Perioperative Fluid Therapy.ppt

8/20/2019 Perioperative Fluid Therapy.ppt

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Perioperative Fluid Management

Oleh

Hasanuddin

Pembimbing

Dr. Abd. Wahab, SpAn


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The principle of uid therapy is tomaintain tissue perfusion

How much should we inuse!

What luids should we use!

How should we monitor luid replacement!

So…


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Total Body Water

• Total body water varies between 55-70% of BW

• Depend on : - age

- se

!ale " fe!ale #!ore fat$

• TBW approi!ately 0% of BW

• & person of 0 'gs (as 0 0% ) * +


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"ntra #ellular Space

# e l l m e

m b r a n e

" n

t r a v a s c u l a r S p a c e

RBC

# a p i l l a r $ m e m b r a n e

Distribution o bod$ luids

total bod$ water %&' (W

)*'

*' +&'

a - )+& me/l

0 -

+ me/l , a - ) + & m e . / l

0 - + m e . / l

"nterstitial

Space

#olloid cr$stalloids

1lucose solution

a - 2 me/l

0 - )*)

me/l


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,o!position of flid

.o!part!ents

plasma interstitial intracellular

CationsNa 140 146 12K 4 4 150Ca 5 3 10Mg 2 1 7

Anions

Cl 103 104 3HCO 24 27 10O4 1 1 !H"O4 2 2 116"rotein 16 5 40


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3$pe o Fluid 4oss in Perioperative Periode

5 (asal luid reuirements

5 Fluid loses on drainage, istel, maagslang6

5 7edistributive and evaporativesurgical losses

5 Fluid shits 83hird space losses65 (leeding

How much should we inused !


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10 #g $ 4 %lg ' 40 %l

10 #g $ 2 %lg ' 20 %l

50 #g $ 1 %lg ' 50 %l

110 %ls & (r )ggest to *reo*erati+e re(idrate ,it( gl)#osa t(at -an .

1/ de-rease sel)ler ins)lin resistan-e *ost o*erati

2/ n-rease %)s-le ton)s *ost o*erati

/ole of -1-2

/e3ire!ents for 70'g !an


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7edistributive and evaporative surgical luid

losses

Degree o tissue trauma Additional luidreuirement

Minimal 8 herniorrhaph$6 & 9 : cc/ ;g/hour

Moderate8 cholec$stectom$6

: 9 + cc/;g/ hour

Severe 8 bowel resection6 + 9 2 cc/;g/hour


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#lass " #lass "" #lass """ #lass "<

(lood loss =p to >*& >*&?)*&& )*&&?:&&& @:&&&

(lood loss

8 '(


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#ourse o h$povolaemic shoc; in absence otherap$

De.o!pen-sation

,o!pen-sation

Bleeding

Heart rate%in

(lood pressure mmHg

9rreversi-bility

3hree Shoc; phases

Bloodpressre

0

*&

)&&

)*&


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Problems with Perioperative Fluid

7eplacement

• We canEt accuratel$ evaluate blood volume

• We canEt accuratel$ identi$ luid overload

• We canEt accuratel$ identi$ h$povolemia

•

We canEt accuratel$ evaluate tissue perusion


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#omplication

• 7is;s o inadeuate resuscitation

4ie?threatening G lactic acidosis, A7F, MOF

on?atal G thirst$, drows$ness, di$, nausea I


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/estri.tive vs +iberal


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}


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Starling #apillar$ Forces

5 3wo orces regulate bul; low across capillariesG

9 H$drostatic 8HP6 and osmotic pressure 8OP6

5 3hese orces eist in two luid compartmentsG

9 (lood 8(6 and interstitial luid 8"F6

Arterial nd


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W(at flid s(old we se >

5 #r$stalloid solutions 9 "sotonic

9 H$potonic 9 h$pertonic

5 #olloid solutions 9 Semi?s$nthetic colloids 9 aturall$ occurring human

plasma derivatives


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Crystalliod Colloid"ntravascular persistance Poor 1ood

Haemod$namicstabilisation

3ransient Prolonged

7euired inusion volume 4arge Moderate

7is; o tissue oedema Obvious "nsigniicant

nhancement o capillar$ perusion

Poor 1ood

7is; o anaph$lais il 4ow to moderate

Plasma colloid osmotic pressure

7educed Maintained

#ost "nepensive pensive

#r$stalloids and colloids


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T(e CrystalloidsCrystalloids are a gro)* o intra+eno)s l)id in ,(i-( %ay e.

