FLUID AND ELECTROLYTE BALANCE

PRESENTED TO:

DR. SUJATA MOHANTY

DR. ZAINAB CHOUDHARY
DR. PANKAJ SHARMA MODERATOR: DR S.P Singh
DR. MONICA KELKAR
DR. UPMA
DR. CHANDERVEER PRESENTED BY:
DR. ANSHUL Neha chauhan
DR.VARUN
DR.SANCHAITA
CONTENTS

• BASIC PHYSIOLOGY: •ORAL REHYDRATION THERAPY

WATER
FLUID BALANCE • IV FLUIDS
FLUID IMBALANCE
SOLUTES • FLUID THERAPY IN SURGICAL
PATIENTS
ELECTROLYTE BALANCE
ELECTROLYTE IMBALANCE
 ACID AND BASE BALANCE
• PRINCIPLES OF FLUID THERAPY
BASIC PHYSIOLOGY

• Body fluids have 2 components:

Water
Solutes- electrolytes and non-electrolytes
WATER
• Total body water content:
60 % of body weight- adult
male
50-55 % of body weight- adult
female
Obese < lean
 SOURCES OF WATER GAIN
• EXOGENOUS SOURCE/SENSIBLE GAIN:
2-3 liters /day

• ENDOGENOUS SOURCES/ INSENSIBLE GAIN :

300ml/day
Oxidation of ingested food

.
SOURCES OF WATER LOSS
• SENSIBLE LOSS- THROUGH URINE:
Normal urine output in 24 hours is 1500ml
.

• INSENSIBLE LOSSES:
LUNGS: 400ml/day water

SKIN: 500ml/day

FAECES: 100ml/day, greatly increased in diarrhea.

FLUID BALANCE
• Neutral balance: input = output
• Positive balance: input > output
• Negative balance: input < output
• Movement of body fluids is via:
Osmosis - diffusion of water
across a selectively permeable
membrane
Diffusion - movement of
particles down a concentration
gradient.
Active transport - movement of
particles up a concentration
gradient; requires energy.
SOLUTES
 Nonelectrolytes – uncharged particles
 glucose
 lipids
 creatinine,
 Urea.

 Electrolytes- charged particles- any substance that dissociates

into ions in aqueous solution.
 inorganic salts
 acids and bases
 some proteins

 MAJOR EXTRACELLULAR ELECTROLYTES: Na+, Cl

 • MAJOR INTRACELLULAR FLUID ELECTROLYTES: K+,
HPO42
 ELECTROLYTE BALANCE
 Body fluids are:
 Electrically neutral
 Osmotically maintained
 Cells are: isotonic with body fluids
ELECTROLYTE BALANCE
Abnormality of fluid and
electrolytes
1) ECF volume disturbances
a) Fluid excess
b) Fluid deficient

2) ECF concentration disturbance

a) Hyponatremia
b) Hypernatremia

3) Disturbances in concentration of ion other then sodium.

ECF volume depletion
Istonic volume depletion Pure water depletion
 Water and salt loss  Predominant water
deficiency with no electrolyte
 Leads to hypovolemia
loss

 Leads to dehydration
CAUSES
ISOTONIC VOLUME
PURE WATER DEPLETION
DEPLETION
 Diarrheoea  Poor oral hygiene
 Vomiting  Diabetes insipidus
 Excess diuresis
Clinical features
ISOTONIC VOLUME
PURE WATER DEPLETION
DEPLETION
 Dry tongue  Excessive thirst
 Tachycardia  CNS manifestation including
 Dizziness confusion, convulsion, coma.
 Hypotension
Management
ISOTONIC VOLUME
PURE WATER DEPLETION
DEPLETION

 0.9% NaCl  Incresed oral water intake

 Dextrose – 5% infusion
ECF volume excess
Water and salt excess Predominant water excess
Causes – Causes –
 CHF  Compulsive water drinker
 Cirrhoris  SIADH
 Nephrotic syndrome
 Renal failure
 Excessive and prolonged
saline administration in
hospitalized patient
Clinical features
Water and salt excess Predominant water excess

