Shaila
Shodhan Kamat
MBBS (Bom) DA (CPS College) MD (Bom) Anaesthesiology
Associate Professor Anaesthesiology Goa Medical College
Goa,
India
Forewords
Ramkumar
Venkateswaran
Muralidhar
Kanchi
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Practical Applications of Intravenous Fluids in Surgical Patients
First Edition:
2013
9789350903957
Printed at
fm4
Dedicated to
All my loving
teachers,
and
The laughing Buddha
who has brightened up my life
and put a smile on everyone's face …
My dear Aahan
You have filled space in my heart which I never knew it was empty. “I never thought I could fall in love again, until you were born.” I want you to bring the ray of happiness in everybody's life which you will come across the way you have brought for us. I want you to understand values of life which I have learned from my grandparents, parents and teachers.
Small things which I have achieved in my life are values that have been inherited from my parents and my grandparents, values that I have seen in my teachers. They taught me the value of integrity, to respect oneself and others and to be honest with oneself. Once you are honest with yourself, it does not take any effort to be honest with others.
I want you to be a good human being. Don't waste your precious energy on gossips, energy vampires, issues of the past, negative thoughts or things you cannot control. Instead, invest your energy in having fun to enjoy the positive present moment. Realize that life is a school and you are here to learn. Problems are simply part of the curriculum that appear and fade away like algebra class, but the lessons you learn will last for lifetime. “The world suffers a lot, not because of the violence of bad people, but because of the silence of good people!” Always stand for right thing even if you are alone.
I want you to promise never to break four things in your life— trust, promise, relation and heart; because when they break, they don't make noise, but pains a lot. My little one, you may not be always successful in your life but the difference between the glowing success story and the crushing failure is not luck or fate or intelligence but it is your ability to bounce back.
May the sun
always shine on your window pane
May a rainbow be
certain to follow each rain
May the hand of a
friend always be near you;
May God fill your heart with gladness to cheer you.
For being more than a teacher
A friend . . . A guide . . .
and an inspiration;
For making me find myself…
This book is dedicated to all my teachers who have taught me from childhood to postgraduation, and all those people who have taught me the meaning of life. It has always been my ardent wish to express my love and respect for them and to share with the world, how a teacher can transform her student. I would also like them to understand the meaning of unseen blessings.
In Adarsh, I met two wonderful souls—Nirmala Pradhan (Pradhan bai) and Rajani Gupte (Gupte bai). I was 10 years old then. They not only taught me their subjects but also inculcated in me the values of life, honesty, self-esteem and positive attitude.
After my SSC (class eleven), I joined Smt Parvatibai Chowgule College, Goa, India. There, I met two more wonderful teachers and human beings—Mrs Vrinda Menon (teacher) and Pradhan Sir. During the first-year science, I had a tough time in understanding subjects due to a change in medium from Marathi to English. But the two of them supported me not only in my studies but also nurtured my all-round development.
My Professor and HOD, Dr DS Dubey, was a wonderful person and teacher. He disciplined us with a loving hand and treated us like family. To my good fortune, Dr Bharati Sardessai joined as a lecturer in the Department, for a year. Even today, after more than 30 years, when I have difficulty in making a decision Dr Bharati is always there with open arms to guide me. Over the years, she has continued to be my best friend, philosopher, guide and teacher.
Dear teachers, though I would like to be a teacher like you, I know I cannot because you are a special gift from God to the thousands of students whom you have taught. If I can do for my students, even one percent of what you did for me, I will have done justice to my profession as a teacher and as an anaesthesiologist.
I take this opportunity to thank each and every person who has intrinsically touched my life and dedicate my book unto them. I feel proud to have such wonderful teachers who have blessed me from their soul to help me to be what I am today. I pray for your good health and happiness.
Forever your loving and naughty student.
