Daily fluid balance

Fluid intake consists of liquid ingested in the form of oral fluids as

well as fluid released during oxidation of consumed food.
Table 25.1 shows the average daily fluid balance for a healthy adult.
It must be noted that insensible losses can increase in conditions of
pyrexia, exertion or warm environments. Patients with a
tracheostomy can lose a larger amount of fluid via insensible losses,
emphasising the importance of humidifica-tion of inspired air. In
addition, fluid loss via the faecal route will inevitably increase in
diarrhoea or more chronic bowel pathologies, such as high-output
stoma, short bowel syndrome and enterocutaneous fistulae.
Prescription of maintenance fluids should aim to restore fluid
losses and provide sufficient water and electrolytes to maintain
the intracellular and extracellular fluid compart-ments, and to
enable the kidneys to excrete waste products.
The normal volume of water required for daily maintenance in a
healthy 70-kg adult is approximately 2.2 litres or 30 mL/kg per
day. Accurate assessment of maintenance fluid volumes
requires both intake and output to be taken into account, in
addition to the patient's body weight.
Fluid replacement should also encompass replacement of key
electrolytes. The approximate daily requirements of the main
electrolytes are as follows:
• sodium: 0.9-1.2 mmol/kg per day
•
•
potassium: 1 mmol/kg per day calcium: 5 mM per day
• magnesium: 1 mM per day
Replacement of fluid and electrolytes should be by the simplest
and safest route of administration. Where feasible the oral route
should be used via oral rehydration solutions. In patients whose
ability to swallow is impaired, fluid may be replaced via feeding
nasogastric tubes or nasojejunal tubes, provided intestinal
absorptive function is maintained.
Intravenous fluid replacement may be necessary in conditions of
gastrointestinal absorptive impairment or large fluid lones that cannot be
quickly replaced via the enteral route. The specific type of fluid
replacement therapy will be determined by the individual patient's needs.
Table 25.2 shows the compe-sition of some commonly used intravenous
fluid replacement solutions, in contrast to the average composition of the
same components in plasma.
In addition to the crystalloid fluid solutions above, fluid can also be
replaced with colloid solutions, which usually contain a form of modified
gelatin. Examples of these inchude Gelofusine® or Volplex®, which both
contain 4% w/v sue-cinylated gelatin, or Voluven®, which contains
hydroxyethyl starch. These solutions are often used as plasma expanders
as the larger molecules are thought to be slower to diffuse into the
extravascular space. Colloids are therefore sometimes used. for fluid
resuscitation in preference to crystalloids, but they can cause renal failure
or coagulopathy. There is ongoing controversy regarding the use of
crystalloids or colloids in the setting of fluid resuscitation. Albumin
solutions have also been used

FLUID THERAPY
• Osmolality of a solution is assessed by the amount of solute
dissolved in a solvent like water measured in weight (kg).
* Osmolarity of a solution is assessed by the amount of solute
dissolved in a solvent like water measured in volume (litre).
* Normal plasma Osmolality is 285 mOsm/kg (275-295).

* It is based on the concentrations of major solutes in plasma.

So sodium concentration contributes mainly to the osmolality.
* Colloidal osmotic pressure is difference in plasma osmotic
pressure and interstitial fluid pressure which is normally 25
mmg, which is mainly by plasma albumin concentration.
Plasma proteins do not go out of capillary wall into the
interstitium.
Principles of Fluid Therapy
Indications
For rapid restoration of fluid and electrolytes in dehydration due to
vomiting, diarrhoea, shock due to haemorrhage or sepsis or burns.
* Total parenteral nutrition.
* Anaphylaxis, cardiac arrest, hypoxia.
Post-gastrointestinal surgeries.
* For maintenance, replacement of loss or as a special fluid.
Advantage
Controlled, accurate and adjustable, rapid and predictable.

Problems in fluid therapy

Needs hospitalisation; costly; needs asepsis
Fluid overload; pulmonary oedema and cardiac failure;
infection
Thrombophlebitis; haematoma; cellulitis in local area
Pyrogenic reaction; air embolism; bacteraemia
Discomfort; poor patient acceptance
Calculation of Drop Rate of IV Fluids
1 mL =16 drops in usual drip set. For microdrip set one mL = 60
drops
a. Quantity of fluid required in liters per day × 10 = Drop rate/
minute. 2.5 litres is usually used quantity of fluid/day. So 2.5
× 10 = 25 drops/minute.
y the amount of solute sured in weight (kg). y the amount of
solute sured in volume (litre). m/kg (275-295).
Fluid volume in mL to be infused in one hour divided by four =
Number of drops/minute. For example, 100 mL/hour means
25 drops/minute.
Number of microdrop/minute = Volume in mL/hour (50
microdrop/minute = 50 mL/hour).
Note:
• Daily requirement of sodium is 100 mEq; potassium is 60 mEg; calcium
is 5 mEq; magnesium 1 mEq.
• One litre of normal isotonic saline contains 154 mEq of sodium.
• Ringer's lactate is the most physiological fluid (crystalloid) containing
sodium—130 mEq/L; potassium—4 mEq/L; chloride 109 mEg/L; lactate
(bicarbonate) -28 mEq/L; and calcium -3 mEq/L. It should be avoided in
liver failure patients. As it does not contain glucose it can be used in
diabetics.
• Other crystalloid fluids—normal saline, dextrose saline, 5% dextrose,
isolyte P, isolyte G, isolyte M.
• Colloids are of large molecules which shift the fluid from interstitial
compartment to intravascular compartment and are used as plasma
expanders. Haemaccel, hetastarch, pentatarch, dextran 40/70 are
colloids.
• Special purpose fluids are sodium bicarbonate 7.5% and 8.4% used in
metabolic acidosis, forced diuresis, hyperkalaemia; mannitol 10/20% used
as an osmotic diuretic agent; hypertonic saline 1.6%, 3%, 5% and 7.5%
used in hyponatraemia of different severity; albumin 4.5 % as plasma
expander; albumin 20% in severe hypoalbuminaemia.
• Weight loss more than 10% of individual's weight in 6 months is called
as significant weight loss.
• Body mass index (BMI) is body weight in kilograms divided by height in
meters squared. BMI less than 18.5 signifies nutritional impairment and
below 15 signifies severe malnutrition.
• Daily fluid loss from kidneys is 1500 mL; from lungs is 400 mL; from skin
is 800 mL; from stool is 60-150 mL.
• Energy requirement per day is 20-30 kca/kg, i.., around 2000 kcal/day
total.
• Glucose requirement is 200 g per day; fat requirement is 200 g per week;
nitrogen (protein) requirement is 0.15 g/kg per day. Nitrogen need
increases to 0.25 g/kg/day in hypercatabolic status.
• Transit time is rapid in jejunum; three times slower in ileum; still slower
• Fluid absorption capacity is 40% in jejunum; 70% in ileum; 90% in colon:
• Eletrolyte and vitamin Be absorption and enteronepatic circulation
occurs in ileum and so ileum is more important than jejunum.