Module name 1

introduction N.B.
therapy = indication &
Functional fluid compartments
contraindications & doses
A. Total Body Water (TBW): ≃ 42 L
• 60% (adult males) of ideal body weight ، ‫اعرف الرموز عشان هستخدمها‬
• 50% (adult females) of ideal body weight ‫بس يف االمتحان ما تستخدمهاش‬
B. Intracellular fluid (ICF): ≃ 25 L
• 35% of IBW or 60% of TBW. • Principal K containing space.

C. Extracellular fluid (ECF): 13.5 L ISF & 3.5 L IVF

• 25% of IBW or 40% of TBW • Principal Na containing space.
• It is subdivided into interstitial fluid (ISF) and intravascular (IVF; about 8% of TBW).
• Osmolarity of blood (280 → 310 or 315) mOsm/L
Daily requirements
• Water: 30 -35 ml / kg / day ≃ 2.5 L /day • Na: 2-3 mEq/kg/24 hours
• K: 1-2 mEq/kg/24 hour • Cl: 2-3 mEq/kg/24 hours
Intravenous
Introduction: Solution is divided into Crystalloids & Colloid
Crystalloids Colloid
Molecular Low (<60,000 Dalton) High (> 60,000 Dalton)
weight of its  escape from the vascular  stay for longer time in the vascular
particles compartment → short plasma half life compartment → long plasma half life
Intravascular
15 - 20 minutes 3 - 6 hours
half-life
Types 1) Isotonic: e.g. Normal saline 1) Natural (Blood derivative)
2) Hypotonic: dextrose 5 % e.g. Albumin, fractionated plasma ptn
3) Hypertonic: hypertonic saline 2) Synthetic e.g. dextran
hydroxyethyl starches (best colloid),
Uses • Resuscitation (1st choice)
Resuscitation only (2nd choice)
• Maintenance
Crystalloid solutions:
❑ Uses:
▪ Largely considered the initial resuscitation fluid in patients with hemorrhagic and septic
shock, burns, and traumatic brain injuries.
▪ A general rule is to replace what is being lost.
o Hypotonic solutions (maintenance type solutions):
For replacement of losses primarily involving water (in NPO patients on the floor),
o Isotonic electrolytes solutions (replacement type solutions):
For replacement of losses involve both water and electrolyte (i.e., blood loss)
 2 Fluid therapy

❑ Comparison
Normal saline 0.9 % Hypertonic saline (e.g. 3%) Dextrose 5 % Lactate
Molecar mass 58 gm/mole 58 gm/mole 180 gm/mol -
Osmolarity 308 mOsm 1020 mOsm 277 mOsm/L -
Tonicity Isotonic Hypertonic Hypotonic Slightly Hypotonic
Distribution of • 750 ml in ISF Mainly in IVF • 700 ml in ICF
(3:1)
1L • 250 ml in IVF • 200 ml in ISF
• 100 ml in IVF
Notes on • Notes on distribution • Notes on distribution • Notes on distribution • Ringer is the most
▪ Noting in ICF: Hypertonicity → Shift Hypotonicity → Shift fluid physiological Crystalloid
no benefit in diarrhea fluid from ICF to IVF So, from IVF to ICF So, • Types of ringer:
▪ 3:1 distribution: o It used in o It used in 1. Ringer solution
blood & colloid are better Brain Edema. dehydration. 2. Ringer lactate
for replacement in severe o Given in o It has no role in (Hartmann's solution)
cases Small amount replacement. Metabolized in Liver
(100 mL/5h)
• Don't give normal saline if : • Glucose is rarely added in 3. Ringer acetate
Serum Na > 130meq/L & the the intraoperative setting, Metabolized in Muscles
patient is stable (especially if although pediatric patients
the patient is diabetic) are prone to hypoglycemia
 half normal saline is better and often need a glucose
in this case source with their fluids.
Undesired • when given in large volumes, Demyelinated syndrome
effect  dilutional hyperchloremic
acidosis (with normal AG)
 insulin resistance

Notes ‫للفهم ال تشغل بها بالك‬

• Molar mass is equivalent to molecular mass in Dalton • tonicity is a measure of the effective osmotic pressure gradient
Metabolic anion gap ‫الدكتور قال ان محلول الملح بيعمل‬ • (compared to plasma osmolarity)
 Module name 3

Colloid solutions:
These solutions are derived either from plasma proteins or synthetic glucose polymers.

Notes
• Crystalloid versus colloid resuscitation continues to be an ongoing debate, but the use of
albumin (5% & 25%) is justified in the presence of hypoalbuminemia or large burns (large
protein loss).
• The synthetic colloids run the risk of antiplatelet effects and should not be administered over
20 mL/kg/day.
(also, some of them affect coagulation factor → consider coagulation factor replacement)
• The dextran has also been found to be antigenic and can produce anaphylactoid reactions.

A. Normal maintenance requirements: (hourly rate based on weight; by 4-2-1 rule)

• 1st 10 kg: 4 mL/kg/hr or 100 mL/kg/day
• 2nd 10 kg: add 2 mL/kg/hr or 50 mL/kg/day
• >20 kg: add 1 mL/kg/hr or 20 mL/kg/day

B. Fluid deficit: Primarily NPO deficit caused by patient fasting.

• NPO deficit = hourly maintenance rate x number of hours NPO
• Replace the first half pre-op. and the remaining over the next 2-3 hours.

C. Intraoperative fluid loss: primarily third space (redistribution) & evaporative losses;
amount based on degree of tissue trauma.
• Minimal (e.g., herniorrhaphy): 0-2 mL/kg/hr
• Moderate (e.g., cholecystectomy): 2-4 mL/kg/hr
• Severe (e.g., bowel resection or exploration): 4-8 mL/kg/hr

D. Abnormal fluid loses: Ryle suction, intestinal stoma, diarrhea

E. Blood loss: (discussed in more details later)
▪ Replace each mL of blood loss with 3 mL of crystalloid, 1 mL colloid solution or 1 mL PRBC.
▪ Transfusion of red blood cells as necessary to maintain hematocrit. (when Reach Transfusion
point (discussed in more details later)

‫ ساعات و داخل عملية أرب ع ساعات‬6 ‫بالعرب شوية لو عيان داخل يعمل عملية و صايم‬
‫ي‬ ‫نتكلم‬
• 1st hour → 1/2 NPO deficit + normal Maintenance + ...etc.
• 2nd hour →1/4 NPO deficit + normal Maintenance + third space.
• 3rd hour → 1/4 NPO deficit + normal Maintenance + third space
• 4th hour → normal Maintenance + third space ()
‫ كل ساعة عادي و و هعوضه عن‬maintenance ‫ ساعات بعوضه زيادة عشان الصيام و هديلة ال‬3 ‫يعن المريض أول‬ ‫ي‬
rd
‫ من اآلخر هروق عىل العيان‬، ‫كبل ساعة و لو حصل فقد يف الشفاط هعوضه برده و لو احتاج دم هنقله‬3 space ‫ال‬
 4 Fluid therapy

Blood loss management Rules:

A. Estimated blood volume (EBV): (According to age)
Age EBV (mL/kg)
Premature infant 95-100
full-term infant 85-90
Infants up to 12 months. 80
Adult men. 70-75
Adult women. 65-70
B. Max allowable blood loss (MABL; Transfusion point)
▪ The maximum allowable blood loss (MABL) refers to the estimated maximum amount of
blood that a patient can lose during surgery without requiring a blood transfusion.
‫بمعن انه بعدها هبدأ انقل للعيان دم‬
▪ The MABL is calculated based on the patient's estimated blood volume (EBV) and initial
hematocrit level (Hct i)
( 𝐻𝑐𝑡 – 𝑡𝑎𝑟𝑔𝑒𝑡 𝐻𝑐𝑡)
= 𝐸𝐵𝑉 𝑥 .
𝐻𝑐𝑡
▪ Roughly it is 20 % of EBV in adult & 10 % of in pediaatric

C. Blood loss replacement

1) Replace every 1 mL blood loss with 3 Ml crystalloid or 1 cc PRBC.
2) PRBC transfusion guidelines: (see later)

D. Compatibility testing:
1) Type specific
2) Type and screen
3) Type and cross match
4) Screening donor blood
(Compatibility ‫ (ال عالقة له بال‬2) if normal do the following :
Test the following Compatibility of the blood
ABO-Rh typing only 99.80% compatible
ABO-Rh and screen 99.94% compatible
ABO-Rh, screen, and cross match 99.95% compatible
N.B. Cross matching confirms ABO-Rh typing, detects antibodies to
the other blood group systems, and detects antibodies in low titers.
1) hematocrit is determined.
▪ screened for antibodies of common infection transferred by
blood transfusion (HBV, HCV, HIV, HLTV, syphilis
▪ ALT is also measured as a surrogate marker of nonspecific
liver infection
 Module name 5

E. Blood component therapy:

Packed RBCs
Indications a need for increased oxygen
includes delivery to end organs
Note
Lower levels of 2,3-DPG
cause a leftward shift of
the Hb– oxygen
dissociation curve
(↑ oxygen affinity of Hb)
FFP
• TTT of known factor
deficiencies,
• Correction of
▪ warfarin therapy,
▪ antithrombin III
deficiency,
▪ coagulopathies with
liver disease or
hemodilution.
Platelets Cryoprecipitate
During surgery platelet transfusions are • hypo fibrinogenemia,
probably not required unless count is • VWD,
less than 50,000/mm3. • hemophilia A
Values of platelet (values / mm3) • preparation of fibrin
• Normal: 150,00-440,000 glue
• Thrombocytopenia: <150,000.
• Intraoperative bleeding
↑ with counts of 40,000-70,000,
• spontaneous bleeding
can occur at counts <20,000

Guidelines • 1 unit lead to (in adults)
▪ ↑ Hct by 3%
▪ ↑ Hb by 1 g/dL.
• 3 mL/kg: ↑ Hb by 1 g/dL.
• 10 mL/kg ↑ Hct by 10%
Precautions • Transfusion tubing should
contain a filter to trap clots.
• Multiple units should be
given through a warmer
Benefits
• Initial dosing is typically • Usual dose is 1 unit / 10 kg
10 to 15 mL/kg • 1 unit of platelets will increase
platelet count 5000-10,000 /mm3
• ABO compatibility is not • ABO compatibility is not mandatory ABO compatibility is not
absolutely necessary. • platelets are stored at room temp. mandatory
• FFP should also be
warmed with transfusion.
• Contain all clotting Single-donor platelets obtained by 10-20 mL/bag;
factors. apheresis are equivalent to 6 platelet which contains
• 30% of each factor concentrate. • 100 units VIII VIII C,
concentration is factor
sufficient for hemostasis • 100 units factor vWF,
• 60 units factor XIII,
• 250 mg fibrinogen
 6 Fluid therapy

Complications of blood transfusion

A. Immune Complications;
1) Hemolytic reactions:
• Causes:
a) Recipient antibody destruction of transfused RBCs.
b) Donar antibody destruction of recipient RBCs
Occasionally, the transfusion of donor RBC antibodies can destroy recipient RBCs.
(Incompatible units of platelet concentrates, FFP, clotting factor concentrates, or
cryoprecipitate may contain small amounts of plasma with anti-A or anti-B
alloantibodies).
• Onset: May be acute or chronic:
a) Acute hemolytic reactions:
▪ Cause:
 Typically caused by ABO incompatibility secondary to misidentification.
 Only 10 – 15 cc of ABO-incompatible blood can cause the reaction.
▪ Epidemiology: The overall risk is 1 : 100,000 transfusions.
▪ Manifestations: In anesthetized patients, it may manifest as unexplained
 Tachycardia,  Diffuse oozing from surgical field.
 Hypotension,  DIC develops rapidly.
 Hemoglobinuria,
 Treatment: see below.
b) Delayed hemolytic reactions: Extravascular hemolysis
▪ Cause: antibodies to non-D antigens of the Rh system or other systems such as
Kell or Duffy.
▪ Manifestations:
 Reaction is typically delayed 2 to 21 days,
 symptoms are generally mild.
▪ Investigations:
 Serum unconjugated bilirubin increases.
 Diagnosed by Coombs test.
▪ Treatment: supportive.
• Treatment of Hemolytic Transfusion Reactions;
1. Stop the transfusion.
2. Check for error in patient identity or donor unit.
3. Investigations
a. Notifying the blood bank & Send donor unit & a fresh blood draw to blood
bank for recross match.
b. Send patient blood sample to Identify.
i. Free hemoglobin, haptoglobin, direct antiglobulin (Coombs) test
ii. coagulation studies, platelet count
c. Send urine for hemoglobin.
 Module name 7

4. Treatment of the following:

a. hypotension with fluids and vasopressors as necessary.
b. Hemoglobinuria: Maintain the urine output at a minimum of 75 -100 mL/hr
by generously administering IV fluids; consider mannitol 12.5 - 50 grams, or
Lasix 20-40 mg.
5. Others
a. If transfusion is required, use type O-negative PRBC and type AB FFP.
b. Monitor for signs of DIC clinically and with appropriate lab studies.
2) Nonhemolytic reactions: Father Used A Green Pen To Teach
a) Febrile reactions:
• Cause: WBCs or platelet sensitization
• Manifestations: characterized by ↑ in temperature without hemolysis.
• Management: Patients with a repeat history should receive leuko-reduced
transfusions only.
b) Urticarial reactions: (Relatively common)
• Manifestations: Erythema, hives, and itching without fever.
• Treatment: antihistamines and steroids.
c) Anaphylactic reactions:
• Severe and typically in immunoglobulin A– (IgA-) deficient patients who receive IgA-
containing blood.
• Treatment: Treatment is supportive but aggressive, typically requiring epinephrine,
fluids, steroids, and antihistamines.
d) Graft-versus-host disease:
• Cause: Cellular blood products contain lymphocytes capable of mounting an immune
response against a compromised recipient.
• Prevention: Irradiation of blood products can inactivate these lymphocytes.
e) Posttransfusion purpura:
• Cause: Platelet alloantibodies may produce a profound thrombocytopenia.
• Platelet count typically drops 5 to 10 days after transfusion.
• Treatment: IV immunoglobulin & plasmapheresis
f) Transfusion-related immunomodulation (TRIM):
• Allogenic transfusion of blood products may diminish immune-responsiveness and
promote inflammation.
• Perioperative transfusion may increase the risk of post-operative bacterial infection,
cancer recurrence, and death.
g) Transfusion-related acute lung injury (TRALI):
• Definition: Acute hypoxemia and noncardiac pulmonary edema occurring with 6 hrs
of blood product transfusion.
• Cause: More common with FFP or platelets.
• Treatment: ttt is supportive and mimics similar ttt strategies for ARDs
 8 Fluid therapy

B. Infectious Complications:
1) Viral
1. Hepatitis: One in 200,000 (hepatitis B) and one in 1,900,000 (hepatitis C) risk
2. HIV: One in 1,900,000 risk
3. HTLV (Human T-lymphotropic virus) 1 & 2: Leukemia & lymphoma viruses, respectively
4. CMV: Typically causes a mild illness but can become more severe in an
immunocompromised host
5. West Nile virus: May result in severe encephalitis
2) Bacterial infections:
o 2nd leading cause of transfusion-associated mortality;
o most common in platelets
3) Parasitic infections: (very rare) Malaria, toxoplasmosis, and Chagas disease;
C. Massive Blood Transfusion Complications:
1) The following is decreased:
1. Platelet: due to dilutional thrombocytopenia
(The commonest cause of nonsurgical bleeding)
2. Temperature (Hypothermia):
• Ventricular arrhythmias progressing to fibrillation can occur at temperatures close to
30°C if products are not warmed.
• Hypothermia can hamper successful cardiac resuscitation.
3. Calcium (hypocalcemia): due to Citrate toxicity:
• Calcium binding by the citrate can produce clinically significant hypocalcemia, leading
to cardiac depression.
• Citrate metabolism is primarily hepatic, and patients with liver dysfunction may
require supplementation.
2) The following is increeased
1. pH (metabolic alkalosis):
• If normal perfusion is restored, the citrate and lactate in transfusion and resuscitation
fluids are converted to bicarbonate by the liver and can produce metabolic alkalosis.
• Significant metabolic acidosis caused by transfusion is uncommon.
2. Hyperkalemia:
• The extracellular concentration of potassium in stored blood steadily increases with
time. The amount is typically less than 4 mEq per unit.
• Hyperkalemia can result if transfusion rates exceed 100 mL/min.
 Module name 9

