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Fluid and Electrolyte Management of the Surgical Patient Jaffar Alkhuzaie M.B.B.Ch, AFRCSI, CABS
Introduction Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively, and post operatively, as well as in response to trauma and sepsis.
Case 1 40 years old male SBO NGT 1500 ml Na 150 K 2.9
Total Body Water 50-60% of total body weight Who is having higher proportion of body weight as water? And Why? Males or Females Lean or Obese Young or elderly
Muscle and solid organs have higher water content than fat and bone Higher proportion of water in: Young Lean Males
Fluid Compartments
Composition of Fluid Compartments
Classification of Body Fluid Changes Normal Exchange of Fluid and Electrolytes Disturbances in Fluid Balance Volume Control Concentration Changes Hyponatreamia Hypernatreamia Composition Changes Hyperkalemia Hypokalemia Hypermagnesemia Hypomagnesemia Hypercalcemia Hypocalcemia Hyperphosphatemia Hypophosphatemia
Case 2 50 years old female Not know to have medical problem SBO due to adhesions On NGT Total intake 2700 ml Total out put 2800 ml
Normal Exchange Normal person consumes 2000ml of H2O 75% oral intake Rest from solid foods Daily water losses 1L in Urine 250 ml in stool 600 insensible losses Skin 75% Lungs 25%
Disturbances in Fluid Balance Extracellular volume deficit: most common in surgical patients Acute Cardiovascular Central nervous system Chronic Decrease skin turgor Sunken eyes & CVS and CNS
System Volume Deficit Volume Excess Generalized Weight loss Weight gain Decreased skin turgor Peripheral edema Cardiac *Tachycardia *Increased cardiac *Orthostasis/ output hypotension *Increased central *Collapsed neck veins venous pressure *Distended neck veins *Murmur Renal Oliguria Azotemia Gastrointestinal Ileus Bowel edema Pulmonary Pulmonary edema
Composition of Gastrointestinal Secretions Type of Volume Na K Cl HCO-3 Secretion mL/24 h mEq/L mEq/L mEq/L mEq/L Stomach 2000-1000 90-60 30-10 130-100 0 Small intestine 3000-2000 140-120 10-5 120-90 40-30 Colon 60 30 40 0 Pancreas 800-600 145-135 10-5 90-70 115-95 Bile 800-300 145-135 10-5 110-90 40-30
Case 3 78 years old male Not know to have any medical problem Had sigmoid colectomy for Ca 2nd day post op Na 130
Hyponatremia Causes Sodium depletion Sodium dilution
Sodium depletion Decrease intake Low Na diet Enteral feeds Increase loss Gastrointestinal Losses Vomiting Prolonged NGT suctioning Diarrhea Renal Losses Diuretics Primary renal disease Depletional hyponatreamia is often accompanied by extracellulr volume deficit
Sodium dilution Due to excess extracellular water Intentional: excessive oral intake Iatrogenic: Intravenous Increase ADH Increase reabsorption of water from the kidneys Drugs Antipsychotics Tricyclic antidepressants Angiotensin-converting enzyme inhibitors Physical signs: usually absent Lap: hemodilution
Hyperosmolar Mannitol Hyperglycemia Pseudohyponatremia Plasma lipids Plasma proteins
Body System Hyponatremia Central Headache, confusion, hyper- or hypoactive deep nervous tendon reflexes, seizures, coma, increased intracranial system pressure Musculoskeletal Weakness, fatigue, muscle cramps/twitching Gastrointestinal Anorexia, nausea, vomiting, watery diarrhea Cardiovascular Hypertension and bradycardia if significant increases in intracranial pressure Tissue Lacrimation, salivation Renal Oliguria
Management of Hyponatremia Exclude Hyperosmolar causes Depletion versus dilution Dehydration or over hydrated Normal volume >>evaluate ADH Na losses Urine Na <20 mEq/L = extrarenal Urine Na >20 mEq/L = Renal
Free water restriction If sever administration Na If neuralgic symptoms are present 3% N.S No more than 1 mEq/L per hour Untill reaches 130 mEq/L or neurological symptoms improve If asymptomatic 0.5 mEq/L per hour maximum 12 mEq/L per day
Hypernatremia Loss of free water Gain sodium in excess
Body System Hypernatremia Central nervous Restlessness, lethargy, ataxia, irritability, tonic spasms, system delirium, seizures, coma Musculoskeletal Weakness Cardiovascular Tachycardia, hypotension, syncope Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears Renal Oliguria Metabolic Fever
Treatment In hypovolemic patients, volume should be restored. Water deficit is replaced using a hypotonic fluid Water deficit (L)=(serum sodium -140 /140) * TBW TBW = 50% for lean men and 40% for women No more than 1 mEq/h and 12 mEq/d for acute.
