fluid.pptx

BASICS OF FLUID THERAPY
Prepared By-
Dr. Ajay Gangwar
3rd year Junior resident
Deptt. Of General Surgery
GSVM Medical College, Kanpur
11-Sep-19
Dr Ajay Gangwar GSVM medical college
Kanpur
1

ACKNOWLEDGEMENT
• Prof (Dr) Sanjay Kala (MS) – (HOD) - for providing me opportunity &
motivation to make this presentation
• Prof (Dr) RK Tripathi (MS, MCh-pediatric surgery) – for reviewing
Fluid therapy in pediatric age group
• Dr Nishant Saxena (MS) – Assistant professor – for his valuable
advise for betterment of presentation
• Dr Subhashini Singh – JR3 OBG - my wife & reviewer of each slide
• Dr Arij Javed – JR3 pediatrics - for Fluid therapy in pediatric age
group

CONTENT
• BASIC PHYSIOLOGY
• FLUID THERAPY- GENERAL
• TYPES OF FLUIDS
• FLUID THERAPY- PEDIATRIC AGE GROUP
• FLUID THERAPY- IN SPECIFIC CONDITIONS
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BASIC PHYSIOLOGY
1st of all let us see distribution of fluids in body-
Total Body Fluid can be divided into Intracellular and Extracellular
TOTAL BODY WATER
(60% OF BODY WEIGHT)
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I.C.F. E.C.F.
40% OF BODY WEIGHT 20% OF BODY WEIGHT
2/3rd OF BODY WATER
-19 Dr Ajay Gangwar GS
1/3rd OF BODY WATER
VM medical college
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PLASMA
5%
INTERSTITIAL
FLUID 15%
INTRACELLULAR FLUID 40%
E.C.F.
1/3rd
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I.C.F.
2/3rd
3rd SPACE (MINIMAL)

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FLUID TYPE TOTAL ICF ECF interstitial Plasma
% OF BODY
WEIGHT
60% 40% 20% 15% 5%
VOLLUME
(for 70 kg
weight)
42 Liter 28 Liter 14 Liter 10.5 Liter 3.5 Liter

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Intracellular Fluid
• 2/3rd of the total body water.
• Found inside the plasma membrane of the body's
cells.
• In humans (average weight 70 KG), about 28 liters.

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Extracellular Fluid
Accounts for 1/3rd of the TBW, either:
Interstitial, Intravascular and 3rd space
1- Interstitial compartment
• small, narrow spaces between tissues or parts of an organ.
• filled with what is called interstitial fluid
• When excessive fluid accumulates in the interstitial space,
edema develops.
• In the average male (70 kg), interstitial space has
approximately 10.5 liters of fluid ( 15% of the TBW)
Importance:
acts as the microenvironment that allows movement of
ions, proteins and nutrients across the cell barrier.

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Extracellular Fluid
2-Intravascular compartment
• Main intravascular fluid in humans is blood.
• Average volume of blood (plasma + cells) in humans is approximately 70-
75 ml/kg (approx. 5 liter in young adult male) (7-8% of body weight)
• Plasma is about 3.5 liter (5% of body weight)
3- Third space
• Third space is space in the body, where fluid does not normally collect
in larger amounts.
• e.g., the peritoneal cavity and pleural cavity are major examples of
the third space.
• Small amount of fluid does exist normally in such spaces, and

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WATER
• Body's primary fluid
• Essential for proper organ system functioning and
survival.
• People can live several days or even weeks without
food, but they cannot survive only a few days
without water .

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WATER
Water has many functions in the body-
• Essential for Cell life .
• Interfere in the Chemical and metabolic reactions.
• Nutrients absorption and transport .
• Regulate the Body temperature .
• Elimination of waste products through urine .

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How much of you is water?
Muscle mass is rich in water.
Adipose Tissue has a lower percentage of water content.
That’s why:
• Obese people- lower percentage of water compared to lean and muscular
people.
• Women- lower percentage of water than men, due to a higher percentage
of body fat.
• Older adults- lower concentration of water, due to an age-related decrease
in muscle mass.
• Children- higher percentage of water- as much as 70-80% in a full-term
neonate.
Total Body Water (TBW), Accounts For-
 Approximately 60% Of Total Body Weight In An Young Adult Male
 About 50% In An Young Adult Female.
 About 80% In New Born Infant.

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NORMAL WATER BALANCE
• Insensible fluid loss = 500 ml through skin
400 ml through lung
100 ml through stool
• Insensible fluid input = 300 ml water due to oxidation
Normal daily insensible fluid loss = fluid loss - fluid
input = 1000 – 300 = 700 ml
So, daily fluid requirement = urine output + 700 ml

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Water Requirements Increase With:
• Fever
• Sweating
• Burns
• Tachypnea
• Surgical Drains
• Polyuria
• Gastrointestinal Losses Through Vomiting Or
Diarrhea
Water Requirements Increase By 100 To 150 ml/Day
For Each Degree Of Body Temperature Elevation.

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ELECTROLYTE CONCENTRATION OF BODY FLUIDS
ELECTROLYTES (mEq/L) ECF ICF
SODIUM 142 10
POTASSIUM 4.30 150
CHLORIDE 104 2
BICARBONATE 24 6
CALCIUM 5 0.01

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FLUID THERAPY
• Oral route is always preferred over IV route.
• Can be life-saving in certain conditions.
• Loss of body water, whether acute or chronic,
can cause a range of problems from mild
headache to convulsions, coma, and in some
cases, death.
• Though fluid therapy can be a lifesaver, it's
never always safe, and can be very harmful.

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FOR PROPER FLUID THERAPY, IT IS NECESSARY TO KNOW
• Etiology of fluid deficit and type of electrolyte imbalance
present
• Associated illness ( i.e. DM, HTN, IHD, RHD, renal or
hepatic disorders, etc.)
• Clinical status ( Hydration, vital data, urine output, etc.)

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BASIC PRINCIPLE OF IV FLUID THERAPY
ADVANTAGE-
• Accurate, Controlled & Predictable Way Of
Administration
• Immediate Response
• Prompt Correction Of Serious Fluid And
Electrolyte Disorder

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INDICATIONS-
• Conditions When Oral Intake Is Not Possible- Coma,
Anesthesia, Surgery
• Severe Vomiting & Diarrhoea
• Moderate To Severe Dehydration & Shock- Urgent Fluid
Replacement Needed
• Severe Hypoglycemia- 25% Dextrose Is Life Saving
• Vehicles For Several Medications- Antibiotics,
Chemotherapeutics Agent, Insulin, Vasopressor Agents
• Total Parenteral Nutrition
• Treatment Of Critical Problems- Shock, Anaphylaxis,
Severe Asthma, Cardiac Arrest, And Forced Diuresis In
Drug Overdose, Poisoning, Urinary Stone

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Disadvantage-
• More Expensive
• Needs Strict Asepsis
• Possible Only In Hospitalized Patient Under
Skilled Supervision
• Improper Selection Of Type Of Fluid Can Lead To
Serious Problems
• Improper Volume & Rate Of Infusion Of Fluid Can
Be Life Threatening
• Improper Technique Of Administration Can Lead
To Complications

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Contraindications-
• Should Be Avoided, If Patient Is Able To Take Oral
Fluid
• Preferable To Avoid IV Fluid In Patient With
Congestive Heart Failure Or Volume Overload
Complications-
• Local: Hematoma, Infiltration, And Infusion Phlebitis
• Systemic: Circulation Overload, Rigors, Air Embolism,
Septicemia
• Other: Fluid Contamination, Fungus In IV Fluids,
Mixing Of Incompatible Drugs, Improper Technique
Of Infusion, IV Set Or IV Catheter Related Problems

Methods of delivering IV fluids
• Conventional IV drip set
• Conventional IV micro drip set
• Infusion pumps
• IV sets with calibrated chambers
More precise &
controlled delivery
but expensive
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Methods to calculate rate of fluid
infusion by Routine IV drip set
Calculation for routine IV drip set-
15 drops = 1 ml
Rule of ten:-
IV fluid in Litre/24 hours x 10 = Drops rate/minute
2 litre fluid in 24 hrs x 10 = 2 x 10 = 20 drops/ minute
3.5 litre fluid in 24 hrs x 10 = 3.5 x 10 = 35 drops/ minute
Drop rate per minute 10 = IV fluid in liter/ 24 hrs
15 drops/minute = 15/10 = 1.5 litre/24 hours
20 drops/minute = 20/10 = 2 litre/24 hours
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infusion by Routine IV drip set
Rule of four:-
Volume in ml/hour 4 = drop rate/minute
60 ml/hour = 60/4 = 15 drops/minute
200 ml/hour = 200/4 = 50 drops/minute
Drop rate/minute x 4 = volume in ml/hour
10 drops/minute = 10x 4 = 40 ml/hour
80 drops/ minute = 80 x4 = 320 ml/hour
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infusion by Routine micro IV drip set
1 ml = 60 drops
micro drop/minute = volume in ml/hour
35 micro drops/minute = 35 ml/hour
50 micro drops/minute = 50 ml/hour
Volume in ml/hour = drop rate/minute
30 ml/hour = 30 micro drops/ minute
45 ml/hour = 45 micro drops/ minute

