Algemene Principes van Vochtbeleid

M. Verhaegen, Hasanul Arifin Anesthesiology UZ KU Leuven

Intraoperative IV Fluid Therapy: Historical Perspective (1)

Fluid restriction
Postoperative Salt Intolerance (Coller et al, Ann Surg 1944, 119: 533-541) No isotonic saline solution or Ringers solution should be given during the day of operation and during the subsequent first two postoperative days

Intraoperative IV Fluid Therapy: Historical Perspective (2)

Trauma/surgery: large fluid deficits

Acute Changes in Extracellular Fluid Associated with Major Surgical Procedures (Shires et al., Ann Surg 1961, 154: 803-810) Major surgery is associated with significant functional extracellular fluid volume deficits Replace with large volumes of balanced electrolyte solutions

Artificile colloden en indicaties albumine Bloedproducten Hemodilutie en autotransfusie Electrolietenafwijkingen Het zuur-base evenwicht Vochtbeleid Vochtcompartimenten

Distributie van water over de vochtcompartimenten Electrolieten samenstelling

Het perioperatieve vochtbeleid

Body Fluid Compartments

Total body water = 60 % of body weight (BW)
2/3 1/3

Intracellular water = 40 % of BW

Extracellular water = 20 % of BW

Plasma (5 % of BW)

% of body weight
Total body water

70 kg male (L)
42 28

60 40

Intracellular

Extracellular

20
5 15

14
3.5 10.5

Intravascular Interstitial

Sendak in Principles and Practice of Anesthesiology (2nd ed), Longnecker et al.,

Extracellular Extravascular Water

Interstitial fluid and lymph Rapid exchange (with plasma) Slow exchange Bone water Cavitary fluids: transudates of plasma E.g. peritoneal, pericardial, pleural Transcellular fluids: active transport mechanisms E.g. salivary, hepatic, biliary, pancreatic, gastrointestinal intraluminal, mucosal, dermal, intraocular, intrathecal
7

Age- and Gender-related Changes in Total Body Water

Total body water (%) Age 1 mo 1 12 mo 1 10 yr 10 16 yr 17 39 yr 40 59 yr Male 76 65 62 59 61 55 Female 76 65 62 57 50 47

> 60 yr

52

46

Hays: Dynamics of body water and electrolytes (1980) In: Maxwell et al (eds): Clinical disorders of fluid and electrolyte metabolism

Relationship Between Body Habitus and Total Body Water in Adults

Total body water (%) Build
Thin Average Obese

Male
65 60 55

Female
55 50 45

Principles and Practice of Anesthesiology (2nd ed), Longnecker et al.

Electrolytes: Physiologic and Chemical Activity

Number of particles/unit volume (m)moles / liter of solution Number of osmotically active particles/unit volume (m)osmoles / liter of solution Number of electric charges/unit volume (m)equivalents / liter of solution

10

Body Fluids: Ionic Composition

Electrical neutrality In any fluid compartment or intravenous solution the number of milliequivalents of cations is balanced by precisely the same number of milliequivalents of anions Chemical combining activity (milliequivalents) 1 equivalent of an anion is the amount which can combine with 1 g of hydrogen

11

Body Fluid Compartments: Composition

Intracellular Extracellular
Intravascular Interstitial

Sodium (mEq/l)
Potassium (mEq/l) Calcium (mEq/l) Magnesium (mEq/l) Chloride (mEq/l) Bicarbonate (mEq/l) Phosphorus (mEq/l) Protein (g/dl)

10
140 <1 50 4 10 75 16

145
4 3 2 105 24 2 7

142
4 3 2 110 28 2 2

Body Fluid Compartments: Composition

Electrolyte CATIONS Sodium Potassium Calcium Magnesium Total ANIONS Chloride Bicarbonate Phosphate Sulfate Organic acids Protein Total 103 27 2 1 5 16 154 109 29 2 1 6 17 164 114 30 2 1 5 1 153 55 195 2 10 108 20 142 4 5 3 154 152 4 5 3 164 145 4 3 1 153 10 156 3 26 195 Plasma
(mEq/L)

Plasma water (mEq/L)

Interstitial fluid (mEq/L)

Intracell. fluid
(mEq/kg H2O)

