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Concept of I/V fluid & its updates on surgical practice
The document discusses intravenous (IV) fluid prescription and management. It notes that many doctors lack knowledge about fluid and electrolyte needs as well as IV fluid compositions. This can lead to inadequate or excess IV fluids, increasing morbidity, mortality, and costs. It recommends doctors have knowledge of physiology, electrolytes, IV fluid types and compositions, fluid selection, and monitoring when prescribing IV fluids. The document provides details on fluid volumes, electrolyte requirements, and types of IV fluids used in different clinical situations. It stresses the importance of ongoing reassessment when managing IV fluids.
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Dr. MD. Majedul Islam Emon is the Registrar at the Department of Surgery, Enam Medical College Hospital.
In 2013, the NICE reported that many I/V fluid prescribers lack knowledge on fluid/electrolyte needs.
Inadequate/excess I/V fluid can increase morbidity, mortality, hospital stays, costs, and result in death.
Good practices for I/V fluid are vital in places like the Emergency Department, ICU, HDU, and Dialysis.
Prescribing I/V fluids requires understanding of body fluid principles, electrolyte physiology, and monitoring.
A 70-kg male comprises 13 kg fat, 57 kg fat-free mass including 42 kg water, critical for bodily functions.
Body weight composition: Infants (90%), Children (70-80%), Adult Males (60%), Adult Females (55%).
Body fluids transport nutrients, maintain blood volume, regulate temperature, and facilitate cellular functions.
Total body fluid is divided into ICF (28L) and ECF (14L). ECF includes interstitial, plasma, transcellular.
Fluid movement is governed by osmotic and hydrostatic pressures between plasma, ISF, and ICF.
Fluid movement varies: water and electrolytes can move freely, while proteins cannot across cell membranes.
Average fluid intake and output for adults is 2600ml daily, balancing drinks, food, metabolism, and losses.
Daily fluid requirement calculations for a 60kg male: 2300 ml based on weight-based volume standards.
Hourly fluid requirement example for a 60 kg male totals 100 ml/hour, equating to 2400 ml/day.
Daily electrolyte requirements for a 60 kg adult include Sodium, Potassium, Chloride, Calcium, Magnesium.
IV fluids categorized into Crystalloids, Colloids, and Blood products based on tonicity.
Examples of isotonic solutions include Normal Saline, Ringers Lactate, with normal plasma osmolality.
List of hypotonic solutions includes 0.45% NaCl, used when plasma osmolality exceeds that of the solution.
Examples of hypertonic solutions include 5% DNS and 3% NaCl, featuring lower plasma osmolality.
Colloids include blood-derived and synthetic types, functioning as plasma expanders in fluid loss conditions.
Colloids retain longer in IV space than crystalloids, requiring rapid action for severe deficits, but at higher cost.
Operative blood loss management suggests saline use, with transfusions considered after significant loss.
Post-surgery transfusion triggers set at 8 g/dl, with a normal Hb allowing considerable blood loss before transfusion.
Criteria for transfusions include symptomatic anemia, significant blood loss, and ongoing iron replacement needs.
FFP provides necessary coagulation factors, indicated for liver disease correction and anticoagulation reversal.
Common IV solutions outlined include Normal Saline and Hartman's solution for clinical applications.
Normal Saline contains Na+ and Cl-, indicated for volume correction, peritoneal wash, and drug dilutions.
5% Dextrose in Water provides crucial postoperative and emergency care, maintaining hydration for NPO patients.
Combination solution of 5% dextrose with saline indicated for intraoperative and postoperative fluid needs.
Ringer’s Lactate has balanced electrolytes, indicated for shock correction and surgical hydration.
Hartmann's Solution, containing essential electrolytes, is used for fluid correction in various shock conditions.
Fluid management challenges include evidence gaps, risks of overload, misinterpretations, and organ dysfunction.
NICE's 4 Rs for fluid prescribing are Resuscitation, Routine maintenance, Replacement, and Redistribution.
Fluid resuscitation protocol involves rapid administration of boluses, monitoring response to ensure proper care.
Daily physiological requirements include fluid volume, electrolytes, and glucose, with specific fluid types suggested.
