SlideShare a Scribd company logo
1 of 20
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
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
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
FLUID COMPARTMENTS
4
5
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
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
TYPES OF IV FLUID
8
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
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
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
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
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
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
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
C. SEPSIS
• Volume deficit due to combination of
- Vasodilation
- Capillary leak
- Insensible losses
• Need for aggressive fluid replacement, particularly in 1st
24hrs
16
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
• 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).
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
20
THANK YOU

More Related Content

What's hot

Fluid management & anesthesia
Fluid management & anesthesiaFluid management & anesthesia
Fluid management & anesthesiaSandro Zorzi
 
Iv fluid therapy (types, indications, doses calculation)
Iv fluid therapy (types, indications, doses calculation)Iv fluid therapy (types, indications, doses calculation)
Iv fluid therapy (types, indications, doses calculation)kholeif
 
Crystalloid
CrystalloidCrystalloid
CrystalloidRashin P
 
Resuscitation Fluids
Resuscitation FluidsResuscitation Fluids
Resuscitation FluidsSun Yai-Cheng
 
Fluid therapy: Principles
Fluid therapy: PrinciplesFluid therapy: Principles
Fluid therapy: PrinciplesSandeep Lahiry
 
Fluids in Intensive Care
Fluids in Intensive Care Fluids in Intensive Care
Fluids in Intensive Care Vineel Bezawada
 
Perioperative fluid therapy
Perioperative fluid therapyPerioperative fluid therapy
Perioperative fluid therapyspecialclass
 
Potassium Management
Potassium ManagementPotassium Management
Potassium Managementcap_0009
 
Intercostal drainage tube insertion
Intercostal drainage tube insertionIntercostal drainage tube insertion
Intercostal drainage tube insertionMahesh Chand
 
Common fluids used in anaesthesia and fluid therapy
Common fluids used in anaesthesia and fluid therapyCommon fluids used in anaesthesia and fluid therapy
Common fluids used in anaesthesia and fluid therapyArowojolu Samuel
 
Intravenous fluid therapy
Intravenous fluid therapyIntravenous fluid therapy
Intravenous fluid therapycharul jakhwal
 
Fluid management in the paediatric patient anaesthetist consideration...
Fluid management in the paediatric patient anaesthetist consideration...Fluid management in the paediatric patient anaesthetist consideration...
Fluid management in the paediatric patient anaesthetist consideration...drriyas03
 
epidural anesthesia
epidural anesthesiaepidural anesthesia
epidural anesthesiaShibinath VM
 

What's hot (20)

Fluid management
Fluid managementFluid management
Fluid management
 
Fluid management & anesthesia
Fluid management & anesthesiaFluid management & anesthesia
Fluid management & anesthesia
 
Iv fluid therapy (types, indications, doses calculation)
Iv fluid therapy (types, indications, doses calculation)Iv fluid therapy (types, indications, doses calculation)
Iv fluid therapy (types, indications, doses calculation)
 
Fluid therapy
Fluid therapyFluid therapy
Fluid therapy
 
Crystalloid
CrystalloidCrystalloid
Crystalloid
 
intravenous fluid
intravenous fluidintravenous fluid
intravenous fluid
 
Resuscitation Fluids
Resuscitation FluidsResuscitation Fluids
Resuscitation Fluids
 
Fluid therapy: Principles
Fluid therapy: PrinciplesFluid therapy: Principles
Fluid therapy: Principles
 
Fluids in Intensive Care
Fluids in Intensive Care Fluids in Intensive Care
Fluids in Intensive Care
 
Perioperative fluid therapy
Perioperative fluid therapyPerioperative fluid therapy
Perioperative fluid therapy
 
Iv fluids
Iv fluidsIv fluids
Iv fluids
 
Iv fluids
Iv fluidsIv fluids
Iv fluids
 
Fluid therapy
Fluid therapyFluid therapy
Fluid therapy
 
Potassium Management
Potassium ManagementPotassium Management
Potassium Management
 
Intercostal drainage tube insertion
Intercostal drainage tube insertionIntercostal drainage tube insertion
Intercostal drainage tube insertion
 
Common fluids used in anaesthesia and fluid therapy
Common fluids used in anaesthesia and fluid therapyCommon fluids used in anaesthesia and fluid therapy
Common fluids used in anaesthesia and fluid therapy
 
Intravenous fluid therapy
Intravenous fluid therapyIntravenous fluid therapy
Intravenous fluid therapy
 
Fluid management in the paediatric patient anaesthetist consideration...
Fluid management in the paediatric patient anaesthetist consideration...Fluid management in the paediatric patient anaesthetist consideration...
Fluid management in the paediatric patient anaesthetist consideration...
 
