Fluids and electrolytes in Maxillofacial Surgery

FLUIDS AND ELECTROLYTES IN
MAXILLOFACIAL SURGERY
DR.VARUN MITTAL
DEPT. OF ORAL AND MAXILLOFACIAL
SURGERY (PG STUDENT)
SRM DENTAL COLLEGE, CHENNAI

BRIEF REVIEW OF
BASICS
 FLUIDS – WATER, BLOOD, NS, RL,
DEXTROSE
 FLUID COMPARTMENTS –
INTRACELLULAR &
EXTRACELLULAR
(INTRAVASCULAR,INTERSTITIAL)
 ELECTROLYTES –
CATIONS (Na⁺, K⁺, Ca⁺⁺ and Mg⁺⁺)
ANIONS (Cl⁻, HCO₃⁻, SO₄³⁻, HPO₄⁻,
Organic Anions and Proteins)

SOME COMMON TERMS
 Homeostasis Ability of the human body to
maintain the internal & external mileu for optimal
function of its cells
 Intracellular fluid volume (ICV) refers to the volume of
fluid inside all cells, it normally contains 26-28 litre (l) out
of the total 42 l of water in a 70-kg person.
 Extracellular fluid volume (ECV) refers to the interstitial
and the plasma volume, it contains the remaining water
(14-16 kg) with most of the water in tissue fluid (ISF) and
about 3 kg of water in plasma
 Dextrans are polysaccharides of high molecular weight
 Dehydration is a clinical condition with an abnormal
reduction of one or more of the major fluid compartments
 Hypernatraemia refers to a clinical condition with plasma-
Na+ above 145 mM

 Hyponatraemia refers to a clinical condition with
plasma-Na+ below 135 mM.
 Edema refers to a clinical condition with an abnormal
accumulation of tissue fluid or interstitial fluid.
 Hyperkalaemia refers to a clinical condition with
plasma-K+ above 5 mM (mmol/L of plasma).
 Hypokalaemia refers to a clinical condition with
plasma-K+ below 3.5 mM.
 Osmolality is a measure of the osmotic active
particles in one kg of water. Plasma-osmolality is
given in Osmol per kg of water. Water occupies 93-
94% of plasma in healthy persons. Plasma osmolality
is normally maintained constant by the antidiuretic
hormone feedback system.
 Overhydration refers to a clinical condition with an
abnormal increase in total body water resulting in an
increased ECV and thus salt accumulation

COMPARTMENTS
• Body fluid is found in
three different fluid
compartments within
the body. These are:
1. Blood plasma
2. Interstitial fluid
3. Intracellular fluid
• Number 1 and 2
above make up the
portion of body fluid
known as
extracellular fluid

Fluids and electrolytes in Maxillofacial Surgery

DAILY INTAKE/OUTPUT OF WATER(Guyton & Hall)
NORMAL HEAVY
EXERCISE
INTAKE
Fluids ingested 2100 ?
From metabolism 200 200
Total
intake
2300 ?
OUTPUT
Insensible -- Skin 350 350
Insensible -- Lungs 350 650
Sweat 100 5000
Feces 100 100
Urine 1400 500

ELECTROLYTES
EXTRACELLULAR –
Na⁺ and Cl⁻ (main),
HCO₃⁻, Protein, Ca⁺⁺
and K⁺
INTRACELLULAR –
K⁺, PO₄³⁻ and Organic
anions (main)
proteins, Mg⁺⁺, Na⁺,
Cl⁻ and HCO₃⁻

BIOCHEMICAL MAINTENANCE
 Normal Potassium
requirement is 1.0
mmol/kg/day = 60
mmol/day
 Normal Sodium
requirement is 1.5-2
mmol/kg/day = 70-
150 mmol/day
 Normal water
requirement is 1.5
ml/kg/h = 2.5 l/day
approx
 As per M² :-
Water 1500 mL
Sodium 50-75 mmols
Potassium 60 mmols

BODY FLUID DISTURBANCES
can be classified into 3 main
categories:-
1. Changes in concentration (hyponatremia,
hypernatremia, hypokalemia etc.)
2. Changes in volume (hypovolemia and
hypervolemia)
3. Acid Base disturbances

HYPONATREMIA
 It is defined as a plasma Na+ <
135mEq/L. It’s the most common
electrolyte abnormality.
 Not all patients with Na+ < 135mEq/L are
true hyponatremic patients.
◦ In conditions like hyperglycemia, hyper
cholesterolemia even if the total body Na⁺ is
normal, the dilutional effects of the above
mentioned compounds results in PSEUDO
HYPONATREMIA

HYPONATREMIA- Types & How to
identify
 The volume status of the individual gives rise to
3 different clinical entities of Hyponatremia
 Hyper volemic Hyponatremia
 Hypo volemic Hyponatremia
 Eu volemic Hyponatremia
 Thus the evaluation of a hyponatremic patient
requires the measurement of
 Plasma osmolality
 Urine osmolality
 Urine Na+
 The common factor to all the true hyponatremic
patients is a reduction in the plasma osmolality
below 270 mOsm/L

