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Fluid restriction
Postoperative Salt Intolerance (Coller et al, Ann Surg 1944, 119: 533-541) No isotonic saline solution or Ringers solution should be given during the day of operation and during the subsequent first two postoperative days
Artificile colloden en indicaties albumine Bloedproducten Hemodilutie en autotransfusie Electrolietenafwijkingen Het zuur-base evenwicht Vochtbeleid Vochtcompartimenten
Intracellular water = 40 % of BW
Extracellular water = 20 % of BW
Plasma (5 % of BW)
% of body weight
Total body water
70 kg male (L)
42 28
60 40
Intracellular
Extracellular
20
5 15
14
3.5 10.5
Intravascular Interstitial
Interstitial fluid and lymph Rapid exchange (with plasma) Slow exchange Bone water Cavitary fluids: transudates of plasma E.g. peritoneal, pericardial, pleural Transcellular fluids: active transport mechanisms E.g. salivary, hepatic, biliary, pancreatic, gastrointestinal intraluminal, mucosal, dermal, intraocular, intrathecal
7
> 60 yr
52
46
Hays: Dynamics of body water and electrolytes (1980) In: Maxwell et al (eds): Clinical disorders of fluid and electrolyte metabolism
Male
65 60 55
Female
55 50 45
Number of particles/unit volume (m)moles / liter of solution Number of osmotically active particles/unit volume (m)osmoles / liter of solution Number of electric charges/unit volume (m)equivalents / liter of solution
10
Electrical neutrality In any fluid compartment or intravenous solution the number of milliequivalents of cations is balanced by precisely the same number of milliequivalents of anions Chemical combining activity (milliequivalents) 1 equivalent of an anion is the amount which can combine with 1 g of hydrogen
11
Sodium (mEq/l)
Potassium (mEq/l) Calcium (mEq/l) Magnesium (mEq/l) Chloride (mEq/l) Bicarbonate (mEq/l) Phosphorus (mEq/l) Protein (g/dl)
10
140 <1 50 4 10 75 16
145
4 3 2 105 24 2 7
142
4 3 2 110 28 2 2
Intracell. fluid
(mEq/kg H2O)
10 Cl10 Na+
2A
6 Cl6 Na+
2B
Plasma water
(mEq/l)
Interstitial fluid
(mEq/L)
CATIONS Sodium Potassium Calcium Magnesium Total ANIONS Chloride 109 114 152 4 5 3 164 145 4 3 1 153
Bicarbonate
Phosphate Sulfate
29
2 1 141
30
2 1 147
Organic acids
Protein (org. anions) Total
6
17 164
5
1 153
Hydrostatic forces Mechanical pressure generated by the heart Weight of blood within the vasculature Osmotic forces The movement of water is governed by the compartmental concentrations of osmotically active substances, predominantly electrolytes Extracellular: sodium, chloride, bicarbonate Intracellular: potassium, magnesium, phosphate, protein
16
Osmotic Pressure
Osmotic pressure is the hydrostatic pressure that must be applied to the solution of greater concentration to prevent water movement across a semi-permeable membrane separating two aqueous solutions of unequal concentration Osmotic pressure is dependent on the number of osmotically active molecules in solution
17
Osmotic Pressure
1 Osmole (Osm)
= 1 gram-molecular weight (1 M) of a nondissociating compound and consists of 6.023 x 1023 molecules = the number of osmoles of solute per liter of solution (solvent plus solute) = the number of osmoles of solute per kilogram of solvent (water) = osmolality x 19.3 (mmHg)
Osmolarity (mOsm / L)
Osmotic pressure
18
Sodium balance
Intracellular Extracellular
10 mEq/l
142 mEq/l
Plasma Osmolality
[Gluc] [BUN]
18
2.8
20
Extracellular osmolality = 290 10 mOsm/kg H2O Serum osmolality < 260 mOsm/kg H2O Serum osmolality > 325 mOsm/kg H2O
Sodium balance