 Odema  Neurological symptoms –

 Tachycardia Confusion
 Ascites Loss of attention
 Pulmonary odema Drowsiness
Nausea
Vomiting
Treatment
Water and salt excess Predominant water excess

 Underlying etiology  Underlying etiology

 Water and salt restricted diet  Fluid restriction
 Diuretics advised  Hypertonic saline and
frusemide (severe excess)
Sodium balance
 Major ECF cation
 Normal ECF sodium value: 140mEq/L
 Function – maintain ECF volume and therefore
maintain blood pressure
 Activates
aldosterone
and
angiotensin II
Increased
sodium
absorption
Decreased
sodium in ECF

Decreased
urinary loss

Normal
sodium conc

Increased Increased
sodium in ECF sodium loss

Decrease Decreased
angiotension renal
II and reabsorption
aldosterone of sodium
SODIUM IMBALANCE

HYPONATREMIA

Plasma sodium level below 135 mEq/ L

 Causes
Decreased • Vomiting
• diarrhea
ECF vol • diuretics

Increased • cirrhosis
• CHF
ECF vol • Renal failure

Normal • SIADH

ECF vol • Post operative pain

CLINICAL FEATURES

MILD MODERATE SEVERE

Anorexia Muscle cramps Drowsiness

Headache Muscular Diminished
Nausea weakness reflexes
Vomiting Confusion Convulsion
Ataxia Coma
Death
 Management

Hypo • Salt and water supplement

• 0.9% NaCl
volemia
• Water restriction
Odema • No salt
• Loop diuretics

Normal • Water restriction

volemia
SODIUM IMBALANCE
HYPERNATREMIA

 >145 mEq/L
CAUSES :
a) Excess water loss:
▪ Severe exercise
▪ Diuretics
▪ Diarrhoea
▪ Burns

a) Water deficit due to impaired thirst

b) Sodium retention: excessive I.V. hypertonic NaCl or

NaHCO3.
CLINICAL FEATURES

• Thirst
• Dry mucous membrane
• Increase temp
• nausea , weakness, Restlessness
 Management
Acute Chronic
 Treat vigorously  Rapid correction is dangerous

with D-5% infusion  Cereberal oedema

 Reduction of sodium by
1mEq/every 2 hrs
Potassium balance
 Major intracellular cation
 Normal serum value : 3.5 – 5.0 mEq/L
 ICF : 150 – 160 mEq/L

 Function – required for normal function of cell and all

muscle
REGULATION OF POTASSIUM BALANCE
Regulation depends on :
1) Plasma concentration of K+
2) Aldosterone influence
 HYPOKALEMIA
Serum potassium< 3.5mEq/L
Cause
 Poor intake
Dietary
Potassium free I.V fluid

 Excessive loss
Vomiting , diarrhoea, sweating
Diuretics , mineralocorticoid excess
Clinical features
MANAGEMENT

• Mild hypokalemia [3.3 to 3.5]- oral

potassium replacement
• Moderate hypokalemia [3.0 to 3.4)
treatment in selected high risk patient

• Severe hypokalemia [<3.0]

1 ) KCl –
preparation of choice – correct
hypovolemia and metabolic alkalosis.
2) Potassium bicarbonate – hypokalemia
with chronic diarrhoea
POTASSIUM IMBALANCE
HYPERKALEMIA

 > 5 mEq/L
 CAUSES :

 Increased intake
I.V fluid containing potassium
Food
 Impaired excretion
Renal failure
Potassium sparing diuretics
ACE inhibitor , NSAID
CLINICAL FEATURES
TREATMENT

 Dietary restriction of potassium- less than 5.5

mEq/L
 • MILD TO MODERATE HYPERKALEMIA-
 Dietary potassium restriction: avoid fruit
juice,coconut water,food rich in potassium.
Avoid medication like: potassium sparing
diuretics,ACE inhibitor.
Loop or thiazides diuretics to increase renal excretion
of potassium.
POTENTIALLY FATAL HYPERKALEMIA occur when
K+ concentration is > 7.5 mEq/L and requires
emergency treatment.

