DR. PRAMILA BAJAJ

1
Perioperative Fluid Management
DR. PRAMILA BAJAJ SR.
PROF. HEAD DEPTT. OF ANAESTHESIA, ADDITIONAL
PRINCIPAL, RNT MEDICAL COLLEGE, UDAIPUR (RAJ.)
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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Perioperative Fluid Management

• Fluid electrolyte management paramount in
  surgical patient.
• Change in Fluid (Fl.) Electrolyte (El.)
  Composition
• Pre.op
• Post op.
• In response to trauma and sepsis

3
Distribution of Body Fluids

• Helps us understand the subject.
• Total body water 50-60 of total body weight.
• Relationship constant for an individual
  reflection of body fat.

4
Distribution of Body Fluids

• Water in muscle solid organs gt Water in fat
  bones ? young, lean adults greater of TBW
  than elderly / obese.
• Av. young adult male 60 water of TBWt
• Av. young adult female 50 water of TBWt,
  b/c of high adipose / fat.
• Estimates of TBW ? Up by 10 in malnourished
• Down by 10-20 in obese.
• New born infants 80 water of TBW ? Decreased
  to 65 by 1 year, then constant.

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Fluid Compartments

• Total Body Water - Extracellular Fluid (20)
• Intracellular Fluid (40),
• TBW ECF ICF

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Normal Water Balance

• How body maintains its water volume?
• Kidneys A major role.
• Oral / iv fluids urine output Important
  parameters of body fluid balance.

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• Insensible fluid input 300 ml water due to
  oxidation
• insensible fluid loss 500 ml through
  skin (400 ml through lung 100 ml through
  stool)
• Fluid loss Fluid input 1000 300 ml 700 ml
• Insensible loss ? in Fever, Hypermetabolism,
  Hyperventilation
• Sweating Active process Loss of electrolytes
  water
• 1. Moderate sweating 500 ml
• 2. Severe Sweating
• High fever
• 3. Burns
• Abd. Surgery

1000 1500 ml
500-3000 ml
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Normal Water Balance

• Kidney must excrete about 500-800 ml urine / day
  (irresp. of oral intake)
• Daily Sodium intake 3-5 gm/d.
• Balanced achieved by kidneys
• In hyponatremia Salt excreted lt1 mEq/d
• In Salt wasting kidneys gt5000 mEq/d.

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Composition of Fluid Compartments
ECF compartment Balance between
electrolytes ECF ICF Principal Cation
Na K, Mg2 Principal Anion Cl-
HCO3- Phosphate Prot. ATP driven Na K
Pump ECF ICF Conc. grad.
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Imp. Points to Remember

1. Proteins important contributors to Osmolality
2. Movement of water across compart. is free but
   that of proteins and ions restricted.
3. Even distribution of water in all compartments.
4. Sodium confined to ECF because of osmotic
   eIectrolyte properties
5. Sodium containing fluids ? distributed in ECF ?
   ?Vol. of IV and interstitial sp. as much as 3
   times of plasma.

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Definitions

• What is Osmotic pressure?- Movement of water
  across C.M. depending primarily upon osmosis.
• - Determines distribution of water among
  different fluid compartment. (ICF ECF)
• generated by solution proportional to no. of
  particles / unit volume of solvent.
• does not depend upon type, valence and weight of
  the particles
• To generate O.P. ? Solute must be unable to cross
  C.M.
• Unit ? osmoles (osm) or milliosmoles (mosm).
• E.g.. One mmol of Nacl ? 2mosm (one each from
  Na Cl-)

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Define Osmolality, Effective Osmolality
Osmolarity

• 2. Osmolality
• Determined by amt. of solute diss. in a solvent
  (water) measured in wt (kg)
• Determinants Conc. of sodium, glucose, urea
  (BUN)
• Calculation
• Serum osmolality 2Na Glucose BUN
• 18 2.8
• Osmolality of ECF and ICF b/w 290-310 Osm in each
  compartment

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• 3. Effective Osmolality
• Determined by solutes which do not freely
  permeate cell wall and hold water within ECF
• Effective Osmolality 2xNa (mEq/L) Glucose
  (mg/dl)/18
• Glucose accounts for only 5 mOsm/kg in effective
  osmolality. ? plasma Na concentration is the
  determinant of the plasma osmolality.
• 4. Osmolarity Determined by amt. of solute
  dissolved in a solvent (water) measured in vol.
  (litre).
• Concentration of solution of a solute diss. in 1
  litre of solvent is expressed as mOsm/L.

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• Concentration of Electrolytes Expressed in
  terms of chemical combining activity or
  equivalents.
• Univalent ion (Sodium) 1 Meq 1 Mmol
• Bivalent ion (Mg) 2 Meq 1 Mmol

Equivalent of an ion Atomic Weight (gm)
Equivalent of an ion Valence
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Paediatric Surgery
How are infants and children different from
adults?

• Fluid Management A critical element in paed.
  surgery b/c infants children sensitive to even
  small degree of dehydration ?Higher requirement
  for water electrolytes / KgBw.
• Inability to excrete water load due to immature
  kidneys ? Overload.
• Complex surgical procedures ?Rapid change in
  fluid requirement ?Frequent assessment and
  modification of fluid therapy.

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Paediatric Surgery

• In O.T. rapid change in req. during
• - Conduct of Anaesth. Surg.
• - Change in temperature
• - Metabolism vol. shift (due to trauma,
  hemorrhage, tissue exposure) ? Intracompartmental
  fluid shift
• Requires fluid replacement with sol. to
  compensate for energy, water, protein
  electrolyte losses.
• Anaesthetist Alert for - obvious fluid loss
• - Hidden fluid loss (insensible loss)
• - Third Space loss

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Physiological Considerations

• Proportion of ECF/ICF change with age.
• Body cells, surrounding fluid in electrical
  equilibrium
• TBW Vol. Fluid exchange rate vary
• with age.

• Before birth, nutrition demands met through
  placental transfer. NFT infant - enough fluid
  reserve to last till full oral breast feed.

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Physiological Considerations ..
TBW Fat
28 wk (1kg) 80 1
Term 70-75 17 ECF (30-40 of TBW) ? gradual shift
3 mths (6kg) 70 30 Further ? in ICF ECFltICF
1 Year 60 ECF ? to 27
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Immature Infants Higher of TBW and ECF Total
blood volume of a newborn infant 8.5 of B.W.
ECF

Intravascular Plasma Vol. Together contribute Interstitial Fluid Vol.

