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Fluid & Electrolyte in Surgical Patient

Fluid & Electrolyte in Surgical Patient. Dr.Mohammad Amin Mirza. Objectives :. Anatomy of Body Fluids Normal Exchange of Fluid & Electrolyte Classification of Body Fluid Changes Fluid and Electrolyte Therapy in Surgical Patients. Total Body Water. body wt% Total body water%

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Fluid & Electrolyte in Surgical Patient

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  1. Fluid & Electrolyte in Surgical Patient Dr.MohammadAminMirza

  2. Objectives : • Anatomy of Body Fluids • Normal Exchange of Fluid & Electrolyte • Classification of Body Fluid Changes • Fluid and Electrolyte Therapy in Surgical Patients

  3. Total Body Water body wt% Total body water% • total 60 100 • intracellular 40* 67 • extracellular 20 33 a-intravasc 5 8 b-interstitial 15 25

  4. Total body water • Water 50-70% of TBW • Sex : • 60% of TBW young male • 50% of TBW young female • Age : • Decrease wt aging • Highest wt newborn 75-80%at 1year 65% elderly 52% M, 49%F

  5. Composition of Fluids plasma interstitial intracellular CationsT=154 T=153 T=200 Na 142144 12 K 4 4 150 Ca 5 3 10 Mg 3 1 40 Anions T=154 T=153 T=200 Cl 103104 3 HCO32727 10 SO4 1 1 - HPO4 2 2 150 Protein 16 5 40

  6. Osmolality • Posm(mOsm/l)= 2x serum [Na] + glocose/18 + BUN/2 • Case : post op pt serum Na 125meq/l RBS 500mg/dl,what is serum Na? • General role , each 100mg/dl rise RBS above normal equivalent to 1.6-3meq/l fall in Na , in this case if excess extracellular water eliminated Na 137meq/l

  7. Osmotic Pressure • Total osmotic pressure of fluid : Is sum of partial P of each solute in that fluid • Osmotic pressure ECF=ICF why ? The total no. of osmotic active particles 290-310 mOsm in each compartment • Bec, the cell membrane completely permeable to water any change in osmotic P in either compartments  redistribution of the water between the compartments

  8. Normal total intake 2-2.5L/day 1- Sensible Oral fluids 800-1500 Solid foods 500-700 2- Insensible Water of oxidation 250 Water of solution 0-500 Water exchange1-Water Intake

  9. 1-Sensible urine 800-1500 intestinal 0-250 sweat 0 2-Insensible lungs/skin* 600 skin 75% lung 25% The insensible water loss from the skin from water vapor in the body not sweats Wt excess heat capacity for insesible loss >>sweating occur >250ml/day per degree of fever Unhumidified tracheostomy wt hyperventilation >> loss throgh the lung 1.5L/day Normal Water Exchange2-water loss

  10. Salt Gain & Loss

  11. Composition of GIT Secretion

  12. Classification of Body Fluid Changes 1-volume changes 2-concentration changes 3-Compositional changes What would happen if ? *If isotonic salt lost or added from the body fluid *if water alone added or lost ECF? *If concentration of other ions than Na in ECF changed without changes in osmotic active particles ?

  13. 1-volume changes • Lab tests reflect changes ECF : BUN ,creatinine , Hct A-volume deficit ECF deficit most common disorder in surg. Pt Loss of water + electrolyte same prop.ECF Causes : Clinical: B-volume excess Inc. in ECF ( plasma + interstitial volume) Causes : Clinical :

  14. 2-concentration changes • Na mainly responsible of ECF osmolarity , determination of serum Na indicate tonicity of the body fluid 1- Hyponatremia C/P *acute symptomatic (Na<130meq/L) *chronic asymptomatic till ( Na <120meq/L) 2- HypenatremiaC/P * Only state in which dry sticky mucous membrane characteristic

