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RESUSCITATION MAINTENANCE
Repair
Intraoperative Hemodynamically
1. Replace acute loss Preop
1.&Replace
post recovery
normal period
loss
stable (hemorrhage, GI loss, (IWL + urine+ faecal)
3rd space etc) 2. Nutrition support
Resuscitation vs Maintenance
RESUSCITATION MAINTENANCE
Elect of High sodium > 100 mmol/L • Moderate sodium 50-100 mmol/L
or colloid • K+ based on daily req
Low or no K+ • 20 drops/min 500 ml/6 hr
20-30 ml/kg/hr (DSS, diarrhea)
2-3 L/10-15 min (hemorrhagic shock)
Fearon KCH, Ljungqvist O, Von Meyenteldt M; Revhavy A, Dejong
CHC, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet ;
Enhanced recovery after surgery: A consensus review of clinical care for
patients undergoing colonic resection. Clinical Nutrition 2005; 24: 466-
477
Pre-
admission
conselling
Perioperative oral
nutrition Fluid and CHO-
loading/no fasting
Stimulation of gut
mortility
Prevention of
nausea and ERAS
vomiting
Avoidance of sodium/
fluid overload
HYPOTHALAMUS
SYMPATHETIC ADENOHYPOFISIS
↑ Cardiac function
↑ Glycogenolysis
• Na+ retention ↑ Blood glucose
↑ Blood redistribution • Water retention ↑ Gluconeogenesis
↑ Glycogenolysis • ↑ Free Amino Acids
↑ Blood glucose ↑ Metabolism ↑ Lipolysis
• ↑ Gluconeogenesis
↑ Lipolysis
↑ Free fatty acids
06/01/12
Vasopressin changes by various
solutions
NaCl
vasopressin
elevation
Glucose
vasopressin
suppression
Sequestration of fluid from ECW
% BODY NORMAL ACUTE INJURY ELECT & IV Col PHASE OF
WEIGHT
RESOLUTION
35
Forming
25 Sequestrated
ECF
20
ISF
Sequestrated Resolving
15 ECF Sequestrated
ECF
10
5
IV
Low Sodium
Better outcome
Restricted volume
Total fluid
Change in
input (ml)
Weight
(kg)
0 1 2 3 4 pop
0 1 2 3 4 5 pop
IV sodium Urine
(mmol) output
(ml)
0 1 2 3 4 pop 0 1 2 3 4 pop
Lobo DN, et al: Lancet 2002; 359;1812-1818; Standard: at least 154 mmol
sodium and 3 L water/day; Restricted: no more than 77 mmol sodium
and 2 L water/day
Dr Iyan Darmawan
Intravenous fluids
Body weight increase
L kg
Methods
48 ASA I-III patients undergoing laparoscopic cholecystectomy
Randomized to 15 ml/kg (restrictive group) or 40 ml/kg
(liberal group) intraoperative lactated Ringer Solution
Results
Liberal group Improved postoperative pulmonary function
Improved exercise capacity after surgery
Reduced stress response
(aldostrenone, ADH and angiotensin II)
Nausea, general well-being, thirst, dizziness, drowsiness,
fatigue, and balance function also significantly improved.
Shires’ theory has been easily accepted in trauma patients with strong
heart, the benefit of youth and a good renal system who tolerate liter and
liter of fluid. While renal failures is avoided, the abdominal
compartment syndrome has appeared and been the price for this
aggressive fluid replacement.
Should prescribe
Low sodium!!
Hill G.L. Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone 1990
LARUTAN Na > 130 mEq/L