Fluid

Management

M.RIZK MD.
Five major aspects are of importance
when volume replacement is considered
1. The type of fluid must be decided,
2. The amount of fluid must be calculated,
3. The criteria for guiding volume therapy
must be defined,
4. Possible side effects should be considered,
5. Costs are of importance.
Perioperative Fluid
Requirements
The following factors must be taken into
account:
Maintenance fluid requirements
NPO and other deficits: NG suction,
bowel prep
Third space losses
Replacement of blood loss
Special additional losses
Maintenance Fluid
Requirements
Insensible losses such as evaporation of
water from respiratory tract, sweat, feces,
urinary excretion. Occurs continually.
Adults: approximately 1.5 ml/kg/hr
“4-2-1 Rule”
ml/kg/hr for the first 10 kg of body weight 4 -
ml/kg/hr for the second 10 kg body weight 2 -
ml/kg/hr subsequent kg body weight 1 -
Extra fluid for fever, tracheotomy, denuded -
surfaces
NPO and other deficits

NPO deficit = number of hours NPO x

maintenance fluid requirement.
Bowel prep may result in up to 1 L fluid
loss.
Measurable fluid losses, e.g. NG
suctioning, vomiting, ostomy output.
Third Space Losses

Isotonic transfer of ECF from functional

body fluid compartments to non-
functional compartments.
Depends on location and duration of
surgical procedure, amount of tissue
trauma, ambient temperature, room
ventilation.
Replacing Third Space Losses

Superficial surgical trauma: 1-2 ml/kg/hr

Minimal Surgical Trauma: 3-4 ml/kg/hr
head and neck, hernia, knee surgery -
Moderate Surgical Trauma: 5-6 ml/kg/hr
hysterectomy, chest surgery -
Severe surgical trauma: 8-10 ml/kg/hr (or
more)
AAA repair, nehprectomy -
Blood Loss

Replace 3 cc of crystalloid solution per

cc of blood loss (crystalloid solutions
leave the intravascular space)
When using blood products or colloids
replace blood loss volume per volume
Other factors

Ongoing fluid losses from other sites:

gastric drainage -
ostomy output -
diarrhea -
Replace volume per volume with
crystalloid solutions
Example

62 y/o male, 80 kg, for hemicolectomy

NPO after 22:00, surgery at 08:00,
received bowel prep
3 hr. procedure, 500 cc blood loss
What are his estimated intraoperative
fluid requirements?
Example (cont.)

Fluid deficit: 1.5 ml/kg/hr x 10 hrs = 1200

ml + 1000 ml for bowel prep = 2200 ml
total deficit: (Replace 1/2 first hr, 1/4 2nd
hr, 1/4 3rd hour).
Maintenance: 1.5 ml/kg/hr x 3hrs =
360mls
Third Space Losses: 6 ml/kg/hr x 3 hrs
=1440 mls
Blood Loss: 500ml x 3 = 1500ml
Total = 2200+360+1440+1500=5500mls
:Intravenous Fluids

Conventional Crystalloids
Colloids
Hypertonic Solutions
Blood/blood products and blood
substitutes
 Fluid Distribution in a 75-kg Adult

1/3
(15L)
Capillary
Plasma
3L Endothelium
Interstitial Intracellular Compartment
Compartment
10L )30L( 2/3

Blood
Cells 2L Cell Membrane
 Fluid Distribution in a 75-kg Adult
Colloid
Saline
Glucose

Capillary
Plasma
3L
Endothelium
Interstitial Intracellular Compartment
Compartment
10L 30L

Blood
Cells 2L Cell Membrane
 From:   Grocott: Anesth Analg, Volume 100(4).April 2005.1093-1106

Colloid

3L /3L = 100 %

Saline

3L / 15 L =20 %
Glucose

3L / 45L = 7 %
Fluid Distribution in a 75-kg Adult
Fluid Replacement Products
 Crystalloids – Ionic solutions that contain small molecules and are able to
pass through semipermeable membranes
 Isotonic solutions: given to expand the ECF volume

 Hypotonic solutions: given to reverse dehydration

 Hypertonic solutions: given to increase the ECF volume and decrease
cellular swelling
 Colloids – solutions that contain high molecular weight proteins or
starch, do not cross the capillary semipermeable membrane, and remain in
the intravascular space (pulling fluid out of the intracellular and interstitial
space) for several days
 Albumin
 Gelatin

