water retention leading to peripheral and pulmonary oedema. If oedema. the goal is to replenish the interstitial dehydration, then crystalloid will be t/t of choice.

 Q. Which I/V fluid should be given intra operatively?  A. Ringers lactate is most widely used fluid, but the selection needs to be individualized depending upon age, vital data, basic etiology and type of surgery required, associated illness and current fluid and electrolyte status.

 Basic guidelines for selection are :  Ringers lactate is used to replace the intraoperative fluid losses. Since it is the most physiological fluid having composition similar to body fluid.  Isotonic saline is used where Ringers lactate is contraindicated or when large vol. of fluid needs to be replaced rapidly i.e. hypovolemic shock.  5D is used as initial fluid replacement, which replaces insensible fluid loss and maintenance fluid deficit during starvation.

 Colloids :  Intraoperative colloids are used selectively when rapid restoration of plasma vol. is needed to correct severe acute hypotension.  Advantages :  It never cross semipermeable membrane and remain in the intravascular compartment. So more effective than crystalloid in treating hypotension.  Increase in the plasma vol. is for prolonged period as compared to crystalloid.  Smaller vol. of colloids improve the haemodynamic status. Avoid excessive salt and water administration, thereby reducing chances of peripheral oedema. oedema.  Better haemodynamic stability so higher systemic oxygen delivery indirectly.

Disadvantages : Much more expensive than crystalloid. Rapid and larger infusion can cause pulmonary oedema. oedema. Higher risk for hypersensitivity reaction and bleeding (esp. with dextran). dextran).  Glomerular filtration is reduced, so increase accumulation of nitrogenous end product.
     Indications :  These are used to treat sudden hypotension due major blood loss till blood is awaited.  Precaution :  Before infusing sample for blood grouping and cross matching should be collected.

 Colloids available :  Albumin 5% or 25% : Very effective in increasing intravascular vol. depletion secondary to blood loss.  Dextran 40% : Effective but expensive plasma expander. Contraindicated in pat with bleeding disorders or severe cardiac or renal failure.  Gelatin polymer : It is a purified protein of animal collagen origin.  Hetastarch : It is a synthetic colloid derived from corn starch.  Plasma : It is the most physiological plasma expander.

Vol. of fluid replacement :

 Q. How much fluid to give ?  A. There is no fixed readymade formula, which can calculate fluid vol. in all pats. After consideration of all existing parameters fluid vol. is calculated for each pat. individually. Infusion of this fluid should be carried out under careful observation to avoid under or over hydration.  Apart from this, factors to be considered :  Age, weight, hydration status, vital data, preoperative and intraoperative urine output, cardiac and renal status and type of fluid to be replaced should be considered while calculating fluid vol.

 Guidelines for calculation :  In adult pats. with no preexisting fluid deficit, amt. of intraoperative vol. can be roughly calculated as below :  Correction of fluid deficit due to starvation.  Maintenance requirement for period of surgery.  Loss due to tissue dissection or haemorrhage

 Vol. to be replaced for starvation fluid deficit = duration of starvation in hrs. 2ml/ kg body weight. This deficit is usually replaced with 5%D. The deficit may be replaced by giving half of the calculated vol. in 1st hr & the other half over next 2hrs in addition to the intraoperative fluid replacement.  Maintenance vol. for intraoperative period = duration of surgery in hrs 2ml/kg body weight or rate of infusion = 2ml/kg body weight per hr.

 Usual fluid require to correct intraoperative fluid loss due to tissue dissection or haemorrhage depends on the type of surgery viz :  In Least surgical trauma no fluid vol. replacement needed.  In Minimal surgical trauma like in tonsillectomy, SMR or septoplasty, septoplasty, they should receive 4ml/kg/hr fluid replacement. In addition maintenance fluid requirement is 2ml/kg/hr.  In Moderate surgical trauma = 6ml/kg/hr fluid replacement is required.  In Severe surgical trauma like radical neck dissection, total hip replacement, pat should receive 10ml/kg/hr of fluid replacement plus 2ml/kg/hr maintenance fluid is required.