HYPERVOLEMIC HYPOVOLEMIC EUVOLEMIC
CCF, Nephrotic
syndrome (CRF) ,
Cirrhosis of liver.
In these
conditions,
urinary osmolality
> plasma
osmolality [conc.
urine] Urinary Na⁺
< 20mEq /L urine
Peripheral
edema
Signs of
dehydration, urinary
Na differentiates, a
renal from an extra
renal cause.
Extra Renal U Na⁺
< 10 mEq/L
Dehydration
Diarrhea
Vomiting
Renal U Na⁺
>20mEq / L Diuretics
ACE inhibitors
Nephropathies
Mineralocorticoid
deficiency
Cerebral Na wasting
syndrome
Patients having
endocrinological
defect SIADH &
Hypothyroidism
Only the volume
status differentiates
them from the
hypovolemic
SIADH is a
diagnosis of
exclusion

CORRECTION – WHEN & HOW?
 When symptomatic
Neurological symptoms & muscle irritability seizures &
altered sensorium
 Hypovolemic hyponatremia of non renal origin -
Treatment involves NS infusion to correct
Hyponatremia & volume deficit
 Hypervolemic hypo Na-
Treatment involves fluid restriction upto 1000ml (NS)
& use of spironolactone 100mg bd or qid
 Hypothyroidism -
Treatment is starting the patient on thyroxine
replacement and gradual correction of sodium with
saline

CORRECTION – HOW MUCH?
 Na⁺ deficit estimation =
(0.6 x Weight in kg)×(140 – Na⁺).
 Target 20 m Eq/L above actual [Na⁺] or 130 mEq/L
 Rate 1 – 1.5 m Eq / L / hr or should not exceed 2
mOsm/kg/h
SIADH : Corrected by
 3% NaCl
 Demeclocycline 300 mg bd.
◦ Takes 1 week for onset of action
 Fluid restriction – 1000 ml / day
 3 % NaCl
given slow 100ml 6 hrly. Along with 1L NS.
Max rate of correction = 0.5 m Eq / hr. / Kg.
= 10 – 12 m Eq / Kg / day

ETIOLOGY & MANAGEMENT OF HYPONATREMIA
HYPONATREMIA ETIOLOGY TREATMENT
Iso-osmotic Pseudohyponatremia(hyperl
ipidemia &
hyperproteinemia, isotonic
infusions, lab error
Correct lipids and protein
levels
Hyperosmotic Hyperglycemia or
hypertonic infusions
Correct hyperglycemia
discontinue hypertonic
fluids
Hypovolemic-hypo-osmotic Renal losses : RTA, adrenal
insufficiency, diuretics
Extra renal : vomiting,
diarrhea, skin &lung loss
Na⁺ deficit replaced as
isotonic NS or RL and
treatment of underlying
cause
Euvolemic- hypo-osmotic H₂O intoxication, renal
failure, SIADH,
Hypothyroidism, analgesics
Thyroxine replacement &
Water restriction with Na⁺ &
saline correction
Hypervolemic- hypo-
osmotic
Urine Na⁺ < 10 : nephritic
syndrome, CHF, cirrhosis
Urine Na⁺ > 10 : iatrogenic
volume overload,
Water restriction upto 1000
ml & use of diuretics

HYPERNATREMIA
 Defined as serum Na⁺ > 145 mEq/L
 Neurologic symptoms - dehydration of brain cells
 Lab tests – SUN & Cr, Urine Na⁺ & osmolality
 An intact thirst mechanism usually prevents
hypernatremia
 Underlying disorders likely to cause hypernatremia
are
Dehydration
Lactulose / mannitol therapy
Central / Nephrogenic DI
 Excess water loss can cause Hyponatremia only
when appropriate water intake is not possible.
(inappropriate fluid therapy / esp. in unconscious
patients )

LAB FINDINGS & TREATMENT
 URINE OSMOLALITY >700 mOsm/L →
insufficient water intake, renal/extra renal water
losses
 URINE OSMOLALITY <SERUM OSMOLALITY
→DI
 Treat the cause.
◦ control hyperglycemia
◦ Discontinue offending drugs
 DI
◦ Central DI = Desmopressin

ETIOLOGY & MANAGEMENT OF
HYPERNATREMIA
HYPERNATREMI
A
HYPERVOLEMIC ISOVOLEMIC HYPOVOLEMIC
ETIOLOGY
Admn of
hypertonic Na
solutions,
mineralocorticoid
excess
Insensible skin &
respiratory loss,
diabetes insipidus
Renal losses, git
losses, respiratory
losses, profuse
sweating &
adrenal
deficiencies
TREATMENT Diuretics Water
replacement
Isotonic NaCl,
then hypotonic
saline

