IV FLUIDS

SQN LDR MANOJ

SURG LT CDR SU SINGH
MAJ IKJOT
Fluid therapy in Neurosurical patients
• Maintaining euvolemia is recommended.
• Dextrose solutions are not recommended
• rapidly distributed throughout body water
• if blood glucose concentrations decrease more rapidly than
brain glucose concentrations, water crosses the blood-brain
barrier and cerebral edema results
• hyperglycemia augments ischemic neuronal cell damage by
promoting neuronal lactate production, which worsens cellular
injury.
• Therefore, crystalloid solutions such as normal saline, Plasma-
Lyte, and lactated Ringer solution are recommended.
• Colloids such as 5% albumin are also an acceptable replacement
fluid, but no improvement in outcome has been shown
Fluid therapy in Traumatic Brain Injury patients
• Hypovolemia in patients with TBI is harmful; maintain
normovolemia
• Intravenous fluids, blood, and blood products as required
• Do not to overload the patient with fluids; avoid hypotonic fluids
• Glucose-containing fluids can cause hyperglycemia; can harm the
injured brain
• Ringer’s lactate solution or normal saline recommended for
resuscitation
• Monitor serum sodium levels; Hyponatremia causes brain edema
Fluid therapy in Traumatic Brain Injury patients
• Mannitol
• Used to reduce elevated ICP
• Preparation: 20% solution (20 g of mannitol per 100 ml of
solution)
• Avoid in patients with hypotension; mannitol does not lower ICP
in patients with hypovolemia and is a potent osmotic diuretic
• This exacerbate hypotension and cerebral ischemia
• Indication for mannitol in euvolemic patient:
• Acute neurological deterioration: sudden onset dilated pupil,
hemiparesis, decreasing sensorium
Fluid therapy in Traumatic Brain Injury patients
• Hypertonic Saline
• used to reduce elevated ICP
• Used in concentrations of 3% to 23.4%
• Preferable agent for patients with hypotension, because it does
not act as a diuretic
• There is no difference between mannitol and hypertonic saline
in lowering ICP, and neither adequately lowers ICP in
hypovolemic patients
Fluid therapy in Preeclampsia and Eclampsia
• Preeclampsia is a multisystem disease of pregnancy characterized
by hypertension, proteinuria, and multiorgan involvement that may
affect the kidneys, liver, pulmonary, and central nervous systems
• Reduced plasma volume, combined with endothelial dysfunction
and hypoalbuminemia
• Association exists between positive fluid balance and the incidence
of pulmonary edema
• Most cases present in the postpartum period, reflecting the
autotransfusion into a vasoconstricted circulation that occurs after
delivery
Fluid therapy in Preeclampsia and Eclampsia
• Patients with preeclampsia should receive restricted volumes of IV
crystalloid (80 mL/hr, including that received as drug diluents) and
fluid balance should be observed carefully
• Oliguria should not be treated by administration of large volumes
of fluids in the presence of normal renal function
• This conservative strategy has not been associated with an increase
in kidney injury
• Any blood loss in the peripartum or perioperative period should be
replaced with an appropriate volume of crystalloid, colloid, or
blood, depending on magnitude
• Invasive monitoring should be used to direct fluid therapy in cases
of severe preeclampsia
Fluid therapy in Ventilated Patients
Arterial Pressure
• arterial waveform analysis predicts hemodynamic response to
intravascular volume expansion
• PPV is more accurate than cardiac filling pressures (CVP, PAOP)
to predict intravascular fluid responsiveness
• Central Venous Pressure
• a poor predictor of fluid status
• Pulmonary Artery Catheter
• Associated insertion risks and lack of documented benefit in the
ICU
• RCTs in patients with ARDS were unable to demonstrate
improved outcomes with the use of PACs as compared to CVP
catheters
Fluid therapy in Ventilated Patients
• Bedside Ultrasonography (including echocardiography)
• Provide rapid information to aid in clinical diagnosis and
management
• USG evaluation of the IVC: Noninvasive method to assess fluid
responsiveness in mechanically ventilatedpatients
• IVC size alone can be an indicator of volume status but not
volume responsiveness
• IVC diameter variation (>15%) with positive-pressure ventilation
has correlated well with volume responsiveness
• Measurements taken during spontaneous respiration are less
reliable because of variability in tidal volume and degree of IVC
collapse
Calculation of Fluids
• The “Classic” Approach to Fluid Management
• Fluids must be given based on an estimation of the following –
• Fluid losses prior to start of anesthesia
• Maintenance requirements
• Normal fluid losses that occur during surgery
• Response to unanticipated fluid (blood) loss
• Titrating fluid requirements to physiologic measures (ex.
