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FLUID & NURITION
THERAPY – PATIENT
OUTCOME Waleed Hamimy
Professor of Anesthesia, SICU & Pain Management
Cairo University
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Introduction
• Fluid therapy is fundamental to the practice of
ANESTHESIA, but the precise type, amount, &
timing of its administration is still the subject of
extensive debate
• This necessitates good understanding of normal
& abnormal physiology & the requirements for
patients under different circumstances
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Introduction
• Lack of knowledge is a cause of morbidity &
mortality due to fluid imbalance
• The fluid & electrolyte content is of vital
importance
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Importance of Fluid Therapy
• Maintain blood volume
• Avoid inadequate perfusion
• Avoid electrolyte disturbances & dehydration
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Errors in fluid management is the
most common cause of morbidity
& mortality
1999
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The right fluid in the
right amount for the
right patient at the
right time
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Type of fluid
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Why do we give fluids?
To
Maintain
To
Replace
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different fluids, along with their carrier solutions
are drugs with different effects.
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To Maintain
• We should know the normal daily requirements of
water & electrolytes
• Water 25-35 ml/kg/day
• Na+ 0.9-1.2 mmol /kg/day
• K+ 1 mmol/kg/day
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Serum Values of Electrolytes
Cations Concentration, mEq/L
Sodium 135 - 145
Potassium 3.5 - 4.5
Calcium 4.0 - 5.5
Magnesium 1.5 - 2.5
Anions
Chloride 95 - 105
HCO3 22 - 27
Phosphate 2.5 - 4.5
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Fluids available
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G 5%
NS
Ringer’s
RL
No electrolytes,
50 g glucose / liter
Na Cl
154 154
Na Cl K Ca HCO3
147 156 4 4.5 0
Na Cl K Ca HCO3
130 109 4 3 28
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• The same applies to colloids
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CONCENTRATION AND
SOLVENT
MEAN MOLECULAR
WEIGHT
MOLAR
SUBSTITUTION
C2/C6
RATIO
MAXIMUM
DAILY DOSE
ml/kg
HES
200/0.5
6% SALINE
10% SALINE
200 0.5 5:1 33
20
HES
130/0.42
6% SALINE 130 0.42 6:1 50
HES
130/0.4
6% SALINE
10% SALINE
130 0.4 9:1 50
33
HES
130/0.4
6%BALANCED
SOLUTIONS130 0.4 9:1 50
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Amount of fluids
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We are used to give excess fluids!!!!
• The following were considered:
• Preoperative fasting
• Losses
• Surgical blood loss
• Evaporation
• Urine output
• VD caused by spinal or epidural anesthesia
• Transfer to the third space
• Trans-capillary leak of albumin caused by injury
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Fluid shifting
• 1st space shifting- normal distribution of fluid in both
the ECF compartment & ICF compartment.
• 2nd space shifting- excess accumulation of interstitial
fluid (edema)
• 3rd space shifting- fluid accumulation in areas that
normally have no or little amounts of fluids (ascites)
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There was always an overestimation of
the total fluids required
• Maintenance 4 : 2 : 1 rule
• Deficit maintenance x h fasting
• Third space loss ??? 10 – 15 ml /kg/h
• Blood loss 3:1 by crystalloids
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Fatal Postoperative Pulmonary Edema*
Pathogenesis and Literature ReviewAllen I. Arieff, MD
• Retrospective analysis of 13 patients with fatal
pulmonary edema.
• Ten were generally healthy while three having serious associated
medical conditions.
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Fatal Postoperative Pulmonary Edema*
Pathogenesis and Literature ReviewAllen I. Arieff, MD
• Conclusions:
• Pulmonary edema can occur within the initial 36 postoperative
hours when net fluid retention exceeds 67 mL/kg/d.
• There are no known predictive warning signs & cardiorespiratory
arrest is the most frequent clinical presentation.
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British Journal of Surgery 2009; 96: 331–341
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CONCLUSION:
Perioperative outcomes favored a GD therapy rather than liberal
fluid therapy without hemodynamic goals. Whether GD therapy is
superior to a restrictive fluid strategy remains uncertain.