1. Antagonism of membrane effects of

hyperkalemia:
injection calcium gluconate
2. Potassium movement into the cell:
insulin and glucose
inj.sodium bicarbonate
B2 agonist
3. Removal of potassium from body:
loop or thiazide diuretics
dialysis
CALCIUM BALANCE
Normal value: 8.4-10.2 mg/dl
 Most in ECF

Functions :
Neuromuscular excitability
Cardiac contractility
Hormone secretion
Blood coagulation
REGULATION OF CALCIUM BALANCE
•PARATHYROID

•VITAMIN D
CALCIUM IMBALANCE
HYPOCALCEMIA

Serum Ca < 8.5 mg/dl

Causes :
1) Hypoalbuminemia
2) Hypoparathyroidism
3) Defect in vitamin D metabolism
CLINICAL FEATURES
MANAGEMENT:
• Asymptomatic Hypocalcemia: oral calcium chloride, calcium
gluconate or calcium lactate.

• Tetany (Acute Hypocalcemia) - IV calcium chloride or calcium

gluconate 10-20 ml I.V. slowly over 10 minutes.

• Chronic or Mild Hypocalcemia: increase dietary calcium.

HYPERCALEMIA
Serum Ca > 10.5 mg/dl
CAUSES :
1) Excess PTH level
2) Malignancy
3) Excessive vit. D
4) Thyrotoxicosis
5) Drugs ( Thiazides)
CLINICAL FEATURES
Clinical features are related to severity and rapidity of
onset. MILD hypercalcemia is generally asymptomatic.
Features of SEVERE hypercalcemia are:
• CNS symptoms: fatigue, weakness ,depression,
confusion, coma.
 GI symptoms : constipation, Anorexia, Nausea,
vomiting.
 Renal symptoms: Polyuria, nocturia, stone formation.
TREATMENT

1) Volume expansion : 4-6 L of NS over first 24 hrs

2) If bone resorption is the cause : Bisphosphonate

therapy ( Pamidronate 60-90 mg I.V. over 2-4 hrs)

3) In vitamin D excess, Glucocorticoids are given.

I.V. Hydrocortisone ( 100-300 mg daily ) or Prednisolone
( 40-60 mg daily ) for 3-7 days.
HYPOMAGNESEMIA (<1.4mEq/L)

• CAUSES:
• Malnutrition, Starvation
• Diuretics, Aminoglcoside antibiotics
• Chronic diarrhoea
• Vomiting

• CLINICAL FEATURES
• Neuromuscular manifestations: similar to hypocalcemia and include lethargy,confusion
Tremor ,tetany.

• CV manifestation: Arrhythmia

• MANAGEMENT:
• Eliminate contributing factors
• IV MgSO4
• Diet Therapy:Foods high in Magnesium: Green leafy vegetables, Nuts, Legumes,
Sea food, chocolate
HYPERMAGNESEMIA (>2.0mEq/L)

• CAUSES:
• Increased Magnesium intake
• Decreased renal excretion
• CLINICAL FEATURES:
• Neuromuscular -Weak voluntary muscle contractions, Drowsiness, lethargy
• CV - Bradycardia, peripheral vasodilatation, hypotension.

