Fluid/s

Prof. Mridul M. Panditrao

Professor, Head & In-Charge of ICU

Dean of Academic Affairs

Department of Anaesthesiology & Intensive Care

Adesh Institute of Medical Sciences & Research

(AIMSR)

Adesh University

Bathinda, Punjab, India

Introduction

Water is life!

Journey of life starts in Water!

Water is also a dramatic Paradox

Too less or too much = Incompatible with life

So the life is geared up around maintaining the

equilibrium !!

In Fact entire life of the living thing is spent in maintaining

The fluid balance

pH balance

Introduction

Quantitatively most important Body constituent

Males = 60%

Of the total body weight

Females 50%

The lesser percentage in females because of larger fat

content.

Water is found in each and every tissue of the body,

including bones and cartilages!

Body

Compartments Total Body Mass

Total Body Water (TBW)

Extra Cellular Fluid (ECF) Intra Cellular Fluid (ICF)

Solid Tissues

Intra Vascular Fluid Interstitial fluid

Distribution of Body water

Intra-Vascular Compartment

5%

Interstitial Compartment

15%

Intra- Cellular Compartment

40%

Tissues

40%

Percentage Distribution of Various Body Compartments

Intra-Vascular Compartment Interstitial Compartment Intra- Cellular Compartment Tissues

Definitions

Total Body Water (TBW) :

The sum of intracellular water and extracellular water (volume)

The latter consisting of

the interstitial or tissue fluid

the intravascular fluid or plasma.

About 60% of body weight

http://medical-dictionary.thefreedictionary.com/total+body+water

http://www.medilexicon.com/medicaldictionary.php?t=99650

Definitions

The Extra-Cellular Fluid (ECF): The water content found outside the body cells

Constitutes two major compartments

Inra-vascular & interstitial

Also contain the trans-cellular fluids that are formed by active transport processes

Include the fluids of the eye and the secretory glands e.g. saliva, GIT and sweat glands

In the cavities and channels of the brain and spinal cord (Cerebrospinal fluid, CSF)

Lymph

In body cavities lined with serous (moisture-exuding) membrane and

In muscular and other body tissues

Ingested water or water produced by the body's metabolic processes (metabolic water).

http://www.britannica.com/EBchecked/topic/199041/extracellular-fluid

Definitions

Intra Cellular Fluid ( ICF):

a fluid within cell membranes of the tissue cells, throughout

most of the body

containing dissolved solutes that are essential to

electrolytic balance and to healthy metabolism.

Also called intracellular water

constituting about 30–40% of the body weight.

http://medical-dictionary.thefreedictionary.com/

www.medilexicon.com/medicaldictionary.php?t=34113

Rule of 1/3

Out of all the compartments in TBW

We can manipulate only ECF Compartment

More specifically only Intra-Vascular Compartment

Quantity of ECF is 1/3rd of the TBW

Quantity of Intravascular Compartment is 1/3rd of ECF

Intra Vascular Volume: Blood

Blood Volume: is the volume of blood (both red blood

cells and plasma) in the circulatory system of any

individual.

Effective Circulating Volume: that proportion of

Intra- vascular volume ( thus of ECF) that is effectively

perfusing the tissue cells

It is in direct proportion to the

ECF

Solute Content dissolved in it ( esp. Na+ salts)

Solutes hold the water in ECF

Solutes:

Solute: A substance dissolved in another substance or water

both of in-organic as well as organic origin

Solutes in ECF: by and large of in-organic type

E.g. Na+, Cl-, HCO3

-,

Solutes in ICF: Mixture of Both

E.g. K+, Organic Phosphate esters( ATP, CreatinePhosphate… etc.)

•Mole - A mole is the amount of a substance that contains the number

of molecules equal to Avogadro's number.•The mass in grams of one mole of a substance is the same as the number of atomic mass units in one

molecule of that substance.

