POST OPERATIVE

INTRAVENOUS FLUIDS
Supervised by : Dr Dilan Zakaria
Presented by: Paiwast Jaza Ameen
Senior house officer of clinical pharmacy program
 TYPES OF IV FLIUDS
 Crystalloids is an aqueous solution of mineral salts and other small,
water-soluble molecules.
 Osmolarity of the solution determines if the solution is hypotonic,
isotonic or hypertonic.
 Any crystalloid solution can freely pass through double barrier of
endothelium. This condition causes up to four-fifth of the infused
crystalloid to distribute directly into the interstitial compartment.
TYPES OF IV FLIUDS
 Colloids are similar to crystalloids but in addition they contain a
substance that cannot diffuse through semi-permeable membranes
owing to its high molecular weight.
 Colloids can be blood products, such as human albumin and fresh
frozen plasma, or they can also be synthetic as; gelatins, dextran, and
hydroxyethyl starches.
 Colloid solutions are prepared by dissolving colloid molecules in
isotonic saline solutions, or more rarely in other crystalloids.
FLIUD AND ELECTROLYTE DISTRIBUTION
DISTRIBUTION OF IV FLUIDS
Intravenous Fluid Infused volume Equivalent Intravascular Volume
(mL) Expansion (ml)
Normal saline 1000 250

Lactate ringer 1000 250

Albumin %5 500 500

Albumin %25 100 500

Dextrose %5 1000 100

Hydroxyethyl starch 6% 500 500

Plasma-Lyte 1000 250

 BLOOD OSMOLARITY
The osmolarity of normal human blood plasma is approximately 300
milliosmole's per liter .
{Osmolarity measures the concentration of solutes within a volume of water.}

Hypotonic: <250 mOsm/L

Isotonic: ~300 mOsm/L
Hypertonic: >375 mOsm/L
 Solution Na+ Cl⁻ K⁺ Ca⁺⁺ HCO₃⁻ pH mOmol/l other

blood 135-145 98-106 3.5-5 8.5-10.5 22-28 7.35-7.45 291

NaCl 150-154 150-154 - - - 5.7 308

%0.9

ringer 147 156 4 4 - 5.7 307

RL 130 109 4 4 28 6.5 273

RA 131 109 4 3 - 5.7 307 Acetate

28mmol/l

0.45%NaCl 77 77 - - - 278
Dextrose %2.5

D5W - - - - - 4.3 278 Glucose

50g/l
 NORMAL SALINE (0.9% sodium
chloride)
 Normal saline causes hyperchloremic acidosis.
Normal saline differs from other IV fluids in two regards: it does not contain a
buffer and it has a higher chloride concentration. Indeed, both the change in serum
chloride and the volume of infused 0.9% NaCl correlated with the degree of
acidosis.
 Expansion of the extracellular fluid with a buffer-free fluid dilutes serum
bicarbonate and therefore causes acidosis. This phenomenon of “dilution acidosis”,
however, is not linear because experimental data showed that a 28% expansion of
the extracellular fluid volume reduced serum bicarbonate by only 10% . The degree
of acidosis is likely attenuated by mobilization of intracellular bicarbonate (e.g.,
from bone) and binding of hydrogen ions by albumin and hemoglobin.
 
RINGER`S LACTATE
Lactated crystalloid fluids have the potential to induce hyperglycemia.
Lactate is a metabolically active compound that is utilized during
gluconeogenesis to produce glucose. Hence, excessive administration of
lactated crystalloids may be of concern in patients with diabetes.
Ringer's lactate solution contains calcium ions. Calcium can induce
coagulation of the blood products in the IV tubing and therefore inhibit
their effective delivery. In patients who require a blood transfusion,
blood products should utilize a separate IV setup.
DEXTROSE 5%
- D5W is not good for patients with renal failure or cardiac problems since it could
cause fluid overload.
- Patients at risk for intracranial pressure should not receive D5W since it could
increase cerebral edema .
- Not used for resuscitation, because the solution won't remain in the intravascular
space.
- D5W shouldn't be used in isolation to treat fluid volume deficit because it dilutes
plasma electrolyte concentrations .
- Never mix dextrose with blood as it causes blood to hemolyze.
- Not used in the early postoperative period, because the body's reaction to the
surgical stress may cause an increase in antidiuretic hormone secretion
POSTOPERATIVE FLUID MANAGEMENT

Fluid management is an important part of overall surgical therapy.

Proper administration of fluids is critical, especially in patients who
undergo major surgeries such as emergency laparotomies, bowel
resections and hepatectomy procedures. Body fluid composition
may change in minutes or hours, resulting in impaired wound
healing and homeostasis. Briefly, choice of strategy in intraoperative
and postoperative fluid management may be significant.
POSTOPERATIVE FLUID MANAGEMENT

The main goal of fluid management is to maintain adequate

tissue perfusion, with minimized risks of complications of
over-hydration, such as pulmonary edema, cerebral edema, and
intestinal edema. Both inadequate and excessive fluid
administration may increase the stress on the circulatory
system, and can affect tissue healing after surgery. From this
perspective, without decent monitoring of patient’s current
status, any strategy may fail.
POSTOPERATIVE FLUID MANAGEMENT
Excessive hydration with crystalloids is related with increased major
complications, such as leakage, peritonitis, sepsis, pulmonary edema
and bleeding in patients who underwent elective colorectal surgery.
Also, intestinal edema is known to be related with increased bacterial
translocation and multiple organ dysfunction syndrome rates .
POSTOPERATIVE FLUID MANAGEMENT

The management of fluid in the postoperative surgical patient can vary

from simple to complex. Postoperative intravenous maintenance fluid
therapy ensures adequate organ perfusion, prevents catabolism, ensures
electrolyte- and pH-balance, and may be all that is required for patients
who undergo surgical procedures that do not significantly alter the
hemodynamic milieu. Typically, such procedures are associated with a
small volume of blood loss (<250 mL), a short course of anesthesia and
surgery (<3 hours), a small volume of intravenous fluid administration
(<30 mL/kg), and little to no extravascular fluid shift in patients without
significant organ dysfunction.
POSTOPERATIVE FLUID MANAGEMENT

However, in many cases, postoperative patients with extensive traumatic or

surgical tissue injury, burns, critical illness, or sepsis require more complex
resuscitative fluid therapy in addition to maintenance therapy to compensate for
preoperative and intraoperative losses, the stress response to surgery, the
underlying disease state, ongoing gastrointestinal fluid loss, blood loss, and
other bodily fluid loss. Such complex fluid management is often needed for
patients who undergo surgical procedures that result in significant blood loss
(>500 mL or 7 mL/kg) , fluid shifting out of the vascular space ("third-
spacing"), large-volume intravenous fluid administration (>30 mL/kg), or
hemodynamic instability .
POST SURGERY STRESS SYNDROM
• The stress response to traumatic or surgical tissue injury is a primal
collection of biochemical pathways designed to facilitate survival
following a major insult. 
• Acute stress leads to increase sympathetic stimuli tachycardia,
vasoconstriction and stress.
• ACTH stimulate Cortisol release ,this promotes gluconeogenesis ,
muscle breakdown and results in hyperglycemia.
• Catecholamines (EN,NE) resulting in vasoconstriction, tachycardia
and catabolism ,increased cardiac output ,hypertension and hyper
glycemia .
POST SURGERY STRESS SYNDROM
• Cytokines- acute phase reactant (e.g., interleukins 1 and 6) generate a
local inflammatory response at the site of injury ,facilitating healing at
sites of tissue disruption .
• Vasopressin (ADH) release in response to elevated plasma
osmolality ,low circulating blood volume and stress.
This results in water retention by the kidney ,which expand the vascular
volume.
Aldosterone –the RASS responds to volume contraction by stimulating
Aldosterone secretion which increases Na and water retention by the
kidney ,thereby expanding the vascular volume.
COMLICATIONS OF POST SURGERY STRESS SYNDROM

• This stress response helps the body to compensate for hypovolemia.

• However it is complications can occur. as an example , aldosterone
leads to acute potassium wasting and secondary hypokalemia, if it is
sever leads to post operative arrhythmia.
• Similarly, cortisol and catecholamine contribute to hyperglycemia that
associated with complications of wound healing in post operative
patients including infection, dehiscence, and non healing.
• Systemic release of inflammatory mediators may results in capillary
leak , tissue injury and systemic organ dysfunction( acute ranal
failure ,respiratory distress syndrome ).
FLUID LOSS AFTER SURGERY
o Bleeding
o Drainage
o Third space
o Insensible losses
INITIAL ASSESMENT
• Sign and symptoms of intravascular volume depletion
• Tachycardia (HR > 100 beats/minute)
• Hypotension (SBP < 80 mm Hg)
• Orthostatic changes in HR or BP
• Increased BUN/S.Cr ratio > 20:1
• Dry mucous membranes
• Decreased skin turgor
• Reduced urine output
• Dizziness
• Improvement in HR and BP after a 500- to 1000-mL fluid bolus
INITIAL ASSESMENT
Any patient who demonstrates hemodynamic instability ( tachycardia ,
hypotension , alternation in mental status , oliguria ((<0.5 mL /kg )),
Lactic acidosis in post operative should be considered for fluid
resuscitation .
ESTIMATE FLUID LOSS
It may be not be possible to reliably calculate the fluid deficit. Instate it
is a common practice to compare the physiologic parameters associated
with hypovolemia to those associated with hemorrhage.
Signs or symptoms usually occur when >15% of blood volume is lost
(e.g., hemorrhage for a 70 kg individual ,a 15% is 750mL .
Ongoing losses from drainage tubes must be accounted .
When it exceeds 400mL in 8 hr. (>50mL /hr. ) .
VOLUME OF REPLACEMENT
The post op. patients can be expected to require a volume that is up to
three times the estimated fluid deficit. Since 2/3 of IV crystalloids are
expected to shift out of the vascular space within hours of administration
due to capillary leak ( as a result of stress response to surgery).
Fluid deficit ratio:
o 1:1 for pt. with normal organ function, ongoing GIT or other losses.
o 3:1 those with sever stress syndrome.
o 0.5 :1 those expected to receive large volume of other fluids
(medication ,blood product),and those not tolerate excessive fluid volume
(pneumonectomy ), permissive oliguria is preferable to pulmonary edema.
FLUID REPLACEMENT SCEDUAL
1. Periodically (e.g. q8 hr.)
2. Keep up with losses on an hourly basis (e.g. during kidney
transplant the pt. is volume loaded during surgery until the
intravascular system is replete. Thereafter ,each hour after
surgery ,the amount of fluid lost is measured and replaced by 1:1 .
 FLUID RESUSITATION

The goal of fluid resuscitation is to restore organ perfusion through the

administration of IV fluid Because intravascular volume depletion can
cause organ dysfunction and death, prompt resuscitation is necessary.
in some cases blood transfusion is also necessary to achieve this goal.
FLUID RESUSITATION
If patients need IV fluid resuscitation, use crystalloids
that contain sodium in the range 130–154 mmol/l, with
a bolus of 500-1000 ml over less than 15 minutes, (30
mg/kg in septic patients) preferably through a large-
bore catheter.
After that patient is reevaluated; this process is
continued as long as signs and symptoms of
intravascular volume depletion are improving .
Consider human albumin solution 4–5% for fluid
resuscitation only in patients with severe sepsis.
FLUID RESUSITATION TYPE
o Crystalloids (0.9% sodium chloride Na=154or lactated Ringer Na=130
solution and plasma-Lyte Na=130) are recommended for fluid
resuscitation in hypovolemia.
o Lactated Ringer solution is historically preferred in surgery and
trauma patients, but no evidence suggests superiority over normal
saline for fluid resuscitation in these settings.
o The pH of RL and NS are below physiologic pH ,which also
contributes to acid-base imbalance.
FLUID RESUSITATION TYPE
o The lactate in lactated Ringer solution is metabolized to bicarbonate,
and it can theoretically be useful for metabolic acidosis; however, it is
metabolism and clearance depend on adequate liver and renal function
(lactate metabolism is impaired during shock). Thus, sometimes
lactated Ringer solution may be an ineffective source of bicarbonate.
o Plasma-Lyte contain acetate, a buffer which is quickly converted to
bicarbonate in most tissues in dependent on liver and kidneys ,but
plasma-Lyte is more expensive .
FLUID RESUSITATION TYPE
o Lactated Ringer solution has been considered to provide a more
physiologic amount of Cl (109 mmol/L) than 0.9% sodium chloride
(154 mmol/L).
o A balanced fluid regimen (e.g., lactated Ringer solution, Plasma-Lyte
140) was associated with a reduction in the incidence of acute kidney
injury compared with a standard regimen (e.g., 0.9% sodium chloride).
FLUID RESUSITATION TYPE
o NS 0.9% is particularly useful in cases of chloride and volume loss as
well as alkalosis (e.g. vomiting).
o NS 0.9% is used in association with blood transfusion ,because not
contain additives like Ca , K ,Mg ,Acetate ,but RL & palsma-Lyte
contain these additive and can result in RBC lysis , clot formation in
tubing , and electrolyte chelation.
o NS 0.9% is use for head injury in whom hypernatremia is preferred to
hyponatremia or lowering serum osmolarity, because brain dose not
tolerate edema well, maintain normal or elevated serum Na ensures
that cerebral edema is minimized.
FLUID RESUSITATION TYPE
o RL and plasma-Lyte should be avoided in pt. with hyperkalemia, poor
renal failure.
o Large volume NS will results hyperchloremic acidosis and renal
vasoconstriction .however a provider may have no other choice in
some cases of renal and/or hepatic failure .( a chloride restrictive
system may reduce incidence of AKD.
o Bicarbonate replacement therapy may be administered as continuous
IV for pt. with bicarbonate loss ( pancreatic fistula , bladder
drained ,pancreas transplant).
FLUID RESUSITATION TYPE
Role of Colloids :
o Colloids are, like crystalloids, widely used in fluid resuscitation. Although
colloids are thought to be more useful than crystalloids for increasing
intravascular volume and providing osmotic pressure, they are both shown
to be similarly effective on mortality.
o The main colloid used in post op pt. is albumin ,mainly for malnutrition or
liver failure .it may maintain oncotic pressure better than crystalloids.
The critical care literature suggests that there is no benefit to using albumin.
o Other colloid as gelatin , dextran and starches are very limited due to their
rheology , anaphylactic and anticoagulant effects.
FLUID RESUSITATION TYPE
o The best volume expander for post op pt. are blood products,
particularly RBC and plasma.
However it is not free from risk (infection , lung injury , multiorgan
failure and systemic inflammatory response syndrome (SIRS) .
The transfusion is limited to those :
 ongoing large volume bleeding .
 Symptomatic anemia related to acute blood loss .
 Reversal of coagulopathy or thrombocytopenia that has risk of post
op.
hemorrhage .
REASSESMENT
If patients are receiving IV fluids for resuscitation, reassess the patient
using the ABCDE approach (Airway, Breathing, Circulation, Disability,
Exposure), monitor their respiratory rate, pulse, blood pressure and
perfusion continuously, and measure their venous lactate levels and/or
arterial pH and base excess according to guidance on advanced life
support.
All patients continuing to receive IV fluids need regular monitoring.
This should initially include at least daily reassessments of clinical fluid
status, laboratory values (urea, creatinine and electrolytes) and fluid
balance charts, along with weight measurement twice weekly.
REASSESMENT
Additional monitoring of urinary sodium may be helpful in
patients with high-volume gastrointestinal losses. (Reduced urinary
sodium excretion [less than 30 mmol/l] may indicate total body sodium
depletion even if plasma sodium levels are normal). Urinary sodium
may also indicate the cause of hyponatremia, and guide the achievement
of a negative sodium balance in patients with oedema. However, urinary
sodium values may be misleading in the presence of renal impairment
or diuretic therapy).
Patients on longer-term IV fluid therapy whose condition is stable may
be monitored less frequently.
REASSESMENT
If patients have received IV fluids containing chloride concentrations
greater than 120 mmol/l (for example, sodium chloride 0.9%), monitor
their serum chloride concentration daily. If patients develop
hyperchloremia or acidemia , reassess their IV fluid prescription and
assess their acid–base status. Consider less frequent monitoring for
patients who are stable.
MAINTENANCE
Maintenance intravenous fluids are indicated in patients who are unable
to tolerate oral fluids or enteral feeding.
The goal of maintenance intravenous fluids is to prevent dehydration
and to maintain a normal fluid and electrolyte balance and provide some
calories.
Maintenance intravenous fluids are typically administered as a
continuous infusion through a peripheral or central intravenous catheter.
MAINTENANCE
Common methods of estimating the daily volume in children and adults:
1- Administer 100 mL/kg for first 10 kg, followed by 50 mL/kg for the
next 10–20 kg (i.e., 1500 mL for the first 20 kg) plus 25 mL/kg for
every kilogram greater than 20 kg.
e.g: For a 50 kg patient
• First 10 kg weight = 1000 mL (100 mL/kg x 10)
• Second 10 kg weight = 500 mL (50 mL/kg x 10)
• Remaining 30 kg weight = 750 mL (25 mL/kg x 30) 
• Total = 2250 mL/day or 94 mL/hr. 
MAINTENANCE
2- Administer 25–40 mL/kg/day (for adults only).
3-Adjust fluids according to the individual patient’s input, output, and
estimated insensible loss. *
ACCP guideline

For obese, adjust the IV fluid prescription to their ideal body weight.
Use lower range volumes per kg (patients rarely need more than a total
of 3 liters of fluid per day.
• Consider prescribing less fluid (for example, 20–25 ml/kg/day fluid
OR 0.5ml/kg/hr.) for patients who are older or frail ,have renal
impairment or cardiac failure ,malnourished and at risk of refeeding
syndrome
MAINTENANCE
4-If patients need IV fluids for routine maintenance alone, restrict the initial
prescription to:
25–30 ml/kg/day of water and
• approximately 1 mmol/kg/day of potassium, sodium and chloride and
• approximately 50–100 g/day of glucose (G5W contain 5g/100ml) to limit
starvation ketosis. (This quantity will not address patients' nutritional needs).
*NICE guidelines

• These are initial prescriptions and further prescriptions should be guided by

monitoring .
 MAINTENANCE
• A typical maintenance intravenous fluid is D5W with 0.45% sodium
chloride plus 20–40 mEq of potassium chloride per liter. [NICE guideline ]

• When prescribing for routine maintenance alone, consider using 25–

30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l
potassium on day 1.[ ACCP –American guideline -]

Prescribing more than 2.5L /day of D5W increases the risk of

hyponatremia.
• The potassium chloride content can be adjusted for the individual patient.
(3.5-S.K)*0.4*WT +DAILY REQUIRMENT -1mEq/kg/day
MAINTENANCE
 It is recommended to add sodium bicarbonate to D5W or
sterile water for injection instead of 0.9% sodium chloride.
 Consider delivering IV fluids for routine maintenance during
daytime hours to promote sleep and wellbeing.
GOALS OF FLIUD THERAPY
BP > 100/70
PR < 120 bpm
Urine out put 30-50 ml hourly
Normal respiration
 Normal temperature
 Warm skin
DURATION OF IV FLUIDS
Non major surgery (no intestine and visceral handling ) only
maintenance IV fluid is to correct NPO state.
Only PO fluid after surgery no IV fluid required.
Major surgery ( including intestine or visceral ) :
Give IV fluid till insuring intestinal movement then restart PO fluid .
Major surgery ( handling of intestinal visceral not done)
IV fluid only for 24-48 hr.
REFERENCES
• MAIN REFRENCES:
• NICE GUIDLINE 2017
• ACCP UPDATES IN THERAPEUTICS 2021.
• https://www.uptodate.com/contents/overview-of-postoperative-fluid-therapy-in-
adults#:~:text=Postoperative%20intravenous%20maintenance%20fluid%20therapy%20ensures
%20adequate%20organ,that%20do%20not%20significantly%20alter%20the%20hemodynamic
%20milieu.
• https://www.nice.org.uk/guidance/cg174/resources/composition-of-commonly-used-crystalloids-table
-191662813
• https://www.pedagogyeducation.com/Main-Campus/Resource-Library/Infusion/Guide-to-
Crystalloids-and-Colloids.aspx#:~:text=Crystalloid%20solutions%20are%20plasma%20volume
%20expanders%20that%20contain,and%20allow%20the%20solution%20to%20move%20through
%20membranes.
• https://www.ncbi.nlm.nih.gov/books/NBK545210/
• https://www.ncbi.nlm.nih.gov/books/NBK537326/#article-20160.s2
• https://www.nice.org.uk/guidance/cg174/chapter/1-Recommendations#principles-and-protocols-for-i
ntravenous-fluid-therapy-2
REFERENCES
• https://www.bmj.com/bmj/section-pdf/750417?path=/bmj/347/79
37/Practice.full.pdf

• https://www.medicineindia.org/pharmacology-for-generic/43/dex
trose-5-normal-saline-09-nacl

• http://www.pathwaymedicine.org/Body-Fluid-Shifts
•
https://www.reference.com/science/osmolarity-normal-human-bl
ood-9b39899645695be2
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506238/