FLUIDS AND

ELECTROLYTES FOR
SURGEONS

Anil S. Paramesh MD, FACS

Associate Professor of Surgery and Urology
Why ?
Essential for surgeons (and all physicians)
Knowledge can diagnose, treat and prevent
many of the problems in surgical patients

Most abnormalities are

relatively simple, and many
iatrogenic
Fluid Compartments

Total Body Water

Relatively constant
Depends upon fat content and varies with age

Men 60% (neonate 80%, 70 year old 45%)

Women 50%
 ICF ECF
1/3
2/3 (40% BW) (20% BW)
Predominant solute Predominant solute
K+ Na+

75% interstitial

25% intravascular

(5% of BW)

Its All About Balance

Gains and Losses

Most individuals ingest approx 2 2.5 L/day
Losses
Sensible and Insensible
Typical adult, typical day
Skin 600 ml
Lungs 400 ml
Kidneys 1500 ml
Feces 100 ml

Balance can be dramatically impacted by

illness and medical care
How much fluid can a patient lose if
a patient could lose fluid?

Sensible losses
Blood (most pts can tolerate 500 cc BL)
Sweat (up to 4 L /day)
Tears (diarrhea)

Insensible losses
Skin 250 cc/day/degree fever
Trach/vent upto 1500 cc/day
Peritoneum - > 1/day
Third spacing
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I LOVE SALT WATER!

 Electrolytes

(mEq/L) Plasma Intracellular

Na 140 12
K 4 150
Ca 5 0.0000001
Mg 2 7
Cl 103 3
HCO3 24 10
Protein 16 40
Fluid Movement

Is a continuous process
Diffusion
Solutes move from high to low concentration
Osmosis
Fluid moves from low to high solute concentration.
Active Transport
Solutes kept in high concentration compartment
Requires ATP
Movement of Water

Osmotic activity

Normal around 300 mOsm/L

Osmolality determined by concentration of

solutes

Plasma (mOsm/L)
2 X Na + Glc + BUN
18 2.8
Fluid Status

Blood pressure
Check for orthostatic changes
Physical exam
Invasive monitoring
Arterial line
CVP
PA catheter
Foley
Volume Deficit

Most common surgical disorder

Signs and symptoms
CNS: sleepiness, apathy, reflexes, coma
GI: anorexia, N/V, ileus
CV: orthostatic hypotension, tachycardia with
peripheral pulses
Skin: turgor
Metabolic: temperature
Hypovolemia
Acute Volume Depletion

Determine etiology
Hemorrhage,
NG, fistulas,
Aggressive diuretic therapy
Third space shifting, burns, crush injuries
Ascites
What kind of fluid are we losing?

Sweat hypotonic (low sodium)

Insensible loss is pure water
GI loss is usually isotonic
Stomach acid, high CL
Pancreas/bile high HCO3
Saliva high K
IV fluids a la carte

NaCl
Normal saline (0.9%) has 154 mEq/L Na, 154
mEq Cl
Normal has 77 mEq Na/Cl
Lactated Ringers
Has 130 Na, 109 Cl (also has some K, Ca,
lactate)
D5Water
Good replacement for insensible losses
Case 1

6 month old boy, born full-term

Developed worsening vomiting during the
past week
Today he is listless, irritable, not tolerating
oral intake
Pulse 145, BP 70/50
Diaper is dry, anterior fontanel depressed
Case 1 Labs

134 92 12
2.8 40 0.8

15
12.3
200

45
Case 1 F & E Problem List
134 92 12
2.8 40 0.8

Hypovolemia
Hypochloremia

Hypokalemia

Alkalosis
Treatment Patient weight is 12 kg

Fluid choice?
Replace volume
Replace K/Cl
How to order
Bolus
Think about rate over time
Adequate access important
What would maintenance fluid choice and
rate be?
4-2-1 rule
Acid Base Balance

Acidosis
May result from decreased perfusion i.e. decreased
intravascular volume
K will move out of cells (K+ - H+ exchange)

Alkalosis
Complex physiologic response to more chronic
volume depletion
i.e. vomiting, NG suction, pyloric stenosis, diuretics
K will move intracellular
Paradoxical Aciduria

Hypochloremic

Na
H

Hypovolemia

Aldosterone
activation
Na

Loop of Henle

Case 1 When should we operate?