Intracellular
P r o t e I n s
Extracellular
Starlings Equation
Q = kA [ ( Pc - Pi ) + s ( pi - pc ) ]
(mEq / L)
Q k A Pc Pi s pi pc
= = = = = = = =
fluid filtration capillary filtration coefficient area of the capillary membrane capillary hydrostatic pressure interstitial hydrostatic pressure reflection coefficient for albumin interstitial colloid osmotic pressure capillary colloid osmotic pressure
23
Osmolality (mOsm/kg)
Plasma ISF
[Na+] (non-protein)
281.4
281.1
Protein
1.2
0.2
Total
282.6
281.3
[Na+] (non-protein)
5431.0
5425.2
Protein
23.2
3.9
Total
5454.2
5429.1
25.1 mmHg
Capillary
Pc = 40 mmHg
Arterial
Pc = 10 mmHg
Venous
pc = 23 mmHg 18
Interstitium
Filtration
Pi = 2 mmHg pi = 4 mmHg
Absorption
Lymphatic drainage
Atrial natriuretic peptide Vasopressine Renin, angiotensin Parathyroid hormone Calcitonin Prostaglandins Dopaminergic receptors a-adrenergic receptors Thirst mechanism Intrinsic renal properties
27
Abnormalities of Volume Concentration Composition Basis for assessment Medical history Physical examination Laboratory data
28
Volume changes
(1)
Volume deficit Insufficient intake External losses Distributional volume deficit Volume excess
29
Transfer of isotonic solution from a functional compartment to a nonfunctional space Equivalent to ECF volume loss Isotonic Both ISF and PV contribute Same systemic manifestations as ECF loss Surgical trauma, muscle injury, burns, peritonitis, ascites
30
Clinical signs
Dry mucous membranes, oliguria Orthostatic hypotension, tachycardia, anorexia, apathy, poor skin turgor
6 - 10
Clinical signs
Supine hypotension, stupor, sunken eyes, cool and dry skin, mild hypothermia Coma, anuria, significant in core temp., dicrotic pulse, pulsus paradoxus, circulatory collapse
Catastrophic
> 20
Volume changes
(2)
Volume deficit Volume excess Iatrogenic Medical condition Cardiac, hepatic or renal dysfunction Mobilization of third space losses
33
Concentration Changes
Disorders of water balance
Loss of extracellular water Increased serum [Na+] Increased serum osmolality Redistribution of water Changes in osmolality and solute concentrations in other fluid compartments
34
Changes in Composition
Changes in acid-base balance Changes in electrolytes Sodium Calcium Magnesium Potassium Changes in plasma proteins
35
Tonicity
Hypertonic
Osmotic pressure > osmotic pressure of body fluids intracellular volume depletion
Hypotonic
Osmotic pressure < osmotic pressure of body fluids cellular swelling
36
Extracellular Osm. Water Hypertonic salt solution Isotonic salt solution Loss of sodium chloride Volume
Na
Electrolytes K Ca (mEq/l)
Cl
Osmol
(mOsm/l)
LR
D5W - LR 0.45% NaCl 0.9% NaCl Albumin 5% 50
130
130 77 154 154
4
4
3
3
109
109 77 154 154
28
28
273
525 154 308 310
ICV ISV PV
D Volume (ml)
Lactated Ringers
Albumin 5%
500
D Volume (ml) 250 0 -250 -500 -750 D 5W LR Alb 5% Alb 25%
PV
41
Fasting Disease-related fluid losses Blood loss Redistribution: Third space fluid loss Other fluid losses
42
(1)
Constant loss of water and electrolytes Skin Insensible losses (evaporation) Perspiration Lungs Insensible losses Kidneys Gastrointestinal tract
43
70 kg adult / 24 h Water (ml) Skin Insensible Perspiration 400 100 Na+ Electrolytes
Lungs Kidney
Gastrointestinal Total
Insensible Urine
Feces
400 1 500
100
K+
Na+, K+
2 500
2500
2100 1900 1700 1500 1000 2300 Computed need for average hospital patients
Starvation Hypothyroidism Addisons disease Obesity associated with hypothalamic or pituitary dysfunction General anesthesia Extremes of age
