FLUID THERAPY IN SURGICAL

PATIENTS
• Multiple factors modify the normal physiology
• Acute stress Sympathetic stimulation
• Increased ACTH Hydrocortisone ,
Aldosterone
• Post-Op pain and stress increased ADH
secretion
• Hypovolemic prior to surgery
• Goal – to maintain BP >100/70 mmHg , PR
<120bpm , hourly urine flow 30-50ml , N.
Temp ,warm skin , normal respiration and
Causes of dehydration in surgical patients:
Vomitings, diarrhea
Nasogastric suction
Drains
Hyperventilation
Preop bowel preparation
THIRD SPACE LOSSES:
Internal redistribution of ECF due to sequestration of fluid in body
Ex: massive ascites, postop swelling of bowel wall and mesentery,
acute severe cellulitis, acute intestinal obstruction, crush injuries

FLUID THERAPY IN SURGICAL

PATIENTS
• Pre operative fluid therapy
• Intraoperative fluid therapy
• Post operative fluid therapy
 PRE-OPERATIVE FLUID
THERAPY
• Treating existing fluid and electrolyte disorders
• However , in emergency conditions though it is
not possible – partly correction
• It is as follows-
1. Correction of hypovolemia
2.correction of anemia
3.correction of other disorders like fluid
overload , hypokalemia , hyperkalemia
 Correction of Hypovolemia
• Hypovolemia reduced perfusion reduced O2 transport
increased tissue hypoxia Organ failure
• Greater the duration greater the risk
• Normal Baroreceptor reflex
• Severe Hypotension or even Acute respiratory failure
• CAUSES
vomiting , NG suction , blood loss , third space loss ,fever ,
hyperventilation , diuretics , diarrhoea , preoperative bowel
preparation
- Third space loss – Massive ascites , crush injuries , acute intestinal
obstruction , acute peritonitis , acute pancreatitis , acute severe
cellulitis , post op swelling of bowel wall and mesentery
-Dehydration (mild , moderate and severe)
• Choice of fluid is for replacement depends on nature of loss ,
hemodynamic status
• 0.9%NS , RL , Wole blood and Colloids are widely used
• Rate of infusion varies depending on severity , on going losses ,
hemodynamic and cardiac , renal status .
• In severe deficit status the rate of infusion may be 1000ml per hour
and gradually reducing the rate as the fluid status improves.
• Depending on severity of dehydration fluid deficit is estimated
roughly as
Mild dehydration = 4% body weight fluid defecit (in litres)
Moderate = 6-8% Bd wt.
Severe = 10% bd wt.
• Monitoring fluid therapy –
Improvement in Tachycardia , Blood pressure
Urine output atleast 30-50 ml/hr (in the absence of diuretics)
Absence of Orthostatic Hypotension
 Correction of
• As storedAnemia
blood is low in 2,3-DPG
• Usually should be done 48-72 hrs pre-operatively
• Packed cells is always preferred preoperatively as it avoids volume
over load

Correction of other factors

•FLUID OVERLOAD
-Rare but due to over aggressive fluid therapy and Third space loss
shift to ECF
-Diuretics , salt and fluid restriction
•HYPOKALEMIA
-many causes like GI loses , K+ free IV fluids infusion , Parenteral
nutrition , obligatory renal loss (20 mEq per day ), Metabolic
alkalosis
-oral potassium foods , oral syrup , or IV 40-60 mEq in 1 lit of NS or
5%Dextrose
•HYPERKALEMIA
- surgical stress, crush injury , catabolic state , potassium infusion in
oliguric or anuric renal failure
 INTRA-OPERATIVE FLUID
THERAPY
• To maintain proper tissue perfusion and oxygenation
• Important causes of hypotension intra operatively are loss of blood , fluid
depletion (Intra-op loss and maintenance deficit) , third space losses ,
evaporative losses from viscera or wound itself , vasodilatory effects of
anesthetic agents
• It can be done with a crystalloid or a colloid
• Crystalloids- more commonly used as it is less expensive , readily
available and reaction free but it’s not confined to intravascular compartment
• Peripheral and pulmonary edema
• Treatment of choice in interstitial dehydration
• Ringer’s lactate is ideal fluid for replenishment with additional advantage of
correction of acidosis
• 5% dextrose used as initial fluid replacement and best for Intracellular
dehydration
• Rapid replacement with dextrose should never be done
• Isolyte-P : Paediatrics(as it avoids sodium over load) and high in
Potassium
• DM – 5%dextrose with insulin
• HTN – 5%dextrose is preferred rather than NS
• Oedematous patients (due to CHF , Cirrhosis or Renal failure ) – RL is
contraindicated and NS is usually avoided , 5% dextrose is given IV slowly in
least possible amount
• TURP and NEUROSURGERY – avoid 5%dextrose
• Any fluid containing large amount of K+ , Mg++ or Ca++ should be avoided
intra-op.
• COLLOID – used for rapid restoration of hemodynamic function
• Donot cross intravascular compartment
• Smaller volumes does the job
• Higeher systemic oxygen delivery indirectly
• Expensive , pulmonary edema , hypersensitivity , bleeding (with
• Hetastarch and plasma are most widely used colloids
• Others are Albumin-5% or 25% , Dextran , Gelatin Polymers ,
Plasma
• Hetastarch less antigenic out of all and Plasma also corrects bleeding
disorders but it has risk of transmitting infective diseases