POTASSIUM
 Normal serum K⁺ level = 3.5 to 5.1 mEq/L
HYPOKALEMIA
 K⁺ level < 3.5 mEq should be treated
 S- K⁺ level; of 3 mEq -> Deficiency of 250 mEq
 KCl is administered at 10 mEq/L/h peripherally or
20 mEq/L/h centrally if EKG changes
 Guidelines
◦ Not > 80mEq correction per day.
◦ Not > 40mEq / pint of IVF (its highly irritant)
◦ Not > 20mEq per hour of correction

HYPERKALEMIA defined as serum K⁺ > 5.1
mEq/L
It is one of the life threatening conditions
because it can cause dysrrhythmia
Treatment is aimed at driving in K⁺ into cells
Treatment Dosage Rationale
Calcium glunocate 10-30 mL in 10% sol i.v. Membrane stabilization
Sodium bicarbonate 50 mEq i.v. Shifts K⁺ into
Glucose- insulin 1amp D50 with 5U n-
insulin
Shifts K⁺ into
Sodium polysterence 50-100g enema+50 mL
70% sorbitol & 100 mL
water
Remove excess
Dialysis Removes excess from
serum

Calcium
 Normal Ca⁺⁺ conc is 8.8 to 10.5 mg/dL
HYPOCALCEMIA ( Ca⁺⁺< 8 mg/dL[SI:
2mmol/L])
Peripheral & perioral paraesthesias
Carpopedal spasm(Trousseau’s sign)
+ve Chvostek’s sign(facial nerve twitch)
Lethargy & irritability
Abdominal pain & cramps
Prolonged QT interval on ECG
Generalized seizures, tetany, laryngospasm
 Emergency (Acute)
◦ 100 – 200mg elemental Ca⁺⁺ IV over 10mts in 50 to 100ml
5D
◦ followed by 1-2mg / Kg / hr infusion 6-12hrs.
 NON Emergencies
◦ Oral Ca supplements

HYPERCALCEMIA ( Ca⁺⁺>12mg/dL
[2.99mmol/L]
 Anorexia, nausea, vomiting, polyuria
 Constipation, abdominal pains, renal colic(stones)
 Fatigue, hypotonia, lethargy, coma
 Shortening of QT interval on ECG
 Treatment usually emergency & aimed at
◦  bone resorption – 1
◦  bone deposition – 2
◦  GIT Absorption – 3
◦  renal clearance – 4.
 Furosemide(Lasix 40 mg with NS at 300-400mL/h) diuresis
4
 Corticosteroids -1,3
 Bisphosphonates – 1
 IV phosphates – 2
 Consider hemodialysis
 Mithramycin( 25μg/kg/ i.v. over 2-3 hrs as last resort)1

MAGNESIUM
Hypomagnesemia (Mg⁺²<1.5 mEq/L)
Etiology-
◦ simulate hypocalcemia
◦ In fact, hypomagnesemia must be ruled out in any case of
refractory hypocalcemia or hypokalemia
Commonest cause is nutritional / debilitating disease/ patient
on
TPN
Clinical presentation- Symptoms of hypocalcemia+
Tremors, vertigo, convulsions, ventricular ectopy
Treatment
Oral – MgO 400 – 3200mg/day . This can cause diarrhea.
Parenteral – 1 to 2g MgSO₄ repeated 4-6 hrly.

Hypermagnesemia (Mg⁺²>3 mEq/L)
Etiology-
Rare, mostly iatrogenic – overzealous correction
Clinical presentation-
Respiratory depression, hypotension,
cardiac arrest, nausea, vomiting,
hyporeflexia, coma.
Treatment-
 Ca gluconate 15mg / Kg over 4 hrs. Calcium acts as direct
Mg antagonist.
 Consider dialysis

PHOSPHATE
Normal level – 2.5 to 4.9 mg/dL
Hypophosphatemia (Po₄³⁻< 2.5 mg/dL)
Clinical presentation-( seen in <1mg/dL)
Lethargy, hypotension, irritability,
cardiac arrhythmias, skeletal demineralization,
hemolysis, paraesthesia
Treatment-
Neutra-Phos or K-Phos 1-2 tabs (250mg PO₄ bid) for
mild cases
K-Phosphate 0.8-0.24 mmol/kg i.v. 8 hrly for severe
cases

Hyperphosphatemia ( PO₄>4.5 mg/dL)
Etiology-
 Hyperphosphatemia occurs primarily due to
defective renal clearance ; and goes hand in hand
with hypocalcemia.
Clinical picture-
Metastatic calcifications
Hypocalcemic symptoms
Management-
Treatment of primary cause (RF)
CRF – dialysis
Chelation – Ca CO₃

FLUID THERAPY…
The Goal of fluid therapy is to correct
hypovolemia with Isotonic or Hypertonic
Crystalloids, Colloids or Blood products.
Establishment of a u/o >0.5 ml/kg/hr and a
return of peripheral perfusion are good
indicators of circulating volume.
Achieved by maintaining fluid input required
under normal circumstances + Replacing the
deficit occurred peroperatively + Matching on
going losses.
The administration of intravenous replacement
fluids restores the circulating blood volume and
so maintains tissue perfusion and oxygenation.

