fluid%20and%20 electrolyte%20 management%20in%20 surgical%20 patient
TRANSCRIPT
Fluid and Electrolyte Management in Surgical
Patient
Fluid and Electrolyte Fluid and Electrolyte Management in Surgical Management in Surgical
PatientPatientDr.KitiDr.Kiti SiriwatanaSiriwatana
Total body water
• Infant=80• Male=65• Female=55• Thin>Fat
Body fluid compartment• ICF=40%• ECF=20%
– Intravascular fluid(plasma) =5%– Interstitial fluid =15%
Total body water
ICF
Intravascular fluid
Interstitial fluid
140
4
103
24
2
145
4
113
28
2
10
160
2
8
38
Na+
K+
Cl-
HCO3-
PO4-
ICFISFSerum
Na+
K+
Cl-
HC
O3-
PO
4-Serum
ICF020406080
100120140160
Serum
ISF
ICF
Osmolality
• Homeostatic machanism by kidney• Serum Osmolality=(Na+x2)+(BUN/2.8)+(Glucose/18)• Fluid movement:Osmolality• Electrolyte movement:Active
transport
ADH
Aldosterone
Fluid
• Crystalloid– Maintenance type fluid:Hypotonic solution– Replacement type fluid:Isotonic solution– Special type fluid:Hypertonic solution
• Colloid– Albumin– Gelatin(Haemaccel)– Starch(H.E.S.)
Example of crystalloid• D5W:Dilutional hyponatremia• NSS:Normal saline:Isotonic saline• Lactated Ringer’s solution
(LRS):Physiologic solution– Liver-Lactate to bicarbonate and energy
• Acetated Ringer’s solution (ARS)– Acetate metabolite by muscle
NaNa++ KK++ CaCa++++ MgMg++++ ClCl-- HCOHCO33 GlucoseGlucose
ECFECF 142 4 5 3 103 27 1205%5%DD//WW 0 0 0 0 0 0 500.9%0.9%NSSNSS 154 0 0 0 154 0 05%5%DD//NN/2/2 77 0 0 0 77 0 505%5%DD//NN/3/3 51 0 0 0 51 0 505%5%DD//NN/5/5 31 0 0 0 31 0 503%3%NSSNSS 513 0 0 0 513 0 0
LRLLRL 130 4 3 0 109 28 0
ARLARL 130 4 2.7 0 108.7 28 0
Crystalloid VS Colloid
• Crystalloid:2-3 Blood loss• Colloid: ~1:1 Blood loss• Blood replacement: for Oxygen
carrier
Fluid and Electrolyte therapy
• Fluid:Quatity:volume
• Electrolyte:Quality:composition
Replacement for what?
• Daily requirement:Fluid maintenance• Fluid deficit:Already loss• Third space loss from surgery• Fluid for blood replacement
Daily requirement:Fluidmaintenance
• Sensible loss:kidney and GI– Urine:800-1200 cc/day
• Insensible loss:skin and lung– Skin:20-400 cc/day– Lung:400-600 cc/day– Insensible perspiration (cc)=B.W. (kg.)x15
• Total:1600-2000 cc/day• I/O record
Daily requirement:Fluidmaintenance 1
• Holliday and Segar• น้ําหนัก 10 Kg แรก = 100 cc/Kg• 10-20 Kg ตอมา = 50 cc/Kg• >20 Kg = 20 cc/Kg• For 24 Hr. of fluid maintenance
Daily requirement:Fluidmaintenance 2
• Fluid maintenance in 1 Hr.• น้ําหนัก 10 Kg แรก = 4 cc/Kg/Hr• 10-20 Kg ตอมา = 2 cc/Kg/Hr• >20 Kg = 1 cc/Kg/Hr• Rate = cc/Hr• Rate/4= drop/min
Daily requirement:Fluidmaintenance 3
• For NPO pt. before surgery• 5% D/N/2 rate 1.5-2 cc/kg/hr
Daily requirement:Fluidmaintenance
• Composition and concentration• Sodium requirement:
– Adult:2-3 mEq/kg/day=100-150 mEq– Child:4 mEq/kg/day
• Potassium requirement:– Adult:1 mEq/kg/day=40-50 mEq– Child:2 mEq/kg/day
• Glucose :125-150 g for prevent ketosis
NaNa++ KK++ CaCa++++ MgMg++++ ClCl-- HCOHCO33 GlucoseGlucose
ECFECF 142 4 5 3 103 27 1205%5%DD//WW 0 0 0 0 0 0 500.9%0.9%NSSNSS 154 0 0 0 154 0 05%5%DD//NN/2/2 77 0 0 0 77 0 505%5%DD//NN/3/3 51 0 0 0 51 0 505%5%DD//NN/5/5 31 0 0 0 31 0 503%3%NSSNSS 513 0 0 0 513 0 0
LRLLRL 130 4 3 0 109 28 0
ARLARL 130 4 2.7 0 108.7 28 0
Daily requirement:Fluidmaintenance
• 5% D/N/2 1000 cc.+ Water 1000 cc.