•i.e. the molecular weight of the substance expressed as grams)

•The mole (symbol: mol) is the base unit in the SI system for the amount of a substance

•Molality of a solution is the number of moles of solute per kilogram of

solvent

•Molarity of a solution is the number of moles of solute per liter of

solution

Avogadro's number - this is the number of molecules in

one mole of a substance (ie 6.022 x 1023)

Osmole

The amount of a substance

that yields, in ideal solution

that number of particles = (Avogadro’s number)

that would depress the freezing point of the solvent by 1.86K

Osmolality & Osmolarity

Osmolality: Osmolality is a measure of the number of

solute particles present in solution

Is independent of the size or weight of the particles

Expressed as : milliosmoles per kilogram of water ( m

Osmol/Kg)

Osmolality of a solution is the number of osmoles of solute

per kilogram of solvent ( m Osmol/Kg)

Osmolarity of a solution is the number of osmoles of solute

per liter of solution ( m Osmol/L)

http://www.anaesthesiamcq.com/FluidBook/fl2_3.php

Osmolality & Osmolarity

The value measured in the laboratory is usually referred

to as the ‘osmolality’

The value calculated from the solute concentrations is

reported by the laboratory as the ‘osmolarity’

The Osmolar gap is the difference between these two

values

Tonicity

Tonicity is the effective osmolality

Is equal to the sum of the concentrations of the solutes

which have the capacity to exert an osmotic force

across the membrane

Osmolality is a property of a particular solution and is

independent of any membrane

Tonicity is a property of a particular solution in reference

to a particular membrane

Tonicity

It is strictly wrong to say this or that fluid is isotonic with

plasma

what should be said is that the particular fluid is isotonic

with plasma in reference to the cell membrane

By convention, this specification is not needed in

practice as it is understood that the cell membrane is the

reference membrane involved.

Tonicity Vs. Osmolality

refers to the relative

concentration of two solutions.

hyperosmotic, means the

concentration of solutes

outside the cell is greater than

the concentration inside the

cell

• refers to what the cell

does in a certain

environment.

• If the environment is

hypertonic, the cell will

shrink due to water

leaving the cell.

• Hypotonic means water

enters the cell makes it to

expand and possibly

explode.

Effect is same:

If a hyperosmolar/ hypertonic solution was administered to a

patient, this would tend to cause water to move out of the cell.

Electrolytes: definition

An electrolyte

is a substance that ionizes when dissolved in suitable

ionizing solvents such as water

This includes most soluble salts, acids, and bases

Some gases, such as hydrogen chloride, under

conditions of high temperature or low pressure can also

function as electrolytes

Cations: Positively charged e.g. Na+, K+, Ca++, Mg++

Anions: Negatively Charged e.g. Cl-, HCO-, OH-, HPO4--

,SO4--

http://en.wikipedia.org/wiki/Electrolyte

Main Electrolytes per Compartment

Electrolytes (mEq/L) ECF: Cations ECF: Anions ICF: Cations ICF: Anions

Sodium Na+ 135 - 145 - 8 -10

Potassium K+ 3.5 - 5.5 148 -152

Calcium Ca++ 7 - 10 0.001

Magnesium Mg++ 1.5 - 4 40!

Chloride Cl- 95 -105 1-2

Bicarbonate HCO3 - 20 - 24 4-7

Phosphate HPO4 +

Sulphate SO4

145 - 155 5 - 9

Plasma Osmolality

Plasma or Serum Osmolality is Number of solutes

dissolved in plasma

Normal range is : 275 -290 m Osmols/ Kg of Plasma

Equation for calculation:

Plasma Osmolality = 2x S. Na + S. Glucose/18 + BUN/2.8

Conversion factor for BUN = B. Urea(mg/dl) /2.14

P. Osmol = 2x S. Na + S Glucose/18 + B. urea x 2.8/ 2.14

Body Water Regulation

Increase in osmolality stimulates osmo-receptors

in antero-lateral hypothalamic nuclei

Thirst

Neuro-hypophysis

ADH & AVP

Decreased excretion by increasing

re-absorption.