Functional Extracellular Fluid Vol. FEFV
ECF also includes III space / transcellular fluid which is physiologically non-functional ECF also includes III space / transcellular fluid which is physiologically non-functional ECF also includes III space / transcellular fluid which is physiologically non-functional
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Interstitial Space

• fluid filtered
• High cir. vol. Vas. Comp. ??? interstitial sp.
  (reservoir)
• fluid filtered
• Low cir. vol. Interstitial sp. ??? Vas. comp.
  ? buildup
• circulatory vol.
• Adolescence FEFV 27-30 Inter. space vol.
  Plasma vol.
• 20 7-10
• Full term infant FEFV 45

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What is the importance of transcellular (III Sp.)
fluid?

• Non functional extracellular fluid
• Unavailable pool of water ? formed by
  transudation from cells and EC space
• E.g. Fluid within GIT formed during-
• Int. Obst.
• Ascitis
• Urine
• Pleural effusion
• Fluid in III space loss
• from FEFV
• Fluid preferred for replacement Ringer lactate

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Intracellular Fluid

• Isotonic Solution ? Cell Vol. constant due to
  free movement of water from within cells
• Hypotonic Solution ? Inward water movement ?
  Increased cell volume
• Intracellular fluid bound to protein
• Energy required for Potassium (inside cell)
  Sodium transport (outside cell).

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Describe the renal physiology in neonates.

• Postnatal shift in body fluid med. by Na and H2O
  excretion by immature kidneys.
• Sodium and water excretion by immature kidneys ?
  Postnatal Mediated by shift in body fluid
• Urine Vol. ? 1st day 0-68 ml
• 7th day 40-300 ml
• At birth GFR 25 of adult rate (20 ml min-1
  1.73m-2)
• Rapid ? in 2 wks slower ? to adult rate by 2 yrs
  of age
• Infants can handle twice the (N) vol. load b/c
  -ve effects of low GFR compensated by ve effects
  of low concentrating high diluting capacity
• Add conc. capacity of infant well below adult.

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Renal Physiology in Neonates .

• Concentrating capacity (Max. osmolality 500-600
  
• (well below adults) Osm/kg) in response to
  water
• Adult (1200 mOsm/ kg)
• Diluting capacity low in dehydrated infants
• If water loaded ? diluting capacity well above
  adults (Osmolality 30-50 mOsm/kg)
• Fasting newborn (72 hours) ? Minimum elevation of
  BUN Na. (Loss of BW 13).
• 8 decrease in BW Neg. N2 balance even when
  fluid given at 50ml/kg/day/ or unlimited amt. of
  breast milk.
• Milk feed ? Positive N2 balance weight gain
• Wilkinson et al. 1962, Lancet 1983

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Electrolyte Physiology

• Sodium Physiology Variable therefore inaccurate
  indicator of hydration.
• Daily requirement (Term infant) ? 2-5 meq kg-1
  day-1
• Term infants retain Sodium when in negative Na
  balance like adults.
• ? cap. to excrete Na when in positive balance.
• Ac. change in balance ? Gross variation in blood
  pressure, Intracerebral hemorrhage.
• PPV use of PEEP ? ?ed Natriuresis, ?ed
  vasopressin, ?ed water retention

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Daily Electrolyte Requirements for Paediatric
patients
Patients wt gt10 kg Patients wt lt10 kg
Sodium 20-150 meq 2-5 meq/ kg
Potassium 20-240 meq 2-4 meq/ kg
Acetate 20-120 meq -
Chloride 20-150 meq -
Calcium 5-20 meq 0.5-3 meq/ kg
Phosphorus 4-24 meq 0.5-1.5 meq/ kg
Magnesium 4-24 meq 0.25-1 meq/ kg
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What are the special features of CVS physiology
in infants?

• Immature myocardium S.N.S. ? Propensity to
  hypovolaemia greater in neonates / infants.
• Myocardial contractility vas. tone
  compliance ? less variable ? tachycardia ? Pri.
  comp. mech. during ? vol.
• Excess ? HR ? C.O. ?
• Anaesth. effect ? Further depression of myocard.
  ? Hypovolemia exaggerated ?maintenance of
  effective vas. vol. in paed. patient essential to
  sustain circulatory function and vital organ
  perfusion in peri-op. period.

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Hepatic Function

• Hepatic function immature
• Carbohydrate reserves accumulate in last TM of
  pregnancy limited stores in pre-term neonates.
• Most pre-term neonate Require 10 dextrose
  infusion to prevent hypoglycemia in early
  perinatal period.

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Hepatic Function .

• Clinically significant hypoglycemia
• Full term neonate lt 30 mgdl-1
• Pre term infant
• First 3 days ? lt 20 mgdl-1
• After 3rd day ? lt 40 mgdl-1
• Treatment Ac. hypoglycemia Bolus 0.5-1.0
  g/kg-1 iv glucose followed by infusion 5-6 mg
  kg-1 as maintenance infusion
• Monitor serial blood glucose.

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Hepatic Function .

• Response to surgical trauma ? Catechol.
• ? glucocort.
• ? blood glucose.
• Hypoglycemia - Unusual during preop. fasting in
  children
• - Uncommon during surgery.
• - Not easily recognized during anaesth.
• Dextrose in patient with prolonged fast prevents
  ketosis, ? protein catabolism post operatively.
• Continue glucose inf. commenced in OT until
  patient awake and oral intake established.

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What are the fluid management protocols in
infants ?

• Divided into 3 phases
• Deficit therapy
• Maintenance therapy
• Replacement therapy
• Deficit Therapy Management of fluid /
  electrolyte loss prior to surgery
• Three components
• Estimate Severity of dehydration
• Determine fluid deficit
• Repair the deficit

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Assessment of dehydration severity in neonates
infants
Signs Symptoms Mild Moderate Severe
Weight loss 3-5 6-9 gt10
General Condition Alert, restless Thirsty, lethargic Cold, sweaty, limp
Pulse N. rate, vol Rapid, weak Rapid, feeble
Respiration Normal Deep, rapid Deep, rapid
Ant. Fontanelle Normal Sunken Very Sunken
Systolic pressure Normal Normal or low Low, unrecordable
Skin turgor Normal Decreases Markedly ?
Eyes Normal Sunken, dry Grossly sunken
Mucus membrane Moist Dry Very dry
Urine output Adequate Less, dark Oliguria, anuria
Capillary refill Normal lt 2 sec gt 3 sec
Estimated deficit 30-50 mg/kg 60-90 ml/kg-1 100 ml/kg
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Fluid Management ..

