Perioperative

Fluid & Electrolytes

Management

Perioperative intravenous fluid therapy is an

area of care that is often left to junior doctors

Lassen K. Brit J Surgery 2009; 96:123-24

Problems with
Solutions
.
The UK National Confidence Enquiry into
Perioperative Deaths report has documented that
a number of surgical patients die because of
inappropriate fluid management by inadequately
trained staff.
Questionnaires to 200 doctors (100 Group A; 50
Group B; and 50 Group C)
Group
A:
pre-registration
questioned within 10 days of
Group B 6-8 weeks; Group
house officers.

house
officers
starting their job;
C surgical senior

Results
.

Only
Only 50%
50% prescribed
prescribed the
the desired
desired amount
amount of
of potassium
potassium
About
About 26%
26% prescribed
prescribed >
>2
2 LL 0.9%
0.9% saline/day.
saline/day.
Less
Less than
than 40%
40% of
of respondents
respondents were
were given
given formal
formal or
or informal
informal
guidelines
guidelines on
on fluid
fluid and
and electrolyte
electrolyte prescribing
prescribing on
on surgical
surgical firms
firms

Knowledge
Knowledge relevant
relevant to
to fluid
fluid and
and electrolyte
electrolyte prescribing
prescribing among
among
surgical
surgical junior
junior doctors
doctors is
is inadequate
inadequate
Teaching
Teaching on
on the
the subject
subject at
at both
both undergraduate
undergraduate and
and
postgraduate
postgraduate levels
levels does
does not
not prepare
prepare junior
junior doctors
doctors for
for the
the
task.
task.

Body Fluid Compartments

2/3

X 50~70%
lean body weight

ICF:
55%~75%

TBW

3/4

Male (60%) > female (50%)

Most concentrated in skeletal muscle
TBW=0.6xBW
ICF=0.4xBW
ECF=0.2xBW

1/3

ECF
1/4

Extravascular
Interstitial
fluid
Intravascular
plasma

Fluid Compartments

Fluid shifts / intakes

Kidneys

Guts

Lungs

Intracellular
30 litres
Interstitial
9 litres

IV 3
litres

Extracellular fluid - 12 litres

Skin

Water Intake and Output

Prospective Audit
Perioperative fluid management
106 consecutive patients
6 months period
54% patients developed at least one
fluid related complication
Longer hospital stay

Walsh SR, et al. Int J Clin Practice 2007

Fluid Administration
Replacement

Maintenance

Perioperative Fluid Management

How much should we infuse?

What fluids should we use?

Traditional Teaching
A typical 70 kg adult
1 liter Normal Saline
2 liters 5% Dextrose
Total Fluid: 3 liters
Total sodium: 154 mEq
Total Potassium: 0

Amount of Fluid ?
Restricted versus Liberal

The debate goes on - - -

A Risky Situation ! !
Risks of inadequate resuscitation
Life-threatening
Nonfatal

Risks of excessive hydration

Life-threatening
Nonfatal

Restricted vs Liberal
Inconsistent results
Restricted volume
Improved outcomes after minor surgery
Dizziness, nausea and vomiting

Major surgery
Postoperative ileus?
Hospital stay?

Laparoscopic cholecystectomy
Anesth Analg 2007; 105: 465-74

Postoperative Fluid Management

Intravascular volume deficit

Preoperative fasting
Increased evaporative fluid loss
Increased third space shifting

Vasoconstriction

Awake patient
Maintenance of blood pressure

Anesthesia induction

Decreased sympathetic tone

Organ dysfunction

Jacob M, e al. Lancet 2007; 369: 1984-86

Liberal Fluid Administration

Improved postoperative pulmonary
function
Improved exercise capacity
General well being
Improved nausea, dizziness and
fatigue

Holte K et al., Annals of Surgery 2004;240:892

Preloading?
Overestimation
Preoperative deficits
Insensible losses

Fluid boluses
No major impact on anesthesia related
hypotension

Liberal fluid regimen

Decreased acute renal failure
Jacob M, et al. Lancet 2007; 369: 1984-86

Restricted Fluid Administration

Randomized, multicenter study
172 patients, 8 hospitals
Elective colorectal resection
Restrictive versus standard
perioperative fluid regimen

