PERIOPERATIVE FLUID PERIOPERATIVE FLUID

THERAPYTHERAPY

Dr. Sayeed NawazConsultant anesthesit

Department of AnesthesiologyKKUH. King Saud University

Total Body Water (TBW)Total Body Water (TBW)

• Varies with age, genderVaries with age, gender• 55%55% body weight in males body weight in males• 45%45% body weight in females body weight in females• 80%80% body weight in infants body weight in infants• Less in obese: fat contains little waterLess in obese: fat contains little water

Final Goals of Fluid resuscitationFinal Goals of Fluid resuscitation

- - Achievement of normovolemia& hemodynamic stabilityAchievement of normovolemia& hemodynamic stability

- Correction of major acid-base disturbances- Correction of major acid-base disturbances- Compensation of internal fluid fluxes- Compensation of internal fluid fluxes- Improvement of microvascular blood flow- Improvement of microvascular blood flow- Prevention of cascade system activation- Prevention of cascade system activation- Normalization of O2 delivery- Normalization of O2 delivery- Prevention of reperfusion cellular injury- Prevention of reperfusion cellular injury- Achievement of adequate urine output - Achievement of adequate urine output

Desirable outcome of fluid Desirable outcome of fluid resuscitationresuscitation

- No peripheral edema- No peripheral edema

- No ARDS- No ARDS

Fluid and Electrolyte RegulationFluid and Electrolyte Regulation

• Volume RegulationVolume Regulation- Antidiuretic HormoneAntidiuretic Hormone- Renin/angiotensin/aldosterone systemRenin/angiotensin/aldosterone system- Baroreceptors in carotid arteries and aortaBaroreceptors in carotid arteries and aorta- Stretch receptors in atrium and juxtaglomerular Stretch receptors in atrium and juxtaglomerular

aparatusaparatus- CortisolCortisol

Preoperative EvaluationPreoperative Evaluationof Fluid Statusof Fluid Status

• Factors to Assess:Factors to Assess:- h/o intake and outputh/o intake and output- blood pressure: supine blood pressure: supine andand standing standing- heart rateheart rate- skin skin - Urinary outputUrinary output- mental statusmental status

Orthostatic HypotensionOrthostatic Hypotension

• Systolic blood pressure Systolic blood pressure decreasedecrease of greater than of greater than 20mmHg20mmHg from supine to standing from supine to standing

• Indicates fluid Indicates fluid deficitdeficit of of 6-8%6-8% body weight body weight-- Heart rate should increase as a compensatory measure Heart rate should increase as a compensatory measure-- If no increase in heart rate, may indicate autonomic dysfunction If no increase in heart rate, may indicate autonomic dysfunction

or antihypertensive drug therapyor antihypertensive drug therapy

Perioperative Fluid RequirementsPerioperative Fluid Requirements

The following factors must be taken into account:The following factors must be taken into account:

1- 1- MMaintenance fluid requirementsaintenance fluid requirements

2- 2- NPONPO and other deficits: NG suction, bowel prep and other deficits: NG suction, bowel prep

3- 3- TThird space and invisible losseshird space and invisible losses

4- 4- RReplacement of blood losseplacement of blood loss

5- Special additional losses: diarrhea5- Special additional losses: diarrhea

1- Maintenance Fluid Requirements1- Maintenance Fluid Requirements

• Insensible losses such as evaporation of water from Insensible losses such as evaporation of water from respiratory tract, sweat, feces, urinary excretion.respiratory tract, sweat, feces, urinary excretion. Occurs continuallyOccurs continually..

• Adults: approximately Adults: approximately 1.5 ml/kg/hr1.5 ml/kg/hr• ““4-2-1 Rule”4-2-1 Rule”

-- 4 ml/kg/hr for the first 10 kg of body weight 4 ml/kg/hr for the first 10 kg of body weight-- 2 ml/kg/hr for the second 10 kg body weight 2 ml/kg/hr for the second 10 kg body weight-- 1 ml/kg/hr subsequent kg body weight 1 ml/kg/hr subsequent kg body weight-- Extra fluid for fever, tracheotomy, denuded surfaces Extra fluid for fever, tracheotomy, denuded surfaces

2- NPO and other deficits2- NPO and other deficits

• NPO deficit = number of hours NPO x NPO deficit = number of hours NPO x maintenance fluid requirement.maintenance fluid requirement.

