PERIOPERATIVE FLUID MANAGEMENT

Guided by Dr. Pinu Ma’am

WE NEED TO DRINK WATER BECAUSE..
 All chemical reactions occur in liquid medium.
 It is crucial in regulating chemical and bioelectrical
 distributions within cells.
 Transports substances such as hormones and nutrients.
 O2 transport from lungs to body cells.
 CO2 transport in the opposite direction.
 Dilutes toxic substances and waste products and
transports them to the kidneys and the liver.
 Distributes heat around the body
 WHERE DOES ALL THIS WATER GO…

 Water constitutes an average 50 to 70% of the total body weight

 Young males - 60% of total body weight

 Older males – 52%

 Young females – 50% of total body weight

 Older females – 47%

 Variation of ±15% in both groups is normal

 Obese have 25 to 30% less body water than lean people.

 Infants 75 to 80%
 - gradual physiological loss of body water
 - 65% at one year of age
 COMPONENTS
COMPONENTS OF
OF THE
THE BODY
BODY FLUID
FLUID

1= Intracellular fluid (ICF)= 70% TBW or 30%(F) - 40% (M)

BW
2= Extracellular fluid (ECF) = 30%TBW or 20% BW
 Interstitial fluid = 7.5% of body weight ( 15%)BW
 Intravascular fluid or plasma volume = 4% of body weight (
5%)BW
 Transcellular fluid = 3.5 % of body weight
REGULATION OF BODY FLUIDS
 TBW content is regulated by the intake and output of water.
 Thirst , the primary mechanism to control water intake , is
triggered by an increase in body fluid tonicity or by decrease in
ECV.
 Two powerful hormonal system regulate total body sodium.
1. The natriuretic peptides , ANP, brain natriuretic peptide ,and C-
type natriuretic peptide, defend against sodium overload .
2. Renin-angiotensin-aldosterone axis defends sodium depletion
and hypovolemia.
Daily fluid replacement = 700 ml + urine
output
Excess water loss
1. fever : 100 ml / degree fever / day
2. Tracheostomy (unhumidified air) : >1.5 L / day

7
INTRAVENOUS FLUID THERAPY
INDICATION :-
 Conditions where oral intake is not possible -Coma, anaesthesia,

severe vomiting and diarrhoea

 Dehydration and shock

 Hypoglycaemia
 Vehicle for I.V. medication e.g. antibiotics, chemotherapeutic

agents, insulin, vasopressor agents

 Total parentral nutrition
 Treatment of critical problems – anaphylaxis, status asthmaticus

or epilepticus, cardiac arrest , forced diuresis in drug overdose,

poisoning, urinary stone
ADVANTAGES :-
 Accurate , controlled and predictable way of administration

 Immediate response due to direct infusion in intravascular

compartment
 Prompt correction of serious fluid and electrolyte

disturbances
DISADVANTAGES :-
 More expensive, needs strict asepsis
 Possible only in hospitalised patient under skilled supervision

 Improper selection of type, volume , rate and technique of

fluid administration can lead to serious problems

CONTRAINDICATIONS :-
 Avoided if patient can take oral fluids

 CHF, pulmonary oedema

COMPLICATIONS :-
 Local : hematoma , infusion phlebitis

 Systemic :
 Large volume can lead to circulatory overload

 Rigors, air embolism

 Septicaemia

 Others – fluid contamination, mixing of incompatible drugs,

improper technique of infusion
CLASSIFICATION OF IV FLUIDS
1.Maintenance fluids : replaces insensible fluid losses from lungs ,
skin , urine and faeces.
Eg.- 5 % dextrose, dextrose with 0.45 % NS
2. Replacement fluids : correct body fluid deficit caused by losses such
as gastric drainage, vomiting , diarrhoea , infection , trauma, burns
Eg.- Isotonic saline, DNS, Ringer’s lactate, Isolyte-M, Isolyte P and
Isolyte G
3. Special fluids :
 Hypoglycemia – 25 % dextrose