• History, Clinical and Evaluation Important
• Confirmation by
• Serum osmolarity and serum sodium
• Acid-base status, Serum pH, Base deficit
• Serum Potassium compared with pH
• Urine Output To rule out ATN
• Hyponatremic Dehydration Serum Osmolarity
• lt270 m.Osmol-1
• Serum Na lt130mEq/L

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Fluid Management ..

• Isonatremic Dehydration Serum Osmolarity
• 270-300 m.Osmol-1
• Serum Na 130-150 mEq/L
• Hypernatremic Dehydration Serum Osmolarity
• gt310 m. Osmol-1
• Serum Na gt150 mEq/L
• Initiate treatment for deficit before
  investigation available
• Initiation with a bolus of NS over 10-12 min to
  improve circulation and restore renal perfusion

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Fluid Management ..

• Patient with known contraction alkalosis 50
  dextrose with 0.9 NS (Reasonable fluid of
  choice)
• Patient with known met. acidosis 250 ml of 0.9
  NS 28 ml of 7.5 Soda bicarbonate solution
  232 ml of 5 dextrose.
• This gives approx. Dextrose 1.2
• Sodium 149 mEq
• Chloride 115 mEq
• Sod. Bicarbonate 25 mEq

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Fluid Management ..

• Lactate / Acetate containing solution aggravate
  met. acidosis because of failure of formation of
  bicarbonate from its precursors due to poor
  circulation status.
• Febrile response to volume contraction Due to
  decrease in skin blood flow ? Decrease heat
  dissipation.
• Hyperosmolarity ? Increased threshold for
  sweating ? Increase calorie and fluid requirement

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Fluid Management ..

• Fluid deficit due to overnight fasting
• Advocated to prevent risk of pul. aspiration
  during anaesthesia
• Children ? residual gastric vol., ? pH Clear
  fluids allowed upto 2 hours before surgery.
• Sphinter W.M. 1990 Anaesth Intensive Care
  18522-526
• Sips of fluid ? peristalsis but no gastric
  secretion if protein absent.
• H2 blockers ? gastric pH, ? gastric vol.
• Sertherland AD et al. 87, Can J. Anaesth 34.
  117-121.

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Fluid Management ..

• Current recommendations
• Clear fluids 2 hours
• Milk 4 hours
• General Rule
• Preop. Fluid deficit Maint./hr. x Hrs of fluid
  restriction

Before Surgery
50 in 1 hour 25 each in next 2 hours
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Maintenance fluid requirements in neonates
infants Daily and hourly
Age (d) / Wt (Kgs) Requirements ml/kg-1 day-1 Hourly mlkg-1hr-1 Type of fluid
1 20-40 2-3 10 dextrose
2 40-60 3-4 10 dextrose in 0.22 saline
3 60-80 4-6 10 dextrose in 0.22 saline
4 80-100 6-8 5-10 dextrose in 0.22 saline
0-10 kgs 100 4 mlkg-1hr-1 5 dextrose in 0.45 saline
10-20 kgs 100050 mlkg-1 40 ml2 mlkg-1hr-1 5 dextrose in 0.45 saline
gt 20 kgs 150020 mlkg-1 60 ml1 mlkg-1hr-1 5 dextrose in 0.45 saline
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Composition of commonly used intravenous fluids
Electrolytes (meqL-1) NS Ringers lactate Isolyte P Plasmalyte A D5 Albumin 5 Hetastrach 6
Na 154 130 26 140 - 14515 154
K - 4 21 5 - lt2.5 -
Cl 154 109 21 98 - 100 154
Mg - - 3 - - - -
Acetate - - 24 27 - - -
Lactate - 28 - - - - -
Glucose (gm) - - 5 - 5 - -
Phosphate (mg) - - 3 - - - -
Osmolarity (mOsmL-1) 308 274 - 295 252 330 310
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Maintenance Fluid Therapy

• Meets ongoing fluid electrolyte demands during
  surg.
• Does not include blood loss / third space loss
  into gut or interstitial space.
• Maintenance Fluid covers
• - Insensible loss evaporative loss
• - Urinary loss
• Insensible loss ? Solute free loss of water
  through skin lungs, usually 30-35 of total
  maint. req.

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Maintenance Fluid Therapy

• Determinants of Insensible loss
• Ambient Temp. Humidity
• Gest. Age Resp. pattern
• Exposed surface area
• Ventilation with humidified gases ? ? insensible
  loss.
• In premature infants and patients with D.
  insipidus ? Obligatory production of dil. urine ?
  Appropriate ? in maintenance fluid required.
• In excess ADH secretion ? Patients unable to ?
  urine osmolality to 300 mOsm ?need to ? vol. of
  maint. fluid

Gastroschisis
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Intravenous fluid requirements in Infants Day 1
of life 2 ml/kg per hour Day 2 of life 3 ml/kg
per hour Day 3 of life 4 ml/kg per
hour Intravenous fluid requirements in
children lt10 Kg 10 ml/kg per day 10-20 Kg 1000 ml
(50 ml/kg per day for each kg over 10 kg) gt20
Kg 1500 ml (20 ml/kg per day for each kg over
20 kg) Wt. 10 12 14 16 18 20 30 mL/h 40 45 50 55 6
0 65 70
Surgical trauma Type of Surgery Fluid replacement
Minimal Inguinal hernia repair 1-2 mlkg-1hr-1
Moderate Ureteral implantation 4 mlkg-1hr-1
Severe Scoliosis, bowel obstruction gt 6 mlkg-1hr-1
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Replacement of blood loss

• In children, all blood loss should be replaced.
• Done with packed RBCs/whole blood/Crystalloid/
  Colloids
• Davenports law
• lt10 blood loss No blood req.
• 10-20 ? Consider case by case
• gt20 Consider packed RBCs/Whole blood
• Replacement Crystalloid 3 ml for each ml of
• blood loss
• Ensure adequate oxygenation
• Minimum hematocrit 30 older children
• 40 neonates acceptable

Sacrococcygeal Teratoma
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Intraoperative Fluid Management

• Responsibility of an anesthesiologist
• Sufficient fluid required to compensate for NBM
  hrs insensible loss during op.
• Loss considerable during major abdominal /
  thoracic surgery
• In most cases 10 ml/kg/hr of Ringer lactate in D5
  in water
• Blood loss Weighing sponges
• Suction bottle accumulation
• Actual loss more because of blood in drapes and
  op. field

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Intraoperative Fluid Management ..

