This document provides guidelines for intravenous fluid therapy for adult surgical patients. It discusses fluid management before, during, and after surgery. Key recommendations include using balanced crystalloid or colloid solutions to treat volume deficits, assessing volume status and response to fluid boluses, achieving euvolemia and minimizing sodium and fluid overload postoperatively, and providing nutrition support while mitigating risks like refeeding syndrome. The guidelines emphasize tailored fluid management based on individual patient factors, goals of fluid resuscitation, and monitoring for fluid balance and adequacy of resuscitation.

1. Fluid and Electrolytes in Surgical
Management

2. Water in Human body
• Adult male has 60% of lean body weight as water.
• While in females its 50% of lean body weight and in new born
its 80%.
Total Body Water = 0.6 >< Lean Body Weight (in male)
0.5 >< Lean Body Weight (in female)
• Muscles & solid organ contain more water and fat & bone
almost lack water.

3. Compartmental water distribution
• Extra cellular 1/3
20% Plasma
80% Interstitium
• Intra cellular 2/3

4. Physiology of body fluids
• Osmolarity =2 Na+ + Glucose/18 + BUN /2.8
• Approximately 2 liter of fluid intake daily intake
75% oral water
25% food
Daily 3-5 g salt
• Out put
1 liter in urine
250 ml stool
600ml insensible loss from lung and skin
A minimum of 500ml urine daily

5. For the ‘average’ 70 Kg man
Total body water is 42 L (~60% of body weight)
28 L is in the intracellular and 14 L in the extracellular compartments
The plasma volume is 3 L
The extravascular volume is 11 L
Total body Na+ is 4200 mmol (50% in ECF)
Total body K+ is 3500 mmol (only about 50-60 mmol in ECF)
Normal osmolality of ECF is 280 –295 mosmol/kg

6. Maintenance requirements
Daily maintenance fluid requirements vary between individuals.
70 Kg male = 2.5 - 3.0L water,
120 – 140 mmol sodium
and 70 mmol potassium
40 Kg woman = 2.0L water,
70 – 90 mmol sodium
and 40 mmol potassium
children
0-10 kg is 100 ml/kg
10-20 kg is 1000 ml + 50 ml/kg for each kg > 10
>20 kg is 1500 ml + 25 ml/kg for each kg > 20

7. Volume deficit
1. Naso gastric suction
2. Vomiting
3. Diarrhea
4. Fistula
5. Burn
6. Peritonitis
7. Soft tissue injury
8. Intestinal obstruction
9. Prolonged surgery

8. Features of volume deficit
1. Weight loss
2. Decreased skin turgor
3. Tachycardia
4. Hypotension
5. Collapsed vein
6. Oliguria

9. Volume excess
1. Iatrogenic
2. Renal dysfunction
3. Congestive heart failure
4. Cirrhosis

10. Features of volume excess
1. Weight gain
2. Peripheral edema
3. Increased central venous pressure
4. Distended neck veins
5. Murmur
6. Pulmonary edema

11. Electrolyte imbalance
• Hyper nateremia
• Hypo nateremia
• Hyper kalemia
• Hypo kalemia

12. Hyper nateremia
• Causes:
A. Hyper volemic
1. Iatrogenic overloading with Na containing fluids.
2. Excess mineralocorticoid
B. Normo volemic
1. Renal (Diabetes insipidus,diuretic and renal disorders)
2. Non renal (GI losses and skin)
C. Hypo volemic
1. Renal (Diabetes insipidus, adrenal failure, osmotic
diuretics and Renal tubular disorders)
2. Non renal (Fever, tracheostomy, diarrhea)

13. Correction
• Calculate water deficit
= serum Na -140 >< Total body water
140
D5%, D 5% in 0.25% NS
Cerebral edema, herniation

14. Hyponatremia• Causes:
1. Fluid overload
a. Iatrogenic over administration of hypotonic fluids
b. Excess oral intake of water or hypotonic fluids
c. Drugs like Tricyclic antidepressant, antipsychotics and ACE inhibitors
d. Post operative patients due to high ADH.
2. Fluid depletion
a. Decreased sodium intake
b. GI losses like vomiting, diarrhea, nasogastric suction
c. Renal loss- high urinary sodium
Features of dehydration
3. Excess solutes
a. Hyper glycemia
b. Excess mannitol administration
4. Pseudo hyponatremia
a. Hyper lipidemia
b. Hyper proteinemia

15. Correction
• Calculate Na+ deficit
Deficit = (140- Serum sodium) >< TBW
Correct 0.5mEq/L to 12 mEq/L in a day
Fast correction can lead to Pontine myelinosis

16. Hyper kalemia
Causes
A. Increased intake
a. Supplements
b. Transfusion
c. Hemolysis
d. Rhabdomyolysis
e. Crush injury
f. GI hemorrhage
B. Increase release by intact cells
a. Acidosis
b. Alteration in extracellular osmolarity
C. Impaired secretion
a. Potassium sparing diuretics
b. Renal failure

17. ECG features
1. Peak T wave
2. Flat P wave
3. PR prolongation
4. QRS prolongation
5. Sine wave

18. Correction
1. Cation exchange resin, kayexalate
2. Glucose and HCO3-, Glucose Insulin
3. If ECG changes occur, Ca++ Cl-
4. Beta agonist
5. Dialysis

19. Hypo kalemia
Causes
A. Decreased intake
a. K+ free fluids
B. Increase loss
a. Hyper aldosterone
b. Diuretics
C. GI loss
a. Diarrhea
b. Vomiting
c. RT aspirate

20. ECG changes
1. U wave
2. T wave
3. ST segment changes
Correction
a. Potassium deficit in mmol is calculated as given below:
Kdeficit (mmol) = (Knormal lower limit - Kmeasured) x kg body weight x 0.4
b. Daily potassium requirement is around 1 mmol/Kg body weight.
c. 13.4 mmol of potassium found in 1 g KCl. (molecular weight KCl = 39.1
+ 35.5 = 74.6)

21. Composition of crystalloids
• 3L of Dextrose saline is not equivalent to 2L 5% Dextrose and 1L Normal
saline
• 3L Dextrose Saline = 3L water and 90 mmol sodium
• 2L 5% Dextrose saline + 1L Normal saline = 3L water and 154 mmol sodium
Hartmann’s
Solution
Normal
Saline
Dextrose
Saline
Sodium (mmol/
l)
131 150 30
Chloride
(mmol/l)
111 150 30
Potassium
(mmol/l)
5 Nil Nil
Bicarbonate
(mmol/l)
29 Nil Nil
Calcium
(mmol/l)
2 Nil Nil

22. Normal saline
• 154 mEq/L
Disadvantages
• Cl- overload
• Hyper chloremic metabolic acidosis
Advantages
• Hypo natremia
• Hypo chloremia

23. Ringer lactate
• Contain lactate gets converted to HCO3-in
liver.
• Advantage
Physiological fluid
• Disadvantage
D isomer shows inflammatory response

24. Colloids
• Stay in intravascular compartment for long
time.
• Disadvantages
Detrimental in severe hemorrhagic shock
when capillary permeability is high it may
worsen edema

25. Composition of colloids
Volume effect (%) Average MW (kDa) Circulatory half life
Gelatins (Haemaccel) 80 35 2-3 hours
4% Albumin 100 69 15 days
Dextran 70 120 41 2-12 hours
6% Hydroxyethyl
Starch
100 70 17 days
• Monodispersed = All molecules of similar molecular weight
• Polydispersed = Molecules have spread of molecular weights

26. Albumin
• Monodispersed
• Sterlized pooled human plasma
• Expensive
• May worsen renal failure, pulmonary edema and
cause hypersensitivity.
• Long half life
• Accounts for 60-80% of normal plasma oncotic
pressure
• No adverse effect on coagulation

27. Dextrans
• Polysaccharides
• Bacteria grown on sucrose medium
• Polydispersed with MW 10-90 kDa
• Reduces plasma viscosity
• Reduces platelet aggregation
• 1-5% develop anaphylaxis

28. Gelatins
• Polypeptides
• Bovine collagen
• Not approved in US
• Polydispersed with MW ~35 kDa
• Rapidly lost from vascular space
Hydroxyethyl starch
• Synthetic polysaccharide polymers derived from
amylopectin
• Polydispersed with MW 50-450 kDa
• Large molecules engulfed by reticuloendothelial system
• Associated with bleeding diathesis, renal dysfunction
and hyperchloremic acidosis

29. Assessment of adequacy of
resuscitation
• Clinical history and observations – Pulse, blood
pressure, skin turgor
• Urine output – oliguria < 0.5 ml/kg/hr
• CVP or pulmonary capillary wedge pressure
• Response of urine output or CVP to fluid challenge
• A fluid challenge should be regarded as a 200-250 ml
bolus of colloid
• This should be administered as quickly as possible
• A response in the CVP or urine output should be seen
within minutes
• The size and duration of the CVP response rather the
actual values recorded is more important

30. GIFTASUP Recommendations (2008)
Guidelines for Intravenous Fluid Therapy for Adult Surgical Patients
Preoperative fluid management
Recommendation 4
In patients without disorders of gastric emptying undergoing elective surgery clear
non-particulate oral fluids should not be withheld for more than two hours prior to
the induction of anaesthesia
Recommendation 5
In the absence of disorders of gastric emptying or diabetes, preoperative
administration of carbohydrate rich beverages 2-3 h before induction of
anaesthesia may improve patient well being and facilitate recovery from surgery. It
should be considered in the routine preoperative preparation for elective surgery
Recommendation 6
Routine use of preoperative mechanical bowel preparation is not beneficial and may
complicate intra and postoperative management of fluid and electrolyte balance.
Its use should therefore be avoided whenever possible
Recommendation 7
Where mechanical bowel preparation is used, fluid and electrolyte derangements
commonly occur and should be corrected by simultaneous intravenous fluid
therapy with Hartmann’s or Ringer-Lactate/acetate type solutions