Case 4 40 years old male Polytrauma # Rt femur and blunt abdominal injury K 2.9
Oliguria And on going blood transfusion
Case 5 40 year old male Case of crohns with entero-cutenous fistula On TPN K 6.5
Potassium Average intake of potassium 50-100 mEq/d 2% of totall body potassium is located within extracellular compartment Normal range 3.5-5.0 mEq/L
Hyperkalemia Excessive potassium intake Oral Intravenous Blood transfusions Increased release of potassium from cells Hemolysis Rhabdomolysis Crush injuries Gastrointestinal hemorrhage Acidosis Rapid increase of extracellular osmolality Impaired excretion by the kidneys Potassium sparing diuretics Angiotensin-Converting enzyme inhibitors Nonsteroidal antiinflammatories Renal insufficiency and renal failure
Symptoms Gastrointestinal Nausea Vomiting Intestinal colic Diarrhea Neuromuscular Weakness Ascending paralysis to respiratory failure Cardiovascular ECG changes Peaked T waves Flattened P wave Prolonged PR interval Widened QRS complex Ventricular fibrillation Cardiac arrhythmias Arrest
Discontinue exogenous potassium Cation-exchange resin, Kayexalate Glucose Insulin Calcium chloride or calcium gluconate All the above measures are temporary lasting from 1 to 4 hours Dialysis should be considered
Hypokalemia More common in surgical patient Inadequate intake Dietary Potassium free IV fluids Total parenteral nutrition with inadequate potassium replacement Excessive renal excretion Hyperaldosteronism Medications Loss in gastrointestinal secreations Vomiting High NGT output Intracellular shift Metabolic alkalosis Insulin therapy Drugs induce magnesium depletion Amphotericin Aminoglycosides Foscarnet Cisplatin ifosfamide
Symptoms Gastrointestinal ileus Constipation Neuromuscular Weakness Fatigue Diminished tendon reflexes Paralysis Cardiac Cardiac arrest ECG changes U waves T wave flattening ST segment changes Arrhythmias
Potassium repletion Orally or intravenous In IV no more than 10 to 20 mEq/h 40 mEq/h when ECG monitoring Caution with oliguria or impaired renal function

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Fluid And Electrolyte

  • 1. Fluid and Electrolyte Management of the Surgical Patient Jaffar Alkhuzaie M.B.B.Ch, AFRCSI, CABS
  • 2. Introduction Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively, and post operatively, as well as in response to trauma and sepsis.
  • 3. Case 1 40 years old male SBO NGT 1500 ml Na 150 K 2.9
  • 4. Total Body Water 50-60% of total body weight Who is having higher proportion of body weight as water? And Why? Males or Females Lean or Obese Young or elderly
  • 5. Muscle and solid organs have higher water content than fat and bone Higher proportion of water in: Young Lean Males
  • 8. Classification of Body Fluid Changes Normal Exchange of Fluid and Electrolytes Disturbances in Fluid Balance Volume Control Concentration Changes Hyponatreamia Hypernatreamia Composition Changes Hyperkalemia Hypokalemia Hypermagnesemia Hypomagnesemia Hypercalcemia Hypocalcemia Hyperphosphatemia Hypophosphatemia
  • 9. Case 2 50 years old female Not know to have medical problem SBO due to adhesions On NGT Total intake 2700 ml Total out put 2800 ml
  • 10. Normal Exchange Normal person consumes 2000ml of H2O 75% oral intake Rest from solid foods Daily water losses 1L in Urine 250 ml in stool 600 insensible losses Skin 75% Lungs 25%
  • 11. Disturbances in Fluid Balance Extracellular volume deficit: most common in surgical patients Acute Cardiovascular Central nervous system Chronic Decrease skin turgor Sunken eyes & CVS and CNS
  • 12. System Volume Deficit Volume Excess Generalized Weight loss Weight gain Decreased skin turgor Peripheral edema Cardiac *Tachycardia *Increased cardiac *Orthostasis/ output hypotension *Increased central *Collapsed neck veins venous pressure *Distended neck veins *Murmur Renal Oliguria Azotemia Gastrointestinal Ileus Bowel edema Pulmonary Pulmonary edema
  • 13. Composition of Gastrointestinal Secretions Type of Volume Na K Cl HCO-3 Secretion mL/24 h mEq/L mEq/L mEq/L mEq/L Stomach 2000-1000 90-60 30-10 130-100 0 Small intestine 3000-2000 140-120 10-5 120-90 40-30 Colon 60 30 40 0 Pancreas 800-600 145-135 10-5 90-70 115-95 Bile 800-300 145-135 10-5 110-90 40-30
  • 14. Case 3 78 years old male Not know to have any medical problem Had sigmoid colectomy for Ca 2nd day post op Na 130
  • 15. Hyponatremia Causes Sodium depletion Sodium dilution
  • 16. Sodium depletion Decrease intake Low Na diet Enteral feeds Increase loss Gastrointestinal Losses Vomiting Prolonged NGT suctioning Diarrhea Renal Losses Diuretics Primary renal disease Depletional hyponatreamia is often accompanied by extracellulr volume deficit
  • 17. Sodium dilution Due to excess extracellular water Intentional: excessive oral intake Iatrogenic: Intravenous Increase ADH Increase reabsorption of water from the kidneys Drugs Antipsychotics Tricyclic antidepressants Angiotensin-converting enzyme inhibitors Physical signs: usually absent Lap: hemodilution
  • 18. Hyperosmolar Mannitol Hyperglycemia Pseudohyponatremia Plasma lipids Plasma proteins
  • 19. Body System Hyponatremia Central Headache, confusion, hyper- or hypoactive deep nervous tendon reflexes, seizures, coma, increased intracranial system pressure Musculoskeletal Weakness, fatigue, muscle cramps/twitching Gastrointestinal Anorexia, nausea, vomiting, watery diarrhea Cardiovascular Hypertension and bradycardia if significant increases in intracranial pressure Tissue Lacrimation, salivation Renal Oliguria
  • 20.