• In a child with normal Hb pre-op. Whole blood /
  packed RBCs infusion if blood loss 10 of B.V.
• FFP/Albumin in extreme dissection without blood
  loss.
• Emergency Trauma / G.I. Bleed ? Continue
  Pre-op. resuscitation with rapid transfusion
  during op.
• Prolonged hours of op.
• ? Monitoring Urine Output
• ? Serum Electrolyte blood glucose
• ? Hematocrit and blood gases.

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• Post Op-Period
• - Optimum replacement and maintenance pre. and
  intraop. ? child in fluid and electrolyte balance
  postop.
• Immediate Post-Op.
• Drainage from chest tube/ intraperitoneal drains
  measured replaced with blood plasma
• GIT drainage collected ? Sample for electrolytes
  ? Measured vol. replaced at intervals of 4-12
  hours.
• Satisfactory oral intake 3-5 days in most cases.

48
Review of Finer Points

• Why fluid therapy needs special consideration in
  children?
• 1) Greater insensible loss
• 2) Greater urinary loss
• 3) Larger turn over
• 4) Inadequate expression of thirst
• 5) Easy fluid overload
• 6) Small total volume required
• 7) Diffusion volume and distribution of body
  water

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Disturbance in Fluid Balance in adults

• Extracellular vol. deficit Common fluid
  disorder in surgical patients.
• Acute deficit associated with CVS CNS signs.
• Chronic deficit ? in skin turgor and sunken
  eyes CVS CNS signs.

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Signs and Symptoms of Volume Disturbances
System Volume Deficit Volume Excess
Generalized Weight loss Decreased skin turgor Weight gain Peripheral edema
Cardiac Tachycardia Orthostasis/ hypotension Increased cardiac output Increased central venous pressure
Collapsed neck veins Distended neck veins Murmur
Renal Oliguria, Azotemia
Gastrointestinal Ileus Bowel edema
Pulmonary Pulmonary edema
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• Laboratory Exam
• Severe deficit ? ? BUN
• ? Hemoconcentration
• ? ? G.F.R.
• ? Urine osmolality gt Serum
  osmolality
• ? Urine Na lt 20 mEq/L.
• Na concentration does not reflect vol. deficit.

52
What are the common causes of vol. def. in
surgical patients?

• Loss of GIT fluid NG suction Peritonitis
• Vomiting Obstruction
• Diarrhoea
• Fistula
• Sequestration sec. to soft tissue injury
• Burn
• Prolonged surgery Intra-abdominal procedure

Intestinal Obstruction
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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
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Electrolyte Abnormalities

• Sodium
• Normal values 135 145 mEq / L
• Concentration Changes Changes in Serum Na
  inversely proportional to TBW

Hyponatremia ? (Excess of ECW)
Volume Status (ECV) ?
High ? Normal ? Low ?
? Intake Hyperglycemia ? Sodium intake
Postop ADH secretion ? Plasma lipids/ proteins Gastrointestinal losses
Drugs SIADH Renal losses
Water intoxication Diuretics
Diuretics Primary renal disease
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• Low Serum Sodium level - Na depletion
• - Dilution Intentional
• Iatrogenic
• To differentiate the Etiology Systemic review
  of the causes
• Exclude hyperosmolar causes (Hyperglycemia /
  Mannitol)
• Consider depletional / dilutional causes
• Extrarenal (GIT) loss Urine Na (lt20 mEq/L)
• Renal loss Urine Na (gt20 mEq/L)

56
How will you treat Hyponatremia?

• Most cases treated by free water restriction
• If severe Restrict Na
• Symptomatic Hyponatremia (lt 120 mEq/L)
• If neurological s/s present Give 3 NS
• ? Na level no more than 1 mEq/L/hour until Se.
  level 130 mEq/L or s/s improve.
• Asym. Hyponatremia ? Na level by no more than
  0.5 mEq/L to a max. of 12 mEq/L/day. slower in
  chr. states
• Rapid correction may cause PONTINE MYELINOLYSIS
  with seizures, weakness / paresis, akiness and
  unresponsiveness ? permanent brain damage death.

57
Hypernatremia (Loss of free water / gain of sodium) ? Hypernatremia (Loss of free water / gain of sodium) ? Hypernatremia (Loss of free water / gain of sodium) ?
Volume status ?
High ? Normal ? Low ?
Iatrogenic Na adm. Nonrenal water loss Nonrenal water loss
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Skin Skin
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Gastrointestinal Gastrointestinal
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Renal water loss Renal water loss
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Renal disease Renal disease
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Diuretics Osmotic diuretics
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Diabetes insipidus Diabetes insipidus
Mineralocorticoid excess Aldosteronism Cushings disease Congenital adrenal hyperplasia Adrenal failure
58

• Hypernatremia - Loss of free water
• gt145 mEq/L Gain of Na in excess of water
• How will you treat Hypernatremia?
• Hypernatremia Treat associated water deficit
• Hypovolemia Treat with normal saline, followed
  by Hypotonic fluid (D5 or D5 in ¼ NS) after
  restoration of adequate volume status.

Water deficit (L) Serum Na 140 X TBW
Water deficit (L) 140 X TBW
? in Se. Na no more than 1 mEq/h and 12
mEq/d. Chr. hypernatremia Sodium correction
(0.7 mEq/L/H) Overly rapid correction Cerebral
edema herniation Freq. neurological and Se. Na
assessment required.
59
Potassium Abnormalities

• Av. Dietary intake 50-100 mEq/d
• Flux of K influenced by Surgical stress
• Injury
• Acidosis
• Tissue Collection
• Extracellular K maintained by renal excretion
  (10-700 mEq/d)
• 2 of total K extracellular Critical to
  cardiac and neuromuscular function.

60
Hyperkalemia

• Serum K level above 5.0 mEq/L. (N) range 3.5
  5.0 mEq/L.

Hyperkalemia Increased intake Potassium
supplementation Blood transfusions Endogenous
load/destruction hemolysis, rhabomyolysis,
crush injury, gastrointestinal hemorrhage Increase
d release of K from cells. Acidosis Rapid rise
of extracellular osmolality (hyperglycemia or
mannitol) Impaired excretion by
kidney Potassium-sparing diuretics, ACE
inhibitors, NSAIDS Renal insufficiency / failure
61
What are the signs symptoms of hyperkalemia?

