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FLUID & NURITION
THERAPY – PATIENT
OUTCOME Waleed Hamimy
Professor of Anesthesia, SICU & Pain Management
Cairo University
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
Introduction
• Lack of knowledge is a cause of morbidity &
mortality due to fluid imbalance
• The fluid & electrolyte content is of vital
importance
Importance of Fluid Therapy
• Maintain blood volume
• Avoid inadequate perfusion
• Avoid electrolyte disturbances & dehydration
Errors in fluid management is the
most common cause of morbidity
& mortality
1999
The right fluid in the
right amount for the
right patient at the
right time
Type of fluid
Why do we give fluids?
To
Maintain
To
Replace
different fluids, along with their carrier solutions
are drugs with different effects.
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
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
Fluids available
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
• The same applies to colloids
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
Amount of fluids
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
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)
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
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.
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.
British Journal of Surgery 2009; 96: 331–341
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.
Even in the postoperative period
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.
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)
Metabolic response to fasting
• metabolic rate substrate oxidation
accelerated catabolism (breakdown of
glycogen, fat & protein).
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
Metabolic response to fasting
• Additionally, overnight fasting variable
degrees of dehydration depending on the
duration of the fasting period
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
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.
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
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)
• 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.
• 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.