FLUID THERAPY

Body Fluid Compartments

Total Body water is:

60% of total body weight in males

55% of total body weight in females

Body Fluid Compartments

70Kg Man
Solids
(40%)

Water

ECF

(60%)

14 Litres

ICF

11 Litres
Plasma 3 Litres

42 Litres

Interstitial fluid

28 Litres

Body fluid compartments

Daily Input Vs Output

Input
Output
2500ml
2500ml
Fluids
1400ml Water
Urine 1500ml
Food
750ml
Metabolism 350ml
Skin
500ml

Insensibl
400ml e losses

Lungs
Faeces 100ml

1000ml

Na 1-1.5mmol/kg/day
K 0.8 - 1 mmol/kg/day

Electrolyte Composition of fluid

Compartments

Osmotic pressure of blood plasma 285 + 5

mOsm / L.
Solution with same osmotic pressure
(isotonic) = 0.96% NaCl, D51/4NS, RL
Lower (hypotonic)= D5W, NS
Higher (hypertonic)= D5NS, D5NS, D5LR,
etc.

Electrolyte content in body

(mEq/l)

Plasma

Interstitial

Interseluler

Kation

Na
K
Ca
Mg

142
4
5
3

114
4
2,5
1,5

15
150
2
27

Total

154

152

194

Anion

Cl
HCO3
HPO4
SO4
Asam organic
Protein

103
27
2
1
5
16

114
30
2
1
5
0

1
10
100
20
0
63

Total

154

152

194

Function of Natrium

Maintaining osmotic pressure and

extracellular fluid volume.
Needs of 50-100 mEq per day or 3-6 gr
Balance is set primarily by the kidneys
1 gram = 17 mEq NaCl
Deficiency is usually due to excessive
infusion without Na, prostate resection
syndrome, decreased secretion of ADH

Function of Kalium

Most found in the cells (150 MEQ / L)

Plasma potassium in only 2% of total

body K, so the lack rarely detected

Useful to stimulate the muscles, sending

electrical impulses, helping O2
utilization, amino acids, glycogen, & cell
formation

Normal serum K rate 3-5 meq / L

Hypokalemia (<3mEq / L) causes muscle

fatigue, paralytic ileus

The daily requirement of water 50 ml /

kg, sodium 2 mEq / kg, potassium 1 mEq
/ kg.

Key Concepts

The intravascular half-life of a crystalloid

solution2030 min, most colloid
solutions have intravascular half-lives
3 - 6 h.
Patients with a normal hematocrit should
generally be transfused only after losses
>1020% of their blood volume.

The most severe transfusion reactions

ABO incompatibility; result in
intravascular hemolysis.
Acute hemolytic reaction : rise in
temperature, unexplained tachycardia,
hypotension, hemoglobinuria, and
diffuse oozing in the surgical field.

Transfusion of leukocyte-containing
blood products appears to be
immunosuppressive.
Immunocompromised and
immunosuppressed patients are
particularly susceptible to severe
cytomegalovirus (CMV) infections
through transfusions.

The most consistent acidbase

abnormality after massive blood
transfusion is postoperative metabolic
alkalosis.
The most common cause of bleeding
following massive blood transfusion is
dilutional thrombocytopenia.

Signs of Fluid Loss (Hypovolemia)

Fluid Loss (Expressed as Percentage of Body
Weight)
SIGN

5%

10%

15%

Mucous membranes

Dry

Very dry

Parched

Sensorium

Normal

Lethargic

Obtunded

Orthostatic changes

None

Present

Marked

In heart rate

> 15 bpm

In blood pressure

> 10 mm Hg

Urinary flow rate

Mildly decreased

Decreased

Markedly decreased

Pulse rate

Normal or
increased

Increased > 100

bpm

Markedly increased >

120 bpm

Blood pressure

Normal

Mildly decreased
with respiratory
variation

Decreased

Presentation of dehydration
Severity of Dehydration

Clinical Findings

Mild
Up to 5% total body water
(3L in 70kg man)

Normal mental state

Dry mucous membranes
Usually thirsty
Blood pressure & heart rate normal
Lower than normal urine output
Skin turgor almost normal

Moderate
5-10% total body water
(5L in 70kg man)

Disinterest in surroundings, can be drowsy

Increased heart rate & respiratory rate
Orthostatic hypotension
Decreased skin turgor
Reduced urine output

Severe
10-15% total body water
(8L in 70kg man)

Reduced conscious level

Fast heart rate
Low blood pressure
Respiratory distress
Oliguria / anuria

Dehydration can be either isotonic dehydration

(Na levels and normal serum osmolarity);
hypotonic / hiponatremik (Na <130 mmol / L) or
serum osmolarity <275 mOsm / L) ;
hypertonic / hipernatremik (Na> 150 mmol / L) or
serum osmolarity> 295 mOsm / L).