Colloid vs Crystalloids
Colloid vs CrystalloidsColloid vs Crystalloids
Colloid vs Crystalloids
 
epidural anesthesia
epidural anesthesiaepidural anesthesia
epidural anesthesia
 

Similar to Fluid management

Fluid in pancreatitis final
Fluid in pancreatitis finalFluid in pancreatitis final
Fluid in pancreatitis finalYouttam Laudari
 
RINGERS LACTATE VS NORMAL SALINE.pptx
RINGERS LACTATE VS NORMAL SALINE.pptxRINGERS LACTATE VS NORMAL SALINE.pptx
RINGERS LACTATE VS NORMAL SALINE.pptxDR ANTHONY KWAW
 
Is there evidence for any fluid therapy in the critically ill? Anders Perner ...
Is there evidence for any fluid therapy in the critically ill? Anders Perner ...Is there evidence for any fluid therapy in the critically ill? Anders Perner ...
Is there evidence for any fluid therapy in the critically ill? Anders Perner ...scanFOAM
 
Fluid management in dialysis
Fluid management in dialysisFluid management in dialysis
Fluid management in dialysisVishal Bagchi
 
Fluid and electrolyte slideshare
Fluid and electrolyte slideshareFluid and electrolyte slideshare
Fluid and electrolyte slideshareDR SAURAV SUMAN
 
Fluid management in pd patient
Fluid management in pd patientFluid management in pd patient
Fluid management in pd patientFarragBahbah
 
Blood transfusion and its implication
Blood transfusion and its implicationBlood transfusion and its implication
Blood transfusion and its implicationZIKRULLAH MALLICK
 
management of a burn patient
management of a burn patient management of a burn patient
management of a burn patient Sumer Yadav
 
Management and theorys of burn patients
Management and  theorys of burn patientsManagement and  theorys of burn patients
Management and theorys of burn patientsyx2b844gcs
 
The initial resuscitation of the burn patient in icu
The initial resuscitation of the burn patient in icuThe initial resuscitation of the burn patient in icu
The initial resuscitation of the burn patient in icuGhaleb Almekhlafi
 
Fluids and electrolytes for sixth year
Fluids and electrolytes for sixth yearFluids and electrolytes for sixth year
Fluids and electrolytes for sixth yearBashar Abass
 
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...Wisit Cheungpasitporn
 
BloodTransfussionGuidelines.pdf
BloodTransfussionGuidelines.pdfBloodTransfussionGuidelines.pdf
BloodTransfussionGuidelines.pdfMerlitaHerbani1
 
fluid threopy in critically ill patients.pptx
fluid threopy in critically  ill  patients.pptxfluid threopy in critically  ill  patients.pptx
fluid threopy in critically ill patients.pptxTiwariBalwan
 
Fluid management in acute pancreatitis
Fluid management in acute pancreatitisFluid management in acute pancreatitis
Fluid management in acute pancreatitisAnupshrestha27
 

Similar to Fluid management (20)

Fluid therapy
Fluid therapyFluid therapy
Fluid therapy
 
Aki
AkiAki
Aki
 
Fluid in pancreatitis final
Fluid in pancreatitis finalFluid in pancreatitis final
Fluid in pancreatitis final
 
RINGERS LACTATE VS NORMAL SALINE.pptx
RINGERS LACTATE VS NORMAL SALINE.pptxRINGERS LACTATE VS NORMAL SALINE.pptx
RINGERS LACTATE VS NORMAL SALINE.pptx
 
Is there evidence for any fluid therapy in the critically ill? Anders Perner ...
Is there evidence for any fluid therapy in the critically ill? Anders Perner ...Is there evidence for any fluid therapy in the critically ill? Anders Perner ...
Is there evidence for any fluid therapy in the critically ill? Anders Perner ...
 