Highlighting incorrect postoperative fluid orders exemplifying miscalculations for a 60 kg patient needing 2400 ml.
Fluid replacement strategies for ongoing and previous losses emphasize electrolyte balance in postoperative care.
Example of fluid regime calculation for a postoperative patient incorporating ongoing loss assessments.
Electrolyte deficit calculation formulas for Na and K deficiencies based on measured levels in patients.
Electrolyte composition in saliva, stomach, duodenum, ileum, pancreas, and bile depicted numerically.
Fluid retention management concerns include assessment of third space losses and challenges in balancing therapy.
Adjustments to fluid therapy involve daily reassessment of clinical status and comprehensive imbalance monitoring.
Factors increasing fluid requirements include fever and fluid loss, while dehydration and other states decrease the need.
Fluid overload causes pronounced symptoms, necessitating emergency measures to halt therapy and manage removal.
Fluid types recommended during surgical recovery focus on counteracting fluid loss and managing patient needs.
Monitoring protocols in recovery include visual inspections and daily electrolyte checks for safe recovery.
Continuous monitoring and adjustment of fluid therapy highlighted through fluid types in varying patient scenarios.
Daily monitoring should track fluid administration across multiple parameters for optimal patient fluid management.
Detailed suggestions for a 60kg patient's fluid therapy emphasize close monitoring for balanced care.
Immediate considerations for patients NPO for extended days to ensure proper fluid management.
Focus on optimizing hemodynamics through careful fluid management in high-risk surgical patients.
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Concept of I/V fluid & its updates on surgical practice
- 1. Dr. MD. MajedulIslam Emon Registrar Department of Surgery Enam Medical College Hospital
- 2. In 2013NICE(National Institute for health and care excellence) reported that: Majority of I/V fluid prescriber(Surgeon/Assisstant surgeon/Trainee) – 1. know neither the fluid and electrolyte needs for the patients 2. nor the specific composition of the fluid
- 3. 1. Inadequate I/Vfluid 2. Excess I/V Fluid Effect/Outcome of lack of knowledge: 1. Increase morbidity and mortality 2. Prolong hospital stay 3. Increase cost 4. Ultimately death…………..
- 4. 1. Emergency Department 2.Acute admission Unit 3. General Ward Place of Good I/V fluid Practice 1. Operation Theatre 2. Intensive care unit(ICU) 3. High dependency unit(HDU) 4. Dialysis Unit
- 5. To prescribe, followingare recommendated : Knowledge of Physiology or principle of body fluid balance Knowledge of Electrolyte physiology Knowledge of Type of I/V fluid and its composition Knowledge of Selection of I/V fluid for the patient Knowlede of Monitoring Knowledge of I/V fluid related events
- 6. The average 70-kgmale can be considered to consist: fat(13 kg) and fat-free mass (or lean body mass: 57 kg) composed primarily of – 1. protein(12 kg), 2. Water (42 kg) and 3. minerals (3 kg)
- 7. Infant 90% ofbody weight Children 70-80% of body weight Male(Ault) 60% of body weight Female(Adult) 55% of Body wight
- 8. ◦ Transport nutrientsto the cells and carries waste products away from the cells ◦ Maintains blood volume ◦ Regulates body temperature ◦ Serves as aqueous medium for cellular metabolism ◦ Assists in digestion of food through hydrolysis ◦ Acts as solvents in which solutes are available for cell function ◦ Serves as medium for the excretion of waste products
- 9. A. Intracellular fluid(ICF)– 28 litres B. Extracellular Fluid(ECF) – 14 litres Distribution of extracellular fluid(ECF) Interstitial fluid(fluid between cells in tissues) – 11 litres Plasma – 3litre Transcellular fluid – 1 litre N.B Transcellular fluid Examples 1. cerebrospinal fluid, 2. ocular fluid and 3. joint fluid
