Fluid balance is an important area of perioperative medicine Perioperative fluids are required to maintain adequate:

hydration blood volume and oxygen delivery renal function electrolyte balance splanchnic and hepatic circulation

Body Fluid Composition

Body Fluid Composition

Physical examination Laboratory examination Haemodynami c monitoring

Most reliable preoperatively Invaluable clues to hypovolemia include Skin turgor, the hydration of mucous membranes, fullness of a peripheral pulse, the resting heart rate and blood pressure and the (orthostatic) changes from the supine to sitting or standing positions, and urinary flow rate Unfortunately, many drugs used during anesthesia alter these signs

serial hematocrits arterial blood pH urinary specific gravity or osmolality urinary sodium or chloride concentration serum sodium serum creatinine to blood urea nitrogen (BUN) ratio. T Laboratory signs of dehydration rising hematocrit, a progressive metabolic acidosis, a urinary specific gravity greater than 1.010, a urinary sodium less than 10 mEq/L, a urinary osmolality greater than 450 mOsm/kg, hypernatremia, and a BUN-to-creatinine ratio greater than 10:1. radiographic signs of volume overload.

Laboratory Evaluation

CENTRAL VENOUS PRESSURE MONITORING

Central venous pressure monitoring is indicated

in patients with normal cardiac and pulmonary function when volume status is difficult to assess. Low values (< 5 mm Hg) may be normal unless associated with other signs of hypovolemia. Central venous pressure readings greater than 12 mm Hg are considered elevated and imply hypervolemia in the absence of right ventricular dysfunction, increased intrathoracic pressure, or restrictive pericardial disease.

PULMONARY ARTERY PRESSURE MONITORING

Pulmonary artery occlusion pressure (PAOP)

readings of less than 8 mm Hg indicate hypovolemia in the presence of confirmatory clinical signs; however, values less than 15 mm Hg may be associated with relative hypovolemia in patients with poor ventricular compliance. PAOP measurements greater than 18 mm Hg are elevated and generally imply left ventricular volume overload. Newer techniques of measuring ventricular volumes with transesophageal echocardiography or by radioisotopes are more accurate but are not as widely available.

Divided into:

Crystalloids-aqueous solutions of inorganic and small organic molecules.

Colloids- homogeneous noncrystalline substances containing large molecules.

Contain electrolytes but lack the large proteins and molecules found in colloids. Safe, nontoxic, reaction free, and inexpensive. Can be classified into isotonic, hypotonic, hypertonic. Can be further categorized into unbalanced with unphysiologic electrolyte composition and no buffers, balanced with physiologic mixture of electrolytes with buffers formulations.

Fluid movements of these three different types of solutions

Favored in the perioperative period. To completely replace an intravascular fluid loss, three to four times the volume lost has to be administered. Normal saline: - Replacement of blood volume and other extracellular fluid losses. - Precaution in situations where local oedema may aggravate pathology: e.g. head injury. - May precipitate volume overload and heart failure. -Side-effects : tissue oedema, hyperchloremic metabolic acidosis.

Lactated Ringer's solution or Asering: -Replacement of blood volume and fluid losses. -Precaution where local edema may develop. - Metabolized to HCO3 in the liver metabolic alkalosis. -Caution in patients with preexisting hyperkalemia - Calcium present prohibits its use in the presence of citrated blood products and may precipitate different drugs (e.g., amphotericin B, thiopental).

Used to provide free water to patients with hypertonic dehydration or hypernatremia. The intravascular volume effect is minor. D5W consists entirely of free water because glucose is being metabolized and water equally distributes in the ICF and ECF compartments. Dextrose-containing solutions should be used with caution in the absence of disease states affecting glucose metabolism because hyperglycemic-induced hyperosmolality, osmotic diuresis, and cerebral acidosis are known complications.

7.5% NaCl are being used in the postoperative period to treat severe hyponatremia. Combined with colloids refers to the concept of small volume resuscitation in patients with severe hemorrhage. These effects have been difficult to replicate clinically and a systematic review of hypertonic saline in resuscitation of patients with trauma, burns, or those undergoing surgery was unable to reach a conclusion regarding benefit or harm.]

High-molecular-weight substances in colloids tends to maintain these solutions intravascularly (half lives 4-6hrs). Solutions are derived from either plasma proteins or synthetic glucose polymers and are supplied in isotonic electrolyte solutions. Substantial cost and occasional complications. Indications (1) fluid resuscitation in patients with severe intravascular fluid deficits (eg, hemorrhagic shock) (2) fluid resuscitation in the presence of severe hypoalbuminemia or conditions associated with large protein losses such as burns.

Used in conjunction with crystalloids when fluid replacement needs exceed 34 L prior to transfusion. It should be noted that these solutions are prepared in normal saline (Cl145 154 mEq/L) and can also cause hyperchloremic metabolic acidosis.