CVP, urine output)
• Step 1: Calculate Preoperative Fluid Losses
• Multiply the maintenance fluid requirements (cc/hr) times
the amount of time since the patient took PO intake
• Estimated maintenance requirements follow the 4/2/1 rule:
4 cc/kg/hr for the first 10 kg, 2 cc/kg/hr for the second 10
kg, and 1 cc/kg/hr for every kg above 20
Calculation of Fluids
• Step 2: Calculate Ongoing Maintenance Requirements
• Based on patient’s weight, using the same 4/2/1 rule as
used to calculate preoperative maintenance requirements.
• Step 3: Calculate Anticipated Surgical Fluid Losses
• Based on patient’s weight and anticipated tissue trauma.
• 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
• Step 4: Adjust for Unanticipated Fluid Losses
• A common recommendation is to give 3 cc of crystalloid for
every 1 cc of blood loss
• Remember to add up lap pads (100-150 cc each) and 4x4s
(10 cc each).
Calculation of Fluids
• Modern Fluid Management
• Based on the concept of goal-directed therapy (GDT)
• Management of fluids such that stroke volume is optimized is
an extremely well-validated approach that has been shown
repeatedly to reduce morbidity
(Hamilton MA et al. Anesth Analg 112: 1392, 2011; Gurgel ST and do Nascimento P Jr.
Anesth Analg 112: 1384, 2011)
• Esophageal Doppler monitoring (EDM) was recently endorsed
by the National Health Service as a rational alternative to
central venous pressure monitoring in patients undergoing
major surgery
• A promising alternative to EDM is optimization of respiratory
variation, although it is not as well validated
• No role for “maintenance” IV fluids in modern fluid management
– rather, fluids are given as targeted boluses when they are
expected to lead to a hemodynamic improvement
Recent Trials and Research in Periop Fluid
Management:
• The VISEP trial
• A two-by-two factorial trial comparing strict to conventional
glucose control as well as lactated ringer’s to low-molecular-
weight hydroxyethyl starch (HES, using a normal saline
carrier) in severe sepsis
• Randomized 537 patients prior to being stopped early
• As compared to Ringer’s lactate, HES in a normal saline
carrier was associated with higher rates of acute renal failure
and renal-replacement therapy
• SAFE trial
• randomized 6997 critically ill patients to albumin or saline
• no difference in mortality
Recent Trials and Research in Periop Fluid
Management:
• 6s Trial
• randomized 804 critically-ill patients to Ringer’s acetate
versus HES 130/0.42 in a balanced electrolyte solution
• Increased rate of death and renal replacement therapy in the
colloid group
• No difference in the absolute volumes administered, with
more fluid administered in the colloid group when corrected
for body weight
• CHEST trial
• randomized 7000 critically-ill patients to 130/0.4 tetrastarch
in normal saline (Voluven) versus normal saline
• trend towards increased mortality in the tetrastarch group
(relative risk 1.06, p = 0.26) but a statistically significant
increase in the need for renal replacement therapy (relative
risk 1.21, p = 0.04)
Recent Trials and Research in Periop Fluid
Management:
• The purported “long term” expansion caused by colloids is a
myth (in reality, colloid expansion lasts only a few hours, after
which the colloids begin to accumulate extravascularly, staying
there for weeks), the risk of edema is no different between
colloids and crystalloids, the true equivolume ratio is probably
1:2 or even as low as 1:1.6
[Hartog CS et al. Anesth Analg 112: 156, 2011]
• “There is no evidence from RCTs that resuscitation with colloids
reduces the risk of death, compared to resuscitation with
crystalloids, in patients with trauma, burns or following
surgery. As colloids are not associated with an improvement in
survival, and as they are more expensive than crystalloids, it is
hard to see how their continued use in these patients can be
justified outside the context of RCTs”
[Perel P et. al. Cochrane Database Systemic Review 4: CD000567, 2007]