Page 1

Perioperative Fluid Therapy

n n n n n n Introduction Evaluation of Intravascular Volume Some Facts on Intravenous Fluids Intraoperative Fluid Therapy Postoperative Fluid Therapy Further Reading

INTRODUCTION Fluid therapy is an important aspect of perioperative management and should be tailored to the individual patient. Optimal fluid therapy begins with clinical assessment of the patient to determine the amount, the nature as well as the speed at which the fluid ould be administered. This is aided by laboratory investigations as well as invasive --aemodynamic monitoring in selected cases. Intraoperative fluid therapy should take into account the preexisting deficit, --aintenance requirement and on-going losses. Choices of fluid include various types 'crystalloid and colloid solutions. In the presence of significant blood loss, blood and _:cod products are required to restore intravascular volume. Postoperative fluid therapy should be individualized as well. Consideration should given to the length and complexity of surgery, the organ system involved in the
PAGE 2

surgery, the patient's general status, and expected time to recommencement of oral intake. These patient groups require careful monitoring of fluid status. Extremes of age groups. Patients with abnormal losses of blood or plasma (e.g., trauma, burns), body fluids (e.g.,

vomiting, diuresis, excessive sweating) or fluids from the third space (e.g., intestinal obstruction). Patients with reduced fluid intake due to various causes, such as malignancy or gastrointestinal diseases, reduced level of consciousness, excessive vomiting. Patients in whom fluid overload is undesirable, such as those with poor cardiac function, renal failure or neurosurgical conditions. Patients undergoing major surgical procedures that are prolonged or complicated with significant fluid shifts and haemodynamic changes.

EVALUATION OF INTRAVASCULAR VOLUME

The intravascular volume is best assessed clinically. Laboratory tests and haemodynamic measurements confirm the clinical impression and serial readings are useful to evaluate the adequacy of fluid therapy. 1. Clinical evaluation The history enables one to identify the patients at risk, and to assess the nature of fluid loss, the extent and severity of dehydration. These signs are noted in physical examination. Mental status. Skin turgor, tension of anterior fontanelle in babies < 18 months, hydration of mucous membrane. Character of peripheral pulse, resting heart rate and blood pressure, effect of postural changes. Urine output. Evidence of overt or occult blood or fluid loss. As shown in Table 4-1, the degree of dehydration is empirically divided into mild (fluid loss of approximately 5% of body weight), moderate (10%) and severe (15% or more). This serves as an approximate guide to indicate the urgency and aggressiveness of fluid therapy.
Page 3 Table 1

2. Laboratory investigations

Laboratory tests are neither sensitive nor specific indicators of the intravascular volume status. Furthermore, not all the test results can be immediately available, and we must rely on our clinical acumen to

assess the patient's intravascular volume status. Full blood count Low haemoglobin in blood loss. High haematocrit in losses of body fluids other than blood. Blood urea and electrolyte concentrations High blood urea in dehydration. Abnormalities in sodium or potassium concentration depending on clinical scenario. Arterial blood gases Metabolic acidosis in shock states with poor organ perfusion and anaerobic metabolism. Increased serum lactate concentration. Urine examination Specific gravity may be high (> 1.010). Urine sodium may be low (< 20 mEq/ml) in an attempt to conserve sodium and water.
Page 4

3. Haemodynamic measurements

Central venous pressure (CVP) This measures the right heart pressure as opposed to pulmonary artery pressure that indicates the left heart pressure. Serial readings are more useful than a single reading for assessing adequacy of fluid therapy Pulmonary artery pressure (PAP) Pulmonary artery catheterization is mainly done in the intensive care setting. It is rarely, if ever, employed in the initial resuscitation stage. It is indicated in patients with significant cardiac disease since the right heart pressure may not correlate with the left heart pressure. Again serial readings are more useful than a single reading. SOME FACTS ON INTRAVENOUS FLUIDS Crystalloid solutions (Table 4-2) are aqueous solutions of low molecular weight ions (salts) with or without glucose. They rapidly equilibrate with, and distribute throughout, the extravascular space. Replacement of intravascular volume deficit with crystalloid solutions generally requires approximately 3 times the volume of estimated deficit. Colloid solutions (Table 4-3) are solutions containing high molecular weight substances such as proteins or large glucose polymers. They maintain plasma oncotic pressure and remain intravascularly for longer periods. Colloid solutions can replace blood loss in a ratio of 1:1-1.5; hence severe intravascular fluid deficits can be more rapidly

and efficiently corrected using colloid solutions. The colloid-crystalloid controversy in resuscitation and intensive care has been in existence for more than 30 years. Reservations regarding colloid solutions exist in situations associated with increased capillary permeability, such as burns, anaphylaxis and multiple trauma. Colloid particles may diffuse into the interstitial space across the leaky capillaries, worsening interstitial oedema and hindering fluid resorption from the interstitium. A definitive answer on the best solution for resuscitation and maintenance does not exist, neither is there an "ideal" intravascular fluid volume replacement strategy. One suspects that the "middle ground" approach is probably the safest: a mixture of crystalloid and colloid solutions, the proportion of each depends very much on the severity of fluid deficit, nature of fluid loss, cost considerations, availability and personal preference.
page 5 Table 4-2. Composition of crystalloid solutions Table 4-3. Composition of colloid solutions Page 6

Crystalloid Solutions Crystalloid solutions can be classified into: Hypotonic solutions (maintenance-type solutions) for correction of deficits primarily due to water loss. Isotonic solutions (replacement-type or balanced salt solutions) for replacement of deficits due to both water and electrolyte losses. Hypertonic solutions (e.g., dextrose 30%, dextrose 50%, hypertonic saline 3%) for total parenteral nutrition (dextrose solutions); treatment of severe hyponatraemia, e.g., in TURP syndrome (hypertonic saline). The role of hypertonic saline in fluid resuscitation is still controversial and being investigated. Glucose solutions are given to prevent hypoglycaemia and ketosis during fasting. They are not recommended for use in resuscitation during cardiac arrest and cerebral ischaemia, as hyperglycaemia is found to be associated with adverse cardiovascular and neurological outcomes. Specific indications for glucose solutions include:
Documented hypoglycaemia due to any cause. Patients at risk for hypoglycaemia, such as: Diabetic patients on long-acting hypoglycaemic agents.

