post op fluid ppt

BY- Prof. M.C.BansalMBBS., MS., FICOG., MICOG.Founder Principal & Controller,

Jhalawar Medical College & Hospital Jjalawar.MGMC & Hospital , sitapura ., Jaipur

TOTAL BODY WATER

Total body water content- 60% of body weight (young adult male) 50% of body weight (young adult female)

Fat contains less water, an obese person has proportionately less body water.

DISTRIBUTION OF BODY FLUID

Intracellular VolumeIntracellular Volume

Extracellular VolumeExtracellular Volume

Interstitial VolumeInterstitial Volume

Plasma VolumePlasma Volume

Total Body WaterTotal Body Water 60%60% 42L42L

40%40% 28L28L

20%20% 14L14L

15%15% 10.5L10.5L

5%5% 3.5L3.5L(AVG. 70 KG WEIGHT)

NORMAL FLUID BALANCE• KidneysKidneys plays a pivotal role in regularization of fluid –

electrolyte balance.

•Oral intake & urine output are imp. measurable parameters.

•Fluid electrolyte output in normal day to day life is in form of:-

a.Sensible- Urine output, Vomiting, Diarrhoea, Excessive sweating (100 ml / degree farenheit rise in temp) b. Insensible- Lungs, Skin, Stools.

•Insensible fluid input = 300 ml due to oxidation

•Insensible loss= 500 ml through SKIN (with normal perspiration at normal temperature) = 400 ml through LUNG (expiration) = 100 ml through STOOL

Daily fluid requirement = Urine Daily fluid requirement = Urine Output+700 Output+700

ml ml

Normal daily insensible loss = (1000-300) ml, i.e. 700 ml.

REGULATION OF WATER INTAKEREGULATION OF WATER INTAKE•The Hypothalamic Thirst Center is stimulated by:

•Decline in plasma volume of 10%–15%•Increases in plasma osmolality of 1–2%•Baroreceptor input, angiotensin II, and other stimuli•Thirst is quenched as soon as we begin to drink water

•Feedback signals that inhibit the thirst centers include: 1. Moistening of the mucosa of the mouth and throat. 2. Activation of stomach and intestinal stretch receptors.

1. OBSTETRIC CONDITIONS Hyperemesis Gravidarum. Pregnancy complicated by Diarrhoea/ Dysentry/ Cholera. Pregnancy assoc with high grade fever & sweating. Pregnancy complicated with burns. Pregnancy with Jaundice. Pregnancy assoc with Renal disease/ DM/ PIH. Bleeding catastrophies assoc with pregnancy & post delivery. Pregnancy with Thyroid disease. Pregnancy with Medical/Surgical illness(oral intake not possible) Pregnancy in obese & lean females. Prolonged diuretic therapy. Exposure to extreme heat/humidity.

2. GYNAECOLOGICAL CONDITIONS

Urinary and Fecal Fistulas

Gyn conditions assoc with preexisting fluid electrolyte imbalance due to med/surgical illness.

(Renal/DM/Chr. Hypertension/CHF/CorPulmonale/Thyroid)

Carcinomas.

CRYSTALLOIDS COLLOIDS BLOOD & BLOOD

PRODUCTS

a. CRYSTALLOIDSa. CRYSTALLOIDS1. Water + Electrolytes

2. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules.

3. Expands intravascular volume to a lesser degree than Colloids.

4. Replenishes interstitial compartment.

5. Leaves intravascular space faster (t1/2 = 20-30 mins) 6. It increases GFR.

7. No allergic reactions.

NORMAL SALINENORMAL SALINE

RINGER LACTATERINGER LACTATE

5% DEXTROSE (D5% DEXTROSE (D55 / GDW) / GDW)

10%, 25%, 50% DEXTROSE10%, 25%, 50% DEXTROSE

DD55 WITH HALF STRENGTH SALINE WITH HALF STRENGTH SALINE

DEXTROSE NORMAL SALINE (DNS)DEXTROSE NORMAL SALINE (DNS)