Fluid management in dialysis
Fluid management in dialysisFluid management in dialysis
Fluid management in dialysis
 
Fluid and electrolyte slideshare
Fluid and electrolyte slideshareFluid and electrolyte slideshare
Fluid and electrolyte slideshare
 
Fluid management in pd patient
Fluid management in pd patientFluid management in pd patient
Fluid management in pd patient
 
Blood transfusion and its implication
Blood transfusion and its implicationBlood transfusion and its implication
Blood transfusion and its implication
 
management of a burn patient
management of a burn patient management of a burn patient
management of a burn patient
 
Management and theorys of burn patients
Management and  theorys of burn patientsManagement and  theorys of burn patients
Management and theorys of burn patients
 
The initial resuscitation of the burn patient in icu
The initial resuscitation of the burn patient in icuThe initial resuscitation of the burn patient in icu
The initial resuscitation of the burn patient in icu
 
Blood Transfusion
Blood TransfusionBlood Transfusion
Blood Transfusion
 
Fluids and electrolytes for sixth year
Fluids and electrolytes for sixth yearFluids and electrolytes for sixth year
Fluids and electrolytes for sixth year
 
Sepsis update 2014
Sepsis update 2014Sepsis update 2014
Sepsis update 2014
 
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...
 
Fluid and electrolytes
Fluid and electrolytesFluid and electrolytes
Fluid and electrolytes
 
BloodTransfussionGuidelines.pdf
BloodTransfussionGuidelines.pdfBloodTransfussionGuidelines.pdf
BloodTransfussionGuidelines.pdf
 
fluid threopy in critically ill patients.pptx
fluid threopy in critically  ill  patients.pptxfluid threopy in critically  ill  patients.pptx
fluid threopy in critically ill patients.pptx
 
Fluid management in acute pancreatitis
Fluid management in acute pancreatitisFluid management in acute pancreatitis
Fluid management in acute pancreatitis
 

More from snich

Management of MDD (based on Malaysia CPG, may 2007)
Management of MDD (based on Malaysia CPG, may 2007)Management of MDD (based on Malaysia CPG, may 2007)
Management of MDD (based on Malaysia CPG, may 2007)snich
 
Defibrillation, cardioversion and pacing
Defibrillation, cardioversion and pacingDefibrillation, cardioversion and pacing
Defibrillation, cardioversion and pacingsnich
 
Insect bites
Insect bitesInsect bites
Insect bitessnich
 
Thalassemia
ThalassemiaThalassemia
Thalassemiasnich
 
THYROID DISEASE
THYROID DISEASETHYROID DISEASE
THYROID DISEASEsnich
 
Respiratory distress of the newborn
Respiratory distress of the newbornRespiratory distress of the newborn
Respiratory distress of the newbornsnich
 
Congenital heart disease
Congenital heart diseaseCongenital heart disease
Congenital heart diseasesnich
 
Skin &soft tissue infection
Skin &soft tissue infectionSkin &soft tissue infection
Skin &soft tissue infectionsnich
 
Spinal shock
Spinal shockSpinal shock
Spinal shocksnich
 
Intestinal obstruction in paeds
Intestinal obstruction in paedsIntestinal obstruction in paeds
Intestinal obstruction in paedssnich
 
Pprom & prom
Pprom & promPprom & prom
Pprom & promsnich
 
early pregnancy complications
early pregnancy complicationsearly pregnancy complications
early pregnancy complicationssnich
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosissnich
 
Pneumothorax
PneumothoraxPneumothorax
Pneumothoraxsnich
 
Sudden cardiac death
Sudden cardiac deathSudden cardiac death
Sudden cardiac deathsnich
 
benign breast disease
benign breast diseasebenign breast disease
benign breast diseasesnich
 
benign tumor of large intestine
benign tumor of large intestinebenign tumor of large intestine
benign tumor of large intestinesnich
 
Somatoform disorder & psychosomatic disorder
Somatoform disorder & psychosomatic disorderSomatoform disorder & psychosomatic disorder
Somatoform disorder & psychosomatic disordersnich
 
