Perioperative Fluid Management

Ike SR
RSHS/FKUP
Bandung
 Type of Fluid Loss in Perioperative Period

• Decrease intake due to fasting

• Increased loses
• Vasodilatation
• Fluid shifts
• Bleeding

• The losses  predominantly from the interstitial compartment

 must in turn be replaced from other compartments
• Measurable losses Un-measurable
• In Acute / massive losses condition  external infusion is
needed
 Redistributive and evaporative surgical fluid
losses

Degree of tissue trauma Additional fluid

requirement
Minimal ( herniorrhaphy) 0 – 2 cc/ kg/hour

Moderate 2 – 4 cc/kg/ hour

( cholecystectomy)
Severe ( bowel resection) 4 – 8 cc/kg/hour
 Perioperative Fluid Requirements

The following factors must be taken into account:

• Maintenance fluid requirements
• NPO and other deficits: NG suction, bowel prep
• Third space losses
• Replacement of blood loss
• Special additional losses
 Perioperative Fluid Management

 How much should we infuse?

 What fluids should we use?
• How should we monitor fluid
replacement?
 How much should we infused ?
 Adequate  what is the parameter ?
 Risks of inadequate resuscitation
− Life-threatening : lactic acidosis, ARF, MOF
 Risks of excessive resuscitation
− Life-threatening : pulmonary edema, cardiac
failure
− Non-fatal; peripheral edema, periorbital edema,
impaired gut function, impaired wound healing
Hypovolemia with insufficient microcirculation 
important factor behind early intestinal disturbances
during SIRS  but compromised intestinal
perfusion and metabolic disturbances after endotoxin
infusion  greatly counteracted with colloid solution

Albumin, Dextran, HES  no difference

 Class I Class II Class III Class IV
Blood loss Up to 750 750-1500 1500-2000 >2000
Blood loss Up to 15% 15-30% 30-40% >40%
( % EBV)
Pulse rate <100 >100 >120 >140
Blood Normal Normal Decrease Decrease
pressure
Pulse Normal or Decrease Decrease Decrease
pressure decrease
Respiratory 14-20 20-30 30-35 >35
rate
Urine >30 20-30 5-15 No UO
output
CNS/ Slightly Mildly anxious Anxious and Confused and
mental status anxious confused lethargic

Fluid crystalloid crystalloid Crystalloid/ Crystallloid/

replacement colloid colloid
Course of hypovolaemic shock in absence of
therapy
Blood pressure mmHg
Heart rate
150 Bleeding min

100

Blood
pressure
50

0 Compen- Decompen- Irreversi-

sation sation bility

Three Shock
phases
}
Combine thoracic epidural and general anesthesia
elective colorectal resection  ASA I – III
 NNT ( Number Needed to Treat )

• NNT to avoid overall complication  4

• NNT to avoid major complication  7
• NNT to avoid minor complication  4
• NNT to avoid tissue healing complication  7
• NNT to avoid Cardiopulmonary complication  6
 How Much Fluid ?

• Adequate fluid  intravascular, interstitial,

intravascular
• Clinical sign
• Hemodynamic monitoring principle
• Organ perfusion
• Microcirculation
 Starling Capillary Forces

• Two forces regulate bulk flow across capillaries:

– Hydrostatic (HP) and osmotic pressure (OP)
• These forces exist in two fluid compartments:
– Blood (B) and interstitial fluid (IF)
IFOP IFOP
Arterial End Venous End

BOP BOP

BHP BHP

IFHP IFHP

Net Lymphatic Net

system
 Perioperative Fluid Management

 How much should we infuse?

 What fluids should we use?
• How should we monitor fluid
replacement?
• Crystalloid solutions • Colloid solutions
– Isotonic – Semi-synthetic
– Hypotonic colloids
– hypertonic – Naturally occurring
human plasma
derivatives
 Crystalloids and colloids
Crystalliod Colloid
Intravascular persistance Poor Good
Haemodynamic
Transient Prolonged
stabilisation
Required infusion volume Large Moderate
Risk of tissue oedema Obvious Insignificant
Enhancement of capillary
Poor Good
perfusion
Risk of anaphylaxis Nil Low to moderate
Plasma colloid osmotic
Reduced Maintained
pressure
Cost Inexpensive Expensive
 Distribution of body fluids
Na = 140 meq/l total body water 60% BW

Capillary membrane
K = 4 meq/l

Na = 140 meq/l
K = 4 meq/l

Cell membrane
Intra Cellular Space
Intravascular Space

5% 40%
Na = 8 meq/l
15% K = 151 meq/l

RBC Interstitial
Space Glucose solution

Colloid crystalloids
Colloids fluid loading leads to greater increase in
preload recruit table LVSWI  due to higher COP 
caused by greater plasma volume ( PV ) expansion

Volume effect is >>>

Colloid loading gives higher CI, PV, and GEDVI

Hemacel
• Saline or colloids  do not affect permeability
• HES decrease permeability due to endothelial protections
• LIS ( lung Injury Score ) may slightly increase in colloid 
estimated by ↓ respiratory compliance  caused by increase
ITBV which IV volume was included ( increased volume due
to increased COP )
ITBV
• Early and late histamine release : Albumin, HES,
Polygeline
• Observation 240 minute ( 4 Hr)
– Early histamine release 100%  30’ ( 50 – 78 % )
– Late  240’  67 – 83%
– All 3 groups caused high incidence of late histamine
release  67%
 Plasma
level of HES
Histamine

Hemacel
• Type of fluid  remains controversy
• RCT  Schorigen et al  comparing HES 6% vs
Gelatin 3%  HES resulted in a higher rate of ARF
• Kidney transplant patients  HES administration
associated with declines in kidney function
• Cittanova et al 1996 published in Lancet , Compare
HES vs Gelatin  kidney transplant : 1st week after
transplant :
– creatinin serum : HES = 3.12 versus Gelatin = 1.45
– Need for RRT : HES = 33% versus Gelatin = 5%

Current Opinion in Critical Care 2006, 12: 527-530

Proporti
on of
patients
without
ARF
Creatinin concentration over 28 days
In elderly patients markers of inflammation and
endothelial injury and activation  higher after
crystalloid versus colloid ( HES 130/0.4)
Pro – inflammatory cytokines
 Conclusions :
Target of Fluid Therapy Perioperative
• Hemodynamic Optimalisation
– In acute emergency resuscitation first priority ; restoration
of an adequate circulating volume  adequate
intravascular volume, DO2, blood pressure, adequate
Microcirculation
– Over hydration  adverse outcome
• Optimal volume distribution
• Electrolyte and Acid – base balance optimalisation
• Specific losses should be replaced with appropriate
fluid crystalloid – colloid, consider both solute,
dissolve solute, electrolyte content, total osmolality, safety, and
side effect
Comparison Whole Haemaccel Electrolyte Plasma prot Dextran 40 HES 6% /
blood solutions fraction Voluven
pH 7,3 - 7,4 7,3 (+/- 0,3) 5,5 - 6,5 6,7 -7,3 4,5 - 5,7 3,5 - 6,0
bufferi capacity
Oncotic Iso-oncotic Iso-oncotic Non-oncotic Iso-oncotic Hyper-oncotic Hyper-oncotic
pressure
Intravascular / Restored / Restored Tissue Restored / Tissue Tissue
interstitial Maintained oedema Maintained dehydration dehydration
fluid balance
Cardiovascula Unlikely Unlikely Unlikely Unlikely Risk increased Risk increased
r overload by volume by volume
expand effect expand effect
Plasma half varies from 4-6 hours very short 5-10 days 10 hours 12 hours
life / few hours (min rather
volume effect to svrl days than hours)
Effect on renal usually not improved in not impaired renal renal function use with
function impaired shock but risk of function may be caution in renal
oedema maintained impaired impairment
Effect on Possible Dilution only Dilution only Dilution only Alters platelet Dilutional
coagulation (factor function and effects on
and activation) coagulation fact coagulation
haemostasis Dilution effect mech and CT
Effect on blood Usually None None None Possible Possible
typi and cross- none
match
Accumulation none None none none RES RES
Haemaccel is based on Ringer solution.
500 ml Haemaccel® 1000 ml
Haemaccel®
Polygeline 17.5 g 35.0 g
Cations: Na+ 72.50 mmol 145.00 mmol
K+ 2.55 mmol 5.10 mmol
Ca2+ 3.125 mmol 6.25 mmol

Anions: Cl- 72.50 mmol 145.00 mmol

PO4-3, SO4-2 traces traces