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Fluids, Electrolytes & IV Therapy
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Fluid management

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Fluid management

  1. 1. B Y : D R I S M A H S U R G I C A L D E P A R T M E N T IV FLUIDS beneficial or more harm? 1
  2. 2. MAIN REFERENCE FLUID MANAGEMENT 2013 Elsevier Ltd. by • Claire Leech BSc MBBS FRCA Specialist Registrar in Anaesthesia & Critical Care, Northern Deanery, UK. • Ian D Nesbitt MBBS FRCA DICM(UK) FFICM Consultant in Anaesthesia & Critical Care at the Freeman Hospital, Newcastle upon Tyne, UK. 2
  3. 3. CONTENTS • Fluid compartments in the body • Normal requirements • Types of IV fluids and choice of fluid • Common issues in fluid management of surgical patients • Fluids issues in burn, trauma & sepsis 3
  4. 4. FLUID COMPARTMENTS 4
  5. 5. 5
  6. 6. NORMAL REQUIREMENTS • Water 35 ml/kg or 2.5 L/day for 70 kg male -fluid losses 1.5L by urine & feces 1.0L by respiration/skin *fever – 10% increase in water losses for every degree temperature rise above 38C • Na+ : 1-1.5 mmol/kg/day • K+ : 1 mmol/kg/day 6
  7. 7. When considering a fluid strategy for a patient the following should be considered: • The patient’s normal requirements • Current volume status; the perioperative patient is often fluid deplete requiring a period of ‘catch up’ • Electrolyte status • On going excessive losses (e.g. high output fistula, high gastric losses, third space losses). Examples such as these may also require consideration of electrolyte supplementation at a different amount to the above • Excessive fluid intake (e.g. drug infusions or antibiotics) 7
  8. 8. TYPES OF IV FLUID 8
  9. 9. Properties of commonly used crystalloids: Fluid Osmolarity Tonicity Na+ K+ Cl- Other pH Hartmann’s 278 Isotonic 131 5 111 Lactate 29 6.5 0.9% saline 308 Isotonic 154 0 154 5 5% dextrose 278 Hypotonic 0 0 0 Dextrose 50 4 9
  10. 10. CRYSTALLOIDS OR COLLOIDS? 10 Crystalloids Colloids Advantages Disadvantages Advantages Disadvantages • Cheap • Non allergic • No transmission of infection • No interference with coagulation • Higher volume needed • Relatively short amount of time remaining intravascularly • Expansion plasma volume far superior • May be salt sparing • Expensive • Risk of allergy • Coagulopathy • Itch • May exacerbate tissue edema *The cost of each life saved using crystalloids is $45.13, and the cost of each life saved using colloidal solutions is $1493.60 - http://www.ncbi.nlm.nih.gov/pubmed/2010737
  11. 11. A. PREOPERATIVE • Pt who undergo major surgery in dehydrated state have worst outcome • Aim is to maintain tissue perfusion and O2 delivery • Bowel preparation & fasting pre op can lead to dehydration • Recommended suitable fasting time by The Association of Anesthetist of the Great Britain and Ireland - 6 hrs for solid food/milk - 2 hrs for clear fluid • Growing evidence that bowel preparation is unnecessary - Advocate supplying pt with carbohydrate drink the night before/morning of surgery to prevent fluid/electrolytes disturbance 11
  12. 12. B. PERIOPERATIVE • Both surgery and anesthesia affect fluid balance - Anesthesia causes vasodilation - Surgery cause hemorrhage, 3rd space losses and evaporative losses • However, excessive IV fluids can cause many complications as inadequate administration of fluids • The administration of fluid should be done to maintain the cardiac output (goal directed therapy) at optimum level to reduce hospital stay and morbidities - Used of additional monitoring measure is often used; including the oesophageal doppler, pulmonary artery catheter, and pulse contour analysis monitors 12
  13. 13. C. POSTOPERATIVE • Management includes the administration of maintenance fluids plus replacement of on going losses. • Close monitoring of electrolytes should be done in addition to this. • Intravenous fluids should be discontinued as soon as the patient is able to tolerate oral fluids. 13
  14. 14. A. BURN • Fluid resus is very important especially for pt with burn of > 10-15% BSA • Damage of skin cause significant fluid loss • Parkland formula (%BSA burn X wt X 4ml)/24 hrs - Half in 1st 8 hrs and half in 16 hrs - Fluid of choice: Hartmann’s • Aim: minimum urine output 0.5ml/kg/hr • Rise of serum lactate may indicate more fluid required 14
  15. 15. B. TRAUMA • For major trauma as per advanced trauma life support protocols; - 2L of warmed Hartmann’s followed by assessment of response - Early aggressive correction of acute coagulopathy using blood and products 15
  16. 16. C. SEPSIS • Volume deficit due to combination of - Vasodilation - Capillary leak - Insensible losses • Need for aggressive fluid replacement, particularly in 1st 24hrs 16
  17. 17. 17 • Volume - The optimal volume of resuscitative fluid is unknown. - As examples, two studies of early goal directed therapy reported mean infusion volumes that ranged from 3 to 5 litersRivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368, & ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370:1683. - The volume of fluid that was administered within the initial six hours of presentation was targeted to set physiologic endpoints (e.g., mean arterial pressure) - Thus, rapid, large volume infusions of intravenous fluids are indicated as initial therapy for severe sepsis or septic shock, unless there is coexisting clinical or radiographic evidence of heart failure. - Fluid therapy should be administered in well-defined (e.g., 500 mL), rapidly infused boluses Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580.
  18. 18. 18 • Choice of fluid A. Crystalloid versus albumin: In the Saline versus Albumin Fluid Evaluation (SAFE) trial, 6997 critically ill patients were randomly assigned to receive 4 percent albumin solution or normal saline for up to 28 days [24]. There were no differences between groups for any endpoint, including the primary endpoint, mortality. Among the patients with severe sepsis (18 percent of the total group), there were also no differences in outcome. In another multicenter open-label randomized trial of patients with severe sepsis or septic shock, the addition of albumin to crystalloid did not improve survival compared to crystalloid alone (31 versus 32 percent) [25]. B. Crystalloid versus hydroxyethyl starch: In the Scandinavian Starch for Severe Sepsis and Septic Shock (6S) trial, 804 patients with severe sepsis were randomly assigned to receive either 6 percent hydroxyethyl starch or Ringer’s acetate at a volume of up to 33 mL/kg of ideal body weight per day [26]. When assessed 90 days after randomization, mortality was increased in the hydroxyethyl starch group (51 versus 43 percent) and more patients in the hydroxyethyl starch group had required renal replacement therapy at some time during their illness (22 versus 16 percent).
  19. 19. CONCLUSION • Normal requirement of body - Water 35 ml/kg or 2.5 L/day for 70 kg male - Na+ : 1-1.5 mmol/kg/day - K+ : 1 mmol/kg/day • Fluid therapy strategy should be individualized • Crystalloids are more beneficial often used than colloids in most conditions • Beware to not give inadequate or excessive fluid therapy – goal directed therapy 19
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