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EVALUATION AND PRESCRIBING FLUID THERAPY
A. Clues From The History-
• GI Losses- Vomiting Or Gastric Outlet Obstruction,
Diarrhoea
• Burns
• Sweating, If Excessive
• Diuretic Therapy
• Past H/O Renal, Cardiac, Hepatic Or Respiratory
Diseases

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B. Clinical Sign & Symptoms
• Excessive Thirst With Dry Tongue, Decrease Skin Turgidity,
Restlessness, Cold Clammy Extremities Reflects
Hypovolemia.
• BP & Pulse- Postural Hypotension And Tachycardia Are
Earliest Sign Of Decreased Intravascular Volume
• Urine Output Per Hour- Reflects Tissue Perfusion
• Oedema, Basal Rales & Weight Gain- Indicates Water
Retention
• Jugular Veins, Central Venous Pressure And Pulmonary
Capillary Wedge Pressure- Very Important Parameters To
Assess Volume Status And To administer IV Fluids Safely &
Adequately In Critical Patients

C. Useful investigations
Blood investigations:
 CBC & hematocrit
 S. Sodium
 Blood urea, S. Creatinine
 S. Protein
 Blood sugar
 In some- ABG, plasma osmolality, plasma vasopressine
(ADH) test
Urine tests:
 Urine specific gravity & osmolality and spot urinary sodium
Other investigations:
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Normal fluid & electrolyte requirement
• Water requirement
= measurable loss (intestinal + kidney) + 700 ml
= 20 to 40 ml/kg/day
= first 10 kg : 100 ml/kg/day or 4 ml/kg/day
10-20 kg : 50 ml/kg/day or 2 ml/kg/day
for rest weight : 20 ml/kg/day or 1 ml/kg/day
Sodium requirement= 100 (60-150) mEq/day or 6 gm NaCl/day
Potassium requirement= 40-60 mEq/day or 1.5 gm KCl/day
Glucose = 100 gm/day

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To provide adequate fluid, sodium, potassium and
glucose to the patient on parenteral fluid therapy, we
need to give-
i. 5% dextrose 2 litre + 500 ml isotonic saline with
5ml inj. KCl 15% in each 500 ml fluid
( 2.5 litre water, 78 mEq Na, 50 mEq K, 100gms glucose)
ii. 1.5 litre isolyte-M + 1 litre 5% dextrose
( 2.5 litre water, 60 mEq Na, 52.5 mEq K, 125 gms glucose)

FLUID THERAPY IN SURGICAL PATIENTS
11-Sep-19
In Surgical patients multiple factors modify the normal
physiology of fluid and electrolyte balance of body
1. Acute stress- physical and mental stress which
occur during and after surgery increased
sympathetic activity tachycardia, vasoconstriction
and stress.
2. In surgical patients Secretion of ACTH increased.
ACTH stimulate adrenal glands to secrete-
(a) increase amount of Hydrocortisone to fight with
acute stress
(b) Aldosterone lead to increase sodium retention and
urinary loss of Po
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3. Post operative Pain and Stress
increase ADH in first 2-3 post op day
water retention,
which can lead to decrease in urinary output to as low as
500ml in 1st post op day.
4. Fluid deficit, due to preoperative oral fluid restriction
(NPO), needs consideration and replacement pre- or
intraoperatively.
5. Abnormal blood as well as fluid loss which occurs before,
during and after various surgery needs proper attention and
careful calculation
6. Patient who is hypovolemic prior to surgery, is very likely to
become Hypotensive during Surgery and anesthesia. So
11-Sep-19Hypovolemia shoD
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Discussed in three Headings
1. Preoperative
2. Intraoperative
3. Postoperative

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PREOPERATIVE FLUID THERAPY
a) Correction of Hypovolemia
b) Correction of anemia
c) Correction of other disorders
HYPOVOLEMIA
• Hypovolemia decrease oxygen transport and increase
risk of tissue hypoxia which lead to organ failure
• Hypovolemia compensated by increase vascular
resistance and heart rate .
• On induction of Anesthesia these compensation are
interrupted and patient develop severe hypotension
or even ARF

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Cause of Preoperative fluid loss-
• Vomiting
• Nasogastric suction
• Bowel preparation
• Diuretic Therapy

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Third Space Loss
Internal redistribution Of ECF due to sequestration
of fluid in body is called third space loss.
Cause-
• Massive ascites
• Acute intestinal obstruction
• Pleural effusion
• Acute pancreatitis
• Acute peritonitis

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Severity of Hypovolemia
Mild(< 2ltr)
• Thirst
• Concentrated
urine
Moderate(2-3ltr)
• Dizziness
• Weakness
• Oliguria
• Postural
hypotension
• + Mild
Severe(>3 litr)
• Confusion
• Stupor
• Systolic BP <
100mm hg
• Tachycardia
• Cold extremites
• Reduce skin
turgor
• + Moderate

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Optimal Rate of Fluid Replacement in
Hypovolemia
Effective Rate of Fluid Replacement per hour
= 50 to 100ml
+ Urine output per hour
+ Ongoing Loss ( such as Diarrhea
or tube drain)

Monitoring Fluid Therapy
Parameters suggest correction of Hypovolemia
• Weight – Regaining weight loss due to fluid loss
• Skin and tongue – Cold clammy extremities, dry tongue,
decrease skin turgidity will change to warn extremities,
moist tongue and normal elasticity of skin.
• Pulse Rate- correction of tachycardia to PR less than 110/min
in young adults.
• Blood Pressure – Patient with shock, hypotension become
normotensive
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Monitoring Fluid Therapy
• Urine output  >30-50 ml/hr in adult or 0.5 to 1 ml/kg/hr in
children in absence of osmotic diuresis or glycosuria
• Blood Urea Creatinine – Both will become normal. High ratio
(>20:1) of Blood urea : creatinine will become normal (10:1)
• Metabolic acidosis- improvement of acidosis with improvement of
peripheral perfusion
• CVP or PAWP – CVP or PAWP will become normal with adequate
fluid replacement
• Sensorium - improvement of anxiety and restlessness

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CENTRAL VENOUS PRESSURE
MONITORING
Direct measurement of blood pressure in right atrium and vena cava
Indication-
• Assess right ventricular function
• Systemic fluid status
• Rapid infusion
• Serious blood assessment
• Shock, Cardiac or critically ill patients in ICU
Common Location Internal Jugular , subclavian vein.
The Tip of Catheter is rest in lower third of superior vena cava.
Normal CVP is 2 -14(6-10) cm of water

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CVP is elevated in (>14 cm of water)-
• Overhydration
• Cardiac cause like congestive heart failure, cardiac temponade,
constrictive pericarditis and tricuspid regurgitation
• Pulmonary cause like embolism, tension pneumothorax , COPD,
Cor Pulmonale and Intermittent positive pressure ventilation (IPPV)
CVP decrease with-
• True Hypovolemia, as in blood loss and dehydration
• Relative Hypovolemia, cause by Peripheral vasodilation as in spinal
anesthesia and anaphylactic shock

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Pulmonary Capillary Wedge Pressure
• PCWP is measured by inserting baloon-tipped,
multi lumen catheter (Swan-Ganz Catheter)
into a peripheral vein.
• Normal = 2-15 mmHg
• PAWP- the most accurate reflection of left
atrial pressure / left ventricular end-Diastolic
pressure (LVEDP), or Preload.

