Fluid Therapy

Irawan Kantawijaya 406127013 Faculty of Medicine Tarumanagara University Surgery and Anesthesia Department Ciawi County Hospital Period: September 30th, 2013 December 7th, 2013

LEMBAR PENGESAHAN

Referat: Fluid Therapy Disusun oleh: Irawan Kantawijaya Fakultas Kedokteran Universitas Tarumanagara 406127013

Sebagai salah satu syarat untuk mengikuti ujian kepaniteraan ilmu Bedah RSUD Ciawi Fakultas Kedokteran Universitas Tarumanagara.

Ciawi, 8 November 2013 Pembimbing Ketua SMF

dr. Sjaiful Bachri, SpB

dr. Sjaiful Bachri, SpB

Chapter I Introduction

Body consists mainly of water. Water and nutrients contained in it that are referred to in the body fluids into the body works by transporting nutrients to all cells of the body and remove waste products from cellular metabolism results to support the sidelines of life. Total body fluid can be vary depending of the age, sex, and lots of body fat. Our body consist of 60% water, while the remaining 40% is a solid substance such as protein, fat, and minerals. The proportion of body fluids decreases with age, and is lower in women because they have more fat, and fat contains less water. While neonates or infants are particularly vulnerable to water loss because it has the highest water content compared to adults. Water content in babies born around 75% body weight, age 1 month 65%, 60% of adult men and 50% women.1 Substances contained in body fluids include water, electrolytes, trace elements, vitamins, and other nutrients such as protein, carbohydrates, and fats. Water and electrolytes into the body will be removed within 24 hours by an amount approximately equal to urine, feces, sweat, and breathing. Our bodies have the ability to sustain or maintain this balance, known as homeostasis. However, parenteral fluid therapy is needed if oral intake is inadequate or can not be sufficient. For example, in patients with coma, severe anorexia, many bleeding, hypovolemic shock, severe nausea, vomiting, or in cases where patients have long fasting for surgery will be performed. In addition, in certain circumstances, fluid therapy can be used as an adjunct to incorporate drugs and nutrients on a regular basis or to maintain acid-base balance. Thus, the general aim of fluid therapy are: 1. Regulate the bodys water and electrolyte balance 2. Nutritional support 3. Intravenous access 4. Overcome the shock

Chapter II Fluid Therapy

I. Normal Body Fluids2
a. Total Body Water
Water constitutes approximately 50 to 60% of total body weight. The relationship between total body weight and total body water (TBW) is relatively constant for an individual and is primarily a reflection of body fat. Lean tissues such as muscle and solid organs have higher water content than fat and bone. As a result, young, lean males have a higher proportion of body weight as water than elderly or obese individuals. An average young adult male will have 60% of his total body weight as TBW, while an average young adult female's will be 50%. The lower percentage of TBW in females correlates with a higher percentage of adipose tissue and lower percentage of muscle mass in most. Estimates of TBW should be adjusted down approximately 10 to 20% in obese individuals and up by 10% in malnourished individuals. The highest percentage of TBW is found in newborns, with approximately 80% of their total body weight comprised of water. This decreases to about 65% by 1 year of age and thereafter remains fairly constant.

b. Fluid Compartments
TBW is divided into two functional fluid compartments, the extracellular and intracellular (Fig. 2-1). The extracellular fluid compartment comprises about one third of the TBW and the intracellular compartment the remaining two thirds. The extracellular water comprises 20% of the total body weight and is divided between plasma (5% of body weight) and interstitial fluid (15% of body weight). Measurement of the intracellular compartment is determined indirectly by subtracting the measured extracellular fluid from the TBW. Intracellular water makes up approximately 40% of an individual's total body weight, with the largest proportion in the skeletal muscle mass.

c. Electrolytes
Cations are the positive electroytes. Anions are the negative electrolytes. They have 3 major functions: 1. Play a big role in water distribution by controlling osmotic pressure. 2. They are necessary for the transmission of impulses 3. They are big part of the acid base balance

II. Classification of Body Fluid Changes2

a. Normal Exchange of Fluid and Electrolytes.
The normal person consumes an average of 2000 mL of water per day, approximately 75% from oral intake and the rest is extracted from solid foods. Daily water losses include about 1 L in urine, 250 mL in stool, and 600 mL as insensible losses. Insensible losses occur through both the skin (75%) and lungs (25%) and by definition is pure water. Insensible losses can be increased by such factors as fever, hypermetabolism, and hyperventilation. Sweating, on the other hand, is an active process and involves loss of (hypotonic) electrolytes and water. To clear the products of metabolism, the kidneys must excrete a minimum of 500 to 800 mL of urine per day, regardless of the amount of oral intake. The normal person also consumes about 3 to 5 g of salt per day, with the balance maintained by the kidneys. With hyponatremia, sodium excretion can be reduced to as little as 1 mEq/d or maximized up to 5000 mEq/d to achieve balance in lieu of salt-wasting kidneys.

b. Disturbances in Fluid Balance.

