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Fluid Therapy In Operative


By: Ahmad Dika Wijaya, S. Ked Wan Irfan Bin Wan Mustapha, S. Ked Sylvia Agestie, S. Ked Mira Wulan Sari, S. Ked

Supervisor: Dr. Endang Melati Maas, Sp. An, KIC, KAP

Introduction
Perioperative fluid deficit occured as a result of the preoperative fasting

Pre-operative fasting for 12 hours or more can lead to a


fluid deficit (water and electrolyte) as much as 1 liter in adult.

The symptoms of fluid deficit cannot be described yet, but


included in it are feeling thristy, sleepy, dizzy.

Introduction...contd

The main purpose of perioperative fluid management is


to replace the deficit in pre operative, during operative,
and post operative.

The management is successful if there is no hypovolemic


and hypoperfusion sign or hypervolemic (lung edema and respiratory failure) sign.

Physiology of Body Fluids


Water is the largest part of the human body, the rates
may change depending on age, gender and obesity
degree of a person.

Changes in the number and composition of body fluids,


which can occur in bleeding, burns, dehydration, vomiting, diarrhea, and preoperative and perioperative

fasting, can cause severe physiological disturbances.

Physiology of Body Fluids...contd

If interference does not adequately corrected prior to the


action of anesthesia and surgery, the risk becomes greater.

Body Water Compartment

Plasma
5% TBW

Interstitial
15% TBW

Intracellular
40% TBW

Capillary membrane

endothel

Blood cell

Fig. Body fluids compartment

Body Water Compartment...cond

Besides water, body fluids contain two kinds of


substances, which are electrolytes and non electrolytes.

Electrolyte is a substance that dissociates in the liquid


and delivers an electrical current.

Electrolytes can be divided into positive ions (cations)


and negative ions (anions).

Body Water Compartment...cond

Cation
Major cation in extracellular fluid is sodium (Na +), while
major cation in intracellular fluid is potassium (K +).

Anion
Major anion in extracellular fluid is chloride (Cl-) and bicarbonate (HCO3-), while the major anions found in

intracellular fluid is phosphate ion (PO43-).

Process of Body Water Movement

Osmotic Difusion

Sodium Potassium Pump

OSMOSIS
OSMOTIC PRESSURE

PERMEABLE MOLECULES, WATER NON PERMEABLE MOLECULES

EQUILIBRIUM STATE

Approximate Fluid Intake and Fluid Loss in Adult

Changes of Body Water


Change of volume
Volume deficit
Volume excess

Change of concentration
Hyponatremia Hypernatremia Hypokalemia Hyperkalemia

Changes of Body Water...cotd

Change of composition
Respiratory acidosis (pH< 3,75 and PaCO2> 45 mmHg) Respiratory alcalosis (pH> 7,45 and PaCO2 < 35 mmHg) Metabolic acidosis (pH<7,35 and bicarbonat <21 mEq/L) Metabolic alcalosis (pH>7,45 and bikarbonat >27 mEq/L)

Fluids In Operative
Disturbances in fluid and electrolyte balance are
common in surgical patients due to a combination of preoperative, perioperative and postoperative factors.

Preoperative factors
Pre-existing conditions

Diagnostic procedures
Drug delivery Surgical preparation Medical management of pre-existing
conditions

Preoperative fluid restriction Pre-existing fluid deficit

Perioperative Factors
Induction of anesthesia Abnormal blood loss Abnormal loss of extracellular fluid into the third space

Loss of fluid due to evaporation from the surgical wound

Postoperative factor
Stress of surgery and postoperative pain Increase of tissue catabolism Decrease in effective circulating volume Risk or the presence of postoperative ileus

Disorders of fluid, electrolyte and acid base that can occurs in


perioperative: Hyperkalemia Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Pathophysiology
Trauma, surgery and anesthesia will cause changes in
water balance and metabolism.

