Fluid management in

Surgery

Dr. Serajus Salekin

MBBS, MS ( Cardiovascular and Thoracic Surgery)
Assistant Professor
Thoracic Surgery Department
Dhaka Medical College Hospital
Total requirement of fluid in post operative
patient :
• Basal requirement/ maintenance.
• Pre-existing dehydration & electrolyte loss.
• Continuing abnormal losses over & above basal
requirements.
 Basal requirements/ maintenance:
• In case of adult
Fluid requirement: 30-40ml/kg/day
Na+ requirement : 2-3 mmol/kg/day
K+ requirement: 1-2 mmol/kg/day
Glucose requirement: 100-150g dextrose/day
Basal requirements/ maintenance:

• In case of children:
For 1st 10kg= 100 ml/kg/day
For next 10 kg= 50 ml/kg/day
For next per kg= 20 ml/kg/day
Ex: A 25 kg children, fluid requires= (10×100)+(10×50)+(5×20)ml
=1600ml/day
• 1 drop = 4 micro drop
• 1 ml = 20 drop
• 1 ml = 60 micro drop
• If I infuse 1000 ml of solution at 10 drop per minute (60 second )
• It will take 24 hour to finish
• 1000 X 20 = 20000 drops
• 20000 ÷ 24 hour = 833.33
• 833.33 ÷ 60 minute = 13. 88
• 13.88 drops per minute or 10 drops ( roughly) per minute
• it means 1000 ml solution can be transfused at 10 drops per minute in 24 hours
• So if I need to transfuse 2500 ml in 24 hours then I need to transfuse at 25 drops per minute
Postoperative fluids:
• 1-Dextrose saline will produce hyponatraemia in a postoperative
patient.
• 2-Alternate bags of saline and dextrose saline with supplementary
potassium give the best balance.
• Fluids distribute into : 1-Colloid(blood, albumin or gelatine solution )
stays in the vascular compartment.
• 2-Saline stays in the extracellular compartment.
• 3-Dextrose eventually goes to all compartment
 In the 1st 24 hours after surgery:
• There is an increased secretion of antidiuretic hormone & aldosterone as a result
of metabolic response to injury. The patient will require no salt and less water
than normal in this period.
Ex: 70 kg male fluid requires 2100-2800ml/day [30-40ml/kg/day]
Average :2500ml/day
So, we can use 2.5 liters 5% DA (which is sufficient)
But in BD our temperature is hot, so sweating occur. So we can replace few
Na+ with fluid. Like 2L 5% DA+ 500ml NS.
In the 2nd 24 hours after surgery:
• The metabolic response to injury diminishes & the patient needs some
electrolyte containing fluids like 0.9% NS.
Ex: we can use 1.5L 5%DA & 1L NS.
 On the 3rd pod & there after:
• Like 2nd POD. Or we can we fluid as required like
1L NS+ 1.5L DA Or 1.5L DNS+ 1L NS.
• Add Potassium. Safe rules for giving potassium
RULE OF 40
1. Urine output at least 40ml/hour
2. Not more than 40mmol/L
3. Not faster than 40mmol/L
 On the 3rd pod:
• We have to do some investigations:
• CBC
• Electrolytes
• S. Albumin (Mainly in case of GIT anastomotic patients. Becasue hypoproteinemia causes
oedema on anastomotic site. So, there is a chance of anastomotic leakage)
• We can change the Na+ & K+ with fluid requirement according to the electrolytes
report.
Correction of Pre-existing dehydration & electrolyte loss