  15. 3-compositional changes : • Compositional abnormalities include: • Changes in acid–base balance • Changes K, Ca, Mg • Acid – Base Balance : The PH of the body fluid maintained within narrow limit 7.4 (7.34 -7.43 ) PH=Pk +log BHCO3 = 27 meq/l =20 =7.4 H2CO3 1.33meq/l 1

  16. 1-Respiratory Alkalosis Cause : hyperventilation ABG: PH , CO2 Compens HCO3 Complication : Cardiac Cerebral hypo K , Ca Treatment : Cause ventilaton 2-Respiratory Acidosis Cause : Inadequate ventilation ABG: PH , CO2 Compens,HCO3 Treatment : Cause ventilation

  17. 3-Metabolic Acidosis Cause : Gain an acid Retention of bicarb 1-Normal anion gap 2-high anion gap ABG PH , HCO3 Comp. CO2 Treatment Cause Na Hco3 indication and contraindication 4-MetabolicAlkalosis Cause Gain Bicarb, Loss of acid Commonest example ABG PH , HCO3 Compens . CO2 Treatment Cause ( Rxpyloric obst.) Treat hypo K No need dec. ventilation

  18. Pyloric obstruction • Resuscitation wt isotonic saline • replacement of K • Correction of Cl in case of resistant metabolic alkalosis • Cl infusion : • 150ml 0.1N hydrochloride in 1L N.S or D5% over 4-6h,wt ABG+chemistry q4-6h, this wt D5%give 300meqHCL • Chloride deficit in 70kg man, Cl level 80meq • As chloride distributed in ECF ( plasma volume =20% body weight) • Cl Deficit =20%BWx [normal Cl level – observed Cl ] (0.2x70)x ( 103-80 ) = 322 meq

  19. 3- Composition Changes: Hyperkalemia • Causes : ( intracellular  extracellular ) • Clinical : 1-GIT 2-CVS • Treatment : • IV 1 gm 10% Ca gluconate over 10-15min • Bicarb + insulin + Gluc (45meq NaHCO3 in 1 L / D10W + 20 unit Regular insulin ) • Definitive : Kayexalate or dialysis

  20. 3- Composition Changes: Hypokalemia • Causes in surgical pt: • Decrease Input : • K free IVF wt renal loss >- 20meq/day • TPN inadequate k • Increase Output: • GIT loss • Renal loss • Movement into cells

  21. C/P of Hypo K: • failure of normal contractility of • Smooth M  paralytic ileus • Cardiac M  ECG (flat T, depressed ST), charac. • Skeletal M  weaknessflaccid paralysis • Treatment : Give K : • No >40meq / L should be added to IVF • No >40meq / h should be the rate of admin. • Contraindication to give K : • Oliguric pt • During first 24h after severe surgical stress

  22. 3- Composition ChangesCa Abnormalities : • Intake : Normal daily intake of Ca 1-3 g • Excretion : majority GIT, 200mg in urine • Normal serum level 8.5-10.5 mg/dl • 55% non- ionized bound to protiens • 45% ionized for neuromuscular stability • The ratio of ionized:non-ionized related to PH acidosis inc,ionized + alkalosis dec,ionized • No indication to give Ca in surgical pt except in specific situations

  23. Hypocalcemia • Causes in surgical pt : • acute Pancreatitis, • Pancreatic & SI fistula • acute &chronic renal failure, • massive soft tissue infection (NF) • Hypo parathyroid • Transient after surg of parathyroid adenoma in pt wt hyperparathyroidism

  24. Hypocalcemia C/P : • Symptomatic if Ca< 8 mg/dl • Neuromuscular signs : • Numbness at circumoral, tips of finger or toes • Muscle & abdominal cramp • Tetany wt Carpopedal spasm ,convulsion • Chovestek sign, Hyperactive tendon reflex • ECG( prolong QT )

  25. Hypocalcemia treatment :(Ca) • Acute symtoms : IV Ca gluconate or CaCl2 • Chronic replacement : oral Ca lactate + or - vitD • Does the pt receiving blood transfusion need Ca ? • NO except in pt receiving blood as rapid as 500ml every 5 -10 min , Ca recommended • Dose : IV Ca gluconate 0.2 g (2ml in 10%CaCl2 sol ), for every 500cc blood , in separate line from the transfusion site, only when the blood transfused by the rate mentioned above & total Ca not >3gm.