Extracellular volume deficit is the most common fluid disorder in surgical patients and can be either acute or chronic. Acute volume deficit is associated with cardiovascular and central nervous system signs, while chronic deficits display tissue signs, such as a decrease in skin turgor and sunken eyes, in addition to cardiovascular and central nervous system signs (Table 2-1). Laboratory examination may reveal an elevated blood urea nitrogen level if the deficit is severe enough to reduce glomerular filtration and hemoconcentration. Urine osmolality will usually be higher than serum osmolality, and urine sodium will be low, typically less than 20 mEq/L. Sodium concentration does not necessarily reflect volume status, and therefore may be high, normal, or low when a volume deficit is present. The most common etiology of volume deficit in surgical patients is a loss of gastrointestinal fluids (Table 2-2) from nasogastric suction, vomiting, diarrhea, or fistula. Additionally, sequestration secondary to soft-tissue injuries, burns, and intra-abdominal processes such as peritonitis, obstruction, or prolonged surgery can also lead to volume deficits.

III. Fluids Control

The goal of this therapy is to correct the fluid and electrolyte imbalances caused by underlying pathologies, and /or to maintain the balance in the event of an illness. The body has 4 main regulating mechanisms used to maintain the consistence of body fluid volume, electrolyte composition and osmolarity. The mechanisms are: 1. Kidneys In conjunction with the cardiac system, kidneys maintain fluid balance by determining the amount and composition of urine that is made and released. Their distal tubules are important in regulating normal osmolarity and fluid volume. Renal Disease, cardiac failure, shock and postoperative stress can impair this system. Adrenal glands, located on top of the kidneys, secrete aldosterone, a hormone that increases the resorption of sodium from the tubules, thus maintaining normal sodium concentrations.

2. Lungs Major source of insensible fluid loss through respiration 3. Skin Major source of insensible fluid loss through perspiration 4. Pituitary Gland Releases (ADH) antidiuretic hormone, which prevents diuresis by increasing the reabsorption of water. In order to treat fluid and electrolyte disorders you will need to do the following 1. Estimate the amount of fluid and/or electrolyte lost. Based on what you calculate, you will determine what type of fluid replacement is needed. 2. Monitor the intake and output Dehydration - Occurs generally when fluid intake is less than fluid output. Dehydration is water deficiency in the body which can be categorized into mild dehydration (less than 5%), moderate dehydration (5 to 10%), and severe dehydration (more than 10%). Properties can be either isotonic dehydration (Na levels and normal serum osmolarity), hypotonic or hiponatremik (Na levels less than 130mmol / L or serum osmolarity less than 275 mOsm / L), or can also hypertonic or hipernatremik (Na levels more than 150 mmol / L or more serum osmolarity of 295 mOsm / L).(2) Overhydration - Occurs when there is an excess of total body water.

IV. Properties of Available Fluids

a. Crystalloid fluids
A liquid containing substances with low molecular weight (<8000 Dalton) with or without glucose. Low oncotic pressure causing it to easily and quickly distributed throughout the extracellular space, so that a given volume should be greater (2.5-4 times) than the volume of blood lost. This fluid has a half-life of intravascular 20-30 minutes. Fluid expansion of intravascular to the interstitial space occurred during the 30-60 minutes after infusion and will be out in 24-48 hours as urine. Crystalloid generally used to increase extracellular volume with or without an increase in intracellular volume. Examples : Ringer's lactate; Ringer; NaCl 0.9% (NS); Dextrose 5% and 10%, Darrow, and D5%+ NS and D5%+1/4NS.