Classification of shock

IV fluid types

Crystalloids

Colloids

Synthetic
Human

Basis of IV fluid therapy

Maintenance
To

Replacement
To

supply daily needs

replace on-going losses

Resuscitation
To

correct an intravascular or extracellular

deficit

Crystalloid

A substance in solution that can diffuse

through a semipermeable membrane
the initial resuscitation fluid
hemorrhagic and septic shock, burn,
head injury to maintain cerebral
perfusion pressure, and in patients
undergoing plasmapheresis and hepatic
resection

For losses primarily involving water,

replacement is with hypotonic
solutions, also called maintenance-type
solutions.
If losses involve both water and
electrolytes, replacement is with
isotonic electrolyte solutions, also
called replacement-type solutions.
Glucose is provided in some solutions to
maintain tonicity or to prevent ketosis
and hypoglycemia due to fasting.

Because most intraoperative fluid losses

are isotonic, replacement-type solutions
are generally used.
The most commonly used fluid is
lactated Ringer's solution.

Crystalloids

Examples

0.9% Saline (Normal saline)

Hartmanns (compound sodium lactate)
Glucose containing solutions
5%

Glucose
10% Glucose
Dextrose-saline

4% glucose & 0.18% saline

5% glucose & 0.45% saline

Crystalloids composition
Solution Na

Cl

Ca

Bicarb

Glucose
g/L

Tonicity

Isotonic

29

Isotonic
Isotonic

K
mmol/l

0.9% Sodium
Chloride
Hartmanns
5% Dextrose
10% Dextrose

15 154
4
13 111
1

(as lactate)

50

100

(hypotonic once
metabolised)

Hyperton
ic
(hypotonic once
metabolised)

4% glucose &
0.18% sodium
chloride

30

30

40

Isotonic

Colloids

Solutions that contain high molecular

weight proteins as well as electrolytes

Unable to diffuse through normal

capillary membranes

Colloids

Examples

Gelatin-based

Gelofusine
Haemaccel

Hydroxyethyl starches (HES)

Pentastarch

Tetrastarch - 6% (HES)

Voluven
Volulyte

Dextran 70

5% - Hemohes
10% - HAES-steril

Rescuflow

Human albumin solutions

HAS 5%
HAS 20%

Max 1.5 L /
24hr
Max 2.5 L/
24hr
50ml/kg/24hr
(3.5l)
Use in trauma, (Max
1L)
250ml followed by
isotonic fluids
Severe allergic
reactions, coagulation
effects

Colloid composition
Solution Na

Cl

M HCO
3
g

MW
Daltons

mmol/l
Gelofusine
Voluven 6%
Volulyte 6%

15 120 0.4 0.4

4
15 154 4
13 110 4 1.5
7

30,000

130,000

34

130,000

(as
acetate)

Distribution of IV fluids

Colloid
5% Dextrose
0.9% Saline

PERIOPERATIVE FLUID
THERAPY

includes replacement of preexisting fluid

deficits, of normal losses (maintenance
requirements), and of surgical wound
losses including blood loss.

NORMAL MAINTENANCE
REQUIREMENTS

Weight

Rate

For the first 10 kg

4 mL/kg/h

For the next 1020 kg

Add 2 mL/kg/h

For each kg above 20

kg

Add 1 mL/kg/h

Example: What are the maintenance

fluid requirements for a 25-kg child ?
Answer: 40 + 20 + 5 = 65 mL/h.

PREEXISTING DEFICITS

Patients presenting for surgery after an

overnight fast without any fluid intake
will have a preexisting deficit
proportionate to the duration of the fast.
The 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 x 8 h, or 880 mL.


SURGICAL FLUID LOSSES

SURGICAL FLUID LOSSES

Blood Loss
Other Fluid Losses

INTRAOPERATIVE FLUID REPLACEMENT

Replacing Blood Loss

Ideally, blood loss should be replaced with

crystalloid or colloid solutions to maintain
intravascular volume (normovolemia) until
the danger of anemia outweighs the risks
of transfusion.
further blood loss transfusions of red
blood cells to maintain hemoglobin
concentration (or hematocrit).
For

most patients, that point corresponds to a

hemoglobin between 7 and 8 g/dL (or a
hematocrit of 2124%).

Patients with a normal hematocrit should

generally be transfused only after losses
greater than 1020% of their blood
volume.