• GIT ? Nausea, Vomiting, Diarrhea
• Neuro-muscular ? Weakness
• Ascending paralysis
• Resp. failure
• CVS Cardiac arrhythmia
• ECG Peaked T wave (Early)
• Flattened P wave
• Prolonged PR interval
• Widened QRS
• Sine wave formation
• VF

62
How will you treat hyperkalemia?

• Potassium removal
• Kayexalate (cation exchange resin)
• Oral administration is 15-30 g in 50-100 mL of
  20 sorbitol
• Rectal administration is 50 g in 200 mL 20
  sorbitol
• Shift potassium
• Glucose 1 ampule of D50 and regular insulin 5-10
  units I.V.
• Bicarbonate 1 ampule I.V.
• Nebulized Albuterol (10-20 mg)

63
How would you treat hyperkalemia? .......

• Goal To decrease body K and shift K from
  extracellular to intracellular.
• Discontinue exogenous K intake (IV, enteral and
  parenteral solution)
• Circulatory overload / Hypernatremia may result
  from Kayexalate and bicarbonate.
• Ca. Gluconate (5-10 ml of 10) / Ca Chloride ? to
  counteract myocardial eff. of Hyperkalemia.
• May cause digitalis toxicity in patients on
  digitalis.
• Dialysis ? When conservative measures fail.

64
Hypokalemia

• Common in surgical patients
• K ? by 0.3 mEq/L for every 0.1 ? in pH above
  normal.
• Mg depletion due to drugs like amphotercin,
  Aminoglycosides, Toscarnet, Cisplatin ? Renal K
  wastage.

65
Hypokalemia

• Inadequate intake
• Dietary, potassium-free intravenous fluids,
  potassium-deficient total parenteral nutrition
• Excessive potassium excretion
• Hyperaldosteronism
• Medications ? Penicillins, diuretics
• Gastrointestinal losses
• Direct loss of potassium from gastrointestinal
  fluid (diarrhea)
• Renal loss of potassium (gastric fluid, either as
  vomiting or high nasogastric output)

66

• What are signs symptoms of hypokalemia?
• GIT - ileus, Constipation.
• Neuromuscular Weakness, fatigue, ? tendon
  reflexes paralysis
• Cardiovascular Cardiac arrest
• Pulseless electric activity
• asystole
• ECG Changes U Waves
• T wave frequency
• ST seg. changes
• Arrhythmia (Patient on digitalis)

67
How will you treat hypokalemia?

• Serum potassium level lt4.0 mEq/L
• Asymptomatic, tolerating enteral nutrition KCl
  40 mEq per enteral access x 1 dose
• Asymptomatic, not tolerating enteral nutrition
  KCl 20 mEq IV q2h x 2 doses
• Symptomatic KCl 20 mEq IV q1h x 4 doses
• Recheck K level 2 hrs after end of infusion if
  lt3.5 mEq/L asymptomatic replace as per above
  protocol

68

• Potassium repletion Determined by symptoms
• Oral Supplementation Mild / asymptomatic.
• IV Not more than 10-20 mEq/h in unmonitored
  setting.
• 40 mEq/hr if ECG monitoring available.
• If sec. to Mg depletion Correct Mg def. first
• Exercise caution in patient without oliguria /
  impaired renal function.

69
Magnesium

• 4th most common mineral in body
• Primarily intracellular
• 1/3 of extracellular Mg bound to serum albumin
• Plasma levels poor indicator in presence of
  Hypoalbuminemia
• Normal dietary intake - 20 mEq (240 mg) / day
• Excretion Feces Urine.

70

• Hypermagnesemia Rare
• Impaired renal function
• Excess intake
• Mg containing laxative / Antacids
• What are the signs symptoms of Hypermagnesemia?
• GIT Nausea Vomiting
• Neuromuscular Weakness, lethargy, decreased
  reflexes.
• CVS Hypotension arrest.
• ECG Increased PR interval
• Widened QRS
• Elevated T waves.

71
Treatment

• How will you treat Hypermagnesemia?
• Withhold exogenous sources of Mg
• Correct volume deficit
• Correct acidosis
• Acute symptoms Inj. Ca chloride 5-10 ml
• Dialysis in severe cases.

72
Hypomagnesaemia
Causes

• Diminished absorption or intake
• Malabsorption, chronic diarrhea, laxative abuse
• Prolonged gastrointestinal suction
• Small bowel bypass
• Malnutrition
• Alcoholism
• Increased renal loss
• Diuretic therapy (loop diuretics, thiazide
  diuretics)
• Hyperraldosteronism, Bartters syndrome
• Hyperparathyroidism, hyperthyroidism
• Hypercalcemia
• Drugs (aminoglycoside, cisplatin, amphotericin B
  Pentamidine)
• Others
• Diabetes mellitus
• Post parathyroidectomy (hungry bone syndrome)
• Respiratory alkalosis
• Pregnancy

73
Treatment Hypomagnesemia

• How will you treat Hypomagnesemia?
• Asymptomatic / Mild Oral supplementation
• Intravenous correction depends upon severity
• Magnesium level 1.0-1.8 mEq/L
• Magnesium sulfate 0.5 mEq/kg in normal saline 250
  mL infused IV over 24 h x 3 days
• Recheck magnesium level in 3 days

74

• Magnesium level lt 1.0 mEq/L
• Magnesium sulfate 1 mEq/kg in normal saline 250
  mL infused IV over 24 h x 1 day, then 0.5 mEq/kg
  in normal saline 250 mL infused IV over 24 h x 2
  days
• Recheck magnesium level in 3 days
• If patient has gastric access and needs a bowel
  regimen
• Milk of magnesia 15 mL (approximately 49 mEq
  magnesium) q24h per gastric tube hold for
  diarrhea

75
Calcium

• Vast majority in bony matrix
• Extracellular fluid lt1
• Se. Ca2 3 forms ? Protein bound 40
• Complexed to anions (PO4) 10
• Ionized 50
• Ionized fraction responsible for neuromuscular
  stability
• Albumin measurement necessary when measuring
  total Ca2
• Adjust total Serum Ca2 down by 0.8 mg/dL
• for every 1-g/dl ? in albumin.
• Acidosis ? Protein binding ? ionized fraction

76
Hypercalcemia

• Defined as Serum Ca gt 8.5 10.5 mEq.
• or
• ? in ionized as Ca level gt 4.2 - 4.8 mg/dl