  26. Hypercalcemia • Causes in surgical pt : • Hyperparathyroidism • Cancer wt bony metastasis (metastatic breast CA on estrogen replacement ) • C/P : • GIT,Neuromuscular,Polyurea, polydepsia • Treatment : • Critical level when Ca >15 mg/dl med ER • Diuresis (salt solution ) • Diuretic (furosemide)

  27. Mg Abnormalities • Total body content of Mg 2000meq • 50% in the bone , slowly exchangable • Majority excreted in feces, rest in urine • Serum Mg(1.5-2.5meq/l), bec mainly ICF 1-Mg Excess : • Causes ; intake , gain • C/P : as hyper K • Rx: IV 5-10 meq CaCl, or Ca Gluc  dialysis

  28. Mg deficiency • Causes : • C/P ; same as hypo Ca • diagnosis • Routine administration considered in TPN pt , or long term parentral fluid wt GIT dysfunction • Management : • IV MgSO4,MgCl2, 2meq/kg/day severe def. • TPN 12-24meq/day

  29. Fluid & Electrolyte Therapy in surgical patient • Parenteral solutions • Preoperative fluid therapy • Intraoperative fluid therapy • Postoperative fluid therapy • Immediate post OP • Late post OP • Special consideration in post OP • Acute renal failure

  30. Parenteral solutoin Cations(mEq/L)Anions(mEq/L)

  31. Parenteral Solutions • RL :ideal for replacement of GIT loss, ECF loss, in absence of gross abnormality in concentration or composition (physiologic solution , minimal effect on the fluid composition or PH even in inf. Large amount) • NaCl :ideal for initial correction of ECF deficit in presence of hypo Na , hypo Cl, metabolic alkalosis ( dilutional acidosis)

  32. Parenteral Solution • M/6 Sodium Lactate : Alternative fluid hyponatremic, hypochloremic moderate metabolic acidosis • 3% NaCl ( Molar Na lactate ) : for rapidly correcting symptomatic hyponatremia • The choice of lactate or chloride depend on accompanying acid-base disorder *Chloride for alkalosis *lactate for acidosis

  33. Pre OP Fluid Therapy • if pre op replacement of ECF volume is incomplete  hypotension wt induction of anesthesia ( compensatory mech. Abolished) • Prevented by replacement of deficit + keeping baseline maintenance to do so • Body Fluid Disorders Categorized into • Volume Abnormalities • Concentration changes • Compositional & miscellaneous changes

  34. Pre OP fluid correction1-volume correction • Depletion of ECF without change in the composition or concentration • Diagnosis clinically : • Mild moderate, severe deficit(4,6-8,10%BW) • Replacement : balanced salt solution as RL • Rate : severe volume depletion 2 L/h , reassess ,in elderly need monitoring even CVP

  35. Pre OP fluid correction2-concentration changes • General Role : • Correction of concentration changes depend whether the pt is symptomatic • If symptomatic hyper or hypo Na , attention to correct the concentration abnormality to the point that symptoms relieved, then attention shifted to correct ass. volume abnormality

  36. Pre OP fluid correction2-concentration (hypo Na) • Case : 70kg women symptomatic hypoNa Na level (120meq/l),calculate Na deficit ? • Na deficit = (normal serum Na – observed Na) X total B water (TBWater= is 50% BW in F, 60% BW in M) This case total body water = 70 x 0.5=35L Na deficit = (140-120meq/L) x 35L = 700meq • Replacement : initially ½ of calculated Na infused by 3% NaCl ,slowly ,rapid infusion cerebral myelinosis once the symptoms alleviated the pt reassessed