• MANAGEMENT:
• Eliminate contributing factors.
• Administer diuretic
• Calcium gluconate reverses cardiac effects
• Diet restrictions
 RANGE
Normal pH: 7.35-7.45
Normal PaCO2: 35-45 mm of Hg
Normal HCO3: 22-26 mEq/L
Respiratory acidosis: PaCO2 > 45mm Hg
Respiratory alkalosis:PaCO2< 35mmHg
Metabolic acidosis: HCO3<22mEq/L
Metabolic alkalosis:HCO3>26mEq/L
REGULATION OF ACID BASE

1) Buffer systems
2) Respiratory regulation
3) Renal regulation
METABOLIC ACIDOSIS
Causes :
1) Increased acid load(Ketoacidosis , Lactic acid)
2) Decreased bicarbonate( Diarrhoea, Duodenal fistula )
3) Addition of exogenous acids
4) Failure to excrete acid(renal failure)
CLINICAL FEATURES
MANAGEMENT
1.Treat the underlying cause

2.Intravenous NaHCO3

3.correct electrolyte imbalance

METABOLIC ALKALOSIS
Causes :
1) Acute alkali administration
2) Excessive vomiting
3) Primary Hyperaldosteronism
CLINICAL FEATURES
MANAGEMENT
 Treat the underlying cause
Administer KCL
H2 or proton pump inhibitors
NaHCO3
Ringer lactate DISCONTINUE
Acetate
citrate
RESPIRATORY ACIDOSIS
pH is less than 7.35 and the paCO2 is greater than
42mmHg
Causes :
1) COPD ,asthma
2) Neuromuscular disorder
3) hypoventilation
CLINICAL FEATURES
MANAGEMENT

1.Treat underlying cause

2.Support ventilation

3.Correct electrolyte imbalance

RESPIRATORY ALKALOSIS
PH is greater than7.45 and the paCO2 is less than
38mmHg.
Cause :Hyperventilation
CLINICAL FEATURES
MANAGEMENT
 Treatment of underlying cause.

 O2 supplementation If hyperventilation is due to

hypoxemia.

 In absence of hypoxemia, hyperventilation needs

reassurance and rebreathing in a paper bag.

 Pretreatment with acetazolamide minimizes symptom due

to hyperventilation at high altitude.
Principle of fluid therapy
 For proper fluid therapy correct-
etiology

Associated illness

clinical status

• As a principle, oral route is always preferred over IV route.

ORT-ORAL REHYDRATION THERAPY:

• ORT is a method to provide fluid, electrolyte and calorie

supplementation orally.

• Mainly for children with diarrhoea/starvation.

ORT-ORAL REHYDRATION THERAPY:

• FLUIDS INCLUDED IN ORT:

Oral Rehydration Solutions: Standard WHO ORS, low sodium ORS,
Low osmolarity WHO ORS.
Home made electrolyte solution: 40 gm sugar and 4 gm salt in one
liter water.

Home available solutions: lemon sarbat, buttermilk with salt and

sugar, coconut water, dal water etc.

• FLUIDS NOT ACCEPTED AS ORT:

Plain water
Glucose water without salt or sweetened drinks
Salt water without sugar.
I.V. FLUID THERAPY

• INDICATIONS OF IV FLUID THERAPY:

When oral intake is not possible: coma, anesthesia, surgery
Severe vomiting, diarrhea
Moderate to severe dehydration and shock, where urgent and rapid
fluid replacement is required.
Hypoglycemia, where 25% dextrose is life saving
For total parenteral nutrition

• CONTRAINDICATIONS OF IV FLUID THERAPY:

When patient can take oral fluids
Preferably avoided in congestive heart failure and volume overload.
CLASSIFICATION OF I.V. FLUIDS
A) CLASSIFICATION ACCORDING TO PARTICLE SIZE:
• Crystalloids:
• Fluids with small “crystalizable” particles.
• pass easily through semipermeable membrane
• can’t remain confined to intravascular compartment - short-lived.

