PERIOPERATIVE FLUID

THERAPY
Sayeed Nawaz
Consultant Anaesthesit
Department of Anesthesiology
KKUH. King Saud University
 Total Body Water (TBW)

• Varies with age, gender

• 55% body weight in males
• 45% body weight in females
• 80% body weight in infants
• Less in obese: fat contains little water
 Final Goals of Fluid resuscitation

- Achievement of normovolemia& hemodynamic stability

- Correction of major acid-base disturbances
- Compensation of internal fluid fluxes
- Improvement of microvascular blood flow
- Prevention of cascade system activation
- Normalization of O2 delivery
- Prevention of reperfusion cellular injury
- Achievement of adequate urine output
 Desirable outcome of fluid
resuscitation
- No peripheral edema

- No ARDS
 Fluid and Electrolyte Regulation

• Volume Regulation
- Antidiuretic Hormone
- Renin/angiotensin/aldosterone system
- Baroreceptors in carotid arteries and aorta
- Stretch receptors in atrium and juxtaglomerular
aparatus
- Cortisol
 Preoperative Evaluation
of Fluid Status
• Factors to Assess:
- h/o intake and output
- blood pressure: supine and standing
- heart rate
- skin
- Urinary output
- mental status
 Orthostatic Hypotension

• Systolic blood pressure decrease of greater than

20mmHg from supine to standing
• Indicates significant fluid loss
- Heart rate should increase as a compensatory measure
- If no increase in heart rate, may indicate autonomic dysfunction
or antihypertensive drug therapy
 Perioperative Fluid Requirements

The following factors must be taken into account:

1- Maintenance fluid requirements
2- NPO and other deficits: NG suction, bowel
preparation
3- Third space and invisible losses
4- Replacement of blood loss
5- Special additional losses: diarrhea
1- Maintenance Fluid Requirements
• Insensible losses such as evaporation of water
from respiratory tract, sweat, feces, urinary
excretion. Occurs continually.
• Adults: approximately 1.5 ml/kg/hour

• “4-2-1 Rule” applies to children

- 4 ml/kg/hr for the first 10 kg of body weight
- 2 ml/kg/hr for the second 10 kg body weight
- 1 ml/kg/hr subsequent kg body weight
- Extra fluid for fever, tracheotomy, open wounds
 2- NPO and other deficits

• NPO deficit = number of hours NPO x

maintenance fluid requirement.
• Bowel prep may result in up to 1 L fluid loss.
• Measurable fluid losses, e.g. NG suctioning,
vomiting, ileostomy output, biliary fistula etc.
 3- Third Space & invisble Losses

• Isotonic transfer of ECF from functional body

fluid compartments to non-functional
compartments.
• Depends on location and duration of surgical
procedure, amount of tissue trauma, ambient
temperature, room ventilation.
 Replacing invisible Losses

• Superficial surgical trauma: 1-2 ml/kg/hr

• Minimal Surgical Trauma: 3-4 ml/kg/hr
- head and neck, hernia, knee surgery
• Moderate Surgical Trauma: 5-6 ml/kg/hr
- hysterectomy, chest surgery
• Severe surgical trauma: 8-10 ml/kg/hr (or more)
- AAA repair, nehprectomy
 4- Blood Loss

• Replace 3 cc of crystalloid solution per cc of

blood loss (crystalloid solutions leave the
intravascular space)
• When using blood products or colloids replace
blood loss volume per volume
 5- Other additional losses

• Ongoing fluid losses from other sites:

- gastric drainage
- ileostomy output
- diarrhea
• Replace volume per volume with crystalloid
solutions
 Example

• 62, male, 80 kg, for hemicolectomy

• NPO after 10 PM, surgery at 8 AM,
• Received bowel preparation
• 3 hours long procedure with blood loss of 500 ml
• What is his estimated intraoperative fluid
requirement?
 Fluid requirement of this patient

