IV FLUIDS
beneficial or more harm?
BY: DR ISMAH
SURGICAL DEPARTMENT 1
MAIN REFERENCE
FLUID MANAGEMENT 2013 Elsevier Ltd. by
• Claire Leech BSc MBBS FRCA
Specialist Registrar in Anaesthesia & Critical Care, Northern Deanery,
UK.
• Ian D Nesbitt MBBS FRCA DICM(UK) FFICM
Consultant in Anaesthesia & Critical Care at the Freeman Hospital,
Newcastle upon Tyne, UK.
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CONTENTS
• Fluid compartments in the body
• Normal requirements
• Types of IV fluids and choice of fluid
• Common issues in fluid management of surgical patients
• Fluids issues in burn, trauma & sepsis
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FLUID COMPARTMENTS
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NORMAL REQUIREMENTS
• Water 35 ml/kg or 2.5 L/day for 70 kg male
-fluid losses 1.5L by urine & feces
1.0L by respiration/skin
*fever – 10% increase in water losses for every degree temperature
rise above 38C
• Na+ : 1-1.5 mmol/kg/day
• K+ : 1 mmol/kg/day
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When considering a fluid strategy for a patient the
following should be considered:
• The patient’s normal requirements
• Current volume status; the perioperative patient is often fluid
deplete requiring a period of ‘catch up’
• Electrolyte status
• On going excessive losses (e.g. high output fistula, high gastric
losses, third space losses). Examples such as these may also
require consideration of electrolyte supplementation at a different
amount to the above
• Excessive fluid intake (e.g. drug infusions or antibiotics)
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TYPES OF IV FLUID
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Properties of commonly used crystalloids:
Fluid Osmolarity Tonicity Na+ K+ Cl- Other pH
Hartmann’s 278 Isotonic 131 5 111 Lactate 6.5
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0.9% saline 308 Isotonic 154 0 154 5
5% 278 Hypotonic 0 0 0 Dextrose 4
dextrose 50
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CRYSTALLOIDS OR COLLOIDS?
Crystalloids Colloids
Advantages Disadvantages Advantages Disadvantages
• Cheap • Higher volume • Expansion • Expensive
• Non allergic needed plasma volume • Risk of allergy
• No transmission far superior • Coagulopathy
of infection • Relatively short • Itch
• No interference amount of time • May be salt • May exacerbate
with coagulation remaining sparing tissue edema
intravascularly
*The cost of each life saved using crystalloids is $45.13, and the cost of each life saved using colloidal
solutions is $1493.60 - http://www.ncbi.nlm.nih.gov/pubmed/2010737
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A. PREOPERATIVE
• Pt who undergo major surgery in dehydrated state have worst outcome
• Aim is to maintain tissue perfusion and O2 delivery
• Bowel preparation & fasting pre op can lead to dehydration
• Recommended suitable fasting time by The Association of Anesthetist of the Great Britain and
Ireland
- 6 hrs for solid food/milk
- 2 hrs for clear fluid
• Growing evidence that bowel preparation is unnecessary
- Advocate supplying pt with carbohydrate drink the night before/morning of
surgery to prevent fluid/electrolytes disturbance
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B. PERIOPERATIVE
• Both surgery and anesthesia affect fluid balance
- Anesthesia causes vasodilation
- Surgery cause hemorrhage, 3rd space losses and evaporative
losses
• However, excessive IV fluids can cause many complications as
inadequate administration of fluids
• The administration of fluid should be done to maintain the cardiac
output (goal directed therapy) at optimum level to reduce hospital
stay and morbidities
- Used of additional monitoring measure is often used; including the
oesophageal doppler, pulmonary artery catheter, and pulse contour
analysis monitors
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C. POSTOPERATIVE
• Management includes the administration of maintenance
fluids plus replacement of on going losses.
• Close monitoring of electrolytes should be done in
addition to this.
• Intravenous fluids should be discontinued as soon
as the patient is able to tolerate oral fluids.
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A. BURN
• Fluid resus is very important especially for pt with burn of >
10-15% BSA
• Damage of skin cause significant fluid loss
• Parkland formula
(%BSA burn X wt X 4ml)/24 hrs
- Half in 1st 8 hrs and half in 16 hrs
- Fluid of choice: Hartmann’s
• Aim: minimum urine output 0.5ml/kg/hr
• Rise of serum lactate may indicate more fluid required
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B. TRAUMA
• For major trauma as per advanced trauma life support
protocols;
- 2L of warmed Hartmann’s followed by assessment of
response
- Early aggressive correction of acute coagulopathy
using blood and products
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C. SEPSIS
• Volume deficit due to combination of
- Vasodilation
- Capillary leak
- Insensible losses
• Need for aggressive fluid replacement, particularly in 1st
24hrs
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• Volume
- The optimal volume of resuscitative fluid is unknown.
- As examples, two studies of early goal directed therapy
reported mean infusion volumes that ranged from 3 to 5 liters
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368, & ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of
protocol-based care for early septic shock. N Engl J Med 2014; 370:1683.
- The volume of fluid that was administered within the initial six
hours of presentation was targeted to set physiologic
endpoints (e.g., mean arterial pressure)
- Thus, rapid, large volume infusions of intravenous fluids are
indicated as initial therapy for severe sepsis or septic shock,
unless there is coexisting clinical or radiographic evidence of
heart failure.
- Fluid therapy should be administered in well-defined (e.g.,
500 mL), rapidly infused boluses
for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines
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• Choice of fluid
A. Crystalloid versus albumin:
In the Saline versus Albumin Fluid Evaluation (SAFE) trial, 6997 critically ill
patients were randomly assigned to receive 4 percent albumin solution or
normal saline for up to 28 days [24]. There were no differences between
groups for any endpoint, including the primary endpoint, mortality.
Among the patients with severe sepsis (18 percent of the total group), there
were also no differences in outcome. In another multicenter open-label
randomized trial of patients with severe sepsis or septic shock, the addition
of albumin to crystalloid did not improve survival compared to
crystalloid alone (31 versus 32 percent) [25].
B. Crystalloid versus hydroxyethyl starch:
In the Scandinavian Starch for Severe Sepsis and Septic Shock (6S) trial, 804
patients with severe sepsis were randomly assigned to receive either 6
percent hydroxyethyl starch or Ringer’s acetate at a volume of up to
33 mL/kg of ideal body weight per day [26]. When assessed 90 days after
randomization, mortality was increased in the hydroxyethyl starch group
(51 versus 43 percent) and more patients in the hydroxyethyl starch
group had required renal replacement therapy at some time during their
illness (22 versus 16 percent).
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CONCLUSION
• Normal requirement of body
- Water 35 ml/kg or 2.5 L/day for 70 kg male
- Na+ : 1-1.5 mmol/kg/day
- K+ : 1 mmol/kg/day
• Fluid therapy strategy should be individualized
• Crystalloids are more beneficial often used than colloids in
most conditions
• Beware to not give inadequate or excessive fluid therapy –
goal directed therapy
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THANK YOU
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