Dr.

Yuliaji Narendra Putra, SpB

RSUD Tidar Magelang
 PARENTERAL FLUID THERAPY

RESUSCITATION REPAIR MAINTENANCE PN

PERFUSION & CORRECT HOMEOSTASIS/ CORRECT

OXYGENATION ELECT & AB SUPPORTIVE NUTRITION ST
 FLUID THERAPY

RESUSCITATION MAINTENANCE
Repair

Crystalloid Colloid ELECTROLYTES NUTRITION

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

Intraoperative Hemodynamically
1. Replace acute loss Preop
1.&Replace
post recovery
normal period
loss
stable (hemorrhage, GI loss, (IWL + urine+ faecal)
3rd space etc) 2. Nutrition support
 (1,2) (3) (4,5)

Preop nutrition or Postop

Intraop isotonic
Carbohydrate Maintenance fluid
crystalloid
Load 800 ml + 200 < 30 ml/kg/24 hr;
> 12-14 ml/kg/hr
ml Na+ 60-100 mEq

Pre Intra- Post-

operative operative operative
• Nygren J. Best Practice & Research Clinical Anaesthesiology Vol. 20, No. 3, pp. 429e438, 2006
• Fearon KCH. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection
Clinical Nutrition (2005) 24, 466–477
• Futier E et al. Conservative vs Restrictive Individualized Goal-Directed Fluid Replacement Strategy in Major Abdominal
Surgery. Arch Surg. 2010;145(12):1193-1200
• 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
• Brandtsruo B. Fluid therapy for the surgical patient. Best Practice & Research Clinical Anaesthesiology Vol. 20, No. 2, pp.
265–283, 2006
 Resuscitation vs Maintenance

RESUSCITATION MAINTENANCE

 Elect of High sodium > 100 mmol/L
 or colloid
 Low or no K+
 20-30 ml/kg/hr (DSS, diarrhea)
 2-3 L/10-15 min (hemorrhagic shock)
• Moderate sodium 50-100 mmol/L
• K+ based on daily req
• 20 drops/min 500 ml/6 hr
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-
477
Pre-
admission
conselling
Perioperative
oral Fluid and CHO-
loading/no
nutrition
fasting

Stimulation of
gut mortility

Prevention
of nausea ERAS
and
vomiting

Avoidance of
sodium/ fluid
overload
Main elements of the ERAS protocol
Summary of stress response
STRESS

HYPOTHALAMUS

SYMPATHETIC ADENOHYPOFISIS

Cardiac function↑ ADRENAL MEDULLA ADRENAL CORTEX THYROID GLAND

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

06/01/12
Vasopressin changes by various
solutions

NaCl
vasopressin
elevation

Glucose
vasopressin
suppression
 Sequestration of fluid from ECW
% BODY NORMAL ACUTE INJURY ELECT & IV Col PHASE OF
WEIGHT
RESOLUTION
35

30 ICF 3rd space

Forming
25 Sequestrated
ECF

20
ISF

Sequestrated Resolving
15 ECF Sequestrated
ECF

10

5
IV

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

I.V. fluids Diuresis
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; 1812-1818

Twenty patients for elective colonic resection

were divided into 2 groups.

Standard group : at least 154 mmol sodium and 3 Ｌ

water/day (generally 1 L 0.9% saline and 2 L 5%
dextrose)
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)
Weight
(kg)

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

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

(minutes)
Median passage of flatus 4 3
(days)
Median postop hospital stay 9 6
(days)
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; 238:641-648

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%
(p=0.007)
• 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

 BUT...
• New evidence exists that Excessive fluid
restriction increased the level of
hypovolemia, leading to reduced ScvO 2
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.

Methods
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
Results
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
Resection
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
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
1999;115:1371-1377
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
 15 yeas ago… 　 The fluid & nutrition therapy for Gastric and Colon
resection
Volume of
Energy infusion(mL)
(kcal)

１５００ ２２５０

１０００ １５００

Normal
Rice
Diet
Norma
l Diet
Gruel

Liquid
５００ ７５０
Diet

M Traditional
Maintenance
F FLUID MF
2000 MF
1000 2000mL 1500mL
MF
mL mL 1000mL

- ２ＰＯＤ- １ＰＯＤ ＯＰＥ １ＰＯＤ2 ＰＯＤ3 ＰＯＤ 4 ＰＯＤ 5 ＰＯＤ 6 ＰＯＤ 7 ＰＯＤ 8 ＰＯＤ 9 ＰＯＤ10 ＰＯＤ
DischargeＤ ay
 Now… The fluid & nutrition therapy for Gastric and Colon
resection
Energy Volume of
(kcal) infusion(mL)

１５００ ２２５０

１０００ １５００
Liquid Rice Normal
Norma
Diet Gruel Diet
l Diet

５００ AF ７５０
200
0 Aminofluid infusion
®
mL AF 2000mL AF
100
0 1000mL
mL

- ２ＰＯＤ- １ＰＯＤ ＯＰＥ １ＰＯＤ2 ＰＯＤ3 ＰＯＤ 4 ＰＯＤ 5 ＰＯＤ 6 ＰＯＤ 7 ＰＯＤ 8 ＰＯＤ 9 ＰＯＤ10 ＰＯＤ
DischargeＤ ay
 The significance of infusing amino acid
Starvation unavoidable nitrogen loss
Aminofluid
quantity
At least 100 g of glucose is
necessary per day
500mL x
（ FAO/WHO
2bags ）
（ amino
(GAMBLE) mgN/kg/day
acid ： 30g ） TOTAL
Urine 37
54mg/kg/day
Protein loss (g)

100 200g
Stool 12 When I convert it into
100g an amino acid
Skin 3
（ 50kg in weight ）
200 Others 2 26.3 g /day※

Glucose 50g
300 ※
： 0.054(g) ×7.5*×50(kg)×1.3** ＝ 26.3(g)
0g * ： convert nitrogen into quantity of amino acid （ 6.25×1.2
（ Starved ） ** ： usually increase by 30% in consideration of
individual difference
400
1 2 3 4 5 6
Period of starvation (days)
 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
management
• However, excess sodium and fluid must be avoided during
postoperative maintenance fluid therapy
• There is good rationale of giving Aminofluid in early postop
period