• Fluid deficit (NPO): 1.5 ml/kg/hr x 10 hrs = 1200 ml +

1000 ml for bowel preparation = 2200 ml is total deficit:
(Replace 1/2 first hour, 1/4 2nd hour, 1/4 3rd hour).
• Maintenance: 1.5 ml/kg/hr x 3hrs = 360mls
• invisible Losses: 6 ml/kg/hour x 3 hours =1440 ml
• Blood Loss: 500ml x 3 = 1500ml
• Total = 2200+360+1440+1500=5500mls
 Intravenous Fluids:

• Conventional Crystalloids
• Colloids
• Hypertonic Solutions
• Blood/blood products and blood substitutes
 Crystalloids

• Combination of water and electrolytes

- Balanced salt solution: electrolyte composition and
osmolality similar to plasma; example: lactated Ringer

- Hypotonic salt solution: electrolyte composition lower

than that of plasma; example: D5W.

- Hypertonic salt solution: 2.7% NaCl.

 Crystalloids in trauma
Advantages:
-Balanced electrolyte solution

-Easy to administer

-No risk of adverse reactions

-No disturbance of hemostasis

-Promote diuresis

-Inexpensive
 Crystalloids
Disadvantages:
-Poor plasma volume support

-Large quantities needed

-Reduced plasma oncotic pressure

-Risk of edema

Risk of hyprthermia
 Hypertonic Solutions
• Fluids containing sodium concentrations greater than
normal saline.

• Available in 1.8%, 2.7%, 3%, 5%, 7.5%, 10% solutions.

• Hyperosmolarity creates a gradient that draws water out

of cells; therefore, cellular dehydration is a potential
problem.
 Hypertonic saline

Advantages:
-Small volume for resuscitation.
-Osmotic effect
-Inotropic effect (increase calcium influx in sarculima)
-Direct vasodilator effect
-Increase renal, mesenteric, splanchnic, coronary blood
flow and arterial blood pressure
 Hypertonic saline

Disadvantages:
• increase hemorrhage from open vessels.
• Hypernatremia
• Hyperchloremia.
• Metabolic acidosis.
 Crystalloids
Lactated Ringer's

Composition: Na 130, cl 109, K 4, ca 3, Lactate 28,

Osmolarity 273 mosmol/l

-Sydney Ringer 1880

-Hartmann added Lactate=LR
-Minor advantage over NaCl
Disadvantages:
-Not to be used for dilution of blood (Ca citrate)
 Crystalloids
Dextrose 5%

Composition: 50 gm /liter, provides 170 kcal /liter

Disadvantages:
-enhance CO2 production
-enhance lactate production
 Composition
Fluid Osmo- Na Cl K
lality
D5W 253 0 0 0
0.9NS 308 154 154 0
LR 273 130 109 4.0
Plasma-lyte 294 140 98 5.0
Hespan 310 154 154 0
5% Albumin 308 145 145 0

3%Saline 1027 513 513 0

 Colloids

• Fluids containing molecules sufficiently large

enough to prevent transfer across capillary
membranes.
• Solutions stay in the space into which they are
infused.
• Examples: hetastarch (Hespan), albumin, dextran.
 Colloids

Advantages:
-Prolonged plasma volume support
-Moderate volume needed
-minimal risk of tissue edema
-enhances microvascular flow
 Colloids

Disadvantages:
Risk of volume overload
Adverse effect on haemostasis
Anaphylactic reaction
Expensive
 Crystalloids versus colloids

Charactor Crystalloids Colloids

In the vein Poor Good
Hemodynamics Transient Prolong
Infusion volume Large Moderate
Plasma COP Reduced Maintain
Tissue edema Obvious Insignificant
Anaphylaxis Non-exist low-mod
Cost Inexpensive Expensive
 Clinical Evaluation of Fluid
Replacement
1. Urine Output: at least 1.0 ml/kg/hour
2. Vital Signs: Blood pressure and heart rate
3. Physical Assessment: texture of skin and mucous
membranes; thirst in an awake patient
4. Invasive monitoring; CVP may be used as a guide
5. Laboratory tests: periodic monitoring of hemoglobin and
hematocrit
 Summary
• Fluid therapy is critically important during the
perioperative period.