 Hypokalemia – inj Kcl

 Metabolic acidosis – inj sodium bicarbonate

RINGER’S LACTATE (RL)
Composition – Na-130 mEq, K- 4 mEq, Cl- 109 mEq, Ca-3
mEq, Bicabonate-28 mEq.
each 100 ml contains – sodium lactate 320 mg, NaCl -600mg,
KCl-40mg, calcium chloride 27 mg

Pharmacological basis :
 Ringer Lactate is the most physiological fluid , as its
electrolyte content is nearly similar to plasma.
 effective in severe hypovolemia as it expands volume due to
high Na content.
 metabolised in liver to bicarbonate so used in metabolic
acidosis.
 Indications
 As Replacement fluid , maintainance fluid
 Diarrhoea induced hypovolemia with hypokalemic
metabolic acidosis
 Fluid of choice in diarrhoea induced dehydration
in paediatric patients
 DKA , provides glucose free water, corrects
metabolic acidosis and supplies potassium
 Severe hypovolemia.
 Contraindications
 Liver disease, severe hypoxia and shock.
 Severe CHF .
 Addison’s disease .
 Simultaneous infusion of RL and blood in one i.v. line-
Calcium in RL binds with the citrate anticoagulant in
blood , promotes formation of blood clots in donor
blood.
 Certain drugs – amphotericin, thiopental, ampicillin,
doxycycline.
 Severe metabolic acidosis.
 In vomiting or continous nasogastric aspiration.
ISOTONIC SALINE (0.9%NS)
 Composition : one litre of fluid contains
Na 154 mEq, Cl 154 mEq
. Each 100ml contains : sodium chloride 0.9gm
. osmolarity – 308 mOsm/L
 Pharmacological basis : provide major Extracellular
electrolytes. Increase the intravascular volume .
. Contraindications
 pre eclamptic patients, CHF, renal disease and cirrhosis
 Dehydration with severe hypokalaemia.
 Indications
 Water and salt depletion – diarrhoea, vomiting, excessive
diuresis or excessive perspiration
 Treatment of hypovolemic shock
 Treatment of alkalosis with dehydration
 Initial fluid therapy in DKA
 Hypercalcemia
 Fluid challenge in prerenal ARF
 Irrigation for washing of body fluids
 Vehicle for certain drugs
 5% DEXTROSE
Composition : Glucose 50 grams in one litre of fluid
Pharmacological basis :
Corrects dehydration and supplies energy( 170Kcal/L). D-5 is best
agent to correct intracellular dehydration . D-5 is selected when
there is need of water but not electrolytes.
Indications :
 dehydration
 Pre and post op fluid replacement
 IV administration of various drugs
 Prevention of ketosis in starvation, vomiting, diarrhoea, high
grade fever
 Adequate glucose infusion protects liver against toxic substances.
 Correction of hypernatremia.
 Contraindications
 Cerebral oedema
 Neurosurgical procedures

 Acute ischaemic stroke

 Hypovolemic shock

 Hyponatremia , water intoxication

 Same iv line blood transfusion

 Uncontrolled DM , severe hyperglycemia.

Precautions:
 I.V. adminisration of dextrose solution (especially
hypertonic) may cause local pain, vein irritation and
thrombophebitis
 Prolonged I.V. adminstration of 5% dextrose can
cause Hypokalemia,Hypomagnesemia and
Hypophosphatemia.

Rate of adminstration – 0.5 gm/kgBW/hr or

666ml/hr 5 % D or 333ml/hr 10 %D
DNS
Composition : Na -154 mEq, Cl - 154 mEq, glucose-50gm
Osmolarity- 585mOsm/L
Pharmacological basis :

Supply major extracellular electrolytes, energy and fluid to correct dehydration.
Like 0.9% istonic saline it rapidly corrects NaCl deficit of ECF ,unlike D-5 % it
does not correct intracellular dehydration.
 Unlike D5 % DNS is not hypotonic hence it is compatible with blood transfusion.

Indications
 salt depletion and hypovolemia.
 vomiting or nasogastric aspiration induced alkalosis and hypochloremia.
Contraindications :
 Anasarca – cardiac, hepatic or renal disease.
 Severe hypovolemic shock –can cause hyperglycemia and osmotic diuresis even in

the presence of fluid deficit.

 DEXTROSE WITH HALF STRENGTH SALINE
Composition : one litre of fluid contains-
Na - 77mEq, Cl- 77mEq, Glucose- 50gm
Each 100 ml contains glucose 5gm and NaCl 0.45gm
Pharmacological basis : It is used when there is need for calories ,more water and
lesser salt replacement
Indications
 Fluid therapy in paediatric patients
 Treatment of severe hypernatremia : as it corrects hypernatremia gently, it avoids
cerebral edema and is safe.
 As maintainance fluid therapy
 Early post operative period
Contraindications :
 Hyponatremia
 Severe dehydration due to diarrhoea and vomiting where there is need for larger salt
replacement.
 INVERTED SUGAR SOLUTION
 One litre of fluid supplies inverted sugar 100gm
Pharmacological basis :
 Inverted sugar is an equimolar mixture, which contains half dextrose and half
fructose.
Indications :
 nausea, vomiting including vomiting of pregnancy.
 In liver diseases as it provides glucose, prevents glycogen depletion and exerts protein
sparing effects.
Adverse effects :
 Large dose of fructose can cause lactic acidosis, hyperuricemia and
hypophosphatemia.
Contraindications :
 Hereditary fructose intolerance
 impaired kidney function or severe liver damage
 Less effective in treatment of hypoglycemia
 Generally more than 25gm of fructose per day is not recommended
RINGER ACETATE :
 Composition :{per litre}
 Calcium Chloride 220 mg
 Magnesium Chloride 95 mg
 Potassium Chloride 300 mg
 Sodium Acetate 2.82 g
 Sodium Chloride 5.91 g
 It is used in patients with diabetes mellitus.
GELOFUSINE :
 Gelofusine is a volume expander that is used as a 
blood plasma replacement if a significant amount of
blood is lost due to extreme hemorrhaging, trauma, 
dehydration, or a similar event.Gelofusine is a 4% w/v
solution of succinylated gelatine (also known as
modified fluid gelatine) used as an intravenous colloid
, and behaves much like blood filled with albumins
. As a result, it causes an increase in blood volume,
blood flow, cardiac output, and oxygen transportation.
FLUID PHARMACOLOGY
 ISOLYTE- G
Gastric replacement solution.
 provides all electrolytes lost by gastric juice and correct
alkalosis.
 contains ammonium ions which is converted into urea and

hydrogen by liver. This hydrogen ion replace the deficit of it

caused by loss of gastric juice.
Indication-
 Vomiting or nasogastric aspiration induced hypochloraemic, hypokalaemic
metabolic alkalosis
 metabolic alkalosis due to excessive administration of sodium bicarbonate or
aggressive diuretic therapy.
 It is ONLY available i.v. Fluid that directly corrects metabolic alkalosis of
any nature.
Contraindications : Hepatic failure, renal failure, metabolic acidosis
 Osmolarity - 580mOsm/ L
 ISOLYTE-M
 Richest source of potassium (35 mEq)
 Ideal fluid for Maintenance
 Indicated in hypokalaemia secondary to
diarrhoea,bilious vomiting , for parenteral fluid
therapy.
 As concentration of sodium is low, it should be
avoided in hyponatremia.
 Contraindications : Renal failure, burns,
adrenocortical insufficiency, Hyponatremia and
water intoxication.
 Osmolarity - 410mOsm/ L
 ISOLYTE -P
 Maintenance fluid for Paediatric population – as they require less
electrolytes and more water.
 it provides almost double water but same electrolytes as isolyte M.
Indication- Excessive water loss or inability to concentrate
urine(diabetes insipidus).
Contraindications :
.Hyponatremia - as it has least concentration of sodium.
. Renal failure - contains high concentration of potassium.
.Hypovolemic shock - as contains low sodium so poor ability to
correct intravascular volume and hypotension. In oliguric child
,high k is not safe.
 Osmolarity - 368mOsm/ L
 ISOLYTE -E