ISOLYTEISOLYTE-- G/E/M/P G/E/M/P

DOUBLE STRENGTH HYPERTONIC SALINEDOUBLE STRENGTH HYPERTONIC SALINE

INVERTED SUGAR SOLUTION INVERTED SUGAR SOLUTION (50% Fructose + 50% Dextrose)(50% Fructose + 50% Dextrose)

CALORIE FREE OR LOW CALORIE CALORIE FREE OR LOW CALORIE CRYSTALLOIDS FLUIDS.CRYSTALLOIDS FLUIDS.

1.FRUCTODEX

2.SUCROSE SOLUTIONS

3.LACTOSE SOLUTIONS

b. COLLOIDS- the volume expandersb. COLLOIDS- the volume expanders

A colloid is a substance(SOLID PARTICLES) microscopically dispersed evenly throughout another substance(LIQUID MEDIA).

A colloidal system consists of two separate phases: a dispersed phase (or internal phase) and a continuous phase (or dispersion medium) in which the colloid is dispersed.

The dispersed-phase particles have a diameter of approximately between 1 and 1000 nm.

3. ALBUMIN (Human Serum Albumin)3. ALBUMIN (Human Serum Albumin) available in strengths of 5%, 25%

4. HETASTARCH 4. HETASTARCH (Hydroxy-ethyl starch) = 6% solution in isotonic saline (4,50,000 mol wt)

1. DEXTRAN 1. DEXTRAN Glucose polymer in sucrose medium. Available- Dextran

70/40. 2. MANNITOL2. MANNITOL

5. GELATIN POLYMERS (HAEMACCEL) = 3.5% solution of polymer gelatin (containing of 35,000 mol wt) Also has Na, Cl, Ca, K

6. PENTASTARCH = low molecular wt derivative of Hetastarch

(10% starch)

c. Blood and blood productsc. Blood and blood products

1.1.WHOLE BLOOD.WHOLE BLOOD.2.2.PACKED RED CELLS.PACKED RED CELLS.3.3.LEUCOCYTE DEPLETED BLOOD.LEUCOCYTE DEPLETED BLOOD.4.4.FRESH FROZEN PLASMA.FRESH FROZEN PLASMA.5.5.PLATELETS.PLATELETS.6.6.FREEZE DRIED FACTORS.FREEZE DRIED FACTORS.

BEFORE STARTING COLLOID THERAPY ONE BEFORE STARTING COLLOID THERAPY ONE SHOULD SHOULD

COLLECT BLOOD SAMPLES FOR ABO-COLLECT BLOOD SAMPLES FOR ABO-RH GROUPING AS RH GROUPING AS

BLOOD LOADED WITH COLLOIDS BLOOD LOADED WITH COLLOIDS INTERFERS WITH INTERFERS WITH

CROSSMATCHING.CROSSMATCHING.

FLUIDSFLUIDS Dextr Na K ClAcetat

eSpecial constt.

mOsm/L

5% Dextrose

50 - - - - 278

0.9% Saline

- 154 - 154 - 308

5D with Half

strength Saline

50 77 - 77 - 432

DNS 50 154 - 154 - 586

RL - 130 4 109 -Lactate28.

Ca-3.274

Iso-G 50 63 17 150 - NH4Cl -70 580

Iso-M 50 40 35 40 20 HPO4-15 410

Iso-P 50 25 20 22 23HPO4-3.

Citrate-3.368

Iso-E 50 140 10 103 47Ca-5.Mg-3.

Citrate-8.595

1)1)MAINTENANCE FLUIDSMAINTENANCE FLUIDSTO REPLACE AMOUNT OF FLUID & ELECTROLYTES LOST.TO REPLACE AMOUNT OF FLUID & ELECTROLYTES LOST.THESE LOSSES ARE POOR IN SALT.THESE LOSSES ARE POOR IN SALT.THUS, FLUIDS SHOULD BE HYPOTONIC TO PLASMA SODIUM.THUS, FLUIDS SHOULD BE HYPOTONIC TO PLASMA SODIUM.

