Fluid Therapy

Average 70 kg person

a. 60% of Total body weight is Water -42 L

b. 40 % of body weight is intracellular fluid
c. 20% of body weight is extracellular fluid
a. 5% intravascular
b. 15% extravascular/ interstitial fluids

Electrolyte composition

Intracellular fluid- low Na, High K+ concentration, organic phosphate and sulphate

Extracellular fluid (intravascular + interstitial)- High Na, Low K+ concentration, Cl, HCO3

2% of the body K+ is in Extracellular fluid

Protein Composition in Extracellular Fluid

Intravascular(plasma) -High protein concentration

Extravascular- Low protein concentration

Both has same amount of electrolytes

In order to fill the intravascular compartment rapidly, a plasma substitute or blood is the choice

 High Colloid Osmotic pressure potential Fluids remain in intravascular space

 Saline solution rapidly distributes over entire extravascular compartment, which is 4x
larger than Intravascular compartment. i.e. 1L of saline, only 250 ml would remain
intravascular
 5% dextrose (water with small amount of dextrose- isotonic solution) – distributes
across both intracellular and extracellular spaces

Fluid Losses

 Fluid is lost from 4 routes

o Kidney
 Regulated by aldosterone and ADH (antidiuretic hormone)
 Aldosterone responds to a fall in glomerular perfusion by salt retention
 ADH responds to increased solute concentration by retaining water in
renal tubules
 Normal urinary losses- 1500-2000ml/day
o Gastrointestinal tract
 300mL in faeces
o Skin
o Respiratory tract
 Losses from the skin and respiratory are called insensible losses
 Insensible Losses is 700mL/ day, insensible production of fluid- 300mL
of metabolic water produced endogenously. Net loss 400
 Total loss daily- 2000 + 300 + 400 = 2700mL/day

Abnormal Fluid Losses

 Kidney
o Most water filtered is reabsorbed in the renal tubules – impaired renal tubules function
caused increased water lost
o Resolving acute tubular necrosis, diabetes insipidus (lack of AVP/ vasopressin-
antidiuretic hormone), head injury
o Production of ADH by tumors- the syndrome of inappropriate tumors (SIADH)
 Water retention and hemodilution

 Gastrointestinal Tract
o Diarrhea
o Ileostomy (piece of the ileum is diverted into an opening in the stomach)- colonic water
reabsorption can’t occur
o Vomiting, nasogastric aspiration and fistulous (Abnormal connection between two body
organs/parts that do not usually connects)- losses in electrolyte rich fluids
 o LARGE occult losses occur in paralytic ileus (obstruction of the ileus due to paralysis of
the intestinal muscles) and intestinal obstruction
 Causes marked Hypovolemia- loss of extracellular fluid, mainly intravascular
volume (not dehydration which is pure water loss)
 Resolution of ileus causes diuresis

 Insensible Losses
o Hyperventilation- increase respiratory losses
o Pyrexia and sweating- increase loss from the skin

 Effects from surgery

o ADH is released in surgery conserving water
o Hypovolemia will cause aldosterone secretion and salt retention by kidney
o K+ is released by damage tissues and can be further increased by blood transfusion, if
renal perfusion is poor, urine output is sparse and the K+ is not excreted but it
accumulates, causing hyperkaliemia which causes arrythmias
o Therefore K+ supplementation may not be necessary in the first 48 hours following
surgery or trauma.
 Colloids – Albumin, Dextran, Hetastarch and Blood
o Promote fluid retention intravascular space, high oncotic pressure
o No advantage over crystalloids
 Crystalloids- normal saline, Lactated Ringer/ Hartmann’s solution, 5%dextrose
o Solutions of water and electrolytes
o Safe and inexpensive, non allergenic
o Isotonic, Hypotonic (free water e.g. 5%dextrose), Hypertonic -NACL
 0.9% NACL- 154meq/ L NACL 04.5% NaCl – 77meq/L NaCl
 Lactated ringers- 130 meq/L Na 5meq/L K+
Pathophysiology of saline induced hyperchloremic metabolic acidosis

When adding normal saline solution, you are increasing chloride levels significantly causing
acidosis

NaCl combines with water and produces HCL + NaOH.

Adding saline causes the chloride to increase more than sodium.