77
Causes of hypercalcemia

• Increased intake or absorption
• Milk-alkali syndrome
• Vitamin D or vitamin A excess
• Endrocrine disorders
• Primary hyperparathyroidism (adenoma,
  hyperplasia, carcinoma)
• Secondary hyperparathyroidism (renal
  insufficiency, malabsorption)
• Acromegaly
• Adrenal insufficiency
• Neoplastic diseases
• Miscellaneous causes
• Thiazide diuretic-induced
• Pagets disease of bone
• Hypophosphatasia
• Immobilization
• Familial hypocalciuric hypercalcemia
• Complications of renal transplantation
• Iatrogenic

78

• What are the signs and symptoms of hypercalcemia?
• GIT Anorexia, Nausea/vomiting, abd. pain
• Neuromuscular Weakness, Confusion, Coma,
  Bonepain
• Renal Polydipsia
• CVS Hypertension, arrhythmia, Polyuria
• ECG Short QT interval
• Prolonged PR QRS interval
• ? QRS Voltage
• T Wave flattening widening
• AV Block ? CHB ? Cardiac arrest

79

• How will you treat Hypercalcemia?
• Symptomatic hypercalcemia (gt12g/dl) requires t/t
• Treatment of hypercalcemia without malignancy
• Start with saline volume expansion ? This ? renal
  resorption of Ca.
• Add loop diuretic after achieving adequate volume
  status. But these are temporary measures.

80

• Drugs
• Biphosphonates
• Calcitonin
• Corticosteroids
• Gallium Nitrate, Mithramycin
• Refractory Hypercalcemia Dialysis

81
Hypocalcemia
Serum Ca2 lt8.5 10.5 mEq/L, ? in ionized Ca2 lt
4.2-4.8 mg/dL

• Decreased intake or absorption
• Malabsorption
• Small bowel bypass, short bowel
• Vitamin D deficit
• Increased loss
• Alcoholism
• Chronic renal insufficiency
• Diuretic therapy
• Endocrine disease
• Hypoparathyroidism (genetic, acquired including
  hypo- and hypermagnesemia)
• Sepsis
• Pseudohypoparathyroidsim
• Calcitonin secretion with medullary carcinoma of
  the thyroid
• Familial hypocalcemia

82

• What are the signs and symptoms of hypocalcemia?
• Neuromuscular Hyperactive reflexes, Parasthesia
• Carpopedal spasm, seizures
• Chvostek sign
• Trosseau sign
• CVS Heart failure, ? cardiac contractility
• ECG Prolonged QT interval
• T wave inversion
• Heart block
• V.F.

83
Hypocalcemia

• How will you treat hypocalcemia?
• Normalized calcium lt4.0 mg/dL
• With gastric access and tolerating enteral
  nutrition Calcium carbonate suspension 1250
  mg/5 mL q6h per gastric access recheck ionized
  calcium level in 3 days
• Without gastric access or not tolerating enteral
  nutrition Calcium gluconate 2 g IV over 1 h x 1
  dose recheck ionized calcium level in 3 days.
• Acute Hypocalcemia Inj. Cal. gluconate 10 iv
• Correct asso. deficit in Mg, K, pH
• Hypocalcemia refractory if Hypermagnesemia is not
  treated first

84
Phosphorus

• Primary intra-cellular divalent anion
• Abundant in metabolically active cells
• Responsible for maintaining energy production
  (ATP)
• Levels controlled by renal excretion

85
Hyperphosphatemia
Causes

• Massive load of phosphate into the extracellular
  fluid
• From outside the body
• Hypervitaminosis D
• Laxatives or enemas containing phosphate
• Intravenous phosphate (especially if renal
  insufficiency coexists)
• Cell destruction by chemotherapy of malig,
  particularly lymphoproliferative disease
• Metabolic acidosis (lactic acidosis,
  ketoacidosis)
• Respiratory acidosis (phosphate incorporation
  into cells is disturbed)
• Decreased excretion into urine
• Renal failure (acute, chronic)
• Hypoparathyroidism
• Pseudohypoparathyroidism
• Excessive growth hormone (acromegaly)
• Pseudoperphosphatemia
• Multiple myeloma, hypertriglyceridemia, cell lysis

86

• What are the signs and symptoms of
  Hyperphosphatemia?
• Mostly asymptomatic
• In advanced cases?metastatic soft tissue deposits
• How will you treat Hyperphosphatemia?
• Phosphate binders Sucralfate
• Aluminum containing antacid
• Dialysis for patient with renal failure

87
Hypophosphatemia
Causes

• Diminished supply or absorption
• Starvation
• Parenteral alimentation with inadequate phosphate
  content
• Malabsorption syndrome, small bowel bypass
• Vitamin D-deficient and vitamin D-resistant
  osteomalacia
• Increased loss
• Phosphaturic drugs theophylline, diuretics,
  bronchodilators, corticosteroids
• Hyperparathyroidsim (primary or secondary)
• Hyperthyroidism
• Renal tubular defects
• Inadequately controlled diabetes mellitus
• Intracellular shift of phosphorus
• Respiratory alkalosis, Salicylate poisoning
• Electrolyte abnormalities
• Hypercalcemia, Hypomagnesemia
• Metabolic alkalosis

88

• What are the signs and symptoms of
  Hypophophatemia?
• Usually not significant unless severe deficiency
• Related to ? O2 del. to tissue and ? in ATP
• Manifest as cardiac dysfunction / Muscle weakness

89
How will you treat Hypophosphatemia?

• Phosphate level 1.0 2.5 mg/dL
• KPHO4 or NaPO4 0.15 mmol/kg IV over 6 h x 1 dose
• Recheck phosphate level in 3 days
• Phosphate level lt 1.0 mg/dL
• Tolerating enternal nutrition KPHO4 or NaPO4
  0.25 mmol/kg over x 1 dose
• Recheck phosphate level 4 hours after end of
  infusion
• KPHO4 or NaPO4 0.25 mmol/kg (LBW) over 6 h x 1
  dose recheck phosphate level 4 hours after end
  of infusion if lt2.5 mg/dL, then KPHO4 or NaPO4
  0.15 mmol/kg (LBW) IV over 6 h x 1 dose

90
How to calculate the rate of fluid infusion?

• For routine IV set
• 15 drops 1 ml
• Rule of TEN for fluid Cal. for 24 hours
• IV fluid in litre / 24 hours x 10 Drop rate /
  min
• Rule of Four for fluid Cal for one hour
• Drop rate / min. x 4 Vol. in ml/ hour
• For micro-drip IV set
• 1 ml 60 ?drops
• No. of ?drops / min Vol. in ml / hr.

