fluid managament by dr shahab

7/27/2019 Fluid Managament by Dr Shahab

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J A M I A I S L A M I A I S H A T U L U L O


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INDIAN INSTITUTE OF MEDICAL SCIENCE AND R


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PG ACTIVITY PRESENTAT

DEPT OF ANESTHESIA


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FLUID MANAGEMEBY

DR SHAHAB SHAIKH

ASSISTANT PROF

DEPT OF PHYSIO


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BODY FLUIDS

Total Body Water (TBW):

Varies with age, gender, body habitus

55 - 60% body weight in males

45 - 50% body weight in females

80% body weight in infants

Less in obese: fat contains little water


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BODY FLUIDS

Body Water Compartments:

Intracellular fluid: 2/3 of TBW

Extracellular fluid: 1/3 TBW

Extravascular fluid: 3/4 of extracellular

Intravascular fluid: 1/4 of extracellular


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BODY FLUIDS

Body Water Compartments


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BODY FLUIDSBody Fluid Electroytes:

ELECTROLYTE ECF (mEq/L) ICF Na 142 10K 4.3 150Cl 104 2Hco3 24 6Ca 5 0.0Mg 3 40


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BODY FLUIDS

Body Fluid Electrolyte:


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BODY FLUIDS

Non Electrolytes of Plasma:


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BODY FLUIDS

Tonicity of Fluids:


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BODY FLUIDS

Daily Intake and Output of Water:


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BODY FLUIDS

Daily Intake

and

Output of Water:


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I V FLUIDS

Classification:

CRYSTALLOIDS

COLLOIDS

BLOOD PRODUCTS


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I V FLUIDS

Crystalloids:

Clear solutions made up of water & ele

These fluids are good for volume expa

Both water & electrolytes will cross me

and achieve equilibrium in 2-3 hours.

3mL of isotonic crystalloid solution are

replace 1mL of patient blood.


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I V FLUIDSCRYSTALLO


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I V FLUIDS

Colloids:

Colloids are large molecular weight so

Do NOT readily cross semi-permeable

membranes or form sediments.

Because of their high osmolarity, thes

important in capillary fluid dynamics

These fluids stay almost entirely in the


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I V FLUIDSCOLLOIDS


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I V FLUIDSCOLLOIDS

Na Cl K Lactate Ca M

GelofusinElohaes,Voluven VolplexHaesterilAlbumin

150 120-150

Haemacell 145 145 5 6

Geloplasma 150 100 5 30 1

Volulyte 137 4 110 1

DEPARTMENT OF ANESTHESIAINDIAN INSTITUTE OF MEDICAL SCIENCE AND RESEARCH


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I V FLUIDS: 5% Dextros

Contains 50 gm Glucose/L

Used for Rx of dehydration, Pre & Poreplacement, IV drugs administration, etc

Contraindicated in Cerebral Edema, Ne

procedures, Ac Stroke, Hypovolem

Hyponatremia Blood transfusion through the same

Dextrose should not be done.

Can be given @ 0.5gm / Kg body Wt. / H


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I V FLUIDS: 0.9% saline

Contains 9.0 gm NaCl/L (Na: 154 mEq, C

Used for Rx of water & salt depletionVomiting, Diarrhoea, Exc sweating, etc.

Rx of Hypovolemic Shock, Hyponatrem

administration, etc.

Contraindicated in Hypertensive pts, ppts,

Used Cautiously in pts with CCF, Rena

cirrhosis, very young or old pts.


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I V FLUIDS: RINGER LACT

Contains Na: 130, Cl: 109, K: 4, Ca: 3

mEq/L. . . . . Most Physiological fluid ! Used forRx of Hypovolemia, Metabolic A

For fluid replacement in Pre. Intra & P

Burns, #s, Peritoneal Irrigation, DKA etc.

Contraindicated in Liver Disease, severeShock pts, Met Alk due to Vomiting or NG

Simultaneous infusion of RL and Blood p

Ca in RL binds with certain drugs and

bioavailability and efficiency.


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I V FLUIDS: The Isolytes

ISOLYTE G: is Gastric replacement sol

Only IV Fluid which directly corrects any Me ISOLYTE M: is Maintenance solution

Richest source of K+ (35 mEq/L)

ISOLYTE E: is Extracellular replaceme

Only IV fluid which corrects Magnesium def Provides maximum HCO3 among all IV fluid

ISOLYTE P: is Pediatric maintenance s

Has half concn. of electrolytes as compared


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I V FLUIDS


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I V FLUIDS


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Assessment of volume status

Mild:

Thirst

Concentrated Urine

Moderate:

Dizziness, Weakness

Oliguria

Postural Hypotension

Low JVP

Severe:

Confusion, S

Systolic BP

mmHg

Tachycardia

Volume

Cold ExtremCapillary filli

Reduced sk


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Assessment of volume status

A more invasive approach:

Urine output

Central venous line

Arterial line

PAWP catheter


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Deficits Maintenance

3rd Space loss

Blood loss

FLUID MANAGEMENT


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FLUID MANAGEMENT

Deficit:

Estimate

Preop NPO (hourly maintenance x duration)

Preop bowel preparation (1-1.5L)

Preop blood loss (trauma) or fluid loss (burn

Typically replaced over first 2-4 hours


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FLUID MANAGEMENT

Maintenance:

(4-2-1 rule) 4 ml/kg/hr for first 10 kg of body weight

2 ml/kg/hr for 2nd 10 kg of body weight

1 ml/kg/hr for each kg of body weight above

Example: 70 kg adult= 40 cc/hr for 1st 10 kg BW

+ 20 cc/hr for 2nd 10 kg BW

+ 50 cc/hr for remaining 50 kg BW

= 110 cc/hr

G


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FLUID MANAGEMENT

Third Space Losses:

Isotonic transfer of ECF from functional bod

compartments to non-functional compartme

Depends on location and duration of surgica

amount of tissue trauma, ambient temperat

ventilation.

FLUID MANAGEMENT


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FLUID MANAGEMENT

Replacing Third Space Losses:

Superficial surgical trauma: 1-2 ml/kg/hr

Minimal Surgical Trauma: 3-4 ml/kg/hr

head and neck, hernia, knee surgery

Moderate Surgical Trauma: 5-6 ml/kg/hr

hysterectomy, chest surgery

Severe surgical trauma: 8-10 ml/kg/hr (or m

AAA repair, nephrectomy

FLUID MANAGEMENT


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FLUID MANAGEMENT

Replacing Blood Losses:

3 to 1 ratio of crystalloid

1 to 1 for colloid or blood

FLUID MANAGEMENT


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Mai

FLUID MANAGEMENT

TIME TO PUT IT ALL TOGETHER:

Deficits

B 3rd Space loss

FLUID MANAGEMENT


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FLUID MANAGEMENT

Calculating Rate of Fluid Infusion:

For routine I.V set 15 drops = 1 ml

Rule of Ten for infusion rate in 24 hrs.

I.V fluid in litre/24 hrs X 10 = Drop rate / min

Rule of Four for infusion rate in 1 hr.

I.V fluid in ml/ hour 4 = Drop rate / min

FLUID MANAGEMENT


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FLUID MANAGEMENT

Risks of Excess Fluid:

Interstitial edema

Impaired cellular metabolism

Poor wound healing

Decreased pulmonary compliance

Heart failure overload

Delayed return of bowel function

Hemodilution

FLUID ANYWAYS


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FLUID ANYWAYS . . .

A DEPT OF ANESTHESIA PRESENT


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A DEPT OF ANESTHESIA PRESENT

THANK Y

Daily Requirements


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Daily Requirements

The normal electrolyte requirements are:

Na+ 1-2 mmol/kg/24 h

K+ 0.5-1 mmol/kg/24 h.

Sodiumimbalance

Definition

Risk factors/etiology

Clinicalmanifestation

Laboratoryfindings


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s

Hyponatr

-aemia It is

defined

as aplasma

sodium

level

below

135

mEq/ L

Kidney diseases

Adrenal

insufficiency

Gastrointestinal

losses

Use of diuretics

(especially with

along with low

sodium diet)