46
Skeletal muscle activity Ingestion of nutrients Caffeine, nicotine Fever, sepsis Elevated ambient temperature Diabetes insipidus Leukemia Polycythemia Dyspnea associated with cardiac, pulmonary, renal disease
47
Urine
Sweat Feces Insensible loss Total
1400
100 100 700 2300
1200
1400 100 600 3300
From Rhoades and Tanner, Medical Physiology, Little, Brown & Co., Boston (1995)
(2)
Volume Basal water losses parallel energy expenditures 4-2-1 Rule Weight (kg) 0-10 Volume required 4 ml/kg/h
11-20
> 20
49
4-2-1 rule
Weight (kg) 0 10 11 - 20 > 20 Volume 4 ml/kg/h 2 ml/kg/h 1 ml/kg/h 70 kg 40 20 50
(3)
51
52
Volume
4-2-1 rule Possibly increased intraoperatively Fever Sweating Denuded skin Exposed peritoneal or pleural surfaces Non-humidified gasses, at high flow rates
53
Composition Water D5W Electrolytes Not for minor surgery in healthy patients Potassium
Bowel preparation
54
2-3 g/kg/d Total parenteral nutrition Insulinoma Prolonged (> 24 h) fasting Starvation Hyperglycemia-induced cerebral acidosis
55
Preoperative fasting fluid deficit Basal maint. fluids/h x npo period (h) st hour: 1 50 % of deficit nd hour: 2 25 % of deficit rd hour: 3 25 % of deficit Additional fluid deficits Disease-related fluid losses External Internal
56
30 25 20 l
l l
Crystalloid l No crystalloid
15
10 5 0
* *
1h * 2h 4h
l * *
6 h 24 h 48 h 72 h
Time
* P>0.05 Elhakim et al., Acta Anaesth Scand (1998), 42
4- 6h
6 - 24 h 24 - 48 h
0
0 0
0
8 3
48 - 72 h
* P>0.05
Gastrointestinal tract Vomiting, diarrhea, ostomy output, overzealous bowel preparation Hidden: bowel obstruction, ileus Volume, concentration and composition disturbances External blood loss Gastrointestinal bleeding Traumatic injuries
59
Pathologic transudate of plasma (pleural, ascitic, pericardial) Anatomical compartment Develop slowly compensation Extracellular tissue fluid Non-anatomical compartment Develop quickly considerable impact on ECF
Sequestered ECF pool Cavitary fluid losses Third space fluid losses Internal blood loss Retroperitoneal hematoma Aorta aneurysm Leaking vascular anastomosis Pelvic or femoral fracture Splenic rupture Liver trauma
62
Assessment of ECF volume deficit 1 % in body weight 10 ml/kg fluid e.g. moderate fluid loss: 8% of body weight 70 kg 8 x 10 x 70 = 5 600 ml Isotonic fluid: water + salt Normal saline (NaCl 0.9%) Balanced salt solution e.g. lactated Ringers
63
Replace over 15 min Redistribution to ISF: 40-60 % within 15-30 min 75 % within 60 min Replace 25-50 % over 1 h Remainder over several hours
64
Blood loss Redistribution and subsequent loss of extracellular and intracellular fluid Replacement with crystalloids
Volume blood:crystalloid ratio 3:1 to 5:1 (even 7:1) Composition NaCl 0.9 % Balanced electrolyte solution
65
Redistribution: Third space fluid loss Sequestered extracellular fluid Volume related to surgical trauma
Replacement fluid
Lactated Ringers Fluid (ml) Duration (min) ECV preop (l) ECV postop (l)
* ** P<0.05 between groups P<0.05 vs preop
Basal fluid losses Internal fluid losses Third space loss Blood loss Accumulation of fluid within body cavities External fluid losses Blood loss Enhanced insensible loss Transcellular fluid loss
69
Basal fluid loss + increased insensible loss Hypotonic maintenance fluids Until adequate oral intake All other postoperative fluid losses Balanced salt solution + electrolytes Postoperative day 1- 3: mobilization of third space fluid losses
70
Cardiovascular parameters ECG Blood pressure Central venous pressure Pulmonary artery catheter Transesophageal echocardiography Perfusion directed therapy Fluid overload
