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Dr. Ehsanur Reza ShovanDr. Ehsanur Reza ShovanAssistant professor, SurgeryAssistant professor, Surgery..

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Fluids

Functions of Water in the BodyFunctions of Water in the Body�-Transporting nutrients to cells and

wastes from cells �-Transporting hormones, enzymes, blood

platelets, and red and white blood cells�-Facilitating cellular metabolism and proper

cellular chemical functioning�-Facilitating digestion and promoting elimination�-Acting as a solvent for electrolytes and

non-electrolytes�-Acting as a tissue lubricant and cushion�-Helping maintain normal body temperature

Our body is as like our earth

Body Fluid Compartments� 2/3 (65%) of TBW is intracellular fluid (ICF)

� 1/3 extracellular fluid (ECF)� 25 % interstitial fluid (ISF)

� 5- 8 % in plasma [(IVF) intravascular fluid]

� 1- 2 % in transcellular fluids � CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)

Normal Composition in Average Man

�When a person loses more than 10% of his total body fluids, he can DIE!!!

VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT

BODY FATBODY FATBecause fat cells contain little Because fat cells contain little water and lean tissue is rich in water and lean tissue is rich in water, the more obese the water, the more obese the person, the smaller the person, the smaller the percentage of total body water percentage of total body water compared with body weight.compared with body weight.

This is also true between sexes This is also true between sexes because females tend to have because females tend to have proportionally more body fat proportionally more body fat than males.than males.

There is also an increase in fat There is also an increase in fat cells in older peoplecells in older people

� Body size/Weight � thin people have more water than chubby ones

77% infant 50% female 60% adult male45% elderly

� Fluid compartments are separated by membranes that are freely permeable to water.

� Movement of fluids due to:

� Diffusion

� Osmotic pressure

� Active transport

� Hydrostatic pressure

� Reabsorption

Movement of FluidsMovement of Fluids

AVENUES BY WHICH WATER ENTERS AND AVENUES BY WHICH WATER ENTERS AND LEAVES THE BODYLEAVES THE BODY

SENSIBLE

- An individual is aware of losing that water.

GIT / Feces

Water loss through defecation/feces is 200cc

KIDNEYS / Urine

Water loss through urination is 1,500ml

INSENSIBLE

- An individual is unaware of losing that water.

SKIN / Perspiration

Water loss through perspiration is 600ml

Causes of Increased Water Loss

�Fever�Diarrhea�Diaphoresis�Vomiting�Gastric suctioning�Tachypnea

Causes of Increased Water Gain

�Increased sodium intake�Increased sodium retention�Excessive intake of water�Excess secretion of ADH

Fluid balanceFluid intake:Exogenous � 2 to 3 litres/24 hrs, half contained in solid foodEndogenous - <500 ml/24 hrs, released from oxidation of ingested food

Fluid output:Urine � 1500 ml/24 hrsVia the skin � 600-1000 ml/ 24 hrsVia the lungs � 400 ml/24 hrsIn faeces � 60 � 150 ml/ 24 hrs

↓Blood volume or ↓BP

Volume receptor

Atria and great veins

Hypothalamus

Posterior pituitary gland

Osmoreceptors in hypothalamus

↑Osmolarity

↑ADH Kidney tubules

↑H2O reabsorption

↑vascular volume and ↓osmolarity

Narcotics, Stress, Anesthetic agents, Heat, Nicotine, Antineoplastic

agents, Surgery

ANTIDIURETIC HORMONE REGULATION MECHANISMSANTIDIURETIC HORMONE REGULATION MECHANISMS

Juxtaglomerular cells-kidney

↓Serum Sodium ↓Blood volume

Angiotensin I

Kidney tubules

Angiotensin II

Adrenal Cortex

↑Sodium resorption (H2O resorbed with

sodium); ↑Blood volume

Angiotensinogen in plasma

AngiotensinAngiotensin--converting converting

enzymeenzyme

ALDOSTERONE

Intestine, sweat glands, Salivary

glands

Via vasoconstriction of arterial smooth muscle

ALDOSTERONEALDOSTERONE--RENINRENIN--ANGIOTENSIN SYSTEMANGIOTENSIN SYSTEM

Fluid Types

� Fluids in the body generally aren�t found in pure forms

� Isotonic, hypotonic, and hypertonic types

� Defined in terms of the amount of solute or dissolve substances in the solution

� Balancing these fluids involves the shifting of fluid not the solute involved

Isotonic Solutions

� No net fluid shifts occur between isotonic solutions because the solution are equally concentrated

