Fluid Management: Understanding Fluid Compartments and Requirements

History = Assessing losses of blood, urine, vomit, diarrhea, and sweat Physical exam = Measuring vital signs and identifying orthostatic changes Laboratory exam = Measuring levels of hemoglobin, sodium, urea, and creatinine Vascular access = Obtaining quickest, simplest, and safest method for fluid resuscitation

Minimal surgical trauma (orthopedic surgery) = 2-5 cc/kg/hr Moderate surgical trauma (bowel resection) = 5-10 cc/kg/hr Major surgical trauma = 10-15 cc/kg/hr Adequate organ perfusion = Urine output greater than 1.0 cc/kg/hr

Peripheral venous access = Quickest, simplest, and safest method; increased risk of infection Internal jugular vein = Most common site used intraoperatively; increased risk of neumothorax External jugular vein = Useful but technically difficult Subclavian site = Increased risk of neumothorax Femoral site = Increased risk of infection and embolism

Apply a tourniquet proximal to the site = Step 1 Choose an appropriate vein and immobilize it = Step 2 and 3 Approach the vein with the IV cannula at an angle nearly parallel to the skin = Step 6 Thread the catheter using your index finger = Step 8

2-5 cc/kg/hr = Minimal surgical trauma (orthopedic surgery) 5-10 cc/kg/hr = Moderate surgical trauma (bowel resection) 10-15 cc/kg/hr = Major surgical trauma

Fluid Management = The goal is to maintain or restore adequate organ perfusion and tissue oxygenation Pre-operative Deficit = Equals basal fluid requirement plus other losses occurring during the pre-operative period Intra-operative losses = Includes blood loss assessment and correction of deficits prior to induction Maintenance Requirements = Calculated using the '4/2/1 rule' and increased in febrile patients

Vascular Access = Part of the assessment of fluid status Assessment of Fluid Status = Involves evaluating peri-operative fluid requirements Types of Fluid = Covers pre-operative deficit and intra-operative losses Blood Loss Assessment = Involves inspecting blood in suction bottles, on drapes, and on the floor

Peri-operative Fluid Management = Covers pre-operative deficit, ongoing maintenance requirements, and intra-operative losses Ultimate Consequence of Inadequate Fluid Management = Hypovolemic shock resulting from insufficient organ perfusion and tissue oxygenation 4/2/1 Rule = Used for calculating maintenance requirements of fluids Febrile Patient Management = Increases maintenance requirements by 10% per degree Celsius elevation in temperature

Basal Fluid Requirement = Part of the pre-operative deficit calculation Third Space Loss = Considered in peri-operative fluid management for ongoing maintenance requirements Delayed Surgery Indication = Recommended if half of the pre-operative deficit cannot be corrected prior to induction Adequate Organ Perfusion = The goal of fluid management

Estimated Blood Loss = Determines if surgery should be delayed if it exceeds 50% of the estimated blood volume Hypovolemic Shock = The ultimate consequence of inadequate fluid management Elevated Temperature = Increases febrile patient's maintenance requirements by 10% per degree Celsius Induction Preparation = Requires correction of half of the pre-operative deficit before initiating anesthesia