1. By:
Iis Martilopa (04104705051)
Olia Indri Saktianingsih (04104705085)
Yarah Azzilzah (04104705264)
Advisor:
Dr. Endang Melati Maas, Sp. An, KIC. KAP

2.  Fluid is the largest part in body.
 The total amount of body fluid volume and
solute, as well as concentration are relatively
constant during steady-state condition.
 Disturbances of composition and volume of
body fluid is one of the most common clinical
problems and important.
 Large disturbances of fluid and electrolyte
balance may quickly lead to changes in
cardiovascular function, neurological, and
neuromuscular

3.  Fluidis the largest part in body.
 TBW (Total Body Water) may change, depending
on age, gender, & degree of obesity
Age Percentage of TBW
Depending on Body weight
Infant 75%
Male(20-40 years old) 60%
Female(20-40 years old) 50%
Geriatrics(> 60 tahun) 45-50%

4.  Fluid
intake comes from: Oral Fluid, Solid
Foods & Oxidative Metabolism.
 Fluid loss
 Insensible Water Loss
 Fluid loss through skin
 Fluid loss through GI tract
 Fluid loss through kidney

5. Fluid Intakes Fluid Loses
Oxidative Metabolism 300 ml Kidney 1200-1500 ml
Oral Fluid 1100-1400 ml Skin 500-600 ml
Solid Foods 800-1000 ml Lungs 400 ml
GI tract 100-200 ml
Total 2200-2700 ml Total 2200-2700 ml

7. Compartment Fluid as Total Body Fluid
percent body Water (%) Volume (L)
weight (%)
Intracellular 40 67 28
Extracellular
Interstitial 15 25 10,5
Intravascular 5 8 3,5
Total 60 100 42

8. TRANSCELLULAR FLUID ( ± 1 – 2 L )
 Cerebrospinal fluid
 Pleura fluid
 Pericardium fluid
 Peritoneum fluid
 Sinovial fluid

9. WATER
ELECTROLYTE
Na+
K+
BODY FLUID PO4 -
Cl-
dll
SOLUTE
NON
ELECTROLYTE
Protein
Urea
Kreatinin
Glukosa

10.  ECF, including plasma & interstitial fluid,
contain sodium & chloride ions in large
amount, bicarbonate ions are also in large
enough quantities, but only a few ions of
potassium, calcium, magnesium, phosphate,
and organic acids.
 ICF only contains a few amount of sodium
and chloride ions and almost no calcium ion.
In fact, this fluid contains a large amount of
potassium ions, phosphate, and proteins.

11. Extracellular
Gram- Intracellular Intravascular Interstitial
Molecular (mEq/L) (mEq/L) (mEq/L)
Weight
Sodium 23.0 10 145 142
Potassium 39.1 140 4 4
Calcium 40.1 <1 3 3
Magnesium 24.3 50 2 2
Chloride 35.5 4 105 110
Bicarbonate 61.0 10 24 28
Phosphorus 31.01 75 2 2
Protein (g/dL) 16 7 2

12.  Osmosis is the net movement of water across
a semipermeable membrane as a result of
difference in non diffusible solute
concentration between the two side.
 Osmotic pressure is the pressure that must
be applied to the side with more solute to
prevent a net movement of water across the
membrane to dilute the solute.
 Osmotic pressure is generally dependent only
on the number of nondiffusible solute
particles.

13.  The osmolarity of the solution is equal to the
number of osmoles per liter of solution.
 The osmolality equals the the number of
osmoles per kilogram of solvent.
 Tonicity refers to the effect a solution has on
cell voluume.
 An isotonic solution has no effect on cell
volume, whereas hypotonic and hypertonic
solution increase and decrease cell volume
respectively.