Prescribing Fluids for surgical Patient

 Replacement for normal losses in a typical Adult

o Administration of 3 L fluid, which comprise of 1 L normal saline (150 mmol NaCl)
together with 2 L of water (as 5% dextrose)
o Potassium may be added to each 1 L bag – 20 mmmol/L
o Alternatively, compound sodium lactate – similar to plasma
o Adjustment to the regime is based on regular clinical examinations, measurement of
losses (urine output- o.5-1 ml/kg/hr), daily weighs (to asses fluid changes), and regular
blood samples for electrolyte determination, CVP, Cardiac Output
 E.g. anuric patient (less that 100mL of urine per day Oliguria- less than
500ml/day)- 1 L of hypertonic dextrose solution without potassium is enough-
reduces catabolism with the breakdown of protein and accumulation of urea
 Maintenance Therapy - Baseline
o In pediatrics, based on weight
 100 ,50, 20 rule ml/kg per day
 4:2:1 hourly rule
o Adults- 30-35 ml/kg/24 afebrile adult
o Electrolyte requirements- Na 1-2 meq/kg/day K 0.5-1 mew/kg/day
o Add insensible losses if excessive- 8-12ml/kg/day
 Replacement for special Losses
 o Include nasogastric aspirate, losses from fistula diarrhea, stoma, ileus (covert loss), loss
of plasma with burns
o Fluid losses calculated carefully and added to daily requirements
 Resuscitation
 Most common Fluid disorder in Surgical Patients is Acute Dehydration
o 2% body weight- dry skin, increase thirst, oliguria, increase urine osmolarity
o 4% dry tongue and axillae, tachycardia, postural hypotension, oliguria
o 6%: life threatening-lethargy, ileus
o Treated with rapid infusion of balance solution, avoid glucose- containing solutions
 Mild 3% - 5% TBW
 Moderate 6% - 10% TBW
 Severe 9% - 15% TBW
 Calculation-% dehydration x (body weight (kg) x %TBW)
o 5%- 15% losses of total body water- thirst, dry mucous membranes, loss of skin turgor,
tachycardia, postural hypotension, low JVP
o <5% fluid losses are hard to determine clinically
o >15%- marked circulatory collapse
o Formula- percentage loss x 60% of total body water x weight in kg
o Loss is purely isotonic, ie gastric juices treated with crystalloid solution (Hartmann
solution)
o RULE- REPLACE ½ OF THE ESTIMATED LOSS QUICKLY (within the first 8 hours), then
reassess before replacement of other fluids over the next 16 hours
o THE best guide to success resuscitation is resumption of normal urine output hourly
urine should be measured
o CVP monitoring help with adjustment of rate of infusion
 Fluid deficit assessment
o History
o Examination
o Biochemistry- prerenal azotemia (high level of nitrogen waste products)
 On going losses
o 1:1 replacement of fluids
o Monitor fluid blance
 Signs and symptoms
 Vital signs
 Urine Out put
 0.5-1 ml/kg/hr adult
 1-2 ml/kg/hr child
 Central Venous Pressure 5-12mmHg

1. Hyponatremia
a. Solute loss >water loss
i. Burns , Excessive sweating , GI losses, Excessive diuretic therapy
b. Fluid over load
 i. Fluid restriction treatment and diuretics

2. Hypernatremia
a. Water deficit> solute deficit
i. Comatose, Excessive insensible losses, Diabetes insipidus, Tube feedings
without adequate water
ii. Hypotonic saline not 0.9% unless in shock, free water
3. Hyperkaliemia
a. Acidosis, trauma
i. 100ml 50% dextrose +insulin, Calcium, Resin, Dialysis

Special cases

Blood loses

Replacement 1:1 Blood, 2:1 Colloid, 3-4:1 Crystalloid

Burns

1. Rules of 9- PALM IS 1%
2. Parkland formula 3-5%mls/kg/%burn for up to 50% burns
a. Does not include 1-degree burns
b. ½ given in 8 hrs, other 1/ over 16 hrs

Rate of Flow

Gray – 16 G, 180ml/min water flow

Green- 18 G 90ml/min

Pink- 20 G 57ml/min

Blue-22G 33ml/min

Yellow- 24G 13ml/min