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Even in the postoperative period
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Conclusions: The use of a restrictive
postoperative fluid protocol significantly
reduces the duration of hospital stay in
patients who have undergone major elective
abdominal vascular surgery.
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Normal Maintenance Requirements
For Water it is typically 35 mL/kg/day
1. 1-10 kg = 100 mL/kg/day {4mL/kg/hr}
2. 11-20 kg = 50 mL/kg/day {2mL/kg/hr}
3. > 21 kg = 20 mL/kg/day {1mL/kg/hr}
4. insensible loss = 700 mL/day or 0.2 cc/kg/day for every 1° C > 37°
Simply, hourly maintenance = 40 + weight (kg)
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Metabolic response to fasting
• metabolic rate substrate oxidation
accelerated catabolism (breakdown of
glycogen, fat & protein).
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Metabolic response to fasting
• Insulin levels are often increased but blood
glucose levels also increase due to the
developed insulin resistance.
• The insulin/glucagon ratio is reduced, resulting in an
increased gluconeogenesis
• Conventional preoperative fasting time may
aggravate insulin resistance hyperglycemia
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Metabolic response to fasting
• Additionally, overnight fasting variable
degrees of dehydration depending on the
duration of the fasting period
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Benefits of less fasting hours
• Reduction of preoperative fasting time seems to have a
beneficial effect on peri-operative thirst, hunger, anxiety &
muscle strength.
• Patients undergoing elective cardiac surgery treated with
the same preoperative fasting protocol were less thirsty
compared with controls & required less intraoperative
inotropic support after initiation of CPB weaning.
Breuer et al. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Anesth Analg. 2006;103:1099-1108.
Hausel et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg. 2001;93:1344-1350
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New recommendation
• Intake of clear fluids until 2 h before surgery &
anesthesia.
• ESPEN recommended, a carbohydrate-rich drink 2 h
before anesthesia (grade A evidence)
1. Noblett et al. Pre-operative oral carbohydrate loading in
colorectal surgery: a randomized controlled trial. Colorectal Dis. Sep 2006;8(7):563-569.
2. Nygren J, Thorell A, Ljungqvist O. Preoperative oral
carbohydrate nutrition: an update. Curr Opin Clin Nutr MetabCare. Jul 2001;4(4):255-259.
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Are these recommendation applied?
• CURRENT KNOWLEDGE, PRACTICE AND ATTITUDE
OF PREOPERATIVE FASTING: A LIMITED
SURVEY AMONG UPPER EGYPT ANESTHETISTS
• ossama Hamdy; Salah M Asseda; Hatem S Ali,
• South valley University
• showed that the majority (72%) of studied Anesthetists
are aware of the new preoperative fasting guidelines;
however, they are still practicing strict preoperative NPO
from midnight. Only 10% follow the new guidelines.
EgJA 2013
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HAS THE IMPLEMENTATION OF THE CURRENT PRE-
OPERATIVE FASTING GUIDELINES (UK GIFTASUP) BEEN
SUCCESSFUL?
AN AUDIT OF CURRENT PRACTICE
Thomas Hall, James Stephenson, Cristina
Pollard, Ashley Dennison. Int. J. Surgery (2012)
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• Methods:
• A prospective audit of all surgical patients undergoing a general
surgical procedure requiring a general anesthetic using a
structured questionnaire over a 20 day period was performed
• Results:
• 75 patients were followed through the perioperative period with 41
elective and 34 emergency cases. The average pre-operative NBM
period for clear liquids was 14 and 19 hours in the elective group
and emergency group respectively. Zero patients in the elective
group had clear fluids 2 hours prior to induction of anesthesia and 2
(5%) patients in this group had clear fluids between 2 & 6 hours
prior to anesthesia.
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• Conclusion:
• The results demonstrate that adherence to the guidelines is poor.
With the advent of enhanced recovery programs and an emphasis
on early enteral feeding post-operatively to maintain ‘normal'
physiology we appear to have forgotten about the pre-operative
period. Education about the guidelines is desperately needed.
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