Perioperative Homeostasis

NUR 311- Spring 2015

Exemplars of Fluid Balance/Homeostasis

Perioperative fluid balance

Fluid volume deficit/excess
CMP/BMP
Electrolyte disorders
Coagulation studies
Goals of Perioperative Fluid Management

Maintain intravascular volume

Maintain cardiac preload
Maintain adequate blood pressure
Maintain adequate perfusion
Optimize Oxygen delivery
Perioperative Nursing Case Study
The Case:
The patient, Mr. Hill, is a 60-year-old man with a
history of osteoarthritis who now requires a left total
hip replacement under general anesthesia. The
surgery is scheduled for tomorrow morning.
Preoperative Care
History
Physical Assessment
Psychosocial Assessment
Teaching
Labs
Imaging
Other Diagnostic Assessment
What preop labs are appropriate for Mr. Hill?

Urinalysis
Blood Type and Screen
CBC
CMP/BMP
Clotting studies
Which preop lab result would require the RN to
take immediate action?
a. INR 0.9
b. WBC 8500/mm3
c. Serum Potassium 2.8 mEq/L
d. Serum Sodium 132 mEq/L

Hypokalemia can slow recovery from

anesthesia and increases cardiac irritability.
What preop imaging would be appropriate for
Mr. Hill?
Chest x-ray
Hip x-ray
CT scan
MRI
EKG (>40 y/o)
Preop IV hydration
Mr. Hill is NPO after midnight for surgery tomorrow
Fasting leads to hypovolemia

The RN starts an IV drip of LR @ 84cc/hr to prevent volume

depletion
Interoperative
The unit RN gives report to the OR holding nurse. Mr. Hill is
brought to the OR holding room and eventually into the OR

As soon as the surgical incision occurs fluid shifts in Mr. Hill begin

During surgery crystalloid solution of Lactated Ringers

administered at 4 ml/kg/hour (so 280 cc/hr if Mr. Hill weighs 70
kg)

Mr. Hill has an estimated blood loss of 400 cc in the OR

Recall the major fluid compartments of the body
Interoperative – fluid sequestration (third
spacing)
Fluid movement into the interstitial fluid
Fluid migrates from the intravascular space to the interstitial space
(non functional area between the cells)
Why?
Body’s adaptive stress response to surgical tissue trauma
Sympathetic nervous system response
Immunologic response
Interoperative – fluid sequestration (third
spacing)
SNS response to surgery
In response to pain, stress, and anxiety the body produces and
releases stress hormones (ADH and aldosterone from RAAS)
Stress activates RAAS when blood is shunted to heart & brain and renal
blood flow is decreased

ADH and aldosterone release result in kidneys retaining sodium

and water
Elevated ADH levels are a universal postoeprative event and levels can
remain elevated for up to 24 hours postoperatively
Interoperative – fluid sequestration (third
spacing)
Immunologic response to surgery
Tissue and blood vessel damage during surgery activate
inflammatory response and release of local mast cells
Mast cells release histamines which cause local vasodilation and
endothelial retraction
Mast cell prostaglandins cause vasodilation and also potentiate
endothelial retraction
Result is increased vascular permeability and capillary fluid leaks into
interstitial spaces
Interoperative – fluid sequestration (third
spacing)
Impact on fluid mechanics:
Vasodilation and increased vascular permeability has two effects

1. Blood accumulates at surgical site and increases hydrostatic

pressure – fluid is forced across membrane into interstitial
space
2. Oncotic pressure is ineffective as large proteins can now leak
through capillary membrane – interstitial osmotic pressure is
therefore increased promoting further movement of fluid
into interstitial space
Interoperative – fluid sequestration (third
spacing)
Impact on fluid mechanics:

Interstitial space

Hydrostatic
Permeability Oncotic
pressure
Capillary pressure
Interoperative – fluid sequestration (third
spacing)
Third spacing clinical presentation and manifestations:
Edema in the subcutaneous tissues presents as swelling
Abdomen ascites – fluid in peritoneal cavity
Pleural effusion
Pericardial effusion
Decreased urinary output
Impaired oxygen and metabolite diffusion
Postoperative Period
2 phases of postop fluid management:

1) Management of vascular volume deficit

• Hypovolemia secondary to blood loss, 3rd spacing, and variable
insensible loss

2) Return of sequestered fluid to the venous system

• Sequestered fluid begins to return to vascular space about 48-72
hours after surgery via lymphatic drainage
Postoperative Period
Phase 1 - Management of vascular volume deficit
(Crystalloid IVF replace insensible loss and 3rd space loss)
Insensible loss anywhere from 0.5 – 2 mL/kg/hr
Peak fluid shift occurs 5 hrs after trauma and persists up to 72
hours
IVF to maintain urine output of at least 30 cc/hr
Postoperative Period
Phase 1 - Management of vascular volume deficit
Acute O.R. blood loss:
Colloids used if blood volume does not improve with
crystalloids – dextran or albumin to expand plasma volume
PRBCs if indicated (total blood volume loss >20% or Hgb<7.5
g/dL)
Mr. Hill is given 1 unit PRBCs in the PACU:
PRBCs useful for replacing routine surgery blood loss
Reduced volume decreased = risk of circulatory overload
Transfer
Mr. Hill is transferred from the PACU to the med/surg unit
He has orders for IV fluid maintenance of D5 0.45% NS @ 110
cc/hr
Continue strict Is&Os
With 3rd spacing fluid intake could exceed output
RN continually assesses for hypovolemia:
Color & moisture of mucous membranes and skin
Skin turgor, texture, & tenting
Hypotension with tachycardia
Delayed cap refill
Decreased peripheral pulses
AMS
Question
Mr. Hill is displaying s/s of hypovolemia secondary to both blood
loss and 3rd spacing. Would you expect Mr. Hill to show weight
gain or weight loss?
While patients with hypovolemia sometimes lose weight, hypovolemia
secondary to 3rd spacing can actually lead to weight gain as the fluid is
taken out of the vascular space and held in the interstitial space
RN must monitor Mr. Hill’s weight carefully
1 kg = about 1 liter of fluid
Postop Weight Gain
ICU Mortality in Patients with
perioperative weight gain Fig. 2.
Perioperative weight gain and mortality of
patients. No patient survived if
perioperative weight gain was more than
20%

