Body fluid compartments, erystalloids & colloids, distribution of infused fluids, assessment & monitoring of fluid status. PRESENTER:- DR PRASAD MODERATOR:- DR P. K.SYAMALA & OR ARATHI SATHEESH Fluid management ‘aim of Per-operative fluid management 1, To avoid dehydration, . 2, Maintain an effective circulating volume and 3, Prevent inadequate tissue perfusion, 1 BODY FLUID COMPAR! MENTS Total body water (TBW) “> 60% of total body weight baw ————A) tracellular lid (CF) 9 55% 08 TH 2) extracellular Mid (ECF) > 45% of TEW. > e¢f————1) Functional > 27.5% of TOW. 2) Sequestered > 17.5% of TW, > Functional———-1) interstitial (SF) > 20% of T8W 2) intra-vascular > 7.5% of TOW © Sequestered- Not immediately availabe for equim with other fluid compartments > Bone & dense connective tissue (15% of TBW ) which is not part of functional ECF due to slow kinetics of water with other compartments. > Tran-cellular fluid (2.5% of TBW) ~ occupied with in epithelia-lined spaces, which functional important fluid. EX: - CSF, GI tract fluid, Synovial fluid, Aqueous humor, Pericardial fluid, Peritoneal fluid, Urine, €* tnterstiia uid use fluid. EX: - Lymphatic thud, Protein POT Intra-vasculars: > Plasma-5.5% of TBW, > sub-tycocalyceal layer-2% of TBW. > Total blood volume—ECF+ICF Factors affect total body water:- 1. Age Page increased—-TBW decreased. 2. Gender more TBW in males than females. 3. Body composition-> more adipose tissue---less TBW. Physicochemical I; ering fluid movement:- 1) DIFFUSION 2) OSMOSIS 3) OSMOLALITY 4) ONCOTIC PRESSURE 5) TONIcITY 1 DIFFUSION: % Diffusion is the process by which solute particles ft the available solvent volume by motic from areas of high to low concentration ‘% The speed of this equilibration is proportional to the Square of the diffusion distance @ Flek’s law of diffusion: d= = DA(bc/ax) Js the net rate of diffusion,O13 the diffson coetticent 416 the crows-sectiona! orea avaiable for diffusion andt ‘defi 4 tne concentrotion (chemical) growent 2L.5MOsI5. ‘© Ha semipermeable membrane Separates pure water from water in which solute is dissoived, water molecules will diffuse across the membrane into the region of higher solute concentration ‘* Osmotic pressure in an kteal solution is affected by temperature and volume, Pena P is the oxmovk pressure, (1118 the number of porticies, Ais the gas constant, T's the absolute temperature and Vis the volume. © Body fluids are not ideal solutions, because interlonic interactions reduce the number of Particles free to exert an osmotic effect The total osmotic pressure of plasma is approximately 5545 mm Hg ALOsMOLAUTY:- The number of moles present in 1 ky of solvent. Normal body osmolality is 285 to 290 mOsm/kg Wis the same in intracellular and extracellular compartments because ofthe tree movement of water between compartments that consequently prevents the development of any osmotic gradients. The largest contribution to plasma osmolality is made by sodium and its Folated anions chloride and bicarbonate. ‘F Wtcan be estimated by: Serum asmoiatity »((2 « Na) + (glucose + 18)+ (urea +2. 8)Nas Glucose is the serum glucose concentration (mg/dt), Urea is the blood urea nitrogen concentration (mg/dL) and i ly Cl - (2* Na) component reflects both Na and its associated anion (predominantly and HCO3-), ALONCOTIC PRESSURE: It is the component of total osmotic pressure that is due to the colloids—that is, lar: ‘molecular-weight particles, predominantly proteins (albumin, globulins, and fibrinogen). OF the total plasma osmotic pressure of 5545 mm Hg, 25 to 28 mm Hg is due to plasma onco pressure. ‘THE GIBBS-DONNAN EFFECT:- ‘® The negative charge on proteins has the net effect of retaining a small excess of Na+ ions withir the plasma, which effectively increases the oncotic pressure above what would be predicted by calculations based purely on protein concentration, ® As the most abundant plasma protein, albumin is responsible for 65% to 75% of plasma oncotic pressure, SLTONICITY;- % This Is the effective osmolality of a solution with respect to a Particular semi-permeabhe membrane and takes into account solutes that do not exert an in vivo osmotic effect, ‘® Tonicity is important in determining in vivo distribution of fluids across a cell membrane, ® Tonicity is sensed by the hypothalamic ‘osmo-receptors, Itcan be estimated by subtracting urea and glucose concentrations from measured osmolality.Fluid compartment barriers:- 1) Cell membrane. 2) vascular endothelium. Cell membrane: The cell membrane separates the intracellular and permeable to large hydrophilic molecules and charged extracellular compartments and as a lipid bilayer is im particles such as free ions, mainly carrier proteins; solutes may cross cell membranes in several ways, A. Primary Active Transport B. Secondary Active Transport C, Solute Channels D. Endocytosis and Exocytosis, vimary Active Transport:- entration gradient requires energy and is therefore direc! 4 Solute transport against a cones coupled to adenosine triphosphate (ATP) hydrolysis. ine triphosphatases (ATPases) ee Ex Nav/K+adenosi 4 This is the fundamental mechanism by which ionic concentration gradients are maintained. secondary Active Transports & thuses concentration gradients set uP PY nTPases to transport a solute driven by an ion mo: down its concentration gradient (mainly sodium). 4 Cottransport when the solute is also movin down its concentration gradient oF 1g moved against its concentration gradient. 4 Countertransport when the solute is Deln solute Channel Ge Faster transport of solutes than by ATPases of transmembrane diffusion.proteins and polypeptides across: cell membrane cause dothelium is particularly relevant perioperatively bet ‘to overcome these losses and maintain adequate uid handling at the capillary level atrium >sense central venous yrtic arch. These are important if I blood pressure.7 The effectors are, se Renen-angiote! sldosterone system anal natriuretic peptide (ANP) 4 Grain agtruretic peptide (BNP) 4) sympathetic nervous system activity Glomerular fi tration rate and plasma sodium concentration. 4 Tebulogiomerular balance Preoperative:: The effects of preoperative fasting. > Bowel preparation can cause a weight loss of 1.5 10 1-7 kgs with a high water and K+ content. ve More severe disturbances of fuid and electrolyte balance can 062 in patients presenting with acute disease requiring surgical intervention, This may be influenced by one or more of the following, 1. Direct intravascular depletion resulting from bleeding. 2. Loss of fluid from the Gi tract. 3, Inflammation-related redistribution from the intravascular to the extracellular compartment. 4, Fluid sequestration in the physiologic third space, with edema, pleural effusions, and ascites. Intraoperative: > Altered distribution of intravascular volume, > Oirect {oss of intravascular volume 25 2 result of bleeding.> Insensible losses. > Inflammation-related redistribution. > Renal output. Postoperative: > Inflammation and Immune Response. » Catabolic Metabolism. » Regulation of Salt and Water Balance.Il, FLUID PHARMACOLOGY > The fluids used in clinical practice are classified into: Crystallotds and Colloids. ¥ Composition of plasma:- Na+ 140 meq/|, kt 5 meq/), Ch 100 meg/|, cor 4.4 med/|, Mgt 2mea/, Heo3-24 mea/|, Lactate> 1 mea/|, Osmolarity> 285 mosmn/I, 1).CRYSTALLOIDS: > Crystalloids are solutions of electrolytes in water Solutions that contain small molecules that flow easily across the cell membranes, allowing for transfer from the blood stream into the cells and body tissues. } Infused crystalloid has been thought to distribute evenly throughout the extracellular compartments. } This will be leads to capillary filtration, leaving approximately one fourth or one fifth of the original volume within the circulating blood volume, v Iris subdivided into: = Isotonic ~- Hypertonic ~Hypotonic> When the the particles (solutes) is similar to that of plasma, So it doesn't moy, concentration of the pa ie - Jins within the extracellular compartment thus increasing intravascular Into cells and remai 8 ul volume. > Types of isotonic solutions include: -0.9% sodium chloride (0.9% NaCl) - Lactated Ringers solution ~ 5% dextrose in water (DSW) -Plamsa-Lyte 0.9% sodium chloride (Normal Saline):- ~ — composition- Na+ 154 mEq/L, Cl 3154 meq/t, Osmolarity-> 308 mOsm/t Simply salt water that contains only water, sodium (154 mEq/L) and chloride (154 meq/t) ¥ Its called “normal saline solution” because the percentage of sodium chloride in the solution is similar to the concentration of sodium and chloride in the intravascular space Indication:- 1 To teat low extracellular fluid, as in fluid volume deficit from. Hemorrhage; Severe vomiting or Siarthea; Heavy drainage from Gt suction, fistulas, or wounds 2- Shock. 3 Milld hyponatremia ‘4 Metabolic acidosis (such as diabetic ketoacidosis) 5 Its the fluid of choice for resuscitation efforts 6 It’s the only fluid used with administration of blood products._pesuations in which increased plasma Nav may be beneficial such asin the presence of cerebral ‘edema. 4: Preexisting Nat or Cl- total body depletion, such as gastric outlet obstruction Problems > A2Linfusion of 0.9% NaCl leads to, ~ An increase in ECF volume, -Dilutional decrease in hematocrit and albumin, Increase in Cl- and K+ concentrations and -Decrease in plasma HCO3-. > The expansion of the ECF is more persistent than with balanced crystalloid solutions. > The excess salt and water load may take multiple days for even a healthy subject to excrete > Infusion of saline leads to a hyperchloremic metabolic acidosis and reduced renal perfusion, > Inhealthy volunteers, the large-volume (50 mL/kg) infusion of 0.9% NaCl Jed to abdominal discomfort, nausea, and vomiting. Ringers lactate: > Hartmann solution or compound Nat lactate. > Compositions; Na+>131 mea/! K+ Smeq/! cat 2-4 meq/! cL} 111 meq/! Lactate 29 meq/! Osmolarity 3273 mOsm/| ptable fluid because its electrolyte content Is 1ys blood serum and plasma. } Ringer's lactate is the most physiologically adal most closely related to the composition of the boo)ain patients, such a5 those with by, a st-line fluid resuscitation for cer > another choice for fr injuries Indications: , ,a or vomiting } 1. Torepla ce GI tract fluid losses ( Diarrhe 2. Fistula drainage 3, Fluid losses due to burns and trauma 4, Patients experiencing acute blood loss or hypovolemia due to third-space fluid shifts Precautions:- 4 LR Is metabolized in the liver, which converts the lactate to bicarbonate. LR is often administered to patients who have metabolic acidosis not patients with lactic acidosis, 4% Don't give LR to patients with liver disease as they cant metabolize lactate used cautiously in patients with severe renal impairment because it contains some potassium 4 LRshouldn't be given to a patient whose pH is greater than 7.5 5% dextrose in water (dSw): > compositions:- Dextrose> 50 gm/I Omolarity 276 mosm/t > Itis considered an isotonic solution, but when the dextrose is metabolized, the solution actually becomes hypotonic and causes fluid to shift into cells, > DSW provides free water that pass through membrane pores to both in cellular and extracellular spaces. > Its smaller size allows the molecules to pass more freely between compartments, thu expanding both compartments simultaneously"HL At provides 170 calories per liter, but it doesn’t replace electrolytes. ‘The supplied calorie doesn't provide enough nutrition for prolonged use. But still can be added to provide some calories while the patient is NPO. Plasma-Lyte:- (Compositions Na+ 140 meq/! K+ Smeq/l Mg++ 3 meq/l Cl-> 98 mea/t Acetate> 27 meg/l Gluconate->23 meq/! Osmolarity ->294 mOsm/! Indications > For fluid replacement (e.g. after burns, head injury, fracture, infection, and peritoneal irritation). > As intraoperative fluid replacement. > In haemorthagic shock and clinical conditions requiring rapid blood transfusions (compatibility with blood). > inmild to moderate metabolic acidosis, also in case of lactate metabolism impairment. Contraindications:- Hyperchloraemia Hypernatraemia Hyperkalaemia Renal failure Heart block Metabolic or respiratory alkalosis Hypocalcaemia or hypochlorhydria vvvvvyyics (amiloride, potassiim i, e with potassium terene) (s2e 45) stances oF > Concomitant us spironolactone, triam| he excipients listed in sections to the active su > Hypersensiivity to any of th utions in usal e of isotonic solutions. ig treated for hypovolemia can quickly develop hypervolemia (jy > Be aware that patients bein volume overload) following rapid or overinfusion of isotonic fluids. > Document baseline vital signs, edema status, lung sounds, and heart sounds before beginning the infusion, and continue monitoring during and after the infusion, > Frequently assess the patient’s response to IV. therapy, monitoring for signs and symptoms of hypervolemia such as: hypertension / bounding pulse / pulmonary crackles / periphera edema / dyspnea / shortness of breath / jugular venous distention (JVD}. > Monitor intake and output. > Elevate the head of bed at 35 to 45 degrees, unless contraindicated. > ifedema is present, elevate the patient’s legs. > monitor for signs and symptoms of continued hypovolemia, including: Urine output of less than 0.5 ml/kg /hour / = Poor skin turgor “Tachycardia - Weak, thready pulse - Hypotension > Educate patients and their families about signs and symptoms of volume overload and dehydration. > Instruct patients to notify if they have trouble breathing or notice any swelling > Instruct patients and families to keep the thead of the bed elevated (unless contraindicated),“The! « iifacelluar fluid volume, so they are used as volume expanders: |! Correction of hypoosmolar hyponatremia. Y* treatment of increased intracranial pressure. may cause endothelial damage and 11.7% Nachmaybe refore be administered into a central vein, » ‘AtNacl concentration greater than 7.5% “used as a sclerosant agent and should the! examples and Indications: ~ 1, 3% sodium chloride (3% NaCl): prescribed for patients in critical situations of severe hyponatremia, 7 an infusion of hypertonic sodium chlor patients with cerebral edema may benefit fro 2. 5% Dextrose with normal saline (DSNS}:- ‘es sodium, chloride and some calories. Precautions with hyperto fluids: } Hypertonic sodium chloride solutions should Tt replac areas with 2 administered only in high acuity constant nursing surveillance for potential complicationsspertonic saline solutions because of their potentiay tor > Maintain vigilance when administering byt causing intrav Shouldn't be given for an indefinite period of time. ascular fluid volume overload and pulmonary edema, prescriptions for their use should state the specific hypertonic fluid to be infused, the total volume to be infused and infusion rate, or the length of time to continue the infusion. > tis better to store hypertonic sodium chloride solutions apart from regular floor stock |\V. Fluids HYPOTONIC FLUIDS » Compared with intracellular fluid (as well as compared with isotonic solutions), hypotonic solutions have a lower concentration of solutes (electrolytes) and osmolality less than 250 mOsm/L, % Hypotonic crystalloid solutions lower the serum osmolality within the vascular space. causing fluid to shift from the intravascular space to both the intracellular and interstitial Spaces. ® These solutions will hydrate cells, although their use may deplete fluid within the circulatory system > Types of hypotonie fluids 0.45% sodium chloride (0.45% NaCl, 0.33% sodium chloride, 0.2% sodium chloride and 2.5% dextrose in water % Hypotonic fluids are used to treat patients with conditions causing intracellular dehydration, when fluid needs to be shifted into the cell, such as: 1. Hypernatremia 2. Diabetic ketoacidosis 3, Hyperosmolar hyperglycemic state.Never give hypotonic solutions to patients who are at risk for Increased ICP because it-may exacerbate cerebral edema. t > Don't tise hypotonic solutions in patients with liver disease, trauma, or burns due to the potential for depletion of intravascular fluid volume, The decrease in vascular bed-volume can worsen existing hypovolemia ‘and hypotension anid cause cardiovascular collapse > Monitor patients for signs and symptoms of fluid volume deficit > In older adult patients, confusion may be an indicator of a fluid volume deficit. Instruct patients to inform you if they feel dizzy or just “don't feel right.” COLLOIDS > Solutions that contain large molecules or ultra-microscopic particles of « homogeneous sonérystallire substance that don't pass the cell membranes. > “Thede gastisles cannot be separated out by filtration or centrifugation. théy remain in the intravascular compartment and expand the feacayatonlie sSemisynthetic colloids->Gelatins : . ->Hydroxyethyl Starches Dextrans, » “Human Plasma Derivatives > Albumin (5%, 20%) > Plasma protein fractions (Plasmanate-5%)Fresh frozen plasma > immunoglobulins 5% albumin (Human albumin solution): Y The most commonly utilized colloid solutions. Y It contains plasma protein fractions obtained from human plasma and works to rapidly expand the plasma volume. ¥ used for: -Volume expansion, -Moderate protein replacement, Achievement of hemodynamic stability in shock states. Y Considered a blood transfusion product and requires all the same nursing precautions used when administering other blood products. Y It ean be expensive and its availability is limited to the supply of human donors. > Contraindications:~ a) Severe anemia. b) Heart failure, ©) Known sensitivity to albumin, d) Angiotensin-converting enzyme inhibitors ( ACEI) should be withheld for at least 24 hours before administering albumin because of the risk of atypical reactions, such as flushing and hypotension > Sings of transfusion reaction may include: fever, flank pain, vital sign changes, nausea, a, dyspnea, and broncho spasm. headache, urtic * If you suspect a transfusion reaction, take these immediate actions: 1. Stop the transfusion, 2. Keep the L.V. line open with normal saline solution. 3. Notify the physician and blood bank 4. Intervene for signs and symptoms as appropriate. 5, Monitor the patient’s vital sign:Hydroxyethalstarches(HES): > HES are modified natural in deri en g units prevents rapid in vivo hydrolysis > Starches are also classified by in vitro molecular weight (MW) into high MW (450 to 480 kDa), medium MW (200 kDa) and low MW (70 kDa). > Smaller HES molecules are rapidly excreted and larger molecules are hydrolyzed to form a greater number of smaller molecules. > Ongoing renal excretion accounts for the elimination of smaller HES molecules and medium-sized molecules being excreted in the bile and feces. > Volulyte: Waxy maize HES 6% (130/0.4) Na+--143 meq/l k+--4 meq/l Cl- 110 meq/l Mgt+---3 meq/l Acetate—34 meq/l Osmolarity—287 mosm/l } Itis another form of hypertonic synthetic colloids used for volume expansion > Contain sodium and chloride and used for hemodynamic volume replacement following major surgery and to treat major bums. Less expensive than albumin and their effets can last 24 1036 hours hylactoid } Problems such as coagulopathy, accumulation, renal dysfunction anda Reactions. Dextrans:- > Dextrans are highly branched polysaccharide molecules produced by the bacterium A he growth medium by Leuconostoc mesenteroides after conversion of sucrose in the g n bacterial dextran sucrase. > Available dextrans have an average MW of 40 kDa or 70 kDaydispersal_né ions means that 4 is ature of dextran solutions polydis it jolloids, the f > As with other c filtered at the proportion of smaller MW molecules are present that are rapidly glomerulus. > 70% of a dextran dose is renally excreted within 24 hours. > Higher MW molecules are excreted into the GI tract or taken up into the mononu phagocyte system, where they are degraded by endogenous dextranases. > Dextrans have a plasma volume effect similar to that of starches, with a duration of 6 to 12 hours. > dextran 40 may be used in microvascular surgery, where its dilutional effects on blood viscosity and anticoagulant effects favor flow in the microcirculation. > Overall, the use of dextrans is limited by their range of toxicities, as follows ~ Antithrombotic effect, ~ Blood cross-matching, Anaphylactoid reactions, ~ Renal dysfunction. Gelatin: > Gelatins are derived from the hydrolysis of bovine collagen, with subsequent modification by succinylation or urea-linkage to form polygeline (Haemaccel) > Compositions: Na+ 145 meq/l K+ 5.1 meq/l Cat 12.5 meq/ Ch 145 meq/I > An infused gelatin bolus will rapidly leave the circulation, predominantly by renal filtration, > It causes reductions in von Willebrand factor (vWE), factor Ville and ex vivo clot . strength.» The highest estimated incidence of severe anaphylactic and anaphylactoid reactions (<0.35%). » The high Ca2+ content (12.Smeq/l) of Haemaccel is a contraindication to co- administration of citrated blood products products in the same infusion set. Precautions when using Colloid solutions: » The patient is at risk for developing fluid volume overload. As for blood products, use an 18-gauge or larger needle to infuse colloids. Monitor the patient for signs and symptoms of hypervolemia, including, - Increased BP -Dyspnea or crackles in the lungs -Edema. Closely monitor intake and output. Colloid solutions can interfere with platelet function and increase bleeding times, so monitor the patient’s coagulation profile. Elevate the head of bed unless contraindicated Anaphylactoid reactions are a rare but potentially lethal adverse reaction to colloids. Take a careful allergy history from patients receiving colloids (or any other drug or fluid), asking 5 lly if they have ever had a reaction to an L,Y, infusion,II ASSESSMENT AND MONITORING OF FLUID STATUS Assessment:- } Assess whether the patient is hypovolaemic. Indicators that a patient may need fluid resuscitation include: “Systolic blood pressure is less than 100 mmHg -Heart rate is more than 90 beats per minute -Capillary refill ime is more than 2 seconds or peripheries are cold to touch -Respiratory rate is more than 20 breaths per minute -National Early Warning Score (NEWS) is 5 or more -Passive leg rising suggests fluid responsiveness > Assess the patient's likely fluid needs from their history, clinical examination, current medications, clinical monitoring and laboratory investigations: ‘* History should include any previous limited intake, thirst, the quantity and composition of abnormal losses and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome. © Clinical examination should include an assessment of the pati -Pulse, blood pressure, capillary refill and jugular venous pressure. - Presence of pulmonary or peripheral edema t's fluid status, including - Presence of postural hypotension. * Clinical monitoring should include current status and trends in: - National Early Warning Score (NEWS) - Fluid balance charts - Weight. Laboratory investigations should include current status and trends in: - Full blood count -Urea, Creatinine and Electrolytes - Blood lactate level.+ Others parameters, -Near infrared spectroscopy, Microdialysis, -GICOr -G1 P measurment “ONITORING:- > All patients continuing to receive IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values and fluid balance charts, along with weight measurement twice weekly. » Central Venous Pressure (CVP). Pulmonary Artery Catheters (pacs) and Pulmonary Artery Occlusion (Wedge) Pressures Wedge Pressure Left = Atrial Pressure « Left ventricular End-Diastolic Pressure (LVEDP). > Cardiorespiratory Interactions and Dynamic Analysis of Fluid Status, > Echocardiography. ELUID THERAPY: > Perioperative Fluid Therapy depending on, > Patient factors, including weight and comorbidity and > Surgical factors such as the magnitude and site of surgery. > ‘The goals of fuid therapy also depending on the severity of surgery and its associated morbidity “>in “low-risk” minor surgery, fluid strategies may influence the incidence of relatively mi > inm or morbidity such as nausea and vomiting or surgery the focus is on the potential for fluid administration to affect major postoperative morbidity, postoperative length of stay, and possibly postoperative mortality> The goals of fluid therapy for major surgery are, V- To ensure adequate circulating volume to support cell deleterious effects of hypoperfusion. ¥ Toavoid the iatrogenic side effects of fluid administration. Quantity of Fluid:- > IV fluid quantities may be given in two main ways: lular O2 delivery and avoid the ¥ By estimating the requirements based on patient weight, the phase of surgery. and nature of losses to estimate the required dose or ¥ By direct measurement of an individual's physiologic variables. and administering fluid in sufficient quantities 10 achieve an improvement in these physiologic variables. so-called goal-directed therapy. Targeting overall fluid balance:- > The most commonly used formula for calculate maintenance fluid flow rates is (42/1) rule which is used for both adults and pediatries > 42/1 nule:-(holliday segar formulae) 4 mikg/hr for first 10 kg (=40mt/hr),then 2 ml/ke/hr for next 10 kg (=20mI/hr),then 1 mi/kg/hr for any kgs over that. Goal-Directed Therapy (GDT):- > The practice of goal-directed therapy (GDT) is based on measuring key physiologic variables related to cardiac output or global 02 delivery > GDT used both in the perioperative and critical care setting > Perioperative GDT is based on measurements from two devices. Pulmonary artery catheter (PAC)--the gold standard hemodynumie moniter. providing measured and derived values for left heart and right-heart fills pressures, mixes and central venous saturations, cardiac output > Esophageal Doppler monitor (EDM)=This device uses trans-esophageal ultrasound measurement of descending aorta blood velocity > Other targets for goal-directed therapy are , Y Arterial blood pressure and waveform analysis,9° Orat ctear fluid intake should continue until 2 hours preoperatively and longer fasting discouraged. ‘The use of preoperative bowel preparation should be restricted to carefully selected cases, and in these cases an infusion of 1 to 2 L of balanced crystalloid with K+ supplementation should be given in the preoperative period. v v In emergency surgery % Patients are likely to have acute disturbances of fluid compartments. They require timely resuscitation guided by rational physiologic endpoints such as blood pressure and heart rate, lactate, urine output, and mixed or central venous 2 saturations. An approach is required 10 provide ongoing fuid resuscitation without compromising carly surgical intervention. Upper Gl losses should be quantified and replaced with isotonic saline and } Lower Gil losses (fistula, ileus, or obstruction) with balanced crystalloid. % K+ should be supplemented as appropriate =7- Low blood pressure: 8- Low body temperature 9- Rapid pulse, often weak and thready > Parameters used to assess volume deficit, 1- Blood pressure 2- Urine output 3+ Jugular venous pressure 4- Urine sodium concentration > Rate of Repletion of Fluid deficit: 1) Severe volume depletion or hypovolemic shock: Y Rapid infusion of 1-2 L of isotonic saline (0.9% NS) as rapidly as possible to restore tissue perfusion. 2) Mild to moderate hypovolemia: Y Choose a rate that is 50-100mL/h greater than estimated fluid losses ¥ calculating fluid loss as follows: = Urine output= SOml/h, -Insensible losses = 30mi/n. -Additional loss such as Vomiting or Diarrhea or high fever (additional 100-150 mi/day for each degree of temp >37 C). Fluid therapy in Pediat > BEARER AfeimdrS susceptible for water loss due to: (WEP HS Lozicalinability of their renal tubules to concentrate RRIgEREab otic rate | REISS tain SLEREEEIOVERTRE catnee} Because of the relatively large body surface area the pedtatrie population are risk for clinically significant preoperative dehydration by fasting, as a result of Timited urinary concentrating ability and ongomy insensible losses, > So, Intraoperative replenishment of these volumes using 25 mlukg of isotonic salt solution for those 3 years of age and younger or 18 mL/kg for those 4 yeary of age and older has been recommended > In preoperative fasting, children may ta fluids up to 2 hours before surgery, reduces the risk for hemodynamically significant clear and potentially carbohydrate-containing preoperative dehydration is infrequent (<2.5%) and related to > The incidence of preoperative hypogly: inappropriately prolonged fasting or other risk factors, such as premature infants, neonates who are small for gestational age, or those with poor nutritional status. > So, Glucose-free balanced crystalloid solutions should therefore be used intraoperatively, except in those at particularly hi ‘> Returning to oral fluids as early as possible Se Ensuring euvolemia to minimize the ADH response % Checking electrolytes at least daily in those still receiving IV fluids > Bxtensive burs create a situation of copious fluid loss from the circulation combined _ with particular sensitivity to the effects of excess fluid administration. '} Local impairment of endothelial barrier function leads to the loss of oncotically active ‘plasma constituents, increased capillary filtration into the interstitial compartment and evaporative transcutaneous fluid loss as a result of loss of skin integrity. IV fluid therapy is generally instituted for bums of greater than 15% total body surface -area in adults and 10% total body surface area in children. > Fluid administration is largely still based on formulas such as the Parkland formula or the Muir and Barclay versions.> Pe nd Burn Fluid Resuscitation Formula, ~ First 8 hours: 2 mL/kg * % TBSA (lactated Ringer solution) ~-Next 16 hours: 2 mL/kg x %TBSA (lactated Ringer soluticn) ~Next 24 hours: 0.8 mLikg * %TBSA (5% dextrose) + 0.015 mL/kg » %TBSA (5% albumin), » Excessive fluid administration in burned patients (“fluid creep”) is not benign. Excess administered fluid will collect in compliant compartments. ¥ Pulmonary edema requiring ventilatory support. Fasciotomies in nonburned muscle compartments, Y Raised intraocular pressure ¥ Conversion of superficial to deep burns have been observed and attributed to fluid resuscitation, ¥ Intra-abdominal hypertension and compartment syndrome are correlated to the volume of fluid administered, with a particular rise when more than 300 mL/kg, is administered in 24 hours. Conversion of superficial 10 deep bums have been observed and attributed to fluid resuscitation, ¥ Intra-abdominal hypertension and compartment syndrome are correlated to the volume of fluid administered, with a particular rise when more than 300 mL/kg is administered in 24 hours. REFERENCES > Miller -8th edition. > Morgan --Sth edition. > Fluids & electrolytes made easy -willis ~ 6th edition > Singh s, kuschner wg, lighthall g. Perioperative intravascular fluid assessment and monitoring: a narrative review of established and ‘emerging techniques. Anesthesiology research and practice. 2011 jul 12;2011. > National clinical guideline centre- intravenous fluid therapy- Dec 2013