Extracellular replacement solution. It has electrolytes similar to

ECF except it has double the concentration of K and acetate
(47mEq).(which will get converted into bicarbonate).
.Only iv fluid to correct Mg deficiency .
.Treatment of diarrhoea, metabolic acidosis, in maintainance of
ECF volume preoperatively.
Contraindications –
 metabolic alkalosis due to vomiting or continuous nasogastric
aspiration.
ISOLYTE FLUIDS
COLLOID
large molecular weight substances that are largely
retained within the intravascular compartment
thereby generating oncotic pressure.
 3 times more potent than crystalloid fluids.

 1 ml blood loss = 1ml colloid = 3ml crystalloids

 In patients with haemorrhagic shock, when

plasma or blood is not available immediately,

infusion of colloids to correct circulatory fluid
volume is vital and life saving.
ALBUMIN
 Physiological plasma protein
 Maintain plasma oncotic pressure
 Heat treated preparation of albumin – 5%, 20% and 25% commercially
available
Pharmacalogical basis :
 5% albumin – COP( colloid osmotic pressure ) of 20 mmHg, expands
plasma volume to the same as volume infused, oncotic effects last 12-18
hours
 25% albumin – COP of 70mmHg ,expands plasma volume by 4-5 times
the volume infused

Rate of infusion :
 Adults – initial infusion of 25 gms (500 ml of 5% solution or 100 ml of
25% solution).
 1 to 2 ml/min – 5% albumin
 1 ml/min - 25% albumin
 Indications :
 acute hypovolemic shock, burns, severe

hypoalbuminaemia
 Correction of Hypoproteinaemia – liver disease, Diuretic

resistant nephrotic syndrome, malnutrition

 In therapeutic plasmapharesis , as an exchange fluid

Precautions and Contraindications :

 Severe anaemia, cardiac failure

 Dehydrated patients may require additional fluids
 Hypersensitivity reaction
DEXTRAN
 Dextran are glucose polymers produced by bacteria(leuconostoc
mesenteroides) incubated in a sucrose medium
2 forms : dextran 70(MW 70,000) and dextran
40(MW 40,000, low molecular weight dextran)

Pharmacological basis :
1. Effectively expand i.v. Volume but its not substitute for whole blood
as it has no oxygen carrying capacity.
 Dextran 40 as 10% solution does greater expansion than dextran 70 as

6% solution but it has shorter duration( 6hrs) due to its rapid renal
excretion.

2. Improves microcirculatory flow and prevention of thromboembolism:

 Indications :
 Hypovolemia correction

 Prophylaxis of DVT and post operative thromboembolism

 Improves blood flow and microcirculation in threatened vascular

gangrene
 Myocardial ischemia, cerebral ischemia, PVD and maintaining

vascular graft patency

Adverse effects
 Acute renal failure

 Interfere with blood grouping and cross matching

 Hypersensitivity reaction
 Precautions
 Dextran should be administered with caution in patients with

 Impaired renal function or oligouria

 Active haemorrhage

 Chronic liver disease

 Patient at risk of developing pulmonary oedema or CHF

 Haematocrit should not be allowed to fall below 30

 Anticoagulant effect of heparin is enhanced by dextran

 Preserve blood sample prior to dextran infusion

 Correct dehydration before or atleast during dextran infusion to

maintain adequate urine flow and prevent ARF

 ContraIndications:
 Severe oligo-anuria and renal failure
 Known hypersensitivity to dextran

 CHF or circulatory overload

 Bleeding disorders like thrombocytopenia, hypofibrinogenemia

 Severe dehydration

Administration :
 DEXTRAN- 40 : given by i.v.infusion as 10% solution in 0.9% NaCl or