71
Regional: Gastrointestinal
Organ specific
Fluid overload
72
Transurethral resection of the prostate Hysteroscopic surgery Absorption can be accurately monitored
73
Fatal Postoperative Pulmonary Edema: Pathogenesis and Literature Review (Arieff: Chest 1999, 115: 1371-1377)
Fatal postoperative pulmonary edema 13 patients (incidence of 0.02 %) 10 generally healthy 3 serious associated medical conditions Age 38 21 y Within 3 postoperative days Range: 3 to 66 h, mean SD: 27 20 h No predictive variables No predictive warning signs Cardiorespiratory arrest first clinical sign in 8 pts Fluid overload as single cause Mean net fluid retention of 7.0 4.5 l first 27 h postop (24 % increase of total body water)
74
Dilutional acidosis
Metabolic acidosis resulting from rapid administration of fluids that contain near-physiologic concentrations of sodium accompanied by anions (usually chloride) other than bicarbonate or bicarbonate precursors, such as lactate. (D.S. Prough, Anesthesiology 2000)
Dose-dependent
75
Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecological Surgery. (Scheingraber et al.: Anesthesiology 1999, 90) Saline (n = 12) Time of infusion (min) Volume after 120 min (ml/kg) Estimated blood loss (ml) Urine output (ml) 135 23 71 14 962 332 717 459 Lact. Ringers (n = 12) 138 20 67 18 704 447 1 075 799
76
23.5 2.2
18.4 2.0
23.3 2.0
23.0 1.1
16.2 1.2
11.8 1.4
15.8 1.4
12.5 1.8
104
115
104
106
pH
# # #
mmHg
50 46 42
Carbon dioxide
38
34
*
* * *
30 26
0
3.0
30
60
90
120 min
Base excess
# # #
mmol/l
Lactate
#*
#* #* #*
mmol/l
-4 -8 -12 0
* * *
90
*
120 min
30
60
60
90
120 min
Sodium
mmol/l
120
Chloride
#* #* * #*
#*
mmol/l
144
#*
#*
#*
#*
140
136 0
*
30 60
*
90
*
120 min
100 0 17.5 15
*
30
*
90
60
120 min
45
40 35
Calculated SID
mmol/l
Prot* * * *
mmol/l
* *
#*
#*
12.5
*
10
30
25 0 30
* *
60 90
*
120 min
3 l of NaCl 0.9 %
3 l of lactated Ringers
27
Switch to balanced electrolyte solution Lactated Ringers Plasmalyte Hyperventilation pH > 7.2 and preferably > 7.3 Furosemide (Fresh frozen plasma) Transfusion criteria
81
V = target volume Ki V
V Ki = constant fluid infusion rate
Kb
Kr (V - V) V
Controlled rate of fluid elimination proportional by a constant Kr to the relative deviation of v from V
Ki
V1
V1
Kt
V2
V2
Kb
Kr(V1 - V1) V1
The net rate of fluid exchange between the 2 compartments is proportional to the difference in relative deviations from the target volumes by a constant Kt
Svensn et al., Anesthesiology (1997), 87
Bolus of fluid Peak effects Rates of clearance Infusion of fluid necessary to maintain PVE at a certain level Effects of anesthesia, surgery and trauma on fluid requirements Usefull during severe pathophysiologic disturbances?
85
0
0.2 0.15 0.10 0.05 0
20
40
60 80 Time (min)
100
120
20
40
60 80 Time (min)
100
120
Volume Kinetics of Ringers Solution during Induction of Spinal and General Anaesthesia. (Ewaldsson and Hahn: Br J Anaesth 2001, 87)
10 patients: 20 ml/kg of Ringer acetate over 60 min (0.33 ml/kg/min) Spinal anesthesia 20 min after start of infusion 5 patients: 350 ml of Ringers over 2 min immediately after spinal followed by Ringers at 0.33 ml/kg/min Ephedrine 5-10 mg IV if SAP < 60 % of baseline Parameters Blood pressure Blood hemoglobin concentration Every 3 min during 60 min
88
Spinal anesthesia
0.33 ml/kg/min during 60 min 350 ml over 2 min 0.33 ml/kg/min during 40 min
Semipermeable membrane
Osmosis
Osmotic pressure
Solvent
Solute
Solution