Psy pneumonic
Psy pneumonicPsy pneumonic
Psy pneumonicsnich
 
caput, cepahlhematoma & sah
caput, cepahlhematoma & sahcaput, cepahlhematoma & sah
caput, cepahlhematoma & sahsnich
 

More from snich (20)

Management of MDD (based on Malaysia CPG, may 2007)
Management of MDD (based on Malaysia CPG, may 2007)Management of MDD (based on Malaysia CPG, may 2007)
Management of MDD (based on Malaysia CPG, may 2007)
 
Defibrillation, cardioversion and pacing
Defibrillation, cardioversion and pacingDefibrillation, cardioversion and pacing
Defibrillation, cardioversion and pacing
 
Insect bites
Insect bitesInsect bites
Insect bites
 
Thalassemia
ThalassemiaThalassemia
Thalassemia
 
THYROID DISEASE
THYROID DISEASETHYROID DISEASE
THYROID DISEASE
 
Respiratory distress of the newborn
Respiratory distress of the newbornRespiratory distress of the newborn
Respiratory distress of the newborn
 
Congenital heart disease
Congenital heart diseaseCongenital heart disease
Congenital heart disease
 
Skin &soft tissue infection
Skin &soft tissue infectionSkin &soft tissue infection
Skin &soft tissue infection
 
Spinal shock
Spinal shockSpinal shock
Spinal shock
 
Intestinal obstruction in paeds
Intestinal obstruction in paedsIntestinal obstruction in paeds
Intestinal obstruction in paeds
 
Pprom & prom
Pprom & promPprom & prom
Pprom & prom
 
early pregnancy complications
early pregnancy complicationsearly pregnancy complications
early pregnancy complications
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosis
 
Pneumothorax
PneumothoraxPneumothorax
Pneumothorax
 
Sudden cardiac death
Sudden cardiac deathSudden cardiac death
Sudden cardiac death
 
benign breast disease
benign breast diseasebenign breast disease
benign breast disease
 
benign tumor of large intestine
benign tumor of large intestinebenign tumor of large intestine
benign tumor of large intestine
 
Somatoform disorder & psychosomatic disorder
Somatoform disorder & psychosomatic disorderSomatoform disorder & psychosomatic disorder
Somatoform disorder & psychosomatic disorder
 
Psy pneumonic
Psy pneumonicPsy pneumonic
Psy pneumonic
 
caput, cepahlhematoma & sah
caput, cepahlhematoma & sahcaput, cepahlhematoma & sah
caput, cepahlhematoma & sah
 

Recently uploaded

High Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near Me
High Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near MeHigh Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near Me
High Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near Menarwatsonia7
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Timevijaych2041
 
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...narwatsonia7
 
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service JaipurHigh Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipurparulsinha
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi NcrDelhi Call Girls
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingNehru place Escorts
 
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original PhotosCall Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photosnarwatsonia7
 
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...narwatsonia7
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknownarwatsonia7
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingArunagarwal328757
 
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...rajnisinghkjn
 
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service MumbaiVIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbaisonalikaur4
 
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...narwatsonia7
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowNehru place Escorts
 
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...Nehru place Escorts
 
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersBook Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersnarwatsonia7
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...narwatsonia7
 

Recently uploaded (20)

High Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near Me
High Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near MeHigh Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near Me
High Profile Call Girls Mavalli - 7001305949 | 24x7 Service Available Near Me
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
 
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
 
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service JaipurHigh Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
 
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original PhotosCall Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
 
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, Pricing
 
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
 
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service MumbaiVIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
 
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
 
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
 
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersBook Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
 
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
 

Fluid management

  • 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. 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. 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
  • 5. 5
  • 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. 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. TYPES OF IV FLUID 8
  • 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. 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. 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. 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. 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. 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. 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. 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 • 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 • 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. 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

Editor's Notes

  1. Hydrostatic pressure, oncotic pressure
  2. Post op: increase ADH secretion as part of surgical stress response may caused transient oliguria
  3. Lactate-anaerobic cellular metabolism-tissue perfusion
  4. http://www.uptodate.com/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults
  5. http://www.uptodate.com/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults