VASCULAR ACCESS AND

FLUID MANAGEMENT ANESTHESIOLOGY | PRELIMS (1st Sem)

Dr. Jhodie Jess Melody Alconcher

OUTLINE
I. VASCULAR ACCESS AND FLUID MANAGEMENT
A. Venous Access
II. FLUID MANAGEMENT
A. Computation
B. Body Fluid Compartments
C. Distribution of Infused Fluids
D. Regulation of ECV
E. Maintenance Requirements for Water, Sodium, and Potassium
III. CALCULATING FLUID REQUIREMENTS
A. Step 1: Maintenance Fluid Requirement
B. Step 2: Fluid Deficit
C. Step 3: Anticipated Surgical Fluid Losses
D. Step 4: Adjust for Unanticipated Fluid Loss
IV. INTRAVENOUS FLUIDS
A. Fluid Status: Assessment and Monitoring

I. VASCULAR ACCESS AND FLUID MANAGEMENT CENTRAL VENOUS ACCESS

 Brief Discussion on the Venous Access  Monitoring of central venous pressure during fluid
 Fluid Management administration or resuscitation.
o Body Fluid Compartments  Invasive monitoring of cardiac output.
o Distribution of Infused Fluids  Obtaining venous access when this is not possible
o Regulation of Extracellular Volume peripherally.
o Fluid Replacement Therapy  Administration of IV fluids, medications, or blood products,
o Different IV Fluids either in large quantities or over a prolonged period of
o Fluid Status: Assessment and Monitoring time;
 Administration of medications that are harmful to
A. VENOUS ACCESS peripheral veins (eg, chemotherapy);
 One of the most basic yet critical components of patient  Long-term access to the central venous system for
care both in hospital and in ambulatory patient settings. repeated procedures, such as blood sampling
 Up to 80% of hospitalized patients receive intravenous  Can be peripherally inserted or centrally inserted
therapy at some point during their admission. o Peripherally inserted central catheters are most
 Medication, fluids, nutrition, and blood products can all be commonly inserted via the basilic, brachial, or
given cephalic veins.
o For central insertion, preferred veins include the
INTRAVENOUS ACCESS internal and external jugular.
 Peripheral Access

 Central Venous Access

II. FLUID MANAGEMENT

PERIPHERAL VENOUS ACCESS

 Most common
 Indications:
o Infusion of IV fluids (maintenance/replacement)
o Blood and blood products.
o Drug administration (continuous or intermittent).
o Prophylactic use before procedures.
o Prophylactic use in unstable patients.

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 Prelims (1st Sem) Vascular Access and Fluid Management
Dr. Jhodie Jess Melody Alconcher
ANESTHESIOLOGY· September 15, 2020

 Principal component of extracellular fluid is SODIUM

o Responsible for much of extracellular fluid
osmolality
 Principal component of intracellular fluid is POTASSIUM
o Key role in the maintenance of transmembrane
potentials

C. DISTRIBUTION OF INFUSED FLUIDS

 Clinical prediction of PV expansion after fluid infusion
assumes that body fluid spaces are static
 Ex of static approach:
o 70 kg with 2,000 ml acute blood loss
o Formula describing the effects of replacement
A. COMPUTATION
with 5% D5W, LR or 5% or 25% human serum
albumin:
o Expected PV increment
 Vol infused x normal PV
distribution vol
o Rearranging the equation:
Vol infused = expected PV increment x distribution vol
normal PV
 If 5% albumin, infused volume initially would remain in the
PV, perhaps attracting additional interstitial fluid
intravascularly
 25% human serum albumin, a concentrated colloid
expands PV by ~400 ml for each 100 ml infused
B. BODY FLUID COMPARTMENTS
D. REGULATION OF ECV
 Total Body Water (TBW)
 TBW content is regulated by the intake and output of water
o Distribution volume of sodium free water
 Thirst
 Extracellular Volume (ECV)
o The primary mechanism of controlling water intake
o Distribution volume of infused Na
o Triggered by an increase in body fluid tonicity or
o Equal [] of Na in IF and PV
decrease in ECV
o Plasma [Na] = 140 mEq/L
 Antidiuretic hormone (ADH)
o Distribution volume for colloid solutions
 Atrial Natriuretic Peptide (ANP)
 Intracellular cat ion [K]
o 150 mEq/L  Aldosterone
 Albumin
o Most important oncotically active constituent of ECV
o Unequally distributed in PV
 ~4 g/dL
o In IFV
 ~1 g/dL

ADH (VASOPRESSIN)
 Synthesize in the supraoptic nucleus of the hypothalamus,
secreted by the posterior pituitary.
 Regulated by the OSMOTIC and NON OSMOTIC
MECHANISM
 Binds to V2 receptors along the basolateral membrane of
collecting ducts, then stimulates the synthesis and
Figure 1. Composition of Intracellular and Extracellular Fluid
insertion of the aquaporin 2 water channel into the luminal
Compartments (in mOsm/L water)
membrane of collecting duct cells

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 Prelims (1st Sem) Vascular Access and Fluid Management
Dr. Jhodie Jess Melody Alconcher
ANESTHESIOLOGY· September 15, 2020

ANTRIAL NATRIURETIC PEPTIDE

 Release by the atrial cell in response to stretch that is
cause by increase blood pressure
 Reduces blood pressure and blood volume by inhibiting
release of ADH, renin, and aldosterone, and directly
causing vasodilation.

ALDOSTERONE
 Part of RAAS
 Aldosterone serves as the principal regulator of the salt
and water balance of the body (salt reabsorption)

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 Prelims (1st Sem) Vascular Access and Fluid Management
Dr. Jhodie Jess Melody Alconcher
ANESTHESIOLOGY· September 15, 2020

Glucose containing fluids

 Prevents hypoglycemia and limit protein
catabolism
 Iatrogenic hyperglycemia – can limit the
effectiveness of fluid resuscitation by inducing
osmotic diuresis
 In critically ill patients, tight control of plasma
glucose (maintenance of plasma glucose
between 80 and 110 mg/dL) is associated with
better outcomes

III. CALCULATING FLUID REQUIREMENTS

 Fluids must be given based on an estimation of the
following –
o Fluid losses prior to start of anesthesia,
o Maintenance requirements,
o Normal fluid losses that occur during surgery, and
response to unanticipated fluid (blood) loss.
o Furthermore, consider titrating fluid requirements
to physiologic measures (ex. CVP, urine output).

A. STEP 1: MAINTENANCE FLUID REQUIREMENT

 Holliday-segar method (4-2-1) rule
o 4 ml/kg/hr for the first 10kg of body weight
o 2 ml/kg/hr for the second 10kg body weight
o 1ml/kg/hr subsequent kg body weight
 Example: 70kg pt
o Maintenance fluid: 40+20+50= 110ml/hr

Compute for the following maintenance fluid requirement

of the following patients:
1. 55 year old, 60 kg man was scheduled for
cholecystectomy.
2. 25 years old, 45 kg patient for mesh hernioplasty
3. 10 year old, 20 kg patient for “E” appendectomy

B. STEP 2: FLUID DEFICIT

 Based on patient’s weight, using the same 4/2/1 rule as
used to calculate preoperative maintenance requirements.
 Number of hours NPO x maintenance fluid

st
Half is given during the 1 hour, then ¼ each of the
remaining hours
E. MAINTENANCE REQUIREMENTS FOR WATER, SODIUM  Sample: 70 kg patient placed on NPO 8 hours prior to the
AND POTASSIUM procedure
Table 1. Hourly and Daily Maintenance Water  maintenance (4-2-1) = 110 cc
Requirements  110 x 8= 880 cc
Wt. (kg) Water (ml/kg/hr) Water (ml/kg/day)
1-10 4 100 Compute for the deficit fluid requirement of the following
11-20 2 50 patients:
21 above 1 20 1. 55 year old, 60 kg man was scheduled for
cholecystectomy. The patient was admitted a day
 Daily adult requirements for prior to operation, ordered NPO 8 hours prior to
o Na = 75 mEq/kg operation.
o K = 40 mEq/kg 2. 25 years old, 45 kg patient for mesh hernioplasty.
 Therefore: Ordered NPO 6 hours prior to operation
o Healthy 70 kg adult require 2,500 mL/day of 3. 10 year old, 20 kg patient for “E” appendectomy. The
water containing [Na] 30 mEq/L and [K] 15-20 patient was ordered NPO 8 hours prior to operation.
mEq/L
 Intraoperatively, fluids containing sodium free water (ex: <
130 mEq/L) are rarely used in adults because of the
necessity for replacing isotonic losses and the risk of
postoperative hyponatremia

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 Prelims (1st Sem) Vascular Access and Fluid Management
Dr. Jhodie Jess Melody Alconcher
ANESTHESIOLOGY· September 15, 2020

C. STEP 3: ANTICIPATED SURGICAL FLUID LOSSES  HES

 Based on patient’s weight and anticipated tissue trauma. A
rough guide can be found in Stoelting:
 Minimal tissue trauma (ex. herniorrhaphy): 2-4 cc/kg/hr
 Moderate tissue trauma (ex. cholecystectomy): 4-6
cc/kg/hr
 Severe tissue trauma (ex. bowel resection): 6-8 cc/kg/hr
 [Stoelting et. al. Basics of Anesthesia, 5th ed. Elsevier –
China, p. 349, 2007]
o 4-6 ml/kg/hr for procedures involving minimal
tissue trauma
o 6-8 ml/kg/hr for those involving moderate trauma
o 8-12 ml/kg/hr for those involving extreme trauma
o Most commonly used synthetic colloid
o Large doses exceeding 20ml/kg/day produced
laboratory evidence of coagulopathy
o Cochrane Systematic Reviews
 “there is no evidence that one colloid is more
effective or safer than any other”
o In severe sepsis
 Fluid resuscitation with HES results in
significantly higher death rates compared
with Lactated ringers

Calculate the anticipated surgical fluid loss:

1. 55 year old, 60 kg man underwent cholecystectomy
for 1 hour (Ans: 360mL)
2. 25 years old, 45 kg patient underwent mesh
hernioplasty for 2 hours (Ans. 360mL)

D. STEP 4: ADJUST FOR UNANTICIPATED FLUID LOSS

 Common recommendation:
o 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.
 REMEMBER:
o Suction bottle
o Operating sponges
 Most general and regional anesthetics cause arteriolar and
venous dilatation, expanding the vascular capacity, which
reduces the peripheral venous pressure, venous return
and cardiac output.
 Fluid must be administered to expand the blood volume to
compensate for venodilatation
 For regional anesthesia:
o Preloading: administration of crystalloid 10-15
ml/kg over 10-15 minutes prior to administration
 A 70 kg patient was brought to the recovery room after a
successful 2 hour exploratory laparotomy for perforated
peptic ulcer. The patient has a blood loss of 500 cc during
the operation. The patient has been admitted prior to
surgery and was placed on NPO x 8 hours. Compute for
the fluid requirement:

IV. INTRAVENOUS FLUIDS

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 Prelims (1st Sem) Vascular Access and Fluid Management
Dr. Jhodie Jess Melody Alconcher
ANESTHESIOLOGY· September 15, 2020

 Laboratory evidence that suggest hypovolemia

o Azotemia
o Low urinary Na
o Metabolic alkalosis (if mild hypovolemia)
o Metabolic acidosis (if severe hypovolemia
 Intraoperative assessment
o Visual estimation
o Assessment of the adequacy of intraop fluid
resuscitaion
 HR
 BP
 UO
A. FLUID STATUS: ASSESSMENT AND MONITORING  0.5-1ml/kg/hr during anesthesia suggest
 Physical signs of hypovolemia adequate renal perfusion
o Oliguria,  Arterial oxygenation
o Supine hypotension  pH
 Implies >30% blood volume deficit
o Positive tilt test
 Increase in HR > 20 beats/min and a dec of References
SBP > 20 mmHg when subject assumes  Dr. Jhodie Jess Melody Alconcher’S ppt
upright position

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