Fluid Management

Written by: AybikeOnur from Fastbleep,

Basics
Intravenous fluids may be used for:
Maintenance
 provide daily fluid requirement in patients unable to take in adequate fluids or
losing increased amounts and correct dehydration
Use crystalloids to maintain volume.
A common regime (for an average 70kg man) to give 3 L fluid with 150 mmol
sodium and 60 mmol potassium is:

 1L normal saline with 20 mmol potassium over 8 hr

 1L 5% dextrose with 20 mmol potassium over 8 hr
 1L 5% dextrose with 20 mmol potassium over 8 hr

Other common regimes are:

 1L normal saline with 20mmol potassium over 8hrs each and 1L of 5%

dextrose with 20mmol potassium for patients with surgical problems (such as
bowel obstruction) that may lead to excessive Na loss. Always check U+Es
before prescribing
 3x 1L of Hartmann’s solution over 8hrs each.  Hartmann's is
physiologically close to plasma but has a lower osmolality. Continuous
therapy can therefore reduce plasma osmolality and it should be avoided in
patients with head injury to avoid exacerbating cerebral oedema.

 
Resuscitation
 The replacement of intravascular volume in hypovolemic patients
Use colloids to replace the intravascular volume fast and effectively. These
fluids (such as gelofusin and dextran) are contain large particles osmotically
active and remain in the intravascular space. These are often used initially in
patient who are hypotensive.
Use crystalloids to expand volume over longer periods of time. These contain
smaller molecules and will distribute over time into the interstitial and
interacellular spaces.
There is no clear benefit in outcome from initial resuscitation with colloids versus
crystalloids and either can be justified. Current ATLS guidelines recommend an
initial 2L of crystalloid (specifically hartmanns) to restore volume in acute
haemorrhage. the amount of crystalloid required to restore circulating volume is
roughly 3-4 times the volume lost.
A common regime to replace fluid loss requires several adjustments and close
monitoring is:

 250 ml colloid (Gelofusine) or 5% dextrose fluid challenge to maintain CVP

at 8-12 cmH2O and BP >120 mmHg (repeat if necessary)
  1 ml/kg/hr normal saline as adjunct fluid therapy
 Additional potassium in 5% dextrose if K+ <3 mmol/L

Severe hemorrhage requires packed red blood cell infusion.

Hartmann’s solution at 20-30 ml/kg/hr can also be used for fluid resuscitation
 

Total body water

70 kg man has ~42 L (%60) body fluids. Distribution of fluid in the body is: 
1/3 in extracellular fluid

 Interstitial fluid                10 L

 Plasma                           3 L
 Transcellular fluid              1 L

2/3 in intracellular fluid

 Red blood cells                 2 L

 Other cells                      26 L

Transcellular fluids include cerebrospinal fluid, synovial fluid, pleural fluid, ocular
fluid, etc.
 
Fluid movement between these compartments are governed by osmotic and
Starling forces:

Osmotic forces:
Osmotic equilibrium at the cell membrane regulates the water balance between
ECF and ICF. Osmotic forces depend on osmolality (Osmoles of solute per
kilogram of solvent). Main solutes include charged (Na+, K+, Cl-, HCO3-) and
uncharged (urea, glucose) molecules.
 
Starling forces:
Starling equation illustrates movement of fluid across capillaries depending on
three factors:

 Hydrostatic forces that push fluid

 Oncotic pressure exerted by proteins in fluid that pulls water
 Permeability of endothelium between plasma and interstitial fluid

On the arterial side of capillary bed, intravascular fluid moves into interstitial
space (higher intravascular hydrostatic force). On the venous side, fluid is
reabsorbed into plasma (lower intravascular hydrostatic force).
When fluid is infused into plasma, hydrostatic forces increase and oncotic
pressure decrease (dilution effect) until fluid is evenly distributed in ECF and
Starling forces are in equilibrium.
 
 

Assessing volume status

History: Patient history, observation and fluid charts, patient notes, etc.
Examination: Blood pressure, pulse, respiratory rate, skin turgor and capillary
refilll time, temperature
Investigations: urine output (<30 ml/hr for 70kg man), central venous pressure
readings, blood tests, chest x-ray
Response to fluid challenge: Give a 500 ml 0.9% saline or 250 ml colloid through
large bore 14G (brown) or 16G (grey) cannula over 5 minutes. Measure response:
 CVP monitoring, pulse or BP increase and reduction of respiratory stress. Repeat
as necessary. Fluid challenge is safe is lungs are clear.
 

