Fluid Management during surgical procedure

 

·        preoperative fluid management:

 Use Ringer's lactate or Hartmann's when a crystalloid is needed for resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.

·         Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It should not be used in resuscitation or replacement fluids. Adult maintenance fluid requirements are Na 50-100 mmol/day and K 40-80 mmol/day in the 1.5-2.5L fluid per day.

·         Patients for elective surgery should NOT be nil by mouth for >2 hours (unless has a disorder of gastric emptying).

·         Patients for elective surgery should be given carbohydrate-rich drinks 2-3h before. Ideally, this should form part of a normal pre-op plan to facilitate recovery.

·         Avoid mechanical bowel preparation:

•         If bowel prep is used, simultaneous administration of Hartmann's or Ringer's lactate should be considered.

•         Excessive fluid losses from vomiting should be treated with a crystalloid with potassium replacement. 0.9% of N.Saline should be given if there is hypochloraemia. Otherwise, Hartmann's or Ringer lactate should be given for diarrhea/ileostomy/ileus/obstruction. Hartmann's should also be given in sodium losses secondary to diuretics.

•         High-risk patients should receive fluids and inotropes.

•         An attempt should be made to detect pre or operative hypovolaemia using flow-based measurements. If this is not available, then clinical evaluation is needed i.e. JVP, pulse volume, etc. Blood loss or an infection causing hypovolaemia should be treated with a balanced crystalloid or colloid (or until blood available in blood loss). A critically ill patient is unable to excrete Na or H20 leading to a 5% risk of interstitial edema. Therefore 5% dextrose, as well as a colloid, should be given.

•         If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes (NICE Guidance CG 174).

 

 

Intra-operative fluid management:

Recommendation:

The latest set of NICE guidelines produced in 2013 relating to intravenous fluids did not specifically address the requirements of intraoperative fluid administration. The reason for this is that administration of fluids in this specific situation does not lend itself to rigid algorithms. With the introduction of enhanced recovery programs 10 years ago there was an increasing emphasis on the concept of fluid restriction. Historically, patients received very large volumes of saline rich solutions peri-operatively. Clearing the sodium load of a single liter of saline may take up to 36 hours or more. This can have deleterious effects on the tissues including the development of edema. This results in poor perfusion, increased risk of ileus, and wound breakdown. A tailored approach to fluid administration is now practiced and far greater usage is made of cardiac output monitors in providing goal-directed fluid therapy.

Intra-operative fluid management:

Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -
Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28
Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -
Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28

 

Post-operative fluid management:

In the UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post-operative patients received enormous quantities of IV fluids. As a result, they developed hyperchloraemic acidosis. With a greater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hartmans) is now favored over normal saline.

The other guidance includes:

• Fluids given should be documented clearly and easily available

• Assess the patient's fluid status when they leave the theatre

• If a patient is hemodynamically stable and euvolemic, aim to restart oral fluid intake as soon as possible

• Review patients whose urinary sodium is < 20

• If a patient is oedematous, hypovolaemia if present should be treated first. This should then be followed by a negative balance of sodium and water, monitored using urine Na excretion levels

• Solutions such as Dextran 70 should be used with caution in patients with sepsis as there is a risk of developing an

acute renal injury.