By: Iis Martilopa (04104705051) Olia Indri Saktianingsih (04104705085) Yarah Azzilzah (04104705264)

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

 Fluid

is the largest part in body. The total amount of body fluid volume and solute, as well as concentration are relatively constant during steady-state condition. Disturbances of composition and volume of body fluid is one of the most common clinical problems and important. Large disturbances of fluid and electrolyte balance may quickly lead to changes in cardiovascular function, neurological, and neuromuscular

 Fluid

is the largest part in body. TBW (Total Body Water) may change, depending on age, gender, & degree of obesity
Age
Infant

Percentage of TBW Depending on Body weight

75%

Male(20-40 years old)

Female(20-40 years old) Geriatrics(> 60 tahun)

60%
50% 45-50%

 Fluid

intake comes from: Oral Fluid, Solid Foods & Oxidative Metabolism.
loss

Fluid

Insensible

Water Loss Fluid loss through skin Fluid loss through GI tract Fluid loss through kidney

Fluid Intakes
Oxidative Metabolism Oral Fluid Solid Foods 300 ml Kidney

Fluid Loses
1200-1500 ml 500-600 ml 400 ml 100-200 ml 2200-2700 ml

1100-1400 ml Skin 800-1000 ml Lungs GI tract

Total

2200-2700 ml Total

Compartment

Fluid as
percent body weight (%)

Total Body
Water (%)

Fluid
Volume (L)

Intracellular
Extracellular Interstitial Intravascular Total

40
15 5 60

67
25 8 100

28
10,5 3,5 42

TRANSCELLULAR FLUID ( 1 2 L )

Cerebrospinal Pleura

fluid

fluid Pericardium fluid Peritoneum fluid Sinovial fluid

WATER

BODY FLUID

ELECTROLYTE Na+ K+ PO4 Cldll SOLUTE

NON ELECTROLYTE Protein Urea Kreatinin Glukosa

 ECF,

including plasma & interstitial fluid, contain sodium & chloride ions in large amount, bicarbonate ions are also in large enough quantities, but only a few ions of potassium, calcium, magnesium, phosphate, and organic acids. ICF only contains a few amount of sodium and chloride ions and almost no calcium ion. In fact, this fluid contains a large amount of potassium ions, phosphate, and proteins.

Extracellular GramIntracellular Intravascular Interstitial

Molecular
Weight Sodium 23.0

(mEq/L)
10

(mEq/L)
145

(mEq/L)
142

Potassium
Calcium Magnesium

39.1
40.1 24.3

140
<1 50

4
3 2

4
3 2

Chloride
Bicarbonate Phosphorus Protein (g/dL)

35.5
61.0 31.01

4
10 75 16

105
24 2 7

110
28 2 2

 Osmosis

is the net movement of water across a semipermeable membrane as a result of difference in non diffusible solute concentration between the two side. 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. Osmotic pressure is generally dependent only on the number of nondiffusible solute particles.

 The

osmolarity of the solution is equal to the number of osmoles per liter of solution. The osmolality equals the the number of osmoles per kilogram of solvent. Tonicity refers to the effect a solution has on cell voluume. An isotonic solution has no effect on cell volume, whereas hypotonic and hypertonic solution increase and decrease cell volume respectively.

1.

VOLUME CHANGE - volume depletion - volume overload CONSENTRATION CHANGE - Hyperosmolality & hypernatremia - Hypoosmolarlty & hyponatremia - Pottasium disturbance - Calcium disturbance - Phosphor disturbance - Magnesium disturbance

2.

The condition that is caused by depletion of extracellular fluid. The most common cause of volume depletion is diarrhea or vomiting. The other causes include trauma, infection, inflamation, bleeding, burns, etc. Volume depletion is devided into 3 types based on the blood sodium level: - Isonatremic (normal blood sodium levels) - Hyponatremic (abnormally low blood sodium levels) - Hypernatremic (abnormally high blood sodium levels)

 Volume

overload is the condition that can be caused by iatrogenic or secondary of renal insuffiency, sirosis or congestive heart failure. Edema is the indication of volume overload in tissues. Classification of edema : Intracelullar Edema & Extracelullar Edema

1.

Sodium Disturbance

Hyperosmolality & Hypernatremia Hypernatremia is nearly always the result of either a loss of water in excess of sodium or retention of large quantities of sodium Clinical Manifestation: restless, lethargy, and hyperreflexia can progresss to seizures, coma, and ultimately death. Treatment of hypernatremia is aimed at restoring plasma osmolality to normal as well as correcting the underlying problem.

Water deficit should generally be corrected over 48 h with hypotonic solution such as D5W. Hypernatremic patients with decreased total body sodium should be given isotonic fluids to restore plasma volume. Hypernatremic patients with increased total body sodium should be treated with loop diuretic along with intravenous D5W.

Hypoosmolality & Hyponatremia

Hyponatremia invariably reflects water retention from either an absolute increase in TBW or loss of sodium in excess of water. Clinical Manifestation : anorexia, nausea, weakness. Progressive cerebral edema, however result in lethargy, confusion, seizures, coma and finally death. Treatment of hyponatremia:
Na+ Deficit = TBW x (desired Na [Na+] present [Na+])

Very rapid correction of hyponatremia has been associated with demyelinating lesion in pons. The correction rate : :0,5 meq/L/horless (mild symptom); 1 meq/L/h or less (moderate symptom); and 1,5 meq/L/h or less (severe symptom).

2. Potassium Disturbance
Hyperkalemia Hyperkalemia exsists when plasma [K] exceeds 5,5 meq/L Hypercalemia can result from (1) an intercompartmental shift of potassium ions (2) decreased urinary excretion of potassium or rarely (3) an increased potassium intake. Clincal manifestation involves CNS (paraesthesia, skeletal weakness) and cardiovascular system (dysrhytmia, ECG changes).