Metabolic acidosis

Weak rapid

pulse

Hypotension

Dizziness

Apprehensionand anxiety

Abdominal

cramps

Nausea and

vomiting

Diarrhea

Coma andconvulsion

Cold clammy

skin

Finger print

impression on

the sternum after

palpation

Personality

Serum sodium

less than

135mEq/ L

serumosmolality less

than

280mOsm/kg

urine specific

gravity less

than 1.010

Sodium Definiti causes Clinical

f

Lab findings ma


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imbalan

-ce

on manifestation

Hypernat

-remia

It is

define

d as

plasma

sodiu

m

level

greate

r than

145m

E

q/L

*Ingestion of

large amount

of

concentratedsalts

*Iatrogenic

administratio

n of

hypertonic

saline IV

*Excess

alderosterone

secretion

Low grade

fever

Postural

hypertension Dry tongue

& mucous

membrane

Agitation

Convulsion

s

Restlessne

ss

Excitability

Oliguria or

anuria

Thirst

Dry

&flushed skin

*high serum

sodium

135mEq/L

*high serum

osmolality295

mO sm/kg

*high urine

specificity

1.030

*Ad

hyp

sol

*R

sod

cer

*Sl

IV

red

mo

the

de

*D

cas

*In

Potassiumimbalances

Definition

Causes Clinicalmanifestation

Lab findings Ma


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Hypokalemi

a

It is

defined

as

plasma

potassiu

m levelof less

than 3.0

mEq/L

*Use of

potassium

wasting

diuretic

*diarrhea,vomiting or

other GI

losses

*Alkalosis

*Cushingssyndrome

*Polyuria

*Extreme

sweating

*excessive

*weak

irregular pulse

*shallow

respiration

*hypotesion

*weakness,

decreased

bowel sounds,

heart blocks ,paresthesia,

fatigue,

decreased

muscle tone

intestinal

obstruction

* K less

than 3mEq/L

results in ST

depression ,

flat T wave,

taller U wave

* K less

than 2mEq/L

cause

widened

QRS,

depressedST, inverted T

wave

Mil

hyp

can

pot

Mod*K-3

100t

pota

rise

Sev

less

200t

leve

*Die

pota

corre

prob

Definition Causes Clinical Lab findings Man


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manifestation

g

Hyperkal

emia

It is

defined

as the

elevation

of

potassiu

m level

above

5.0mEq/L

Renal failure ,

Hypertonic

dehydration,

Burns& trauma

Large amount of

IV administration

of potassium,

Adrenal

insufficiency

Use of

potassium

retaining

diuretics &

ra id infusion of

Irregular slow

pulse,

hypotension,

anxiety,

irritability,

paresthesia,

weakness

*High serum

potassium

5.3mEq/L

results in

peaked T

wave HR 60

to 110

*serum

potassium of

7mEq/Lresults in low

broad P-

wave

*serum

potassium

levels of

8mE /L

*Die

pota

less

*Mild

be c

impr

forci

salin

wast

*Sev

man

1.inf

gluco

the a

pota

myo

2.inf

Calciumimbalan

ces

Definition

Causes Clinicalmanifestation

Labfinding

s

M


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ces s

hypocal

cemia

It is a

plasma

calcium

level

below

8.5

mg/dl

Rapid

administration of

blood containing

citrate,

hypoalbuminemi

a,

Hypothyroidism ,

Vitamindeficiency,

neoplastic

diseases,

pancreatitis

Numbness

and tingling

sensation of

fingers,

hyperactive

reflexes,

Positve

Trousseaus

sign, positive

chvosteks sign,

muscle

cramps,

pathological

fractures,

Serum

calciu

m less

than

4.3

mEq/L

and

ECG

change

s

1.Asymtom

treated wit

chloride, ca

calcium lac

2.Tetany fro

hypocalcem

chloride or

avoid hypot

and other d

3.Chronic o

can be trea

of food high

Calciumimbalanc

e

Definition Causes Clinicalmanifestation

Lab findings Man


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e

Hypercal

cemia

It is

calcium

plasma

level over5.5 mEq/l

or 11mg/dl

Hyperthyro

idism,

Metastaticbone tumors,

pagets

disease,

osteoporosis

,

prolonged

immobalisatio

n

Decreased

muscle tone,

anorexia,

nausea,

vomiting,

weakness ,

lethargy,

low back painfrom kidney

stones,

decreased

level of

consciousness

& cardiac

High serum

calcium level

5.5mEq/L,

x- ray

showing

generalized

osteoporosis,

widened

bone

cavitation,

urinary

stones,

elevated BUN

25mg/100ml,

1.IV

rapi

prom

excr

2.Pl

antit

decr

calc

3.Ca

seru

4.Co

com

and

abso

5. If

Acid-Baseimbalance

Definition Causes Clinicalmanifestation Lab findings


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Respiratory

acidosis

Hypoventilatio

n& excessive

CO2

production

It is a

clinical

disorder

in which

the pH isless than

7.35 and

the

paCO2 is

greater

than

42mmHg

COPD,

neuromuscular

disorder,

Guillian-Barre

syndrome,Myssthenia

gravis,

Respiratory

center

depression,

Drugs, late

ARDS,

Dyspnea ,disorientation

, coma

PH lesser than

7.35,

Paco2 greater

than 45mmHg,

Hyperkalemia,Hypoxemia

RespiratoryAlkalosis

Hyperventilation

It is aclinical

condition

in which

the

arterial

Ph is

greater

than7.45

Hypoxemia,impaired lung

expansion,

thickened

alveolar

capillary

membrane,

Chemical

stimulation of

Tachypnea,giddiness,

dizziness,

syncope,

convulsions

, coma,

weakness,

paresthesia

, tetany

PH greaterthan 7.35

PaCO2 lesser

than 35

mmHg,

Hypokalemia,

Hypocalcemia

Definition causes Clinicalmanifestation

Lab findings


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Metabolic

Acidosis

It is a

clinical

condition in

which theHCO3 &

pH is

decreased

Renal failure,

Diabetic

ketoacidosis,

Lactic acidosis,ingested toxins,

renal tubular

acidosis

Hyperventilatio

n confusion,

drowsiness,

coma,headache

PH< 7.35,

HCO37.45

HypokalemiaHypocalcemi

a

PaCO2

normal or

increased

fluid managament by dr shahab

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