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General Surgery ~~ Fluid management in Adults Previous lecture slides produced in R2.
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2009/8/19 ⼩小港外科 Intern teaching R2 ⿈黃昱豪
Fluid Management in Adults
Surgeon’s Maintenance Fluid
Human beings are built by water......
Male (60%) > female (50%)
⼥女⼈人是⽔水作的??
Biomedical Importance of WaterHomeostasis (CES)
Water distribution
PH maintenance
Maintain Electrolyte Concentration
Set of Fluid Balance
Depletion (dehydration)
Intoxication (over-hydration)
Osmotic & non osmotic mechanism
Body Fluid Compartments:
ICF: 55%~75%
Intravascular àplasma
X 50~70% lean body weight
Extravascular àInterstitial
fluid
TBW
ECF
3/4
1/4
Male (60%) > female (50%)
TBW(Total Body Water)=0.6xBW
ICF=0.4xBW
ECF=0.2xBW
2/3
1/3
Mr.Iron, 60-Kg male, he has......IVW
Ans: 60Kg x 60%(man) x 1/3(ECF) x 1/4(IV) = 3kg intravascular water (about 3000 ml plasma)
Composition of Body Fluids:
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations AnionsEC
FIC
F
Osmolarity = solute/(solute+solvent) Osmolality = solute/solvent (290~310mOsm/L)
Tonicity = effective osmolality Plasma osmolility = 2 x (Na) + (Glucose/18) + (Urea/2.8)
Plasma tonicity = 2 x (Na) + (Glucose/18)
Regulation of Fluids:
Hydrostatic pressure v.s. Oncotic pressure à Albumin is the major determining oncotic pressure
Regulation of Fluids:
Renal sympathetic nerves
Renin-angiotensin-
aldosterone system
Atrial natriuretic peptide (ANP)
Fluid management
intake, produce
output, loss
FLUID REQUIREMENTS
Sources Losses (35ml/kg/day)
Water 1500 ml Urine (0.5~1ml/kg/hr)
1500 ml
Food 800 ml Stool 200 ml
Oxidation 300 ml Skin (12ml/kg/day)
500 ml
Resp. Tract 400 ml
Total 2600 ml Total 2600 ml
Practically Daily Input/Output balance = +500ml
Fluid Management
lMaintenance+Deficit+Ongoing loss
Maintenance DeficitOngoing loss
Maintenance fluid
Maintenance Fluid:Water require, Rule:
100-50-20(60kg=2300ml/day) 100ml/kg/d(for 1st 10kg) +50ml/kg/d(for 2nd 10kg)+20ml/kg/d(per add 1 kg)
4-2-1(60kg=100ml/hr=2400ml/day) 4ml/kg/hr(for 1st 10kg) +2ml/kg/hr(for 2nd 10kg)+1ml/kg/hr(per add 1 kg)
1.5ml/kg/hr(60kg=90ml/hr=2160ml/day) Electrolytes require:
- Na+: 2-3mmol/kg/day
- K+: 1~2mmol/kg/day
Glucose supplement(if NPO):
100~150g dextrose/per day
"Two stereoisomers (isomeric molecules whose atomic connectivity is the same but whose atomic arrangement in space is different.) of the aldohexose sugars are known as glucose, only one of which (D-glucose) is biologically active. This form (D-glucose) is often referred to as dextrose monohydrate, or, especially in the food industry, simply dextrose (from dextrorotatory glucose).
Mr.Iron, 60-Kg male, NPO Maintenance Fluid......
1. Daily Na Requirement=3meq/kg ×60kg=180meq
Daily K Requirement=1meq/kg ×60kg=60meq
2. Maintenance water=2300ml=2.3L
3. 【Na】of fluid=180meq÷2.3L=
78meq/L≒1/2 normal saline
4. 0.9%NaCl=154meq/L
MAINTENANCE vs. REPLACEMENT
n Maintenance:
• Provide normal daily requirements:
• Water: 2.5 L
• Sodium ½ or ¼ NS
• KCl 40-60 meq
n Example:
D5 ½ NS with KCL 20 meq/L running at 100 ml/hr
Intravenous Fluids:• Crystalloids • Colloids • Blood/blood products and blood
substitutes
Parenteral Fluid Therapy:
Crystalloids:
- contain Na as the main osmotically
active particle
- useful for volume expansion (mainly
interstitial space)
- for maintenance infusion
- correction of electrolyte abnormality
Crystalloids: Isotonic crystalloids
- Lactated Ringer’s, 0.9% NaCl
- only 25% remain intravascularly
Hypertonic saline solutions
- 3% NaCl
Hypotonic solutions
- D5W, 0.45% NaCl
- less than 10% remain intra-
vascularly, inadequate for fluid
resuscitation
Colloid Solutions:
Contain high molecular weight
substancesàdo not readily migrate across
capillary walls
Preparations
- Albumin: 5%, 25%
- Dextran
- Gelofusine
- Voluven
Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3- Dextrose mOsm/L
ECF 142 4 5 103 27 280-310
Lactated Ringer’s 500 130 4 3 109 28 273
0.9% NaCl 500 154 154 308
0.45% NaCl 500 77 77 154
D5W/D10W 50/100
D2.5/0.45% NaCl 500 77 77 25 406
3% NaCl 513 513 1026
Taita No.3 500 75 12 26 20 285Taita No.4 500 110 20 102 8 300Taita No.5 400 36 18 3 17 100 669
Common parenteral fluid therapy-Crystalloid
Acetate:20 Phosphate:6
Acetate:16 Phosphate:12
Acetate:28 Phosphate:12
Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3- Dextrose mOsm/L
ECF 142 4 5 103 27 280-310
6% Hetastarch 500 154 154 310
5% Albumin 250,500 130-160 <2.5 130-16
0 330
25% Albumin 20,50,100 130-16
0 <2.5 130-160 330
Common parenteral fluid therapy-Colloid
The Influence of Colloid & Crystalloid on Blood Volume:
1000cc
500cc
500cc
500cc
200 600 1000
Lactated Ringers
5% Albumin
6% Hetastarch
Whole blood
Blood volumeInfusion volume
Deficits fluid
NPO and other deficits
• NPO deficit =number of hours NPO x maintenance fluid requirement. • Bowel prep may result in up to 1 L fluid
loss.