 Ringer lactate Most physiological fluids. Many are used as replacement therapy, among others, to hypovolemic shock, diarrhea, trauma, and burns. Lactate contained in the RL will be metabolized by the liver to bicarbonate to improve conditions such as metabolic acidosis. Potassium contained in the RL is not enough for day-to-day maintenance, especially for the case of potassium deficit. So if it does not contain glucose will be used as maintenance fluid should be added glucose to prevent ketosis. Ringer Composition approaching physiological, but when compared with RL there are some shortcomings, such as: o Cl- levels are too high, so that when large amounts can cause dilutional acidosis, acydosis hyperchloremia. o Not containing lactate can be converted into bicarbonate to mitigate acidosis. o Can be used in cases with hyperchloremia dehydration, vomiting and others. NaCl 0,9% (Normal Saline) Used as a resuscitation fluid (replacement therapy), especially for the case: o o Low levels of Na+ Instances where RL is not suitable for use, as in alkalosis and potassium retention o o Fluid choice for hyperchloremia cases, head trauma Used to dilute the red blood cells before transfusion

Has some disadvantages : Does not contain HCO3 Not containing K + Levels of Na + and Cl-is relatively high so that can happen hypercholremia acidosis, dilutional acidosis, and hypernatremia.
Dextrose 5% & 10%

Used as maintenance fluid in patients with sodium or fluid intake restrictions replacement in pure water deficit. Perioperative use for:

Ongoing metabolism Provide water needs

Prevent hypoglycemia Maintaining existing protein, needed at least 100 g of KH to prevent breaking of body protein content.

Lower levels of free fatty acids and ketone Preventing ketosis, it takes a minimum of 200 g of KH

Intravenous fluids containing dextrose, 5% dextrose in particular should not be given to patients with head injury (neuro-trauma). Dextrose and water can move freely into the brain cells. once it is in the brain cells, dextrose will be metabolized by the rest of the water, which causes brain edema. Darrow Used in potassium deficiency, to replace the daily loss, wasted a lot of potassium (diarrhea, diabetic acidosis). D5%+NS and D5%+1/4NS For maintenance, add 20mEq/L KCl. b. Colloidal fluids Fluid contains substances with high molecular weight (> 8000 Dalton), such as proteins. This fluid contains large molecules such as albumin in the plasma function that will stay in the intravascular long enough. The half-life is 3-6 hours intravascular colloid, so that a given volume is equal to the volume of blood lost. Examples : albumin colloid fluids, blood products (RBC), plasma protein fraction (plasmanat) and synthetic colloids (dextran, hetastarch). c. Special fluid Used for correction or special indications. Example: 3% NaCl, bic-nat, mannitol. Based on the purpose of the fluid, there are 3 types (4): 1. Maintenance Fluid only patient does not have excess losses above insensible loss. If no other intake he needs approximately 30ml/kg/24hrs. He may only need part of this if receiving other fluid. Patients having to fast for over 8-12 hours should be started on IV maintenance fluid. 2. Replacement Replacement of losses, either previous or current. If losses are predicted it is best to replace these later rather than give extra fluid in anticipation of losses which may not occur. This fluid is in addition to maintenance fluid. Check blood gases. 3. Resuscitation

The patient is hypovolaemic as a result of dehydration, blood loss or sepsis and requires urgent correction of intravascular depletion to correct the deficit.

V. Fluid Therapy in Surgery2,5

Fluid in the body under normal circumstances should be sufficient, it's normal obtained from food and beverages. Within 24 hours, the water and electrolyte can come out through urine, feces, sweat and respiratory water vapor. Had fluid imbalance occurs in the body, caused by long fasting, because of stripe gastrointestinal surgery, many bleeding, hypovolemic shock, severe anorexia, nausea, vomiting and other mass, fluid therapy is needed to meet the body's needs. Among other goals of fluid therapy alone is: Replace water and electrolyte deficiencies. Meet the needs of the body. Overcome the shock. Overcome disorders caused of therapy given. In addition to getting drugs and food substances are routinely. Can also to maintain the acid-base balance.

Disturbances in fluid and electrolyte balance is common in surgical patients due to a combination of factors preoperative, perioperative and postoperative. a. Preoperative Fluid Therapy The administration of maintenance fluid should be all that is required in an otherwise healthy individual prior to the time of surgery. This does not, however, include replacement of a pre-existing deficit or ongoing fluid losses. A frequently utilized formula for calculating maintenance fluids is as follows: For the first 0 to 10 kg Give 100 mL/kg per day For the next 10 to 20 kg Give an additional 50 mL/kg per day For weight >20 kg Give 20 mL/kg per day However, many surgical patients have volume and/or electrolyte abnormalities associated with their surgical disease. Preoperative evaluation of a patient's volume status and pre-existing electrolyte abnormalities are an important part of preoperative assessment and care. Volume deficits should be considered in patients presenting with obvious