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Indication of PAWP-
1. In critically ill, haemodynamically unstable patients.
2. In elderly patients or in patients with history of ischemic heart disease
requiring massive fluid replacement e.g. severe dehydration , shock ,
burns etc.
3. In ARDS, for control optimum fluid delivery.
NOTE - CVP can be high in hypovolemic patients due to right ventricular
failure, pulmonary hypertension or patient taking mechanical
ventilation.
In all these condition PAWP is low in Hypovolemic patient.
So, PAWP is better guide for fluid replacement

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Rough guide line for hypovolemia
A. Mild Dehydration – 4% body weight fluid deficit
B. Moderate Dehydration – 6-8% body weight fluid
deficit
C.Severe Dehydration – 10% body weight fluid deficit (
for ex in severe dehydration in 50kg patient = 50×10 =
5 litre fluid deficit)

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Correction Of Anemia
• To establish haemodynamic stability
• For proper tissue oxygenation
• Proper post operative recovery and healing
When to correct Anemia
In case of elective surgery correction of anemia by blood
transfusion should be done 48 to 72 hrs prior to surgery

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Correction of other factors
• Fluid overload – occur due to over aggressive fluid therapy or
returning of fluid collected in third space into ECF
compartment
correct by Diuretics, salt restriction and fluid restriction.
• Hypokalemia – due to GI losses ( vomiting , nasogastric
aspiration ), potassium free iv fluid or metabolic alkalosis
( cause renal excretion and intracellular shift of potassium)
• Hyperkalemia – mainly due to surgical stress acidosis and
catabolic state lead to hyperkalemia

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INTRAOPERATIVE FLUID THERAPY
Proper fluid therapy will avoid hypovolemia and hypotension.
It also maintain proper tissue perfusion and oxygenation.
Cause of intraoperative fluid loss-
• Loss of blood
• Fluid depletion
• Third space loss
• Vasodilatory effect of anesthetic agent
• Evaporative loss from viscera

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Guideline for Calculation-
There is no fixed ready formula which can calculate fluid volume
in all patients.
In adult patients with no pre-existing Fluid deficit, amount of
intra operative volume can be roughly calculated as below-
1. Correction of fluid deficit due to starvation
2. Maintenance requirement for period of surgery
3. Loss due to tissue dissection or haemorrhage
plus
plus

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Guideline for Calculation-
1. Volume to be replaced for starvation fluid deficit = duration
of starvation (hrs) × 2ml/kg body weight
the deficit is usually replaced by giving half of calculated
volume in 1st hr and half over next 2 hrs in addition to intra
operative fluid replacement
2. Maintenance volume for intra operative period = duration
of surgery (hrs) × 2ml/kg body weight
3. Loss due to tissue dissection or haemorrhage depend on
type of surgery

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Fluid Loss in different type of surgery
Type of surgery Fluid volume (ml/kg/hr)
a. LEAST TRAUMA NIL
b. MINIMAL TRAUMA 4
c. MODERATE TRAUMA 6
d. SEVERE TRAUMA 10

Fluid Loss in different type of surgery
a. Least trauma – surgery with least trauma , there is
minimal loss of blood or fluid include ophthalmic surgery ,
cystoscopy = (Nil)
b. Minimal trauma – surgery with minimal tissue include
tonsillectomy, nasal repair and plastic operation. =
(4ml/kg/hr)
c. Moderate trauma – surgery with moderate tissue trauma
include hernia repair, appendicectomy, procedure on
extremeties, thoracotomy, etc = (6ml/kg/hr)
d. Severe surgical trauma – bowel resection for intestinal
obstruction , radical mastectomy, radical neck dissection =
(10ml/kg/hr)
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Calculation
If 40 yrs male weighing 50 kg NPO for 10 hrs need to be subjected for appendicectomy (
duration of surgery 1hr) calculate how much fluid to be given
Total fluid required-
1. Correction of starvation deficit = duration of starvation in hr × 2ml/kg
= 10×2×50
= 1000 ml
2. Maintenance need during operative period
= duration of surgery in hr × 2ml/kg
= 1×2×50
= 100 ml
3. Correction of operative loss
Appendicectomy involves moderate surgical trauma
= 6ml/kg/hr
= 6×50×1
= 300 ml
So total intra operative fluid requirement = 1+2+3
= 1000ml + 100ml + 300ml = 1400ml

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BLOOD TRANSFUSION
• It is the most physiological way to replace blood loss.
• It is best agent to correct hypotension secondary to blood loss
• To ensure adequate tissue oxygen delivery
How to estimate intraoperative blood loss-
a) a simple way to estimate blood loss during a surgical
operation is to weigh the sponges before and after the use
b) The difference in gram is equivalent to the volume of blood
in ml
c) Add to this the volume of blood in the operating room
suction bottle

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Factor to be considered for intraoperative blood
transfusion
A. Preoperative hemoglobin or hematocrit –
In normal adult patient oxygen carrying capacity is unaffected till Hb
is as low as 8 gm/dl and hematocrit 25%, provided there is no
hypovolemia.
Therefore, patient with normal Hb and hematocrit can tolerate blood
loss well, but preoperatively anemic patient needs blood transfusion.
B. Percentage loss of blood volume –
Total blood volume in body varies according to body weight (Total
blood volume is 90ml/kg in new born, 80ml/kg in infant , 70ml/kg in
child and adult male and 65ml/kg in adult female).

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For example : loss of 500 ml in 70 kg body weight in adult male ( where
total blood volume in ml = 70 x wt = 70 x 70 = 4900 ml) is the loss less
than 10% of the total volume which is not a significant loss and may
not require blood transfusion.
But 500 ml blood loss in a 20 kg boy with total blood volume of 1400
ml ( 70 x 20 kg = 1400 ml) is roughly 30 % of the total blood volume
which can be life threatening, if not treated timely with blood
transfusion.
C. Others factors
• Vital data – emergency surgery in hypotensive patient needs blood
transfusion even with lesser blood loss.
• Hydration status- patient with uncorrected hypovolemia
preoperatively needs blood transfusions with lesser loss.
• Age - patient with IHD needs greater Hb for proper oxygenation.
• Young adult tolerate blood loss better than old people.

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How to estimate newer/subsequent Hb status
after intra operative blood loss
Hb status after blood loss is calculated by 3 steps-
Step 1 : To convert volume of blood lost into loss as % of preoperative Hb
% reduction of Hb = 1.25 × volume of blood loss
weight
Step 2 : To covert % reduction of Hb into reduction of Hb in gm/dl
Reduction of Hb in gm/dl = preoperative Hb × % reduction of Hb
100
Step 3: Pre operative Hb (gm/dl) – reduction of Hb gm/dl

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= 11.2 gms/dl
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For example
If patient with 50 kg weight with 14 gm/dl preoperative Hb , losses 800ml of
the blood. What will be subsequent Hb status?
Step 1
% reduction of Hb = 1.25 × volume of blood loss
weight
= 1.25× 800 = 20%
50
Step 2
Reduction of Hb in gm/dl = preoperative Hb × % reduction of Hb
100
= 14× 20
100
Step 3 Hb status after blood loss
= 2.8 gms/dl
= pre operative Hb gm/dl – reduction of Hb in gm/dl
= 14 - 2.8

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When to give blood transfusion intraoperatively?
• Blood loss > 20% of blood volume.
• Replacement of blood loss between 10% and 20% of total
volume is a matter of clinical discretion ( if Hb after blood
loss is less than 10 gm/dl, so blood transfusion need).
• In adult, when intraoperative blood loss is 500 ml to 1000
ml usually single unit of blood require.
• Blood transfusion is necessary, if Hb fall below 8gm/dl.

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Maximum allowable blood Loss
• Amount of blood loss which do not require blood transfusion is Maximun
allowable blood loss
MABL = starting pt hct – 25 × estimated blood volume
starting pt hct
• Ex : In a adult male with 60 kg weight and 35% hematocrit what is
maximum allowable blood loss
• MABL = (35 – 25) ×60×70 = 1200ml
35
so if more than 1200ml blood is loss then transfusion require

Post Operative Fluid Therapy
• Depends upon the clinical judgment of the patient’s status.
• No formula is perfect in planning fluid therapy in postoperative
period.
• Aim of therapy to maintain-
 blood pressure (>100/70mm Hg)
 pulse rate <120/min
 urine output between 30 to 50 ml/hour
 along with normal temperature , warm skin, normal respiration , sensorium.
Cause of Hypovolemia in postoperative period-
• Blood loss
• Fluid loss
• Third space loss
• Delay in operation due to long OT list
• Vomiting
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Post Operative Fluid Therapy
• Depends upon-
type of surgery – minor or major
nature of surgery -- surgery on limbs, abdominal
surgery, etc
• Short operative procedure and, who do not require
handling of intestine or viscera with little morbidity
will require only maintenance I.V. fluid to correct for
the NPO state. After 4-5 hrs oral fluids is restarted
and I.V. fluid is not needed like, hernia, minor
orthopedic operations on limbs, minor plastic
surgery.

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• Patients with major surgeries like intestinal
resection with anastomosis or total colectomy,
where intestinal viscera need rest requires
postoperative I.V. fluids for a few days. After
ensuring normal movement of intestine, oral fluid
intake is restarted.
•Where handling of intestine is not required I.V. fluid is
required for 24-48 hrs. e.g. cardiac surgery, coronary
bypass surgery, total hip replacement etc.