 Blood transfusion :  Intraoperative blood transfusion is often life saving and should be used judiciously.  Advantage :  It is the most physiological way to replace blood loss. As blood remains entirely in intravascular compartment, it is the best agent to correct hypotension secondary to blood loss. Blood transfusion has added advantage to ensure adequate tissue oxygen delivery.  Disadvantage :  Not readily available and needs time for cross matching , it has definite risk of transmitting infections like hepatitis, AIDS, malaria, etc.

 Q. How to decide need of blood transfusion ?  A. Factors to be considered for intraoperative blood transfusion are :  Preoperative Hb% - in normal adult pat. oxygen carrying Hb% capacity is unaffected till it is as low as 8gm% & hematocrit 25%, provided there is no hypovolemia. hypovolemia.  % loss of blood vol.  Others : vital data hypotensive pat needs blood transfusion even with lesser blood loss.  Hydration status : hypovolemic pat. needs BT.  Age : young adults tolerate blood loss better than old pat.  Pat with IHD needs greater Hb for proper oxygenation

 Q. When not to give BT ?  A. It is unnecessary to replace blood loss of less than 500ml in adult with normal preoperative Hb or loss of 10% of estimated blood vol. is well tolerated. Such losses is replaced by RL or NS.  As a rule blood loss needs to be replaced with 3times vol. of crystalloids.  Q. When to give BT intraoperatively ?  A. Blood loss >20% of blood vol. needs BT, without considering preoperative Hb status.  One unit of BT needed when blood loss is within 0.5L to 1L, BT is necessary if Hb is likely to fall below 8gm% after blood loss.

Post operative fluid therapy :

 The administration of fluid and electrolytes during the P.O. period depends upon the clinical judgement of the patients status.  Goal of fluid therapy :  The aim is to maintain reasonable BP >100/70 mmHg, pulse rate less than 120beats/min and an hourly urine flow b/w 30 and 50ml with normal body temp., warm skin, normal respiration and sensorium. sensorium.

 Q. What factors should be consider before writing P.O. I/V fluid ?  A. Following points to be consider :  Age, weight, vital data, hydration status and urine output.  Preoperative diagnosis, nature of surgery and blood loss.  Nature and vol. of fluid and blood replaced intraoperatively. intraoperatively.  Drain output, nasogastric adpiration, fluid lost at injury site adpiration, or operative site.  Renal status, associated illness and associated electrolyte and acid base disorders.  Loss due to atmospheric temp., pyrexia, hyperventilation.

 Q. What are the routine P.O. orders of I/V fluid for first 3 days ?  A. Usual prescription of P.O. I/V fluid in NPO pats. is : For 1st 24 hrs of surgery : 2L 5%D or 1.5 L 5%D + 0.5L isotonic saline.  2nd P.O. day : 2L of 5%D + 1L of NS  3rd P.O. day : similar fluid + 40 60 mEq K /day.

 Q. Why usually K is avoided in I/V fluids for first 2 PO days ? A. It is avoided because :  Pats may have oliguria or azotemia. So till urine output is azotemia. established and normal renal status is ensured, K supplementation can be risky.  PO tissue trauma may release K from IC to EC compartment, which may cause K.  Intraoperative or post operative transfusion of stored blood or haemolysed blood may add large amt. of K.  PO metabolic acidosis will shift IC K to extracellularly. extracellularly.  As body has large store of K intracellularly K will not occur.

 Q. How long to infuse I/V fluid Post operatively?  A. It is a wrong method to infuse total I/V fluids within 8 to 12 hrs in PO period and not giving any infusion in rest of the period. Maintenance fluids should be administered at a steady rate over an 18 to 24 hr period. If given over a short period, renal excretion of the excess salt and water may occur. But as the normal losses continue over the full 24 hr period, body will be deprived of their fluid need during the remaining period.  Q. Which fluids should be given to replace additional losses in PO pats. ? A. For prolonged vomiting and nasogastric suction : fluid of choice is NS.  For blood loss : if vol is less, replacement is done with 3 times vol of isotonic saline or RL, but if the loss is greater, we have to think about BT.

Thank you