• The most important goal is to maintain

hemodynamic stability and protect vital organs
from hypoperfusion (brain, heart, kidneys, liver.)

• All sources of fluid losses must be accounted for.

• Good fluid management goes a long way toward

preventing problems.
 Transfusion Therapy

- 60% of transfusions occur perioperatively.

- responsibility of transfusing perioperatively is with the
anesthesiologist.
 Blood Groups
Antigen on Plasma Incidence
Blood Group erythrocyte Antibodies White African-
Americans
A A Anti-B 40% 27%
B B Anti-A 11 20
AB AB None 4 4
O None Anti-A 45 49
Anti-B
Rh Rh 42 17
 Cross Match

• Major:
- Donor’s erythrocytes incubated with recipients plasma
• Agglutination:
- Is a sign of incompatibility
- Type Specific:
- Only ABO-Rh determined;
 Type and Screen

• Donated blood that has been tested for ABO/Rh

antigens and screened for common antibodies
(not mixed with recipient blood).
- Used when usage of blood is unlikely, but needs to be
available (hysterectomy).
- Chance of hemolytic reaction: 1:10,000.
 Blood Components

 Prepared from Whole blood collection

 Whole blood is separated by differential centrifugation
 Red Blood Cells (RBC’s)
 Platelets
 Plasma
 Cryoprecipitate
 Others include Plasma proteins— Coagulation
Factors, albumin, Growth Factors,
Transfusion Complications

 Acute Transfusion Reactions

 Chronic Transfusion Reactions
 Transfusion related infections
 Acute Transfusion Reactions

 Hemolytic Reactions (AHTR)

 Febrile Reactions
 Allergic Reactions
 TRALI
 Coagulopathy with Massive transfusions
 Bacteremia
Complications of Blood Therapy
• Hemolytic:
- Wrong blood type administered (oops).
- Activation of complement system leads to intravascular
heamolysis, spontaneous hemorrhage.

Signs:
hypotension,
fever, chills
dyspnea, skin flushing,
substernal pain , Back/abdominal pain
Oliguria Dark urine Pallor
Complications of Blood Therapy

Signs are easily masked by general

anesthesia.
- Free Hemoglobin in plasma or urine
- Acute renal failure
- Disseminated Intravascular
Coagulation (DIC)
 Complications (cont.)

• Transmission of Viral Diseases:

- Hepatitis C; 1:30,000 per unit
- Hepatitis B; 1:200,000 per unit
- HIV; 1:450,000-1:600,000 per unit
- Parasitic and bacterial transmission very low
 What to do?
If an AHTR occurs

 STOP TRANSFUSION
 Maintain IV access and run IVF (NS or LR)
 Monitor and maintain BP/pulse
 Give diuretic, maintain urine output, fluid therapy
 Obtain blood and urine for transfusion reaction workup
 Send remaining blood back to Blood Bank
 Monitoring in AHTR

 Monitor patient clinical status and vital signs

 Monitor renal status (BUN, creatinine)
 Monitor coagulation status (DIC panel– PT/PTT,
fibrinogen, D-dimer/FDP, Platelets,
 Antithrombin-III)
 Monitor for signs of hemolysis
 Massive Blood Transfusion

 Massive transfusion is generally defined as the

need to transfuse one to two times the patient's
blood volume. For most adult patients, that is the
equivalent of 10–20 units
 Problems of massive transfusion

 Dilutional thrombocytopenia and coagulopathy

 Citrate toxicity
 Hypothermia
 Metobolic alkalosis
 Hyperkalemia ( stored blood )
 DIC
 How to avoid problems of
massive transfusion

 Use autologous blood transfusion

 Cell saver technology
 Substitute to blood

artificial blood ( perflurocarbons )

 Blood Substitutes

• Potential Advantages:
- No cross-match requirements
- Long-term shelf storage
- No blood-borne transmission
- Rapid restoration of oxygen delivery in traumatized
patients
- Easy access to product (available on ambulances, field
hospitals, hospital ships)