Continue…
To replace abnormal losses of blood, plasma
or other extracellular fluids by increasing the
volume of the vascular compartment, principally
in:
 Treatment of patients with established
hypovolaemia: e.g. haemorrhagic shock
 Maintenance of normovolaemia in patients with
ongoing fluid losses: e.g. surgical blood loss.

AVAILABLE REPLACEMENT FLUIDS, COMPOSITION
& CHOICE…
Crystalloids having Molecular Wt < 8000
and low oncotic pressure; eg. Normal
saline(NS), dextrose 5%, 4%,
Hartmann's solution(sodium lactate)or
LR
Colloids having Molecular Wt >8000
and high oncotic pressure; eg. Dextran,
gelatin (Gelofusine, Haemaccel,
Hespan)
Blood products - Whole blood, fresh
frozen plasma, albumin solution, Conc

Composition of Crystalloids…
Fluid Glucose
g/L
Na⁺ mmol K⁺ mmol Cl⁻ mmol Kcal/L
D5W(5% to
50%
Dextrose in
water)
50 to 500 --- --- --- 170 to 1700
NS(0.9%
NaCl)
--- 154 --- 154 ---
D5NS
(0.9% NaCl)
50 154 --- 154 50
D5LR(5%
dextrose in
RL)
50 130 4 110 180
Lactated
Ringer
--- 130 4 110 <10
1/2NS to
1/5
NS(.45% to
.19% NaCl)
--- 77 to 31 --- 77 to 31 ---

Are excluded from the intracellular compartment
because the cell membrane is generally
impermeable to sodium.
 Cross the capillary membrane from the vascular
compartment to the interstitial compartment.
 Are distributed through the whole extracellular
compartment.
 Normally, only a quarter of the volume of
crystalloid infused remains in the vascular
compartment, therefore AS A RULE:
To restore circulating blood volume
(intravascular volume), crystalloid solutions
should be infused in a volume at least three
times the volume lost.

CRYSTALLOIDS...
Lactated Ringer’s Solution:- Sydney Ringer,
London physician in 1882 (“balanced” salt sol)
Alexis Hartmann in 1930, introduced Na-
lactate, hence named Lactated Ringer or
Hartmann’s sol in England
Formulated with an electrolyte composition
same as plasma, Lactate provides buffering
capacity
Metabolized in liver and kidney to pyurvate &
finally to HCO₃⁻+CO₂+H₂O or to
HCO₃⁻+glucose with an ↑ in plasma glucose
of 50 to 100 mg/dL.

Normal Saline (NS) is mild hypertonic. No
Ca⁺², so preferred as a diluent for tranfused
blood, as no chance of interference with citrate
anticoagulant.
Used less frequently for resuscitation from
hemorrhagic shock.
Plasmalyte-A isotonic crystalloid similar to LR, but
without Ca⁺² and acetate and gluconate instead of
lactate.
Developed for use in resuscitation and designed
to be compatible with transfused blood products.
Contains Mg⁺² offers advantage as less acidic and
closer to plasma osmolarity

COLLOIDS…
 As they tend to remain within the vascular
compartment they require smaller infusion volumes
than crystalloids. They are usually given in a volume
equal to the blood volume deficit.
 Mimic plasma proteins, thereby maintaining or
raising the colloid osmotic pressure of blood
 Provide longer duration of plasma volume
expansion than crystalloid so require smaller
infusion volumes.
 Supplementary infusions will be needed to maintain
blood volume in conditions such as:
 Trauma, Acute and chronic sepsis, Burns as
capillary permeability is increased, they may leak
from the circulation and produce only a short-lived

COMPOSITION OF COLLOIDS…
Fluid Na⁺ K⁺ Ca⁺² Cl⁻
Colloid
Osmotic
Pressure
Albumin 5% 130-160 <1 V V 27
Gelatin
(Gelofusin)
154 <0.4 <0.4 125 34
Hydroxyethy
l Starch 6%
154 0 0 154 28
Dextran 60
(3%)
130 4 2 110 22
Gelatin
(Haemaccel
)
145 5.1 6.25 145 27
Ionic
composition
of n-plasma
135-145 3.8-5.1 2.2-2.6 100-110 27

COLLOIDS…
Albumin 5% most commonly used colloid in
American Trauma care, rapidly expands plasma
volume, also associated with few side effects
and toxicities
In patients with total body fluid overload and
hypoalbuminemia (1⁰) may benefit from 25%
albumin.
Starch solutions prepared by adding polymers
of amylopectin to simple saline(Hespan) or to a
balanced salt sol (Hextend), later being more
hemostatic in some trials is becoming common
choice in American Practice. They may cause
coagulopathy at dose >20mL/kg or after about
1500 mL of total fluid admn.

 Dextrans are glucose polymers can be used alone
as a colloid volume expander or in combination with
Hypertonic Saline.
 Carries disadvantages like-They carry von-Willebrand
like effect on platelet function, also associated with HS
reactions and impaired renal functions.
 Hypertonic Saline with or without adding dextrans
has been studied extensively and a mixture of 6%
dextran 70 with 7.5% HS has been approved in
several European countries. Provides advantage as it
adds “small volume” (4ml/kg) when infused. This has
made HS popular choice for fluid resuscitation.
 Mattox et al. showed in 1991 that prehospital HSD
resulted in a survival benefit in severe injuries and ↓
infection chances.
 Coimbra et al demonstrated that HS resuscitation ↓ the
susceptibility to sepsis following hemorrhagic shock.

Crystalloids Vs Colloids
 Advantages include-
 Few side-effects
 Low cost
 Wide availability
 Efficacious
 Disadvantages include-
 Short duration of action
 Required in large quantity
 Lack of O₂ carrying
capacity
 May cause oedema
 Weighty and bulky
 Advantages include-
 Longer duration of action
 Less fluid required to
correct hypovolaemia
 Less weighty and bulky
 Disadvantages include-
 No evidence that they
are
more clinically effective
 Higher cost
 May cause volume
overload
 May interfere with
clotting
 Risk of anaphylactic
reactions

BLOOD PRODUCTS…
Transfusion with whole blood is rarely indicated,
as component therapy allows specific
deficiencies correction, allows longer storage
and reduces the risk for transfusion reactions.
However, even where quality standards are very
high, transfusion carries some risks. If standards
are poor or inconsistent, transfusion may be
extremely risky.
Blood products include-
 Packed RBC’s
 Platelets
 Fresh frozen plasma and Factor VIII, IX
 Cryoprecipitate
 Plasma protein Fractions

Packed Red Blood Cells…
 150–200 ml red cells from which most of the plasma
has been removed
 Hemoglobin approximately 20 g/100 ml (not less than
45 g per unit) & Haematocrit 55%–75%
 Indications:
◦ Preoperative anemia <9g/dl,
◦ Active bleeding, with sign & symptoms of hypovolemia
unresponsive to crystalloid or colloid infusions,
◦ Prophylactic transfusion to prevent morbidity from anemia at
greater risk for tissue hypoxia
◦ Replacement of red cells in anemics and also with crystalloid
replacement fluids or colloid solution in acute blood loss.
 Red cell suspension are prepared by adding ±100 ml
normal saline, adenine, glucose,mannitol solution to
achieve better flow rates.

Platelets…
Prior to surgical and major invasive procedures
when the platelet count is <50000 μL
Prevention or treatment of non surgical bleeding
due to thrombocytopenia and Platelet function
defects
Patient with accelerated platelet destruction with
acute blood loss.
One unit of platelets will increases platelet count
5000-10,000/mm3
Dose 1 unit of platelets per 10 kg body weight
Intraoperative bleeding increases with counts of
40,000-70,000/mm3, and spontaneous bleeding
can occur at counts <20,000/mm3

Fresh Frozen Plasma…
 Contains normal plasma levels of stable clotting factors,
albumin and immunoglobulin
 Factor VIII level at least 70% of normal fresh plasma level
 250 cc/bag(1 unit); contains all coagulation factors except
platelets
 Dose→10-15 mL/kg ↑plasma coagulation factors to 30% of
normal; fibrinogen levels ↑by 1 mg/mL of plasma
transfused; acute reversal of warfarin requires 5-8 mL/kg
of FFP. ABO compatibility is mandatory
 Replacement of multiple coagulation factor deficiencies:
e.g.
— Liver diseases
— Warfarin (anticoagulant) overdose
— Depletion of coagulation factors in patients receiving
large

Cryoprecipitate…
Prepared from fresh frozen plasma by
collecting the precipitate formed during
controlled thawing at +4°C and
resuspending it in 10–20 ml plasma
10-20 mL/bag(1 unit); contains 80-100
iu/pack factor VIII, 100 iu/pack factor vWF,
60 iu/pack factor XIII, and 150-300 mg/pack
fibrinogen
Indications include hypofibrinogenimia, von
Willebrand disease, DIC with depleted XIII

Eye to the future
1. Better Monitors- Access severity of
ischemia. Near-infrared tissue spectrometry
currently used in trauma center in ICU in
US.
2. Improved Hemorrhage Control- Locally
applied thrombotic agents(fibrin sprays,
thrombin bandages) systemic
procoagulants( fac VIIa will ↓ period of
active hemorrhage
3. Better Fluids- Blunting Perfusion Injury- Ringer’s
Ethyl Pyurvate solution & pentoxifylline

 Ringer’s Ethyl Pyurvate solution- 3-C
carboxylic acid, pyurvic acid integral
intermediary metabolism of glucose & some
amino acids. Pyurvate has advantages as a
resucitation fluid but fairly unstable. Sims et
al (Care Med 2001; 29: 1513-1518)found
that ethylated pyurvate is stable & much
more soluble in RL.
 Pentoxifylline- a methlxanthine derivative is
reported with several advantages. Improved
cardiopulmonary function in septic shock
patients and its been formulated that
hypertonic PTX (HSPTX), as opposed to RL,
would attenuate end-organ injury without
compromising hemodyanmic.