gastrointestinal loss such as emesis or diarrhea, as well as in patients with poor oral intake secondary to their disease. Less obvious are those fluid losses known as third-space or nonfunctional losses that occur with gastrointestinal obstruction, peritoneal or bowel inflammation, ascites, crush injuries, burns, and severe soft tissue infections (such as necrotizing fasciitis). The diagnosis of volume deficit is primarily clinical (see Table 2-1), though the physical signs may vary with the chronicity of the deficit. Cardiovascular signs (tachycardia and orthostasis) predominate with acute volume loss and are accompanied by oliguria and hemoconcentration. In general, acute volume deficits should be corrected prior to the time of operation. Once a volume deficit is diagnosed, prompt fluid replacement should be instituted, usually with an isotonic crystalloid, depending on the particular electrolyte profile. Patients with cardiovascular signs of volume deficit should receive a bolus of 1 to 2 L of isotonic fluid followed by a continuous infusion. Close monitoring during this period is imperative. Resuscitation should be guided by the reversal of the signs of volume deficit such as restoration of vital signs, maintenance of adequate urine output (1/2 to 1 mL/kg per hour in an adult), and correction of base deficit. Patients who fail to correct their volume deficit, those with impaired renal function, and the elderly should be considered for more intense monitoring in an ICU setting for measurement of central venous pressure or cardiac output. If symptomatic electrolyte abnormalities accompany volume deficit, the abnormality should be corrected to the extent that the acute symptom is relieved prior to surgical intervention. For correction of severe hypernatremia associated with a volume deficit, it is safer to slowly correct the hypernatremia with 0.45% saline or even lactated Ringer's rather than 5% dextrose alone. This will safely and slowly correct the hypernatremia and correct the associated volume deficit. b. Intraoperative Fluid Therapy With the induction of anesthesia, compensatory mechanisms are lost and hypotension will develop if volume deficits are not appropriately corrected prior to the time of surgery. Hemodynamic instability can be avoided by correcting known fluid losses, replacing ongoing losses, and providing adequate maintenance fluid therapy preoperatively. In addition to measured blood loss during surgery, open abdominal surgeries are associated with continued third-space losses due not only to the pre-existing conditions but also to exposed bowel during the time of surgery. Large soft tissue wounds, complex fractures with

associated soft tissue injury, and burns all have additional third-space losses that must be considered in the operating room. c. Postoperative Fluid Therapy Postoperative fluid therapy should be based on the patient's current estimated volume status and projected ongoing fluid losses. Any deficits from either preoperative or intraoperative losses should be corrected and ongoing requirements should be included along with maintenance fluids. Third-space losses, though difficult to quantitate, should be included in fluid replacement strategies. In the initial postoperative period, an isotonic solution should be administered. The adequacy of resuscitation should be guided by the restoration of vital signs and urine output and, in more complicated cases, by the correction of base deficit or lactate. If uncertainty exists, a central venous catheter or Swan-Ganz catheter can be inserted to help guide fluid therapy. After the initial 24 to 48 hours, fluids can be changed to 0.45% saline with added dextrose in patients unable to tolerate enteral nutrition. If normal renal function and adequate urine output are present, potassium may be added to the intravenous fluids. Daily fluid orders should begin with assessment of the patient's volume status and assessment of electrolyte abnormalities. In general, there is no need to check electrolyte levels in the first few days of an uncomplicated postoperative course. All known losses (gastrointestinal, drains, and urine output) as well as insensible losses are replaced with the appropriate parenteral solution. d. Special Considerations in the Postoperative Patient Volume excess is a common disorder in the postoperative period. The administration of isotonic fluids in excess of actual need may result in volume expansion. This may be due to the overestimation of third-space losses or ongoing gastrointestinal losses that are difficult to quantitate, such as diarrhea. The earliest sign of volume overload is weight gain. The average postoperative patient who is not receiving nutritional support should lose approximately 1/4 to 1/2 pound per day. Additional signs of volume excess may also be present as listed in Table 2-1. Peripheral edema may not necessarily be associated with volume overload, as overexpansion of total extracellular fluid may exist in association with a deficit in the circulating plasma volume. Volume deficits also can be encountered in surgical patients if preoperative losses were not completely corrected, intraoperative losses were underestimated, or

