Table of Contents
1 Normal Water Balance 1
Water homeostasis 1
Distribution of total body water 1
Regulation of total body water 2
Regulation of total body water 3
2 Distribution of Body Fluid 38
Units of measurement 38
Osmoles 38
Basic concepts of osmotic activity 38
Difference between osmolality and tonicity 40
Clinical significance of tonicity 40
Osmotic pressure 41
Colloid osmotic pressure 41
Effective osmotic pressure 41
Osmosis 41
Compartmental distribution of total body water 43
Intracellular fluid 45
Extracellular fluid 45
Clinical importance of negative pressure in the interstitial space 49
Summary of total body water 51
Summary of water control in the body 52
3 Pharmacology of Crystalloids 53
Crystalloids 53
Mechanism of actions of crystalloids 55
Types of solutions 55
5% Dextrose 55
Normal saline (isotonic saline) or 0.9% NaCI 59
Dextrose saline (5% Dextrose and 0.9% NaCI) 67
Ringer's lactate 61
Isolyte P 63
Electrolyte contents of commonly used crystalloid intravenous fluids 64
4 Pharmacology of Colloids 66
General characteristics of colloids 66
Types of colloidal plasma substitutes 69
Functions of colloid plasma substitutes 70
Indications of colloids 70
Human albumin 71
Functions of albumin in health 73
Metabolism 73
Albumin in critical illnesses 74
Indications for the infusion of albumin 74
Dextran 79
Types of dextran 79
Clinical effects and advantages 80
Dextran 40 84
Dextran 70 85
Gelatin solutions 86
Haemaccel 93
Gelofusine 95
5 Pharmacology of Hydroxyethyl Starch 99
General pharmacological properties of HES 99
Degree of volume expansion 104
Nomenclature of HES 104
Summary of general pharmacological properties of HES 105
Metabolism of HES 106
Disadvantages 106
Special precautions 112
Clinical uses of hydroxyethyl starch 112
Advantages of HES 113
Evaluation of HES 113
First-generation HES-Hetastarch-HES 450/0.7 113
Second-generation HES-Pentastarch HAES-Steril (200/0.5)-3%, 6%, 10% 114
Third-generation HES:Tetrastarch 117
Pharmacodynamics 117
Pharmacokinetics 118
Indications and clinical use 119
Contraindications 119
Warning and precautions 119
Adverse reactions 120
Tetrastarch in special patient groups 121
Effects on microcirculation and oxygenation by tetrastarch 121
Effects on systemic inflammation and endothelial activation by tetrastarch 122
Characteristics of some available colloids 126
Tetrastarch v/s pentastrach: summary 126
6 Current Consensus on Crystalloids and Colloids in the Perioperative Period 128
Colloid solutions 128
Crystalloid solutions 129
Clinical significance of reflection coefficient 129
Points to remember 129
Accepted statements of colloid/crystalloid 130
Current controversies of fluid and volume management 130
7 Fluid Replacement Therapy 136
Types of fluid used for volume replacement 136
Osmosis 137
Practical fluid balance 137
Mechanism of action of fluids 139
Points to remember 140
Resuscitation of body spaces with various solutions 141
General principles of fluid replacement 141
Perioperative fluid therapy 142
Assessment of daily fluid requirement 143
Maintenance fluids 143
Goals of intraoperative fluid administration 144
Replacement fluids 144
Hole in the bucket analogy 149
8 Perioperative Fluid Therapy in Infants and Children 150
Fluid therapy in infants and children 150
Important differences between infant, children and adult 150
Important points for calculating the fluid requirement 154
Assessment and correction of any fluid deficit 155
Maintenance fluids 155
Neonatal maintenance fluid requirement 155
Infants and older children maintenance fluid requirement 156
Important facts about administering dextrose solutions 156
Avoid dextrose 4% or 5% 157
Fluid and dextrose management during surgery 157
Important points to remember regarding calculation of fluids in infant and children 158
Management of perioperative fluid therapy 159
Important points to remember in perioperative fluid management 159
Importance of composition of intravenous fluids 159
Goals of perioperative fluid administration 161
Preoperative management 161
How to evaluate preoperative deficit 163
Important key points 173
9 Fluids Therapy in Trauma Resuscitation 174
The golden hour 174
Goals of fluid administration 175
Types of fluids for volume replacement 175