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Routine postoperative orders of I.V.
fluid for first three days
• First 24 hrs of surgery : 2 liters 5 %-dextrose or 1.5
liters 5 %- dextrose +500 ml isotonic saline.
• Second post operative day: 2 liters of 5%-dextrose
+ 1 liter 0.9% saline.
• Third post operative day: similar fluid + 40-60 mEq
potassium per day.
• Maintenance fluids should be administered at a
steady rate over an 18 to 24 hour period.

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11-Sep-19 67
Different types of
fluids

Types of Fluids
The fluids used in clinical practice are usefully
classified into colloids, crystalloids and blood
products
1. Colloid-
• Contains large molecules, that don't pass the cell
membranes
• When infused, they remain in the intravascular
compartment and expand the intravascular
volume and they draw fluid from extravascular
11-Sep-19
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Kanpur
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Types of Fluids
2. Crystalloid Solutions-
• contains small molecules
• flow easily across the cell membranes
• transfer from the bloodstream into the cells and
body tissues
• increases fluid volume in both the interstitial and
intravascular spaces (Extracellular)
• The principal component of crystalloid fluids is
sodium chloride
• Sodium is the principal determinant of extracellular
volume, and is distributed uniformly in the
extracellular fluid.

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11-Sep-19 70
Crystalloid Solutions
• as plasma volume is only 25% of the interstitial
fluid volume  only 25% of an infused
crystalloid fluid will expand the plasma volume
 while 75% of the infused volume will expand
the interstitial fluid.
• Thus, the predominant effect is only 25% of
transfused crystalloids remains in the
intravascular space
• 75% diffuses into interstitial space

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General characteristics of Crystalloid
• Contains water and electrolytes
• Non-ionic solutions expands all the
compartments; i.e. intracellular and extracellular
space
• Sodium cannot gain access into the intracellular
space. Hence all sodium will remain in the
extracellular space thus expanding it.

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Classification of IV fluids
Maintenance Fluid-
• Replaces Fluid Lost From Lungs, Skin, Urine And Feces.
• Should Be Hypotonic To Plasma Sodium.
• eg.- 5D, Dextrose With Half Isotonic Saline
Replacement Fluid-
• Formulated To Correct Body Fluid Deficit Caused By Losses
Such As Gastric Drainage, Vomiting, Diarrhoea, Fistula Drains,
Oozing From Trauma, Infection, Burns, etc.
• eg.- Isotonic Saline, DNS, RL, Isolyte-M, P,G
Special Fluid-
Used For Special Indications- Hypoglycemia, Hypokalemia And
Metabolic Acidosis
• eg.- 25%D, Inj. Sodium Bicarbonate, Inj Potassium Chloride

Kanpur
11-Sep-19 75
NORMAL SALINE
• One of the most commonly administered
crystalloids
Composition
• Na-154 meq/l
• Cl- 154 meq/l
• pH- 5.7
hence it affects the acid base balance of the
body

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11-Sep-19 76
NORMAL SALINE
Pharmacological basis
1. Provide major extracellular electrolytes.
2. Corrects both water and electrolyte deficit.
3. Increase the intravascular volume substantially.
Volume effects of NS
• Infusion of 1 liter of 0.9% NaCl adds-
 275 mL to the plasma volume and
 825 mL to the interstitial volume
•total increase in extracellular volume (1,100 mL) is slightly
greater than the infused volume. This is the result of a fluid
shift from the intracellular to extracellular fluid, which occurs
because 0.9% NaCl is slightly hypertonic in relation to
Extracellular fluid

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11-Sep-19 78
NORMAL SALINE
Acid-Base Effect
•Large-volume infusions of 0.9% NaCl produces
a metabolic acidosis
•Saline-induced metabolic acidosis is a
hyperchloremic acidosis, and is caused by the
high concentration of chloride in 0.9% saline
relative to plasma (154 versus 103 mEq/L)

Kanpur
11-Sep-19 79
NORMAL SALINE
Interstitial edema
Promote interstitial edema more than other
crystalloid fluids with a lower sodium content (e.g.
Ringer’s lactate, Plasma-Lyte) through
1. Increased sodium load from 0.9% NaCL, which
increases the “tonicity” of the interstitial fluid
2. Sodium retention by suppressing the renin-
angiotensin-aldosterone axis
3. Decreases in renal perfusion have also been
observed after infusion of 0.9% NaCl,
presumably as a result of chloride-mediated
renal vasoconstriction.

Kanpur
11-Sep-19 80
NORMAL SALINE
Indications
• To maintain effective blood volume and blood pressure in
emergencies
• Water and salt depletion – diarrhoea, vomiting, excessive
diuresis or excessive perspiration
• Hypovolemic shock- distributed in extracellular space
expanding the intravascular volume. Ideal fluid to increase
blood pressure.
• Preferred in case of brain injury, hypochloremic metabolic
alkalosis , hyponatremia
• Initial fluid therapy in DKA
• In patients with hyperkalemia like renal failure
• Fluid challenge in prerenal ARF
• Irrigation for washing of body fluids
• Vehicle for certain drugs

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11-Sep-19 81
NORMAL SALINE
Limitations/ Contraindications
• Avoid in Hypertension, Pre-eclamsia and in patient
with edema due to CCF, renal failure and cirrhosis
• In dehydration with severe hypokalaemia – deficit of
intracellular potassium – infusion of NS without
additional K+ supplementation can aggravate
electrolyte imbalance
• Large volumes or too rapid administration can cause
sodium accumulation and pulmonary edema.
• Increased chloride content in relation to plasma can
cause hyperchloremic metabolic acidosis in large
volume administration

RINGER LACTATE
Composition-
Ion concentration RL-
o Sodium – 131 meq/L
o Chloride – 111 meq/L
o Potassium – 5 meq/L
o Calcium – 2 meq/L
o Bicarbonate – 29 meq/L
Each 100 ml contains-
o sodium lactate - 320mg
o NaCl - 600mg
o KCl- 40mg
o CaCl- 27mg
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RINGER LACTATE
Advantage :
Lack of significant effect on acid base balance
Disadvantage:
•Presence of ionized calcium in ringer’s lactate  can
binds to citrated anticoagulant in stored blood 
promote formation of clots (clot formation does not
occur if the volume of Ringer’s solution does not exceed
50% of the volume of packed RBCs)
•In critically ill patients, with impaired lactate clearance
due to circulatory shock or hepatic insufficiency,
Ringer’s lactate infusion can increase serum lactate
levels

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11-Sep-19 84
RINGER LACTATE
• Ringer Lactate is the most physiological fluid,
as the electrolyte content is similar to that of
plasma Larger volumes can be infused
without the risk of electrolyte imbalance
• Due to high Na ( 130 mEq/L) content RL
rapidly expands intravascular volume effective
in treatment of hypovolemia
• Sodium Lactate in RL is metabolized to
bicarbonate in the liver  useful in correction
of metabolic acidosis

Kanpur
11-Sep-19 85
RINGER LACTATE
Indications :
• Volume Correction in severe hypovolemia
• Replacing fluid in post operative patients,
burns, fractures.
• Diarrhoea induced hypokalemic metabolic
acidosis and hypovolemia.
• Fluid of choice in diarrhoea induced
dehydration in pediatric patients.
• In DKA , provides glucose free water, correct
metabolic acidosis and supplies potassium
• Maintenance fluid during surgery

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11-Sep-19 86
RINGER LACTATE
Contraindications
• Severe liver disease, severe hypoxia , shock – impaired
lactate metabolism –lactic acidosis.
• Severe CHF - lactic acidosis takes place.
• Addison’s disease
• In vomiting or continuous nasogastric aspiration,
hypovolemia is associated with metabolic alkalosis - as
RL provides HCO3- Worsens alkalosis.
• Simultaneous infusion of RL and blood- inactivation of
anticoagulant by binding with calcium in RL – clots in
donor blood.
• Certain drugs – amphotericin, thiopental, ampicillin,
doxycycline should not be mixed with RL – calcium
binds with these drugs and reduces bioavailability and
efficiency

Kanpur
11-Sep-19 87
STEROFUNDIN ISO
Balanced crystalline sollution
COMPOSITION
• SODIUM
• POTASSIUM
• MAGNESIUM
• CALCIUM
• CHLORIDE
• ACETATE
• MALATE
145.0 mmol/L
4.0
1.0
2.5
127.0
24.0
5.0
• pH
• Osmolarity
5.1-5.9
309 mmol/L