Dry patient
Nil-by-mouth, increased fluid loss (diarrheaot vomiting), thirst and dry mouth
Low CVP, low BP, tachycardia, weight several kg below pre-op weight
Decreased urine output
Bloods: urea disproportionately raised to creatinine, high sodium and potassium
levels
Fluid challenge may not be sufficient to raise CVP initially
 
 
Overloaded patient
Fluid intake > output
Raised CVP, pulmonary oedema, weight several kg above pre-op weight
Blood sodium level may be low
X-ray may show pulmonary oedema and effusion
CVP rises and plateaus with fluid challange
 

Fluid and electrolyte balance

Daily requirements

 Water: 40 ml/kg/day (rough estimation, see below for exact calculation)

 Sodium ~ 100 mmol
 Potassium ~60 mmol

 
Daily fluid balance of 70 kg man:
 

Intake: ~2500 ml

 1500 ml – liquid intake

 750 ml – food
 250 ml – oxidative phosphorylation

 
Output: ~ 2500 ml

 1500 ml – urine*
 100 ml – feces
 900 ml – insensible loss (skin, lungs)

* Minimal volume of urine a healthy person needs to produce is 0.5 – 1 ml/kg/hr

 

Maintenance fluid requirement for healthy nil-by-mouth patient:

 4 ml/kg/hr for first 10 kg of patient’s weight

 2 ml/kg/hr for second 10 kg of patient’s weight

 1 ml/kg/hr for every kg after that

 + 100 mM sodium and 60 mM potassium

For example:
 A 70 kg man will require 2650 ml fluid per day: 40 + 20 + 50 = 110 ml/hr --> 2640
ml/day + 100 mM Na+ and 60 mM K+
 A 40 kg woman will require 2160 ml fluid per day: 40 + 20 + 20 = 80 ml/hr --> 1920
ml/day + 100 mM Na+ and 60 mM K+
 
Daily fluid requirements increase in illness:

 Fever (500 ml/day for every degree above 37oC)

 Breathlessness and tachypnoea
 Diarrhoea and vomiting
 Haemorrhage
 Surgical drains, stoma and fistulae
 Polyuria
 Third space losses (pancreatitis, bowel obstruction,  and after laparotomy)
 SIRS – capillary leak

 
Fluid requirements in resuscitation depends on stages of hypovolemic shock:
Stage 1 (< 15% or <750ml loss):  Normal blood pressure as compensated by
increased systemic vascular resistance --> give Crystalloid
Stage 2 (15-30% or 750-1500ml):  Tachycardia, postural hypotension, +/- sweating
and anxiety – partially compensated by increased systemic vascular resistance
--> give Colloid
Stage 3 (30-40% or 1500-2000ml):  Systolic blood pressure <100 mmHg,
tachycardia, tachypnoea, altered mental state (confusion) --> give Colloid + Blood
Stage 4 (>40% or >2000ml):  Very low blood pressure, bradycardia, weak pulse
pressure, depressed mental state, urine output negligible --> give Colloid + Blood
 
Fluid overload risk is high in:

 Cardiac failure patients

 Chronic renal failure patients
 Elderly patients

 
 Post-operation fluid maintenance

 Aim for urine output of >30ml/hr

 Maintenance fluid regime (see above)
 Avoid potassium in the first 24-48 hr post-op
 Encourage patient to start oral fluids as soon as possible
 Account for extra fluid losses (drains, fever, etc.)

 
 

Intravenous fluids

Crystalloids are water with electrolytes, which form a true solution and are able
to pass through a semipermeable membrane. Crystalloids are lost rapidly from
intravascular space into interstitial space (depending on the osmolality), and they
remain in extracellular compartment for about 45 minutes. Therefore they require
larger volumes than colloids for fluid resuscitation. Eventually water from
crystalloids diffuse through intracellular fluid as well (membrane pumps and
metabolism alter crystalloid distribution and osmotic forces)

 Normal saline is an isotonic solution of 150 mmol/L NaCl

 5% dextrose acts as free water and is hypotonic – distributes to ECF and
ICF rapidly
 Hartmann’s solution is an isotonic physiological solution with electrolyte
composition similar to ECF

Advantages:

 Cheap and readily available

 Safe and free of side effects (if used correctly)

Disadventages:

 Higher volumes needed to restore intravascular volume

 Hartmann’s solution is contraindicated in diabetes mellitus
(gluconeogenic), renal failure (risk of hyperkalemia) and liver failure (risk of
lactic acidosis)
 Colloids: Water with large molecules or microscopic particles, which are
dispersed through water and do not form a true solution. These particles do not
pass through semipermeable membranes. Therefore colloid solutions remain in
intravascular space longer depending on molecular weight of colloids.
Natural:

 Packed red blood cells increase hematocrit by 3-4% and hemoglobin by

1g/dL per 1 unit infused. They efficiently restore intravascular volume in
hemorrhage and oxygen carrying capacity.
 Human albumin solution with 4.5% albumin reflects normal plasma. It is
used in patients with low albumin, such as burn and chronic liver failure
patients.

Synthetic:

 Haemaccel and Gelofusine are water solutions with gelatine (degradation

product of animal collagen) and electrolytes
 Hydroxyethylated starch (HES) contains different sized hydroxyethylated
polysaccharide, which amylase cannot breakdown. Its volume expanding
effect is long and depends on molecular size.

Advantages:

 Restore intravascular volume fast

 Improve oxygen carrying capacity (packed red blood cells only)

Disadvantages:

 High costs and limited supply of natural colloids

 Allergic reactions to gelatine
 HES cannot be used to replaced >30% of loss due to renal failure risk
 Risk of transmitted infections
 Risk of haemolytic reaction to unmatched blood

Case scenarios

 25-year-old goalkeeper fell on left side of his chest reaching for the ball.
Now his ribs hurt a lot. He is alert with pulse of 120 beats per minute, blood
pressure of 150/100 mmHg, respiratory rate 24 per minute and apyrexial. He is
clammy to touch. What is the ideal initial fluid management for him?

 
This man most likely has injured his spleen and losing blood into abdominal
cavity. He is probably in stage II hypovolemic shock and can progress to stage III.
Sympathetic response to bleeding causes hypertension, tachycardia, tachypnea
and sweating. He needs colloids (Gelofusine) to replace intravascular fluid and
achieve adequate hemodynamic response for a long period. Adequate amount of
colloids can be determined by series of fluid challenges. Crystalloids (0.9% saline
or 5% dextrose) can later be added to further increase fluid input.
 
 

 60 year old woman with intestinal obstruction has the following fluid
balance chart:

- Intake: nil by mouth, 3000 ml IV normal saline

- Output: 500 ml urine, 3500 ml from nasogastric tube
Last blood results show low potassium. She weighs 60 kg, is apyrexial and has
normal BP and heart rate. She complains of a dry mouth. Which fluids are required
for the next day before surgery?
 
First we need to calculate her current water deficit. Her total fluid output is 5000
ml (another 1 L from insensible losses) and total input is 3000 ml. This leaves a
deficit of 2000ml. For the next 24 hours she needs IV fluids to replace this 2000
ml on top of her normal needs.
Her normal daily fluid requirement is 2400 ml (calculated using her weight:
(4*10+2*10+1*40)*24ml). Since she is nil-by-mouth, her only water input is ~250
ml metabolic water. Adding all her requirements, she needs minimum of 4000 ml
fluids(2000+2400-250). Replacement fluids for anticipated losses from
nasogastric tube can be prescribed as well, but caution must be taken to avoid
overloading. Possible regimes are:
-       4 L Hartmann’s solution over 24 hours
-       2 L 5% dextrose (replace deficit) and 2 L Hartmann’s solution over 24
hours
In this scenario preferring Hartmann’s solution over 0.9% saline is important to
correct hypokalemia. Blood tests should be repeated to re-check electrolyte
levels.
 

Electrolyte composition of body fluids

This is a reference section for those interested in numbers
 
Electrolyte composition of IV fluids

References:
1.         McLatchie GR, Borley NR, Chikwe J, Ovid Technologies Inc. Oxford
handbook of clinical surgery. Oxford ; New York: Oxford University Press; 2007. 
2.         Cooper N, Forrest K, Cramp P. Essential guide to acute care. 2nd ed.
Malden, Mass.: Blackwell BMJ Books; 2006.
3.         Kumar PJ, Clark ML. Kumar & Clark's clinical medicine. 7th ed.
Edinburgh ; New York: Saunders Elsevier; 2009.
4.         Goldberg A, Stansby G. Surgical talk : revision in surgery. 2nd ed.
London, Singapore ; Hackensack, NJ: Imperial College Press ; Distributed by
World Scientific; 2005.