91
Preoperative Fluid Therapy

• A frequently used formula for maintenance fluid
• for first 10 Kg 100 ml / kg / d
• for next 10-20 Kg Additional 50 ml/kg/d
• for wt. gt 20 kg 20 ml / kg / day
• But many surgical patients have vol. /
  electrolyte disturbance associated with their
  disease.
• Therefore, pre-op. volume status and electrolyte
  assess a must.
• Vol. deficits in patients with ? Emesis /
  Diarrhea
• Poor intake
• III space loss
• GI dysfunction
• Peritoneal / bowel inflammation
• Ascitis, crush injuries

92

• Tachycardia Orthostasis predominate with acute
  vol. loss accompanied with oliguria
  hemoconcentration
• Ac. volume deficits should be corrected prior to
  surgery.
• Start fluid replacement with isotonic crystalloid
  depending upon electrolyte profile.

93

• Patient with CV signs of volume deficit ?
• 1-2 L of isotonic fluid followed by continuous
  infusion
• Resuscitation guide - Reversal of signs of
  volume deficit (Vital signs)
• - Adequate urine output (½ 1 ml / kg / hour in
  adult)
• - Correction of base deficit
• Close monitoring essential in all esp. so in
  patients with impaired renal function
• Electrolyte abnormality correct to the extent
  that ac. S/S relieved prior to surgery.

94
Intraoperative Fluid Therapy

• Compensatory mechanism lost with induction of
  anaesthesia.
• Hypotension will manifest if volume deficit
  present.
• Measure blood loss, III space loss, loss from
  exposed bowel, large soft tissue wounds, complex
  fractures and burns and replace accordingly.

95

• In general which fluid is appropriate
  intraoperatively?
• Selection of fluid needs to be individualized
  depending upon age, vitals, basic etio. and type
  of surgery and asso. Illness.
• RL To replace I.O. fluid loss
• Most physiological fluid, also corrects
  acidosis
• NS Used intraop when RL contraind. or when large
  vol. of resuscitation required like hypovol.
  shock
• D5 Initial fluid replacement
• - Replacement for insensible fluid loss
• - Maintenance fluid deficit during starvation
• - Corrects intracellular dehy. provides
  calories

96
Postoperative Fluid Therapy

• Should be based on patients current estimated
  volume status and projected ongoing losses.
• Any pre. / intraop. deficit should be corrected
  and ongoing req. included in maintenance.
• III sp. losses should be included.
• In early post op. period Isotonic solution
• Guide Vital Signs and Urine output
• If uncertainty CVP / Swan-Ganz Catheter

97

• After 24-28 hours Change to 0.45 Saline
  without added dextrose in patient unable to
  tolerate enteral nutrition.
• Add potassium if renal function and urine output
  adequate.
• Daily fluid requirement based on volume
  electrolyte status.
• No need for electrolyte measurement in
  uncomplicated cases

98
What are special considerations in postoperative
fluid therapy?

• Overestimation of losses may lead to volume
  excess
• Earliest sign Weight gain
• Av. Post op. patient not requiring nut. support
  loses ¼ to ½ pound /day.

99

• What problems can occur if following iv fluids
  are used as sole agents for maintenance?
• 1) D5 Provides only water glucose. No
  electrolytes.
• Risk of Hyponatremia / Hypokalemia
• 2) DNS Contains Na 154 mEq/L,
• No Potassium, (N) child requires 30-50
  mEq
• Risk of hypernatremia, hypokalemia
• 3) RL Na 130 mEq, Pot. 4 mEq, No glucose
• Risk of Hypernatrania, Hypokalemia,
  Hypoglycaemia

100

• Can we use D5 in initial phase of shock?
• No, because
• 1 litre D5 ? ? in intravascular
• volume by 83 ml
• Contains no electrolytes ? electrolytes
  disturbance
• Rapid infusion ? Osm. diuresis ?Detrimental

Omphalocele
101
Management in Neuro-surgical patients

• Special challenge to anesthesiologists
• Often receive diuretics (Mannitol/ Frusemide) to
  treat cerebral edema
• ? large amounts of IV fluids to correct pre-op
  dehydration and to maintain intra/post op.
  hemodynamic stability
• Fluid restriction if excessive ? Hypotension ? ?
  ICP ? ? CPP ? devastating

102

• Little human data on the impact of fluid on brain
• IV fluid therapy manipulates ?
• 1. Osmolality
• 2. Colloid oncotic pressure
• 3. Hematocrit ? 30-33 ?optimal viscosity O2
  carrying capacity ? may improve neurological
  outcome.
• Hct lt30 ? ? neurological injury

103
How will you control ICP and brain swelling?

• Diuretics Mannitol Frusemide used extensively
• Mannitol Creates an osmotic gradient between
  intravas. comp and brain parenchyma
• Frusemide Reduces cell swelling
• Also ? CSF production
• Hypertonic salt solutions primarily used for
  small vol. resuscitation in patient with hemo.
  Shock
• Data suggest that they ? ICP and improve CPP
  similar to Mannitol.
• Disadvantages Danger of Hypernatremia
• Rebound ? ICP

104

• 3. Hypertonic / Hyperoncotic solution
• (E.g. Hypertonic Hetastarch or Dextrose solution)
• Have powerful hemodynamic properties
• Advantageous in patients with head injury and
  multiple trauma for prevention of secondary
  ischemic brain damage
• Small volume can restore normovolemia rapidly
• Successfully used to treat ? ICT in patients with
  head injury and stroke

105
Implications for Patient Care

• Fluid Restriction Moderate fluid restriction
  causes ? in serum osmolality and prevents
  hypo-osmotically driven edema ? beneficial
• Intra Op. Replacement
• Rate should be sufficient to replace urinary
  output and insensible losses
• Repeat osmolality check required
• Small volume of RL safe
• If large vol. required use a more isotonic
  fluid or a combination of isotonic crystalloid
  and colloid

106

• Post op. Period - Large volume not required
• Periodic osmolality check and give fluids
  accordingly
• What are the points to be remembered for a head
  injury patient?
• Prompt restoration of systemic pressure is
  essential
• Avoid Hypotonic solution (RL),
• Avoid glucose containing solution
• Give fluids with osmolality around 300 mOsm/L
• Colloids for large volume deficit