postoperative losses were greater than appreciated. The clinical manifestations are described in Table 2-1 and include tachycardia, orthostasis, and oliguria. Hemoconcentration also may be present. Treatment will depend on the amount and composition of fluid lost. In most cases of volume deficit, replacement with an isotonic fluid will be sufficient. e. Other fluids loss At each surgery is always going to lose fluids more prominent than bleeding as a result of evaporation and translocation of internal fluid. Fluid loss due to evaporation (evaporation) will be mainly on surgery with wide surgical wounds and old. While the displacement fluid or more commonly known term or transfer to a third space sequestration could result in massive intravascular fluid deficit. Tissue trauma, inflammation or infection may lead to sequestration of fluid into the interstitial space and the displacement of serous fluid (ascites) or to the intestinal lumen. As a result, the number of functional ionic liquids increases in the extracellular space. Fluid shifts that occur can not be prevented by limiting fluid and can be detrimental to the functional fluid in the extracellular compartment and can also be detrimental to the functional fluid in the extracellular space. f. Impaired renal function Trauma, surgery and anesthesia can result in: Glomerular Filtration Rate (GFR = Glomerular Filtration Rate) declined. Na+ reabsorption in the tubules increased in part due to increased aldosterone levels. Increased levels of anti-diuretic hormone (ADH) causes water retention and Na+ reabsorption in the collecting ducts (collecting tubules) increases. The kidneys are unable to excrete the "free water" or to produce urine hipotonis.

VI. Dehydration
Dehydration is water deficiency in the body which can be categorized into mild dehydration (less than 5%), moderate dehydration (5 to 10%), and severe dehydration (more than 10%). Properties can be either isotonic dehydration (Na levels and normal serum osmolarity), hypotonic or hiponatremik (Na levels less than 130mmol / L or serum osmolarity less than 275 mOsm / L), or can also hypertonic or hipernatremik (Na levels more than 150 mmol / L or more serum osmolarity of 295 mOsm / L).3

Maintainance Fluid Therapy and Fluid Correction for Dehydration Maintenance fluid therapy aims to maintain the balance of body fluids and nutrients. IV fluid should be given via volumetric pump if a patient is on fluids for over 6 hours or if the fluid contains potassium. Always prescribe as ml/hr not x hourly bags. Never give maintenance fluids at more than 100ml/hour. Preferred maintenance fluids: 0,18% saline / 4% dextrose with or without a potassium (KCl 10/20 mmol) in 500 ml. 1 liter bags are available. The fluid if given at the correct rate provides all water and Na /K requirements until the patient can eat and drink or be fed. Excess volumes of this fluid (or any) fluid may cause hyponatraemia. Alternatively 5% dextrose 500ml and 0.9% NaCl 500ml may be used in a ratio of 2 bags of 5% dextrose to 1 bag of 0.9% NaCl. Prescribe each bag with added potassium (KCl 20mmol) if patient has normal or low potassium. Patients with renal failure: Consult a senior doctor for fluid advice. If the serum potassium is above 5mmol/l or rising quickly do not give potassium containing fluids.

Electrolyte requirements Sodium 1 mmol/kg/24hrs (approx. 1x500ml 0.9%NaCl) Potassium 1 mmol/kg/24hrs (give KCl 20mmol in each bag) Calories: minimum of 400kcal/24hrs to help with electrolyte handling and to help avoid insulin resistance. Magnesium, calcium and phosphate may fall in sick patients monitor and replace as required. Grade I Blood Loss (% Blood Volume) Blood Loss (ml) Pulse Blood Pressure Urine Production (ml/Hhour) RR Mental Status Fluid Replacement (Rule 3:1) 15 % 750 < 100 N > 30 14 20 Less Anxious Grade II 15 30 750-1500 > 100 N 20 30 20 30 Anxious Grade III 30 40 1500 2000 > 120 Decrease 5 15 30 40 Grade IV > 40 % > 2000 > 140 Decrease > 35

Anxious and Confused and Confused Lethargy Cristaloid and Blood Cristaloid and Blood

Cristaloid Cristaloid

Chapter III Conclusion

Body contains 60% water which is also called the body fluids. Body fluids contained there in nutrients crucial role in cell metabolise, so it is very important to support life. In surgery, the body is dehydrated because of bleeding during surgery plus fasting before and after surgery. Disturbances in fluid and electrolyte balance is common in surgical patients due to a combination of factors preoperative, perioperative, and postoperative. Parenteral fluid therapy is used to maintain and restore the normal volume and composition of body fluids. in fluid therapy needs to be aware of patients according to age and condition, as well as intravenous fluids themselves. Types of liquids that can be given to fluid therapy is crystalloid and colloid fluids.

Reference
1. Lobo, DN. Lewington AJP. Allison, SP. (2013). Basic Concepts of Fluid and Electrolyte Therapy. Germany. 2. Brunicardi, F.C. Biliar, T.R. Dunn, D.L. (2007). Schwartzs Principles of Surgery. Chapter 2: Fluid and Electrolytes Management of Surgical Patient. 3. Consortium of New Jersey Nurse Educators, Adult IV Therapy Course, 5th ed. 2008.
4. Morgan GE, Mikhail MS. Clinical Anesthesiology. (2006). 4 ed. Appleton & Lange Stamford.
5.
th

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical . Patients http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf