Perioperative Fluid Management

Oleh
Hasanuddin
Pembimbing
Dr. Abd. Wahab, SpAn

The principle of fluid therapy is to

maintain tissue perfusion

So
How

much should we infuse?

What fluids should we use?
How should we monitor fluid replacement?

Total Body Water

Total body water varies between 55-70% of BW
Depend on : - age
- sex
male > female (more fat)
TBW approximately 60% of BW
A person of 60 kgs has 60 x 60% = 36 L

Distribution of body fluids

RBC

Colloid

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

15%
Interstitial
Space
crystalloids

Cell membrane

5%

Capillary membrane

Intravascular Space

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

total body water 60% BW

Intra Cellular Space

40%
Na = 8 meq/l
K = 151
meq/l
Glucose solution

Composition of fluid
compartments
plasma

interstitial

intracellular

Cations
Na
K
Ca
Mg

140
4
5
2

146
4
3
1

12
150
10
7

Anions
Cl
HCO
SO4
HPO4
Protein

103
24
1
2
16

104
27
1
2
5

3
10
116
40

How much should we infused ?

Type of Fluid Loss in Perioperative Periode
Basal fluid requirements
Fluid loses on drainage, fistel, maag
slang)
Redistributive and evaporative
surgical losses
Fluid shifts (Third space losses)
Bleeding

Role of 4-2-1
Requirements for 70kg man
10 kg x 4 ml/kg

40 ml

10 kg x 2 ml/kg

20 ml

50 kg x 1 ml/kg

50 ml
110 mls / hr

Suggest to preoperative rehidrate with glukosa that can :

1. decrease seluler insulin resistance post operatif
2. Increase muscle tonus post operatif

Third Space Losses

Superficial Surgery : 1-2 ml/kg/hr
Minor Surgery : 3-4 ml/kg/hr (THT,
hernia)
Moderate Surgery : 5-6 ml/kg/hr
(histerektomy, chest surgery)
Mayor Surgery : 8-10 ml/kg/hr (nephrectomy)

Redistributive and evaporative surgical fluid

losses
Degree of tissue trauma

Additional fluid
requirement

Minimal ( herniorrhaphy)

0 2 cc/ kg/hour

Moderate
( cholecystectomy)
Severe ( bowel resection)

2 4 cc/kg/ hour
4 8 cc/kg/hour

Class I

Class II

Class III

Class IV

Blood loss

Up to 750

750-1500

1500-2000

>2000

Blood loss
(%
EBV)

Up to 15%

15-30%

30-40%

>40%

Pulse rate

<100

>100

>120

>140

Blood
pressure

Normal

Normal

Decrease

Decrease

Pulse
pressure

Normal or
decrease

Decrease

Decrease

Decrease

Respiratory
rate

14-20

20-30

30-35

>35

Urine
output

>30

20-30

5-15

No UO

CNS/
mental status

Slightly
anxious

Mildly anxious

Anxious and
confused

Confused and
lethargic

Fluid
replacement

crystalloid

crystalloid

Crystalloid/ Crystallloid/
colloid/blood colloid/blood

Course of hypovolaemic shock in absence of

therapy
Blood pressure mmHg
150

Heart rate
min

Bleeding

100
Blood
pressure

50

Compensation

Decompensation

Three Shock
phases

Irreversibility

Problems with Perioperative Fluid

Replacement

We cant accurately evaluate blood volume

We cant accurately identify fluid overload
We cant accurately identify hypovolemia
We cant accurately evaluate tissue
perfusion

Adequate what is the parameter ?

Adequate fluid intravascular, interstitial,
intraceluler
Clinical sign
Hemodynamic monitoring principle
Organ perfusion
Microcirculation

Complication
Risks of inadequate resuscitation
Life-threatening : lactic acidosis, ARF, MOF
Non-fatal : thirsty, drowsyness, dizzy, nausea &

Vomiting

Risks of excessive resuscitation

Life-threatening : pulmonary edema, cardiac failure
Non-fatal; peripheral edema, periorbital edema,

impaired gut function, impaired wound healing

Restrictive vs Liberal

Combine thoracic epidural and general anesthesia

elective colorectal resection ASA I III

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)
Arterial End

Net

IFOP

IFOP

BOP

BOP

BHP

BHP

IFHP

IFHP
Lymphatic
system

Venous End

Net

Oxigen Delivery
DO2 = QB x CaO2 x 10
CaO2 = (Hb x 1,34 x SaO2)+ PaO2 x 0,003

What fluid should we use ?

Crystalloid solutions
Isotonic
Hypotonic
hypertonic

Colloid solutions
Semi-synthetic colloids
Naturally occurring human
plasma derivatives

Crystalloids and colloids

Intravascular persistance
Haemodynamic
stabilisation
Required infusion volume
Risk of tissue oedema
Enhancement of capillary
perfusion
Risk of anaphylaxis
Plasma colloid osmotic
pressure
Cost

Crystalliod

Colloid

Poor

Good

Transient

Prolonged

Large

Moderate

Obvious

Insignificant

Poor

Good

Nil

Low to moderate

Reduced

Maintained

Inexpensive

Expensive

The Crystalloids
Crystalloids are a group of intravenous fluid in which may be:
Ionic solution
Ringer lactate/ acetate
NaCl physiologic (0.9% saline)
Hartmans solution
Etc
Mostly iso-osmolar = isotonic
Cheap, easy to manufacture
Has no immunologic reaction
Mainly confined to the extracellular fluid
Non ionic
Dextrose 5%
Maltose 10%
Etc
Distributed to intracellular space

Electrolyte Comparison
Between RL & NaCl 0.9%
Na+

K+

Ca+

Cl-

Lactate

Osm.

Plasma

140

103

300

Ringer Lactate

130

109

28

273

NaCl

154

154

308

Practical crystalloid therapy

If you infuse NaCl 0.9% 1000ml, all the Na + will
remain in the ECF
As NaCl is isotonic there is no change in ECF
osmolality and no water exchange occurs
across the cell membrane
NaCl expands ECF only
Intravascular volume will be increased by 250ml

Practical crystalloid therapy cont

If you infuse glucose 5% 1000ml, the glucose

will enter the cell and be metabolised

The water expands both ECF and ICF in

proportion to their volumes

The ECF volume will increase by 333ml
Intravascular volume will only increase by

approximately 100ml

The Colloids
Colloids are fluids which contain oncotic
particles, therefore exert an oncotic pressure
Blood
Plasma
Albumin
Artificial colloids = plasma expander
Gelatins, from collagen (Haemaccel & Gelofusine)
Dextran is a polysaccharides (Dextran 70 & 40)
HES (Hydroxyethyl starch) e.g. hemohes 6% / 10%

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 >>>

 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 )

How should we monitor fluid replacement?

BP, HR, UO
Filling pressures
Gastric pHi
Transthoracic or transeophageal
echo
Goal-directed Rx

Monitoring
The best estimate of the volume
required is the patients response
After therapy started observe
vital signs
urine output (> 0.5mls/kg/hr)
central venous pressure

Postoperative fluid therapy

Check IV regime ordered in op form
Assess for deficits by checking I/O chart and vital
signs
Calculate maintenance requirements
Usually K+ not started in first 24 hrs
Monitor carefully vital signs and urine output
Cardiac, renal and liver failure still must
resuscitate. Endpoint are less predictable, monitor
more intensively (ICU & Invasive monitoring)

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
Specific losses should be replaced with appropriate fluid
crystalloid colloid, consider both solute, dissolve solute,
electrolyte content, total osmolality, safety, and side effect