Good surgeon who decide to open ‫ رياض عدنان عويد العطار‬.

‫د‬
But the best surgeon who decide not open
: Parenteral Fluid Therapy
: A. Principles of Fluid Management

of body wt. are water(60% male and 50% female and infant up to 50-75%-
.75%-80% till 1 year of age
Increase fat decrease %water ,increase age decrease %water due to decrease -
.muscles mass
Body water =42 L (28 L intracellular which its 40% body wt. and mainly in -
the skeletal muscles , 14L extracellular which its 10,5 interstitial and 3,5
intravascular )
I.C.(cation are k ,Mg – anion are protein and phosphate) -
E.C. ( cation are Na ,Ca –anion are CL ,bicarbonate)-

Daily intake= 2000-2500 cc water \day (1500 cc oral intake and remainder -
by solid food
: Daily GIT secrete= (8-10 L) water/24 hrs- -
saliva=1500cc(500-2000cc), gastric juice=2500cc(100-4000cc), - -
. Bile=500cc(50-800cc), pancr.=700cc(100-800cc) , Int.=3000cc
Daily loss (stool=250cc , urine=800-1500cc , insensible loss=600cc (75% -
skin vapor ,25% lung. pure water loss replaced by 5% G\W ) )
Fever increase loss 250cc \every 1 increase temperature above normal -
Sweating may reach 4L \hr loss water-
Tracheostomy may reach 1500 cc\day loss water-
GIT loss usu.isotonic or slightly hypotonic fluid-
stomach, small bowel, Bile fluid are rich in CL-
pancreas and Bile are rich in Hco3-
Saliva high K-
: Normal values -
Na=137-147 mmol/L
CL=95-105 mmol/L
K=3,5-5 mmol/L
Ca =2.2-2.5 mmol/L(9-11 mg/dl)
Mg=0.7-0.9 mmol/L
Bicarbonate =25-30 mmol/L
Normal values :meq/L -
S.I.=Na 140 ,CL=104 ,K=5 ,Hco3= 30-
Saliva =10 , 10 ,26 ,30-
Gastric=60 ,130 ,10-
Pancre=140 ,75 ,5 ,105-
Colon =60 ,40 ,30 , 40-

: Maintenance-1

fluids: should be administered at rate that is sufficient to maintain urine -

output of 0.5-1 ml/kg/hr in adult .it can basis of body wt. as: 100ml/kg/day
for first 10kg , 50ml/kg/day for second 10kg , and 20ml/kg/day for remain
.body wt. OR in general 25-30ml/kg/day

Electrolyte maintenance : Na(1-2mmol/kg/day) ,k (0.5-1 mmol/kg/day) , -

.)CL 1 mmol/kg/day

Glucose : 50-100 gm /day ( e.g. G/W 5% contain 5 gm glucose /every 100 -

ml )

Intraoprative fluid management :replacement of perioperative ongoing loss -2

. include blood loss ,third space loss, insensible loss

The fluids used crystalloid three to four volume blood loss intraoperative or
.colloid or blood same volume blood loss intraoperative

Also insensible or third space loss depend on size and extended of tissues
trauma like 1-3ml/kg/hr loss for inguinal surgery or 3-7ml/kg/hr for laparotomy
with less tissue trauma or 9-11ml/kg/hr for more tissues trauma like whipple
surgery

Postoperative fluid management : required careful evaluation of patient and -3

should maintain adequate urine output (0.5-1 ml/kg/hr).zero day fluid need
G/W according to the wt. of patient and fluid with electrolyte add in day one
post-operative or if there is gastric drainage fluid type its (D5% 0,45NaCl
+20meq K ) AND pancreatic and biliary and small and large intestine loss
. drainage replace with Ringer Lactate fluid

blood replacement = 70 ml/kg-

Plasma replacement =20 ml/kg

massive blood transfusion if > 10 unite /24hr so give {fresh frozen plasma 1:1 -
blood, and 6:1 blood and keep platelet count >100.000 ,and cryoprecipitate
every 6 unite blood check fibrinogen level if <100 give 20gm (20
.unite)fibrinogen }

give Ca ampule for every 3-4 unite blood to prevent risk of DIC due to citrate in -
.storage blood bag lead to decrease ionized Ca in storage blood

. blood unite must give within not more than 4 hr to decrease infection cx -

blood loss :{ rib # =100-200 ml ,Tibia # =300-500 ml , Femur # =800-1000 ml , -

. Pelvic # =>1000 ml } loss

Massive haemothorax if > 1500ml blood drainage by chest tube in first -

.insertion or if > 200ml blood in first 3-4 hr so need thoracotomy

.If bleeding continuous the risk of death increase 1% for every 3 minutes -

B-Crystalloids :are fluid contain Na as the major particle .use for volume
:expansion ,maintenance ,electrolyte disturbance correction

Isotonic crystalloids : Ringer lactate and 0.9% Normal saline .its distribute -1
manly extracellular fluid so use GI loss mainly ringer and NS use mainly in
hyperkalemia ,hypercalcemia ,hyponatremia ,hypochloremia or metabolic
. alkalosis
Hypertonic saline solutions : 3% NaCl alone or with colloid like dextran good -2
for resuscitation of shock or burn bur had risk of ( hypernatremia , hyper
osmolality , hyperchloremia , hypokalemia , central pounten demyelination with
. raped infusion .so use with caution

Hypotonic solutions : D5%W ,0.,45 NaCl distribute throughout the total body -3
water compartment ,expanding the intravascular compartment of 105 volume
infusion so not use for volume expansion .so they use for replace free water
. deficit ( as in hyponatremia )

C- Colloid solutions : contain high molecular weight substance that remain

intravascular space .Early use for resuscitation lead to more raped tissues
perfusion and less fluid requirement for resuscitation. Its more expensive than
: crystalloid

Albumin preparations : Its mainly extracellular distribution and initially -1

intravascular . preparations of 255 albumin (100ml) and 5% albumin 9500 ml )
expand the intravascular volume by equivalent amount ( 450-500 ml ) .Albumin
25% is indicate in edematous patient to mobilize interstitial fluid into the
intravascular space . they are not use in patient with adequate colloid oncotic
pressure ( serum albumin >2.5 mg/dl , total protein >5 mg/dl ) , for chronic
. illness (cirrhosis or nephrotic syndrome or nutritional sources

Dextran : short acting ,for acute replace intravascular volume .side effects -2
( renal failure ,osmotic diuresis ,coagulopathy due to affect decrease factor VIII
and VWF and inhibit platelets aggregation so affect cross matching so take
blood sample before given , increase blood glucose and protein, hyperchloremic
.acidosis

Hetastarch : long acting ,expanding intravascular , its increase risk of acute -3

kidney injury and backed RBC ,and sepsis

: CRYSTOLOID FLUID( meq\L)-

N\S 0,9%=Na 154 ,CL 154 ,OSM=308-
Ringer Lactate = Na 130 ,CL 109, K 3-5, Hco3 28 ,Ca 3,OSM 280 -
Hypertonic saline 3% =513 Na+CL-
Half saline(0.45%) =77 Na+CL-
G\W 5% =50gm\L ,OSM 284-
Na Bicarbonate =Na 150 ,150 Hco3-
: Colloid-
Medium acting (Albumin =5% +10%,pentasrarch ) -
Short acting (Dextran +gelaten ( hemacel ,gelfucin )) -
Long acting ( hexastarch ) -

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When there is bleeding don’t worry it's not your blood just
.stop the bleeding then thinking about the solution