VOLUME OF FLUID REPLACEMENT

Guidelines for correction:

1.Correction of fluid deficit due to starvation
+
2.Maintenance requirement for period of surgery
+
3.Loss due to tissue dissection or hemorrhage
1. Volume to be replaced for starvation fluid deficit =
duration of starvation(in hours) *2 ml/kg bd wt.
This deficit is replaced with 5% dextrose usually .By giving half
of the calculated in first hour and remaining in the next two hours
2. Maintenance volume for intra operative period =
duration of surgery(in hours) * 2ml/kg bd wt.
3. Loss due to tissue dissection or hemorrhage =
different fluid loss in different types of surgery

Type of Surgery Fluid

volume(ml/kg/hr)
1 Least trauma(Ophthalmic surgery , cystoscopy etc) Nil
2 Minimal trauma (ENT surgeries , plastic repairs) 4
3 Moderate trauma (hernia , appendicectomy, 6
procedures on extremities , thoracotomy etc)
4 Severe trauma(Bowel resection , radical mastectomy , 10
Example :
If 40 years male , weighing 50 kg , NPO for 10 hours needs to
subjected for appendicectomy (duration of surgery one
hour),Calculate how much fluid to give?
Ans: 1.Correction of starvation deficit
=10 hrs * 2ml/kg * 50kg
= 10*2*50 =1000 ml
2.maintenance during operative period
=1hr *2ml/kg * 50 kg
=1*2*50 =100ml
3.correction of operative loss (appendicectomy – moderate trauma )
=6ml/kg/hr
=6*50*1 =300ml
So total intraoperative fluid requirement = 1+2+3
=1400ml
 Hemostatic Resusciation
FRESH FROZEN PLASMA: Presently one unit of FFP for

every one or two units of packed RBCs is practised

.Transfusion of FFP aimed at maintaining INR < 1.5 and

activated PTT < 1.5 times normal.provodes factors

II,V,VIII,IX,X,XI and antithrombin III

CRYOPRECIPITATE : Fibrinogen , vWF , factor VIII ...

One Cryoprepitate provides more fibrinogen in lesser

volume ... One cryoprecipitate is equal to two FFPs in terms

of fibrinogen.
• PreOperative hemoglobin if less than 10gm/dl usually will need
blood transfusion (Oxygen carrying capacity is unaffected till hb is
as low as 8gm/dl and hematocrit 25% )
• Percentage of blood loss
- Total blood volume in body varies according to body weight
- 90 ml/kg in New born , 80ml/kg in Infants , 70 ml/kg in child and

adult males, 65 ml/kg in adult females

-when loss is less than 10% of total blood volume transfusion is not
required
• Other factors :
-vital data(emergency surgery in hypotensive patient need BT)
-Hydration status
-Age , IHD need greater Hb for proper oxygenation
Q.) loss of 400 ml of blood in 70 Kg adult male . Is that a significant
blood loss ?
A.) total blood volume in 70 kg male = 70 ml/kg* 70 kg =4900 ml
As 400 ml is less than 10% of blood volume , which is not a
significant blood loss , therefore blood transfusion is not
required.
But in a 30kg boy it is signicant loss and life threatening too

Q.) Estimation of newer Hb status after intra operative blood loss ?