� 0.9% Sodium Chloride Solution

� Ringer�s Solution

� Lactated Ringer�s Solution

� Doesn�t cause shrinking or swelling of the cell

Hypotonic Solutions

� Has a lower solute concentration than another solution

� Fluid from the hypotonic solution would shift into the second solution until the two solutions had equal concentrations

� 5% DEXTROSE & WATER� 0.45% SODIUM CHLORIDE� 0.33% SODIUM CHLORIDE

Hypertonic Solutions

� Has a higher solute concentration than another solution

� Fluid from the second solution would shift into the hypertonic solution until the two solutions had equal concentrations

� 3% SODIUM CHLORIDE� 5% SODIUM CHLORIDE� WHOLE BLOOD� ALBUMIN� TOTAL PARENTERAL NUTRITION

Commonly used fluids -Ringer�s lactate Solution-Normal Saline-5% DA-5% DNS

Water requirements:Depends on �size, age and temperature

Children require relatively more water than adult, because �

-larger surface area per unit of body -weight-greater metabolic activity due to growth-poor concentrating ability of immature kidneys

Requirements of water in adult:- 1.5 litres /m2 (most accurate)- 30-40 ml /kg (more practical)

Requirement of water in children

Weight (kg)Weight (kg) Water requirementWater requirement

00--1010 4 ml /kg /hr4 ml /kg /hr

1010--2020 40 ml/kg/hr + 2ml/kg/hr for each kg > 10 kg40 ml/kg/hr + 2ml/kg/hr for each kg > 10 kg

> 20 kg> 20 kg 60 ml/kg/hr + 1ml/kg/hr for each kg >20 kg60 ml/kg/hr + 1ml/kg/hr for each kg >20 kg

FLUID VOLUME DEFICIT

HypovolemiaHypovolemiaA decreased blood volume that may be caused

by internal or external bleeding, fluid losses, or inadequate fluid intake.

(Taber�s Online Dictionary, 2007)

Fluid Volume Deficit (FVD) or Extracellular Fluid Volume Deficit (ECFVD)

HypovolemiaHypovolemiaFVD occurs when the loss of ECF exceeds the

intake of fluid.(Smeltzer et al, 2008)

Hypovolemia or FVD ≠ dehydration

FVD → Fluid Loss = Electrolyte LossRatio Remains the Same (usually)

CAUSES

� Diabetes insipidus� Fever� Diarrhea� Renal failure� Lack of fluid intake� Malnutrition� Vomiting� Diaphoresis

Pathophysiology and Clinical Pathophysiology and Clinical ManifestationsManifestations

DECREASED FLUID VOLUMEDECREASED FLUID VOLUME

Stimulation of thirst Stimulation of thirst center in hypothalamuscenter in hypothalamus

Person complains of thirstPerson complains of thirst

↑↑ ADH SecretionADH Secretion

↑↑ Water resorptionWater resorption

↓↓ Urine OutputUrine Output

ReninRenin--AngiotensinAngiotensin--Aldosterone System Aldosterone System

ActivationActivation

↑↑ Sodium and Sodium and Water ResorptionWater Resorption

↑↑ Urine specific gravity Urine specific gravity

Pathophysiology and Clinical ManifestationsPathophysiology and Clinical ManifestationsUNTREATED FLUID VOLUME DEFICITUNTREATED FLUID VOLUME DEFICIT

Depletion of fluids availableDepletion of fluids available

↑↑ BODY TEMPERATUREBODY TEMPERATURE

Dry mucous membranesDry mucous membranes

Difficulty with speechDifficulty with speech

Cells become unable to continue Cells become unable to continue providing water to replace ECF providing water to replace ECF

losseslosses

Signs of circulatory collapse Signs of circulatory collapse

↓↓ blood pressureblood pressure

↑↑ heart rateheart rate

↑↑ respiratory raterespiratory rate

Restlessness and ApprehensionRestlessness and Apprehension

� Encourage increase oral fluid intake

� Administer IVF (LR or NSS)

� Monitor I & O� Replace fluid loss

gradually over 48 hours� Monitor Na levels, urine

specific gravity

MANAGEMENT

LABORATORY TESTS FOR EVALUATING FLUID STATUS

� Osmolality � measures the solute concentration per kilogram in blood and urine.

