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Fluid Management 2015

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0% found this document useful (0 votes)
14 views58 pages

Fluid Management 2015

Uploaded by

Jaser Yamin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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FLUID

FLUID BALANCE
BALANCE
AND
AND
FLUID
FLUID MANAGEMENT
MANAGEMENT
Dr Abdallah Hawari,MD, MRCSI
General and minimally invasive Surgeon
Head of endoscopic surgery , Al-Makassed hospital , Al-Quds
‫بسم هللا الرحمن الرحيم‬

‫وجعلنا من‬ ‫(((‬ ‫‪‬‬


‫الماء كل شيئ‬
‫حي)))‬
FLUID COMPARTMENTS
FLUID COMPARTMENTS

Total body fluids


60% of BW

Extra cellular Extra cellular


Intracellular fluid
interstitial fluid intravascular fluid
40% of BW
15% of BW 5% of BW
FLUID BALANCE
 The extra cellular compartment is balanced
between the principle cations (Na) and the
principle anions Cl & HCO3.

 The intra cellular compartment is balanced


between the principle catios K & Mg and the
principle anions protein & phosphate.

 The concentration gradient between the


compartments is maintained by ATP driven Na-K
pump that located in the cell wall
• The plasma protein maintain the
water balance across the capillary
endothelium.
• Water is distributed eventually
through out all fluid compartments of
the body.
 Sodium confined to the EC compartment ,
and because of its osmotic & electrical
properties , it remain associated with
water, therefore Na-containing fluid are
distributed through out the EC and add
volume to both IS & IV volume . So given
Na-containing I.V fluid will expand both IV
& IS ( by approximately 3 times as much
as plasma.
OSMOTIC PRESURE
NORMAL BODY FLUID CHANGES
 The normal daily fluid out put is as follow:
 1500 ml urine
 900 ml insensible loss (skin & lungs)
 100-250 ml in stool

 The insensible loss increase by (fever,


hyper metabolic state, hyperventilation,
treacheostomy )
NB :
INSENSIBLE LOSS through both
the respiratory system & the skin
sweating is hypotonic fluid , that need
to be replaced by water only .
VOLUME CONTROL
 The main mechanisms are mainly the
osmorceptors & the baroreceptors
o Osmoreceptors :
are specialized R. which
induced thirst sensation to increase fluid
intake , and by the hypothalamus to
produce vasopressin that increase the
fluid reabsorption by the kidney .
o Baroreceptors :
specialized receptors
found in carotid sinuses & aortic arch
which produce
1-neural (sympath. & parasympath.)
2-hormonal ( renine –angiotensin-
aldosterone, atrial natriureic P. , renal
PG )
BODY FLUID REQUIRMENTS

 The human need daily amount of fluid to


maintain urine out put to excrete the
salts load , which is generally equal to
0.5-1 ml/kg/hr.
 If the patient is fasting, still he is in need
for the fluid to maintain the physiological
& biological processes , which is called
the maintenance fluid.
 Body fluid requirements =
{ maintenance + deficit }

Maintenance calculated as follow :


 First 10kg 100 ml / kg

 Second 10kg 50ml / kg

 >20kg20ml / kg
e.g:
Young patient weighted 70kg needs fluid as
follow :

(10*100) +(10*50)+(50*20)
1000 + 500 + 1000 = 2500ml
HOW TO CHOSE THE TYPE OF
FLUID
• The amount of fluid estimated as
mentioned
• To chose the type of fluid, this depend on
the body requirements of sodium and
energy.
• The daily sodium requirement is 2-3
meq/kg/day.
• If the 70kg man need 2500 ml , what is the
fluid type .
70*3=210 meq
Each 1 liter of NS contain 154 , so the
patient need nearly 1,5 L.
The rest of the fluid is chosen as free
water ( dextrose 5%), to avoid sodium
over load.
 Patient with dehydration has
Hypovolemia.
 This dehydration due to fluid loss that
associated with other electrolyte
abnormality and acid-base disturbances
that need correction.
 The correction need to be rapid given as
expansion , if no limitation.
FLUID ADEQUACY
TYPES OF FLUID
 COLLOID:
 Blood & blood products
 Albumin
 Dextran
 Starch
 Glycerin
• CRYSTALOID:
 Normal saline 0.9%, contain 154 meq Na/L & 154
meq Cl/L
 Ringer lactat , contain 130 meq Na/L, 109 meq
Cl/L, 28 meq lactat/L.
 M/6 sodium lactat , contain 167 meq Na, & 167
meq Cl
 3% sodium chloride, contain , 513 meq Na, 513
meq Cl.
 Dextrose saline , contain NS+ 50 gm glucose /L.
 0.45% dextrose saline, contain 77 meq
Na/L , 77 meq Cl/L +50 gm glucose /L.
 5% dextrose water
 10% dextrose water
 20% dextrose water
 50% dextrose water
Electrolytes care
 Potassium
 Chloride
 Magnesium
 Calcium
 Phosphorus
 Trace elements
 Trace Metal
1. Zinc 10-20 mg
2. Copper 0.5-2.0 mg
3. Chromium 20 μg
4. Selenium 70-150 μg
5. Manganese 2-2.5 mg
6. Iron 25 mg
SHOCK
 Definition :
Tissue hypo perfusion that is
in sufficient to maintain normal aerobic
metabolism
MICRCIRCULATION
CHANGES