  37. Continue Pre OP fluid correction2-concentration Na • If Profound hypo Na ( correction no > 12meq/L/24h ) • If hypo Na +Volume deficit: the remainder of ressucitation continued wt isotonic (Nacl in akalosis, M/6 lactate in acidosis), till symp,if Na normalized RL • If hypo Na + Volume Excess (care) after small amount of hypertonic saline to relive the symptoms water restriction Rx of choice

  38. Continue Pre OP fluid correction2-concentration Na • Severe symptomatic Hypernatremia wt volume deficit : • Safest method : ½ strength NaCl or ½ strength RL • D5W may infused slowly till symptomatic relieve, if ECF osmolarity dec.too rapidly convulsion & coma • In absence of significant volume deficit: Water adm. in caution to avoid hypervolemia

  39. Intra OP Fluid Therapy Clinical Guide Lines for Intra OP fluid Administration: • Blood should be replaced as it is lost to maintain acceptable RBC mass irrespective of any fluid or electrolyte • The replacement of ECF should begin during OP • Balanced salt solution needed during OR 0.5-1L/h to maximum 2-3L during 4h major abdominal OP, unless other measurable losses 4. Crystalloid not albumin ?

  40. Post OP Fluid Therapy1-Immediate Post OP • Assessment of the post OP at recovery room: • Quantitative : OP loss estimated by surgeon <15-40% than the actual loss • Qualitative : V/S + urine out put ,etc • Optimal Accepted parameters in post op: • BP 90/60 mmHg • pulse < 120bpm • urine out put 30-50ml/h.

  41. 1-Immediate Post OPVolume Replacement • Deficit + maintenance • For pt wt circulatory instability , add 1Lisotonic salt stat, wt frequent check to clarify the situation • For maintenance : D5 0.45% NS ( k? ) • K : unnecessary to add K during the 1st 24h after OR, unless definitive deficit exist. • K : can be added for maintenance in pt without complication and need short term IVF • K : contraindicated for pt wt prolong OP trauma had >1 episode of hypotension or post traumatic hemorrhagic hypotension all oliguric renal failure

  42. 2-Late Post OP • Accurate measurement and replacement of all losses (sensible + insensible loss) • 1-Estimated Insensible loss (skin & lung) 600ml/day ,increased by hyperventilation , hyper metabolism and fever upto 1.5L/day Replacement wt D5W • 2-Measures sensible loss A- GIT loss : usually the loss isotonic or hypotonic Replaced by isotonic salt solution ,replace losses volume for volume

  43. 2-Late Post OP • 2-Cont,Sensible loss: B-Sweat : not a problem except in febrile pt water loss 250ml/day per degree fever But excessive sweating cause considerable Na loss in unacclimatized pt C-Urine : volume not replaced in ml/ml basis usually 1L of maintenance IVF given to replace daily UOP Replacement : in healthy by D5W+minimal salt but in elderly wt salt losing kidney or head injury water alone can  hyponatremia , salt added acc.to urinary Na loss

  44. Fluid and Electrolyte Therapy Surgical patients have • Maintenance volume requirements • On going losses • Volume excess/deficits • Maintenance electrolyte requirements • Electrolyte excess/deficits

  45. 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 HCT

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

  47. Maintenance 70 Kg Man Needs 10 x 100 = 1000 10 x 50 = 500 50 x 20 = 1000 2500 mls / d

  48. Maintenance Electrolyte Requirements • Na 1-2 meq/Kg/day • K 0.5-1 meq/Kg/day • Usually no K given until after urine output is adequate and U/E done. K should be given with care, by infusion slowly - never bolus • Ca, PO4, Mg not required for short term

  49. On Going Losses • NG • drains • fistulae • third space losses Concentration is similar to plasma Replace with isotonic fluids

  50. Time Frame for Replacement • Usually correct over 24 hours • For ill patients calculate over shorter period and reassess e.g. 12 hours or 3 hours for e op cases • Deficits - correct half the amount over the period and reassess

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