 Dextran

 HES
Crystalloids

Combination of water and electrolytes

Balanced salt solution: electrolyte -
composition and osmolality similar to
plasma; example: lactated Ringer’s,
.Normosol
Hypotonic salt solution: electrolyte -
composition lower than that of plasma;
.example: D5W
Colloids

Fluids containing molecules sufficiently -

large enough to prevent transfer across
.capillary membranes
Solutions stay in the space into which -
.they are infused
Examples: hetastarch (Hespan), -
.albumin, dextran
Synthetic Colloid

1915 Gelatin
World WarⅠ

1945 DEXTRAN
World WarⅡ

1960 HES
War In Vietnam
Gelofusin 1965
1980 HAES-steril
New Generation HES

2000
A Class of Its Own
 Properties of resuscitation fluids

Crystalloid Gelatin Albumin HES

Molecular Weight

60 da 30-35 kda 69kda 130-450 kda

Volume Effect

10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs

รูปที่ 16
Hypertonic Solutions

Fluids containing sodium concentraions -

.greater than normal saline
Available in 1.8%, 3%, 5%, 7.5%, 10% -
.solutions
Hyperosmolarity creates a gradient that -
draws water out of cells; therefore,
cellular dehydration is a potential
.problem
Common parenteral fluid therapy
Solutions Volumes +
Na +
K +
Ca2 +
Mg2 Cl
- HCO3
-
Dextrose mOsm/L
ECF 142 4 5 103 27 280-310
Lactated
130 4 3 109 28 273
Ringer’s

NaCl 0.9% 154 154 308

NaCl 0.45% 77 77 154

D5W 0 0 0 253

D5/0.45%
77 77 50 406
NaCl

NaCl 3% 513 513 1026

6%
500 154 154 310
Hetastarch
130- 130-
Albumin 5% 250,500
160
2.5<
160
330

25% 130- 130-

20,50,100 2.5< 330
Albumin 160 160
Plasma Osmolarity
 Heart Rate

Blood
Pressure

CVP
Skin
Perfusion Urinre Cardiac
Out Put Out Put
Clinical Evaluation of Fluid
Replacement
1. Urine Output: at least 1.0 ml/kg/hr
2. Vital Signs: BP and HR normal (How is the
patient doing?)
3. Physical Assessment: Skin and mucous
membranes no dry; no thirst in an awake
patient
4. Invasive monitoring; CVP or PCWP may be
used as a guide
5. Laboratory tests: periodic monitoring of
hemoglobin and hematocrit
Summary

Fluid therapy is critically important

during the perioperative period.
The most important goal is to maintain
hemodynamic stability and protect vital
organs from hypoperfusion (heart, liver,
brain, kidneys).
All sources of fluid losses must be
accounted for.
Good fluid management goes a long
way toward preventing problems.
Transfusion Therapy

22 million blood components

administered annually in U.S.
pRBC’s, whole blood, fresh frozen plasma,( -
. ).platelets, etc
12,000,000 units of pRBC’s annually
.of transfusions occur perioperatively 60% -
responsibility of transfusing perioperatively -
.is with the anesthesiologist
When is Transfusion
?Necessary
“Transfusion Trigger”: Hgb level at
which transfusion should be given.
Varies with patients and procedures -
Tolerance of acute anemia depends
on:
Maintenance of intravascular volume -
Ability to increase cardiac output -
Increases in 2,3-DPG to deliver more of -
the carried oxygen to tissues
Oxygen Delivery
Oxygen Delivery (DO2) is the oxygen that
is delivered to the tissues
DO2= Cardiac Output (CO) x Oxygen
Content (CaO2)
Cardiac Output (CO) = HR x SV
Oxygen Content (CaO2):
O2 saturation + PaO2(0.003))Hgb x 1.39( -
Hgb is the main determinant of oxygen -
content in the blood
Oxygen Delivery (cont.)

