1. BY- Prof. M.C.Bansal
MBBS., MS., FICOG., MICOG.
Founder Principal & Controller,
Jhalawar Medical College & Hospital Jjalawar.
MGMC & Hospital , sitapura ., Jaipur
2. TOTAL BODY WATER
Total body water content-
60% of body weight (young adult male)
50% of body weight (young adult female)
Fat contains less water, an obese person has proportionately less body water.
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6. NORMAL FLUID BALANCE
• Kidneys plays a pivotal role in regularization of fluid – electrolyte balance.
•Oral intake & urine output are imp. measurable parameters.
•Fluid electrolyte output in normal day to day life is in form of:-
a.Sensible- Urine output, Vomiting, Diarrhoea, Excessive sweating
(100 ml / degree farenheit rise in
temp)
b. Insensible- Lungs, Skin, Stools.
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7. •Insensible fluid input = 300 ml due to oxidation
Normal daily
•Insensible loss= 500 ml through SKIN insensible loss =
(with normal perspiration at (1000-300) ml,
normal temperature) i.e. 700 ml.
= 400 ml through LUNG (expiration)
= 100 ml through STOOL
Daily fluid requirement = Urine Output+700
ml
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9. REGULATION OF WATER INTAKE
•The Hypothalamic Thirst Center is stimulated by:
•Decline in plasma volume of 10%–15%
•Increases in plasma osmolality of 1–2%
•Baroreceptor input, angiotensin II, and other stimuli
•Thirst is quenched as soon as we begin to drink water
•Feedback signals that inhibit the thirst centers include:
1. Moistening of the mucosa of the mouth and
throat.
2. Activation of stomach and intestinal stretch
receptors.
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15. a. CRYSTALLOIDS
1. Water + Electrolytes
2. Crystalloids are aqueous solutions of mineral salts or other water-soluble
molecules.
3. Expands intravascular volume to a lesser degree than Colloids.
4. Replenishes interstitial compartment.
5. Leaves intravascular space faster (t1/2 = 20-30 mins)
6. It increases GFR.
7. No allergic reactions.
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19. b. COLLOIDS- the volume
expanders
A colloid is a substance(SOLID PARTICLES) microscopically dispersed
evenly throughout another substance(LIQUID MEDIA).
A colloidal system consists of two separate phases: a dispersed
phase (or internal phase) and a continuous phase (or dispersion medium) in
which the colloid is dispersed.
The dispersed-phase particles have a diameter of approximately between
1 and 1000 nm.
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21. 1. DEXTRAN Glucose polymer in sucrose medium. Available- Dextran
70/40.
2. MANNITOL
3. ALBUMIN (Human Serum Albumin) available in
strengths of 5%, 25%
4. HETASTARCH (Hydroxy-ethyl starch) = 6% solution in isotonic
saline (4,50,000 mol wt)
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22. 5. GELATIN POLYMERS (HAEMACCEL) = 3.5%
solution of polymer gelatin (containing of 35,000 mol wt) Also has Na, Cl, Ca, K
6. PENTASTARCH = low molecular wt derivative of Hetastarch
(10% starch)
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24. c. Blood and blood
products
1.WHOLE BLOOD.
2.PACKED RED CELLS.
3.LEUCOCYTE DEPLETED BLOOD.
4.FRESH FROZEN PLASMA.
5.PLATELETS.
6.FREEZE DRIED FACTORS.
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25. BEFORE STARTING COLLOID THERAPY
ONE SHOULD
COLLECT BLOOD SAMPLES FOR
ABO-RH GROUPING AS
BLOOD LOADED WITH COLLOIDS
INTERFERS WITH
CROSSMATCHING.
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28. 1) MAINTENANCE FLUIDS
TO REPLACE AMOUNT OF FLUID & ELECTROLYTES LOST.
THESE LOSSES ARE POOR IN SALT.
THUS, FLUIDS SHOULD BE HYPOTONIC TO PLASMA SODIUM.
EG.) 5D, DEXTROSE WITH HALF STRENGTH SALINE.
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29. 2) REPLACEMENT FLUIDS
FORMULATED TO CORRECT BODY FLUID DEFICITS CAUSED BY LOSSES
eg. Gastric Drainage, Vomiting, Diarrhoea, Intestinal Trauma, Oozing from
g.
Trauma site etc.
EG.) NORMAL SALINE, DNS, RINGER LACTATE, ISOLYTE-P/M/G.
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30. 3) SPECIAL FLUIDS
USED FOR SPECIAL NEEDS- HYPOGLYCEMIA, HYPOKALEMIA,
METABOLIC ACIDOSIS.