• Bowel prep may result in up to 1 L fluid loss.Bowel prep may result in up to 1 L fluid loss.• Measurable fluid losses, e.g. NG suctioning, Measurable fluid losses, e.g. NG suctioning,

vomiting, ostomy output, biliary fistula and tube.vomiting, ostomy output, biliary fistula and tube.

3- Third Space & invisble Losses3- Third Space & invisble Losses

• Isotonic transfer of ECF from Isotonic transfer of ECF from functionalfunctional body body fluid compartments to fluid compartments to non-functionalnon-functional compartments.compartments.

• Depends on location and duration of surgical Depends on location and duration of surgical procedure, amount of tissue trauma, ambient procedure, amount of tissue trauma, ambient temperature, room ventilation.temperature, room ventilation.

Replacing invisible LossesReplacing invisible Losses

• Superficial surgical trauma: 1-Superficial surgical trauma: 1-22 ml/kg/hrml/kg/hr• Minimal Surgical Trauma: 3-Minimal Surgical Trauma: 3-44 ml/kg/hrml/kg/hr

- - head and neck, hernia, knee surgery head and neck, hernia, knee surgery

• Moderate Surgical Trauma: 5-Moderate Surgical Trauma: 5-66 ml/kg/hr ml/kg/hr-- hysterectomy, chest surgery hysterectomy, chest surgery

• Severe surgical trauma: Severe surgical trauma: 88-10 ml/kg/hr (or more)-10 ml/kg/hr (or more)-- AAA repair, nehprectomy AAA repair, nehprectomy

4- Blood Loss4- Blood Loss

• Replace Replace 3 cc3 cc of crystalloid solution per cc of of crystalloid solution per cc of blood loss (crystalloid solutions leave the blood loss (crystalloid solutions leave the intravascular space)intravascular space)

• When using blood products or colloids replace When using blood products or colloids replace blood loss volume per volumeblood loss volume per volume

5- Other additional losses5- Other additional losses

• Ongoing fluid losses from other sites:Ongoing fluid losses from other sites:-- gastric drainage gastric drainage-- ostomy output ostomy output-- diarrhea diarrhea

• Replace volume per volume with crystalloid Replace volume per volume with crystalloid solutionssolutions

ExampleExample

• 62 y/o male, 80 kg, for hemicolectomy62 y/o male, 80 kg, for hemicolectomy• NPO after 10 PM, surgery at 8 AM,NPO after 10 PM, surgery at 8 AM,• Received bowel preparation Received bowel preparation • 3 hours long procedure with blood loss of 500 ml3 hours long procedure with blood loss of 500 ml• What is his estimated intraoperative fluid What is his estimated intraoperative fluid

requirement?requirement?

Fluid requirement of this patientFluid requirement of this patient

• Fluid deficit (NPO)Fluid deficit (NPO): 1.5 ml/kg/hr x 10 hrs = 1200 ml + : 1.5 ml/kg/hr x 10 hrs = 1200 ml + 1000 ml for bowel preparation = 2200 ml is total deficit: 1000 ml for bowel preparation = 2200 ml is total deficit: (Replace 1/2 first hour, 1/4 2nd hour, 1/4 3rd hour).(Replace 1/2 first hour, 1/4 2nd hour, 1/4 3rd hour).

• MaintenanceMaintenance:: 1.5 ml/kg/hr x 3hrs = 360mls 1.5 ml/kg/hr x 3hrs = 360mls• invisible Lossesinvisible Losses:: 6 ml/kg/hour x 3 hours =1440 ml 6 ml/kg/hour x 3 hours =1440 ml• Blood LossBlood Loss:: 500ml x 3 = 1500ml 500ml x 3 = 1500ml• TotalTotal = 2200+360+1440+1500=5500mls = 2200+360+1440+1500=5500mls

Intravenous Fluids:Intravenous Fluids:

• Conventional CrystalloidsConventional Crystalloids• ColloidsColloids• Hypertonic SolutionsHypertonic Solutions• Blood/blood products and blood substitutesBlood/blood products and blood substitutes

CrystalloidsCrystalloids

• Combination of Combination of water and electrolyteswater and electrolytes- Balanced salt solution: electrolyte composition and Balanced salt solution: electrolyte composition and

osmolality similar to plasma; example: lactated Ringerosmolality similar to plasma; example: lactated Ringer

- Hypotonic salt solution: electrolyte composition lower Hypotonic salt solution: electrolyte composition lower than that of plasma; example: Dthan that of plasma; example: D55W.W.

- Hypertonic salt solution: 2.7% NaCl.Hypertonic salt solution: 2.7% NaCl.