Gibbs - Donnan Principle

Equilibrium 5 Pr5 Na+
1A Non-diffusible protein anions

10 Cl10 Na+
2A

5 Pr5 Na+ 4 Cl4 Na+

1B

6 Cl6 Na+
2B

Na+1B x Cl-1B = Na+2B x Cl-2B Electrical neutrality

Plasma water
(mEq/l)

Interstitial fluid
(mEq/L)

CATIONS Sodium Potassium Calcium Magnesium Total ANIONS Chloride 109 114 152 4 5 3 164 145 4 3 1 153

Bicarbonate
Phosphate Sulfate

29
2 1 141

30
2 1 147

Organic acids
Protein (org. anions) Total

6
17 164

5
1 153

Water Distribution and Movement

Hydrostatic forces Mechanical pressure generated by the heart Weight of blood within the vasculature Osmotic forces The movement of water is governed by the compartmental concentrations of osmotically active substances, predominantly electrolytes Extracellular: sodium, chloride, bicarbonate Intracellular: potassium, magnesium, phosphate, protein
16

Osmotic Pressure

Osmotic pressure is the hydrostatic pressure that must be applied to the solution of greater concentration to prevent water movement across a semi-permeable membrane separating two aqueous solutions of unequal concentration Osmotic pressure is dependent on the number of osmotically active molecules in solution

17

Osmotic Pressure

1 Osmole (Osm)

= 1 gram-molecular weight (1 M) of a nondissociating compound and consists of 6.023 x 1023 molecules = the number of osmoles of solute per liter of solution (solvent plus solute) = the number of osmoles of solute per kilogram of solvent (water) = osmolality x 19.3 (mmHg)

Osmolarity (mOsm / L)

Osmolality (mOsm / kg H2O)

Osmotic pressure

18

Sodium balance
Intracellular Extracellular

10 mEq/l

142 mEq/l

Plasma Osmolality
[Gluc] [BUN]

Sosm (mOsm/kg H2O) = (2 x [Na+]) +

18

2.8

[Na+] in mEq/l Glucose in mg/dl BUN = blood urea nitrogen in mg/dl

20

Extracellular osmolality = 290 10 mOsm/kg H2O Serum osmolality < 260 mOsm/kg H2O Serum osmolality > 325 mOsm/kg H2O

Neurologic abnormalities Confusion Obtundation Abnormal muscular activity Seizures

Sodium balance
Intracellular
P r o t e I n s

Extracellular

Oncotic pressure Membrane permeability Hydrostatic pressure Lymphatic drainage

Starlings Equation
Q = kA [ ( Pc - Pi ) + s ( pi - pc ) ]
(mEq / L)

Q k A Pc Pi s pi pc

= = = = = = = =

fluid filtration capillary filtration coefficient area of the capillary membrane capillary hydrostatic pressure interstitial hydrostatic pressure reflection coefficient for albumin interstitial colloid osmotic pressure capillary colloid osmotic pressure
23

Osmolality (mOsm/kg)
Plasma ISF

[Na+] (non-protein)

281.4

281.1

Protein

1.2

0.2

Total

282.6

281.3

Osmotic pressure (mmHg)

Plasma ISF

[Na+] (non-protein)

5431.0

5425.2

Protein

23.2

3.9

Total

5454.2

5429.1

25.1 mmHg

Capillary

Pc = 40 mmHg
Arterial

Pc = 10 mmHg
Venous

pc = 23 mmHg 18

Interstitium

Filtration

Pi = 2 mmHg pi = 4 mmHg

Absorption

Lymphatic drainage

Control of Body Fluid Compartments

Atrial natriuretic peptide Vasopressine Renin, angiotensin Parathyroid hormone Calcitonin Prostaglandins Dopaminergic receptors a-adrenergic receptors Thirst mechanism Intrinsic renal properties
27

Volume and Electrolyte Status

Abnormalities of Volume Concentration Composition Basis for assessment Medical history Physical examination Laboratory data

28

Volume changes

(1)

Volume deficit Insufficient intake External losses Distributional volume deficit Volume excess

29

Distributional Volume Deficit

Transfer of isotonic solution from a functional compartment to a nonfunctional space Equivalent to ECF volume loss Isotonic Both ISF and PV contribute Same systemic manifestations as ECF loss Surgical trauma, muscle injury, burns, peritonitis, ascites

30

Extracellular Fluid Deficit: Clinical Findings (1)

Decrease in body weight (%) Mild Moderate
3-5

Clinical signs

Dry mucous membranes, oliguria Orthostatic hypotension, tachycardia, anorexia, apathy, poor skin turgor