Need to wait until adequately resuscitated

Why

Monitor by:
Normalized vital signs
Good urine output
Normalized labs
Case 2

64 year old, 50 kg, had colon resection 5

days ago
doing well .until.
Suddenly develops atrial fibrillation with rapid
ventricular response
P 120, irregular; BP 115/70; RR 20
Temp 38.7
Confused, anxious
Case 2 Labs

128 100 12
3.0 22 0.8
Mg 1.1

8.9
16.3
180

28
Case 2
Diagnoses?

New onset A fib, why?

Hypervolemia

Hyponatremia

Hypokalemia

Hypomagnesemia

Anemia
Case 2
Why does patient have hypervolemia?
Increased Antidiuretic Hormone
(ADH)

Causes
Surgical stress (physiologic)
Cancers (pancreas, oat cell)
CNS (trauma, stroke)
Pulmonary (tumors, asthma, COPD)
Medications
Anticonvulsants, antineoplastics, antipsychotics,
sedatives (morphine)
Hyponatremia how to classify

Na loss
True loss of Na
Dilutional (water excess)
Inadequate Na intake
Classified by extracellular volume
Hypovolemic (hyponatremia)
Diuretics, renal, NG, burns
Isovolemic (hyponatremia)
Liver failure, heart failure, excessive hypotonic
IVF
Hypervolemic (hyponatremia)
Glucocorticoid deficiency, hypothyroidism
Patient was receiving maintenance fluids

D5 0.45NS at 125 ml/hr

Case 2 - How to treat

A fib: ACLS protocol

Correct electrolytes
Replace Mg and K
Decrease volume, fluid restriction
Case 3

23 year old with jejunostomy

Had colon and ileum resected due to injury
Tolerates some oral nutrition, but has high
output from jejunostomy (2.5 liters per day),
therefore requires TPN
P 118, BP 105/60
Case 3 Labs

154 114 28
3.2 16 2.4
Glucose 213

Mg 1.4

9.7
10.3
380

28
Current Problems

Hypovolemia
Increased plasma osmolarity
2 X 154 + (213/18) + (28/1.8) = 335
Hypernatremia
Renal insufficiency
Acidosis
Case 3 - Hypovolemia

Fistula output
High volumes can rapidly lead to dehydration
Electrolyte composition can be difficult to
estimate
Can send aliquot to laboratory
May need to be replaced separately from
maintenance (TPN) fluids
Hyperglycemia
Hypernatremia

Relatively too little H2O

Free water loss (burns, fever, fistulas)
Diabetes insipidus (head trauma, surgery,
infections, neoplasm)
Dilute urine (Opposite of SIADH)
Osmotic diuresis
Nephrogenic DI
Kidney cannot respond to ADH
Too much Na, usually iatrogenic
Hypernatremia

Free water deficit:

[0.6 X wt (kg)] X [Serum Na/140 - 1]

Example:

Na 154, 60 kg person

(0.6 X 60) X [(154/140) - 1]

36 X [1.1 -1]

36 X 0.1 = 3.6 Liters

 154 114 28
Case 3 How to Treat 3.2 16 2.4

Correct hyperglycemia
Replace pre-existing volume deficits
Reduce ostomy output if possible
What to do with:
Acidosis?
Hypokalemia?
Case 4

58 year old, had a recent kidney transplant

Laboratory calls with critical value:
Potassium 5.9

What to do?
Case 4

Evaluate the patient

Exam
ECG
Order repeat labs
Hyperkalemia - Common Causes

Hemolyzed specimen

Underlying disease
Renal failure
Rhabdomyolysis

Associated medications
Too much K+, ACE inhibitors, beta-blockers,
antibiotics, chemotherapy, NSAIDS,
spironolactone
Potassium and Ph

Normally 98% intracellular

Acidosis
Extracellular H+ increases, H+ moves
intracellular, forcing K+ extracellular
Alkalosis
Intracellular H+ decreases, K+ moves into cells
(to keep intracellular fluid neutral)
Hyperkalemia - Treatment

Emergency (> 6 mEq/l)

Monitor ECG, VS
Calcium gluconate IV (arrhythmias)
Insulin and glucose IV
Kayexalate, Lasix + IVF, dialysis
Mild to Moderate
Mild: dietary restriction, assess medications
Moderate: Kayexalate
Severe: dialysis