Therefore: DO2 = HR x SV x CaO2

If HR or SV are unable to compensate,
Hgb is the major deterimant factor in O2
delivery
Healthy patients have excellent
compensatory mechanisms and can
tolerate Hgb levels of 7 gm/dL.
Compromised patients may require
Hgb levels above 10 gm/dL.
Blood Volume

1. Neonate 85 ml/kg
2. Infant 80 ml/kg
3. Male adult 75 ml/kg
4. Female adult 65 ml/kg

 Hematocrit = Hemoglobin X 3
 Estimated Blood Loss
1. 4X4 gauze 10 ml
2. Laparotomy pad 100 ml
3. Suctioned volume – irrigation

 Replacing Blood Loss

1. Fluid replacement solutions
2. Allogenic blood components
3. Autologus Blood Transfusion
BLOOD TRANSFUSION
Indications
Hypovolemia is not an indication for
transfusion
Decreased oxygen carrying capacity is an
indication for transfusion

No more triggering number for

transfusion
Transfusion Indications
 HEMOGLOBIN
1. Patient condition
2. Age
3. Cardiovascular status
4. Chronic anemia
5. Anticipated blood loss
6. Blood volume
7. Cardiac output
8. Oxygen saturation
Transfusion Indications
 Adequate oxygen carrying capacity
can be met by 7 g/dl hemoglobin
 Healthy patients tolerate a
hemoglobin level of 5 g/dl
 There was no statistical
significance of hemoglobin
concentration on patient outcome
unless it was less than 3 g/dl
Transfusion Indications
 Decreased oxygen carrying capacity->
1. Increased heart rate
2. Increased contractility

 Less toleration:
1. Myocardial impairment
2. Medications
ASA Taskforce for Blood
Components Therapy

1. Transfuse rarely if Hgb > 10 g/dl

always if Hgb< 6 g/dl
2. Consider the patient condition
3. Don’t use a triggering number
4. Use autologus transfusion
5. Indication for autologus transfusion
are more liberal
Complication of transfusion
1. Impaired oxygen transport
2. Coagulopathies
3. Citrate intoxication
4. Hyperkalemia
5. Hypothermia
6. Acid-base Abnormalities
7. Infusion of microaggregates
8. Hemolytic transfusion reactions
9. Non hemoytic transfusion reactions
10. Blood born infections
11. Transfusion induced immunodepression
BLOOD COMPONENTS
THERAPY
 Benefits :
1. Specific replacement of the elements
2. Easier handling
3. Getting most benefit of blood
 Blood components available:
1. Red Blood Cells
2. Platelets
3. Fresh Frozen Plasma
4. Cryoprcipitate
Preoperative Blood Donation
 Any patient can give:
1. 1 unit of blood
2. Hemoglobin 11 g/dl
3. No less than 72h
4. 72h before surgery
5. Up to 8 units
6. Even children of less than 1y old
Component Therapy
A unit of whole blood is divided into components;
Allows prolonged storage and specific treatment of
underlying problem with increased efficiency:
packed red blood cells (pRBC’s)
platelet concentrate
fresh frozen plasma (contains all clotting factors)
cryoprecipitate (contains factors VIII and fibrinogen;
used in Von Willebrand’s disease)
albumin
plasma protein fraction
leukocyte poor blood
factor VIII
antibody concentrates
Packed Red Blood Cells
1 unit = 250 ml. Hct. = 70-80%.
1 unit pRBC’s raises Hgb 1 gm/dL.
Patient hemoglobin levels down to 7
gm/dL are generally tolerated if
intravascular volume is maintained.
Mixed with saline: LR has Calcium
which may cause clotting if mixed with
pRBC’s.
Platelet Concentrate
Treatment of thrombocytopenia
Intraoperatively used if platelet count drops
below 50,000 cells-mm3 (lab analysis).
1 pooled unit of platelets increases platelet
count 5000-10000 cells-mm3 (1 donor=6
pooled u and ↑ plt by 50000cells-mm3 )
Risks:
Sensitization due to HLA on platelets -

Viral transmission -
Fresh Frozen Plasma

Plasma from whole blood frozen within 6

hours of collection.
Contains coagulation factors except platelets
Used for treatment of isolated factor deficiences,
reversal of Coumadin effect, TTP, etc.
Used when PT and PTT are >1.5 normal
Risks:
Viral transmission
Allergy
Complications of Blood
Therapy
Transfusion Reactions:
Febrile; most common, usually controlled -
by slowing infusion and giving antipyretics
Allergic; increased body temp., pruritis,
urticaria.
Rx: antihistamine,discontinuation.
Examination of plasma and urine for free
hemoglobin helps rule out hemolytic
.reactions
Complications of Blood
Therapy (cont.)
 Hemolytic:
Wrong blood type administered (oops).
Activation of complement system leads to
intravascular hemolysis, spontaneous hemorrhage.
Signs: hypotension,fever, chills, dyspnea, skin
flushing, substernal pain. Signs are easily masked
by general anesthesia.
Free Hgb in plasma or urine
Acute renal failure
Disseminated Intravascular Coagulation (DIC)
Treatment of Acute Hemolytic
Reactions

