FLUID THERAPY

Body Composition
In avarage young adult

Body Composition % of body weight

Protein & related 18 %
substance
Fat 15 %
Mineral 7%
Water 60 %
55 % of total body weight in females
Body Fluids
Water content in body is divided into 2 compartements :

1. Extracellular fluid
(ECF)
- Fluid outside the cells
- 1/3 volume of fluid in body
(= 33% of TBW)
- Contains ion & nutrient for
cellular life

2. Intracellular fluid (ICF)

- Fluid inside the cells
- 2/3 volume of fluid in body
(= 67% of TBW)
Movement of fluids due to
1) Hydrostatic pressure:
It is the force that exerted by a fluid against the capillary
wall.

2) osmotic pressure:
The pressure exerted by the flow of water through a
semi-permeable membrane separating two solutions
with different conc. of solute
Transport of fluid
Diffusion (Passive transport)
it is the movement of substances across a membrane from
higher to lower concentration (down a concentration gradient)
o Active transport
It is the movement of substances across a membrane against
gradient (from low concentration to high concentration). Active
transport requires energy (ATP)
o Osmosis
It is diffusion of a solvent (usually water molecules) through a
semi-permeable membrane from an area of low solute
concentration to an area of high solute concentration.
 Transport of fluid (cont.)
Osmotic pressure:
It is pressure which forces the water to move from where
there is little dissolved solute to where there is lots
dissolved solutes.
It is determined by the number of particles per unit volume of
fluids
Osmoles id the unit used to express the concentration in term of
numbers of particles.
Osmolarity
o Number of osmoles of solute per litre of solution
o 285 +/- 5 mOsm/L
Osmolality
o Number of osmoles of solute per kilogram of solvent
o 290 mOsm/kg
 Fluid Imbalance
Fluid volume deficit Fluid volume excess
(Hypovolemia) (Hypervolemia)
Common Causes Common Causes:
- Hemorrhage - Congestive Heart Failure
- Vomiting - Early renal failure -
- Diarrhea Excessive sodium ingestion
- Burns - Iv therapy isotonic, colloid,
- Diuretic therapy plasma/blood >>
- Fever
- Impaired thirst
Basis of IV Fluid Therapy
Maintenance
Supply daily needs
oReplacement
To replace on-going losses
oResuscitation
To correct an intravascular or extravascular
deficit
Signs of Fluid Loss
(Hypovolemia)
 Presentation of dehydration
Severity of Dehydration Clinical Findings

Mild Normal mental state

Up to 5% total body water
(3L in 70kg man)
Dry mucous membranes
Usually thirsty
Blood pressure & heart rate normal
Lower than normal urine output
Skin turgor almost normal

Moderate Disinterest in surroundings, can be drowsy

5-10% total body water Increased heart rate & respiratory rate
(5L in 70kg man) Orthostatic hypotension
Decreased skin turgor
Reduced urine output

Severe Reduced conscious level

10-15% total body water Fast heart rate
(8L in 70kg man) 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
 Fluid Therapy
The fluid used in clinical Distribution of IV Fluids
practice are usefully
classified into :

Crystalloids
- Ringer Acetate
- Ringer Lactate
- NaCl 0,9%

Colloid
- Synthetic : dextran
- Human : plasma,
albumin
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.
Crystalloid
Solution that contain small molecules that flow easily
across the cell membranes (semi permeable
membranes), allowing for transfer from the bloodstream
in to the cell and body tissue
o It is subdivided into :
1. Isotonic stay in the
intravascular space expands
the intravascular compartment
2. Hypertonic draw fluids into
intravascular compartment
from the cells & interstitial
compartment
3. Hypotonic shift fluid out of
the intravascular
compartment, hydrating cells
amd the interstitial
compartment
Colloids
Colloid : high-molecular-weight solutions, draw
fluid into intravascular compartement via
oncotic pressure (pressure exerted by plasma
proteins not capable of passing through
membranes on capillary walls). Plasma
expanders, as they are composed of
macromolecules, and are retained in the
intravascular space.
Colloids
Types
Albumin
Blood
Plasma
Artificial colloids = plasma expander
6% Hydroxyethylstarch (HES) solutions
Hextend : HES in lactated electrolyte solution
Hespan : HES in NS
Dextran
Gelatins
Combined Hypertonic-Dextran solutions
 Blood and Blood Products
 Perioperative Fluid Therapy
includes replacement of preexisting fluid deficits,
of normal losses (maintenance requirements), and
of surgical wound losses including blood loss.
Estimating Maintenance
Fluid Requirements
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
Intraopertaive 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
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%; RBCVlost = RBCVpreop
RBCV30%.
5. Allowable blood loss = RBCV x 3.
Estimate Blood Volume
 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 mL.

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)
Clinical guidelines commonly used include:
1U of red blood cells will increase hemoglobin 1
g/dL and the hematocrit 23% (in adults);
10-mL/kg transfusion of red blood cells will
increase hemoglobin concentration by 3 g/dL and
the hematocrit by 10%.
Replacing Redistributive and
Evaporative Losses