- 11. Plasma >ISF > ICF Plasma and ISF seperated by capillary membrane ISF and ICF separated by cell membrane 2 pressure COP(Colloidal osmotic pressure) and Hydrostatic pressure(HP) also play a part in fluid movement COP tendency to keep/ draw fluid inside the vessels but HP tends to push fluid out
- 12. Between Plasma andISF: H2O and electrolyte freely mobile Protein cant move Between ISF and ICF H2O freely mobile Electrolyte restrictly permeable(Move in fluid imbalance)
- 14. Intake Volume(ML) OutputVolume(ml) Drink 1500 Urine 1500 Water from food 700 Insensible loss 1000 Metabolic 359 Faeces 100 Total 2600 Total 2600
- 15. Adult 30-40 ml/kg/dayor 1st 10 kg 100 ml/kg/day 2nd 10 kg 50 ml/kg/day After each/1 kg 20 ml/kg/day Example 60 kg male would require 10 x 100 = 1000 ml 10 x 50 = 500 ml 40 x 20 = 800 ml Total = 2300 ml/day
- 16. 1st 10kg = 4 ml/kg/ hour 2nd 10 kg = 2 ml/kg/ hour After 20 kg = 1 ml/kg/hour Example 60 kg male would require 10 x 4 = 40 ml 10 x 2 = 20 ml 40 x 1 = 40 ml Total 100 ml/hour (2400 ml/day)
- 17. Daily requirements ofmajor electrolytes: Sodium 1 mmol /kg/ day Potassium 1 mmol/kg/ day Chloride 1 mmol/kg/ day Calcium 2 g/ day Magnesium 20 mEq / day Glucose 100gm/day Example of a 60 kg woman - 60 mmol needed for Na, K, Cl
- 18. A. Crystalloid B. Colloid C.Blood products On the basis of tonicity 1. Isotonic 2. Hypertonic 3. Hypotonic
- 19. 1. Isotonic(tonicity similarto plasma) solution 5% DA 0.9% NaCl(Normal Saline) Hartman solution Ringers Lactate solution NB. Normal plasma osmolality 280-295 mOsm
- 20. Hypotonic Solution(plasma osmolalityis more than that of solution) 0.45% NaCl, 0.33% sodium chloride, 0.2% sodium chloride, and 2.5% dextrose in water
- 21. 2. Hypertonic solution(plasmaosmolality is less than that of solution) 5% DNS 3% NaCl
- 22. Solutions containing high-molecularweight substances such as proteins or large glucose polymers. Types of Colloids Blood derived Human albumin. Synthetic * Hydroxyethyl Starches(Hespan) * Gelatins(Haemaccel) * Dextrans. Function: Plasma expanders by increasing plasma oncotic pressure moving fluids from IS to IV spaces i. e. Abnormal protein loss. e.g peritonitis & Severe burns.
- 23. Differences between colloidsand crystalloids Colloids stay more in IV space (3-6 h.) but Crystalloids (20- 30 m.) Colloids 3 times potent than crystalloids. Severe IV fluid deficits can be more rapidly corrected using colloids. Colloid resuscitation more expensive. Rapid administration of large amounts of crystalloids (>4-5L) is more frequently associated with significant tissue edema.
- 24. 1. Inpractical terms, operative blood loss up to 500 ml can be replaced with saline(Colloid or crystalloid) Only if >1 L of blood has been lost in a healthy adult should you consider giving blood.
- 25. For themajority of patients undergoing elective or emergency surgery a transfusion trigger of 8 g dl"1 is appropriate. A pt undergoing operation with a normal Hb of approximately 14 g dl"1 can afford to lose 1.5 litres of blood before red cell transfusion becomes necessary. Recent RCT showed A trigger haemoglobin of 7-8 g dl- 1 is therefore appropriate even in the critically ill. critical level of of Hb is 4-5 g dl"1. because at this level, oxygen consumption begins to be limited .
- 26. Pre-Operative: 1. Pt issymptomatically anemic 2. Hb< 6gm/dl 3. HCT < 21% 4. Bone marrow failure resulting from drug or RT or CT Per operative/post operative: Blood loss> 1-1.5 litre N.B: One unit of red cells raises the haemoglobin by 1 g dH. Transfusion may correct a severely low haemoglobin but not correct iron deficiency So Oral iron replacement therapy is required for 4-6 months. Alternatively, give a total dose infusion of iron.
