Water exchang :

3. Water exchang : • Daily intake 2000 – 2500 cc by mouth 1500 cc in solid food 500 – 1000 cc • Daily output urine 800 - 1500 cc stool 250 cc insensible loss 600 cc

4. Adult 30-35 cc/kg 2000 – 2500 cc Daily water requirement : • Child 1st 10 kg wt 100 cc/kg 2nd 10 kg wt 50 cc/kg Each additional kg 20 cc/kg

5. Electrolyte requirement: • Adult Na 50 – 90 meq / day K 60 meq / day • Child • Na 3 meq / kg / day • K 2 meq / kg / day

6. Volume changes : • Volume deficit Vomiting Peritonitis Diarrhea Obstruction • Volume excess Iatrogenic Renal failure Cirrhosis Heart failure

7. Acid-Base balance : • Important Buffers Intracellular Proteins Phosphate Extracellular Bicarbonate – Carbonic acid

8. Acid-Base disorders : Acute • Respiratory Chronic • Metabolic Acute Chronic

9. Acid-Base disorders : (acute) pH pco2 HC03 • Respiratory N Acidosis • Respiratory N Alkalosis

10. Acid-Base disorders : (chronic) pH pco2 HC03 • Respiratory Acidosis • Respiratory Alkalosis

11. Acid-Base disorders : (acute) pH pco2 HC03 • Metabolic N Acidosis • Metabolic N Alkalosis

12. Acid-Base disorders : (chronic) pH pco2 HC03 • Metabolic Acidosis • Metabolic ? Alkalosis

13. Solutions : (meq/L) Na K Ca Cl Hco3 • Extracellular F. 142 4 5 103 27 4 -- 109 28 130 • Lactated ringer • Nacl 0.9 % 154 -- -- 154 --

14. Solutions : (meq/L) Na K Ca Cl Hco3 • D5%W -- -- -- -- -- 52 -- -- 52 -- • 1/3 2/3 • 3% Nacl 513 -- -- -- 513

15. A resonable solution for maintenance: • D5% 45% Nacl + K • Adult 1/3 2/3 + K • Child D5% W + K + Na

16. Nonfunctional fluids: ( Third space ) • Ascites , Pleural effusion The bowel wall , Peritoneum , …

17. Rate of fluid administration: • Severity of disturbance • Type of disturbance • Ongoing loss • Cardiac status

18. 1 cc Fluid • 15 Drops • 60 Microdrops

19. Adequate volume replacement : • Normal Pulse rate • Normal Blood pressure • Adequate Urine output Adult 30 – 35 cc / hr Child 0.5 – 1 cc / kg / hr

21. Elective operation ( 100g glucose/day) Nutrition in the surgical patients: • Elective operation in seriously ill patient

22. Enteral Nutrition : • Enteral + Parenteral • Parenteral

23. Oral Enteral Nutrition : • Nasogastric tube • Orogastric tube • Gasterostomy tube • Jejunostomy tube

24. > 20% burn Energy Expenditure: 100% • Severe infection 50% • Multiple Fx 20% • Normal BEE

25. Basal energy expenditure Nutritional assessment: • Previous malnutrition • Severity of disease • Physical activity

26. Harris & Benedict Basal energy expenditure: Weight (kg) Height (cm) Age (year)

27. Adult 30-35 Kcal/kg Basal energy expenditure: • Child for each ml water 1 kcal 1st 10 kg wt 100 ml/kg 2nd 10 kg wt 50 ml/kg Each additional kg 20 ml/kg

28. Maximum benefit (calory/ nitrogen = 100-150 kcal/g) Parenteral Alimentation: 20% • Infused simultaneously

29. Newborn with GI anomaly Indication of IV alimentation : • Malabsorption or GI enzyme deficiency • Adult with short bowel syndrome • Prolonged paralytic ileus • Patient who cannot ingest food

30. Postpound inevitable dying Contraindication of IV alimentation : • Severe metabolic derangement • Normal GI tract feeding • Decerebrated or dehumanized • Infant < 8 cm small bowel • Good nutritional status