Parenteral fluid therapy

Know, Calculate and be comfortable

Dr. Mahmoud W. Qandeel

Outlines
• Introduction
• Fluids types
– Crystalloids
– Colloids
• Fluid management
– Maintenance
– Intra-op
– Post-op
– Losses

Dr. Mahmoud W. Qandeel

 Fluid therapy is often poorly
taught, poorly understood and
poorly done

Dr. Mahmoud W. Qandeel

About fluid therapy , one of the following is false :
(6/2019)
A. It’s classified into crystalloid and colloid types.
B. Normal saline contents are Na 154 meq/L and Cl 154 meq/L and
osmolarity is 308 mOsm/L.
C. Ringer lactate contents are Na 130 meq/L , K 4meq/L , Ca 3 meq/L ,
CL 109meq/L , Lactate 28meq/L and osmolarity 274mOsm/L.
D. Dextrose 5 water contents are glucose 5 gram/L and osmolarity is
152mOsm/L.
E. Normal saline and ringer lactate are isotonic solutions.

Dr. Mahmoud W. Qandeel

Fluid and electrolyte management are paramount to the care of the
surgical patient.

Changes in both fluid volume and electrolyte composition occur

preoperatively, intraoperatively, and post operatively, as well as in
response to trauma and sepsis.

Dr. Mahmoud W. Qandeel

 Reasons for fluid therapy
• Preserve oxygen delivery to tissues
• Correct hypovolaemia
Colloids + RBCs
• Maintain cardiac output
• Optimise gas exchange
• Replace electrolytes & water Crystalloids
• Maintain urine output

Identify what is the goal

Choose fluid which best achieves the goal
Dr. Mahmoud W. Qandeel
 How does a surgical patient differ??
• Secretion of stress hormones (ADH, aldosterone, steroids).
• NPO
– Disease process
– Preoperative preparation
– Postoperative consideration
• GI losses
– Disease process
– Preoperative preparation
• Increased insensible fluid loss.
• Third space losses.
• Drains.
• Fistulas.

Always remember the medical state of the patient and the drugs he is using
Dr. Mahmoud W. Qandeel
 Fluids
• Crystalloids
• Colloids

When choosing type of fluid consider:

– What are the patients deficiencies
– The compartments that require replacement

Dr. Mahmoud W. Qandeel

Common parenteral fluid therapy

X X

Dr. Mahmoud W. Qandeel

 Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3- Dextrose mOsm/L
ECF 142 4 5 3 103 27 280-310

Lactated Ringer’s 130 4 3 109 28 273

0.9% NaCl 154 154 308

0.45% NaCl 77 77 154

D5W 50

D5/0.45% NaCl 77 77 50 406

3% NaCl 513 513 1026

6% Hetastarch 500 154 154 310

5% Albumin 250,500 130-160 <2.5 130-160 330

25% Albumin 20,50,100 130-160 <2.5 130-160 330

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Crystalloids:

Dr. Mahmoud W. Qandeel

 Crystalloids:
• Isotonic crystalloids
- Lactated Ringer’s, 0.9% NaCl, Hartman
- Distributes in the ECF (30-60 min)
- Only 25% remain intravascularly
- GI losses, operative losses

• Hypertonic saline solutions

- 3% NaCl

• Hypotonic solutions
- D5W, 0.45% NaCl
- Distributes in the entire body evenly
- less than 10% remain intravascularly,
inadequate for fluid resuscitation
Dr. Mahmoud W. Qandeel
 Crystalloid solution
1. Safe , nontoxic, reaction free, inexpensive.
2. Complication is edema if large volumes are needed.
3. During surgery isotonic solution favored (normal saline -
lactate ringer and plasma lyte)

Dr. Mahmoud W. Qandeel

 Colloid Solutions:
• Contain high molecular weight substances→do not readily migrate across capillary
walls.
• The solution remains in the circulation until colloid particles are removed.
Distributes to ECF in 6-24h (also contains electrolytes).

• Used for resuscitation

• 500 ml 5% Albumin vs. 100 ml 25% Alubmin

• Preparations
- Albumin: 5%, 25%
- Dextran
- Gelifundol

Dr. Mahmoud W. Qandeel

 Colloids Complications
1. Hypersensitivity reactions (anaphylaxis )
2. Pruritis (hetastarch)
3. Couglopathy (dextran 70 and hetastarch) > 1 litter
• Dextran ( platelet aggregation , adhesive)
• Hetastarch (reduction in factor Vlll and VOB factor)

These colloid is best avoided in patients with coagulopathy.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
 Maintenance
• To maintain UOP 0.5-1 ml/ kg /hr
• 100 ml/ kg / day for the first 10 kgs
• 50 ml/ kg /day for the second 10 kgs
• 20 ml/ kg / day for the subsequent kgs
• Should contain Na & K
• e.g ( D5/0.45 % NaCl + 20-30 mmol/l K )

Dr. Mahmoud W. Qandeel

 Maintenance requirements

• Up to 10 kg = 4cc/kg/hr = 100cc/kg/d
• 11-20kg = add 2cc/kg/hr = 50cc/kg/d
• 21kg and above = add 1cc/kg/hr = 25cc/kg/d

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
• The value used for this method is generally 35–40
mL/kg/day, adjusted higher or lower based on age

• Older adults often require only 15 mL/kg/24-hr

maintenance due to ??

Dr. Mahmoud W. Qandeel

• Sodium: Normally, people take 150–200 mEq sodium daily, much of which
is excreted in the urine.
A. If the body needs to conserve sodium, it can reduce renal excretion to less
than 1 mEq/day.
B. Daily homestasis is easly maintained with 1–2 mEq/kg/day.

• Potassium: The normal daily intake of potassium is 40–120 mEq/day, with

about 10%–15% excreted in urine; an amount 0.5–1 mEq/kg/day is
appropriate to maintain homestasis.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Evaluating maintenance rates
• Urine output

Dr. Mahmoud W. Qandeel

 Preoperative management

Pre-existing volume & electrolyte abnormality should be

corrected

Dr. Mahmoud W. Qandeel

 Intraoperative management
• Include maintenance for case duration, Hge. & third space loss

• Third space loss & insensible loss:

• 1-3 ml/kg/hr for minor procedure (small incision like hernia)
• 3-7 ml/kg/hr for mod. procedure (medium incision sigmoidect.)
• 9-11 ml/kg/hr for major procedure (large incision like whipple)

• Blood loss ( 1ml blood or colloid / 1ml blood loss or 3ml

crystalloid / 1ml blood loss ).

Dr. Mahmoud W. Qandeel

 Postoperative fluid management
• Careful evaluation
• UOP monitoring
• GIT losses by NG tube or gastrostomy more than 250 ml should be
replaced by equal crystalloid
• Mobilization of third space loss start after 3 days post op.
• If volume excess , diuretics can be used.

Dr. Mahmoud W. Qandeel

In general
• Gastric losses should be replaced with D5 S 0.45 with 20meq KCL

• Biliary , pancreatic , small bowel by RL

Dr. Mahmoud W. Qandeel

 GIT LOSSES
• Vomiting, diarrhea
• NG tube losses
• Small bowel fistula
• Ileostomy , colostomy losses
• Pancreatic ,biliary fistulae

Dr. Mahmoud W. Qandeel

Which of the following IV solution has almost
the same electrolytes like plasma:
A. Dextrose 5%
B. Dextran 40
C. Normal saline
D. Dextrose saline
E. Ringers lactate

Dr. Mahmoud W. Qandeel

Which of the following IV solution has almost
the same electrolytes like plasma:
A. Dextrose 5%
B. Dextran 40
C. Normal saline
D. Dextrose saline
E. Ringers lactate

Dr. Mahmoud W. Qandeel

 Patient with hemorrhagic shock, the best IV
solution to be given until blood is at hand is:

A. G/W 5%
B. G/W 10%
C. Ringer's lactate
D. Albumin
E. Aminoacid solution

Dr. Mahmoud W. Qandeel

 Patient with hemorrhagic shock, the best IV
solution to be given until blood is at hand is:

A. G/W 5%
B. G/W 10%
C. Ringer's lactate
D. Albumin
E. Aminoacid solution

Dr. Mahmoud W. Qandeel

Which one of the following IV solutions contains
potassium (K):
A. Ringer's lactate
B. Dextran 40
C. Dextran 70
D. Dextrose water 5%
E. Dextrose saline

Dr. Mahmoud W. Qandeel

Which one of the following IV solutions contains
potassium (K):
A. Ringer's lactate
B. Dextran 40
C. Dextran 70
D. Dextrose water 5%
E. Dextrose saline

Dr. Mahmoud W. Qandeel

 Which of the following IV solutions is the
best plasma expander:
A. 5% dextrose water
B. 0,9% NaCl
C. 0,45% NaCl
D. Gelfusine
E. 0,18% NaCl

Dr. Mahmoud W. Qandeel

 Which of the following IV solutions is the
best plasma expander:
A. 5% dextrose water
B. 0,9% NaCl
C. 0,45% NaCl
D. Gelfusine
E. 0,18% NaCl

Dr. Mahmoud W. Qandeel

 All of the following could be used as volume
replacement in children, except:
A.Plasma
B.Albumin
C.Factor 8
D.Normal saline
E.Blood

Dr. Mahmoud W. Qandeel

 All of the following could be used as volume
replacement in children, except:
A.Plasma
B.Albumin
C.Factor 8
D.Normal saline
E.Blood

Dr. Mahmoud W. Qandeel

About fluid therapy , one of the following is false :
(6/2019)
A. It’s classified into crystalloid and colloid types.
B. Normal saline contents are Na 154 meq/L and Cl 154 meq/L and
osmolarity is 308 mOsm/L.
C. Ringer lactate contents are Na 130 meq/L , K 4meq/L , Ca 3 meq/L ,
CL 109meq/L , Lactate 28meq/L and osmolarity 274mOsm/L.
D. Dextrose 5 water contents are glucose 5 gram/L and osmolarity is
152mOsm/L.
E. Normal saline and ringer lactate are isotonic solutions.

Dr. Mahmoud W. Qandeel

About fluid therapy , one of the following is false :
(6/2019)
A. It’s classified into crystalloid and colloid types.
B. Normal saline contents are Na 154 meq/L and Cl 154 meq/L and
osmolarity is 308 mOsm/L.
C. Ringer lactate contents are Na 130 meq/L , K 4meq/L , Ca 3 meq/L ,
CL 109meq/L , Lactate 28meq/L and osmolarity 274mOsm/L.
D. Dextrose 5 water contents are glucose 5 gram/L and osmolarity is
152mOsm/L.
E. Normal saline and ringer lactate are isotonic solutions.

Dr. Mahmoud W. Qandeel

 The composition of Ringer Lactate is :
(4/2018)
A. Na 145 , Cl 109 , K 4 , Ca 2.7 , Hco3 28
B. Na 130 , Cl 103 , K 4 , Ca 2.7 , Hco3 28
C. Na 145 , Cl 109 , K 4 , Ca 2.7 , Hco3 28
D. Na 154 , Cl 109 , K 4 , Ca 4 , Hco3 28
E. Na 130 , Cl 109 , K 4 , Ca 2.7 , Hco3 28

Dr. Mahmoud W. Qandeel

 The composition of Ringer Lactate is :
(4/2018)
A. Na 145 , Cl 109 , K 4 , Ca 2.7 , Hco3 28
B. Na 130 , Cl 103 , K 4 , Ca 2.7 , Hco3 28
C. Na 145 , Cl 109 , K 4 , Ca 2.7 , Hco3 28
D. Na 154 , Cl 109 , K 4 , Ca 4 , Hco3 28
E. Na 130 , Cl 109 , K 4 , Ca 2.7 , Hco3 28

Dr. Mahmoud W. Qandeel

 One of the following is true regarding the
electrolyte concentration in Hartman’s solution :
( 4/2017)

A. Chloride 200 mmol/L

B. Lactate 70 mmol/L
C. Sodium 131 mmol/ L
D. Potassium 40 mmol/L
E. Calcium 15 mmol/L

Dr. Mahmoud W. Qandeel

 One of the following is true regarding the
electrolyte concentration in Hartman’s solution :
( 4/2017)

A. Chloride 200 mmol/L

B. Lactate 70 mmol/L
C. Sodium 131 mmol/ L
D. Potassium 40 mmol/L
E. Calcium 15 mmol/L

Dr. Mahmoud W. Qandeel

 Maintenance fluid rate for a 50kg patient is :
( 4/2018)
A. 120 ml/hr
B. 90 ml/hr
C. 60 ml/hr
D. 30 ml/hr
E. 150 ml/hr

Dr. Mahmoud W. Qandeel

 Maintenance fluid rate for a 50kg patient is :
( 4/2018)
A. 120 ml/hr
B. 90 ml/hr
C. 60 ml/hr
D. 30 ml/hr
E. 150 ml/hr

Dr. Mahmoud W. Qandeel

 A 30 kg child has an estimated daily fluid
requirement of :
( 10/2016 )

A. 40 ml/hr
B. 50 ml/hr
C. 60 ml/ hr
D. 70 ml/ hr
E. 80 ml/ hr

Dr. Mahmoud W. Qandeel

 A 30 kg child has an estimated daily fluid
requirement of :
( 10/2016 )

A. 40 ml/hr
B. 50 ml/hr
C. 60 ml/ hr
D. 70 ml/ hr
E. 80 ml/ hr

Dr. Mahmoud W. Qandeel

 65 year old male had an entero-cutaneous fistula
originating from the jejunum , suffered from
inflammatory bowel disease , which of the following
would be the most appropriate replacement for his loss ?
(4/2017)
A. DW 5%
B. N/S 3%
C. Ringer lactate
D. 0.9% sodium chloride
E. 6% sodium bicarbonate solution
Dr. Mahmoud W. Qandeel
 65 year old male had an entero-cutaneous fistula
originating from the jejunum , suffered from
inflammatory bowel disease , which of the following
would be the most appropriate replacement for his loss ?
(4/2017)
A. DW 5%
B. N/S 3%
C. Ringer lactate
D. 0.9% sodium chloride
E. 6% sodium bicarbonate solution
Dr. Mahmoud W. Qandeel
How many calories per liter in Dextrose 5% ?
(4/2017)
A. 150
B. 170
C. 180
D. 200
E. 250

Dr. Mahmoud W. Qandeel

How many calories per liter in Dextrose 5% ?
(4/2017)
A. 150
B. 170
C. 180
D. 200
E. 250

Dr. Mahmoud W. Qandeel

 How many Kcal contained in 1 liter of G/W
20% is:

A.100 Kcal
B.400 Kcal
C.800 Kcal
D.1000 Kcal
E.2000 Kcal

Dr. Mahmoud W. Qandeel

 How many Kcal contained in 1 liter of G/W
20% is:

A.100 Kcal
B.400 Kcal
C.800 Kcal
D.1000 Kcal
E.2000 Kcal

Dr. Mahmoud W. Qandeel