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11-Sep-19 88
STEROFUNDIN ISO
Indications-
• Replacement of extracellular fluid losses in the cases of
Isotonic dehydration, where acidosis is present or
imminent.
Contraindication-
• Hypervolemia
• Severe CHF
• Renal failure with oliguria or anuria
• Severe general edema
• Hyperkalemia & hypercalcemia
• Metabolic alkalosis

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11-Sep-19 89
DEXTROSE SOLUTIONS
• D5 water (5%D)
• Dextrose with 0.9% NS ( DNS ).
• Dextrose with 0.45% NS (D 1/2NS )
• 10% dextrose
• 25% dextrose
EFFECT OF DEXTROSE IN FLUID :
*Protein sparing effects
*Volume effect
*Lactate production.
*Effect of hyperglycemia

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11-Sep-19 90
DEXTROSE SOLUTIONS
Protein sparing effect
• Earlier, it was used to provide calories in patients
who were unable to eat
• 50 grams of dextrose per liter provides 170 kcal
• Infusion of 3 liters of a D5 solution daily provides
3 x 170 = 510 kcal/day
which is enough non-protein calories to limit
the breakdown of endogenous proteins to
provide calories (i.e., protein-sparing effect)
• It is no longer used frequently as most patients
with long-term Nil by mouth have enteral tube
feedings or TPN

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11-Sep-19 91
DEXTROSE SOLUTIONS
Volume Effects-
5%D
• 50 gm of dextrose adds 278 mOsm/L to IV fluids
• Osmolality close to that of plasma
• However, dextrose is taken up by cells and
metabolized, this osmolality effect rapidly wanes, and
the added water then moves into cells.
• The infusion of one liter of 5D results in an increase in
ECF (plasma plus interstitial fluid) of about 350 mL,
which means the remaining 650 ml (two-thirds of the
infused volume) has moved intracellularly. Therefore,
the predominant effect of D5W is cellular swelling.

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11-Sep-19 92
DEXTROSE SOLUTIONS
Volume Effects-
DNS
• Total osmolality is 560 mOsm/L (278 of dextrose and
308 0f 0.9 NaCl) which is almost twice the normal
osmolality of the extracellular fluid
• If glucose utilization is impaired (as is common in
critically ill patients), large-volume infusions of D5W
can result in cellular dehydration

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11-Sep-19 93
DEXTROSE SOLUTIONS
Enhanced lactate production
•In healthy individuals, 5% of infused glucose is
directed towards lactate formation.
•In critically ill patients, 85% of glucose is
diverted to lactate production.
•when circulatory flow is compromised,
infusion of 5% dextrose solutions can result in
lactic acid production and significant elevations
of serum lactate

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11-Sep-19 94
DEXTROSE SOLUTIONS
Hyperglycemia
It has several deleterious effects in critically ill
patients including –
• immune suppression
• increased risk of infection
• aggravation of ischemic brain injury
Considering the high risk of hyperglycemia in
ICU patients, and the numerous adverse
consequences of hyperglycemia, infusion of
dextrose containing fluids should be avoided
whenever possible.

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11-Sep-19 95
5 % DEXTROSE
Composition : Glucose 50 gms/L + free water
Pharmacological Basis
• Corrects Dehydration And Supplies Energy ( 70kcal/L)
•Administered safely at the rate of 0.5gm/kg/hr without
causing glycosuria
Metabolism
• Dextrose is metabolised leaving free water distributed
in all compartments of the body.
• A proportion of dextrose load contributes to lactate
formation–
 5% in healthy subjects
 85% in critically ill patients hence not the preferred fluid.

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11-Sep-19 96
5 % DEXTROSE
Indications of 5%D
• Prevention and treatment of intracellular dehydration
• Cheapest fluid to provide adequate calories to body
• For pre and post operative fluid management
• IV administration of various drugs
• Treatment and Prevention of ketosis in starvation,
vomiting, diarrhoea
• Adequate glucose infusion protects liver against toxic
substances.
• Correction of hypernatraemia due to pure water loss
(Diabetes insipidus)

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11-Sep-19 97
5 % DEXTROSE
Limitations of 5D
1. Neurosurgical procedures - can aggravate Cerebral oedema
and increase ICT
2. Acute ischaemic stroke
• hyperglycemia aggravates cerebral ischaemic
brain damage.
• Dextrose metabolism aggravates tissue acidosis in
ischaemic areas- anaerobic oxidation of glucose produces
more
lactic acid and free radicals
3. Hypovolemic shock
• Poor expansion of intracellular volume.
•Faster rate of infusion causes osmotic diuresis 
worsens shock and false impression of the hydration
status  reduced fluid replacement.
4. Hyponatremia & water intoxication - 5%D worsens both
conditions

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11-Sep-19 98
5 % DEXTROSE
Limitations of 5D
5. Hypernatremia – fast infusion of 5D rapidly corrects
hypernatremia but correction occurs slowly in
brain cells, so swelling of brain cells can lead to
permanent neurological damage. Moreover rapid
infusion of 5D induces osmotic diuresis which
aggravates hypernatremia
6. Can cause Hypokalemia, hypomagnesemia and
hypophosphatemia
7. Blood and dextrose solutions should not be
administered in same IV line – haemolysis ,
clumping seen due to hypotonicity of the
solution.
8. Uncontrolled DM , severe hyperglycemia

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11-Sep-19 99
DEXTROSE SALINE (DNS)
Composition
• Na- 154 mEq/L
• CI- 154 mEq/L
• Glucose- 50 gm/L
•supply major extracellular electrolytes, energy and
fluid to correct dehydration
•In presence of incompletely or partially corrected
shock patient will have increased urine output (due to
diuresis)
•Unlike 5D, DNS is not hypotonic (due to NaCl) and
hence it is compatible with blood transfusion

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11-Sep-19 100
DEXTROSE SALINE (DNS)
Indications
•Conditions with salt depletion and hypovolemia - not
the ideal fluid though. Faster rate of infusion causes
osmotic diuresis  worsens shock and false impression
of the hydration status  reduced fluid replacement
•Correction of vomiting or nasogastric aspiration
induced alkalosis and hypochloremia along with supply of
calories
Limitations
• Anasarca – cardiac, hepatic or renal cause
•Severe hypovolemic shock – rapid correction is needed.
Faster infusion can cause osmotic diuresis and worsen the
condition

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11-Sep-19 101
DEXTROSE WITH HALF STRENGTH SALINE
Composition : 5% dextrose with 0.45% NS
NaCl – 77 meq/L each, glucose 50 gm/L
•Contains 50% salt as compared to DNS /NS and used when
there is need for calories , more water and less salt.
Indications
1. Fluid therapy in paediatric – In paediatric group ratio of
requirement of water : NaCl is double as compared to
adults
2. Treatment of severe hypernatremia – It corrects
hypernatremia gently, it avoids cerebral edema
3. Maintenance fluid therapy and in early post operative
period.
Limitations
1. Hyponatremia
2. Severe dehydration where larger salt replacement is
needed

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11-Sep-19 102
10% DEXTROSE & 25% DEXTROSE
Composition
1 liter of 10%D has 100 Gms glucose
1 liter of 25%D has 250 Gms glucose
Pharmacological basis:
• It is hypertonic crystalloid fluid
•Supplies energy and prevents catabolism useful
when faster replacement of glucose is needed like
in Hypoglycemic coma
•In patients with fluid restriction- CCF, Cirrhosis
and Renal failure

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11-Sep-19 103
10% DEXTROSE & 25% DEXTROSE
Indications
• Rapid correction of hypoglycaemia .
•In liver disease, if given as first drip, it inhibits
glycogenolysis and gluconeogenesis
• Nutrition to patients on maintainance fluid therapy.
• Treatment of hyperkalemia with Insulin
Limitations
•In patients with dehydration , anuria , intracranial
hemorrhage and in delirium tremens
•Avoided in patients with diabetes unless there is
hypoglycemia.
•Rapid infusion of 25D can cause glycosuria . Hence in
the absence of hypoglycemia it should be infused slowly
over 45 - 60 min

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11-Sep-19 104
HYPEROSMOLAR FLUIDS
 MANNITOL
 HYPERTONIC SALINE
MANNITOL
• Osmotic diuretic
• Metabolically inert in humans
•Elevates blood plasma osmolality  enhanced flow of water
from tissues, including the brain and cerebrospinal fluid, into
interstitial fluid and plasma
•As a result cerebral edema, elevated ICP, and CSF volume
and pressure may be reduced
• Complications associated are
- Rebound edema
- Dehydration due to osmotic diuresis
- Renal failure