Immediate discontinuation of blood

products
Maintenance of urine output with
crystalloid infusions
Administration of mannitol or
Furosemide for diuretic effect
Complications (cont.)
Transmission of Viral Diseases:
Hepatitis C; 1:30,000 per unit
Hepatitis B; 1:200,000 per unit
HIV; 1:450,000-1:600,000 per unit
22 day window for HIV infection and test
detection
CMV may be the most common agent
transmitted, but only effects
immunocompromised patients
Parasitic and bacterial transmission very low
Other Complications
Decreased 2,3-DPG with storage: ? Significance
Citrate: metabolism to bicarbonate; Calcium binding

Microaggregates (platelets, leukocytes): micropore

filters controversial
Hypothermia: warmers used to prevent

Coagulation disorders: massive transfusion (>10

units) may lead to dilution of platelets and factor V
and VIII.
DIC: uncontrolled activation of coagulation system
Autologous Blood
Pre-donation of patient’s own blood prior to
elective surgery
1 unit donated every 4 days (up to 3 units)
Last unit donated at least 72 hrs prior to
surgery
Reduces chance of hemolytic reactions and
transmission of blood-born diseases
Not desirable for compromised patients
Administering Blood Products
Consent necessary for elective transfusion
Unit is checked by 2 people for Unit #, patient
ID, expiration date, physical appearance.
pRBC’s are mixed with saline solution
Products are warmed mechanically and given
slowly if condition permits
Close observation of patient for signs of
complications
If complications suspected, infusion
discontinued, blood bank notified, proper steps
taken.
Autotransfusion
Commonly known as “Cell-saver”
Allows collection of blood during
surgery for re-administration
RBC’s centrifuged from plasma
Effective when > 1000ml are collected
Intraoperative Blood
Recovery
 Technique:
1. Blood is suctioned
2. Filtered
3. Heparanised or citrated
4. Centrifuged
5. Washed
6. Collected
7. Reinfused
Intraoperative Blood
Recovery
 Complications:
1. Air embolisation
2. Hemolysis and renal injury
3. Dilutional thrombocytopenia & coagulopathy
4. Contamination with:
 Intestial contents
 Malignant cells
 Amniotic fluid
 Urine
Intraoperative Blood
Recovery
 Patient selection:
1. Blood loss > 20%
2. Transfusion in more than 10%
3. Mean transfusion > 1 unit
Acute Normovolemic
Hemodilution
 Definition:
1. Removing blood
2. Replacement by fluids
3. Reinfusing the blood
 Advantages
1. Almost risk free
2. Oxygen transport is intact
3. No hypothermia or thrombocytopenia
4. Improved tissue circulation
5. It’s done by us
Acute Normovolemic
Hemodilution
 As effective as predonation
Easier and less expensive
 Significantly decreases the allogenic
transfusion requirements
 The best results are when:
1. Hemoglobin is high
2. Blood removed is high
3. Blood loss is high
Acute Normovolemic
Hemodilution
 Blood replacement by fluid
Decreased oxygen carrying capacity
Compensated by increased cardiac output
& diverting blood to vital organs

 When to use it:

1. Estimated blood loss is > 25%
2. Initial hemoglobin > 11 g/dl
Acute Normovolemic
Hemodilution
 Safety:
1. In CAD and cerebral vascular disease
Hgb 7g/dl is safe
2. Global tissue oxygenation is preserved
when Hct is 17%
 Contraindications:
1. Renal disease
2. Pulmonary disease
3. Liver disease
Acute Normovolemic
Hemodilution
 Technique:
1. Induce general anesthesia
2. Withdraw blood from central or arterial lines
3. Infuse colloids or crystalloids
4. Collect blood in bags with CPD preservative
5. Keep the blood in the room
6. Reinfuse blood when the major blood loss is
over
Acute Normovolemic
Hemodilution
volume estimated initial Hct - desired Hct
to = blood X
remove volume average hematocrit

The complications are mainly :

• Cerebral ischemia
• Cardiac ischemia
Type and Screen
Donated blood that has been tested for
ABO/Rh antigens and screened for
common antibodies (not mixed with
recipient blood).
Used when usage of blood is unlikely, but -
.needs to be available (hysterectomy)
Allows blood to be available for other -
.patients
.Chance of hemolytic reaction: 1:10,000 -
CONCLUSION
?How much of what