Insensible water loss

Skin = 400 - 450 ml/day

RS = 400 - 500 ml/day

GIT (Stool) = 100-200ml/daay

Sweat is not insensible loss

Total Minimal loss around 1L/day

Calculation

Daily Total imperative requirement in a surgical patient/

person is

= absolutely required minimal Urine output + 800-1000 ml

In a 60 kg male

i.e. 0.6-0.7ml/kg/hr + 800-1000 ml

40ml/hr = 1000ml + 1000 ml

2000ml/24 hrs = 80 – 100ml/hr

Classification of I V Fluids

Blood and Products

I V Fluids

Non blood I V Fluids

Crystalloids Colloids

Glucose Containing

Electrolyte solutions

Mixed

Proteinous Non proteinous

Polygelins

• Haemaccel

• Gelofusin

Albumin

20% & 5%Starches Dextrans

HES

PentaStarch

Tetrastarch

Lomodex (Dextran 40)

Macrodex (Dextran 70)

Rheomacrodex (Dextran

110)

Relative tonicity

Isotonic : R L, 1N NaCl,D5W (inside body becomes

hypotonic)

Hypertonic: 5DNS, 5D in RL, 5D in ½ N NaCl, 3% NaCl

Hypotonic: ½ N NaCl

20% Albumin has osmotic effect 5 times its volume

i.e. 100 ml will increase plasma volume by 400-500ml

Given at the rate of 1-2 ml/min

Correcting fluid deficit is absolutely inperative

5% will increase only by 100 ml ( 0.5-1 ml/min)

Colloids: Dextrans

Dextrans are branched polymers of Glucose molecule

40, 70 and 110 are, mol. Wts : 40000, 70000 and 110000 Daltons

40 is 10% while 70 is 6%

Act as Antithrombotic, by decreasing RBC aggregation

Total dose not more than 20ml/kg in 24 hrs

Hyperglycemic effect

Not commonly used nowadays

Colloids : starches

Excellent Volume expanders

All of the volume remains inside Intra vascular compartment

Effect lasts for 4-6 hours

Interference with platelet aggregation: HES> Penta> tetra,

Least

Increase the volume by nearly 100 to 150 % depending upon

% conc.

Tetrastarch: Voluven Better of all

Made from corn starch: least antigenic

Up to 35ml – 50 ml/ kg/ 24 hours can be given

Colloids: Polygelins

Modified: degraded gelatin polymers

Derived from animal bones

Can expand plasma by 50%

Do not have any interference with agglutination, platelet

aggregation

Have been found have variety of allergic reactions :

minor to anaphylaxis

Have been implicated in transmission of Creutzfeldt-

Jakob’s disease (Mad Cow disease) to humans

Slowly becoming obsolete

Hypovolemia

ECF Volume Reduced

Extra renal

Hemorrhage

Gastro-intestinal

Skin

Renal

Diabetes insipidus

Diabetes mellitus

Drugs: Diuretics

Hypoaldosteronism

Salt wasting nephropathies

Hypovolemia

ECF Volume increased ( Low circulatory/Intra-Vascular volume)

Decreased Cardiac Output

CCF

Redistribution of Fluid

Decreased PCOP

Cirrhosis

Nephrotic Syndrome

Capillary leak

Ischemic Bowel: Third space loss

Ac. Pancreatitis

Increased Venous Capacitance

Anaphylaxis

Mixed of all

SEPSIS

Diagnostic Criteria

S. Na: Low if both Na+H2O, High if only H2O

BUN/ S. Creatinine raised & BUN: Creatinine ratio > 20:1

:: .. If Pre-Renal azotemia

CVP: 2 tests

Lower than normal (8 – 10 CM H2O) = In IPPV patient deduct PEEP of more than 5 cm

H2O :

Volume Challenge: 250-500 ml of rapid infusion RL/NS will increase CVP, but cannot sustain it

more than 10 minutes.