.
• Colloids:
• Larger molecules so retained within vascular system unlike crystalloids.
• So, are more effective than crystalloids as plasma volume expander.
• 3 times more potent than crystalloid fluids for vascular volume.
CLASSIFICATION OF I.V. FLUIDS

B) CLASSIFICATION ACCORDING TO USE:

• Maintenance fluids:
replace fluids lost from lungs, skin, urine, faeces (salt poor loss)
Egs: D5, D1/2NS

• Replacement fluids:

to correct fluid deficit caused by gastric drainage, vomiting,

diarrhoes, oozing from trauma,
infections, burns etc.
Egs: NS, DNS, RL, Isolyte-M, P and G.

• Special fluids:
for special indications like hypoglycemia, hypokalemia, metabolic
acidosis etc.
Egs: D25, inj. Sodium bicarbonate, inj potassium chloride.
PHARMACOLOGY OF I.V. FLUIDS:
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS COMMENT
(In 1 liter BASIS
fluid)

D5 (5% 50 gm • Prevention and Cerebral Best to correct

Glucose is
DEXTROSE) glucose treatment of oedema intracellular
consumed and
dehydration Hypovolemic dehydration.
water is
• Cheapest fluid to shock Sodium free
distributed
provide calories Potassium free
proportionately
in all body fluids • Pre- and post-op Hyponatremia
fluid replacement
and water
So,it is selected • Correction of intoxication
when there is hypernatremia due
need of water to pure water loss.
Uncontrolled
and not diabetes and
electrolyte. severe
hyperglycemia.
 Pharmacolo Indication Contraindicatio Comment
gical basis n

NS(0.9 • NaCl is • Water and salt • CHF, renal

% NaCl) majorly in depletion disease, cirrhosis
extracellula • Treatment of • dehydration with
r fluid so hypovolemic severe
NS shock, alkalosis hypokalemia
provides with dehydration,
extracellula hyponatremia.
r
electrolytes
.
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS COMMENT
(In 1 liter fluid) BASIS

DEXTROSE HALF 50gm glucose used where fluid therapy in Hyponatremia

SALINE 4.5g NACl there is pediatric
need for patients
calories, treatment of
more water severe
and less hypernatremia
salts: Eg: (without risk of
PEDIATRIC cerebral
patients oedema)
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

DNS (DEXTROSE 50 gm glucose Supplies Correction of Not preffered in severe

NORMAL 9gm NACl extracellular salt depletion Hypovolemic shock.
SALINE) electrolytes and
and energy hypovolemia
Along with fluid. with supply of
Unlike D5, it energy
does not Correction of
correct vomiting or
intracellular aspiration
dehydration induced alkalosis

.
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS COMMENT
(In 1 liter fluid) BASIS

RL (RINGER’S Sodium Large Na Severe In liver disease, Most

LACTATE content- hypovolemia - physiological
Potassium rapidly Severe CHF fluid-electrolyte
expands content nearly
Chloride intravascular Vomiting or similar to plasma.
volume. So even large
continuous
Calcium RL is . amounts can be
nasogastric
Bicarbonate metabolized Diarrhea . infused without
aspiration
to induced risk of electrolyte
bicarbonate hypovolemia imbalance.
in liver- with
hypokalemic
metabolic
acidosis.
Diabetic
ketoacidosis
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS COMMENT
(In 1 liter fluid) BASIS

SODIUM Inj NaHCO3 7.5%,In severe Metabolic Respiratory

Complications
BICARBONATE 25 ml ampoule metabolic acidosis alkalosis,
with acidosis, RL metabolic like hypokalemia,
Na and wont Hyperkalemia alkalosis, volume overload
bicarbonate work as hypokalemia and
conversion of hypocalcemia
lactate can occur.
to bicarbonate is
impaired here
sodium
bicarbonate is
effective
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

POTASSIUM 15%KCl in 10 When Na KCl added to Cautious use in

CHLORIDE ml soln has: various K free renal failure
1.5 gm KCl and K are I.V. fluids for As hyperkale
both lost, prevention of Mia is a risk.
hypokalemia
kidneys
retain Na at
the cost of k
,result in
hypokalemia.
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