These changes primarily as a result of:


Cells damage at the site of surgery Loss and fluid shifts either local or general Effect of fasting pre-operative, during operative and post-operative Increase of metabolism, tissue damage and healing phase

Pathophysiology...contd

Changes that occur include hormonal changes such as:


Increase of adrenaline and non-adrenaline levels until
the third day after surgery or trauma Increase of glucagon levels in plasma Hormones secretion from the anterior pituitary gland also increased, the growth hormone and

adrenocorticotropic hormone (ACTH)

Pathophysiology...contd

Increase of antidiuretic hormone (ADH) levels that lasted

until day 2-4 after surgery / trauma


Due to the increase of ACTH, aldosterone secretion also increased Prolactin levels are also rising, especially in women compared with men

Basics of Perioperative Fluid and Electrolyte Therapy

There are several factors to be considered in


perioperative fluid administration: Needs normal daily fluid and electrolyte

Fluid and electrolyte deficits pre surgical


Fluid loss during surgery Impaired renal function

Deficit Replacement Pre-Operative

Fluid deficit due to surgery and anesthesia preparation


(fasting, lavement) must be taken into account and as far as possible be replaced in pre-surgery before induction

Loss of fluid in the ECF is replaced with hypotonis fluid


such as physiological saline, Ringer lactate and Dextrose

Fluid Therapy During Operative

The amount of fluid replacement during surgery is


calculated based on basic needs coupled with fluid loss
due to surgery (bleeding, fluid translocation and evaporation).

Types of fluids given depends on the surgical procedure


and the amount of blood lost

Fluid and Electrolyte Therapy in Post-Operative



The fulfillment of basic needs, daily, water, electrolytes

and calories / nutrients.


Water needs for people in the basal state

approximately 50 ml/kgBB/24 hours. Replacing fluids lost in the post surgical Continuing the fluid deficit replacement The correction of balance disturbance casued by fluid therapy

Kinds of Fluids
Crystalloid Fluids This fluid has a composition similar to extracellular fluid (CES = CEF). Advantages: cheap, easily available at any health center, no need to do a cross match, does not cause allergic or anaphylactic shock, simple storage and can be stored longer. As effective as colloid fluid administration to overcome the deficit in intravascular volume. Half-life of crystalloid fluid in the intravascular space of about 20-30 minutes.

Crystalloids Composition

The Colloids
Colloid Fluids Also referred to as a plasma substitute fluids or commonly called "plasma substitute" or the "plasma expander". The substances have a high molecular weight by osmotic activity that causes this fluid tends to persist for longer time (a half-life 3-6 hours) in the intravascular space. Often used for rapid fluid resuscitation, especially in hypovolemic shock / hermorhagik or in patients with severe hypoalbuminemia and loss of protein which many (eg burns). Disavantages of plasma expander are expensive and can cause anaphylactic reactions (although rare) and can cause interference on the "cross match".

Conclusion
Body fluids is a solution consisting of water (solvent) and certain
substances (solutes).

Body fluids are distributed between two main compartments


separated by a cell membrane: intracellular fluid and extracellular fluid

Electrolytes are chemicals that produce electrically charged particles


called ions if it is in solution.

Electrolytes contained in the body include sodium, potassium,


calcium, magnesium, chloride, bicarbonate, phosphate, and sulfate.

Conclusion...contd

Body fluid and electrolyte balance is affected by several


factors: age, sex, fat cells, stress, pain conditions, diet,
environmental temperature, treatment, medical

treatment, and surgery.

The exchange of fluid between compartments can be


done by osmosis, diffusion and sodium potassium pump.

Conclusion...contd

Fluid and electrolyte balance in the process of surgery


should be considered, because the slightest disruption
hemodynamics that are not followed up immediately will cause a fatal condition for patients.

Each fluid and electrolyte balance disorders have


different clinical manifestations causing different

management. In addition, fluid and electrolyte balance


disorders also affect the anesthetic considerations.

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