6 - 10

Extracellular Fluid Deficit: Clinical Findings (2)

Decrease in body weight (%) Severe
11 - 15

Clinical signs
Supine hypotension, stupor, sunken eyes, cool and dry skin, mild hypothermia Coma, anuria, significant in core temp., dicrotic pulse, pulsus paradoxus, circulatory collapse

Catastrophic

> 20

Volume changes

(2)

Volume deficit Volume excess Iatrogenic Medical condition Cardiac, hepatic or renal dysfunction Mobilization of third space losses

33

Concentration Changes
Disorders of water balance
Loss of extracellular water Increased serum [Na+] Increased serum osmolality Redistribution of water Changes in osmolality and solute concentrations in other fluid compartments
34

Changes in Composition

Changes in acid-base balance Changes in electrolytes Sodium Calcium Magnesium Potassium Changes in plasma proteins

35

Tonicity

Relative osmolality of solutions Isotonic

Osmotic pressure = osmotic pressure of body fluids

Hypertonic
Osmotic pressure > osmotic pressure of body fluids intracellular volume depletion

Hypotonic
Osmotic pressure < osmotic pressure of body fluids cellular swelling
36

Extracellular Osm. Water Hypertonic salt solution Isotonic salt solution Loss of sodium chloride Volume

Intracellular Osm. Volume

Sugar (g/l) D5W D5W + 40 mEq/l KCl D10W 50 50 100

Na

Electrolytes K Ca (mEq/l)

Cl

Other anions (mEq/l)

Osmol
(mOsm/l)

252 40 333 505

LR
D5W - LR 0.45% NaCl 0.9% NaCl Albumin 5% 50

130
130 77 154 154

4
4

3
3

109
109 77 154 154

28
28

273
525 154 308 310

Administration of 250 ml of fluid

250 200 150 100 50 0 D 5W

ICV ISV PV

D Volume (ml)

Lactated Ringers

Albumin 5%

Prough, Anesthesiology Clinics of North America (1996)

Administration of 250 ml of fluid

1000 750 ICV ISV

500
D Volume (ml) 250 0 -250 -500 -750 D 5W LR Alb 5% Alb 25%

PV

Prough, Anesthesiology Clinics of North America (1996)

Intraoperative Fluid Management

Volume, composition and concentration of intravenously administered fluids should be adjusted to maintain baseline function of vital organ systems

41

Intraoperative Fluid Management

Basal fluid requirements Correction of preoperative fluid deficits

Fasting Disease-related fluid losses Blood loss Redistribution: Third space fluid loss Other fluid losses

Intraoperative fluid losses

42

Basal Fluid and Electrolyte Losses

(1)

Constant loss of water and electrolytes Skin Insensible losses (evaporation) Perspiration Lungs Insensible losses Kidneys Gastrointestinal tract

43

70 kg adult / 24 h Water (ml) Skin Insensible Perspiration 400 100 Na+ Electrolytes

Lungs Kidney
Gastrointestinal Total

Insensible Urine
Feces

400 1 500
100

K+
Na+, K+

2 500

Basal water losses parallel energy expenditures

Maintenance fluids (hospitalized pts): 100 ml/100 kcal/d

2500
2100 1900 1700 1500 1000 2300 Computed need for average hospital patients

From Holliday MA and Segar WE, Pediatrics (1957)

Decreased Metabolic Rate

Starvation Hypothyroidism Addisons disease Obesity associated with hypothalamic or pituitary dysfunction General anesthesia Extremes of age

46

Increased Metabolic Rate

Skeletal muscle activity Ingestion of nutrients Caffeine, nicotine Fever, sepsis Elevated ambient temperature Diabetes insipidus Leukemia Polycythemia Dyspnea associated with cardiac, pulmonary, renal disease
47

Daily loss of water (mL)

Normal activity and temperature Normal activity, high temperature

Urine
Sweat Feces Insensible loss Total

1400
100 100 700 2300

1200
1400 100 600 3300

From Rhoades and Tanner, Medical Physiology, Little, Brown & Co., Boston (1995)

Basal Fluid and Electrolyte Losses

(2)

Volume Basal water losses parallel energy expenditures 4-2-1 Rule Weight (kg) 0-10 Volume required 4 ml/kg/h