107
Subarachanoid Hemorrhage (SAH)

• Avoid Hypovolemia and Hyponatremia
• Isotonic crystalloids usually take care of
  hyponatremia
• If severe hyponatremia use mild hypertonic
  fluids (1.25 or 1.5 saline)
• Avoid fluid restriction
• Hypertensive / Hypervolemic therapy widely
  accepted to prevent cerebral vasospasm

108
Management of patients with renal diseases

• What are the General Rules?
• Fluid restriction required in edematous and
  oliguric patients to avoid volume overload,
  pulmonary congestion, hypertension / hyponatremia
• Anuric patient Fluid restricted upto 500 ml/day
  only
• Oliguric patient Fluid intake Urine Output
  500 ml
• Monitor urine output chart and daily weight.
• Loss of weight ? ? in accumulated fluid ? ? edema

109

• Do not chase urine output in edematous patient
• Urine output ? in response to diuretic therapy
• Aim is removal of accumulated fluid, therefore
  continue fluid restriction.
• 3. Salt restriction req. to ? edema, pulmonary
  congestion and hypertension.
• 4. Avoid Hyperkalemia Can be fatal
• Avoid K rich food
• Avoid K rich IV fluids

110

• Acute renal failure ? Characterized by rapid
  decline in renal function.
• Accumulation of water, crystalloid solutes and
  nitrogenous end products.
• Has varied presentation
• Pre-renal azotemia
• Non-oliguric ac. renal failure
• Oliguric renal failure
• Diuretic phase of ac. renal failure

111

• Pre-renal Azotemia
• Pt. improve with early adequate fluid therapy
• 0.5 1 Lt. isotonic saline infused over 30-60
  min. if no response ? IV diuretics to promote
  urine flow
• Monitor Pulse, BP and JVP
• Give isotonic saline in hypotensive states.
• With-hold K till urine output is established.

112

• Non-oliguric ARF
• Due to Septicemia, drug toxicity, A.I.N.
• Diagnosis difficult as there is no ? urine
  output.
• High index of suspicion req.
• Do not need fluid or salt restriction
• Restrict Potassium intake.
• Oliguric ARF If urine output lt40 ml/d in adults
  or lt0.5 ml/kg/hr in children
• ? excretion of water, electrolytes, nitrogenous
  waste products
• Restrict Salt and water (esp. K)
• Maintain daily wt loss chart. (Daily loss of 0.2
  to 0.3 kg ideal)
• - Treat with diuretics to establish urine
  outflow.
• - If ineffective - Mannitol/ low dose dopamine
  (lt3 µg/kg/min)

113

• Diuretic phase of ARF
• Renal functions recover through repair of renal
  tissue.
• - Do not chase urine output at this stage
• - Avoid volume depletion and dehydration
• - Replace deficit of NaCl, HCO3, K, Mg etc.
• - Preferred IV fluid 0.45 saline with K as
  required

114
Chronic Renal Failure

• CRF due to chr. glom. disease
• S/S of volume overload and hypertension
• ? restrict fluid and salt intake
• Diuretics
• Avoid Hyperkalemia
• Preferred IV fluid D-5 or D-10
• CRF due to chronic tubulo-interstitial disease
• - Absence of edema / Volume dep. due to polyuria
• Advise plenty of fluid and salt intake to prevent
  dehydration
• Correct Met. acidosis ? Give Sodium Bicarbonate
• Avoid treat hyperkalemia

115
How will you manage TURP syndrome?

• S/S secondary to neuro., CVS and electrolyte
  imbalance due to absorption of irrigation fluid
  through prostatic veins.
• Risk factors - Surgery gt 60 min
• - Prostate (Resected wt gt30 gms)
• - Irrigant volume gt 30 L
• - Inexperience

116

• Prevention Early diag. and prompt treatment
• Correct pre-existing Hyponatremia (risk factor)
• Irrigation fluid flow lt 300 ml / min
• Avoid 5 Dextrose pre-op.
• ? pre-op. maintenance fluid.
• Prophylactic use of Frusemide
• Treatment
• Terminate surgery
• Diuretics 66 cases corrected
• Fluid restriction
• Mannitol 15
• Hypertonic saline Slow I.V. 3 hypertonic
  saline.
• In general 200 ml sufficient

117
Patient with Trauma

• Tissue injury ? activated sys. infl. response ?
  permeability of vas. endo ? Tissue edema
• Plasma shifts to interstitial extra-cellular sp.
  ? ? intravascular volume

Concurrent hemorrhagic insult ? further reduction
in plasma volume
118
How will you resuscitate patients with trauma?

• Fluid Resuscitation
• Improves outcome ? morbidity
• Restores physiological homeostasis
• Balanced salt solution infusion current
  standard
• Give as rapid as possible 1-2 L in adults
• 20 ml / kg in children
• No reported difference in outcome with
  crystalloid v/s colloid resuscitation

119

• Options
• Isotonic crystalloids Readily available, least
  expensive but larger infusion volume
  required
• Oncotic pr ? ? interstitial edema ? detrimental
  to lung
• Hypertonic crystalloids
• Restore blood volume by maintaining a contracted
  interstitial space
• Small volume required
• Believed to have positive inotropic effect on
  myocardium ? in renal, mesenteric coronary
  blood flow

120

• Colloids
• - Favored by some
• - More rapid and effective correction of
  intravascular volume deficits
• - Natural Colloids Carry the risk of
  transmission of infection (HCV, HIV etc.)
• - Anaphylactoid reaction

121
Combined Crystalloid Colloid Resuscitation

• Currently under investigation
• Hypertonic component ? draws water out of
  intra-cellular space replenishes extra-cellular
  space.
• Colloid component ? transiently partitions this
  fluid in plasma space ? prolongs beneficial
  hemodynamic effects
• Studies indicate improved survival when
  hypertonic saline and Dextran40 (HSD) are used
  together.
• HSD infusion Corrects meta. derangement
• improves arterial O2 tension
• ? mesenteric renal micro-circulation

122
Conclusion

• Accurate fluid, electrolyte assessment therapy
  essential
• Precise calculation of preop. deficits,
  maintenance ongoing loss req. a must for proper
  management of fluid homeostasis
• Practical wisdom indicates it is dose rather than
  the type of fluid that is important
• Judicious fluid management a keen eye on pts
  status go a long way in benefiting the pt.

123
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