A Rational Approach to Perioperative Fluid Management

Chappell, Daniel; Jacob, Matthias; Hofmann-Kiefer, Klaus; Conzen,
Peter; Rehm, Markus
Anesthesiology. 109(4):723-740, October 2008.
doi: 10.1097/ALN.0b013e3181863117Copyright © 2010
Anesthesiology. Published by Lippincott Williams & Wilkins. 27
Postop Day 1
Phase 1 continued – managing vascular volume deficit
Expected Labs?
See Labs
Decreased H/H (if low volume due to blood loss)
Increased H/H (if low volume due to fluid shift and
hemoconentration)
Elevated BUN, Serum Creatinine, and Osmolarity
Electrolyte imbalances
Hypo or hypernatremia
Hyperkalemia – K+ leaks into extracellular fluid after cell trauma
Postop Day 1
Phase 1 continued – managing vascular volume deficit
Start maintenance fluids using 4-2-1 rule:
Mr. Hill = 70 kg
1-10kg 4cc/kg/hr 40 cc/hr

11-20kg 2cc/kg/hr 20 cc/hr

21 + kg 1cc/kg/hr 50 cc/hr

Fluid maintenance rate 110 cc/hr

Postop Day 2
Phase 2 – Return of sequestered fluid to the venous system
Reabsorption phase
Tissues begin to heal and fluid is transported back to vascular space
about 48-72 hours after surgery via lymphatic drainage
Signs of hypovolemia resolve
Hemodilution: excessive fluid in the vascular space
The most common cause of fluid overload in this phase is
overcorrection of previous vascular volume deficit
Postop Day 2
Phase 2 – Fluid reabsorption phase:
Focus on preventing circulatory overload and hypertension which can
lead to pulmonary edema
What s/s of fluid overload should the RN assess for?
Neck-vein distension
Puffy eyelids
Pitting edema
Weight gain
Hypertension with tachycardia
Tachypnea
SOB
Cough
Lung crackles on auscultaion
Postop Day 2
Phase 2 – Fluid reabsorption phase:
What lab results would indicate that Mr. Hill has developed fluid
volume overload?
See Labs
Decreased H&H and RBCs, “dilutional anemia”
Decreased Na, “dilutional hyponatremia”
Decreased protein and albumin

What type of medication can be administered to help correct Mr. Hill’s

fluid overload?
Diuretic!!
 Question
Mr. Hill is given a one time dose of 40 mg IV Lasix (furosemide).
Which change indicates to the nurse that the diuretic is
effective?
A. Weight loss of 7 lbs
B. Heart rate increased from 72-90
C. Respiratory rate decreased from 20 to 16
D. Morning blood glucose decreased from 142 md/dL to 110 mg/dL
Postop Day 3
Mr. Hill’s morning labs are as follows:
Hgb = 25 d/dL
Hct = 60%
Serum glucose = 190 mg/dL
BUN = 25 md/dL
What has the previous diuresis done to Mr. Hill’s vascular fluids?
Hemoconcentration!
Results in: elevated plasma levels of H&H, serum osmolarity,
glucose, BUN, and electrolytes when H20 lost and other
substances remain
Postop Day 3
Now what?
Encourage PO intake if Mr. Hill can tolerate it
Ensure fluids are offered and ingested at least Q2hours

If IV fluid maitenance fluids are continued would you expect an

isotonic, hyptertonic, or hypotonic solution to be ordered?

Continue monitoring weight (Q24hours) and strict intake & output

Postop Assessment of Fluid Balance
Fluid Volume Deficit Fluid Volume Excess
Central Nervous System Headache Headache, Behavior changes,
Apprehension
Agitation
Renal Negative fluid balance, Acute weight Positive fluid balance, Acute weight gain
loss >0.2 kg/day, Concentrated/dark >0.5 kg/day
amber urine
Respiratory Thick tenacious sputum, Difficulty Crepitation on auscultation, Tachypnea,
obtaining SpO2 due to poor peripheral Decreasing SpO2, Persistent
perfusion cough/wheeze
Frothy pink sputum, Pulmonary edema
Cardiovascular Tachypnea, Postural hypotension, Tachycardia, Hypertension, Bounding
Sluggish capillary refill, Poor filling of pulse, Raised jugular venous pressure,
doralis pedis veins, Low jugular venous S3 heart sound
pressure
Skin/Mucous Membranes Flushed dry skin, Dry tongue, Thirst, Peripheral edema, Moist tongue
Cool peripheries

Serum Biochemistry Raised urea, creatine, osmolarity, and Decreased hematocrit, Decreased
hematocrit albumin/protein
 Perioperative Systemic Effects
Perfusion

Skin GU
Integrity

Mr. Hill Psychosocial

Neuro

GI
Oxygenation