� Osmolarity � concentration of solution per liter.� BUN � (10-20 mg/dL)made up of urea, an end product of

protein metabolism by the liver.� Creatinine (0.7 to 1.5 mg/dL)- end product of muscle

metabolism� Serum electrolytes� CBC

Collaborative Care Key PointsCollaborative Care Key Points

�� 1 Liter of water = 1 kg of water by weight1 Liter of water = 1 kg of water by weight�� Fluid replacement are calculated according to Fluid replacement are calculated according to

this ratio plus 1.5 L to fulfill the current daily this ratio plus 1.5 L to fulfill the current daily needsneeds

�� For example, JUAN, a oneFor example, JUAN, a one--yearyear--old, lost 1 kg of old, lost 1 kg of water from diarrhea as weighed from his diaper water from diarrhea as weighed from his diaper over the last 24 hours. Therefore, since 1 kg=1 L, over the last 24 hours. Therefore, since 1 kg=1 L, fluid replacement therapy for him will involve 1 L fluid replacement therapy for him will involve 1 L of fluids + 1500 L.of fluids + 1500 L.

�� Oral fluid resuscitation is preferable but if the Oral fluid resuscitation is preferable but if the patient is unable to tolerate fluids, IV Therapy patient is unable to tolerate fluids, IV Therapy may be orderedmay be ordered

�� Vital signs should be assessed regularlyVital signs should be assessed regularly

Collaborative Care Key PointsCollaborative Care Key Points��....

�� Postural hypotension Postural hypotension is common for postural persons is common for postural persons with fluid volume deficit. How do we assess this?with fluid volume deficit. How do we assess this?

�� For example, in the care of LOIDA, a 31 year old with For example, in the care of LOIDA, a 31 year old with severe DHN, you take her blood pressure (130/80) and severe DHN, you take her blood pressure (130/80) and pulse (75) while shepulse (75) while she��s lying down. Then you ask her to s lying down. Then you ask her to sit at the edge of bed. When you take her blood sit at the edge of bed. When you take her blood pressure again, you get 115/80 and when you take her pressure again, you get 115/80 and when you take her pulse, you get 80. This is consistent with intravascular pulse, you get 80. This is consistent with intravascular volume depletion.volume depletion.

�� Daily weighing Daily weighing is also useful to monitor fluid and is also useful to monitor fluid and electrolyte balanceelectrolyte balance

�� Laboratory results Laboratory results should be reviewed for various fluid should be reviewed for various fluid and electrolyte disturbances so that appropriate and electrolyte disturbances so that appropriate adjustments to therapy can be initiatedadjustments to therapy can be initiated

Fluid replacement:Depends on - basal requirements- pre-existing dehydration and electrolyte loss- continuing abnormal loss over and above basal requirements

Basal requirements: 30-40 ml/kg of water

Fluid replacement:��.

Pre-existing dehydration

Assessment of deficit from Patient�s historyClinical examination ( weight, pulse, blood pressure, urine output, sign & symptoms of dehydration)Measurement of central venous pressure (normal 3-8 cm of H2O, low reading indicate dehydration)Laboratory test (plasma albumin & hematocrit to assess ECF loss)

Basal requirements can be meet up by 0.9% NaCl, Ringer�s- lactate/ Hartrmann�s saline, 5% dextrose, Dextrose-4%+ 0.18% NaCl saline

Purpose of glucose to make the solution isotonic, not to provide calorie.

ECF losses of water & electrolytes should be replaced either with normal saline or Ringer�s lactate solution with added potassium.

Plasma replacement:

Plasma products: Human plasma protein fraction (HPPF), Human albumin solution (HAS)

Plasma substitutes: Dextran, Gelatin, Hemaccel, Gelofusin (in acute hypovolaemia), Hetastarch (in continuing hypovolaemia, limit the dose upto 1500 ml/70 kg ), Hextend (electrolyte balanced colloid solution)

6 litres of crystalloid are needed to expand the plasma by 1 litre

Operative fluid balance:

For the 1st 36 hrs postoperatively there is water and sodium retention.

Operative blood loss up to 500 ml can be replaced with saline, if blood loss > 1litre, consider blood transfusion.

Give a unit of FFP for every 4-6 units of stored blood transfusion.

Operative fluid balance:In intra-abdominal surgery give up to 2 litres of Hartmann�s solution, it compensate for starvation, ECF loss, evaporation and blood loss

Post operative fluid: Basal requirements plus 1mmol of Na+ & 1 mmol K+ plus additional blood or colloid if significant wound drainage.

