FLUID THERAPY

The lifesaving procedure of fluid therapy was first introduced by Latta (1831) in Scotland,
when he treated cholera patients by injecting 6 pints (3.5liter) of saline within 30 minutes.

Plasma osmolality - Define

Plasma osmolality is a function of the ratio of body solute to body water; it is regulated by changes in
water balance.

2. Effective circulating volume

Effective circulating volume is defined as that part of the extracellular fluid (ECF) that is in the vascular
space and effectively perfusing tissues. It varies directly with ECF volume and also with total body sodium,
since sodium salts are the primary ECF solutes holding water in the extracellular space. Therefore,
regulation of sodium balance, by changes in renal sodium ion, and the maintenance of effective circulating
volume, are closely related.

TYPES OF FLUID THERAPY:

1. Replacement therapy.

• Water and electrolyte therapy

• Blood, blood products or plasma substitutes.]

2. Supportive therapy.

• Glucose, dextrose and fructose solutions

• Proteins and amino acids
• Fats and vitamins

3. Adjunctive therapy.

• Treatment of specific disorders e.g. hypertonic solutions as renal and non-

renal (osmotic) diuretics for excessive extravascular fluid. Urea, sucrose,
20-25% mannitol and 10-50% dextrose solutions, solutions for peritoneal
dialysis.

Fluids and electrolytes balance is of outmost importance in surgical patients

suffering from dehydration e.g. in case of severe diarrhea.

NORMAL DISTRIBUTION OF BODY WATER:

Water is the largest constituent of the body.

❖ Total body water (TBW) is 70% of total body weight of which,

➢ 50% intracellular (ICF)
➢ 20% extracellular (ECF_
▪ 15% in interstitial space
▪ 5% in plasma
ELECTROLYTES:

Cations: Sodium potassium, calcium and magnesium

Anions: Chloride, bicarbonate, sulfate, phosphate, proteins

MAJOR CATIONS AND ANIONS OF BODY

CATIONS ANIONS
+
ECF Na Cl- , HCO3-
+
ICF K PO4-, proteins
NORMAL WATER AND ELECTROLYTE EXCHANGE:
❖ Normal sources to maintain TBW are
➢ Consumed water
➢ Water in food
➢ Metabolic water generated by nutrient or tissue oxidation
❖ Normal sources of fluid loss from TBW are
➢ Sensible losses
▪ Urine, 12-24 ml/lb/day
➢ Insensible losses
▪ Faeces, respiration, sweating, 10ml/lb/day

REGULATION OF NORMAL BODYWATER BALANCE:

Physiological control mechanism exists which is important in maintaining the zero

water balance. This mechanism includes:

a. Thirst
b. Renal mechanism (ADH, Aldosterone)
c. Gastrointestinal mechanism i.e. altered absorption
d. Metabolic water from oxidation of tissue.

The major defense against hyperosmolality (accumulation of solute in excess of body

water) is increased thirst. Although the kidney can minimize water losses via the action of
ADH, water deficits can be corrected only by increased dietary intake

Alterations in plasma osmolality of as little as 1% - 2% are sensed by osmoreceptors in the

hypothalamus. These receptors initiate mechanisms that affect water intake (via thirst) and
water excretion (via antidiuretic hormone [ADH]) to return plasma osmolality to normal.

Three major mechanisms alter effective circulating volume:

1) The sympathetic nervous system,

2) Angiotensin II, and
3) Renal sodium excretion.

Volume depletion, sensed by arterial baroreceptors as hypotension, causes an increase

in peripheral sympathetic tone. Increased sympathetic tone returns volume to normal by
initiating specific compensatory changes. These compensatory changes include the
following:

o Venous constriction: Increased venous return

 o Increased myocardial contractility and heart rate: Increased
cardiac output
o Arterial vasoconstriction: Increases systemic vascular
resistance and blood pressure
o Increased renin secretion: Increases levels of angiotensin II
which is a potent vasoconstrictor
o Increased renal tubular sodium resorption (due to increased
levels of angiotensin II and aldosterone).
• Electrolyte Abnormalities
o Hyponatremia
▪ Most common cause is excess free water, not deficit of sodium
▪ Common in postop period, due to ADH secretion
▪ CNS effects with acute drop to 120 mEq/l
▪ Since most surgical patients are eu- or hypervolemic, treat with free
water restriction
▪ Avoid rapid infusion of hypertonic saline (central pontine myelinolysis)
o Hypernatremia
▪ Usually excess free water loss in setting of hypovolemia
▪ May be due to excess sodium in IV fluids
▪ CNS effects with sodium > 160 mEq/l
▪ Treat with free water; avoid rapid correction (cerebral edema)
o Hypokalemia
▪ Muscle weakness with levels < 2.5 mEq/l, affecting respiration, intestinal
motility
▪ Cardiac arrhythmias , EKG abnormalities
▪ Reduction in serum level by 1 mEQ/l: 100 to 200 mEq body deficiency
▪ IV replacement at 10 mEq/hr; oral replacement if possible
o Hyperkalemia
▪ Reduced renal excretion is usual cause in surgical patient
▪ Crush injuries, reperfusion of ischemic limbs, blood transfusions
▪ Rule out hemolyzed blood specimen as cause of false value
▪ Cardiac effects: peaked T waves, ventricular fibrillation
▪ Treatment: sodium bicarbonate, or insulin/glucose to shift potassium
intracellularly
▪ Calcium gluconate IV to stabilize membrane potentials
▪ Diuretic (eg. furosemide) IV to increase urinary excretion
▪ Potassium resin binder (eg. Kayexalate) in sorbitol (removes 1 mEq
potassium per gram)
▪ Dialysis
o Hypocalcemia
▪ Hypoparathyroidism after thyroid/parathyroid surgery
▪ Acute pancreatitis, pancreatic or small bowel fistulas
▪ May result from hypomagnesemia
▪ No treatment for low levels with hypoalbuminemia and normal ionized
calcium levels
▪ Muscle cramps, hyperactive DTR's, Chvostek sign, prolonged QT
interval
▪ Treatment: IV calcium gluconate or chloride at a rate not exceeding 50
mg/min
o Hypercalcemia
▪ Primary hyperparathyroidism, malignant disease with bony metastases or
PTH-like factors
▪ Neuromuscular effects, shortening of QT interval, GI side-effects
▪ Prompt treatment over 14 mEq/l: saline with diuretics, hydration
 ▪ Mithramycin, calcitonin
o Magnesium: half in bone; most of remainder in intracellular space
▪ Less than 1% total body Mg in extracellular space
▪ Primarily excreted by kidneys
o Hypomagnesemia
▪ Low intake combined with increased GI losses
▪ Prolonged IV fluids without Mg
▪ Malabsorptive states (steatorrhea)
▪ Symptoms similar to hypocalcemia
▪ May cause hypocalcemia (impaired PTH secretion)
▪ Treatment of major deficits: IV repletion, at 50 to 100 mEq/day of
magnesium sulfate. Bolus 2 to 4 gm over 4 hours (1 gm = 8 mEq)
o Hypermagnesemia
▪ Renal failure is primary cause
▪ Burns, crush injuries may also produce
▪ Causes depressed neuromuscular function
▪ Treatment: withhold Mg-containing drugs, expand volume, slow IV
infusion of calcium (5 to 10 mEq)
o Hypophosphatemia
▪ Muscular weakness, respiratory weakness, paresthesias
▪ Causes: Inadequate repletion in TPN, malabsorption, phosphate binding
agents
▪ Replace: Sodium or potassium phosphate- 10 to 20 mmol/4 hours IV
o Hyperphosphatemia
▪ With hypercalcemia, produces 'metastatic' calcifications
▪ Causes: renal insufficiency, hypoparathyroidism
▪ Treatment: Phosphate-binders with aluminum hydroxide or carbonate

DEHYDRATION:

Commonly used term dehydration implies a deficit of body water. It is of three major types:

1) Isotonic: Loss of water and Sodium in proportions similar to those in plasma. (loss
from GIT)
2) Hypotonic: Loss of sodium in excess of water. (inability of kidney to consume
sodium)
3) Hypertonic Loss of water in excess of sodium. (Little water intake, heat stroke,
diabetes inspidus)

DIAGNOSIS OF DEHYDRATION:

❖ Consideration of the body weight

➢ Because of the 70% of the body weight is water, any change in the fluid status of
the animal is reflected by change in body weight.
❖ Clinical signs exhibited by the animal
➢ Signs that may be indicative of the dehydration are
▪ Loss of elasticity and pliability (turgor) of the skin,
▪ Dryness of the oral mucosa,
▪ Depression of the eyes into the orbit,
▪ Prolonged capillary refill time
 Following are some guidelines for estimating the %age dehydration

Estimated
percentage Physical Examination Findings
Dehydration

<5 History of fluid loss but no findings on physical examination

Dry oral mucous membranes but no panting or pathological

5
tachycardia

Mild to moderate decreased skin turgor, dry oral mucous membranes,

7
slight tachycardia, and normal pulse pressure.

Moderate to marked degree of decreased skin turgor, dry oral mucous

10 membranes, tachycardia, and decreased pulse pressure.

Marked loss of skin turgor, dry oral mucous membranes, and

12
significant signs of shock.

❖ Use of certain laboratory aids

➢ PCV
➢ Total solid conc. of plasma (TS)
➢ Urine specific gravity
➢ Blood urea nitrogen concentration

STATES THAT REQUIRE FLUID THERAPY:

❖ Operative and postoperative

❖ Blood loss
❖ Vomiting
❖ Diarrhea
❖ Starvation
❖ Dehydration
❖ Shock
❖ Oedema and ascites
❖ Nephritis
CLACULATION OF THE FLUID TO BE ADMINISTERED:

1. Replacement Volume: Volume of the fluid needed for returning the patient to the
normal state. Or it is the deficit volume. This can be calculated by two ways;
a. Using previously known body weight e.g. a dog presented to you with the
weight decrease of 2 lb in one day and clinical examination reveals
dehydration. This 2 lb weight lost is actually loss of water.
1 lb of water = 500 ml of water
2 lb of water = 2 X 500 =1000 ml
b. Using clinical estimation of the dehydration e.g. in case of a 18 kg dog
suffering from 10 % dehydration, we can calculate replacement volume by
the following formula;

% dehydration X body weight (Kg)

10/100 X 18 = 0.1 X 18 = 1.8 Kg
This 1.8 Kg means animal has lost the 1.8 L of fluid. Thus we will
administer 1800 ml of fluid to correct the dehydration.

2. Maintenance Volume: Volume of the fluid required to replace ongoing losses e.g.
urine, sweating, faeces etc. As a thumb rule we take 10 ml/lb/day for the insensible
losses and 10-20 ml/lb/day for the sensible losses or measured urine out put.

3. Continuing Losses Volume: Volume of fluid to replace the continuing abnormal

losses e.g. losses through vomiting, diarrhea etc. Again a general rule is to estimate
the volume of fluid loss and then double this estimate.

FLUID ADMINISTERATION:

1) Routes of fluid administration:

a) Oral Route: For the administration of the high caloric density preparations. Bu this
route should not be used in case of vomiting and diarrhea.
b) Subcutaneous Route: Used in case of puppies and kittens or whenever there is
circulatory collapse. Isotonic solutions should be used through this route. The
drawbacks are slow absorption and only limited amount of fluid can be given
through this route.
c) Intravenous Route: Most commonly used route. It is very fast replying route i.e. the
correction of the fluid disorders can be done in lesser time than above-mentioned
routes.
d) Intraperitoneal Route: Large volumes may be given rapidly by this route. But in
case of hypovolemia absorption will be delayed. There is always a risk of peritonitis
because of damage to visceral organs.

2) Rate of Infusion: A general guideline for the intravenous fluids is to administer at the
rate of 15ml/Kg/hour. One milliliter represents 16 drops. Thus the 15 ml/Kg/hour
becomes 240 drops/kg/hour. For example in case of 20 Kg dog,

Weight X 15 ml/Hour = 20 X 15 = 300 ml/ hour

= 300/60 = 5ml / minutes
 = 5 X 16 = 80 drops/min.
General Precautions:

• Fluids should be wormed to body temperature. Cold fluids may cause local
vasoconstriction retarding the rate of absorption. Cold fluids given IV may produce
cardiac arrhythmias or cardiac arrest.
• Fluids should be administered rapidly at first and then at decreasing rate until the
situation stabilizes.

COMPLICATIONS OF FLUID THERAPY:

• Acute Overhydration: Due to fluid overload. Pulmonary edema is the terminal

event of overhydration before this you will first note an increased serous nasal
discharge, followed by chemosis and finally pulmonary congestion.
• Particulate Contamination: Presence of other contaminates in the poorly
prepared fluids by substandard manufacturers. The particulates as small as 12
microns in diameter can block pulmonary vessels.
• Mixture Incompatibility: Example. Drugs and fluids given in combinations.
• Inappropriate Fluid Selection: Fluid should be properly selected considering the
electrolyte, acid-base status, osmolality etc.
Different Fluids and their composition:

Buffer Calories Osmolality

Solution Na+ K+ Cl- Ca++ Mg++ MEq/L Kcal/L mOsm/L

Dextrose 5% in
- - - - - - 170 278
Water

Dextrose 2.5%
77 - 77 - - - 85 280
in 0.45% Saline

Ringer’s Lactate Lactate

130 4 109 3 - 9 272
Solution 28

Ringer’s
147 4 156 4.5 - - - 309
Solution

Acetate
Normosol-R 27
140 5 109 - 3 15 294
(Multisol-R) Gluconate
23

Dextrose 5% in Lactate
130 4 109 3 - 179 525
Ringer’s Lactate 28

Normal Saline
154 - 154 - - - - 308
(0.9%)

Dextrose 50% - - - - - - 1700 2525

Dextrose 5% in
154 - 154 - - - 170 -
Saline (0.9%)

Potassium
- 2 2 - - - - -
Chloride
 SELECTION OF FLUIDS FOR SELECTED DISEASES

SERUM

CONDITION Na+ Cl- K+ HCO3- Volume FLUID OF CHOICE

NORMOSOLR-R + KCl or
Diarrhea D D D D D
Lactated Ringer's + KCl

Pyloric obstruction D D D I D 0.9% NaCl + KCl

NORMOSOLR-R + KCl,

Dehydration I I N N/D D Lactated Ringer's + KCl,

0.9% NaCl + KCl, 5% dextrose

Congestive heart 0.45% NaCl + 2.5% dextrose +

N/D N/D N N I
failure KCl, 5% dextrose

End-stage liver 0.45% NaCl + 2.5% dextrose +

N/I N/I D D I
disease KCl

Acute renal failure 0.9% NaCl,

I I I D I
-Oliguria NORMOSOLR-R + KCl,
D D N/D D D
-Polyuria Lactated Ringer's + KCl,

NORMOSOLR-R,
Chronic renal failure N/D N/D N D N/D
Lactated Ringer's solution, 0.9%
NaCl

Adrenocortical
D D I N/D D 0.9% NaCl
insufficiency

Diabetic ketoacidosis D D N/D D D 0.9% NaCl (+ KCl)

D = Decreased I = Increased N = Normal