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Yuliaji Narendra Putra, SpB

RSUD Tidar Magelang



Na > 100 mEq/l Dextran Na 30-60 mEq/L Amino acids
(RA/RL/NS) HES K 20 mEq/L Carbohydrates

Intraoperative Hemodynamically
1. Replace acute loss Preop
post recovery
normal period
stable (hemorrhage, GI loss, (IWL + urine+ faecal)
3rd space etc) 2. Nutrition support
Resuscitation vs Maintenance


 Elect of High sodium > 100 mmol/L • Moderate sodium 50-100 mmol/L
 or colloid • K+ based on daily req
 Low or no K+ • 20 drops/min 500 ml/6 hr
 20-30 ml/kg/hr (DSS, diarrhea)
 2-3 L/10-15 min (hemorrhagic shock)
Fearon KCH, Ljungqvist O, Von Meyenteldt M; Revhavy A, Dejong
CHC, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet ;
Enhanced recovery after surgery: A consensus review of clinical care for
patients undergoing colonic resection. Clinical Nutrition 2005; 24: 466-
Perioperative oral
nutrition Fluid and CHO-
loading/no fasting

Stimulation of gut

Prevention of
nausea and ERAS

Avoidance of sodium/
fluid overload

Main elements of the ERAS protocol

Summary of stress response




Blood pressure ↑
Blood redistribution
↑ Adrenaline
↑ Glucagon
↑ Noradrenaline ↑ Glucocorticoid ↑ T4

↑ Cardiac function
↑ Glycogenolysis
• Na+ retention ↑ Blood glucose
↑ Blood redistribution • Water retention ↑ Gluconeogenesis
↑ Glycogenolysis • ↑ Free Amino Acids
↑ Blood glucose ↑ Metabolism ↑ Lipolysis
• ↑ Gluconeogenesis
↑ Lipolysis
↑ Free fatty acids

Purpose: Maintain homeostasis, increase body resistance, tissue healing etc

4D 1-2 D 2-8 W months Dr Iyan Darmawan

Vasopressin changes by various


Sequestration of fluid from ECW

30 ICF 3rd space

25 Sequestrated

Sequestrated Resolving
15 ECF Sequestrated



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

I.V. fluids
ICF =intracellualr fluid; ISF =interstitial fluid; IV =intravascular
Perioperative IV Fluid Restrictions Helpful in
Colorectal resection

Low Sodium
Better outcome
Restricted volume

1. Bandstrup. Ann Surg.2003;238:641-648

2. Lobo DN. Lancet. 2002 May 25;359(9320):1812-8.
Dr Iyan Darmawan

Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowland

BJ, Allison S; Effect of salt and water balance on recovery
of gastrointestinal function after elective colonic resection
: a randomized controlled trial. Lancet 2002; 359; 1812-

Twenty patients for elective colonic resection

were divided into 2 groups.

Standard group : at least 154 mmol sodium and 3L

water/day (generally 1 L 0.9% saline and 2 L 5%
Restricted group: no more than 77 mmol sodium and 2 L
water/day (generally 0.5 L 0.9% saline and 1.5 L 5%
dextrose or 2 L 4% dextrose)
Dr Iyan Darmawan

Weight change and 24-hr total fluid input, intravenous sodium

and urine output in patients undergoing elective colonic resection

Total fluid
Change in
input (ml)

0 1 2 3 4 pop
0 1 2 3 4 5 pop
IV sodium Urine
(mmol) output

0 1 2 3 4 pop 0 1 2 3 4 pop
Lobo DN, et al: Lancet 2002; 359;1812-1818; Standard: at least 154 mmol
sodium and 3 L water/day; Restricted: no more than 77 mmol sodium
and 2 L water/day
Dr Iyan Darmawan

> 3 L; 154 mEq < 2 L; 77 mEq

Mean Gastric emptying time 175 72.5

Median passage of flatus 4 3
Median postop hospital stay 9 6
No of patient with complication 7 1
Dr Iyan Darmawan

Brandstrup B, Tonnsen H, Beier-Holgersen R, Hjortso E, Ording H, et

al. Effects of Intravenous fluid restriction on postoperative
complications : Comparison of two perioperative fluid regimens. A
randomized assesor-blinded multicenter trial. Ann Surg 2003; 238:641-

Intravenous fluids
Body weight increase

L kg

The restricted fluid regimen significantly reduced postoperative

complications both by intention to treat (33% vs 51% P.0013) and per-
protocol (30% vs 56% P0.003 ) analysis . The members of both
cardiopulmonary (7% vs 24% P0.007) and tissue-healing complications
16% vs 31% P0.04) were significantly reduced.
Results (restricted vs standard)

• Overall postop complications 33% vs

51% (p = 0.013)
• Cardiopulmonary comp 7% vs 24%
• Tissue-healing complications 16% vs
31% (p =0.04)
• Deaths 0% vs 4.7% (p=0.12)

Brandstrup B . Ann Surg.2003;238:641-648

• New evidence exists that Excessive fluid
restriction increased the level of
hypovolemia, leading to reduced ScvO2
and thereby increased incidence of
postoperative complications.

Arch Surg. 2010;145(12):1193-1200

Dr Iyan Darmawan

Arkilic C, Taguchi A, Sharma N, Ratnaraj J, Sessler Dl, read TE,

Fllshan JW, Kurg A; Supplemental perioperative fluid
administration increase tissue oxygen pressure. Surgery 2003; 133:
49 -55
Fifty-six patients undergoing colon resection assigned into two groups
Aggressive : a bolus of 10 ml/kg before induction of anesthesia.16-18
ml/kg/hr fluid management
Conservative : 8 ml/kg/hr

Conclusion. Supplemental perioperative (intra- and post-)

fluid administration significantly increase tissue perfusion
and tissue oxygen pressure(subcutaneous oxygen tension)
Dr Iyan Darmawan

Holte K. Klarkov B, Christensen DS, Lund C, Nielsen KG, Bie P,

Kehlet H: Liberal versus restrictive fluid administration to
improve recovery after laparoscopic cholecystectomy: A
randomized, double-blind study. Ann Surg 2004; 240: 829-829.

48 ASA I-III patients undergoing laparoscopic cholecystectomy
Randomized to 15 ml/kg (restrictive group) or 40 ml/kg
(liberal group) intraoperative lactated Ringer Solution
Liberal group Improved postoperative pulmonary function
Improved exercise capacity after surgery
Reduced stress response
(aldostrenone, ADH and angiotensin II)
Nausea, general well-being, thirst, dizziness, drowsiness,
fatigue, and balance function also significantly improved.

Liberal fluid administration improved recovery after surgery

Dr Iyan Darmawan

Maharaj CH, Kallam SR, Malik A, Hassett P, Grady D, Laffey G:

Preoperative intravenous fluid therapy decrease postoperative
nausea and pain in high risk patients. Anesth Analg 2005; 100:
675- 82.
Eighty ASA grade 1-III patients for diagnostic gynecologic laparoscopy
Large volume : (2 ml/kg/h fasting) Control : (3 ml/kg alone)
Overall incidence and interval frequency of postoperative nausea and vomiting

The preoperative administration of 2 ml/kg of compound sodium

lactate solution for every hour of fasting is recommended to patients
with an increased PONV risk presenting for ambulatory surgery
Dr Iyan Darmawan

The reasons why intravenous infusion therapy are controversial

Historical background and diverse indications for various patients of

different pathophysiological situations.

Shires’ theory has been easily accepted in trauma patients with strong
heart, the benefit of youth and a good renal system who tolerate liter and
liter of fluid. While renal failures is avoided, the abdominal
compartment syndrome has appeared and been the price for this
aggressive fluid replacement.

Liberal fluid administration : Arkilic C et al (2003): Colon Resection,

Maharaj CH et al: Gynecologic
Laparoscopy(20005) Holte et al (2004):
Laparoscopic Chotecystectomy Holte et al
(2004): Knee Anthroplasty
Restrictive administration Labo DN et al (2002): Elective Colonic
Resection Randstrup B et al (2003): Colorectal
Other reasons
Hypoalbuminemia, ECF expansion and Picking
the right infusion

Should prescribe

Low sodium!!

Hill G.L. Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone 1990
LARUTAN Na > 130 mEq/L

Na+ K+ Cl- Dextrose mOsm/L)

(mEq/L) (mEq/L) (mEq/L) (g/L)

NaCl 0,9% 154 - 154 - 308

Ringer 147 4 155,5 - 310
RL/ RA 130 4 109 - 273
Plasma 142 4 103 285 + 5
Pulmonary oedema may ensue within 36 hr postoperatively if net water
retention > 67 ml/kg/d postop water input should be < 2000 ml

Recovery of GI function is faster in patients of colonic resection receiving

postop fluid < 2 L; 77 mEq Na+ than group receiving > 3 L; 154 mEq Na+
Post op Na+ intake 60-100 mEq/day

Water and sodium excretion is slower in postop patients receiving infusion

containing higher sodium

Minimum 400- 600 kcal is sufficient in early postop period

(Protein-sparing effect)

Patients with hypoalbuminemia have expanded ECV, and administration

of high sodium may aggravate delayed wound healing
1. Arieff Allen L. Fatal Postoperative Pulmonary Edema. Pathogenesis & Literature Review. CHEST
2. Lobo DN et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic
resection. Lancet 2002 May 25.359(5320):1792-3
3. Hill G.L. Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone 1990
4. Fiona REID, Dileep N. LOBO, Robert N. WILLIAMS, Brian J. ROWLAND Sand Simon P. ALLISON
(Ab)normal saline and physiological Hartmann's solution: a randomized double-blind crossover study
Clinical Science (2003) 104, (17–24)
• : Hill Harris-Benedict  > 90% patients will get excess of 500 kcal
TEE 40 kcal/kg/day  30% overfeeding

• Saito TEE 25-30 kcal/kg/day

1 Marik PE : 20 kcal/kg/day in septic patients

2006: Boitano M : 10-20 kcal/kg/day

Dr Iyan Darmawan
Dr Iyan Darmawan

Aminofluid in postoperative patients

• 10-20 kcal kg is ideal during flow phase; moderate glucose supply prevents
worsening of stress-induced hyperglycemia (1)
• Patient with moderate stress and can’t eat less than 7 day period may
tolerate 500-600 kcal/day (2)
• Amino acids in combination with glucose is required to minimize negative
nitrogen balance and overcome postoperative fatigue (3)
• Zinc promotes wound healing, support immune function, cellular growth and
bosy antioxidant system (4)
• Na+ in moderate amount prevents iatrogenic fluid overload; K+ prevents
potassium depletion
Take Home Messages
• Preoperative glucose-containing fluid by the oral or
intravenous route improves outcome; a deficit due to fasting
should not exist
• Intraoperative conservative fluid management results in less
incidence of hypovolemia , hypoperfusion and postop
complications compared to excessively restricted fluid
• However, excess sodium and fluid must be avoided during
postoperative maintenance fluid therapy
• There is good rationale of giving Aminofluid in early postop