Fluid Management

Suparto
Anesthesia Department
Medical Faculty Christian Krida Wacana University

Osmosis
Osmosis is the movement of water (solvent
molecules) across a semipermeable membrane
from a compartment in which the nondiffusable
solute (ion) concentration is lower to a
compartement in which the solute concentration
is higher (Ganong 2003)

Osmotic pressure
Is the pressure that must be applied to the
side with more solute to prevent a net
movement of water across the membrane to
dilute the solute

 Osmolality is the number of particles (osmoles) in

a kilogram of fluid;
Osmolarity is the number of particles in a liter of
fluid.
These terms are often used interchangeably
because the density of water is 1 kg/L. Normal
serum osmolality is around 285-295 mOsm/L.

 Tonicity, describe the osmolarity of a solution

relative to plasma
Isotonic, solutions that have the same
osmolarity as plasma (no transfer of fluid into
or out of cells occurs)
Hypertonic, those with higher osmolarity (cells
shrink)
Hypotonic, those with lower osmolarity (cells
swell)

Jenis dan Jumlah cairan tubuh

Cairan tubuh 60%

CES 20%

Plasma darah
5%

Cairan interstitial
15%

CIS 40%

 Distribusi cairan tubuh manusia dewasa:

Total Body Water :
(M) 60% BB (600ml/kg)
(F) 50% BB (500ml/kg)

Whole Blood (M) 66ml/kg, (F) 60 ml/kg

Blood represents about 11-12% of the total body
fluid Marino PL. The ICU Book 3rd ed; 2007: 211-229
Average blood volume(Morgan & mikhails Clinical Anesthesiology, 5th Ed)
Neonates: Premature 95 ml/kg, Full term 85 ml/kg
Infants 80 ml/kg
Adult: Men 75 ml/kg, Women 65 ml/kg

In nonobese individuals, the blood volume varies in

direct proportion to the body weight, averaging 70
ml/kg for lean men and woman (stoelting 4th ed; 658)

Kebutuhan pada orang dewasa

Air 25-40ml/kgBB/hari, or 1.5ml/kg/jam
Kalium 1mEq/kgBB/hari
Natrium 2 mEq/kgBB/hari

Holliday-Segar Formula for Maintenance Fluid

Requirements by Weight
Wt (kg)

Water
ml/day

ml/hr

0-10

100/kg

4/kg

11-20

1000+50/kg for
each kg >10

40+2/kg for
each kg >10

>20

1500+20/kg for
each kg >20

60+1/kg for
each kg >20

Faktor modifikasi kebutuhan cairan

Kebutuhan Ekstra

Penurunan kebutuhan

Demam (10%-12% setiap

1C >37C)
Hiperventilasi
Suhu lingkungan tinggi
Aktivitas ekstrem
Setiap kehilangan
abnormal

Hipotermia (12% setiap 1C

<37C)
Kelembaban sangat tinggi
Oliguria atau anuria
Hampir tidak ada aktivitas
Retensi cairan (gagal
jantung)

What Fluid?

Pemberian Infus
Terapi Cairan

Resusitasi

Kristaloid
Ring As
Ring Laktat
Ringer fundin

Rumatan

Koloid

Elektrolit

Nutrisi

Gelofusine
Hes
Dextran
Albumin

Aminofluid
KAEN

Clinimix
Aminofluid

 Type of Fluid
Crystalloid (RL, NS, D5%)
Small molecules (< 8000 dalton)

Colloid (Albumin, Dextran, Hetastarch)

Large molecules (> 8000 dalton)

Red blood cells (WB, PRBC)

To increase the oxygen carrying capacity of blood

Crystalloid VS Colloid resuscitation

 Crystalloid:
Distributed in the
extracellular fluid
only 25% of the infused
volume will remain in the
vascular space and expand
the plasma volume

 Crystalloids are categorized by their tonicity, a

synonym for osmolality. A fluid that's isotonic has the
same number of particlesthe same osmolalityas
plasma.
Therefore, an isotonic solution won't promote the
shift of fluids into or out of the cells, causing them to
swell or shrink.
Ringer Asering and lactated Ringer's (LR) solution are
two of the most commonly used isotonic fluids.

 Dextrose 5% in water (D5W) is another isotonic

crystalloid. However, it's not used for resuscitation
because, as its glucose is metabolized, this fluid
quickly becomes hypotonic.
In fact, D5W is a good source of free water. As with
other hypotonic fluids, such as 0.45% NS, the water
quickly shifts out of the vascular bed and into the
cells, by way of osmosis.