Foreword
fm7Fluid therapy is one of the basic medical interventions that cuts across all medical and surgical disciplines. Patients belonging to all age groups, presenting with a multitude of disease conditions, challenge the physician and surgeon alike, with regard to the nature and quantity of intravenous fluids that they need to receive. Maintenance of the milieu intérieur is one of the important arms of the treatment that needs to be addressed before the patient is on the road to recovery. Needless to say, a physician/surgeon must understand the physiology of fluids and electrolytes before he/she can evaluate the extent to which pathophysiology of the disease has altered this delicate balance. Knowledge of the pharmacology of fluid and electrolyte solutions currently available also goes a long way in scientific prescription of fluids and electrolytes.
I am truly impressed with the simple yet comprehensive approach that Dr Shaila Shodhan Kamat has adopted in writing this Practical Applications of Intravenous Fluids in Surgical Patients. She has covered physiology, pathophysiology, pharmacology as well as clinical medicine with equal expertise. Years of clinical and teaching experience have been culled to present this rather complex information in an eminently readable format. The spectrum of topics chosen as well as the depth of coverage will make this book a very useful companion, not only to the beginners but also to the advanced practitioners of medicine.
I congratulate Dr Shaila Shodhan Kamat on her authoring this elegant treatise on intravenous fluids. I am sure that this book will, in no time, become a must-read for physicians and surgeons, especially those in the fields of anaesthesiology, surgery, intensive care and emergency medicine.
Ramkumar Venkateswaran MD
Professor of Anaesthesiology
Kasturba Medical College
Manipal University Karnataka, India
Forword
fm8Intravenous fluid therapy is an essential component of management of patients in operating rooms and intensive care units. Intravenous route of the fluid administration is the most efficient way to deliver fluid and medications throughout the body. Fluid, thus, administrated must be appropriately prepared with the correct composition to suit the needs of a particular patient. Needless to say, the nature, amount and speed of intravenous fluid administered is influenced by age, disease condition and other patient characteristics.
This textbook is a compendium of recent knowledge about the various kinds of intravenous fluids available and the technique of administration. The book has been written by a well-known teacher, Dr Shaila Shodhan Kamat who has dedicated time and effort to provide the readymade information on a rather confusing and difficult topic. The book is expected to help health care professionals across the disciplines of anaesthesia, surgery, general medicine, paediatric medicine, intensive care medicine and nursing.
I congratulate Dr Shaila Shodhan Kamat for having brought out the book for the benefit of medical practitioners.
I recommend the book to be read not only by postgraduate students of anaesthesia but also Fellows, residents, teachers and faculty of intensive care medicine. I wish good luck to Dr Shaila Shodhan Kamat in this venture and in future ventures too!
“I expect to pass through life but
once. Therefore, if there be any kindness I can show,
or any good thing I can do to any fellow
being, let me do it now, and not defer or
neglect it, as I shall not pass this way again.”
—William Penn
Muralidhar Kanchi MD MBA
Director (Academic)
Chief Consultant and Professor
Anaesthesia and Intensive Care
Professor of International Health
University of Minnesota, USA
Narayana Hrudayalaya Hospitals
Anekal, Bengaluru, Karnataka, India
Preface
Love the people who treat you right.
Forget about the ones who don't.
Believe that everything happens for a reason.
As a medical student, both during my graduation and postgraduation, I struggled to understand the topic of intravenous fluids. I found it to be a difficult, complicated and boring topic. Ironically, when I joined as a Consultant in the Department of Anaesthesiology, I had to teach my PG students, the very same topics that I had difficulty understanding during my PG days. After I started taking lectures on intravenous fluids as well, I received a request from my friends (fellow anaesthesiologists) to take Continuing Medical Education (CME) for them as well. Hence, Dr Marilyn Nazareth, Head, Department of Anaesthesiology, organised a CME on intravenous fluids for all the doctors practicing in Goa, India. This was attended by doctors from all specialities in large numbers.