MANNITOL
11-Sep-19
Limitations
• Anuria due to severe renal disease
• patients with hypotension
•Severe pulmonary congestion or frank pulmonary
edema
•Active intracranial bleeding except during
craniotomy
• Severe dehydration
•Progressive renal damage or dysfunction after
institution of mannitol therapy, including increasing
oliguria and azotem
Dr A
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Kanpur
HYPERTONIC SALINE
• Available as 1.8%, 3% , 5%, and 7.5%
% solution of
NaCl
Gm/L Na
(Meq/L)
Cl
(Meq/L)
1.8% 18 308 308
3% 30 573 573
5% 50 855 855
7.5% 75 1283 1283
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Kanpur
HYPERTONIC SALINE
PHARMACOLOGICAL PROPERTIES
Hypertonic nature of these solutions draws water out of the
intracellular compartment into the extracellular
compartment
USES
•Plasma volume expansion: The hypertonic nature of these
solutions draws water out of the intracellular compartment
and into the extracellular (including plasma) volume and may
therefore achieve plasma volume expansion while
minimizing the volume of fluid administered. However,
clinical trials have not shown any benefits.
• Correction of hypo-osmolar hyponatremia
• Treatment of raised ICT - superior to mannitol
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Isolyte G,M,P,E
ISOLYTE G ISOLYTE M ISOLYTE P ISOLYTE E
DEXTROSE 50 50 50 50
Na 63 40 25 140
K 17 35 20 10
Cl 150 40 22 103
Acetate --- 20 23 47
Lactate --- --- --- ---
NH4Cl 70 --- --- ---
Ca --- --- --- 5
Mg --- --- --- 3
HPO4 --- 15 3 ---
Citrate --- --- 3 8
mOsm/L
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11-Sep-19 109
INDICATIONS AND LIMITATIONS
ISOLYTE G :
• Vomiting / NGT induced hypochloremic,
hypokalemic metabolic alkalosis  NH4 gets
converted to H+ and urea in the liver.
• Treatment of metabolic alkalosis.
Limitations : hepatic failure, renal failure, metabolic
acidosis
ISOLYTE M:
• Richest source of potassium (35mEq)
• correction of hypokalaemia.
LIMITATIONS : Renal failure , burns, adrenocortical
insufficiency.

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INDICATIONS AND LIMITATIONS
ISOLYTE P:
• Maintenance fluid for children.
• Excessive water loss or inability to concentrate
urine .
LIMITATIONS : Hyponatremia , renal failure.
ISOLYTE E:
• Extracellular replacement fluid, additional
potassium and acetate.
• Corrects Mg deficiency.
•Treatment of diarrhoea and metabolic acidosis.
LIMITATIONS : metabolic alkalosis.

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11-Sep-19 111
COLLOIDS
• Large solute molecules
• MW >30000 Daltons that do not readily pass
from plasma to interstitial fluid.
• Largely remain in intravascular compartment.
• Retained molecules create an osmotic force
called colloidal osmotic pressure or oncotic
pressure.
• In normal plasma; the plasma proteins are the
major colloids present

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11-Sep-19 112
General characteristics of colloids
This characteristic determines their behavior in the
intravascular compartment
1. Large Molecular weight
2. Plasma volume expansion- determined by the
molecular weight
3. Osmolality
4. Colloid osmotic pressure – determines the
volume of expansion
5. Plasma Half Life- depends on the molecular
weight and the route of elimination
6. Electrolyte content – sodium content
7. Acid base composition – albumin and gelatin
have physiologic pH, others are acidic

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11-Sep-19 113
COLLOIDS
Capillary fluid Exchange
Direction and rate of fluid exchange (Q) between capillary
blood and interstitial fluid is determined, in part, by the
balance between the-
• hydrostatic pressure in the capillaries (Pc) promotes the
movement of fluid out of capillaries
• colloid osmotic pressure of plasma (COP)favors the
movement of fluid into capillaries.
Q = PC ~ COP
 Pc = about 20 mm Hg
(30 mm Hg at the arterial end of the capillaries and 10 mm Hg
at the venous end)
 COP = about 28 mm Hg
So, the net forces normally favor the movement of fluid into
capillaries (which preserves the plasma volume)
• About 80% COP is due to the albumin

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11-Sep-19 114
COLLOIDS
Resuscitation Fluids
• Crystalloid fluids reduce the plasma COP
(dilutional effect), which favors the movement of
these fluids out of the bloodstream
• Colloid fluids can preserve the normal COP (iso-
oncotic fluids), which holds these fluids in the
bloodstream,
• or they can increase the plasma COP
(hyperoncotic colloid fluids), which pulls
interstitial fluid into the bloodstream

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11-Sep-19 115
COLLOIDS
• Colloid fluid is about 3 times more effective in
expanding the plasma volume than the
crystalloid fluid

COLLOIDS
Natural
colloids
Plasma
proteins 4%
5%
Fresh Frozen
Plasma
Albumin
5%,20% 25%
Artificial
colloids
Dextrans Gelatins HES
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ALBUMIN
• Versatile plasma protein
• synthesized only in the liver
• half-life of approximately 20 days.
• Principal determinant of plasma colloid osmotic pressure- COP ( 75% of the oncotic
pressure)
• principal transport protein in blood
• has significant antioxidant activity
• 5% albumin ( 50gm/L or 5gm /dl) has COP of 20 mmHg (similar to plasma) &
expands plasma volume to same as volume infused
• 25% albumin ( 250gm/L or 25gm /dl) has COP of 70 mmHg & expands plasma
volume by 4 to 5 times the infused volume
• In adults –
 1 To 2 ml/min – 5%Albumin
 1 ml/min - 25%Albumin

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11-Sep-19 118
ALBUMIN
Indications:
•Emergency treatment of shock, specially due to the loss
of plasma.
• Acute management of burns
• Fluid resuscitation in intensive care
• Clinical situations of hypo-albuminemia
I. Following paracentesis.
II. Patients with liver cirrhosis.
III. After liver transplantation.
• Spontaneous bacterial peritonitis
• Acute lung injury
• Correction of diuretic resistant nephrotic syndrome
•In therapeutic plasmapheresis, albumin is used as an
exchange fluid to replace removed plasma

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11-Sep-19 119
ALBUMIN
Precautions and contraindications
• Because it does not replace lost volume, but instead shifts
fluid from one compartment to another, 25% albumin
should not be used for volume resuscitation in patients
with blood loss
• 5% albumin is safe to use as a resuscitation fluid, except
possibly in traumatic head injury
• Hyperoncotic (25%) albumin has been associated with an
increased risk of renal injury and death in patients with
circulatory shock
• Fast infusion will rapidly increase circulatory volume with
resultant vascular overload and pulmonary oedema
• Contraindicated in severe anaemia and cardiac failure
• Dehydrated patient may require additional fluids along with
albumin
• Should not be used as parenteral nutrition

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11-Sep-19 120
GELATIN POLYMERS( HAEMACCEL)
• Large MW protein, formed from hydrolysis of
bovine collagen.
• The MW ranges from 5,000 to 50,000 with a
weight average MW of 35,000.
• 3 types of gelatin solutions-
Succinylated or modified fluid gelatins
(e.g.,Gelofusine, Plasmagel, Plasmion)
Urea-crosslinked gelatins (e.g., Polygeline)
Oxypolygelatins (e.g., Gelifundol)

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Metabolism:
• Rapidly excreted by the kidney.
• Peak plasma concentration falls by half in 2.5
hours.
• duration of action is shorter in comparison to
both albumin and starches
Indications :
• Rapid Plasma Volume Expansion In Hypovolemia
• Volume Pre Loading In Regional Anaesthesia

Advantages:
•Cost effective: cheaper as compared to albumin
and other synthetic colloids.
•No limit of infusion: Gelatins do not have any
upper limit of volume that can be infused as
compared to both starches and dextrans.
•Less effect of renal impairment: Gelatins are
readily excreted by glomerular filtration as they are
small sized molecules.
Disadvantages:
•Anaphylactoid reactions: Gelatins are associated
with higher incidence of anaphylactoid reactions as
compared to natur
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HYDROXYETHYL STARCH
• Chemically modified polysaccharide
• composed of long chains of branched glucose
polymers substituted periodically by hydroxyl
radicals (OH), which resist enzymatic
degradation
• Elimination involves hydrolysis by amylase
enzymes in the bloodstream, which cleave the
parent molecule until it is small enough to be
cleared by the kidneys
• HES are derivatives of amylopectin, which is a
highly branched compound of starch

Kanpur
11-Sep-19 124
HYDROXYETHYL STARCH
Indications
a) Stabilization of systemic haemodynamics
b) Anti-inflammatory properties: HES has been shown to
preserve intestinal microvascular perfusion in
endotoxaemia due to their anti-inflammatory properties
Advantages
1. Cost effectiveness: HES is less expensive as compared to
albumin and is associated with a comparable volume of
expansion.
2. Maximum allowable volume: Maximum volume which can
be transfused of medium weight HES (130 kDa) with
medium degree of substitution (0.4) is greater as
compared to other synthetic colloids like dextrans.
3. The estimated incidence of anaphylactic reactions is less
compared to other colloids.