 Colloid:
Contain large molecules
do not readily move into
the interstitial fluid
At least 75% will remain in
the vascular space
More effective for
augmenting plasma volume

Colloids
Advantages

Disadvantages

Volume expansion
Longer duration of
action

Anaphylaxis
Expensive
Poss coagulopathy

Crystalloids
Advantages

Disadvantages

Easily available
Free of anaphylactic
reaction
Economical

Shorter duration of
action

Perioperative fluid management

Female 25 yo. 50 kg for tonsilectomy

NPO for 8 hours.

Preoperative fluid deficit

NPO deficit: 1.5ml/kg/jam x 8 jam = 75ml/jam
Replace in 1st hour, 2nd hour, 3rd hour

600 ml deficit: 300ml 1st , 150ml 2nd , 150ml 3rd

OR
4x10 + 2x10 + 1x30 = 90ml/jam x 8 jam = 720ml

Intraoperative fluid requirement

Preop deficit: 600ml
Maintenance: 1.5ml/kg/jam: 75ml
Replace redistribution and evaporative surgical fluid
losses (controversial) : 2ml x 50kg = 100ml
Degree of tissue trauma

Additional fluid requirement

Minimal (herniotomi)

0-2 ml/kg

Moderate (cholecystectomy)

2-4 ml/kg

Severe (bowel resection)

4-8 ml/kg

Blood loss

 Replacing blood loss

Hb <7 g/dl resting cardiac output to
maintain a normal O2 delivery, careful to elderly
patient
If needed check mixed vein O2 saturation
Colloid : blood = 1:1 ratio
Sponges 4x4 hold 10ml of blood
Lap sponges hold 100-150 ml

 Case: female, 50Kg, ht 35%

How much blood loss will decrease her hematocrit
to 30%?
Estimated blood volume: 50kg x 70ml = 3500ml
Red blood cell volume35% = 3500ml x 35%= 1225ml
Red blood cell volume 30% = 3500ml x 30%= 1050ml
Red cell loss at 30%= 1225-1050 = 175ml
Allowable blood loss= 3x 175ml = 525ml

 Clinical guidelines:
1 unit PRC will increase Hb 1 g/dl and Ht 2-3% in
adults
10 ml/kg transfusion of PRC will increase Hb by 3
g/dl and Ht 10%

 Tatara T, Nagao Y, Tashiro C. The effect of duration of

surgery on fluid balance during abdominal surgery: a
mathematical model. Anesth Analg 2009; 109:211-6
Showed that infusion rates of between 2-18.5ml/kg/h in
surgery of duration <3 h did not cause significant
interstitial oedema,
but in surgery lasting >6 h, the therapeutic window
narrowed to between 5-8 ml/kg/h, after which a
significant increase in interstitial fluid was seen

Introduction to shock
Combination of hemodynamic parameters

Mean Arterial Pressure < 60 mmHg

Systolic blood Pressure < 90 mmHg
Clinical: UO
Metabolic Acidosis

Kegagalan sirkulasi dlm mencukupi kebutuhan

O2 jaringan tubuh
First.
Identify the cause of shock
Reverse tissue hypoperfusion

Severity of blood loss

Class I
Loss of 15% of BV or less ( 10 ml/kg)
Clinical finding are minimal or absent
5 ml/kg

Class II
Loss of 15-30% of BV (10-20ml/kg)
Compensated phase (systemic vasoconstriction,
UO 20-30 ml/hr)
15 ml/kg

 Class III
Loss 30-45% of BV (20-30ml/kg)
Decompensated phase (hypotension, UO <15
ml/hr, depressed mentation, lactat acumulation in
blood >2 mEq/L)
25 ml/kg

Class IV
Loss > 45% (>30ml/kg)
Irreversible phase (UO <5 ml/hr, refractory to
volume replacement, lactat >4 to 6 mEq/L)
35 ml/kg

Severity of Blood Loss

Variable

II

III

IV

SBP

Normal

Normal

Pulse

<100

>100

>120

>140

RR

14-20

20-30

30-40

>35

Mental
status
BL (ml)

Anxious

Agitated

Confused

Lethargic

BL (%)

<15

<750

750-1500 1500-2000

15-30

30-40

>2000

>40

Stadium Shock
Stadium Kompensasi:
Transcapillary refill replenish 15% of blood
volume (interstitial fluid into capillaries)
Sekresi Vasopressin, RAA retensi air, sodium
dlm sirkulasi
refleks simpatis
Resistensi sistemik
Resistensi Arteriol diastolic pressure

HR
Manifestasi: taki, gelisah, kulit pucat dan dingin,
pengisian kapiler lambat (> 2 detik)