Choice of fluids in various conditions 175
Oxygen transport in the high-risk or critically ill surgical patient 180
Route and rate of fluid administration in various conditions 180
End point of fluid therapy and monitoring 181
Measure of preload-central venous pressure 181
Complications of transfusion 182
10 Fluid Therapy in Fever 183
Definition of fever 183
Important facts about fever 183
Temperature control by the hypothalamus 184
Resetting the hypothalamic temperature-regulating centre in febrile diseases 184
Mechanism of action of pyrogens in causing fever-role of interleukin-l 184
Effects of changing the set-point of hypothalamic temperature controller 185
Crisis or flush 186
Fever caused by brain lesions 186
Postoperative fever 187
Clinical significance of fever 187
Assessment 190
Management 190
Assessment for fever when infection is suspected 190
Management for fever when infection is suspected 190
Points to remember before administering anaesthesia 191
Mechanism of action of antipyretics 191
Goals for anaesthetising patients having fever 192
11 Fluids in Intestinal Obstruction 195
Problems faced by anaesthesiologist with intestinal obstruction 195
Systemic derangements with intestinal obstruction 195
Approach towards a patient with intestinal obstruction 200
Preoperative preparation 202
Assessment of adequacy of fluid replacement 205
Important points to remember 205
Clinical response of the patient after infusion of fluids 205
Benefits of volume loading 205
12 Fluid Management in Neurosurgical Patients 206
Principles of water movement across blood-brain barrier (BBB) 206
Basics of fluid movement in the CNS 208
Basic concepts of perioperative management of fluids 214
Intraoperative fluid management of neurosurgical patients 215
Use of hyperosmolar fluid for cerebral dehydration 218
Fluid management in neurosurgical patients under special circumstances patient for craniotomy 222
Fluids during aneurysmal surgery 222
Fluids in patients with diabetes insipidus with traumatic brain injury 223
Fluids in postoperative and neurointensive care units 224
Newer developments 225
13 Fluid Therapy in Traumatic Brain Injury 227
The "Lund concept" for TBI 227
Fluid resuscitation in traumatic brain injured patients 229
Basic concepts in fluid management in traumatic brain injury patients 230
Focus on preventing further injury in traumatic brain injury patients 230
Summary of choice of fluids 238
14 Fluid Therapy in Pre-eclampsia and Eclampsia 239
Incidence of pre-eclampsia 239
Definition of pre-eclampsia 239
Definition of proteinuria 239
Classification of pregnancy induced hypertension 240
Pathophysiology 241
Effects on various systems 242
Clinical importance of oxygen delivery 246
Choice of analgesia/anaesthesia in pre-eclamptic patients 246
Fluid therapy in pre-eclampsia 246
Basic concepts of prehydration 247
Safety precautions while prehydrating patient 247
Prehydration before regional anaesthesia 248
Precautions before initiation of regional analgesia 248
Fluid management in pregnant patients in specific conditions 249
Important points to remember for selecting fluids in PET patients 251
Goals of fluid management in pregnant patients with pre-eclampsia 252
Current consensus in fluid therapy in PET 253
Assessment of renal function and fluid balance 254
Management of acute pulmonary oedema (APO) 254
Care of pre-eclamptic patients after parturition 255
15 Fluid Management in the Ventilated Patient 256
Physiological considerations 256
Homeostatic responses to maintain plasma volume 257
The influence of positive pressure ventilation on fluid balance 260
Summary of IPPV and PEEP on water balance 261
The Starling equation 261
Factors which help to prevent alveolar oedema 263
Goals of fluid management in the ventilated patient 264
Maintenance fluids 265
Clinical applications of central venous pressure (CVP) or pulmonary artery occlusion pressure (PaOP) 266
Replacement fluids 267
Resuscitative fluids 267
Choice of resuscitation fluids 267
Monitoring fluid therapy 272
Minimally invasive methods 273
Invasive measures 274
Conclusion 275
16 Calculation of Fluids 276
Drop rate calculation of fluid 276
Calculations for drug infusions 276
Index 279