  • 21. Management of Hyponatremia Exclude Hyperosmolar causes Depletion versus dilution Dehydration or over hydrated Normal volume >>evaluate ADH Na losses Urine Na <20 mEq/L = extrarenal Urine Na >20 mEq/L = Renal
  • 22. Free water restriction If sever administration Na If neuralgic symptoms are present 3% N.S No more than 1 mEq/L per hour Untill reaches 130 mEq/L or neurological symptoms improve If asymptomatic 0.5 mEq/L per hour maximum 12 mEq/L per day
  • 23. Hypernatremia Loss of free water Gain sodium in excess
  • 24. Body System Hypernatremia Central nervous Restlessness, lethargy, ataxia, irritability, tonic spasms, system delirium, seizures, coma Musculoskeletal Weakness Cardiovascular Tachycardia, hypotension, syncope Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears Renal Oliguria Metabolic Fever
  • 25.
  • 26. Treatment In hypovolemic patients, volume should be restored. Water deficit is replaced using a hypotonic fluid Water deficit (L)=(serum sodium -140 /140) * TBW TBW = 50% for lean men and 40% for women No more than 1 mEq/h and 12 mEq/d for acute.
  • 27. Case 4 40 years old male Polytrauma # Rt femur and blunt abdominal injury K 2.9
  • 28. Oliguria And on going blood transfusion
  • 29. Case 5 40 year old male Case of crohns with entero-cutenous fistula On TPN K 6.5
  • 30. Potassium Average intake of potassium 50-100 mEq/d 2% of totall body potassium is located within extracellular compartment Normal range 3.5-5.0 mEq/L
  • 31. Hyperkalemia Excessive potassium intake Oral Intravenous Blood transfusions Increased release of potassium from cells Hemolysis Rhabdomolysis Crush injuries Gastrointestinal hemorrhage Acidosis Rapid increase of extracellular osmolality Impaired excretion by the kidneys Potassium sparing diuretics Angiotensin-Converting enzyme inhibitors Nonsteroidal antiinflammatories Renal insufficiency and renal failure
  • 32. Symptoms Gastrointestinal Nausea Vomiting Intestinal colic Diarrhea Neuromuscular Weakness Ascending paralysis to respiratory failure Cardiovascular ECG changes Peaked T waves Flattened P wave Prolonged PR interval Widened QRS complex Ventricular fibrillation Cardiac arrhythmias Arrest
  • 33. Discontinue exogenous potassium Cation-exchange resin, Kayexalate Glucose Insulin Calcium chloride or calcium gluconate All the above measures are temporary lasting from 1 to 4 hours Dialysis should be considered
  • 34. Hypokalemia More common in surgical patient Inadequate intake Dietary Potassium free IV fluids Total parenteral nutrition with inadequate potassium replacement Excessive renal excretion Hyperaldosteronism Medications Loss in gastrointestinal secreations Vomiting High NGT output Intracellular shift Metabolic alkalosis Insulin therapy Drugs induce magnesium depletion Amphotericin Aminoglycosides Foscarnet Cisplatin ifosfamide
  • 35. Symptoms Gastrointestinal ileus Constipation Neuromuscular Weakness Fatigue Diminished tendon reflexes Paralysis Cardiac Cardiac arrest ECG changes U waves T wave flattening ST segment changes Arrhythmias
  • 36. Potassium repletion Orally or intravenous In IV no more than 10 to 20 mEq/h 40 mEq/h when ECG monitoring Caution with oliguria or impaired renal function