- 27. Requirement 15ml/kg/day One unit contain 150ml FFP Frozen at -30°C. stored upto 12 months. Once thawed it should be used within 2 h because degradation of the clotting factors at room temperature. FFP contains coagulation factors, including the labile factors V and VIII and the vitamin K-dependent factors II, VII, IX and X. Indication: To correct abnormal coagulation in patients with liver disease. To reverse oral anticoagulation as from, for example, over warfarinization. DIC Massive BT
- 28. 1. Normal Saline 2.5% DA 3. 5% DNS 4. Hartman solution 5. Rigers Lactate
- 29. Contaion :Na+ 154 mmol/L, Cl+ 154 mmol/L Isotonic(308 mOsm/L) Indication: 1. Correction of volume in shocked pt due to Hge, burn, dehydration 2. Peritoneal wash(lavage), stomach Wash, 3. Syringe wash, injured area, wound burn, ulcer 4. Dressing purpose 5. Dilution of drug 6. Preservative
- 30. Contaion –50 gm Glucose(dextrose)/L Isotonic(280 mOsm/L) Indication: 1. Posotoperative Patient(When kept NPO) 2. Post head injury Pt 3. Channel maintainence for emergency medication
- 31. Contaion :Na+ 154 mmol/L, Cl+ 154 mmol/L 50 gm Glucose(dextrose)/L Hypertonic(320mOsm/L) Indication: Intraoperative fluid Post operative fluid Resuscitation
- 32. Contaion :Na+ 130 mmol/L, Cl- 130 mmol/L K+ 5 mmol/L Lactate 29 mmol/L Isotonic(280 mOsm/L) Indication: Correction of volume in shocked pt due to Hge, burn, dehydration Intraoperative fluid Post operative fluid
- 33. Contaion :Na+ 131 mmol/L, Cl- 111 mmol/L K+ 5 mmol/L Ca+ 2 mmol/L HCO3 29 mmol/L Isotonic(280 mOsm/L) Indication: Correction of volume in shocked pt due to Hge, burn, dehydration Intraoperative fluid Post operative fluid
- 36. Problem: 1. Lack ofevidence of study 2. Problem with salt and water overload: Renin anigiotensin, aldosterone, ADH system Provision of high inappropriate I/V fluid Misinterpretation of postop dilutional hyponataremia Misconception of body potassium Malnutrition 3. Problem in making accurate assessment of abnormal fluid and electrolyte loss 4. Problem from internal fluid redistribution. 5. Problem of organ dysfunction. 6. Problem of poor record keeping.
- 37. NICE designated4 R for prescribing fluid along with 5th R for reassessment : 1. Resuscitation 2. Routine maintainence 3. Replacement 4. Redistribution All are depend on : History General Examination CVP Electrolyte measurement Urine output External loss Weight chart
- 38. Who need? Acutemulti system trauma Acute post operative haemorrhage Sepsis Why need? To restore intravascular fluid What type of fluid? Normal Saline, Hartman, Ringers lactate, Albumin, Haemaccel How ? Initial – 500ml bolus over < 15 min then reassess, if still need resuscitation then give another 250 ml bolus no response >2000ml over 2 hour already given but no response-> seek expert help
- 39. It provide dailyphysiological fluid and electrolyte requirements How much Normal Requirements: Fluid 30-40 ml kg/kg/day Na+ and K+, 1 mmol/kg/day Glucose 100gm/day What type of fluid? 5% DA Normal Saline Hartman
- 40. This fluidprescribing is wrong. If the Pt Wt is 60 kg then he need 2400ml fluid So , 5% glucose 2000ml 0.9% saline 500ml Is appropriate for Postop order
- 41. Provision of fluidfor ongoing fluid and elctrolyte loss , previous deficit with daily maintenance fluid When to give: Electrolyte imbalance(detected by daily electrolyte measurement) Fistula(ECF), Ileostomy, NG aspiration or drainge, vomiting, diarrhoea, abdominal drain tube collection. What type of fluid? Normal Saline with added potassium Riger’s Lactate Hartman
- 42. A 60kg Pt with abdominal surgery on 1st post operative day, with NG collection 300 ml and drain tube collection 200 ml, prescribe his fluid regime: His daily requirement is 2400ml Today Ongoing loss is 500 ml(Total 2900ml) So fluid therapy should be 5% glucose 1400ml 5% DNS 500ml Rigers lactate 1000ml
- 43. calculate the deficit:Formula For Na deficit = (Normal Na level- Measured plasma level of Na)X Wt in KgX0.6 For K deficit = (Normal K level- Measured plasma level of K)X Wt in KgX0.2
- 44. Na K ClHCO3 Saliva 10 25 10 30 Stomach 50 15 110 Duodenum 140 5 100 Ileum 140 5 100 30 Pancrease 140 5 75 1115 Bile 140 5 100 35
- 46. Despite fluidtherapy they are not remain in the circulation and not participate in normal exchange mechanism(third space fluid loss) Check for edema, ascities, renal failure, liver failure, post operative fluid retention Best fluid therpay is difficult, too little- to hypovolumia - too more , fluid overload So it is best to reduce overall fluid and electrolyte provision to permit a negative sodium and water balance to aid edema resolution.