VOLUME CORRECTION
1. In Dehydrated individuals (severity)
2. In Normal recovering healthy adult (ideal)
3. According to type & rate of fluid loss
including-
Trauma, Haemorrhagic shock, Burn
4. In Pediatric patients and elderly patients
5. In special conditions including-
Renal failure, Liver Failure, Factor
deficients,
GA contraindication

IMPORTANT POINTS TO REMEMBER…
The PROTEIN SPARING EFFECT is one of the goals of
basic i.v. therapy. Admn. of glucose at least 100 mg/day
↓↓ Protein loss by more than half.
Success of Fluid Replacement is monitored by-
a) Fall in pulse
b) Rise in BP
c) Restoration of urine output
Vascular compartment is the most accessible compartment
followed by interstitial & ICC
ECF maintains shorterm regulation of BP, maintains BP
& its osmolarity prevents swelling and shrinkage of cells
(change in ECF Vol. can ↑ or ↓ BP)
Total Na⁺ load(qty. of Na⁺ and not conc.) in ECF determines
the total amount of H₂O that will be osmotically retained.

Maintenance fluid therapy is affected by-
1) Age (generally increased in children &
reduced in
old age)
2) Weight ( less in obese patients)
3) Significant fever ( Should be increased by
10%
for each degree centigrade >37⁰ C)
4) Hyperventilation & high
temperature(increased)
5) Reduced in- Hypothermia, some instances

 Fluid replacement should, if possible, match
the volume and composition of fluid lost.
 The goal of fluid therapy is to correct
hypovolemia with crystalloid, colloid or blood
products.
 Establishment of a urine output >0.5 mL/kg/hr
and a return of peripheral perfusion are good
indicators of circulating volume.

IN DEHYDRATION STATE…
 Loss of fluid from ECF compartment produces
clinical picture commonly k/as Dehydration.
 Clinical Picture-
Intravascular → Pulse pressure is↓, Tachycardia
Extracellular → Eyeball turgor ↓
Intracellular → Skin turgor at forehead/ sternum
 Classification & Assessment Management

Type Age Clinical presentation
MILD
5% Wt loss
O to 6 yrs – 5%
6 or more – 4%
Alert, Tears Normal, Thirst,
mild oliguria,
no detectable physical
signs
MODERATE
5-10% Wt loss
0 to 6 m – 10&
6m to 6 yrs – 7.5%
6 or more – 6%
Lethargic, Dry mucus
membrane, Tears ↓,
Marked thirst, oliguria,
tachycardia, slightly sunken
eyes
SEVERE
10% or more
Wt loss
0 to 6 m – 15%
6 to 6 yrs – 10%
6 or more – 8%
Loss of skin tone &
tissue turgor, Tears
absent, Mucus membrane
cracked, cold clammy
skin, Tachycardia,
sunken eyes, severe

Management…
Mild to moderate: ORT at 5 mL/min. If evidence
of bowel obstruction, ileus, or acute abdomen
exists, then intravenous rehydration is indicated
at 20-30 mL/kg (isotonic NaCl sol over 1-2 h).
Severe: 1) Initial management i.v. rapid admn. of
20 mL/kg of RL or isotonic NaCl sol.(500mL in 15
min, 500mL in next 45 min, 500mL in next 1hr)
2) Phase 2 focuses on deficit replacement,
provision of maintenance fluids, and replacement
of ongoing losses. 4, 2, 1 formula is used:
for first 10 kg, 4ml/kg/h
for next 10 kg, 2ml /kg/h
for each additional kg, 1ml/kg/h
eg. 55 kg male 40ml+20ml+35ml=95ml/kg/hr

The patient is evaluated at the end of 2 hrs.
Always look for  JVP / Basal rates / CVP if
available.
If rehydration is on correct lines, one can find u /o
increasing. If u/o doesn’t rise even with 2/3 volume
replacement, one can try (10 – 20)mg Furosemide
to r/o prerenal renal failure.
 If there is no response to diuretics, one should not
hesitate to start 5u /Kg/min of dopamine. If the kidney
doesn’t open up even with this, the patient has most
probably gone into intrinsic renal failure.
 A good urine output is an indirect indicator of
adequacy of circulation.
 In course of rehydration, if u/o > 1ml / kg / hr., patient
can be taken up for anesthesia.

Normal Healthy Patient…(Ideal example)
Maintenance or Base line Fluid requirements
Best to stick to usual 2 to 3 liters & not challenge
the kidney.
According to KG formula a 70 kg male requires
about 120mL/hr infusion rate of D51/5NS with 10
mmol KCl/Pint(500mL)
This will deliver about 3 liters of free water/day.
Role of NS (0.9%) → Major ECF cation and
constitutes nearly for 50% tonicity which is 300
mOsm/L normally.
Role of Dextrose 5% → To provide a tonicity similar
to plasma, sugar metabolizes & free water remains &
gets distributed.
K⁺ is added as it is intracellular & not readily available

 If NS is given separately than balanced
solutions can be admn. alternatively.
 NS (0.19% to 0.9%) with Dextrose 5% or
 Dextrose 5% with Lactated Ringer solution.
 Urine output consideration-
 Oliguria is common during immediate post-op
period (mostly adrenal cortex response to
stress, ↑ in ADH and aldosterone is released
in first 24 hrs and Na⁺ and water are retained.
Also GA→ Renal blood flow↓ and GFR)
 Persistent oliguria(less than 20mL/hr) related to
hypovolemia

TPN (total parentral nutrition)…
 Can meet complete calorific demand
 Associated with technical difficulties.
 If enteral feeding cannot be started for
3 PODs, TPN must be begun to meet
energy demands.

Type & rate of fluid loss including-
Trauma, Haemorrhagic shock, Burn…
Trauma can be Road Traffic Accident or
Surgical.
Management of Circulatory disorder comes
after Airway and Breathing management
Vitals Sign assessed include-
 Appearance of the patient
 Mental status
 Pulse rate (>120 mm Hg in adult)
 Blood pressure
 Capillary refill (blanch test) & Skin
perfusion(Grade III and Grade IV)
 ↓Urine output due to ↓intravascular volume

CLASS I CLASS II CLASS III CLASS IV
Blood
Loss(mL)
UP to 750 mL 750-1500 mL 1500-2000 mL >2000 mL
% Blood loss Up to 15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure Normal Decreased Decreased Decreased
Respiratory
Rate
14-20 20-30 30-40 >35
Urine output
ml/h
>30 20-30 5-15 Negligible
CNS/mental
status
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic
Fluid
replacemnet(3:
1)
Crystalloid Crystalloid Crystalloid &
Blood
Crystalloid &
Blood

Laboratory Work up…
 Ability to rapidly measure Hb, arterial blood gases and
serum lactate level is essential to any trauma center.
 Serum Lactate level and base deficit are both good
early measures of the depth of shock, and are currently
the best single markers available for the adequacy of
resuscitation.
 Base deficit is calculated from the measured arterial
PCO₂ and pH. Hb may vary but may be kept maintained at 8-
10mg/dL.
 Pressure measurement- Placement of an arterial line early
during fluid resuscitation is strongly adviced.
 Urine output- ↓ with ↓ renal perfusion. Prolonged duration
indicates renal system failure
 TEE- Best available test for assessing volume status and
cardiac function(directly reveals contractility also)

Adequate Intravenous Access…
Resuscitation depends on the ability to deliver
fluids to the intravascular space.
Current ATLS protocol recommend the
immediate placement of Two Large-bore(16 gauge
or more) peripheral IVs in any patient in
hemorrhagic shock. If not than Subclavian vein is
most common choice although femoral vein
placement is easier.
Fluid therapy matches with severe dehydration
therapy.
 As per ATLS manual LR is the first choice and NS is
the second choice.
 Plasmalyte-A designed to be compatible with blood

Lactated Ringer’s given 2L rapidly in 10-15 min
(20mL/kg for child)in case of prolonged
hypovolemic shock and then observed.
If no rise in BP upto 80-100 mm Hg, additional
fluid is given with blood with control of loss.
Initially O -ve blood(urgent), Type specific
blood(5-15 mins), then cross matched (30 mins).
Fresh Frozen Plasma(FFP) is used as volume
expander, also provides clotting factors. As a
rule, FFP is given after every 4U to 5U of blood,
especially if PRBC’s are administered. Hextend
generally used.
Platelet is administered if the count is

Still A Controversy…(Literature discussed)
Various studies include-
 Kramer et al;(1989) Trauma patients should be
resuscitated with crystalloids, whereas colloids are
effective in nonseptic, nontraumatic elective cases.
 Choi et al;(1999) found out lower mortality rate in
trauma patients who received crystalloids
compared to colloids.
 Cochrane group et al;(1998) in a study on 1419
patients found that albumin resulted in 6%
increase in the absolute risk of death compared to
patients who received only crystalloids.
 SOAP(Sepsis occurrence in Acutely Ill
patients) study;(2005) Done in Europe concluded
that albumin administration resulted in generally
worse outcomes at 30 days, especially in trauma

