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Principals of fluids and electrolytes management

Principals of fluids and electrolytes management. Ram Elazary , MD General Surgery Department Hadassah Hebrew University Medical Center Campus Ein-Kerem , Jerusalem. Total Body Water. body weight% Total body water% Total 60 100 I ntracellular 40 67 E xtracellular 20 33

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Principals of fluids and electrolytes management

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  1. Principals of fluids and electrolytes management Ram Elazary, MD General Surgery Department Hadassah Hebrew University Medical Center Campus Ein-Kerem, Jerusalem

  2. Total Body Water body weight% Total body water% Total 60 100 Intracellular 40 67 Extracellular 20 33 Intravascuar 5 8 Interstitial 15 25

  3. Composition of Fluids plasma interstitial intracellular Cations Na 140 146 12 K 4 4 150 Ca 5 3 10 Mg 2 1 7 Anions Cl 103 104 3 HCO 24 27 10 SO4 1 1 - HPO4 2 2 116 Protein 16 5 40

  4. Control of Volume Kidneys maintain constant volume and composition of body fluids • Filtration and reabsorption of Na • Regulation of water excretion in response to ADH Water is freely diffusible • Movement of certain ions and proteins between compartments restricted

  5. Control of Volume Effective circulating volume • Portion of ECF that perfuses organs • Usually equates to Intravascular volume Third space loss • Abnormal shift of fluid for Intravascular to tissues eg bowel obst, i/o, pancreatitis

  6. Normal Water Exchange Mean daily (ml) Minimal daily (ml) SensibleUrine 800-1500 600Intestinal up to liters Sweat up to liters 500 InsensibleLungs/Skin 600-900 600-900 ( 10%/1 o rise in Temp)

  7. Normal source of water ~2000ml - 1300 free water intake 700 bound to food additional water from catabolism

  8. Water and Eletrolytes Exchange Surgical patients prone to disruption: • NPO • anaesthesia • Trauma (surgery) • sepsis

  9. Fluid and Electrolytes Therapy Surgical patients need: • Maintenance volume requirements • On going losses • Volume excess/deficits • Maintenance electrolyte requirements • Electrolyte excess/deficits

  10. 1. Volume Deficit • vital signs changes • Blood pressure • Heart rate • CVP • Peripheral temperature and capillary filling time • urine output low

  11. 1. Volume Deficit • Decreased skin turgor • Sunken eyes • Oliguria • Orthostatic hypotension • High BUN/Creatine ratio • Plasma Na may be normal

  12. Fluids resusitation • Adults: 1000 ml • Pediatrics: 20 ml/kg Fluids of crystaloids (NS or RL) Repeated dose

  13. 2. Maintenance Requirements This includes: insensible loss urinary stool losses Body weight Fluid required0-10Kg 100ml/kg/dnext 10-20Kg 50 ml/kg/dsubsequent Kg 20ml/kg/d15ml/Kg/d for elderly

  14. 70 Kg Man Needs 1st 10kg x 100mls = 1000mls 2nd 10kg x 50mls = 500mls Next 50kg x 20mls= 1000mls TOTAL 2500 mls /d

  15. Maintenance Electrolyte Requirements Na 1-2mEq/Kg/d K 0.5 - 1 mEq/Kg/d • Usually no K given until urine output is adequate • Always give K with care, in an infusion slowly - never bolus (max 0.2% KCL through peripheral IV)

  16. Na 1gr = 17 mEq • K 1gr = 13.6 mEq • 70 Kg H2O 2500ml Na 70*2 =140 mEq = ~ 9gr K 70*1 =70 mEq = ~ 5gr 2500 0.45NS + 0.2%KCl 100ml/h

  17. fluids composition

  18. 3. On Going Losses • NGT • drains • fistulae • third space losses

  19. 4. Volume Excess • Over hydration • Mobilization of third space losses Signs • weight gain • pulmonary edema • peripheral edema • S3 gallop

  20. Fluid and Electrolyte Therapy Goals • normal hemodynamic parameters • normal electrolyte concentration Method replace deficits normal maintenance requirements ongoing losses

  21. Fluid and Electrolyte Therapy Normal maintenance requirements • use BW formula On going losses • measure all losses in I/O chart • estimate third space losses Deficits • estimate using vital signs • estimate using U/O

  22. Fluid and Electrolyte Therapy The best estimate of the volume required is the patients response After therapy started observe • vital signs • Urine output (0.5mls/Kg/hr) • Central venous pressure

  23. Time Frame for Replacement • Usually correct over 24 hours • For ill patients calculate over shorter period and reassess e.g. 1, 2 hours or 3 hours for e op cases • Deficits - correct half the amount over the period and reassess

  24. Postoperative Fluid Therapy • Check IV regimen ordered in op form • Assess for deficits by checking I/O chart and vital signs • Maintenance requirements calculated • Usually K not started • Monitor carefully vital signs and urine output

  25. Postoperative Fluid Therapy • Urine specific gravity may be used (1.010 - 1.012) • CVP useful in difficult situations (5-15 cm H20) • Body weight measured in special situation e.g. burns

  26. Concentration Changes • changes in plasma Na are indicative of abnormal TBW • losses in surgery are usually isotonic • hypoosmolar condition usually caused by replacement with free water

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