9oni. soltion

? /inger la.tate4 a.etate

? @a,l p(ysiologi. #0A% saline$

? 6art!anCs soltion

? t.

• ostly iso-os!olar ) isotoni.

• ,(eap easy to !anfa.tre

• 6as no i!!nologi. rea.tion

• ainly .onfined to t(e etra.elllar flid

@on ioni.

? Detrose 5%

? altose 20%

? t.

• Distribted to intra.elllar spa.e


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le-trolyte Co%*arison

Bet,een NaCl 0/8

Na9

K9

Ca9

Cl!

a-tate Os%/=las!a 20 5 20* - *00

/inger +a.tate 2*0 * 20 18 17*

@a,l 25 - - 25 - *08


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=ra.ti.al .rystalloid t(erapy

• yo) in)se NaCl 0/8 1000%l: all t(e Na9 ,ill

re%ain in t(e C;

• As NaCl is isotoni- t(ere is no -(ange in C;os%olality and no ,ater e$-(ange o--)rs

a-ross t(e -ell %e%rane

• NaCl e$*ands C; only

• ntra+as-)lar +ol)%e ,ill e in-reased y 250%l


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=ra.ti.al .rystalloid t(erapy .ont…

• yo) in)se gl)-ose 58 1000%l: t(e gl)-ose

,ill enter t(e -ell and e %etaolised

• T(e ,ater e$*ands ot( C; and C; in

*ro*ortion to t(eir +ol)%es

• T(e C; +ol)%e ,ill in-rease y 333%l

• ntra+as-)lar +ol)%e ,ill only in-rease y

a**ro$i%ately 100%l


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T(e ,olloids

,olloids are flids w(i.( .ontain on.oti.

parti.les t(erefore eert an on.oti. pressre

• Blood

• =las!a• &lb!in

• &rtifi.ial .olloids ) plas!a epander

?

? H #6ydroyet(yl star.($ e/g/ (e%o(es 68 & 108


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#olloids luid loading leads to greater increase in

preload recruit table 4


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5 Saline or colloids do not aect permeabilit$

5 HS decrease permeabilit$ due to endothelial protections

5 4"S 8 lung "nKur$ Score 6 ma$ slightl$ increase in colloid

estimated b$ L respirator$ compliance caused b$ increase"3(< which "< volume was included 8 increased volume dueto increased #OP 6


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How should we monitor luid replacement!

• (P, H7, =O

• Filling pressures

• 1astric pHi

• 3ransthoracic or transeophageal

echo

• 1oal?directed 7


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• C(e-# @ regi%e ordered in o* or%

• Assess or dei-its y -(e-#ing &O -(art and +ital

signs

• Cal-)late %aintenan-e re)ire%ents

• s)ally K9 not started in irst 24 (rs

• Monitor -are)lly +ital signs and )rine o)t*)t

• Cardia-: renal and li+er ail)re still %)stres)s-itate/ nd*oint are less *redi-tale: %onitor

%ore intensi+ely =C n+asi+e %onitoring>

=ostoperative flid t(erapy

# l i


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#onclusions G

3arget o Fluid 3herap$ Perioperative

5 Hemod$namic Optimalisation 9 "n acute emergenc$ resuscitation irst priorit$ J restoration

o an adeuate circulating volume adeuate

intravascular volume, DO:, blood pressure, adeuate

Microcirculation 9 Over h$dration adverse outcome

5 Optimal volume distribution

5 Speciic losses should be replaced with appropriate luid

cr$stalloid 9 colloid, consider both solute, dissolve solute,electrol$te content, total osmolalit$, saet$, and side eect


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Perioperative Fluid Therapy.ppt