The CME was being highly appreciated by the delegates, who found the difficult topic being made simple and interesting. Following the success of the CME on intravenous fluids, my fellow anaesthesiologists, students and friends insisted upon and encouraged me to start work on a book about intravenous fluids. My former students too were encouraging me, through e-mails, to write this book. Egged by everyone, I began work on this Herculean task two years ago in 2010. My first book on Mechanical Ventilation has been highly acclaimed by junior and senior doctors, all over India. The book was later published by McGraw-Hill internationally, which gave moral support to write the book.
The health care field today is in critical need of skilled professionals to care for patients who require intravenous fluids for diagnostic and therapeutic purposes. Intravenous fluids are a cornerstone in the treatment of any patient. Perioperative management of surgical patients with intravenous fluids is the responsibility of the anaesthetist, but many others, including the surgeons, must be oriented with the principles that guide the therapy. The amount of fluid infused has been shown to significantly affect the morbidity and outcome of the postoperative period. Another important insight is that guiding fluid therapy by dynamic haemodynamic measures, reduces the risk of postoperative complications.
The book does not have the ambition to provide full coverage of all special fields of surgery in which fluid therapy is being used but is an attempt to provide an easy to understand, practical guide to intravenous fluid use.
Shaila Shodhan Kamat
fm10
Acknowledgements
If you look for good, you'll find good.
If you look for bad, you'll find bad.
In life, you always find what you look for.
The only thing that matters is - what you choose to see.
Publishing a book is no mean task. Nor is it possible without the support of many hands. Though not possible to name each and every one here, I take this opportunity to acknowledge a few who saw me through this arduous but highly fulfilling task.
I am fortunate to have received valuable suggestions and to have had the forewords written by Dr Ramkumar Venkateswaran and Dr Muralidhar Kanchi. Both are not just the greatest anaesthesiologists of the times, but also wonderful human beings. My gratitude unto them.
Many thanks to my sister Rukma Naik and my daughter Salonee Hitesh Jain for meticulously improving the text and to my younger daughter Asmani Venkatram Shirgaonkar for the beautiful cover design. Dr Marilyn Nazareth Professor and Head, Department of Anaesthesiology, Goa Medical College, Goa, India, has always provided unflinching support for my academic growth. To her, I will remain ever grateful.
A special appreciation to my mother Rekha Naik for her constant, unconditional support, and to my uncles late Mr Anant (Babu) Naik and Damodar N Naik for their love and protection which they have showered on me throughout my life.
Behind every successful woman is the helping hand of her husband, children and siblings. I whole-heartedly appreciate the support and patience of my husband Dr Shodhan, and my loving sister Nita Sudil Manerkar.
My sincere thanks to Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing this book.
The book would not have been completed without the support of my friends and well-wishers, who are too numerous to mention individually. I am thankful to all my students (past and present) whose love, inspiration and whole-hearted admiration for my teaching has been a great positive force for my continuous academic and spiritual growth.
Though I am not an overtly religious person, I have always felt God's presence in my life and without His kind hand guiding me, the book would not have seen light of day.