Liquid
❑ Definition: anything that can flow (either liquid or gasses).
❑ Types
Types 1) Solution 2) Suspension 3) syrup
Definition Homogeneous fluid Heterogeneous fluid surgery liquid
example as normal saline Antiacid, antibiotic Antitussive

❑ Role of solutions
▪ Treat any dehydration.
▪ Resuscitation & fluid management (if loss < transfusion point)

Calculation of osmolarity of a solution

❑ Rule of calculation
▪ Osmolarity = molarity x n,
▪ Molarity = the number of moles of solute per liter of solution
𝑚𝑜𝑙𝑒𝑠 𝑚𝑎𝑠𝑠 / 𝑚𝑜𝑙𝑎𝑟 𝑚𝑎𝑠𝑠
= =
𝑙𝑖𝑡𝑒𝑟 𝑙𝑖𝑡𝑒𝑟
(molar mass is equivalent to molecular weight in Dalton)
▪ n = the number of particles that dissociate from the solute molecule
(e.g. in NaCl: Each molecule dissociates into two particles Na+ and Cl-., so n = 2

1) Normal saline (Saline 0.9 %)

So osmolarity of a 0.9% NaCl solution is calculated by the following steps
1. Determine the molarity of NaCl:
o 0.9% NaCl is equivalent to 0.9 g NaCl per 100 mL of solution, = 9 g NaCl per 1 liter of
solution.
o The molar mass of NaCl is 58.44 g/mol,
𝑚𝑎𝑠𝑠 / 𝑚𝑜𝑙𝑎𝑟 𝑚𝑎𝑠𝑠 9 𝑔𝑚 /𝟓𝟖.𝟒𝟒
o So,The molarity of NaCl = = = 0.154 M.
𝑙𝑖𝑡𝑒𝑟𝑠 𝟏
2. Determine the number of particles that dissociate from NaCl:
Each molecule dissociates into two particles Na+ and Cl-., so n = 2.
3. Calculate the osmolarity:
Osmolarity = molarity x n = 0.154 M x 2 = 0.308 Osm/L or 308 mOsm/L.

Compared to plasma osmolarity, it is isotonic

 10 Fluid therapy

2) Dextrose 5%
1. Determine the molarity of Dextrose 5% :
o 5% dextrose is equivalent to 50 g dextrose per liter of solution.
o The molar mass of dextrose is 180.16 g/mol,
𝑚𝑎𝑠𝑠 / 𝑚𝑜𝑙𝑎𝑟 𝑚𝑎𝑠𝑠 50 𝑔𝑚 /180.16
o So, the molarity of dextrose = = = 0.277 M
𝑙𝑖𝑡𝑒𝑟𝑠 1
2. Determine the number of particles that dissociate from dextrose:
Dextrose does not dissociate, so n = 1.
3. Calculate the osmolarity:
Osmolarity = molarity x n = 0.277 M x 1 = 0.277 Osm/L or 277 mOsm/L.
Compared to plasma osmolarity, it is hypotonic

،‫ عندما أضيع أيام عمري بالقلق من احتمال وقوع بعض المشكالت‬:‫يقول أحدهم‬
‫ لقد أرهقت نفس ر‬:‫أتذكر قصة الرجل العجوز الذي قال ل ف أخر عمره‬
‫كتيا بالتفكي‬ ‫ي‬ ‫ي ي‬
.‫يف مشكالت معظمها لم يحدث‬
‫ فثق بالل وال‬..‫الحال‬
‫ي‬ ‫ إنه فقط يفسد يومك‬..‫ القلق من الغد لن يغيه‬:‫باختصار‬
. ‫تسمع لوساوس الشيطان‬
‫منقول‬