EG.) 5D, DEXTROSE WITH HALF STRENGTH SALINE. EG.) 5D, DEXTROSE WITH HALF STRENGTH SALINE.

2) REPLACEMENT FLUIDS2) REPLACEMENT FLUIDS

FORMULATED TO CORRECT BODY FLUID DEFICITS CAUSED BY LOSSES FORMULATED TO CORRECT BODY FLUID DEFICITS CAUSED BY LOSSES eg. Gastric Drainage, Vomiting, Diarrhoea, Intestinal Trauma, Oozing from eg. Gastric Drainage, Vomiting, Diarrhoea, Intestinal Trauma, Oozing from Trauma site etc.Trauma site etc.

EG.) NORMAL SALINE, DNS, RINGER LACTATE, ISOLYTE-P/M/G.EG.) NORMAL SALINE, DNS, RINGER LACTATE, ISOLYTE-P/M/G.

3)3)SPECIAL FLUIDSSPECIAL FLUIDS

USED FOR SPECIAL NEEDS- HYPOGLYCEMIA, HYPOKALEMIA, USED FOR SPECIAL NEEDS- HYPOGLYCEMIA, HYPOKALEMIA, METABOLIC ACIDOSIS.METABOLIC ACIDOSIS.

EG.) 25% DEXTROSE, INJ SODIUM CARBONATE, INJ EG.) 25% DEXTROSE, INJ SODIUM CARBONATE, INJ POTASSIUM CHLORIDEPOTASSIUM CHLORIDE

ADVANTAGESADVANTAGES

1.Accurate, controlled & predictable way of administration.2.Immediate response due to direct infusion into IV compartment.3.Prompt correction of serious fluid & electrolyte imbalance.

INDICATIONS

1. When oral intake not possible. Eg. Anaesthesia, Surgery.

2. Severe vomiting &/or diarrhoea.3. Moderate to severe dehydration & shock.4. Hypoglycemia. 25% Dextrose is life saving.5. Vehicle for IV medications.6. Total parenteral nutrition.

DISADVANTAGES

1.More expensive.2.Needs strict asepsis.3.Possible only at a hospital setting.4.Improper selection of fluid can be harmful.5.Improper volume and rate of infusion can be life threatening.6.Improper technique of administration can lead to complications.7.Strict & natural electrolyte balance is ideally not possible, whereas natural oral intake is superior. So, oral fluid and diet tharapy should be restarted as early as possible.

COMPLICATIONSCOMPLICATIONS1.1.LOCALLOCAL Haematoma Infiltration and Infusion phlebitis. Allergy to fluids / iv lines.

2.2.SYSTEMICSYSTEMIC Circulatory overload, in cardiac patients getting rapid or large volumes of infusion. Rigors. Air Embolism. Septicaemia.

• RATE OF FLUID INFUSION DEPENDS UPON URGENCY, NEED OF FLUID REPLACEMENT & INDICATION.

•16 drops = 1 ml (for Routine IV Set)

•RULE OF TEN RULE OF TEN – IV fluid in Litre/24 hrs x 10 = Drop Rate / Minute•RULE OF FOURRULE OF FOUR – Drop Rate/minute x 4 = Volume in ml / Hour •1 ml = 60 drops. (for Micro Drip Set)

• Micro drop rate / Minute = Volume in ml / hour.

CHARACTERISTIC TYPE OF FLUID

Most PhysiologicalMost Physiological Ringer Lactate.Ringer Lactate.

Rich in SodiumRich in Sodium NS, DNS.NS, DNS.

Rich in ChlorideRich in Chloride NS, DNS, Isolyte-G.NS, DNS, Isolyte-G.

Rich in PotassiumRich in Potassium Isolyte- M, P, G.Isolyte- M, P, G.

