Fluid Therapy

Total Body Water

• Extracellular space is broken

down into 15% interstitial and
5% plasma.
• Total body water decreases
with age; 75-80% newborn
infant’s weight is water.

Critical care secrets ed 5

 Sensible and Insensible fluid losses
• Insensible losses (nonmeasurable)
• Skin: 600ml
• Lungs: 200ml
• Sensible losses (measurable)
• Fecal: 200ml
• Urine: 800-1500ml
• Sweat: Variable

Total fluid losses of 2000-2500ml/ day, 24 hour fluid requirement of 30-

35 ml/kg to maintain normal fluid balance
Critical care secrets ed 5
 Fluid Shift
• Rapid water movement between
ECF and ICF in response to osmotic
gradients

2018 Pearson Education, inc.

Morgan & Mikail Clinical Anesthesiology
5th ed
 Intravenous Fluids
May consist of infusion of crystalloids, colloids or combination of both.
• Crystalloid: aqueous solution of ions with/ without glucose polymers,
rapidly equilibrate and distribute throughout extracellular fluid space.
• Colloid: maintain plasma colloid oncotic pressure and mostly remain
intravascular.

Morgan & Mikail Clinical Anesthesiology 5th ed

 Crystalloid Solution
• Initial resuscitation fluid in patients with hemorrhagic and septic
shock, in burn patients, patients with head injury (to maintain
cerebral perfusion pressure), and in patients undergoing
plasmapheresis and hepatic resection.
• For losses primarily involving water replacement is hypotonic
solutions (maintenance type solutions)
• Losses involve water and electrolytes  isotonic electrolyte solution
(replacement type solutions). May include glucose to prevent ketosis
and hypoglycaemia.

Morgan & Mikail Clinical Anesthesiology 5th ed

Morgan & Mikail Clinical Anesthesiology 5th ed
Colloid Solutions
• Mostly have intravascular half lives 3-6 hours, decreased blood
coagulability, anti inflammatory effect.
Indication:
• fluid resuscitation in patient with severe intravascular fluid deficits
(hemorrhagic shock) prior to the arrival of blood transfusion.
• Fluid resuscitation in the presence of severe hypoalbuminemia or
condition with large protein losses (burns).
Perioperative fluid therapy
Normal maintenance requirements
• In the absence of oral intake, deficiency of fluid and electrolyte results
from continued urine formation, gastrointestinal secretions, sweating,
and insensible losses from the skin and lungs.
 Maintenance fluid therapy
Indicated for patients who cannot or are not allowed to take fluids orally.
• Normal daily maintenance dose
• Adults: 30 mL/kg of water, 1 g/kg of glucose (to prevent starvation ketosis), 1–3
mEq/kg of Na+, 1–3 mEq/kg of Cl-, and 0.5–1 mEq/kg of K+ per day
• Children: Holliday-Segar formula (4,2,1 rule) : 4 mL/kg/hr for the first 10 kilograms +
2 mL/kg/hr for the next 10 kilograms + 1 mL/kg/hr for the remaining weight
• Neonates: 150 mL/kg/day
• Certain conditions may alter the amount of maintenance fluids required.
• ↑ Maintenance fluids: fever , tachypnea
• ↓ Maintenance fluids: congestive cardiac failure, low output renal failure

Stroud M. Intravenous fluid therapy in adults in hospital; Holliday MA, Ray PE, Friedman AL. Fluid therapy for children
Perioperative fluid therapy
Preexisting Deficits
• After an overnight fast without any fluid intake surgical patients will
have a preexisting deficit proportionate to the duration of the fast. Th
e deficit can be estimated by multiplying the normal maintenance
rate by the length of the fast.
For the average 70-kg person fasting for 8 h, this amounts to (40 + 20 +
50) mL/h × 8 h, or 880 mL. In fact, the real deficit is less as a result of
renal conservation.
Replacement of free water deficit
• Indicated to treat dehydration and/or hypernatremia
• Free water deficit = k × weight (kg) × (Current [Na+]/140 – 1)
k = 0.6 (adult male, children), 0.5 (females), 0.5 (elderly males), or 0.45
(elderly females)
• Intravenous fluids that can be used to replace free water deficit
• 5% dextrose
• Hypotonic saline (e.g., ½NS, ¼NS)
Fluid resuscitation
• Patients who are in hypovolemic shock require rapid fluid infusions in
the form of fluid challenges to maintain intravascular volume.
• Rapid infusion of a 500 mL (Pediatric dose: 10–20 mL/kg) bolus of
normal (isotonic) saline (NS) or lactated Ringer's solution (RL) within
15 minutes
• Observe the patient for a clinical response
• Repeat the fluid bolus infusion if the clinical response is inadequate.
• An inadequate response to fluid resuscitation is characterized by:
• Low urine output (< 0.5 mL/kg/hr; best indicator)
• Increased heart rate
• Low blood pressure
• Low CVP (central venous pressure)
• If the patient does not respond to multiple fluid challenges:
• Consider the use of vasopressors and/or inotropes
• Consider other causes of shock besides hypovolemia (e.g., cardiogenic shock,
sepsis).
 Classes of haemorrhagic shock and the fluid
administered in each class

Critical care secrets ed 5

National Clinical Guideline
Center 2015
National Clinical Guideline
Center 2015
National Clinical Guideline
Center 2015
National Clinical Guideline
Center 2015
National Clinical Guideline
Center 2015
National Clinical Guideline
Center 2015