• 5%D/N/2 2000 cc.
• 5% D/NSS 1000 cc.+ Water 1000 cc.
Fluid deficit,already loss
• Volume deficit assesment from history taking and physical examination
• Mild dehydration:3% B.W.• Moderate dehydration:6% B.W.• Severe dehydration:9% B.W.
STAGE 0-5%Dehydration
5-10%Dehydration
10-15%Dehydration
Appearance Freshful Restless SemicomatoseSkinturgor Normal or slightly
Eyes Normal or sunken Sunken
Mucous membrane Dry red Very dry Very dry, cyanosisH.R. 130 160
% B.W. loss 2-5 % 5-10 % > 10 %Skin temperature Warmer Cold or warm ColdFontanelle (inchild)
Normal Maybe sunken Sunken
อาการ Deficit (% body wt.)Early Thirst 2 %Moderate
Marked thirstDry mouthOliguriaWeaknessMalaiseLoss of skin turgorMental change
6 %
SevereSevere mental changeHallucinationGross weakness
7-14 %
Fluid deficit,already loss
• Composition assesment:Fluid loss from what?
• Vomitting?• Diarrhea?• NG-tube?• T-tube?
Na+ K+ Cl HCO3
Stomach 10 26 10 30
Duodenum 140 5 80 0Diarrhiastools 120 25 90 45Pancreas 140 5 75 115Bile 145 5 100 35
NaNa++ KK++ CaCa++++ MgMg++++ ClCl-- HCOHCO33 GlucoseGlucose
ECFECF 142 4 5 3 103 27 1205%5%DD//WW 0 0 0 0 0 0 500.9%0.9%NSSNSS 154 0 0 0 154 0 05%5%DD//NN/2/2 77 0 0 0 77 0 505%5%DD//NN/3/3 51 0 0 0 51 0 505%5%DD//NN/5/5 31 0 0 0 31 0 503%3%NSSNSS 513 0 0 0 513 0 0
LRLLRL 130 4 3 0 109 28 0
ARLARL 130 4 2.7 0 108.7 28 0
Fluid deficit,already loss
• Diarrhea จะเลือกใช N/2+KCl 30 mEq/l• Vomiting จะเลือกใช N/2+KCl 10 mEq/l• NG tube ใช N/2+KCl 10 mEq• T tube (ในการผาตัดทอน้ําดี) ใช LRL
Third space loss
• Volume:– Major surgery:8 cc/kg/hr– Moderate surgery:6 cc/kg/hr– Minor surgery:4 cc/kg/hr– OMFS:2-4 cc/kg/hr
• Composition:LRS,ARS
Blood loss therapy• Acceptable blood loss (ABL)• (Hct -30) x ปริมาณเลือดในรางกาย x 3/100• < 1/3 ABL—LRS,ARS 2-3:1 of blood loss• >1/3 ABL--LRS,ARS 2-3:1 of blood loss or
Albumin 1:1 of blood loss• = ABL---Packed red cell(PRC) 0.5:1 of
blood loss
Fluid therapy during the operation
• Maintenance• Preoperative deficit
– ½ in first hour– ¼ in second hour– ¼ in third hour
• Third space loss• Blood loss during the operation
Fluid and electrolyte abnormality
• Volume disturbance• Concentration disturbance:Sodium• Composition disturbance:Others
electrolyte
Volume disturbance
• Volume excess
• Volume deficit (dehydration)
Concentration disturbance
• Hyponatremia (Water intoxication)-Water shift to icf:cell swelling esp.brain
• Hypernatremia (Water deficit)– Dehydration
Composition disturbance
• Hypokalemia– กลามเนือ้ออนแรง,ทองอืด,หัวใจเตนไมเปนจังหวะ
• Hyperkalemia– คลื่นไส อาเจียน ปวดทอง ทองเสีย หัวใจเตนไมเปนจังหวะ
The End