31. Recommendation 8
Excessive losses from gastric aspiration or vomiting should be treated preoperatively
with an appropriate crystalloid solution which includes an appropriate potassium
supplement. Hypochloraemia is an indication for the use of 0.9% saline, with sufficient
additions of potassium and care not to produce sodium overload. Losses from
diarrhoea, ileostomy, small bowel fistula, ileus or obstruction should be replaced
volume for volume with Hartmann’s or Ringer-Lactate/acetate type solutions. “Saline
depletion,” for example due to excessive diuretic exposure, is best managed with a
balanced electrolyte solution such as Hartmann's
Recommendation 9
In high risk surgical patients, preoperative treatment with intravenous fluid and
inotropes should be aimed at achieving predetermined goals for cardiac output and
oxygen delivery as this may improve survival
Recommendation 10
Although currently logistically difficult in many centres, preoperative or operative
hypovolaemia should be diagnosed by flow-based measurements wherever possible.
The clinical context should also be taken into account as this will provide an important
indication of whether hypovolaemia is possible or likely. When direct flow
measurements are not possible, hypovolaemia will be diagnosed clinically on the basis
of pulse, peripheral perfusion and capillary refill, venous pressure and Glasgow Coma
Scale together with acid-base and lactate measurements. A low urine output can be
misleading and needs to be interpreted in the context of the patient’s cardiovascular
parameters above

32. Recommendation 11
Hypovolaemia due predominantly to blood loss should be treated with either a
balanced crystalloid solution or a suitable colloid until packed red cells are available.
Hypovolaemia due to severe inflammation such as infection, peritonitis, pancreatitis
or burns should be treated with either a suitable colloid or a balanced crystalloid. In
either clinical scenario, care must be taken to administer sufficient balanced crystalloid
and colloid to normalise haemodynamic parameters and minimise overload. The
ability of critically ill patients to excrete excess sodium and water is compromised,
placing them at risk of severe interstitial oedema. The administration of large volumes
of colloid without sufficient free water (e.g. 5% dextrose) may precipitate a
hyperoncotic state
Recommendation 12
When the diagnosis of hypovolaemia is in doubt and the central venous pressure is
not raised, the response to a bolus infusion of 200 ml of a suitable colloid or
crystalloid should be tested. The response should be assessed using the patient’s
cardiac output and stroke volume measured by flow-based technology if available.
Alternatively, the clinical response may be monitored by measurement/estimation of
the pulse, capillary refill, CVP and blood pressure before and 15 minutes after
receiving the infusion. This procedure should be repeated until there is no further
increase in stroke volume and improvement in the clinical parameters

33. Intraoperative fluid management
Recommendation 13
In patients undergoing some forms of orthopaedic and
abdominal surgery, intraoperative treatment with
intravenous fluid to achieve an optimal value of stroke
volume should be used where possible as this may reduce
postoperative complication rates and duration of hospital
stay
Recommendation 14
Patients undergoing non-elective major abdominal or
orthopaedic surgery should receive intravenous fluid to
achieve an optimal value of stroke volume during and for
the first eight hours after surgery. This may be
supplemented by a low dose dopexamine infusion

34. Postoperative fluid, and nutritional
management
Recommendation 15
Details of fluids administered must be clearly recorded and
easily accessible
Recommendation 16
When patients leave theatre for the ward, HDU or ICU their
volume status should be assessed. The volume and type of
fluids given perioperatively should be reviewed and
compared with fluid losses in theatre including urine and
insensible losses
Recommendation 17
In patients who are euvolaemic and haemodynamically stable
a return to oral fluid administration should be achieved as
soon as possible

35. Recommendation 18
In patients requiring continuing i.v. maintenance fluids, these should be sodium
poor and of low enough volume until the patient has returned their sodium
and fluid balance over the perioperative period to zero. When this has been
achieved the i.v. fluid volume and content should be those required for daily
maintenance and replacement of any on-going additional losses
Recommendation 19
The haemodynamic and fluid status of those patients who fail to excrete their
perioperative sodium load, and especially whose urine sodium concentration is
<20mmol/L, should be reviewed
Recommendation 20
In high risk patients undergoing major abdominal surgery, postoperative
treatment with intravenous fluid and low dose dopexamine should be
considered, in order to achieve a predetermined value for systemic oxygen
delivery, as this may reduce postoperative complication rates and duration of
hospital stay

36. Recommendation 21
In patients who are oedematous, hypovolaemia if present must be treated,
followed by a gradual persistent negative sodium and water balance based on
urine sodium concentration or excretion. Plasma potassium concentration
should be monitored and where necessary potassium intake adjusted
Recommendation 22
Nutritionally depleted patients need cautious refeeding orally, enterally or
parenterally, with feeds supplemented in potassium, phosphate and
thiamine. Generally, and particularly if oedema is present, these feeds should
be reduced in water and sodium. Though refeeding syndrome is a risk,
improved nutrition will help to restore normal partitioning of sodium,
potassium and water between intra and extra-cellular spaces
Recommendation 23
Surgical patients should be nutritionally screened, and NICE guidelines for
perioperative nutritional support adhered to. Care should be taken to
mitigate risks of the refeeding syndrome