• Patients who arrive in a dehydrated state clearly need to be resuscitated with

fluid over & above their basal requirements. Usually this will be done
intravenously.
Mainly identify from which compartment or compartments fluid has been
lost.
Assess the extent of the dehydration.
• Isotonic solutions – normal saline (0.9% ),
• Hypotonic solution – 0.45% saline 2.5% dextrose
• Hypertonic solution – Hartmanns solution, Ringers lactate , 5% DNS
• Total Body Water
• Intracellular Fluid
• Extracellular Fluid
Total body water
• constitutes 50-70 % of total body weight
• fat contains little water, the lean individual has a greater proportion of
water to total body weight than the obese person
• total body water as a percentage of total body weight decreases
steadily and significantly with increasing age
 % of Body Weight % of Total Body Water
• Body Water 60 100
• ICF 40 67
• ECF 20 33
• Intravascular 4 8
• Interstitial 16 25
ICF
• largest proportion in the skeletal muscle
• potassium and magnesium are the principal cations
• phosphates and proteins the principal anions
ECF
• interstitial fluid: two types
• functional component (90%) - rapidly equilibrating
• nonfunctioning components (10%) - slowly equilibrating
• connective tissue water and transcellular water called a “third space”
or distributional change
• sodium is the principal cation
• chloride and bicarb the principal anions
Fluid taken
• Salt Gain & Losses
• daily water gains - normal individual consumes 2500 mL water per day
• approximately 2000-2200 mL taken by mouth
• rest is extracted from food as the product of oxidation, about 300-500
mL
Fluid loss
• daily water losses -60-150 mL in stools, 1500 mL in urine, and 600 mL
as insensible loss
• total losses ~ 2.2 liters -Insensible loss: skin (75%) and lungs (25%)
• increased by hypermetabolism, hyperventilation, and fever
• 250 mL/day per degree of fever
• unhumidified tracheostomy with hyperventilation = insensible loss up
to 1.5 L/day
Volume changes
• If isotonic salt solution is added to or lost from the body fluids, only
the volume of the ECF is changed, ICF is relatively unaffected
• If water is added to or lost from the ECF, the conc. of osmotically
active particles changes
• Water will pass into the intracellular space until osmolarity is again
equal in the two compartments
Volume Deficit
• ECF volume deficit is most common fluid loss in surgical patients
• most common causes of ECF volume deficit are: GI losses from
vomiting, nasogastric suction,diarrhea, and fistular drainage
• other common causes: soft-tissue injuries and infections, peritonitis,
obstruction, and burns
Volume Deficit
• signs and symptoms of volume deficit: CNS: sleepy, apathy – stupor,
coma
• GI: dec food consumption – N/V
• CVS: orthostatic, tachy, collapsed veins - hypotension
• Tissue: dec skin turgor, small tongue – sunken eyes, atonia
Volume excess
• Iatrogenic or Secondary to renal insufficiency, cirrhosis, or CHF
• signs & symptoms of volume excess: CNS: none
• GI: edema of bowel
• CVS: elevated CVP, venous distension – pulmonary edema
• Tissue: pitting edema – anasarca
Concentration Changes
• Na+ primarily responsible for ECF osmolarity
• Hyponatremia and hypernatremia often occur if changes are severe
or occur rapidly
• The concentration of most ions within the ECF can be altered without
significant osmolality change, thus producing only a compositional
change
• Example: rise of potassium from 4 to 8 mEq/L would significantly
effect the myocardium, but not the effective osmotic pressure of the
ECF
Pre operative fluid
• Correction of Volume Changes: Volume deficits result from external
loss of fluids or from an internal redistribution of ECF into a
nonfunctional compartment
• nonfunctional because it is no longer able to participate in the
normal function of the ECF and may just as well have been lost
externally
• Correction of Concentration Changes: If severe symptomatic hypo or
hypernatremia complicates the volume loss, prompt correction of the
concentration abnormality to the extent that symptoms are relieved is
necessary
Post operative fluid
• replace losses & supply a maintenance:
• open abdomen losses: 8 cc/kg/hr
• NGT & urine output
• Blood loss
• Replace with solution (LR or NS)
• unwise to administer potassium during the first 24 h, until adequate
urine output has been established even a small quantity of potassium
may be detrimental because of fluid shifts
Postoperative fluids:
• 1-Dextrose saline will produce hyponatraemia in a postoperative
patient.
• 2-Alternate bags of saline and dextrose saline with supplementary
potassium give the best balance.
• Fluids distribute into : 1-Colloid(blood, albumin or gelatine solution )
stays in the vascular compartment.
• 2-Saline stays in the extracellular compartment.
• 3-Dextrose eventually goes to all compartment
Water require
• Rule: 100-50-20
• (60kg=2300ml/day)
• 100ml/kg/d(for 1st 10kg) ＋ 50ml/kg/d(for 2nd
10kg) ＋ 20ml/kg/d(per add 1 kg)
• 4-2-1(60kg=100ml/hr=2400ml/day)
• 4ml/kg/hr(for 1st 10kg) ＋ 2ml/kg/hr(for 2nd 10kg) ＋ 1ml/kg/hr(per
add 1 kg)
• 1.5ml/kg/hr(60kg=90ml/hr=2160ml/day)
Electrolytes require:
• Na+: 2-3mmol/kg/day
• K+: 1~2mmol/kg/day
• Glucose supplement(if NPO): 100~150g dextrose/per day
MAINTENANCE
• Maintenance: • Provide normal daily requirements:
• Water: 2.5 L
• Sodium ½ or ¼ NS
• KCl 40-60 meq n Example: D5 ½ NS with KCL 20 meq/L running at
100 ml/h
THANK YOU