USG & IVC = correlation between

IVC size, Respiration & CVP

IVC size decreases with respiration

IVC Size Respiratory

change

CVP cm

H2O

<1.5 Total Collapse 0-5

1.5 -2.5 >50% Collapse 6-10

1.5 -2.5 < 50% Collapse 11-15

>2.5 <50% Collapse 16-20

>2.5 No Change >20

Hemorrhagic Hypovolemia: Surgical

Calculate Estimated Blood Volume (EBV): approx. 75-80 ml/ Kg

Categorize the blood loss: Fromme - Boezaart Surgical Field Grading

Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional

endoscopic sinus surgery. Canadian Journal of Anaesthesia 1995; 42: 373-6

F-B

Grade

% age of

EBV

Fluid to be

transfused

1 - 2 Less than

10

Maintenance with

NaCl/ RL=

1ml/kg/hr

3 10 - 20 Increase the rate

of Crystalloid =

2ml/kg/hr

4 20 – 25% Colloid

5 25% or

more

Stat Blood

transfusion

Management : Non Hemorrhagic Hypovolemia

Intra-Venous Fluids : Irrespective of Na level.. Initial fluid is NS

If Na low– 0.9% N NaCl

If Hypernatremia : ½ N NaCl

Strict I/O chart with Hourly urine record

Choice of I V fluid as per I-V Compartment stay : 1 Liter

Type of fluid Intra vascular in

ml

Interstitium in ml Intra cellular in

ml

5% D/W 75-100 (10%) 230 - 260 ( 20-

23%)

670 (67%)

1 N NaCl 300 (30%) 700 (70%) 0 (0%)

1/2N NaCl 170 (17%) 500 (50%) 330 (33%)

Colloids 1000 (100%) 0 (0%) 0(0%)

According to indication

Pathology Choice of IV Fluid

Non-Hemorrhagic hypovolemic

shock

NaCl/RL/Colloids

Diarrhea RL/ NaCl

Vomiting Isolyte G, NaCl

DKA NaCl

Burns RL

Starvation 5% D/W

Maintenance Adult Isolute M

Maintenance Pediatric Isolyte P

Required Na = desired Na – actual Na x ( 0.6 x Body weight in Kg.): 0.5 females

Protocol

Impossible to measure exactly the total deficit

Empirically : RL or NaCl at the rate of 30ml/Kg bolus

RL is preferred as less chances of Hyperchloremic metabolic

acidosis

Strict watch on: vitals, CVP, Urine output, GCS, ABG

Maintain CVP 8-12cm H2O

Urine 0.5-0.6ml/kg/hr

Improved sensorium

Decreased Hematocrit and BUN: creatinine ration> 20:1

Decreased Metabolic Acidosis

SIADH

Syndrome of impaired water excretion with retention of

water leading to increase in TBW, hyponatremia but NO

CLINICAL OEDEMA

Multiple aetio-pathgeneses: stress, surgery, anesthesia,

pain, sepsis, inflammatory process, tumors, CNS

disorders

Low Na: 130, low osmolality < 270 mosm/L ,but

normovolemia

Increased urine osmolality>100mosm/L,

urine Na> 40mEq/L

Normal renal,endocrine, K levels and acid-base

balance

Correct underlying cause

Fluid restriction: < 800ml/day

Loop Diuretic

Hypertonic (3%) NaCl

High Protein diet will increase renal water

excretion

SIADH

DKA

Triad: Hyperglycemia, Dehydration and Hyperketonemia with

Metabolic acidosis

Deficit levels in DKA

Fluid deficit: 100ml/Kg---- 50% replace with NaCl (ECF)

---- 50% replace with dextrose (ICF)