Brandstrup et al. Ann Surg 2003;238:641

Restricted Fluid Administration

Restricted Group

Standard Group

Postoperative
complications

33

51

Cardiopulmonary

24

Tissue healing

16

31

Deaths

Brandstrup et al. Ann Surg 2003;238:641

Gynecological Surgery
Randomized study
141 patients undergoing elective
surgery
30 mls/kg versus 10 mls/kg
Better results with liberal fluid use
Reduced nausea, vomiting and antiemetic use
Magner et al. Brit J Anesthesia 2004;93(3):381

Clinical Implications of Excess

Fluid
Increased demand on cardiac
function
Increase in postoperative
cardiac morbidity

Fluid accumulation in lungs

Pneumonia and respiratory
failure

Excretory demands on
kidneys
Inhibitory effects of
anesthetics and analgesics
Holte K, et al. Brit J Anesth 2002; 89 (4): 622-32

IV Fluid Overload
Decrease muscular oxygen tension
Impaired gut function
Cause general edema
Peripheral edema
Periorbital edema

Impede tissue healing

Clinical Implications Fluid

Restriction
Lactic acidosis
Compromised renal function
Multisystem organ failure

Perioperative Fluid Management

How much should we infuse?

What fluids should we use?

Fluid Electrolyte Balance

Surgical patients have special needs
Nil orally
Anesthesia
Trauma
Sepsis

Stress Response
Antidiuresis and oliguria
Vasopressin
Catecholamines
RAAS

Salt and water retention even in

presence of overload
Ability to excrete free water is limited

PHYSIOLOGICAL RESPONSE
TO
Stress - Surgery
Stress - Anaesthesia
ADH
Aldosterone
Renin

Retention of
H2O + Na+
Loss of K+

2-4 Days

Sequestration of fluid from ECW

% BODY
WEIGHT

NORMAL ACUTE INJURY

ELECT & IV Col

35
30

PHASE OF
RESOLUTION

3rd space

ICW

25
20
IF

15

Forming
Sequestrated
ECF

Sequestrated
ECF

Resolving
Sequestrated
ECF

10
5
PL

Kokko & Tannen Fluids & Electrolytes. WB Saunders 3 ed.p738

I.V. fluids

Diuresis

Hyponatremia Usually Excess

Free Water
Free water replacement of isotonic
losses
Increased ADH secretion
Excess solute e.g. glucose intracellular water shifts to ECF
(Dilutional)

Hyponatremia Usually Excess

Free Water
Features - depends on rapidity
Acute drop below 120
weakness
fatigue
confusion
cramps
nausea/vomiting
headache/delirium/seizures/coma
permanent CNS damage

Trends in Perioperative Fluid Management

Before 1960s fluid restriction (Moore)

After 1960s fluid liberalization (Shires)
1970s invasive monitoring
1970s - dopamine
1970s crystalloid/colloid controversy
(TMTN)
1980s recognition of glucose risk (Lanier)
1980s cerebral effects of tonicity (Todd)
Present red states (Arieff, Kehlet,
Brandstrup) vs. blue states (Holte, Kehlet)

Saline

Plasma
3L

Glucos
e

Capillary
Capillary
Endothelium
Endothelium
Interstitial
Compartment
10L

Intracellular Compartment
30L

Blood
Cells
2L

Fluid Distribution in a 75-kg Adult

The Oliguric Patient

Significant intravascular
hypovolemia?
Clinical signs of intravascular volume
Interpretation of urine output

Urine output
is not a reliable marker of
hydration status in
postoperative Patients

Stress-induced ADH and Aldosterone cause water retent

Metabolic Consequences of Saline Infusions

Saline Infusion Produces DoseDependent Hyperchloremic Acidosis

McFarlane et al. Anaesthesia 1994;49:779

Scheingraber et al. Anesthesiology
1999;90:1265
Waters et al. Anesthesiology 2000;93:1184
Rehm et al. Anesthesiology 2000;93:1174
Liskaser et al. Anesthesiology 2000;93:1170

(Ab) Normal Saline

Chloride overload along with sodium
overload
Hyperchloremia
Renal vasoconstriction
Reduced GFR

