Fluid Management

FLUID MANAGEMENT

FLUID MANAGEMENT Body Fluid CompartmentsTotal Body Water = 60% body weight70Kg TBW = 42 L2/3 of TBW is intracellular (ICF)40% of body weight, 70Kg = 28 L1/3 of TBW is extracellular (ECF)20% of body weight, 70Kg = 14 LPlasma volume is approx 4% of total body weight, but varies by age, gender, body habitusRegulation of Fluids:

Renal sympathetic nerves Renin-angiotensin- aldosterone system Atrial natriuretic peptide (ANP)

FLUID THERAPYRESUSCITATIONMAINTENANCE FLUID THERAPYNUTRITION

RESUSCITATION FLUID: CRYSTALLOID RATIO 3-6 : 1 e.g RINGER LACTAT/ ASETAT NaCl 0,9 % COLLOID RATIO 1 : 1

BILA Hb < 8 g% ( 20-24 % ) , blood transfusionChoice of fluidsCrystalloids

Colloids

Blood productsWhole bloodpRBCFFPPlatelets

5 Crystalloids: - contain Na as the main osmotically active particle - useful for volume expansion (mainly interstitial space) - for maintenance infusion - correction of electrolyte abnormality6CrystalloidsAdvantagesInexpensiveVery low incidence of adverse reactions

DisadvantagesShort lived hemodynamic improvement (intravascular t: 20 30 mins.)Peripheral/pulmonary edema7Crystalloids:

Colloidscontains high MW substances - proteins, large glucose polymers

maintain plasma oncotic pressure

intravascular t: 3 6 hrs.

9ColloidsAdvantagesSmaller infused volume

Prolonged increase in plasma volume

Minimal peripheral edema

DisadvantagesExpensive

Coagulopathy

Pulmonary edema

Anaphylactoid reactionsColloid Solutions:

Transfusion: pRBCMABL of 10-20 % EBVMABL = EBV (pt initial Hct lowest acceptable Hct) pt initial HctHb: 7- 10 g/dlHct: 21-30 %Higher target Hct for certain pts

12Transfusion: FFPIndication: treatment of isolated factor deficiencies, reversal of warfarin therapy, correction of liver disease associated coagulopathy

Initial therapeutic dose: 1015 mL/kg

Goal: 30% of the normal coagulation factor concentration

Transfusion: PlateletsIndication: pts with thrombocytopenia or dysfunctional platelets in the presence of bleeding

Transfusion threshold: Plt counts less than 50,000 x 109/L

4 2 1 Rule100 50 20 Rule for daily fluid requirements4 mL/kg for 1st 10 kg2 mL/kg for 2nd 10 kg1 mL/kg for each additional kgMaintenance Fluids: Example60 kg female1st 10 kg: 4 mL/kg x 10 kg = 40 mL2nd 10 kg: 2 mL/kg x 10 kg = 20 mLRemaining: 60 kg 20 kg = 40 kg 1 mL/kg x 40 kg = 40 mLMaintenance Rate = 120 mL/hrFluid DeficitsFastingBowel Loss (Bowel Prep, vomiting, diarrhea)Blood Loss TraumaFracturesBurnsSepsisPancreatitis

Insensible Fluid LossEvaporativeExudativeTissue Edema (surgical manipulation)Fluid Sequestration (bowel, lung)Extent of fluid loss or redistribution (the Third Space) dependent on type of surgical procedureMobilization of Third Space Fluid POD#3Insensible Fluid Loss4 6 8 RuleReplace with Crystalloid (NS, LR, Plasmalyte)Minor: 4 mL/kg/hrModerate: 6 mL/kg/hrMajor: 8 mL/kg/hr

Example68 kg female for laparoscopic cholecystectomyFasted since midnight, OR start at 8amMaintenance = 40 + 20 + 48 = 108 mL/hrDeficit = 108 mL/hr x 8hr = 864 mL 3rd Space (4mL/kg/hr) = 272 mL/hrGoals of Fluid ResuscitationEasily measured

MentationBlood PressureHeart RateJugular Venous PressureUrine Output

Goals of Fluid ResuscitationA little less easily measured

Central Venous Pressure (CVP)Left Atrial PressureCentral Venous Oxygen Saturation SCVO2Goals of Fluid ResuscitationA bit more of a pain to measure

Pulmonary Capillary Wedge Pressure (PCWP)Systemic Vascular Resistance (SVR)Cardiac Output / Cardiac Index

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