14. 1. VOLUME CHANGE
- volume depletion
- volume overload
2. CONSENTRATION CHANGE
- Hyperosmolality & hypernatremia
- Hypoosmolarlty & hyponatremia
- Pottasium disturbance
- Calcium disturbance
- Phosphor disturbance
- Magnesium disturbance

15.  The condition that is caused by depletion of
extracellular fluid.
 The most common cause of volume depletion is
diarrhea or vomiting. The other causes include
trauma, infection, inflamation, bleeding, burns,
etc.
 Volume depletion is devided into 3 types based
on the blood sodium level:
- Isonatremic (normal blood sodium levels)
- Hyponatremic (abnormally low blood
sodium levels)
- Hypernatremic (abnormally high blood sodium
levels)

17.  Volume overload is the condition that can be
caused by iatrogenic or secondary of renal
insuffiency, sirosis or congestive heart
failure.
 Edema is the indication of volume overload
in tissues.
 Classification of edema : Intracelullar Edema
& Extracelullar Edema

18. 1. Sodium Disturbance
Hyperosmolality & Hypernatremia
 Hypernatremia is nearly always the result of
either a loss of water in excess of sodium or
retention of large quantities of sodium
 Clinical Manifestation: restless, lethargy, and
hyperreflexia can progresss to seizures, coma,
and ultimately death.
 Treatment of hypernatremia is aimed at
restoring plasma osmolality to normal as well
as correcting the underlying problem.

19.  Water deficit should generally be corrected
over 48 h with hypotonic solution such as
D5W.
 Hypernatremic patients with decreased
total body sodium should be given isotonic
fluids to restore plasma volume.
 Hypernatremic patients with increased total
body sodium should be treated with loop
diuretic along with intravenous D5W.

20. Hypoosmolality & Hyponatremia
 Hyponatremia invariably reflects water retention from
either an absolute increase in TBW or loss of sodium in
excess of water.
 Clinical Manifestation : anorexia, nausea, weakness.
Progressive cerebral edema, however result in
lethargy, confusion, seizures, coma and finally death.
 Treatment of hyponatremia:
Na+ Deficit = TBW x (desired Na [Na+] – present [Na+])
 Very rapid correction of hyponatremia has been
associated with demyelinating lesion in pons.
 The correction rate : :0,5 meq/L/horless (mild
symptom); 1 meq/L/h or less (moderate symptom); and
1,5 meq/L/h or less (severe symptom).

21. 2. Potassium Disturbance
Hyperkalemia
 Hyperkalemia exsists when plasma [K]
exceeds 5,5 meq/L
 Hypercalemia can result from (1) an
intercompartmental shift of potassium ions
(2) decreased urinary excretion of potassium
or rarely (3) an increased potassium intake.
 Clincal manifestation involves CNS
(paraesthesia, skeletal weakness) and
cardiovascular system (dysrhytmia, ECG
changes).

22.  Treatment of hyperkalemia:
 Treatment is directed at reversing cardiac
manifestation, anda skeletal muscle
weakness and restoring of plasma K to
normal
 calcium 95-10 ml of 10% calcium gluconate or
3-5 ml of 10% calcium chloride) partially
antagonizes the cardiac effects of
hyperkalemia and is useful in patients with
marked hyperkalemia.

23. Hypokalemia
 Is defined as plasma [K+] less than 3,5 mEq/l.
 Hypokalemia can occur as result of (1)
intercompartmental shift of K+ (2) increased
potassium loss or (3) an inadequate potassium intake.
 Clinical Manifestation : abnormality of ECG, sketetal
muscle weakness, muscle cramping, tetany, and
rarely rhabdomyolisis.
 Treatment of hypokalemia:
- oral replacement with potassium chloride solution is
generally safest (60-80 mEq/d).
- intravenous replacement of potassium chloride
should usually reserved for patient with or risk for
serious cardiac manifestation or muscle weakness

24. Fluid management is aimed to replacement of
water and electrolyte depletion, shock
therapy, and solves another abnormalities
that occur because of therapy.
Intravenous fluid management, consists of:
- Crystalloid Fluid
- Colloid Fluid
- Combination both of them

25.  This fluid has composition that is similar to ECF.
 Crystalloid solutions are aqueous solutions of low
molecular-weight ion (salts) with or without
glucose..
 Half time of crystalloid solution in intravascular
is about 20-30 minutes.
 Crystalloid should be considered as resuscitation
fluid in patients with hemorrhagic and septic
shock, in burn patients, in patients with head
injury to maintain cerebral perfusion pressure,
and in patients undergoing plasmapharesis and
hepatic resection.

26.  If 3-4 l of crystalloid has given, and
hemodynamic responses inadequate, colloid
may be added.
 Solution are chosen according to the type of
fluid loss being replaced.
 For loses primarily involving water 
hypotonic solution  maintenance type
solution
 If loses involve both water and electrolyte 
isotonic solution  replacement type
solution.

27.  The most commonly used fluid is lactated
Ringer’s solution.
 When NS is given in large volume, can
produces a dilutional hyperchloremic acidosis
because of its high sodium and chloride (154
mEq/l).
 NS is the preferred solution for
hypochloremic metabolic alkalosis and for
diluting PRC prior to transfusion.
 D5W is used for replacement of pure water
deficits and as a maintenance fluid for
patients on sodium restriction.
 Hypertonic 3% saline is employed in therapy
of severe symptomatic hyponatremia.

29.  Colloid is called as plasma replacement fluid
or usually called “plasma substitute” or
“plasma expander”
 The osmotic activity of high molecular
weight substances in colloid tends to
maintain these solution intravascularly.
 Most colloid solutions have intravascular half-
lives between 3-6 h.

30.  Generally accepted indicatons for colloid
include:
1.Fluid resusitation in patients with severe
intravascular fluid deficit (eg. Hemorrhagic
shock) prior to the arrival of blood
transfusion.
2.Fluid resusitation in the presence of severe
hypoalbuminemia or condition associated
with large protein losses such as burns.

33. Perioperative fluid therapy includes
replacement of preexisting fluid deficits of
normal losses (maintenance requirements),
and surgical wound losses including blood
loss.

34.  Normal Maintenance Requirements
in the absence of oral intake, fluid & electrolyte deficits
can rapidly develop as result of continued urine
formation, gastrointestinal secretions, sweating and
insensible loses from skin and lung.
Weight Rate
For the first 10 kg 4 ml/kg/h
For the next 10-20 kg add 2 ml/kg/h
For each kg > 20 kg add 1 ml/kg/h
Eg: what are the maintenance fluid requirements for 25 kg
child? 40 + 20 + 5 = 65 ml/h

35.  Preexisting deficit
 Patients presenting for surgery after an
overnight fast without any fluid intake will have
a preexisting deficit proportionate to the
duration of the fast.
 Preexisting deficit = normal maintenance rate
x length of the fast
 Eg : for average 70 kg, fasting for 8 h, this
amounts to (40+20+50)ml/h x 8 h = 880 ml
 Fluid is given ½ part for the first hour, ¼ part for
the next second hour, and ¼ part for the next
third hour.

36.  Intraoperative Fluid Replacement
Intraoperative fluid therapy should include
supplying basic fluid requirements and
replacing residual preoperative deficit as
well as intraoperative losses (blood, fluid
redistribution, and evaporation)

37. 1. Replacing Blood Loss
Ideally, blood loss should be replaced with crystalloid or
colloid to maintain vascular volume until the danger of
anemia outweighs the risk of transfusion.
The transfusion point can be determined preoperatively
from the hematocrit and by estimating blood volume.
Age Blood Volume
Neonates
- Premature 95 mL/kg
- Full-term 85 mL/kg
Infants 80 mL/kg
Adults
- Men 75 mL/kg
- Woman 65 mL/kg

38.  Patientswith normal hematocrit should
generally be transfused only after losses
greater than 10-20 % of their blood volume.

39. 2. Replacing Redistributive & Evaporative
Losses
Because these losses are primarily related to
wound size and the extent of surgical dissection
and manipulation procedures can be classified
according to the degree of tissue trauma
Degree of Tissue Tauma Additional Fluid Requirement
Minimal (eg hernioraphy) 0 – 2 ML/KG
Moderate ( eg cholecystectomy) 2 – 4 ML/KG
Severe(eg bowel resection) 4 – 8 ML/KG

40. Perioperative Fluid Therapy:
1. Maintenance = (4 x the first 10 kg) + (2 x the
next 10-20 kg) + (1 x each kg > 20 kg)
2. Preexisting deficit = Maintenance x length of
fasting
3. Redistributive & Evaporation (IWL) = degree of
tissue trauma x BB
The first hour = ½ part = (½ P) + M + IWL
The second hour = ¼ part = (¼ P) + M + IWL
The third hour = ¼ part = (¼ P) + M + IWL