11-20
> 20

40 ml/h + 2 ml/kg/h above 10 kg

60 ml/h + 1 ml/kg/h above 20 kg

49

4-2-1 rule
Weight (kg) 0 10 11 - 20 > 20 Volume 4 ml/kg/h 2 ml/kg/h 1 ml/kg/h 70 kg 40 20 50

Total 110 ml/h

Basal Fluid and Electrolyte Losses

(3)

Electrolytes Sodium: Potassium: Calcium:

1 2 mEq/kg/d 1 1.5 mEq/kg/d 1 1.5 mEq/kg/d

51

Intraoperative Fluid Administration

Maintenance fluids Correction of fluid deficit Replacement of intraoperative fluid losses

52

Intraoperative Maintenance Fluids (1)

Volume

4-2-1 rule Possibly increased intraoperatively Fever Sweating Denuded skin Exposed peritoneal or pleural surfaces Non-humidified gasses, at high flow rates

53

Intraoperative Maintenance Fluids (2)

Composition Water D5W Electrolytes Not for minor surgery in healthy patients Potassium

Bowel preparation

54

Intraoperative Maintenance Fluids (3)

Glucose Indicated in type I diabetes mellitus

2-3 g/kg/d Total parenteral nutrition Insulinoma Prolonged (> 24 h) fasting Starvation Hyperglycemia-induced cerebral acidosis
55

Indicated if risk of hypoglycemia

Avoid if risk of cerebral ischemia

Correction of Preoperative Fluid Deficit

Preoperative fasting fluid deficit Basal maint. fluids/h x npo period (h) st hour: 1 50 % of deficit nd hour: 2 25 % of deficit rd hour: 3 25 % of deficit Additional fluid deficits Disease-related fluid losses External Internal
56

30 25 20 l

l l

Crystalloid l No crystalloid

VAS for nausea (mm)

15
10 5 0

* *
1h * 2h 4h

l * *

6 h 24 h 48 h 72 h

Time
* P>0.05 Elhakim et al., Acta Anaesth Scand (1998), 42

Vomiting (n) Crystalloid Day unit (6 h) 6h3d 0- 2h 2- 4h 2 0 * 2 0 No crystalloid 3 8 2 1

4- 6h
6 - 24 h 24 - 48 h

0
0 0

0
8 3

48 - 72 h
* P>0.05

Elhakim et al., Acta Anaesth Scand (1998), 42

External Fluid Losses

Gastrointestinal tract Vomiting, diarrhea, ostomy output, overzealous bowel preparation Hidden: bowel obstruction, ileus Volume, concentration and composition disturbances External blood loss Gastrointestinal bleeding Traumatic injuries
59

Volume and composition of gastrointestinal fluids

24 h vol. (mL) Saliva Stomach Pancreas Bile Jejunum Ileum Colon
500-2000 1000-2000 300-800 300-600 2000-4000 1000-2000 -

Na+ (mEq/L) 2-10 60-100 135-145 135-145 120-140 80-150 60

K+ (mEq/L) 20-30 10-20 5-10 5-10 5-10 2-8 30

Cl(mEq/L) 8-18 100-130 70-90 90-130 90-140 45-140 40

HCO3(mEq/L) 30 0 95-120 30-40 30-40 30 -

From Miller, Anesthesia, 5th ed.

Internal Fluid Losses (1)

Sequestered ECF pool Cavitary fluid losses

Pathologic transudate of plasma (pleural, ascitic, pericardial) Anatomical compartment Develop slowly compensation Extracellular tissue fluid Non-anatomical compartment Develop quickly considerable impact on ECF

Third space fluid losses

Internal blood loss

61

Internal Fluid Losses (2)

Sequestered ECF pool Cavitary fluid losses Third space fluid losses Internal blood loss Retroperitoneal hematoma Aorta aneurysm Leaking vascular anastomosis Pelvic or femoral fracture Splenic rupture Liver trauma
62

Correction of Preoperative Diseaserelated Fluid Losses (1)

Assessment of ECF volume deficit 1 % in body weight 10 ml/kg fluid e.g. moderate fluid loss: 8% of body weight 70 kg 8 x 10 x 70 = 5 600 ml Isotonic fluid: water + salt Normal saline (NaCl 0.9%) Balanced salt solution e.g. lactated Ringers

63

Correction of Preoperative Diseaserelated Fluid Losses (2)