 Stadium Dekompensasi:
Perfusi jaringan buruk

O2
Metabolisme anaerob laktat asidosis
Penumpukan CO2 Asam Karbonat
Kontraklititas miokardium terhambat

Gangguan metabolisme energy Na+/K+ pump di

tingkat seluler Kerusakan sel
Pelepasan mediator vaskuler: histamin, serotonin,
cytokines
Vasodilatasi arteriol
Permiabilitas kapiler venous return , Cardiac output

Manifestasi: taki, TD , oliguria, kesadaran

menurun, asidosis, perfusi perifer buruk

 Stadium Irreversible
Kerusakan dan kematian sel multi organ
failure

Manifestasi: nadi tak teraba, TD tak

terukur, anuria

 The end point of the fluid resuscitation

phase is
restoring peripheral perfusion and BP and
returning increased heart rate toward
normal.

 Atasi penyebab
Traditional end point of volume
resuscitation
MAP 65-70mmHg
Capillary refill time < 2 seconds
UO > 0.5 ml/kg/hour (adults)
O2 ssat > 95%
CVP 8-12 mmHg

Kasus:
Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengan
kesadaran menurun. Riwayat diare dan muntah 1 hari
SMRS.
PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR
120x/min, RR 25x/min, T 38C, mata tampak cekung, bibir
dan mukosa mulut sangat kering, turgor kulit menurun,
lain2 dalam batas normal

DEHIDRASI

Tanda-tanda Kehilangan Cairan (Dehidrasi)

Morgan & Mikhails Clinical Anesthesiology, 5th Ed

Tanda

Kehilangan cairan dalam persentase berat badan

5%

10%

15%

Membran
mukosa

Kering

Sangat kering

Panas dan kering

Sensori

normal

letargi

melambat

Perubahan
orthostatik

Tidak ada

ada

Jelas
>15bpm
>10 mmHg

Denyut nadi

Normal /

>100 bpm

>120bpm

Laju aliran urine

Tek. darah

normal

dgn variasi
respirasi

Back to the case.

Kasus:
Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengan
kesadaran menurun. Riwayat diare dan muntah 1 hari
SMRS.
PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR
120x/min, RR 25x/min, T 38C, mata tampak cekung, bibir
dan mukosa mulut sangat kering, turgor kulit menurun,
lain2 dalam batas normal

 Step I: focus on emergency management

IV fluid 20ml/kg isotonic crystalloid
Additional boluses if needed

Step II: focuses on deficit replacement

daily fluid requirements (100-50-20) +
Fluid deficit

Total step II:

of the volume administered in 8 hr
of the remainder administered in 16 hr

Check electrolyte
*Emedicine.medscape.com

Case
Defisit: 60 kg x 10% = 6 kg = 6 L = 6000 ml
Bolus: 20 ml x 60 kg = 1200 ml/30 menit-1 jam
Sisa defisit: 4800 ml
50% (2400 ml) dalam 8 jam pertama
50% (2400 ml) dalam 16 jam berikutnya

Terapi Cairan dan Elektrolit SMF Anestesi & Terapi intensif FK UNDIP
dr. Ery Leksana, Sp.An.KIC

Volume Infusion
A. Catheter Size
The rate of volume infusion is determined by
the dimensions of the vascular catheter, not
the size of the vein
For rapid volume resuscitation, cannulation of
peripheral veins with short catheter is
preferred to cannulation of large central veins
with long catheters

 Hb and Hct
Poor correlation between blood volume defisit
and Hb in acute hemmorrhage, dilutional
decrease in Hb and Hct, NEVER be used to
evaluate acute blood loss Marino PL. The ICU Book 3 ed; 2007:
rd

211-229

Appropriate treatment of hypovolemia is

volume replacment!!

Estimating the Volume Resuscitation Volume

1.
2.
3.
4.

Estimate normal blood volume

Estimate % loss of blood volume
Calculate volume deficit
Determine resuscitation volume

 Example:
M, ideal body weight 70 kg with GI bleeding, HR 135
bpm, class II hemorrhage (15ml/kg)
15x70 = 1050ml
Crystalloid: 1050/0.25 = 4200ml
Colloid: 1050/0.75 = 1400ml
Resuscitation with crystalloid 3x than with colloid

Conclusion
Understand the stages of hypovolemic shock
and associated pathophysiological changes
Early detection of compensated shock so that
fluid can be given adequately
Know how much fluid must be given
Indication of blood transfusion
How to know the success of resuscitation

Tell me, Ill forget

Show me, I may remember
But involve me and Ill understand

Thank you