Crystalloids in traumaCrystalloids in traumaAdvantages:Advantages:

--Balanced electrolyte solutionBalanced electrolyte solution

-Easy to administer-Easy to administer

-No risk of adverse reactions-No risk of adverse reactions

-No disturbance of hemostasis-No disturbance of hemostasis

-Promote diuresis-Promote diuresis

-Inexpensive-Inexpensive

Crystalloids Crystalloids Disadvantages:Disadvantages:

--Poor plasma volume supportPoor plasma volume support

-Large quantities needed-Large quantities needed

-Risk of Hypothermia-Risk of Hypothermia

-Reduced plasma oncotic pressure-Reduced plasma oncotic pressure

-Risk of edema-Risk of edema

Hypertonic SolutionsHypertonic Solutions

• Fluids containing sodium concentrations greater than Fluids containing sodium concentrations greater than normal saline.normal saline.

• Available in 1.8%, 2.7%, 3%, 5%, 7.5%, 10% solutions.Available in 1.8%, 2.7%, 3%, 5%, 7.5%, 10% solutions.

• Hyperosmolarity Hyperosmolarity creates a gradient that draws water out creates a gradient that draws water out of cells; therefore, cellular dehydration is a potential of cells; therefore, cellular dehydration is a potential problem.problem.

Hypertonic salineHypertonic saline

Advantages:Advantages:-Small volume for resuscitation. -Small volume for resuscitation. -Osmotic effect-Osmotic effect-Inotropic effect ( increase calcium influx in sarculima )-Inotropic effect ( increase calcium influx in sarculima )-Direct vasodilator effect-Direct vasodilator effect-Increase MAP, CO-Increase MAP, CO-Increase renal, mesenteric, splanchnic, coronary blood -Increase renal, mesenteric, splanchnic, coronary blood

flow.flow.

Hypertonic salineHypertonic saline

Disadvantages: Disadvantages: • increase hemorrhage from open vessels.increase hemorrhage from open vessels.• HypernatremiaHypernatremia• Hyperchloremia. Hyperchloremia. • Metabolic acidosis.Metabolic acidosis.

CrystalloidsCrystalloidsLactated Ringer'sLactated Ringer's

Composition: Composition: Na 130, cl 109, K 4, ca 3, Lactate 28, Na 130, cl 109, K 4, ca 3, Lactate 28, Osmolarity 273 mosmol/lOsmolarity 273 mosmol/l

-Sydney Ringer 1880-Sydney Ringer 1880-Hartmann added Lactate=LR-Hartmann added Lactate=LR-Minor advantage over NaCl-Minor advantage over NaClDisadvantages: Disadvantages: -Not to be used for dilution of blood (Ca citrate)-Not to be used for dilution of blood (Ca citrate)

CrystalloidsCrystalloidsDextrose 5%Dextrose 5%

Composition: 50 gm /liter, provides 170 kcal /literComposition: 50 gm /liter, provides 170 kcal /liter

Disadvantages:Disadvantages:

-enhance CO2 production-enhance CO2 production

-enhance lactate production-enhance lactate production

CompositionComposition

Fluid Osmo-lality

Na Cl K

D5W 253 0 0 0

0.9NS 308 154 154 0

LR 273 130 109 4.0

Plasma-lyte 294 140 98 5.0

Hespan 310 154 154 0

5% Albumin 308 145 145 0

3%Saline 1027 513 513 0

ColloidsColloids

• Fluids containing Fluids containing molecules molecules sufficiently large sufficiently large enough to prevent transfer across capillary enough to prevent transfer across capillary membranes.membranes.

• Solutions stay in the space into which they are Solutions stay in the space into which they are infused.infused.

• Examples: hetastarch (Hespan), albumin, dextran.Examples: hetastarch (Hespan), albumin, dextran.

ColloidsColloids

Advantages:Advantages:

-Prolonged plasma volume support-Prolonged plasma volume support

-Moderate volume needed-Moderate volume needed

-minimal risk of tissue edema-minimal risk of tissue edema

-enhances microvascular flow-enhances microvascular flow

ColloidsColloids

Disadvantages:Disadvantages:

Risk of volume overloadRisk of volume overload

Adverse effect on haemostasisAdverse effect on haemostasis

Anaphylactic reactionAnaphylactic reaction

ExpensiveExpensive

Crystalloids versus colloidsCrystalloids versus colloids

CharactorCharactor Crystalloids ColloidsCrystalloids Colloids

In the vein Poor GoodIn the vein Poor Good

Hemody. Stability Transient ProlongHemody. Stability Transient Prolong

Infusion volume Large ModerateInfusion volume Large Moderate

Plasma COP Reduced MaintainPlasma COP Reduced Maintain

Tissue edema Obvious InsignificantTissue edema Obvious Insignificant

Anaphylaxis Non-exist low-modAnaphylaxis Non-exist low-mod

Cost Inexpensive ExpensiveCost Inexpensive Expensive

Clinical Evaluation of Fluid Clinical Evaluation of Fluid ReplacementReplacement

1. Urine Output: at least 1.0 ml/kg/hour1. Urine Output: at least 1.0 ml/kg/hour2. Vital Signs: Blood pressure and heart rate 2. Vital Signs: Blood pressure and heart rate 3. Physical Assessment: texture of skin and mucous 3. Physical Assessment: texture of skin and mucous

membranes; thirst in an awake patientmembranes; thirst in an awake patient4. Invasive monitoring; CVP may be used as a guide4. Invasive monitoring; CVP may be used as a guide5. Laboratory tests: periodic monitoring of hemoglobin and 5. Laboratory tests: periodic monitoring of hemoglobin and

hematocrithematocrit

SummarySummary• Fluid therapy is critically important during the Fluid therapy is critically important during the

perioperative period.perioperative period.

• The most important goal is to maintain The most important goal is to maintain hemodynamic stability and protect vital organs hemodynamic stability and protect vital organs from hypoperfusion (heart, liver, brain, kidneys).from hypoperfusion (heart, liver, brain, kidneys).

• All sources of fluid losses must be accounted for.All sources of fluid losses must be accounted for.

• Good fluid management goes a long way toward Good fluid management goes a long way toward preventing problems.preventing problems.

Transfusion TherapyTransfusion Therapy

-- 60% of transfusions occur perioperatively.60% of transfusions occur perioperatively.

-- responsibility of transfusing perioperatively is with the responsibility of transfusing perioperatively is with the anesthesiologist.anesthesiologist.

Blood GroupsBlood Groups

Antigen onAntigen on Plasma Plasma IncidenceIncidence

Blood GroupBlood Group erythrocyteerythrocyte AntibodiesAntibodies WhiteWhite African-African-AmericansAmericans

AA AA Anti-BAnti-B 40%40% 27%27%BB BB Anti-AAnti-A 1111 2020ABAB ABAB NoneNone 44 44OO NoneNone Anti-AAnti-A 4545 4949

Anti-BAnti-BRhRh RhRh 4242 1717

Cross MatchCross Match• Major:Major:

-- Donor’s erythrocytes incubated with recipients plasmaDonor’s erythrocytes incubated with recipients plasma

• Minor:Minor:-- Donor’s plasma incubated with recipients erythrocytes Donor’s plasma incubated with recipients erythrocytes

• Agglutination:Agglutination:-- Occurs if either is incompatible Occurs if either is incompatible

• Type Specific:Type Specific:-- Only ABO-Rh determined; Only ABO-Rh determined;

Type and ScreenType and Screen

• Donated blood that has been tested for ABO/Rh Donated blood that has been tested for ABO/Rh antigens and screened for common antibodies antigens and screened for common antibodies (not mixed with recipient blood).(not mixed with recipient blood).- - Used when usage of blood is unlikely, but needs to be Used when usage of blood is unlikely, but needs to be

available (hysterectomy).available (hysterectomy).

-- Chance of hemolytic reaction: 1:10,000. Chance of hemolytic reaction: 1:10,000.

Blood ComponentsBlood Components

Prepared from Whole blood collectionPrepared from Whole blood collection Whole blood is separated by differential centrifugationWhole blood is separated by differential centrifugation

Red Blood Cells (RBC’s)Red Blood Cells (RBC’s) PlateletsPlatelets PlasmaPlasma

» CryoprecipitateCryoprecipitate» OthersOthers

Others include Plasma proteins— Coagulation Factors, Others include Plasma proteins— Coagulation Factors, albumin, Growth Factors, Colloid volume expandersalbumin, Growth Factors, Colloid volume expanders

Transfusion ComplicationsTransfusion Complications

Acute Transfusion Reactions (ATR’s)Acute Transfusion Reactions (ATR’s)Chronic Transfusion ReactionsChronic Transfusion ReactionsTransfusion related infectionsTransfusion related infections

Acute Transfusion ReactionsAcute Transfusion Reactions

Hemolytic Reactions (AHTR)Hemolytic Reactions (AHTR) Febrile Reactions Febrile Reactions Allergic ReactionsAllergic Reactions TRALITRALI Coagulopathy with Massive transfusionsCoagulopathy with Massive transfusions BacteremiaBacteremia

Complications of Blood TherapyComplications of Blood Therapy (cont.)(cont.)