U.S.MILITARY TACTICAL COMBAT CASUALTY CARE
GUIDELINES FOR FLUID RESUSCITATION…
Adopted guidelines for fluid resuscitation in the
field based on the logistical advantages of
Colloid solutions (Less volume to transport).
 Condition Recommended
treatment
 Controlled hemorrhage No fluids
necessary
without shock
 Controlled hemorrhage Hespan 1000 cc
with shock

Responses to Initial Fluid Responses…
Parameter
evaluated
Rapid response Transient
response
No response
Vital Signs
Return to normal
Transient
improvement,
Recurrece of ↓ BP
& ↑ HR
Remain abnormal
Estimated Blood
loss
Minimal 10-20% Moderate and
ongoing 20-40%
Severe >40%
Need for more
crystalloid
Low High Very High
Need for Blood Low Moderate to high Immediate
Blood preparation Type & crossmatch Type-specific Emergency blood
release
Need for operative
intervention
Possibly Likely Highly likely

End Parameters of Volume Resuscitation…
Primary goal is the restoration of Oxygen into
the vital organs to sustain aerobic
metabolism. (Cardiac output and Hb% are
major determinants)
Goals of volume resuscitation-
 Cardiac index >3L/min/m²
 Oxygen uptake (Vo₂) >100mL/min/m²
 Serum lactate < 4 mmol/L
 Base deficit -3 to +3 mmol/L
 Central venous pressure=15mm of Hg

In BURN…
If burn area >15% in adult and > 10% in child
Parkland formula: Total fluid required during
the first 24 hours is as follows-
 Fluid required=
(%body burn)(body wt)4 ml
 Replace with LR solution over 24 hours, as
½ total over first 8 hrs(from time of burn)
¼ total over second 8 hrs
¼ total over third 8 hrs
Rule of Nines is followed

In Pediatrics…
 According to formula-
 Ist 10 Kg 100ml/kg/day = 4ml/kg/hour
 2nd 10 Kg 50ml/kg/day = 2ml/kg/hour
 Each Kg 20ml/kg/day =1ml/kg/hour
M² Method- 1500ml/m²/day
Assessment of a child-
 Capillary refill, pulse rate, blood pressure, skin tone
 State of fontenelle, sunken eye, dry mouth
 Specific gravity of urine (eg. 1.030 highly conc.)
 Weight loss if possible
Difference in management-
 Precise administration of the level of electrolytes
 After major surgery or trauma ↓ requirements because
fluid retention is promoted.( 1st day 50%, 2nd day 75%)

A WORD OF CAUTION…
 Plasma should never be used as a
replacement fluid.
 Plain water should never be infused
intravenously. It will cause haemolysis
and will probably be fatal.
 Dextrose (glucose) solutions do not
contain sodium and are poor
replacement fluids. Do not use to treat
hypovolaemia unless there is no
alternative.

Some Special Situations… [ARF]
 Acute Renal shutdown refers to NIL urine
output.
 Hence the fluid requirement is only to
balance the insensible loss. Which
amounts to 750ml / 70Kg / 24hrs.
 This volume is replaced as ½ NS with 5D
solution ( 5% Dextrose with 0.45% NaCl )
 During the recovery phase when the
patient produces urine, RL can be used in
a volume of ( 30 + previous hour’s urine
output) in the next hour.

Fluids in Liver Failure…
 Fluid replacement during Ascitic tapping
◦ No definite guidelines
◦ During replacement, observe neck veins and
auscultate for basal rates.
◦ fluid of choice is colloids – HES, Gelatin, FFP
 Advisable to have a CVP line in any case
of laparotomy and it should guide fluid
administration
 Every third pint of fluid should be a colloid

Blood loss Related Issues…
 In a patient with normal Hb. (> 12 gm), there
is no need to replace blood loss by
transfusion; if loss is < 20 % of circulating
blood volume( 70 ml / Kg bwt)
 To maintain BP, twice the volume of blood
loss is given as crystalloids apart from the
10ml / kg / hr. maintenance.
 If Hb < 10 gms, any blood loss to be
replaced by transfusion.
 Throughout surgery keep an eye on. u/o,
neck veins & capillary filling time.

Determing i.v. rate
 For a MAXI drip- 10 drops/ml used
thus
 10 drops/min = 60ml/h or
 16 drops/min = 100ml/h
 For a MINI drip- 60 drops/ml used thus
 60 drops/min = 60 ml/h or
 100 drops/min = 100ml/h

References
 Clinics Of North America Vol 18, No1,
Feb 08
 Bailey & Love’s Short Surgery of
practice
 Fluids & Electrolytes in the Surgical
Patients by- Carlos Pestana
 Trauma –ER & Surgical Management
–
William C. Wilson

Fluids and electrolytes in Maxillofacial Surgery

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