Newborns, particularly preterm neonates and babies of diabetic mothers.

Patients with severe liver disease in whom glycogen store may be depleted.

Colloid Solutions Colloid solutions are either synthetic or derived from blood. Examples of each are: Synthetic colloid solutions: dextrose starches (e.g., hydroxyethyl starch, dextran solutions), gelatin solutions (e.g., Haemaccel, Gelafundin, Gelafusinefl. Blood-derived colloid solutions: human albumin 5% or 25%, plasma protein fraction (e.g., Plasmanate, Plasmatein.0). Colloid solutions are indicated in these clinical situations: Severe intravascular fluid deficits, such as haemorrhagic shock before blood is available for transfusion. Severe hypoalbuminaemia and large protein losses, seen in severe liver disease and burns respectively.
Page 7

Improvement of microcirculation in vascular surgery or reimplantation of limb or digits with dextran solutions, especially Dextran 40 for its " antisludging" properties. -7:Dblems of colloid solutions include: Cost, in particular the newer HES solutions. Allergic reactions, estimated to be in the range of 0.033-0.22%. Interference with blood-typing (dextran > 20 ml/kg/24 hr). Association with acute renal failure. Coagulopathy as a result of interference of platelet function and dilutional effect.

INTRAOPERATIVE FLUID THERAPY

7'ree aspects of fluid therapy should be considered. Maintenance requirement This is required to replace losses from urine, gastrointestinal tract secretions, perspiration and insensible loss via the respiratory tract. Maintenance requirement may be higher in certain situations, e.g., fever, hypermetabolic states, tachypnoea. A rough estimation of the maintenance requirement can be obtained by applying the formula:

first 10 kg: 4 ml/kg/hr 11-20 kg: 40 ml/hr + 2 ml/hr for every kg above 10 kg 21 kg and above: 60 ml/hr + 1 ml/hr for every kg above 20 kg

Preexisting deficit
This depends on the length of fasting before surgery and is derived from

normal maintenance per hour multiplied by number of hours of fasting. The fluid deficit is increased when there are abnormal fluid losses, such as bleeding, vomiting, diuresis, diarrhoea, fluid sequestration, and increased insensible losses.
Page 8 3. On-going losses

Other than intraoperative blood loss, fluid losses include: Drainage of ascitic fluid or cystic fluid. Fluid sequestrated in the gastrointestinal tract. Evaporation from exposed surgical field. Tissue oedema when it is traumatized, inflamed or infected. One should keep abreast with intraoperative fluid losses, and the type of intravenous fluids administered should reflect the nature of fluids lost. For example, colloid solution should be used to replace ascitic or cystic fluid with high protein content. Evaporative losses from the surgical field are estimated according to the degree of surgical exposure. This is empirically classified as superficial, moderate and severe, and estimated to be 1-2 mg/kg/hr, 3-4 mg/kg/hr and 6-8 mg/kg/hr respectively. However, too much importance should not be placed on formulae and figures. Ultimately it depends on close monitoring and assessment of the patient's intravascular volume status by clinical means. Intraarterial BP and CVP monitoring should be employed in major surgery where significant fluid and blood losses are anticipated. Hourly urine output should be measured by means of continuous bladder drainage. There is no hard and fast rule as to when the patient should receive blood transfusion. While every attempt is made to avoid allogeneic blood transfusion in order to reduce the risks of disease transmission and transfusion reactions, this should not be withheld from patients who suffer massive blood loss. Autologous blood transfusion, if applicable, may be used as part of the blood conservation strategies.

POSTOPERATIVE FLUID THERAPY

The amount and nature of fluids administered again depend on the patient's status, anaesthetic and surgical factors. These guidelines should be noted.

 Surgery done under regional anaesthesia and/or sedation, not involving the gastrointestinal tract No postoperative fasting is required. Allow clear fluids and later solids as tolerated.
Page 9

Minor surgery done under general anaesthesia, not involving the gastrointestinal tract Allow oral fluids when the patient is fully conscious and not nauseous. Start with clear fluids, then soft diet and finally solids as tolerated. Discontinue intravenous fluid administration when the patient can tolerate oral intake. Major surgery, or surgery involving the gastrointestinal tract Maintain intravenous hydration of 2.5 L/24 hr in a 60-kg adult with crystalloid solutions in the form of dextrose saline, normal saline or Ringer's lactate. Close haemodynamic monitoring is required. Send blood samples for full blood count, glucose, urea and electrolyte concentrations. Attempt early feeding if postoperative recovery is uneventful. Consider total parenteral nutrition if oral intake may be delayed.

FURTHER READING
1. Rosenthal MH. Intraoperative fluid management: What and how much? Chest

1999;115:106S-112S.
1. Choi PTL, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid

resuscitation: A systematic review. Crit Care Med 1999;27:200-10.

2. Boldt J. New light on intravascular volume replacement regimens: What

did we learn from the past three years? Anesth Analg 2003;97:1595-604. -1. Boldt J. Volume replacement in the surgical patient: Does the type of solution make a difference? Br J Anaesth 2000;84:782-93.