D25 (INJ 25% 1 L of 25% dextrose Supplies Hypoglycemia avoid in diabetic patients
DEXTROSE) Has 250g glucose energy in concentra or
tted form,i,e, larger hypoglycemic
Glucose in smaller coma
Volume to provide provide
Energy. nutrition to
patient on
. maintenance
fluid therapy
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

ALBUMIN Heat treated Maintains plasma Plasma volume Avoid in patients

D 25%)
(5%, preparation of osmotic presuure. expansion with cardiac insufficiency.
human serum 5% soln expands Correction of,
albumin in 5% plasma volume to hypo-
and 25% roughly same as proteinemia
solution. volume infused,
25% solution
expands plasma
volume 4-5l
times.. Oncotic
effect lasts 12-18
hours.

.
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

DEXTRAN Glucose polymers Cause Correction of Severe -

(40 and 70) Produced by bacteria. Plasma volume hypovolemia- renal failure
expansion
short term
Available in 2 forms: Without oxygen
rapid volume Known
Dextran 70 and dextran Carrying capacity.
expansion hypersensitivity
40.- Prophylaxis of to dextran
deep vein Severe CHF or
thrombosis and circulatory
thromboemboli overload
improvement in micro sm.
Circulation and prevention -
Of thromboembolism.
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

GELATIN Sterile, Correction of Contains

Contains
POLYMERS colloidal hypotension in calcium, cant be
polymer of plasma
(HAEMACC . shock, burns, used with
degraded volume
EL) trauma and post- citrated blood.
gelatin (35gm) substitute.
operative
with blood loss.
electrolytes Remains in
(sodium,
chloride, blood for 4-5

calcium, hours and

potassium) expands
plasma
volume by
about 50% of
infused
volume.
 COMP. PHARMACOL. INDICATIONS CONTRAINDICTIONS
(In 1 liter fluid) BASIS

HETASTARCH Synthetic colloid Esterification Hypovolemia

(HYDROXYET (starch with retards and shock CHF,
HYL STARCH) >90%esterified degradation Adv: non impaired renal
amylopectin) of starch, antigenic function
available as 6% causing
solution in NS. longer
plasma Less expensive
expansion than albumin
(>24hrs)
Slightly more
potent than
albumin.
Other electrolytes
 Invert sugar solution,
 Isolyte M-ideal maintenance fluid and best to give
K+
 Isolyte G-only fluid to correct metabolic alkalosis
 Isolyte P- for paediatric patients
 Isolyte E- only fluid which correct Mg deficiency,
use in long term therapy.
MONITORING OF I.V. FLUIDS:
1. WEIGHT: regaining of weight loss due to fluid loss.
2. SKIN AND TONGUE: regaining warm extremities, moist tongue and normal elasticity of
tongue.
3. SENSORIUM: improvement of anxiety and restlessness
4. URINE OUTPUT:
• urine output > 30-50 ml/hr in adults or > 0.5ml/kg/hr in children
• absence of osmotic diuresis.

5. PULSE RATE:
• Correction to < 100/min in young adults
.
6.BLOOD PRESSURE: Hypotensive to normotensive.

7.URINARY SODIUM:
• increase in urinary Na excretion (>25 mEq/L).

• If < 25, patient needs additional fluid replacement.

8. METABOLIC ACIDOSIS: improvement in acidosis.

9. CVP AND PAWP: low CVP and PAWP will become normal.
ADMINISTRATION OF I.V. FLUIDS
• METHODS OF DELIVERY:
• conventional I.V sets
• micro drip sets
• precise and controlled delivery by infusion pump
• I.V. sets with calibrated chambers.
Method to calculate rate of infusion
 For Routine I.V set: 15 drops = 1 ml fluid