 Shock induce profound changes in tissue


microcirculation that are thought to
contribute to organ function, organ
dysfunction , and the systemic
consequences of sever shock.
What happen after fluid loss ?

 Sympathetic activity produce larger


arterioles vasoconstriction, but the distal
smaller arterioles dilate presumably due to
local mechanism.
 There is decrease in the capillary
perfusion and decrease in blood flow
that result in decrease the capillary
hydrostatic pressure , that will
promote the fluid influx to the
intravascular space from IS space to
increase the circulatory circulation.
• By the time, at the small capillary level,
wither the shock is due to Hge or septic
shock , capillary occlusion occur due to:
1-endothelial cell swelling.
2-neutrophile slugging & adherence.

This will prevent the capillary perfusion


 Endothelial swelling occur due to:
 Cellular hypoxia
 Continuo's pro-inflammatory mediators stimulation
that released by the adherent neutrophile.

As the time passed with out intervention this will lead to


prevent reperfusion even with adequate resuscitation ,
which is the irreversible shock stat.
CELLUAR EFFECT
 NORMAL cellular activity need O2.
 In shock due to hypo perfusion this lead to
inadequate O2 delivery.
 Inadequate O2 mitochondrial respiration
sever impartment { term called dysoxia }
 The cell activity become anaerobic, and
this lead to lactic acid accumulation .
Intracellular acidosis
cause
I. Alter the cellular enzyme activity
II. Alter gene expression
III. Impair metabolic pathway
IV. Impair cell ions exchange
V. Change cellular Ca activity , that
impair the cell signalling for specific
enzyme activity
 The Na, K movement through the
cell wall is controlled by the Na-k
ATPase, which is an active process
that need energy.
 It make efflux of 3 Na and influx of
2K.
 In case of cellular dysoxia, as there
is inadequate energy this lead to
intracellular accumulation of Na.
 Water will follow the sodium in to
inside the cell, that lead to cell
swelling .

 By the time this will to cell wall rupture


and lysosoms leak  lead to cell
death by necrosis.
Over all as there is fluid loss and fluid
sequestration to cellular space, this will
lead to intravascular and interstitial
volume depletion.
So during resuscitation, it is mandatory to
replace both the IV & IS deficit.
As the colloid remained in IV space only,
and it increase the fluid influx by oncotic &
the osmotic effect, it increase the IS
deficit.
Cellular uptake 

ECS

Transcapillary influx
 To chose suitable fluid you need fluid
that compensate both the IV & IS
deficit.

 The best fluid to be use is crystalloid.


 The blood transfusion in surgical patient
categorized in to the following:

i. Acute loss due to trauma .


ii. Acute loss during surgery.
iii.The patient is anemic preoperatively.
Acute loss

 All type of trauma that lead to bleeding


wither overt or covert bleeding, the signs
and symptoms depend on the amount of
blood loss. The evaluation of the patient
will reflect the amount of loss.
 Over all the amount of loss need
replacement by fluid, the type of fluid
chosen regarding the patient condition.
Physiological changes in HGE
% Blood loss <15 15-30 30-40 40>

Blood loss 750< 750-1500 1500-2000 2000>

HR N 100> 120> 140>

BP N N SBP SBP SBP


DBP DBP DBP
RR N

UO N OLIGURIA ANURIA

Mental state MINIMAL MILD ANXIATY CONFUSION LETHERGY


ANXIATY
CLASS I II III IV
 The blood transfused to the patient from
anther person after preparation and full
investigation of the blood, then cross
match done between the patient serum
and the donor RBC.
 This type of blood called homologous
transfusion.
Alternatives to homologous blood
transfusion
I. Infection
II. Immune reaction:
1. Acute hemolytic reaction
2. Delayed hemolytic transfusion reaction
3. Nonhemolytic immune transfusion reaction
4. Noncardiogenic pulmonary edema
5. GVHD
III. Volume over load
IV. Massive transfusion
Massive transfusion
THANK
YOU
Dr
DrAbdallah
AbdallahHawari
Hawari

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