- 47. Why? Toaltered or stop the fluid therapy How: 1. Daily reassessment of clinical fluid status 2. Daily Fluid balance chart(Input/Output) 3. Measurement of CVP, PAWP 4. Wt measurement twice weekly Laboratory: 1. Daily measurement of Urea, creatinine, electrolyte, Hb%, Albumin 2. Urinary Na+, K+, Albumin
- 48. Fluid requirement Increasedin: Fever(if 101 add 7% extra fluid) Hyperthyroidism Hyperventilation Abnormal fluid loss, etc Fluid requirement decreased in: Hypothermia Raised humidity Hypothyroidism Immobilise pt Uncoscious Pt Cerebral edema: Meningitis, stroke Fluid retention Oliguria CCF, etc
- 49. Cause: Excessinfusion of 5% DA/Hypotonic saline Misinterpretation of fluid regime in Pt with CRF, Head injury Pt, cerebral infection Pt Excess irrigation during prostatectomy. C/F: A. Peripheral edema(if >2L): Puffy face, ankle edema, ascities, pleural effusion B. Raised JVP, BP may raised C. Urine out put> 2ml/kg/hour D. Cerebral edema, confusion, convulsion , coma Investigation: S. Na+, Hb%, PCV, Albumin(all are decreased) Treatment: Its an emergency 1. Stop all fluid therapy 2. Mannitol diuretis(not by frusemide because which causes both water and Na+ loss) 3. Monitoring the Patient.
- 50. The patientis starved for 6-12 h, there may be blood loss, plasma loss, ECF loss and evaporation of water from exposed bowel -> As part of the stress response to surgery the patient retains water and sodium. What Fluid to give ? Hartmann's solution 5 ml/kg/h.
- 51. 5 %DA = 1600 ml 0.9% NaCl = 500 ml Ringer lactate = 500 ml Monitoring: patients thirst, puffiness of face, CVP, peripheral perfusions, leg edema, chest, urine output Daily: elctrolytes, CBC
- 52. 5 %DA = 1600 ml 5% DNS = 500 ml Ringer lactate = 1000 ml Monitoring: patients thirst, CVP, peripheral perfusions, leg edema, chest, urine output Daily: elctrolytes, CBC
- 53. 5 %DA = 1600 ml 5% DNS = 500 ml Ringer lactate = 500 ml Monitoring: patients thirst, CVP, peripheral perfusions, leg edema, chest, urine output Daily: elctrolytes, CBC
- 54. 5 %DA = 1100 ml 5% DNS = 1000 ml Ringer lactate = 500 ml 60 mmol KT/day Monitoring: patients thirst, CVP, peripheral perfusions, leg edema, chest, urine output Daily: elctrolytes, CBC
- 55. Consider If Patientis NPO more than 5 Days.
- 56. Principle: intensivemonitoring and aggressive management of perioperative Hemodynamics in high risk patients to optimize oxygen delivery or manipulate a patient’s physiology to achieve targets that are associated with an improved outcome Aim: The right fluid, for the right patient, at the right time What Goal we can target: 1. Stroke volume 2. Oxygen Delivery or consumption How to achieve: By measurements of cardiac output (CO) which direct the use of I/V fluid and ionotrpes. What operations? Which patients? expected blood loss >500 mL( major abdominal general surgical, orthopedics, urological, gynae) Trauma, pt with sepsis, burn