Fluids and electrolytes in

surgical patientsPresented by :

Dr.Abdullah j. Al-Qattan

OUTLINE

1. BODY WATER AND FLUIDS VOLUMES2. OSMOTIC PRESSURE3. SIGNS AND SYMPTOMS OF VOLUME DISTURBANCES4. HYPERNATREMIA AND HYPONATREMIA5. HYPERKALEMIA AND HYPOKALEMIA6. TYPES OF FLUIDS

BODY WATER AND FLUIDS VOLUMES

• TBW IS 50%-60% OF BODY WEIGHT

• TBW IN NEWBORNS IS HIGHR (75%-80%) OF BODY WEIGHT

BODY WATER AND FLUIDS VOLUMES

• 2/3 OF TBW IS INTRACELLULAR FLUID (40% BODY WEIGHT)

• 1/3 OF TBW IS EXTRACELLULAR FLUID (20% BODY WEIGHT)

• EXTRA CELLULAR COMPOSITION :PLASMA (1/4 ECF) , (5% OF BODY WEIGHT)INTERSTITIAL FLUID (3/4 ECF) , ( 15% OF BODY

WEIGHT)

OSMOTIC PRESSURE• THE PHYSIOLOGIC ACTIVITY OF ELECTROLYTES IN SOLUTION

DEPENDS ON THE NUMBER OF PARTICLES PER UNIT VOLUME.

• THE OSMOLALITY OF THE INTRACELLULAR AND EXTRACELLULAR FLUIDS IS MAINTAINED BETWEEN 290 AND 310 MOSM IN EACH COMPARTMENT

• HOW TO CALCULATE SERUM OSMOLARITY ??

QUESTION• WHAT IS THE APPROXIMATE SERUM OSMOLARITY FOR A

PATIENT WITH THE FOLLOWING FINDINGS ?? Na 130 CL 94 K 5.2 CO2 14 GLUCOSE 360 BUN 84 CREATININE 3.2

a) 270b) 290c) 310d) 330

Calculated serum osmolality = (2 sodium) + ✖️(glucose 18) + (BUN 2.8) ➗ ➗

SO = (2 130) + (360 18) + (84 2.8)✖️ ➗ ➗

SO = 310

Schwartzs Principles of Surgery: Absite and Board Review. 9TH ED.

SIGNS AND SYMPTOMBS OF VOLUME DISTURBANCESHYPOVOLEMIC HYPRVOLEMIC

GENERALIZED WEIGHT LOSS WEIGHT GAIN

DECREASE SKIN TURGORE PREIPHERAL EDEMA

CARDIAC TACHYCARDIA INCREASE CARDIAC OUTPUT

ORTHOSTASIS HYPOTENSION

INCREASED CENTRAL VENOUS PRESSURE

COLLAPSED NECK VEINS DISTENDED NECK VEINS

RENAL OLIGURIA ……...

GI ILEUS BOWEL EDEMA

PULMONARY …….. PULMONARY EDEMA

HYPERNATREMIA

• HYPERNATREMIA RESULTS FROM EITHER A LOSS OF FREE WATER OR A GAIN OF SODIUM IN EXCESS OF WATER.

• IT CAN BE ASSOCIATED WITH AN INCREASED, NORMAL, OR DECREASED EXTRACELLULAR VOLUME

WHAT ARE THE CAUSES OF

HYPERNATREMIA ??

SYSTEM BODY HYPERNATREMIA

CENTRAL NERVOUS SYSTEM

RESTLESSNESS, LETHARGY, ATAXIA, IRRITABILITY, TONIC SPASMS, 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

CLINICAL MANIFESTATIONS OF HYPERNATREMIA

HYPONATREMIA

• A LOW SERUM SODIUM LEVEL OCCURS WHEN THERE IS AN EXCESS OF EXTRACELLULAR WATER RELATIVE TO SODIUM, EXTRACELLULAR VOLUME CAN BE HIGH, NORMAL, OR LOW

• HYPONATREMIA IS ALWAYS ASSOCIATEDN WITH HYPOOSMOLALITY , IN CASE OF HYPONATREMIA WITHOUT HYPOOSMOLALITY NAMED “PSEUDOHYPONATREMIA”

WHAT ARE THE CAUSES OF

HYPONATREMIA ??

CLINICAL MANIFESTATIONS OF HYPONATREMIA

BODY SYSTEM HYPONATREMIA

CENTRAL NERVOUS SYSTEM HEADACHE, CONFUSION, HYPERACTIVE OR HYPOACTIVE DEEP TENDON REFLEXES, SEIZURES, COMA, INCREASED INTRACRANIAL PRESSURE

MUSCULOSKELETAL WEAKNESS, FATIGUE, MUSCLE CRAMPS

GI ANOREXIA, NAUSEA, VOMITING, WATERY DIARRHEA

CARDIOVASCULAR HYPERTENSION AND BRADYCARDIA IF INTRACRANIAL PRESSURE INCREASES SIGNIFICANTLY

TISSUE LACRIMATION, SALIVATION

RENAL OLIGURIA

HYPERKALEMIA

• HYPERKALEMIA IS DEFINED AS A SERUM POTASSIUM CONCENTRATION ABOVE THE NORMAL RANGE OF 3.5 TO 5.0 MEQ/L.