Further reducing kidney ability

(Ab) Normal Saline

Persistent hyperchloremia after
saline infusions reflect the lower
Na:Cl ratio in saline (1:1) -- Infusions of 0.9% saline produces a
significant hyperchloremic acidosis - The decrease in the anion gap is
more pronounced with saline --Awad S, et al. Clinical Nutrition 2008; 27: 179-188

Potassium Depletion
Protein catabolism
RAAS activity
Decreased ability of kidneys to
excrete sodium

Daily Sodium requirement for a healthy

70 kg man (desired
.. answer highlighted)
mmol/day

<60

Group A (%) Group B (%) Group C (%)

60-100

18

10

36

101-150

26

60

38

151-180

18

37

20

18

>180
Dont know

Daily potassium requirement for a healthy

..
70 kg man (desired answer highlighted)
mmol/day

Group A (%) Group B(%)

Group C (%)

<60

38

22

20

60-80

47

70

70

14

>80
Dont know

Exogenous Potassium
IV fluids
Sterile, closed system

Exogenous addition
Open system
Contamination
Inadequate mixing

Layering Effect
Potassium is added to IV fluids
Density differences
Concentrated layer of potassium
forms
Serious effects on the heart

POTASSIUM CHLORIDE IS
PARTICULARLY PRONE TO THIS
LAYERING EFFECT

British National Formulary

March 2009

Control of Concentrated Electrolyte Solutions

Statement of Problem and Impact:
Concentrated potassium chloride has been identified as a high risk
medication by organizations in Australia, Canada, and the United
Kingdom of Great Britain and Northern Ireland (UK)

Patient Safety Solutions

| volume 1, solution 5 | May 2007

Homogenized Solution
EACH DROP HAS THE SAME
CONCENTRATION

Plabolyte-M and Plabolyte-40

British Consensus Guidelines

Intravenous Fluid Therapy
for Adult Surgical Patients

(http://www.asgbi.org.uk/en/surgical resources and documents/)

Pre-Operative Fasting
In patients undergoing elective surgery clear
non-particulate oral fluids should not be
withheld for more than two hours prior to the
induction of anaesthesia.

Preoperative administration of carbohydrate rich

beverages 2-3 h before induction of anaesthesia
may improve patient well being and facilitate
recovery from surgery.

Bowel Preparation
Routine use of preoperative mechanical bowel
preparation is not beneficial and may complicate
intra and postoperative management of fluid and
Electrolyte balance. Its use should therefore
be avoided whenever possible.

Where mechanical bowel preparation is used,

fluid and electrolyte derangements commonly
occur and should be corrected by simultaneous
intravenous fluid therapy with Hartmanns
or Ringer-Lactate/acetate type solutions.

Recommendations
Balanced salt solutions should replace 0.9% saline

To meet maintenance requirements, adult patients

should receive sodium 50-100 mmol/day,
potassium 40-80 mmol/day
in 1.5-2.5 litres of water by the oral, enteral
or parenteral route (or a combination of routes).

Balanced Salt Solutions

Ringolact

Ringolact-D

0.9% Saline

Sodium

130

130

154

154

Chloride

108

108

154

154

---

---

Calcium

2.7

2.7

---

---

Bicarbonate

28

23

---

---

---

50

---

50

Potassium

Dextrose

Dextrose
Saline

Conclusion

Goal Directed Fluid Therapy

Non-bowel surgery
more liberal fluid improves symptoms

Goal Directed Fluid Therapy

Replacement
Ringolact
Ringolact-D

Maintenance
Plabolyte-M
Plabolyte-40

Requirements in a 60 kg patient
5% D/W: 2 L 5% D/W: 1 L
D/Saline:1 L D/Saline:2 L

Plabolyte-M
3L

Daily
Requirement

Sodium

154 mEq

308 mEq

180 mEq

60-120
mEq

Chloride

154 mEq

308 mEq

180 mEq

As needed

Potassium

60 mEq

60-120
mEq

Calcium

9 mEq

300 mEq

Bicarbonate

69 mEq

As needed

Dextrose

150

150

150

Variable

Meeting Daily Requirements

K+
(mEq)

Na+
(mEq)

Cl- (mEq)

HCO3(mEq)

Plabolyte-M
(2 liters)

40

120

120

46

Plabolyte40
(1 litre) +
Plabolyte-M
(2 litres)

80

120

160

46

A Little Ignorance
..........can go a Long Way

Thank you for your Attention