The amount of blood loss necessary for

the hematocrit to fall to 30% can be
calculated as follows:

1. Estimate blood volume.

2. Estimate the red blood cell volume
(RBCV) at the preoperative hematocrit
(RBCVpreop).
3. Estimate RBCV at a hematocrit of 30%
(RBCV30%), assuming normal blood volume
is maintained.
4. Calculate the red cell volume lost when
the hematocrit is 30%; RBCV
=

Estimate blood volume

Average Blood Volumes

Age

Blood Volume

Neonates
Premature
Full-term

95 mL/kg
85 mL/kg

Infants

80 mL/kg

Adults
Men
Women

75 mL/kg
65 mL/kg

EXAMPLE
An 85-kg woman has a preoperative
hematocrit of 35%. How much blood loss
will decrease her hematocrit to 30%?

Estimated blood volume = 65 mL/kg x 85

kg = 5525 mL.
RBCV35% = 5525 x 35% = 1934 mL.

RBCV30% = 5525 x 30% = 1658 mL.

Red cell loss at 30% = 1934 1658 = 276

mL.
Allowable blood loss = 3 x 276 mL = 828

Therefore, transfusion should be

considered only when this patient's
blood loss exceeds 800 mL.
Transfusions are not recommended until
the hematocrit decreases to 24%
(hemoglobin < 8.0 g/dL)

Other useful guidelines

1U of red blood cells will
hemoglobin 1
g/dL and the hematocrit 23% (in
adults);
10-mL/kg transfusion of red blood cells
will hemoglobin concentration by 3 g/dL
and the hematocrit by 10%.

Replacing Redistributive &

Evaporative Losses
Redistribution and Evaporative Surgical Fluid
Losses
Degree of Tissue Trauma Additional Fluid
Requirement
Minimal (eg, herniorrhaphy) 02 mL/kg
Moderate (eg,
cholecystectomy)

24 mL/kg

Severe (eg, bowel

resection)

48 mL/kg

INTRAOPERATIVE TRANSFUSION
PRACTICES

Packed Red Blood Cells

ideal for patients requiring red cells but not
volume replacement (eg, anemic patients in
compensated congestive heart failure).
Surgical patients require volume as well as red
blood cells crystalloid can be infused
simultaneously through a second intravenous
line for volume replacement.

Fresh Frozen Plasma (FFP)

contains all plasma proteins, including all clotting factors.

indicated in the treatment of isolated factor deficiencies,

the reversal of warfarin therapy, and the correction of
coagulopathy associated with liver disease.

Each unit of FFP generally increases the level of each

clotting factor by 23% in adults.

The initial therapeutic dose is usually 1015 mL/kg.

The goal is to achieve 30% of the normal coagulation

factor concentration.

may also be used received massive blood transfusions

and continue to bleed following platelet transfusions,
antithrombin III deficiency/thrombotic thrombocytopenic
purpura.

Each unit of FFP carries the same infectious risk as a unit of

Platelets

should be given to patients with thrombocytopenia /

dysfunctional platelets in the presence of bleeding.

Prophylactic platelet transfusions platelet counts

<10,00020,000 x 109/L increased risk of spontaneous
hemorrhage.

Platelet counts <50,000 x 109/L are associated with

increased blood loss during surgery.

Thrombocytopenic patients about to undergo surgery or

invasive procedures should receive prophylactic platelet
transfusions preoperatively: the platelet count should be
increased to approximately 100,000 x 109/L.

Each single unit of platelets may be expected to the count

by 10,00020,000 x 109/L.

Granulocyte Transfusions

indicated in neutropenic patients with bacterial infections

not responding to antibiotics.

very short circulatory life span, so that daily transfusions of

1010 granulocytes are usually required.

the incidence of graft-versus-host reactions, pulmonary

endothelial damage, and other problems associated with
transfusion of leukocytes (see below), but may adversely
affect granulocyte function.

The availability of filgrastim (granulocyte colonystimulating factor, or G-CSF) and sargramostim

(granulocyte-macrophage colony-stimulating factor, or GMCSF) has greatly reduced the use of granulocyte
transfusions.

DAFTAR PUSTAKA

Morgan GE, Mikhail MS, Murray MJ. 2006.

Chapter 29.Fluid Management &
transfusion in Morgans Clinical
Anesthesiology. 4th ed. United States:
McGraw-Hill Companies.
Duncan A. 2012. IV Fluid Therapy. The
University of
Manchester.www.cmft.nhs.uk/undergrad/
students/.../IVfluidtherapy_000.ppt. 24
Juli 2013.