Corrects AcidosisCorrects Acidosis Ringer’s lactate, Isolyte- E, P, M.Ringer’s lactate, Isolyte- E, P, M.

Corrects AlkalosisCorrects Alkalosis Isolyte- G.Isolyte- G.

Cautious in Renal FailureCautious in Renal Failure Ringer’s Lactate, Isolyte- E, G, M, P.Ringer’s Lactate, Isolyte- E, G, M, P.

Avoided in Liver FailureAvoided in Liver Failure Ringer’s Lactate, Isolyte- G.Ringer’s Lactate, Isolyte- G.

Glucose freeGlucose free NS, Ringer’s Lactate.NS, Ringer’s Lactate.

Sodium freeSodium free 5%, 10%, 20%, 25% Dextrose.5%, 10%, 20%, 25% Dextrose.

Potassium freePotassium free NS, DNS, Dextrose fluids.NS, DNS, Dextrose fluids.

o Fluid administration depends upon clinical judgement of patients status.

oAIM - To maintain reasonable blood pressure (>100/70 mmHg), Pulse rate <120/min, hourly Urine output of 30-50ml/hour, with normal temperature, warm skin, normal respiration & sensation.

o RINGER LACTATE is the most physiological fluid, because it’s constitution is similar to ECF.(Na-130, K-4, Cl-109,

Lactate(bicarbonate)-28, Ca-3 mEq/L)

• Depends On Type & Duration Of Surgery.

•Patients subjected to short operative procedures, who don’t need handling of the intestinal viscera (D&C, D&E, T.L, Bartholin’s Abscess/Cyst removal etc) will need only maintenance IV fluids to correct deficit due to NPO state.

•After 4-6 hrs oral intake is restarted, provided pre-op GI preparation optimal, least handling of intestines during operation, no injury to the GI & patient has no nausea/vomiting/ abdominal distention.

• Patients with major surgeries (Hysterectomies, Caesarean Sections, Cystectomy, Exploratory Laprotomy, Wertheim’s Operative procedures, Prolapse repairs etc) where intestinal viscera need rest, require post op IV fluids for few days.

•After ensuring normal bowel sounds & thus adequate bowel movements, oral intake is gradually restarted, starting with oral sips, followed by semisolid food, and ultimately normal diet.

1. Pre-op inadequate correction of hydration status with proper fluid or inadequate Intraop maintenance by fluid infusion.

2. Inappropriate calculation of required fluid volume.3. Intra-op blood loss replaced with equal volume of

crystalloid. IDEAL IS TO REPLACE VOLUME OF BLOOD LOST WITH

THREE TIMES VOLUME OF CRYSTALLOIDS, which maintain the intravascular blood volume and cardiac output, but oxygen carrying capacity will be compromised.

thus, blood should be arranged as soon as

possible.

4. Fluid lost from naso-gastric tubes, fistulae, drains if not considered.

5. Excessive loss due to hypermetabolism, pyrexia, hyperventilation.

6. In early post-op period if there is hypotension, disproportionate anaemia…think of internal bleeding unless proved otherwise & inadequate fluid replacement.

BEFORE PRESCRIBING POST-OP FLUIDS, ONE SHOULD CONSIDER:- Age, Weight, Vital data, Hydration status, Urine output of the patient. Pre-op diagnosis, Nature of surgery, Intra-op blood loss. Nature & Volume of fluid / blood used intra-op. Drain output, Nasogastric feeding tube output, Fluid loss at wound site. Associated illness if any- eg. Protein losing Nephropathy, Chr HTN, DM, CHF etc. Insensible losses due to ambient temperature, pyrexia, hyperventilation, obese/lean & thin body mass.

1) WHY MAINTAINENCE FLUIDS ON 1ST POST-OP DAY ARE LESS IN SALT & OF LOW TOTAL VOLUME ?