• IT IS CAUSED BY EXCESSIVE POTASSIUM INTAKE, INCREASED RELEASE OF POTASSIUM FROM CELLS, OR IMPAIRED POTASSIUM EXCRETION BY THE KIDNEYS

CAUSES OF HYPERKALEMIA• INCREASED INTAKE :

POTASSIUM SUPPLEMENTATIONBLOOD TRANSFUSION

• INCREASED RELEASE :ACIDOSISHYPERGLYCEMIA

• IMPAIRED EXCRETION :RENAL FAILURE

CLINICAL MANIFESTATIONS OF HYPERKALEMIA

SYSTEM HYPERKALEMIA

GI NAUSEA/VOMITING, COLIC, DIARRHEA

NEUROMUSCULAR WEAKNESS, PARALYSIS, RESPIRATORY FAILURE

CARDIOVASCULAR ARRHYTHMIA, ARREST

RENAL …..

ECG CHANGES IN HYPERKALEMIA

ECG changes progress as follows :

peaked T – wave >> widening of QRS complex >> prolongation of P-R interval >> loss of P wave >> ST segment depression >> ventricular fibrillation and asystole.

TREATMENT OF HYPERKALEMIA

• POTASSIUM REMOVAL : KAYEXALATE DIALYSIS

• SHIFT POTASSIUM : GLUCOSE 1 AMPULE OF D 5 AND REGULAR INSULIN 5–10 UNITS IV BICARBONATE 1 AMPULE IV

• DECREASE CARDIAC EFFECTS : CALCIUM GLUCONATE 5–10 ML OF 10% SOLUTION

HYPOKALEMIA

• HYPOKALEMIA IS MUCH MORE COMMON THAN HYPERKALEMIA IN THE SURGICAL PATIENT

• IT MAY CAUSED BY INADEQUATE POTASSIUM INTAKE, EXCESSIVE RENAL POTASSIUM EXCRETION, POTASSIUM LOSS IN PATHOLOGIC GI SECRETIONS

CAUSES OF HYPOKALEMIA

• INADEQUATE INTAKE : DIETARY , POTASSIUM FREE INTRAVENOUS FLUID

• EXCESSIVE POTASSIUM EXCRETION : HYPERALDOSTERONISM

• GL LOSSES : DIRECT LOSS OF POTASSIUM FROM GI FLUID “DIARRHEA” RENAL LOSS OF POTASSIUM

CLINICAL MANIFESTATIONS OF HYPOKALEMIA

SYSTEM HYPOKALEMIA

GI ILEUS, CONSTIPATION

NEUROMUSCULAR DECREASED REFLEXES, FATIGUE, WEAKNESS, PARALYSIS

CARDIOVASCULAR ARREST

TREATMENT OF HYPOKALEMIA

• SERUM POTASSIUM LEVEL <4.0 MEQ/L: ASYMPTOMATIC, TOLERATING ENTERAL NUTRITION: KCL 40 MEQ

PER ENTERAL ACCESS OD ASYMPTOMATIC, NOT TOLERATING ENTERAL NUTR. : KCL 20 MEQ

IV Q2H BID SYMPTOMATIC: KCL 20 MEQ IV Q1H × 4 DOSES

RECHECK POTASSIUM LEVEL 2 H AFTER END OF INFUSION; IF <3.5 MEQ/L AND ASYMPTOMATIC, REPLACE AS PER ABOVE PROTOCOL

IV replacement shouldn’t exceed 240mEq/day

IV FLUIDS

FLUID & ELECTROLYTE REQUIREMENTS

The 1st 10 kg >>> 100 ml/kg/day The 2nd 10 kg >>> 50 ml/kg/day Wt. above 20kg >> 20 ml/kg/day

TYPE OF FLUIDS

• IV FLUID MAY CONSIST OF INFUSIONS OF CRYSTALLOID , COLLOID , OR A COMPINATION OF BOTH.

• Crystalloids : Aqueous solutions of LMW salts with or without glucose. most common useing

• Colloids : contain high MW substances such as proteins or large glucose colloids have been shown to improve oxygen transport, myocardial

contractility and cardiac output

CRYSTALLOID SOLUTIONS

• Intravascular half life is 20 – 30 minutes.• The most commonly used fluid is lactated Ringer’s solution: - Generally it has the least effect on ECF composition, and it is the most physiologic solution when large volumes are needed. - Lactate is converted by the liver into bicarbonate.

CRYSTALLOID SOLUTIONS• Normal Saline:

- When given in large volumes, it produces dilutional hyperchloremic acidosis bec. Of its high Na+ & Cl- contents ( Plasma bicarbonate conc. decreases as Cl- conc. Increases). - NS is a preferred solution for hypochloremic metabolic alkalosis and for diluting PRBCs prior to transfusion.

CRYSTALLOID SOLUTIONS• D5W: - Used for replacement of pure water deficits and as a maintenance fluid for patients on sodium restriction.

• Hypertonic 3% saline: - Treatment of severe symptomatic hyponatremia.

COLLOID SOLUTIONS• Intravascular half life 3 – 6 hours.• The substantial cost and occasional complications tend to limit their use.• Generally accepted indications for use: 1- Severe intravascular fluid deficits ( hemorrhagic shock) prior to arrival of blood for transfusion. 2- Severe hypoalbuminaemia or conditions associated with large protein losses such as burns.

COLLOID SOLUTIONS

• Several colloid solutions are generally available.

• They are derived from either plasma proteins or synthetic glucose polymers, and they are supplied in isotonic electrolyte solutions.

REFERENCES

• SCHWARTZS PRINCIPLES OF SURGERY: ABSITE AND BOARD REVIEW. 9TH ED.

• SCHWARTZS PRINCIPLES OF SURGERY 10TH ED• SABISTON TEXTBOOK OF SURGERY 19TH EDITION• KUWAITI BOARD LECTURE , DR.KHAJA

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