Ideally: preoperative correction < 20 % of blood volume

Replace over 15 min Redistribution to ISF: 40-60 % within 15-30 min 75 % within 60 min Replace 25-50 % over 1 h Remainder over several hours

Large deficit and surgery not urgent

Correction of electrolyte abnormalities

64

Replacement of Intraoperative Fluid Losses (1)

Blood loss Redistribution and subsequent loss of extracellular and intracellular fluid Replacement with crystalloids

Volume blood:crystalloid ratio 3:1 to 5:1 (even 7:1) Composition NaCl 0.9 % Balanced electrolyte solution

Colloids Blood products Third space losses

65

Cervera et al., Am J Surg (1975), 129

Replacement of Intraoperative Fluid Losses(2)

Redistribution: Third space fluid loss Sequestered extracellular fluid Volume related to surgical trauma

Minor: Intermediate: Major:

2 - 4 ml/kg/h 4 - 8 ml/kg/h 8 - 15 ml/kg/h

Replacement fluid

NaCl 0.9 % Balanced electrolyte solution

Continues 24 48 h Mobilization 1 3 days postoperatively

67

Lactated Ringers Fluid (ml) Duration (min) ECV preop (l) ECV postop (l)
* ** P<0.05 between groups P<0.05 vs preop

D5 W 530 92 * 187 113 12.5 2.4 10.6 1.9 **

1660 96 253 50 12.5 2.3 12.3 7.0

Roberts et al., Ann Surg (1985), 202

Postoperative Fluid Losses

Basal fluid losses Internal fluid losses Third space loss Blood loss Accumulation of fluid within body cavities External fluid losses Blood loss Enhanced insensible loss Transcellular fluid loss
69

Postoperative Fluid Therapy

Basal fluid loss + increased insensible loss Hypotonic maintenance fluids Until adequate oral intake All other postoperative fluid losses Balanced salt solution + electrolytes Postoperative day 1- 3: mobilization of third space fluid losses

70

Intraoperative Fluid Therapy: Lack of Good Target Points (1)

Cardiovascular parameters ECG Blood pressure Central venous pressure Pulmonary artery catheter Transesophageal echocardiography Perfusion directed therapy Fluid overload

71

Intraoperative Fluid Therapy: Lack of Good Target Points (2)

Cardiovascular parameters Perfusion directed therapy Global

Lactate Gastrointestinal Pco2 tonometry Kidney: urine output

Regional: Gastrointestinal

Organ specific

Fluid overload

72

Intraoperative Fluid Therapy: Lack of Good Target Points (3)

Fluid overload Intraoperative absorption of irrigating fluids during endoscopic surgery

Transurethral resection of the prostate Hysteroscopic surgery Absorption can be accurately monitored

73

Fatal Postoperative Pulmonary Edema: Pathogenesis and Literature Review (Arieff: Chest 1999, 115: 1371-1377)

Fatal postoperative pulmonary edema 13 patients (incidence of 0.02 %) 10 generally healthy 3 serious associated medical conditions Age 38 21 y Within 3 postoperative days Range: 3 to 66 h, mean SD: 27 20 h No predictive variables No predictive warning signs Cardiorespiratory arrest first clinical sign in 8 pts Fluid overload as single cause Mean net fluid retention of 7.0 4.5 l first 27 h postop (24 % increase of total body water)

74

Hyperchloremic Metabolic Acidosis

Dilutional acidosis

Metabolic acidosis resulting from rapid administration of fluids that contain near-physiologic concentrations of sodium accompanied by anions (usually chloride) other than bicarbonate or bicarbonate precursors, such as lactate. (D.S. Prough, Anesthesiology 2000)

Dose-dependent

75

Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecological Surgery. (Scheingraber et al.: Anesthesiology 1999, 90) Saline (n = 12) Time of infusion (min) Volume after 120 min (ml/kg) Estimated blood loss (ml) Urine output (ml) 135 23 71 14 962 332 717 459 Lact. Ringers (n = 12) 138 20 67 18 704 447 1 075 799
76

Saline 0 min 120 min

Lactated Ringer s 0 min 120 min

Bicarbonate (mM) Anion gap (mM) Chloride (mM)

23.5 2.2

18.4 2.0

23.3 2.0

23.0 1.1

16.2 1.2

11.8 1.4

15.8 1.4

12.5 1.8

104

115

104

106

Scheingraber et al., Anesthesiology 90 (1999)