GA & Post-op pain leads to increase secretion of ADH & Aldosterone. (response to stretch & stress)

Thus, salt & water are retained by the kidney. To avoid, overloading of either salt/water, fluids low in

their sodium content, and of low total volume are used.

2) WHEN ON 1ST POST-OP DAY, SALT CONTAINING FLUIDS ARE TO BE USED ?

To infuse salt rich fluids is not a routine in all patients. Special conditions are:- a) Elderly patients with salt losing nephropathy. b) Patients on simultaneous treatment with diuretics &

mannitol. c) To replace nasogastric aspiration & drainage output. d) After major surgeries, wherein intestinal/renal

handling has been significant, saline is transfused to replace third space losses.

3) WHY USUALLY POTASSIUM IS AVOIDED IN FLUIDS FOR 1ST TWO POST-OP DAYS ?

Patients may have oliguria / azotemia. So, till urine output is established & normal renal status ensured, potassium supplementation can be risky.

Post-op tissue trauma causes release of K+ from intracellular to extracellular compartment, which may cause hyperkalemia.

Intra-op / Post-op transfusion of stored or haemolysed blood may add large amounts of K+.

Post-op metabolic acidosis will shift intracellular K+ extracellularly.

As body has large stores of intracellular K+, non replacement for first 2-3 days will not cause hypokalemia.

4) WHICH FLUIDS TO BE USED TO REPLACE ADDITIONAL LOSSES ?

Prolonged Vomiting/Nasogastric Suction- Ideal fluid is NS. If urine output is adequate, K+ added after 2nd day. After initial two days, even Iso-G can be added in

amounts similar to upper GI loss, provided the urine output & renal status are normal. Decision to add K+ in fluid therapy should be guided by Serum K+ estimation & bedside ECG.

Fluid loss due to small bowel fistulas causing diarrhoea- RL is ideal for replacement, may need additional HCO3- & K+ supplementation.

Blood loss- to be replaced with three times the volume of NS or RL.

For larger losses, should be replaced with blood at the earliest.

5) HOW TO INFUSE FLUIDS POST OPERATIVELY ?

It’s a wrong method to infuse the entire volume over 8-12 hours.

Maintenance fluids are to be given at a steady rate over 24 hours.

If given at a fast rate & over a short period- CHF, Lung oedema, may develop

Renal excretion of excess salt & water will cause fluid-electrolyte imbalance.

Body losses continue over the 24 hours and beyond, fluids of different compositions are given, alternated & additives may be added as per need, evenly distributed throughout the post-op period.

IN POST OP/ POST DELIVERY CONDITIONS IN POST OP/ POST DELIVERY CONDITIONS WHERE EARLY ENTERAL FLUID THERAPY WHERE EARLY ENTERAL FLUID THERAPY CANT BE STARTED, REPLACEMENT OF CANT BE STARTED, REPLACEMENT OF ADEQUATE CALORIES SHOULD BE DEALT ADEQUATE CALORIES SHOULD BE DEALT PROPERLY, SO THAT PATIENT DOESN’T PROPERLY, SO THAT PATIENT DOESN’T DEVELOP HYPOGLYCEMIA, ACIDOSIS, DEVELOP HYPOGLYCEMIA, ACIDOSIS, AZOTEMIA, BODY PROTEIN LOSES VIA AZOTEMIA, BODY PROTEIN LOSES VIA

GLUCONEOGENESIS. GLUCONEOGENESIS.

Monitoring of iv fluid therapy1.Clinical judgement of degree of hydration/ dehydration.2.Pulse rate, Blood Pressure monitering.3.Strict recording of input- volume of fluid, type of fluid, 4.Strict recording of sensible fluid loss i.e urine output, sweating(temperature), vomitings, diarrhoea, drains output, nasogastric aspiration etc.5.Serum electrolytes estimation should be done.

6. Haematocrit.7. Blood urea & Serum creatinine.8. Urinary Na excretion estimation.9. Metabolic acidosis (urine pH with litmus paper test)10.CVP or PAWP.

post op fluid ppt

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