EG.) 25% DEXTROSE, INJ SODIUM CARBONATE, INJ POTASSIUM
CHLORIDE
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31. ADVANTAGES
1.Accurate, controlled & predictable way of administration.
2.Immediate response due to direct infusion into IV compartment.
3.Prompt correction of serious fluid & electrolyte imbalance.
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32. INDICATIONS
1. When oral intake not possible. Eg. Anaesthesia, Surgery.
2. Severe vomiting &/or diarrhoea.
3. Moderate to severe dehydration & shock.
4. Hypoglycemia. 25% Dextrose is life saving.
5. Vehicle for IV medications.
6. Total parenteral nutrition.
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33. DISADVANTAGES
1.More expensive.
2.Needs strict asepsis.
3.Possible only at a hospital setting.
4.Improper selection of fluid can be harmful.
5.Improper volume and rate of infusion can be life threatening.
6.Improper technique of administration can lead to complications.
7.Strict & natural electrolyte balance is ideally not possible, whereas natural
oral intake is superior. So, oral fluid and diet tharapy should be restarted as
early as possible.
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34. COMPLICATIONS
1.LOCAL
Haematoma
Infiltration and Infusion phlebitis.
Allergy to fluids / iv lines.
2.SYSTEMIC
Circulatory overload, in cardiac patients getting rapid or large volumes of
infusion.
Rigors.
Air Embolism.
Septicaemia.
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35. • RATE OF FLUID INFUSION DEPENDS UPON URGENCY, NEED OF
FLUID REPLACEMENT & INDICATION.
•16 drops = 1 ml (for Routine IV Set)
•RULE OF TEN – IV fluid in Litre/24 hrs x 10 = Drop Rate / Minute
•RULE OF FOUR – Drop Rate/minute x 4 = Volume in ml / Hour
•1 ml = 60 drops. (for Micro Drip Set)
• Micro drop rate / Minute = Volume in ml / hour.
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36. CHARACTERISTIC TYPE OF FLUID
Most Physiological Ringer Lactate.
Rich in Sodium NS, DNS.
Rich in Chloride NS, DNS, Isolyte-G.
Rich in Potassium Isolyte- M, P, G.
Corrects Acidosis Ringer’s lactate, Isolyte- E, P, M.
Corrects Alkalosis Isolyte- G.
Cautious in Renal Failure Ringer’s Lactate, Isolyte- E, G, M, P.
Avoided in Liver Failure Ringer’s Lactate, Isolyte- G.
Glucose free NS, Ringer’s Lactate.
Sodium free 5%, 10%, 20%, 25% Dextrose.
Potassium free NS, DNS, Dextrose fluids.
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37. o Fluid administration depends upon clinical judgement of patients status.
oAIM - To maintain reasonable blood pressure (>100/70 mmHg), Pulse
rate <120/min, hourly Urine output of 30-50ml/hour, with normal
temperature, warm skin, normal respiration & sensation.
o RINGER LACTATE is the most physiological fluid, because it’s
constitution is similar to ECF.(Na-130, K-4, Cl-109,
Lactate(bicarbonate)-28, Ca-3 mEq/L)
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38. • Depends On Type & Duration Of Surgery.
•Patients subjected to short operative procedures, who don’t need handling of
the intestinal viscera (D&C, D&E, T.L, Bartholin’s Abscess/Cyst removal etc)
will need only maintenance IV fluids to correct deficit due to NPO state.
•After 4-6 hrs oral intake is restarted, provided pre-op GI preparation optimal,
least handling of intestines during operation, no injury to the GI & patient has
no nausea/vomiting/ abdominal distention.
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39. • Patients with major surgeries (Hysterectomies, Caesarean Sections,
Cystectomy, Exploratory Laprotomy, Wertheim’s Operative procedures,
Prolapse repairs etc) where intestinal viscera need rest, require post op IV fluids
for few days.
•After ensuring normal bowel sounds & thus adequate bowel movements, oral
intake is gradually restarted, starting with oral sips, followed by semisolid food,
and ultimately normal diet.
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40. 1. Pre-op inadequate correction of hydration status with proper fluid or
inadequate Intraop maintenance by fluid infusion.
2. Inappropriate calculation of required fluid volume.
3. Intra-op blood loss replaced with equal volume of crystalloid.
IDEAL IS TO REPLACE VOLUME OF BLOOD LOST WITH
THREE TIMES VOLUME OF CRYSTALLOIDS, which
maintain the intravascular blood volume and
cardiac output, but oxygen carrying capacity
will be compromised.
thus, blood should be arranged as
soon as possible.
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41. 4. Fluid lost from naso-gastric tubes, fistulae, drains if not considered.