fm11Abbreviations
ABG —
Arterial blood gas analysis
ACE —
Angiotensin converting enzyme
ADH —
Antidiuretic hormone
ADP —
Adenosine diphosphate
AHF —
Anti haemophilic factor
AHH —
Acute hypervolaemic haemodilution
AKI —
Acute kidney Injury
ALI —
Acute lung injury
ALT —
Alanine aminotransferase test
ANH —
Acute normovolaemic haemodilution
ANP —
Atrial natriuretic peptide
APO —
Acute pulmonary oedema
ARDS —
Acute respiratory distress syndrome
ARF —
Acute renal failure
AST —
Aspartate amino transferase test
AVP —
Arginine vasopressin
BBB —
Blood brain barrier
BNP —
B-type or brain natriuretic peptide
BSS —
Balanced salt solution
BV —
Blood volume
CBV —
Cerebral blood volume
Cl —
Chloride
COP —
Colloid osmotic pressure
COX —
Cyclo-oxygenase
CPM —
Central pontine myelinolysis
CSF —
Cerebrospinal fluid
CSW —
Cerebral salt wasting
CVP —
Central venous pressure
Da —
Dalton
DC —
Differential count
DDAVP —
1-Desamino-8-D-arginine vasopressin
DI —
Diabetes insipidus
DIC —
Disseminated intravascular coagulation
DO2 —
O2 delivery
DS —
Degree of substitution
EBL —
Estimated blood loss
EBV —
Estimated blood volume
ECF —
Extracellular fluid
ECFV —
Extracellular fluid volume
ECG —
Electrocardiogram
ECS —
Extracellular space
EFD —
Estimated fluid deficit
EFR —
Estimated fasting requirement
EFR/hr —
Estimated fluid requirement per hour
ELAM-1 —
Endothelial leucocyte adhesion molecule-1
FFP —
Fresh frozen plasma
GFR —
Glomerular filtration rate
GP —
Glycoprotein
H+ —
Hydrogen
Hb —
Haemoglobin
HCl —
Hydrochloric acid
HCO3 —
Bicarbonate
Hctf —
Final lowest acceptable haematocrit (HCt)
Hcti —
Initial haematocrit (HCt)
HES —
Hydroxyethyl starch
HS —
Hypertonic saline
HUS —
Haemolytic uraemic syndrome
ICAM-1 —
Intercellular adhesion molecule-1
ICF —
Intracellular fluid
ICP —
Intracranial pressure
ICS —
Intracellular space
IL —
Insensible Loss
IL-6 —
Interleukin-6
IL-8 —
Interleukin-8
INR —
International normalised ratio
IO —
Intraosseous
ISF —
Interstitial fluid
ISS —
Interstitial space
IVF —
Intravascular fluid
IVS —
Intravascular space
JG —
Juxtaglomerular
jv —
Net filtration or the net driving force
Kf.c —
Capillary filtration coefficient
K+ —
Potassium
KCL —
Potassium chloride
kDa —
kiloDalton
Kfc —
Capillary filtration coefficient
MAP —
Mean arterial pressure
MDWR —
Minimal daily water requirement
MFGs —
Modified fluid gelatins
Mn —
Number average molecular weight
mOsm —
milliosmoles
MS —
Molar substitution
Mw —
Mean molecular weight
MW —
Molecular weight
Mw —
Weight average molecular weight
NAD —
Nicotinamide adenine dinucleotide
NBM —
Nil by mouth
NPO —
Nil per oral
NSAIDs —
Non-steroidal anti-inflammatory drugs
Osm —
Osmoles
osmol/kg —
Solute per kilogram of solvent or Osm/kg
osmol/L —
Solute per litre of solvent or Osm/L
πcap —
Oncotic pressure in the capillary
πint —
Oncotic pressure in the interstitium
P —
Proteins
PaOP —
Pulmonary artery occlusion pressure
Pcap —
Hydrostatic pressure in the capillaries
PCV —
Packed cell volume
PCWP —
Pulmonary capillary wedge pressure
PEEP —
Positive end-expiratory pressure
PGE2 —
Prostaglandin E2
PGI2 —
Prostaglandin I2
PICU —
Paediatric intensive care unit
PIH —
Pregnancy induced hypertension
Pint —
Hydrostatic pressure in the interstitium
Posm —
Plasma osmolality
PPF —
Plasma protein fraction
PPV —
Positive pressure ventilation
PRBC —
Packed red blood cell
RAAS —
Renin-angiotensin-aldosterone system
RBC —
Red blood corpuscle
RBSL —
Random blood sugar level
RES —
Reticuloendothelial system
RNA —
Ribonucleic acid
σ —
Osmotic reflection coefficient
SAFE —
Saline versus albumin fluid evaluation
SAH —
Sub-arachnoid haemorrhage
SIADH —
Syndrome of inappropriate anti-diuretic hormone
SOAP —
Sepsis occurrence in acutely ill patients
TBI —
Traumatic brain injury
TBW —
Total body water
TC —
Total count
TNF —
Tumour necrosis factor
Tr —
Traces
TTP —
Thrombotic thrombocytopenic purpura
vWF —
von Willebrand factor