Kanpur
11-Sep-19 125
HYDROXYETHYL STARCH
Disadvantages
• Increase in Serum amylase concentration during
and 3-5 days after discontinuation
• Affects coagulation by prolonging PTT, PT and
bleeding time by lowering fibrinogen , decrease
platelet aggregation , VWF , factor VIII
• HES products with medium to high MW are
associated with oliguria, increased creatinine, and
acute kidney injury in critically ill patients with
preexisting renal impairment
• Accumulates in reticuloendothelial system and
causes pruritis

11-Sep-19 126
Kanpur
DEXTRAN
• Dextrans are highly branched polysaccharide
molecules
• These glucose polymers are produced by
bacterium (leuconostoc mesenteroides) incubated
in sucrose medium by bacterial dextran sucrase
Physicochemical properties
• Two dextran solutions are now most widely used,
6% solution with an average molecular weight of
70,000 (dextran 70)
10% solution with an average weight of 40,000
(dextran 40, lowDrm
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11-Sep-19 127
Kanpur
DEXTRAN
•Effectively expand intravascular volume  dextran 40
produces greater plasma expansion than dextran-70 but short
duration( 6hrs) and rapid renal excretion
• Anti thrombotic effect - inhibits platelet aggregation
•Improves microcirculatory independently of volume
expansion by decreasing the viscosity of blood by
hemodilution and by inhibiting erythrocytic aggregation
Metabolism & Excretion
• Kidneys primarily excrete dextran solutions
•Smaller molecules (14000-18000 kda) are excreted in 15
minutes whereas larger molecules stay in circulation for
several days
• Up to 40% of dextran-40 and 70% of dextran-70 remain in
circulation at 12 hrs. Dr Ajay Gangwar GSVM medical college

DEXTRAN
Degree of volume expansion
• Both dextran preparations have a colloid osmotic pressure
of 40 mm Hg
• Both cause a greater increase in plasma volume than
either 5% albumin or 6% hetastarch.
• Dextran-70 may be preferred because the duration of
action (12 hours) is longer than that of dextran-40
Indications
•Improves microcirculatory flow in microsurgical
reimplantations also and used for DVT prophylaxis
•Extracorporeal circulation: It has been used in
extracorporeal circulation during cardio-pulmonary bypass
•Correction of hypovolemia – from burns, surgery, trauma.
There is 100- 150% increase in intravascular volume.
11-Sep-19
Kanpur
128

DEXTRAN
to 21
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/kg.
Contraindications
• Severe oligo-anuria and renal failure
• Severe CHF
• Bleeding disorders- Thrombocytopenia, hypofibrinogenemia
• Severe dehydration
• Known hypersensitivity to dextran
Precautions
• Administered with caution in CLD, Impaired renal function (osmotically mediated
renal injury), active haemorrhage
• Correct dehydration before or during dextran infusion to prevent ARF
•Dextrans coat the surface of red blood cells and can interfere with the ability to
crossmatch blood
• Anticoagulant effect of heparin is enhanced
•Dextrans produce a dose-related bleeding tendency-- impaired platelet
aggregation, decreased levels of Factor VIII and von Willebrand factor, and enhanced
fibrinolysis. The hemostatic deD
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129

Kanpur
11-Sep-19 130

Kanpur
11-Sep-19 131
FLUID THERAPY IN
PEDIATRIC AGE GROUP

Kanpur
11-Sep-19 132
DAILY FLUID REQUIREMENT DURING
1ST WEEK OF LIFE (ml/kg/day)
Birth
weight
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 &
ONWARD
<1500 gm 80 95 110 120 130 140 150
>1500 gm 60 75 90 105 120 135 150
10% DEXTROSE ISOLYTE-P

NORMAL DAILY REQUIREMENTS IN
PEDIATRIC AGE GROUP
11-Sep-19
• SODIUM= 3 mEq/Kg
• POTASIUM & CHLORIDE= 2 mEq/Kg
• GLUCOSE= 5 gm/Kg
MAINTENANCE FLUID IN PEDIATRIC AGE GROUP (can
also in neonates) =
NS 5% DEXTROSE + INJ. KCl 2 mEq (1 ml) for each
2 100 ml fluid
10- 15% Increase In Maintenance Fluid For Each 1 Degree
(1.8 F) Rise In TemperD
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Kanpur
133

Kanpur
11-Sep-19 134
FLUID THERAPY IN HYPOVOLEMIC
SHOCK IN PEDIATRIC AGE GROUP
• NS  20 ml/kg Bolus
– (repeat upto 60 ml/kg) i.e. upto 3 bolus
– MONITOR-
» HEART RATE ( should fall by 15/minute)
» Respiratory rate (should fall by 5/minute)
» Liver
» Crepts

Kanpur
11-Sep-19 135
SEVERE DEHYDRATION D/T ACUTE
GASTRO ENTERITIS IN PEDIATRIC AGE
GROUP
AGE 30 ML/KG 70 ML/KG
< 1 YEAR OVER 1 HOUR OVER 5 HOUR
> 1 YEAR OVER ½ HOUR OVER 2 ½ HOUR
RL with 5% dextrose ( NS/RL alone can be used alternatively)

FLUID USED DURING SURGERY & 6-8 HOURS POST OP IN
PEDIATRIC AGE GROUP = RL or D5 N/2
D5 N/2 + K  17 Calories/ 100 ml
~20% OF DAILY CALORIC NEED
WEIGHT LOSS PER DAY = 0.5-1% PER DAY
Prevents ketone production
Helps to minimise protein degradation
post operative patient
D5 NS + K 
Indication-
– volume depleted state
– hyponatremia
– at risk of non osmotic ADH production
» lung infection
» CNS infection
11-Sep-19
– post operative patienDtr(A
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Kanpur
136

Kanpur
11-Sep-19 137
Fluid therapy - in
specific conditions

Kanpur
11-Sep-19 138
HYPOVOLEMIC SHOCK
Isotonic saline (NS) is selected as an initial fluid.
Because-
• 1 liter of NS will expand intravascular volume by 300ml
• Unknown glycemic status -(Dextrose solutions will rise glucose
level rapidly)
• Unknown renal status – RL can cause hyperkalemia or lactic
acidosis
• Reaction free (compared to colloids), Least expensive and readily
available
RL is preferred IV fluid after urine output is established
• RL is most physiological fluid  large volume can be infused
without electrolyte imbalance
• In shock, hepatic conversion of lactate to bicarbonate is
unpredictable

Hypovolemic Shock
Colloids in Hypovolemic shock-
• More effective plasma expanders  restricted to
intravascular compartments
• Lesser risk of pulmonary edema
• Primary indication is hypotension in protein losing state –
burns
• Although used in shock , they offer little or no advantages
over crystalloids
Blood in hypovolemic shock –
• In patients who are bleeding
• Severe Anemia
• Hematocrit should not be raised over 35%  increase in
11-Sep-19
blood viscosity  sta
Dr
sAija
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y Gangwar GSVM medical college
Kanpur
139

Fluid therapy in vomiting d/t GOO
HYPOKALEMIC HYPOCHLOREMIC METABOLIC ALKALOSIS
Na+ loss dehydration Loss of Cl- Loss of H+
Increase
aldosterone
Increased Na absorption
Increased K secretion &
urinary loss
Increased
bicarbonate
absorption in
proximal tubule
HYPOKALEMIA
When severe hypokalemia
for increased Na
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HYPOCHLOREMIA
METABOLIC ALKALOSIS
Increased H+ secretion
in distal tubules
Kanpur
PARADOXICAL
ACIDURIA
140

Fluid therapy in vomiting d/t GOO
Isotonic saline & isolyte G are used
Infusion of isotonic saline
VOLLUME
CORRECTION
SODIUM
SUPPLEMENTATION
CHLORIDE
SUPPLEMENTATION
Decreased renal
HCO3-
absorption
Decrease aldosterone
Decrease urinary
H+ loss & K+ loss
CORRECTS METABOLIC
ALKALOSIS
PREVENTS
HYPOKALEMIA
CORRECTS
HYPOCHLOREMIA
Favors bicarbonate
secretion
Efficacy of fluid therapy: clinicaly+ U/O + urinaKraynppurH(acidic= more vigorous treatment required)
11-Sep-19 141

