1. MUDr. Štefan Trenkler, PhD. I. KAIM UPJS LF a UNLP Košice Water balance, infusions Košice 2012

2. Distribution of body fluids and the Na & K concentrations in the body water compartments Lobo DN: Physiological Aspects of Fluid and Electrolyte Balance, 2002 42 l = 28 + 14 (3,5 + 10,5) litres

4. Fluid balance

6. Water, electrolytes homeostasis Adequate volume of circulating plasma = normal tissue perfusion ECF volume ~ total body Na + content Kidney – filtration, reabsorbtion of water, Na + Hormones – renin, aldosteron, ADH; ANP Potassium

7. Na+: 1,5 mmol/kg/d K+: 1 mmol/kg/d

8. Homeostasis disturbances Water – hyper and dehydratation Osmolality (Na) – hyper a hypoosmolality Oncotic disturbances Ions disturbances ABG disturbances

9. Osmotic pressure Osmotic pressure is force per area that prevents water from passing through membrane!

10. Osmotic pressure (e.g. erytrocyte)

12. Fluid input Maintaining the IC and EC fluid volume 1. Basic requirements (30 ml/kg/d) (1000 ml NS 0.9%; 2000 ml free water (Glu); 60 mmol KCl) 2. Pre-existing deficit (signs of dehydratation/hypovolemia - assessment) 3. Additional losses

13. Hydratation status, intravascular volume assessment History Physical examination (P, BP, RR, CR, MM, diuresis) Tests results (Na, K, osmolality, HTC, urea) Patient response to the fluid administration (physiological parameters) (10 – 20 ml NS 0.9%/kg)

14. Hypovolemia (fluid depletion) Hypotension MAP<65 mm Hg, tachykardia  Diuresis  body weight MAC (MLAC)  CVP  PAWP  LVEDP (TEE)

15. Distribution of infused fluids in the body water compartments Lobo DN: Physiological Aspects of Fluid and Electrolyte Balance, 2002

16. Crystalloids composition

17. Colloids Natural Plasma 5 % (frozen) Albumin 4,5 %, 20 % Synthetic Gelatine Dextran 40, 70 Hydroxyetylstarch – HAES, Voluven,

18. Crystalloids vs colloids No differences in clinical outcome More oedema with crystalloids More rapid replacement with colloids (permeability) Risk vs benefit; cost Newer (better) HEAS? Mixture of C&C

19. Fluid replacement Loss of 1 liter of blood: Replacement: 1 l of blood or 1 l of colloid (IV) or 4 l of crystalloid (EC) or 12 l of glucose (IV + EC + IC) Distribution volumes of fluids ! Speed of looses Replace what is lost Volume vs haemoglobin Oral/GI route has preference!!!

20. Guidelines for transfusion of red cells AAGBI 2001 Normally patients should not be not transfused if the haemoglobin concentration is >100 g/l. A strong indication for transfusion is a haemoglobin concentration <70 g/l. Transfusion will become essential when the haemoglobin concentration decreases to 50 g/l. A haemoglobin concentration between 80 and 100 g/l is a safe level even for those patients with significant cardiorespiratory disease. Symptomatic patients should be transfused

21. Transfusion trigger HB (g/L)Clinical situation 100Acute coronary syndrome 90Stabile heart failure 80Aged, vascular surgery, sepsis 70All other patients

22. Blood transfusions In the meantime – complex decision; prudent and conservative management, based on: - awareness of risks - individual haemoglobin level (70-100 g/L) - clinical judgement based on the sound understanding of the normal and pathological physiology - normovolaemia Unit-by-unit basis (1 u ~  15 g/l), re-evaluation Departmental/hospital guidelines; regular audit Haemovigilance system

23. Fluid regime 1.Preoperative deficits 2.Maintenance fluids 3.Blood loss 4.Losses to the third space

24. Situation Blood volume: 70 ml x 80 kg = 5600 ml Blood loss: 20% ~  25-30 g/l = 90 g/l

25. End