Dextran is available as dextran 70 and dextran 40 which have average molecular weights of 70,000 and 40,000, respectively. Dextran 40, improves blood flow through the microcirculation, presumably by decreasing blood viscosity. Decreased platelet adhesiveness, suppress factor VIII, increased fibrinolisis. Renal dysfunction may be a tubular obstruction, swelling, and vacuolization of tubular cells. Infusions exceeding 20 mL/kg per day can interfere with blood typing, may prolong bleeding time (dextran 40), and have been associated with renal failure. Can also be antigenic, and both mild and severe anaphylactoid and anaphylactic reactions are described.

Produced by degradation of bovine collagen and chemical modifications. Three types of gelatins are available: oxy-crosslinked, urea-crosslinked, and succinylated gelatins. It seems that hemostasis could be impaired by an interference of gelatin with the function of coagulation factors and by a disturbance in the quality of fibrin polymerization. The exact mechanism however remains to be elucidated. Disadvantages of gelatins are their bovine origin with the hypothetical potential of transmitting prion diseases. Most frequent incidence of allergic reactions among all colloids (six times higher compared with HES; incidence 0.35%).

Hetastarch is available as a 6% solution with an average molecular weight of 450,000. Derived from amylopectin. Small molecules are eliminated by the kidneys, whereas large molecules must be first broken down by amylase. Highly effective as a plasma expander and is less expensive than albumin. Nonantigenic, and anaphylactoid reactions are rare. Coagulation studies and bleeding times are generally not significantly affected following infusions of up to 0.51.0 L.

Purified from pooled human plasma. Heated and sterilized, the risk of bacterial or viral disease transmission should be eliminated. A systematic review estimated that for each 2.5-g/L decrement in serum albumin concentration the risk of death increases by 24% to 56%. Used in the management of acute restoration of an effective circulating volume due to hemorrhage, the acute management of burns, and clinical situations associated with hypoproteinemia. No evidence that albumin reduces mortality rates. As a result of these recent findings and the high costs of albumin, routine use of albumin for volume replacement should be reconsidered. The relative risk of albumin to develop an allergic reaction is 3.4 times less than that of gelatins and almost identical to that of HES.

Crystalloids, when given in sufficient amounts, are just as effective as colloids in restoring intravascular volume. Replacing an intravascular volume deficit with crystalloids generally requires three to four times the volume needed when using colloids. Most surgical patients have an extracellular fluid deficit that exceeds the intravascular deficit. Severe intravascular fluid deficits can be more rapidly corrected using colloid solutions. The rapid administration of large amounts of crystalloids (> 45 L) is more frequently associated with significant tissue edema.

maintenance requirements, replacement of pre-existing fluid deficits Replacement of surgical wound losses

Clinical assessment of the patients fluid status : need replacement or maintenance only If there is a fluid deficit, identification the nature of the fluid deficit. The type of fluid

Rate of fluid administration

The clinical endpoint Continued monitoring of fluid and electrolyte status.

Replace urine formation, gastrointestinal secretions, sweating, and insensible losses from the skin and lungs Fluid
4 mL/kg/hour for the first 10 kg 2 mL/kg/hour for the second 10 kg 1 mL/kg/hour for remaining weight if the

weight abouve 20 kg.

Normal Losses : preoperative fasting

Replace with : maintenance x fasting

duration (h)

Abnormal Losses :
bleeding, vomiting, diuresis, and diarrhea Ideally those should be calculated and

replaced Beware of Hypovolemia need replacement

Blood Loss
Estimates the blood loss Replace with : 3-4 times volume of blood loss with crystalloid Same amount with colloid

Replace with solution until the danger of

anemia outweight the risk of transfusion indication of transfusion

Hb < 7, Ht < 21, blood loss > 10 - 20%

Other fluid loss

Because of evaporation or internal

redistribution Depends on the size of surgical wounds :

Minimal : 0-2 mL/kg Moderate : 2-4 mL/kg Severe : 4-8 mL/kg

For replacement of fluid loss

Better to use RL than NS NS hyperchloremic acidosis, especially in

surgical patient Dextrose 5% can not be used for replacement of fluid loss except in significantly water deficit

For maintenance
Must met the electrolyte requirements : Na : 3 meq/kgBW/day K : 1 meq/kgBW/day

In more seriously ill surgicalpatients with significant comorbidities and increased urea production, there is reduced ability to concentrate urine. As a consequence it requires two or more times the normal volume of urine to excrete a sodium and chloride load given in the perioperative period. Potassium depletion due to RAAS activity and the cellular loss of potassium which accompanies protein catabolism, reduces the ability to excrete a sodium load. Acute kidney injury may occur due to abdominal compartment syndrome compressing the kidney externally, and increased intra-capsular pressure due to edematous renal tissue Intravascular hypovolemia because of a sustained increase in systemic capillary permeability, which then activates the RAAS and secretion of vasopressin, which lead to further sodium and water retention. Intracellular sequestration of sodium and fluid due to lack of intracellular energy and failure of the Na/K-ATPase pump.

Assess haemodynamic status Restore the sodium and fluid balance to normal Nutritional support

Best choice : oral intake