Fluid Replacement TherapyAdministration routes

� Oral route : oral ingestion of fluids and electrolytes as liquids or solids administered directly into the GI tract

� Nasogastric route: instillation of fluids and electrolytes through feeding tubes, such as NG, gastrostomy and jejunostomy tubes

� I.V. route: administration of fluids and electrolytes directly into the bloodstream using continuous infusion, bolus, or I.V. push injection through peripheral or central venous site

Fluid Replacement TherapyISOTONIC SOLUTION

FactsFacts ExamplesExamples UsesUses

--same osmolality as plasma (app. same osmolality as plasma (app. 275 to 295 mOsm/kg)275 to 295 mOsm/kg)

--vascular space osmolality not vascular space osmolality not altered by infusionaltered by infusion

--expand intracellular and expand intracellular and extracellular space equally; degree extracellular space equally; degree of expansion correlates with of expansion correlates with amount of fluid infusedamount of fluid infused

--no solutionno solution--related shifting related shifting between ICF and ECF spacesbetween ICF and ECF spaces

--cells neither shrink nor swell with cells neither shrink nor swell with fluid movementfluid movement

Dextrose 5% in Dextrose 5% in water,water,

Normal Saline Normal Saline Solution,Solution,

Lactated Ringers Lactated Ringers SolutionSolution

--Fluid loss and Fluid loss and dehydrationdehydration

--HypernatremiaHypernatremia

--Blood transfusion, Blood transfusion, fluid challenges, fluid challenges, resuscitation, shock, resuscitation, shock, metabolic alkalosis, metabolic alkalosis, hypercalcemia, hypercalcemia, hyponatremiahyponatremia

--Acute blood loss, Acute blood loss, burns, dehydration, burns, dehydration, hypovolemiahypovolemia

Fluid Replacement TherapyHYPOTONIC SOLUTION

Fluid Replacement TherapyHYPERTONIC SOLUTION

HypervolemiaHypervolemiaECF → H2O gain is balanced with retention of

sodium

Usually secondary to retention of sodium

Concentration of sodium to H2O is balanced �serum sodium levels usually WNL

Extracellular Fluid Volume Excess (ECFVE)

FLUID VOLUME EXCESS

CAUSES1. Excess fluid or sodium intake

a. IV administration of NSS or LRb. High intake of dietary Na

2. Fluid and Na retention3. Fluid shift into the intravascular space

a. Burnb. use of plasma albumin

4. Hormonal Imbalances - ADH 5. Can occur secondary to heart failure, renal

failure, or cirrhosis of liver

FLUID EXCESS/HYPERVOLEMIAFLUID EXCESS/HYPERVOLEMIA

Psychiatric Psychiatric Disorders, SIADH, Disorders, SIADH,

Certain head injuriesCertain head injuries

Dietary Sodium Dietary Sodium IndiscretionIndiscretion

Renal and endocrine Renal and endocrine disturbances, disturbances,

malignancies, adenomasmalignancies, adenomas

OverhydrationOverhydrationExcessive Sodium Excessive Sodium

IntakeIntake

Failure of renal or Failure of renal or hormonal regulatory hormonal regulatory

functionsfunctions

FLUID VOLUME EXCESS/HYPERVOLEMIAFLUID VOLUME EXCESS/HYPERVOLEMIA

� Edema� Increase in weigHt� Puffy eyelids� Poor skin turgor� Tachypnea� Dyspnea� Distended neck veins &

tachycardia� Increased blood pressure� Crackles & wheezes � Maybe ascites & pleural effusion� Increase in CVP

Signs and symptoms

Hypervolemia

� Diagnostic Findings:� Decreased hematocrit resulting from hemodilution

� Normal serum Na level

� Low serum K and BUN levels � either due to hemodilution or higher levels may indicate renal

failure

� Low oxygen level

� Abnormal chest x-ray� Indicates fluid accumulation

� May reveal pulmonary edema or pleural effusions

MANAGEMENT

� Monitor I & O� Limit water� Skin care� Turn patient every 2 hours� O2� Limit Na� Monitor electrolyte values

Water intoxication:- over prescribing of 5% glucose solution to post operative patient

- colorectal washout with plain water

- excessive uptake of water from irrigation ( in TURP)

- SIADH ( in head injury, pneumonia, empyema, oat cell carcinoma of bronchus

Clinical features of water intoxication

Drowsiness, weakness, convulsion and comaNausea and vomiting of clear fluid

Signs � puffiness of face, pitting edema, polyuria, low sp. Gravity, respiratory distress

Treatment:Restriction of water intakeNever use diuretics and hypotonic solution except

grave condition

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