5. Excessive loss due to hypermetabolism, pyrexia, hyperventilation.
6. In early post-op period if there is hypotension, disproportionate anaemia…
think of internal bleeding unless proved otherwise & inadequate fluid
replacement.
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42. BEFORE PRESCRIBING POST-OP FLUIDS, ONE SHOULD CONSIDER:-
Age, Weight, Vital data, Hydration status, Urine output of the patient.
Pre-op diagnosis, Nature of surgery, Intra-op blood loss.
Nature & Volume of fluid / blood used intra-op.
Drain output, Nasogastric feeding tube output, Fluid loss at wound site.
Associated illness if any- eg. Protein losing Nephropathy, Chr HTN, DM,
CHF etc.
Insensible losses due to ambient temperature, pyrexia, hyperventilation,
obese/lean & thin body mass.
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43. 1) WHY MAINTAINENCE FLUIDS ON 1 ST POST-OP DAY ARE
LESS IN SALT & OF LOW TOTAL VOLUME ?
GA & Post-op pain leads to increase secretion of ADH & Aldosterone.
(response to stretch & stress)
Thus, salt & water are retained by the kidney.
To avoid, overloading of either salt/water, fluids low in their sodium
content, and of low total volume are used.
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44. 2) WHEN ON 1 ST POST-OP DAY, SALT CONTAINING FLUIDS ARE
TO BE USED ?
To infuse salt rich fluids is not a routine in all patients.
Special conditions are:-
a) Elderly patients with salt losing nephropathy.
b) Patients on simultaneous treatment with diuretics & mannitol.
c) To replace nasogastric aspiration & drainage output.
d) After major surgeries, wherein intestinal/renal handling has been
significant, saline is transfused to replace third space losses.
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45. 3) WHY USUALLY POTASSIUM IS AVOIDED IN FLUIDS FOR 1 ST
TWO POST-OP DAYS ?
Patients may have oliguria / azotemia. So, till urine output is established &
normal renal status ensured, potassium supplementation can be risky.
Post-op tissue trauma causes release of K+ from intracellular to
extracellular compartment, which may cause hyperkalemia.
Intra-op / Post-op transfusion of stored or haemolysed blood may add large
amounts of K+.
Post-op metabolic acidosis will shift intracellular K+ extracellularly.
As body has large stores of intracellular K+, non replacement for first 2-3
days will not cause hypokalemia.
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46. 4) WHICH FLUIDS TO BE USED TO REPLACE ADDITIONAL
LOSSES ?
Prolonged Vomiting/Nasogastric Suction- Ideal fluid is NS.
If urine output is adequate, K+ added after 2nd day.
After initial two days, even Iso-G can be added in amounts similar to upper
GI loss, provided the urine output & renal status are normal. Decision to add
K+ in fluid therapy should be guided by Serum K+ estimation & bedside
ECG.
Fluid loss due to small bowel fistulas causing diarrhoea- RL is ideal for
replacement, may need additional HCO3- & K+ supplementation.
Blood loss- to be replaced with three times the volume of NS or RL.
For larger losses, should be replaced with blood at the earliest.
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47. 5) HOW TO INFUSE FLUIDS POST OPERATIVELY ?
It’s a wrong method to infuse the entire volume over 8-12 hours.
Maintenance fluids are to be given at a steady rate over 24 hours.
If given at a fast rate & over a short period- CHF, Lung oedema, may develop
Renal excretion of excess salt & water will cause fluid-electrolyte imbalance.
Body losses continue over the 24 hours and beyond, fluids of different
compositions are given, alternated & additives may be added as per need,
evenly distributed throughout the post-op period.
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49. IN POST OP/ POST DELIVERY CONDITIONS
WHERE EARLY ENTERAL FLUID THERAPY
CANT BE STARTED, REPLACEMENT OF
ADEQUATE CALORIES SHOULD BE DEALT
PROPERLY, SO THAT PATIENT DOESN’T
DEVELOP HYPOGLYCEMIA, ACIDOSIS,
AZOTEMIA, BODY PROTEIN LOSES VIA
GLUCONEOGENESIS.
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50. Monitoring of iv fluid
therapy
1.Clinical judgement of degree of hydration/ dehydration.
2.Pulse rate, Blood Pressure monitering.
3.Strict recording of input- volume of fluid, type of fluid,
4.Strict recording of sensible fluid loss i.e urine output, sweating(temperature),
vomitings, diarrhoea, drains output, nasogastric aspiration etc.
5.Serum electrolytes estimation should be done.
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51. 6. Haematocrit.
7. Blood urea & Serum creatinine.
8. Urinary Na excretion estimation.
9. Metabolic acidosis (urine pH with litmus paper test)
10. CVP or PAWP.
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