FLUID THERAPY IN TURP SYNDROME
Clinical entity characterized by sign and symptoms secondary to
neurological , cardiovascular and electrolyte imbalance  resulting
from absorption of irrigation fluid through prostatic vein or breaches in
prostatic capsule during TURP
Average rate of fluid absorption from prostatic bed= 20 ml/min
Patients have greater risk, if-
• Resection time longer than 60 min
• Weight of prostate more than 30 gm
•Irrigate volume more than 30 litre
Glycine is preferred Irrigation fluid-
• refractive index allow good vision for prostatic resection
• 1.5% glycine is isotonic solution  do not change tonicity of
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Kanpur
142

Distilled water carries more risk –
• it is hypotonic
• Carries greater risk for hemolysis , dilutional hyponatremia ,
shock , renal failure
Sign and symptoms of TURP syndrome-
• Headache
• Nausea , vomiting
• Dizziness
• Shortness of breath
• Tight feeling in chest
• Bradycardia
• Hypertension
11-Sep-19
Kanpur
143

How to assess volume of absorbed irrigation fluid-
volume absorbed in (ltr) = preoperative S. Na × ECF -ECF
postoperative S.Na
ECF is 20% of body weight, so ECF = 0.2 × weight in kg
How do we prevent TURP Syndrome-
• Patient with pre existing hyponatremia are greater risk for TURP, so
correct preop hyponatremia
• The ideal height of irrigation fluid is 60 cm avoid height greater
than 60 cm
• Restricting duration of TURP less than 1 hr
• Early diagnosis and treatment can prevent onset of TURP syndrome
Kanpur
11-Sep-19 144

Kanpur
Treatment of TURP Syndrome
• Termination of surgery
• Diuretics and fluid restriction – Frusemide 1mg/kg will
increase water excretion and reduce circulatory overload
• Hypertonic saline – for correction of severe and
symptomatic hyponatremia. Slow administration of 3%
Hypertonic saline with i.v. Frusemide. Rapid administration
leads to pulmonary oedema and central pontine myelinolysis
• Other supportive measures:-
Oxygen administration: for pulmonary edema
Seizure: diazepam, barbiturates, or phenytoin
IV Calcium: to treat acute cardiac disturbances
Blood transfusion
11-Sep-19 Dr Ajay Gangwar GSVM medical college 145

Fluid In Neurosurgery Patients
• Isotonic saline
5% albumin iso to hyperosmotic
6% hetastarch
have minor effect on the brain’s water content or ICP
 safe to infuse
• Osmolality of RL = 274 mOsm/L
Osmolality of 5%-dextrose = 278 mOsmol/L
both of them are hypotonic
can increase ICP and cerebral oedema

11
s
-Sh
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o
19uld be avoided or should be used judiciously.
146
Kanpur

Kanpur
11-Sep-19 147
• 5%- Dextrose  hypotonic  accelerates ICP
and cerebral oedema in acute ischemic brain
damage  produces more lactic acid & free
radicals  further damages the brain

Kanpur
11-Sep-19 148
Guidelines of fluid management of
increased ICP
• Acute phase: MANNITOL is main stay of therapy.
Prolonged administration should be avoided.
• Maintenance therapy:
FLUID RESTRICTION AND DIURETICS are the mainstay.
Initial aim- to produce isovolumic hyperosmolality i.e.
elevate serum osmolality without reducing the
intravascular volume .
Best fluid for this purpose is isotonic saline with added
potassium chloride.

Fluid therapy in Burns
• Fluid resuscitation in first 24 hours
• Fluid therapy from 24 to 48 hours
• Fluid therapy after first 48 hours
Indication of I.V. resuscitation are :
1. adults with >15-20% burns
2. child with >10% burns
3. electric burn with haemochromogens in the urine
4. the extremes of age or elderly patients with pre exisisting
cardiac or pulmonary disease
• During initial period fluid resuscitation sodium rich I.V
. fluid in
11-Sep-19
large quantity is requiredD
.r Ajay Gangwar GSVM medical college
Kanpur
149

FLUID THERAPY IN FIRST 24 hrs
• RL is the most preferred fluid for initial fluid resuscitation
• (PARKLAND FORMULA)
Volume required= 4 ml× %TBSA of burns × body weight (in KG)
24 hrs period from the time of burn accident
Upto a 50% of burn i.e. even for burn >50% we use 50% in formula
• Out of total fluid requirement for 24 hours-
half is given in first 8 hrs from time of burn
remaining half is given over the next 16 hrs
•e.g. 40% burn in 60 kg female ( 4x40x60 = 9600 ml of RL)
4800 ml in first 8 hours & 4800 ml in next 16 hours
• Electrolyte free fluid i.e. 5%-dextrose are avoided for initial fluid
resuscitation
• Colloid infusion is either ineffective or destructive in early period
• BT is usually avoided initially
11-Sep-19
Kanpur
150

How to manage large thermal burns
unresponsive to “adequate resuscitation”?
11-Sep-19
Causes:
• underestimation of severity of injury
• Cardiac depression
• Vasoconstriction
Management:
• Early introduction of colloid containing sollutions
• Use of cardiotonic drugs (dopamine or dobutamine)
Requires invasive mo
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Kanpur
151

Kanpur
11-Sep-19 152
FLUID THERAPY FROM 24 hrs to 48 hrs
• During 2nd post burn day  volume of fluid infused per
hour should be roughly reduced by 25-50%
• Fluid infused – 5% dextrose.
but if sodium supplementation is needed
0.45% saline can be added
RL or
• Amount of colloid infused after 24 hrs depends on
degree of burns. Volume roughly 0.3-0.5 ml/kg/% of
burns. Albumin is often preferred

Kanpur
11-Sep-19 153
Fluid therapy after 48 hrs
• Is the sum of normal maintenance requirements plus
replacements of abnormal losses
• Maintenance requirement contains water, sodium 3
mEq/kg and potassium 2mEq/kg
• 5% dextrose volume required is 1 ml/kg/% burns.
Albumin with aim to maintain serum albumin >2.5gm/dl.

Kanpur
11-Sep-19 154
Calculation of fluid requirement after 48 hrs
• Maintenance
100 ml/kg for each kg 1-10 kg
50 ml/kg for each kg 11-20kg
20 ml/kg for each kg over 20kg
• Evaporative water loss
1 ml/kg/%burn

Kanpur
11-Sep-19 155
FLUID THERAPY IN RENAL DISEASES
GENERAL PRINCIPLES
1. FLUID RESTRICTIONS:
Fluid Intake = U/O + 500 ml/Day (In Oliguric
Patients). Strict Urine Output Chart & Daily Weight.
2. DO NOT CHASE U/O IN EDEMATOUS PATIENT
3. SALT RESTRICTIONS: 2-3 Gms Salt Per Day
4. AVOID HYPERKALEMIA: Avoid Foods Rich In K+ (Fruits,
Coconut Water, Dry Fruits)

Kanpur
11-Sep-19 156
ACUTE RENAL FAILURE
1. Prerenal azotemia:
• Fluid challenge- 500-1000 ml of NS is infused over
30-60 minutes under close observation
• Monitoring of fluid administration- pulse, BP, JVP,
urine flow chart, daily weight.

Kanpur
11-Sep-19 157
2. Non-oliguric ARF:
Cause- septicemia, aminoglycoside toxicity, AIN
• No reduction in urine output
• Donot need fluid or salt restrictions
• Periodic evaluation for hyperkalemia &
metabolic acidosis

Kanpur
11-Sep-19 158
3. Oliguric ARF:
u/o < 400 ml/day in adults
< 0.5 ml/kg/hour in children
• Restricted fluid & salt intake
• Establish urine flow- IV frusemide, 20%
mannitol, low dose Dopamine (3 micro
gm/kg/min)
• Manage hyperkalemia
• Manage metabolic acidosis
• IV fluid- 5% or 10% dextrose prefered

Kanpur
11-Sep-19 159
4. Diuretic phase of ARF:
• Proper fluid replacement
• Deficit of NaCl, HCO3, K, Mg should be replaced
• Prefered IV fluid is 0.45% saline + K

Kanpur
11-Sep-19 160
CHRONIC RENAL FAILURE
• Restrict Fluid & Salt Intake
• Diuretics- Edematous Patient Needs Frusemide
• Avoid Hyperkalemia
• Fluid: D5% Or D10% Prefered
• Treat Acidosis: Sodium Bicarbonate
• Treat Hypocalcemia & Hyperphosphatemia:
Calcium Carbonate + Calcitriol
• Prevent Hypermagnesemia: by avoiding Mg
containing antacids or laxatives

THANKING YOU
Kanpur
11-Sep-19 161

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