5% glucose , in the first 24 hrs – dose should not exceed 20ml/kg. It can be
given subsequently in dose of 10ml/kg per day upto 5 days
DEXTRAN- 70 : given by i.v.infusion as 6% solution . The total dose should

not exceed 20ml/kg in the first 24 hrs and 10ml/kg in subsequent days
HYDROXYETHYL STARCH(HETASTARCH)

 It is synthetic colloid available in 6% solution in isotonic saline. It is a

starch that is composed of more than 90% esterified amylopectine.
 Esterification retards degradation leading to longer plasma expansion

 6% starch - MW 4,50,000

Pharmacological basis :
 Osmolarity – 308 mosm/L

 Higher colloidal osmotic pressure than 5% albumin ( 30 vs 20mmHg

respectively)
 After i.v. Hetastarch infusion, molecules with low molecular weight are

excreted in urine in 24 hrs. Larger molecular weight fractions are

metabolized and eliminated slowly.
 Advantages :
 Non antigenic
 Does not interfere with blood grouping
 Greater plasma volume expansion for a longer period and effect lasts for
about 24 hrs
 It is less expensive than albumin

Disadvantages :
 Increase in Serum amylase(marker of acute pancreatitis) concentration
during and 3-5 days after discontinuation of hetastarch.
 It has no oxygen carrying capacity so one should not allow hematocrit to fall
below 30%.
Indications :
 Hypovolemia correction and shock
 Same as dextran
Contraindications :
 Bleeding disorders , CHF

 Impaired renal function

Administration :
 Adult dose 6% solution – 500ml to 1 lit

 Total daily dose should not exceed 20ml/kg

Adverse effects :
 Allergic or sensitive reactions

 Anaphylactic reactions
PENTASTARCH
 LMW derivative of hetastarch(2,64,000) 3%, 6% and 10% solution in
isotonic saline
 Differs from hetastarch in having a Lower degree of esterification
 Higher colloidal oncotic pressure
 Lesser effect on coagulation
 10% pentastarch solution can increase plasma volume 1.5 times of the
infused volume
 Indications, contraindications and side effects are similar to hetastarch
GELATIN POLYMERS (HAEMACCEL)
 Sterile, pyrogen free 3.5 % solution
 Polymer of degraded gelatin with electrolytes

Composition :
Each litre contains : polymer from degraded gelatin 35gm
Na – 145mEq Ca- 12.5mEq
Cl - 145mEq K - 5.1mEq
Indications :
 Rapid plasma volume expansion in hypovolaemia

 Prophylactic use in major surgery to reduce total volume of fluid

replacement
 Priming of heart lung machines
 Advantages :
 Does not interfere with coagulation, blood grouping and cross
matching
 Remains in blood for 4 to 5 hrs

 Infusion of 1000 ml expands plasma volume by about 50% of infused

volume
Precautions :
 Contains no preservative, so ensure clear solution before infusion

 Contains calcium so should not be mixed with citrated blood

Side effects :
 Hypersensitivity reaction
Characteristics of I.V.colloid fluids per 100ml infusion

Type of fluid Effective plasma volume Duration of expansion

expansion

5% albumin 70 – 130 ml 16 hrs

25% albumin 400 – 500 ml 16 hrs

6% hetastarch 100 – 130 ml 24 hrs

10% pentastarch 150 ml 8 hrs

10% dextran 40 100 – 150 ml 6 hrs

6% dextran 70 80 ml 12 hrs
SPECIAL FLUIDS
25% DEXTROSE
 Available as 100 ml of 25% dextrose contains 25 gram glucose.
Supplies energy and prevents catabolism.
 Indications :
• Rapid correction of Hypoglycemia or hypoglycemic coma.
• To provide nutrition to pt on maintenance fluid therapy.
• For treatment of hyperkalemia,with 10 units of regular insulin,to
prevent hypoglycemia.
• Contraindication :
• Dehydrated patient with anuria,intracranial or intraspinal
haemorrhage.
• To be avoided in diabetic pt unless there is severe hypoglycemia.
Thanking You