 RULE OF TEN: the number of drops per

minute =fluid infusion in 24 hours (in liters)
x 10
 RULE OF FOUR: fluid volume (in
ml/hour)/4= number of drops per minute
 For Micro drip set: 60 drops = 1 ml
FLUID THERAPY IN SURGICAL PATIENTS
• Following factors modify normal physiology in surgical patient:

1. ACUTE STRESS: physical and mental stress- increased sympathetic

stimulation- tachycardia, vasoconstriction and further stress.
2. INCREASED ACTH SECREATION: surgery induced - ACTH stimulates
adrenals to secrete:
• Hydrocortisone - to fight with acute stress
• Aldosterone - sodium retention and potassium loss.
3. POST-OPERATIVE PAIN AND STRESS:
• increased ADH secretion from post pituitary in first 2-3 post-op day
• water retention and decreased urine output to as low as 500 ml on
first post-op day.
• Hence maintenance fluid required on first post-op day is lesser.
4. FLUID LOSSES: blood and fluid losses
during surgery
PRE-OPERATIVE FLUID THERAPY: GOALS

1. CORRECTION OF HYPOVOLEMIA:
• Hypovolemia - decreased oxygen transport - increasing the risk of
tissue hypoxia and organ failure.
• Pre-surgically, increased vascular resistance and heart rate compens
it by normal baroreceptor reflexes. But these reflexes are lost on
induction of anesthesia, so patient may develop severe hypotension

• How to correct it:

0.9 % saline,ringer’s lactate,colloids are
most widely used.
PRE-OPERATIVE FLUID THERAPY: GOALS

2. CORRECTION OF ANAEMIA:
• To establish haemodynamic stability- for proper tissue oxygenation,
to cope up with possible operative blood loss and for proper post-
operative recovery and healing.

• Blood transfusion - at least 48-72 hours prior to surgery

• Packed cell - preferred - prevents volume overload.

3. CORRECTION OF FLUID OVERLOAD:

• common problem with hospitalized patients
• CHF, renal failure and liver cirrhosis.
• Diuretics, salt restriction and fluid restriction
• Dialysis - severe renal failure.
• AIM:
 To avoid hypovolemia and hypotension, maintain tissue perfusion,
oxygenation.
Crystalloids Colloids
Cheap ,easily available Expensive
reaction free Hypersensitivity reaction

Most commonly used Selectively used

Can escape the vascular can’t escape the vascular

space space
Slow Rapid restoration of plasma
volume
• CALCULATION OF INTRAOPERATIVE FLUID REQUIRED: sum of:

1. Correction of fluid deficit due to starvation:

Duration of starvation (hours) X 2 ml/kg body weight
2. Maintenance requirement for period of surgery: Duration of
surgery (hours) X 2ml’kg body weight or Rate of infusion = 2ml/kg
body weight/hour
3. Loss due to tissue dissection of haemorrhage: Amount of fluid
lost, according to type of surgery-
least surgical trauma (nil)
minimal surgical trauma (4ml/kg/hour)
moderate trauma (6ml/kg/hr)
severe trauma (10ml/kg/hr)
POSTOPERATIVE
 Depends upon the patient’s status.

 GOAL: to maintain
reasonable blood pressure (>100/70)
pulse rate less than 120/min
hourly urine flow between 30 and 50 ml
normal temperature, warm skin, normal
respiration and sensorium.
 ROUTINE POST-OPERATIVE ORDERS (in NPO patients):-
modified according to situation.
 First 24 hours of surgery: 2 litres 5% dextrose, or, 1.5 litres D5 and
0.5 litres NS.
 Second post-operative day: 2 litres D5 and 1 litre NS
 Third post-operative day: Similar fluid + 40-60 mEq potassium per
day.

 POST-OPERATIVE FLUID ELECTROLYTE PROBLEMS:

1. Volume excess:
2. Hyponatremia:
3. Hypernatremia:
4 Post-operative oliguria:
5. Hypokalaemia: most common electrolyte abnormality
6. Hyperkalaemia:
Thank you.