• Hemolytic: Hemolytic: - Wrong blood type administered (oops).Wrong blood type administered (oops).- Activation of complement system leads to intravascular Activation of complement system leads to intravascular

hemolysis, spontaneous hemorrhage.hemolysis, spontaneous hemorrhage.

Signs:Signs: hypotension,

fever, chills

dyspnea, skin flushing,

substernal pain , Back/abdominal pain

Oliguria Dark urine Pallor

Complications of Blood TherapyComplications of Blood Therapy (cont.)(cont.)

Signs are easily masked by general anesthesia.Signs are easily masked by general anesthesia.- Free Hgb in plasma or urine Free Hgb in plasma or urine - Acute renal failureAcute renal failure- Disseminated Intravascular Coagulation (DIC)Disseminated Intravascular Coagulation (DIC)

Complications (cont.)Complications (cont.)

• Transmission of Viral Diseases:Transmission of Viral Diseases:- Hepatitis C; 1:30,000 per unitHepatitis C; 1:30,000 per unit- Hepatitis B; 1:200,000 per unitHepatitis B; 1:200,000 per unit- HIV; 1:450,000-1:600,000 per unitHIV; 1:450,000-1:600,000 per unit- Parasitic and bacterial transmission very lowParasitic and bacterial transmission very low

Treatment of Acute Hemolytic Treatment of Acute Hemolytic ReactionsReactions

• Immediate Immediate discontiuediscontiue transfusion and send blood transfusion and send blood bags to lab.bags to lab.

• Maintenance of urine output with crystalloid Maintenance of urine output with crystalloid infusionsinfusions

• Administration of mannitol or Furosemide for Administration of mannitol or Furosemide for diuretic effectdiuretic effect

What to do?What to do?If an AHTR occursIf an AHTR occurs

STOP TRANSFUSIONSTOP TRANSFUSION ABC’sABC’s Maintain IV access and run IVF (NS or LR)Maintain IV access and run IVF (NS or LR) Monitor and maintain BP/pulseMonitor and maintain BP/pulse Give diureticGive diuretic Obtain blood and urine for transfusion reaction workupObtain blood and urine for transfusion reaction workup Send remaining blood back to Blood BankSend remaining blood back to Blood Bank

Monitoring in AHTRMonitoring in AHTR

Monitor patient clinical status and vital signsMonitor patient clinical status and vital signs Monitor renal status (BUN, creatinine)Monitor renal status (BUN, creatinine) Monitor coagulation status (DIC panel– PT/PTT, Monitor coagulation status (DIC panel– PT/PTT,

fibrinogen, D-dimer/FDP, Plt, Antithrombin-III)fibrinogen, D-dimer/FDP, Plt, Antithrombin-III) Monitor for signs of hemolysis Monitor for signs of hemolysis

Massive Blood TransfusionMassive Blood Transfusion

Massive transfusionMassive transfusion is generally defined as the is generally defined as the need to transfuse one to two times the patient's need to transfuse one to two times the patient's blood volume. For most adult patients, that is the blood volume. For most adult patients, that is the equivalent of 10–20 unitsequivalent of 10–20 units

Problems of massive transfusionProblems of massive transfusion

Dilutional thrombocytopenia and coagulopathyDilutional thrombocytopenia and coagulopathy Citrate toxicityCitrate toxicity Hypothermia Hypothermia Metobolic alkalosisMetobolic alkalosis Hyperkalemia ( stored blood )Hyperkalemia ( stored blood ) DICDIC

How to avoid problems of How to avoid problems of massive transfusionmassive transfusion

Use autologous blood transfusionUse autologous blood transfusion Cell saver technologyCell saver technology Substitute to bloodSubstitute to blood

artificial blood ( perflurocarbons )artificial blood ( perflurocarbons )

Blood SubstitutesBlood Substitutes (cont.) (cont.)

• Potential Advantages:Potential Advantages:- No cross-match requirementsNo cross-match requirements- Long-term shelf storageLong-term shelf storage- No blood-bourne transmissionNo blood-bourne transmission- Rapid restoration of oxygen delivery in traumatized Rapid restoration of oxygen delivery in traumatized

patientspatients- Easy access to product (available on ambulances, field Easy access to product (available on ambulances, field

hospitals, hospital ships)hospitals, hospital ships)