A.)a) % reduction in Hb = 1.25 * volume of blood loss/weight
b) Reduction of HB in gm/dl = Preoperative Hb* % reduction in
Hb
c) Hb status after blood loss =
=preop Hb – reduction of Hb in gm/dl
Q.) If patient with 50 KG weight , with 14 gm/dl pre operative hb ,
loses 800 ml of blood , what will be the subsequent Hb status?
A.) % reduction of Hb = 1.25 * 800/50 = 20%
Reduction of Hb in gm/dl = 14 * 20/100 = 2.8 gm/dl
Present Hb status = 14-2.8 = 11.2 gm/dl

• Loss of less than 10% of blood volume doesnt need BT , such

loses are replaced by RL or Isotonic Saline
• Blood loss greater than 20 % will definitely need BT irrespective
of pre-op haemoglobin
• BT in Blood loss between 10% and 20% is a matter of clinical
discretion
Maximum allowable blood loss(MABL)
Amount of blood loss which doesn’t require blood
transfusion is MABL
It is calculated by using pre op patient’s hematocrit
and lowest acceptable hematocrit 25%
MABL = (starting pt Hct -25)/ starting pt Hct *Est. blood volume

Q.) Adult male 60 kg and 35% hematocrit , MABL?

A.) MABL = (35-25)/35 * 60 kg * 70 ml/kg
= 1200 ml
So, if intra operative blood loss exceeds 1200 ml blood
transfusion is required .
 POST-OPERATIVE FLUID
THERAPY
• In short operative procedures will require only maintenance
fluids to correct deficit due to NPO(Hernia and minor plastic
procedures) , after 4-5hrs oral fluids can be restarted
• Major operations like Resection and anastomosis of intestine ,
total colectomy etc , where intestines and viscera need rest ...
Require Post op iv fluids for few days after ensuring normal
bowel movement , oral fluid intake is started
• Cardiac intervention , coronary bypass graft where handling of
intestine is not done , require IV fluids for 24-48 hrs
• CAUSES of hypovolemia in post-op pts :
NG aspirations , Drains , Fistulas , Third space loss ,
Hypermetabolism ,Hyperventilation , Pyrexia , delay in
operation , fluid lost at wound injury or operative site , Renal
problems
• In Early post-op period , if there is hypotension with
disproportionate anemia , this is due to INTERNAL
BLEEDING unless proven otherwise.
• Post-op pain and stress causes increased secretion of ADH and
ALD
• ROUTINE POST-OP IV FLUID first 3 days:
Day 1 – 2 lit 5% Dextrose + 500 ml Isotonic Saline
Day 2 – 2 lit 5% Dextrose + 1 lit of isotonic saline
Day 3 – 2 lit 5% Dextrose + 1 lit of isotonic saline
+ 40-60mEqof Potassium per day
• First 2-3 post-op days K+ is avoided
-as pt may be in oliguria/ azotemia
-post op tissue trauma
-metabolic acidosis
.’.giving K+ in first 2 days can be risky
 • Maintenance fluids administered at a steady rate over 18-24 hrs
• FLUID OF CHOICE:
-Prolonged vomitings and NG suction – ISOTONIC SALINE
If U.O is adequate – K+ is added 2nd day
- small bowel fistulas causing diarrhoea – Ringers’s Lactate
+/- (Bicarbonate) +/- (K+) ...to treat metabolic acidosis
- LOSS OF BLOOD – If <500ml not required , 3 times
volume crystalloids can be given
- If >500-1000ml- Blood or colloids
COMPLICATIONS OF POST OP FLUIDS
1. VOLUME OVERLOAD 4. POST-OP OLIGURIA
2. HYPONATREMIA 5. HYPOKALEMIA
3. HYPERNATREMIA 6.HYPERKALEMIA
• Decrease in serum sodium conc. Is mostly due to water excess
and not sodium deficit and that is due to Stress induced anti
diuresis in surgical patients and iatrogenic administration of
electrolyte free iv fluids
• Hyponatremia in euvolemic patients without tachycardia or
hypotension is most commonly due to Inappropriate ADH
activity – SIADH
• During fluid therapy rising value of urinary sodium suggests
correction of both hypovolemia and renal hypoperfusion
• Urinary Chloride concentration is more useful in monitoring fluid
therapy of vomitings and ketoacidosis