Lactated Ringers Normal saline

7.50 7.45 7.40 7.35 7.30 7.25 7.20 0 4 0 30 60 90 120 min

pH
# # #
mmHg

50 46 42

Carbon dioxide

38
34

*
* * *

30 26

0
3.0

30

60

90

120 min

Base excess
# # #
mmol/l

Lactate
#*
#* #* #*

2.5 2.0 1.5 1.0 0.5 0.0 0 30

mmol/l

-4 -8 -12 0

* * *
90

*
120 min

30

60

60

90

120 min

* P<0.05 intragroup # P<0.05 intergroup

Scheingraber et al., Anesthesiology 90 (1999)

Lactated Ringers Normal saline

148

Sodium
mmol/l

120

Chloride
#* #* * #*

#*

mmol/l

144

#*

#*

#*

#*

115 110 105

140

136 0

*
30 60

*
90

*
120 min

100 0 17.5 15

*
30

*
90

60

120 min

45
40 35

Calculated SID
mmol/l

Prot* * * *

mmol/l

* *

#*

#*

12.5

*
10

30
25 0 30

* *
60 90

*
120 min

7.5 0 30 60 90 120 min

* P<0.05 intragroup # P<0.05 intergroup

Scheingraber et al., Anesthesiology 90 (1999)

Replacing 1 Liter of Blood Loss with Crystalloid (3:1)

Crystalloid Excess chloride load (mmol)
165

3 l of NaCl 0.9 %

3 l of lactated Ringers

27

Hyperchloremic Metabolic Acidosis: Therapy

Switch to balanced electrolyte solution Lactated Ringers Plasmalyte Hyperventilation pH > 7.2 and preferably > 7.3 Furosemide (Fresh frozen plasma) Transfusion criteria

81

Plasma Volume Expansion (PVE): Static Concept

PVE = Volume infused x
Plasma volume Distribution vol.

Distribution volume: D5W Lactated Ringers NaCl 0.9%

= total body water = extracellular vol. = extracellular vol.

82

One-compartment Volume of Fluid Space Model

V = expandable space of volume

V = target volume Ki V
V Ki = constant fluid infusion rate

Kb = basal rate of fluid elimination (perspiration, basal diuresis)

Kb

Kr (V - V) V

Controlled rate of fluid elimination proportional by a constant Kr to the relative deviation of v from V

Svensn et al., Anesthesiology (1997), 87

Two-compartment Volume of Fluid Space Model

Ki

V1

V1

Kt

V2

V2

Kb

Kr(V1 - V1) V1

Secondary fluid space

The net rate of fluid exchange between the 2 compartments is proportional to the difference in relative deviations from the target volumes by a constant Kt
Svensn et al., Anesthesiology (1997), 87

Plasma Volume Expansion (PVE): Kinetic Analysis

Bolus of fluid Peak effects Rates of clearance Infusion of fluid necessary to maintain PVE at a certain level Effects of anesthesia, surgery and trauma on fluid requirements Usefull during severe pathophysiologic disturbances?

85

0.2 0.15 0.10 0.05 0

Plasma dilution, (v V)/V

Single bolus of Ringers 40 ml/min for 40 min

0
0.2 0.15 0.10 0.05 0

20

40

60 80 Time (min)

100

120

Bolus + continuous infusion of Ringers at 25 ml/min

20

40

60 80 Time (min)

100

120

Hahn and Svensen, Br J Anaesth (1997), 79

Hahn and Svensen, Br J Anaesth (1997), 79

Volume Kinetics of Ringers Solution during Induction of Spinal and General Anaesthesia. (Ewaldsson and Hahn: Br J Anaesth 2001, 87)

10 patients: 20 ml/kg of Ringer acetate over 60 min (0.33 ml/kg/min) Spinal anesthesia 20 min after start of infusion 5 patients: 350 ml of Ringers over 2 min immediately after spinal followed by Ringers at 0.33 ml/kg/min Ephedrine 5-10 mg IV if SAP < 60 % of baseline Parameters Blood pressure Blood hemoglobin concentration Every 3 min during 60 min
88

Spinal anesthesia

0.33 ml/kg/min during 60 min 350 ml over 2 min 0.33 ml/kg/min during 40 min

Rapid infusion group

Ewaldsson and Hahn, Br J Anaesth (2001), 87

Semipermeable membrane

Osmosis

Osmotic pressure

Solvent

Solute
Solution