Na 7-10 mEq/Kg

K 3-5 mEq/kg

PO4 5-7

Ca 1-2

Mg 1-2

ABG: severe acidosis with HCO3 grossly reduced

DKA: Management

A,B, C

Fluid Therapy

NaCl: 10-15ml/Kg/hr. up to 50ml/kg in first 4 hours

1000ml in first 30 min : next 1000 in 1hour: next 1000 in next 2

hours: next 1000 in next 2-4 hours

When Blood sugar to 250mg/dl: D5W 1000ml/ 8hourly : continue

with NaCl and D5W 1000 ml every 12 hours

Nearly 6 liters fluid in first 24 hours

Strict watch on CVP, I/O, urine, ABG(acidosis), sensorium, S. Na

levels

Strict watch On S. K levels.

DKA : Insulin

Role of Insulin: if K > 3.3 mEq/Lit

After intial NaCl infusion has started

Initial Infusion of 0.15 Unit/Kg regular = 10 units/ hr

Or Add 50 units in 50 ml NaCl

6units/hr infusion initially

Reduce to 5 units/hr when glucose < 500mg/dl

Reduce to 4 units/hr when glucose < 400 mg/dl

Reduce to 3 units/hr when glucose < 300 mg/dl

Reduce to 2 units/hr when glucose < 200 mg/dl

Maintain on 0.05-0.1unit/kg/ hr infusion

Switch over to sub cutaneous once sugar <200, HCO3 >18

DKA: Potassium Replacement

Despite total Body K deficit S.K is normal

With Volume replacement the K level drops

K <3.5 = KCl 40 mEq/L : Give 1 L of NaCl

K 3.5- 5 = KCl 20 mEq/L :Give 1 L of NaCl

K > 5 or Anuria NO KCl to be given

EKG:

Tall Ts HyperKalemia &

Flat Ts and Us HypoKalemia

DKA: HCO3

Not Recommended routinely

Only if

pH <7, Shock/ Coma, CVS/RS , Hyper Kalemia

If ABG not available:

(24 - pt’s HCO3) x (0.5 x Wt. in Kgs.)

If ABG available:

HCO3 required = BE x 1/3 of Body Wt. in Kg. & ½ correction

DKA : Supportive T/t

O2 By mask/ Venti-Mask / ETT & IPPV

CVP

N G / Urinary Catheter = I/O Balance

Colloid If MAP< 60 mmHg/ Syst BP< 90mm Hg

Antibiotics/Gastric Prophylaxis/

Mg and PO4 correction if required

Burns : Fluid Therapy

Goals:

To Maintain tissue perfusion : confirmed by hrly urine

output

To reduce the rate of catabolism or

To overcome the negative effects of Catabolism

If less than 20% burns = Oral fluids.. Exceptions facial,

hand and genital burns

If more : Parkland’s formula = total vol. in first 24 hours.

Parkland’s Formula

4ml/Kg/% burn for adult & 3ml/Kg/% burn for children

Ringer’s Lactate only

Total calculation to be transfused in first 24 hours

50%( half the volume) given in first 8 hours

Remaining 50% ( half) in next 16 hours

Children:

4 ml/kg/% burn in 0 – 10 kg

40 ml/hr + 2ml/hr for 10 – 20 kg

60 ml/ hr + 1ml/kg/hr for more than 20 kg

Next24 hours: No crystalloids, 5% Albumin (Colloid)

Up to 60% of estimated Plasma Volume

D5W as maintenance for urine: 0.5 – 1 ml/hour

Modified Parkland formula

Initial 24 hours R L 4ml/kg/ % burn

Next 24 hours Colloid infusion 5% albumin 0.3 -1

ml/kg/% burns

Parkland’s formula

Conclusion

Fluid Therapy is the ‘ Make’ or ‘Break’ for many

patients.

Especially in evolving/ imminent or existing Crisis

Understanding and executing appropriate fluid

therapy is the most essential duty of a clinician

A small oversight or miscalculation can cause a

major disaster for the patient

Continuous updating of our knowledge is most

essential

Thank You!