Third Space Losses• Isotonic transfer of ECF from functional body
fluid compartments to non-functional compartments. • Depends on location and duration of surgical
procedure, amount of tissue trauma, ambient temperature, room ventilation.
Department of Anesthesiology Uniformed Services University of the Health Sciences
Replacing Third Space Losses• Superficial surgical trauma: 1-2 ml/kg/hr
• Minimal Surgical Trauma: 3-4 ml/kg/hr
- head and neck, hernia, knee surgery
• Moderate Surgical Trauma: 5-6 ml/kg/hr
- hysterectomy, chest surgery
• Severe surgical trauma: 8-10 ml/kg/hr (or more)
- AAA repair, nehprectomy
Department of Anesthesiology Uniformed Services University of the Health Sciences
Ongoing loss fluid
• Measurable fluid losses:
• Foley tube
• NG suctioning/vomiting
• ostomy output
• PTGBD, T-tube
• Bleeding
!
!
!
• Unmeasurable fluid losses:
• Fever(Temp of 38.3C~39.4C, >24hr ==>500ml ;>37C, 100~150ml/C)
• Ventilator
• Bleeding
Composition of GI Secretions:Source Volume (ml/24h) Na+* K+ Cl- HCO3
-
Salivary 1500 (500~2000) 10 (2~10) 26 (20~30) 10 (8~18) 30
Stomach 1500 (100~4000) 60 (9~116) 10 (0~32) 130 (8~154) 0
Duodenum 100~2000 140 5 80 0
Ileum 3000 140 (80~150) 5 (2~8) 104 (43~137) 30
Colon 100-9000 60 30 40 0
Pancreas 100-800 140 (113~185) 5 (3~7) 75 (54~95) 115
Bile 50-800 145 (131~164) 5 (3~12) 100 (89~180) 35
* Average concentration: mmol/L
Other factors• Ongoing fluid losses from other sites:
- gastric drainage - ostomy output - diarrhea - PTGBD, T-tube
• Replace volume per volume with crystalloid solutions
Blood Loss
• Replace 3 cc of crystalloid solution per cc of blood loss (crystalloid solutions leave the intravascular space)
• When using blood products or colloids replace blood loss volume per volume
Example• Mr.Michelin, 62 y/o male, 80 kg, for hemicolectomy
• NPO after 2200, surgery at 0800, received bowel prep
• 3 hr. procedure, 500 cc blood loss
• What are his estimated intraoperative fluid requirements?
Example (cont.)• Ans: • Fluid deficit: 1.5 ml/kg/hr x 10 hrs = 1200 ml + 1000
ml for bowel prep = 2200 ml • Maintenance: 1.5 ml/kg/hr x 3hrs = 360mls • Third Space Losses: 6 ml/kg/hr x 3 hrs =1440 mls • Blood Loss: 500ml x 3 = 1500ml • Total = 2200+360+1440+1500=5500mls
Monitor
Hypovolemia
Signs of Hypovolemia: Diminished skin turgor
Dry oral mucus membrane
Oliguria
- <500ml/day
- normal: 0.5~1ml/kg/hr
Tachycardia
Orthostatic hypotension/Hypotension
Hypoperfusionàcyanosis
Altered mental status
Orthostatic Hypotension
• Systolic blood pressure decrease of greater than 20mmHg from supine to standing
• Indicates fluid deficit of 6-8% body weight
- Heart rate should increase as a compensatory measure
- If no increase in heart rate, may indicate autonomic dysfunction or antihypertensive drug therapy
Clinical Diagnosis of Hypovolemia:
Thorough history taking: poor intake, GI
bleeding…etc
BUN : Creatinine > 20 : 1
- BUN↑: hyperalimentation, glucocorticoid
therapy, UGI bleeding
Increased specific gravity
Increased hematocrit
Electrolytes imbalance
Acid-base disorder
Hypervolemia
Signs of Hypervolemia:
Hypertension
Polyuria
Peripheral edema
Wet lung
Jugular vein engorgement
Especially when hypo-albuminemia
Management of Hypervolemia:
Prevention is the best way
Guide fluid therapy with CVP level or
pulmonary wedge pressure
Diuretics
Increase oncotic pressure: FFP or
albumin infusion (may followed by diuretics)
Dialysis
Summary• Fluid therapy is critically important during the
perioperative period. • The most important goal is to maintain hemodynamic
stability and protect vital organs from hypoperfusion (heart, liver, brain, kidneys). • All sources of fluid losses must be accounted for. • Good fluid management goes a long way toward
preventing problems.
歡迎加⼊入外科的⾏行列