 Treatment

of hyperkalemia: Treatment is directed at reversing cardiac manifestation, anda skeletal muscle weakness and restoring of plasma K to normal calcium 95-10 ml of 10% calcium gluconate or 3-5 ml of 10% calcium chloride) partially antagonizes the cardiac effects of hyperkalemia and is useful in patients with marked hyperkalemia.

Hypokalemia
Is defined as plasma [K+] less than 3,5 mEq/l. Hypokalemia can occur as result of (1) intercompartmental shift of K+ (2) increased potassium loss or (3) an inadequate potassium intake. Clinical Manifestation : abnormality of ECG, sketetal muscle weakness, muscle cramping, tetany, and rarely rhabdomyolisis. Treatment of hypokalemia: - oral replacement with potassium chloride solution is generally safest (60-80 mEq/d). - intravenous replacement of potassium chloride should usually reserved for patient with or risk for serious cardiac manifestation or muscle weakness

Fluid management is aimed to replacement of water and electrolyte depletion, shock therapy, and solves another abnormalities that occur because of therapy. Intravenous fluid management, consists of: - Crystalloid Fluid - Colloid Fluid - Combination both of them

This fluid has composition that is similar to ECF. Crystalloid solutions are aqueous solutions of low molecular-weight ion (salts) with or without glucose.. Half time of crystalloid solution in intravascular is about 20-30 minutes. Crystalloid should be considered as resuscitation fluid in patients with hemorrhagic and septic shock, in burn patients, in patients with head injury to maintain cerebral perfusion pressure, and in patients undergoing plasmapharesis and hepatic resection.

 If

3-4 l of crystalloid has given, and hemodynamic responses inadequate, colloid may be added. Solution are chosen according to the type of fluid loss being replaced. For loses primarily involving water hypotonic solution maintenance type solution If loses involve both water and electrolyte isotonic solution replacement type solution.

 The

most commonly used fluid is lactated Ringers solution. When NS is given in large volume, can produces a dilutional hyperchloremic acidosis because of its high sodium and chloride (154 mEq/l). NS is the preferred solution for hypochloremic metabolic alkalosis and for diluting PRC prior to transfusion. D5W is used for replacement of pure water deficits and as a maintenance fluid for patients on sodium restriction. Hypertonic 3% saline is employed in therapy of severe symptomatic hyponatremia.

 Colloid

is called as plasma replacement fluid or usually called plasma substitute or plasma expander The osmotic activity of high molecular weight substances in colloid tends to maintain these solution intravascularly. Most colloid solutions have intravascular halflives between 3-6 h.

 Generally

accepted indicatons for colloid

include: 1.Fluid resusitation in patients with severe intravascular fluid deficit (eg. Hemorrhagic shock) prior to the arrival of blood transfusion. 2.Fluid resusitation in the presence of severe hypoalbuminemia or condition associated with large protein losses such as burns.

Perioperative fluid therapy includes replacement of preexisting fluid deficits of normal losses (maintenance requirements), and surgical wound losses including blood loss.

 Normal

Maintenance Requirements

in the absence of oral intake, fluid & electrolyte deficits can rapidly develop as result of continued urine formation, gastrointestinal secretions, sweating and insensible loses from skin and lung. Weight For the first 10 kg For the next 10-20 kg For each kg > 20 kg Rate 4 ml/kg/h add 2 ml/kg/h add 1 ml/kg/h

Eg: what are the maintenance fluid requirements for 25 kg child? 40 + 20 + 5 = 65 ml/h

 Preexisting

deficit

Patients presenting for surgery after an overnight fast without any fluid intake will have a preexisting deficit proportionate to the duration of the fast. Preexisting deficit = normal maintenance rate x length of the fast

Eg : for average 70 kg, fasting for 8 h, this amounts to (40+20+50)ml/h x 8 h = 880 ml Fluid is given part for the first hour, part for the next second hour, and part for the next third hour.

 Intraoperative

Fluid Replacement

Intraoperative fluid therapy should include supplying basic fluid requirements and replacing residual preoperative deficit as well as intraoperative losses (blood, fluid redistribution, and evaporation)

1.

Replacing Blood Loss

Ideally, blood loss should be replaced with crystalloid or colloid to maintain vascular volume until the danger of anemia outweighs the risk of transfusion. The transfusion point can be determined preoperatively from the hematocrit and by estimating blood volume.
Age Blood Volume

Neonates
Premature Full-term 95 mL/kg 85 mL/kg

Infants
Adults Men

80 mL/kg

75 mL/kg

Woman

65 mL/kg

 Patients

with normal hematocrit should generally be transfused only after losses greater than 10-20 % of their blood volume.

2. Replacing Redistributive & Evaporative Losses

Because these losses are primarily related to wound size and the extent of surgical dissection and manipulation procedures can be classified according to the degree of tissue trauma
Degree of Tissue Tauma Minimal (eg hernioraphy) Moderate ( eg cholecystectomy) Severe(eg bowel resection) Additional Fluid Requirement 0 2 ML/KG 2 4 ML/KG 4 8 ML/KG

Perioperative Fluid Therapy:

1. Maintenance = (4 x the first 10 kg) + (2 x the next 10-20 kg) + (1 x each kg > 20 kg) 2. Preexisting deficit = Maintenance x length of fasting 3. Redistributive & Evaporation (IWL) = degree of tissue trauma x BB The first hour The second hour The third hour = part = ( P) + M + IWL = part = ( P) + M + IWL = part = ( P) + M + IWL