Fluids & Electrolytes

After Cardiac
Surgery
Rodina Sobhy (MD)
 Fluids After Cardiac Surgery
Day one:
 50% of maintenance
 If neonate: G10% (Neoment)
 If > 30 days: G5% (Pediament)
 Monitor serum electrolytes daily
 Some recent studies recommend 2.5% dextrose
in 0.4% normal saline in children < 4 yrs.
 Fluids After Cardiac Surgery
 If pulmonary &/or systemic edema are
not present:
 Fluid intake can be increased over 3 days
to achieve 80% of maintenance in
ventilated patients.
 100% of maintenance in non ventilated
patients
 Fluids After Cardiac Surgery
 If pulmonary &/or systemic edema are
present:
 Fluid restriction is maintained.
 Diuretics are usually required.
 Frusemide infusions are effective in
unstable patients.
 Fluids After Cardiac Surgery
 Peritoneal dialysis or hemofiltration may
be required if renal function is impaired.
 Fluids After Cardiac Surgery
 Modifications:
 Fever: increase 10% with every one
degree increase in temperature.
 Hypothermia: Fluid requirement
decreases by 10% for every degree
decrease in temperature.
 Fluids After Cardiac Surgery
 Preterm requirements (120ml / kg)>
Fullterm.
 If phototherapy: Increase fluid intake by
30%.
 Renal Failure: Insensible water loss (0.3X
maint.) + UOP
 Electrolytes After Cardiac
Surgery
Potassium
 Target potassium is 3.8 to 4.3 mmol/L.
A bolus of potassium is given only if:
 Serum K < 3.3 mmol/L.
 Urine output >1ml/kg/hr.
 Electrolytes After Cardiac
Surgery
 In patients with tachyarrhythmias, a bolus
of potassium is considered if serum K is
<4 mmol/L.
 Infuse prescribed supplement over 30-60
min. via a clearly labelled syringe & a
central line.
 Electrolytes After Cardiac
Surgery
 Maximum potassium dose 0.5 mmol/kg
over one hour.
 Always infuse via central line, never
peripheral line.
 Recheck potassium after infusion.
 Electrolytes After Cardiac
Surgery
 Give precise instructions about strong
potassium infusion to bedside nurse:
 Concentration.
 Duration.
 Monitoring.
 Stress dangers of flushing.
 Dedicated infusion line essential.
 Electrolytes After Cardiac
Surgery
 Mild Hyperkalaemia:
1. Remove/shift K from body/plasma
efficiency.
 Stop all prescription administration of K
 Give frusemide 1mg/kg IV.
 Correct metabolic or respiratory acidosis.
 Salbutamol: Continuous nebulised salbutamol
is moderately effective but it is ineffective in
betablocked patients.
 Electrolytes After Cardiac
Surgery
2. Investigate, diagnose & treat potential
causes.
3. Monitor response to treatment.
Recheck plasma K every 30 min.
N.B. If arrhythmia occur or K rises above 6
mmol/L___ progress to emergency
management.
 Electrolytes After Cardiac
Surgery
Severe Hyperkalaemia:
 If K > 6.5 mmol/L at any time
 If K > 6 mmol/L after diuretics treatment of
mild hyperkalaemia
 Electrolytes After Cardiac
Surgery
1. Calcium Chloride.
N.B. Calcium salts are incompatible with
sodium bicarbonate & shouldn’t be infused
through the same line.
2. Insulin: 0.05 units/kg then 0.05
units/kg/hour with 0.5 g/kg glucose for
2 hours may be used.
N.B. Monitor Blood glucose frequently
 Electrolytes After Cardiac
Surgery
3. Dialysis: Peritoneal dialysis or
continuous veno-venous hemofiltration
 Electrolytes After Cardiac
Surgery
Ionized Hypocalcaemia
If ionized calcium < 1 mmol/ L
 Haemodynamically
unstable____Calcium infusion or slow
bolus.
 Haemodynamically stable____ ↑
maintenance ca intake in diet or PN
 Electrolytes After Cardiac
Surgery
 Monitoring:
Check calcium 2 hourly initially then every 4
hours.
 Precautions:
1. Ca should only be given in central lines.
2. Ca is incompatible with citrated blood
products & sodium bicarbonate.
 Electrolytes After Cardiac
Surgery
3. Bradycardia can result from rapid
administration.
4. Hypocalcaemia worsens digoxin toxicity,
may worsen neurological outcome after
hypoxic ischemic events & causes
vasoconstriction.
i.e. ↑ B.P. at the expense of ↑ afterload.
 Electrolytes After Cardiac
Surgery
Hyponatraemia:
C/P___ Lethargy, apathy, nausea, vomiting,
seizures & coma.
Management:
1. Evaluate ECF volume.
A. If Low__ Loss Na > water
e.g. Diarrhea, N.G. losses, Chest tube drainage,
Acute tubular necrosis, Postobstructive
diuresis, diuretics.
 Electrolytes After Cardiac
Surgery
Treatment
a. Plasma expansion with isotonic solutions,
b. Volume correction will suppress ADH &
allow spontaneous correction oh
hyponatraemia.
 Electrolytes After Cardiac
Surgery
B. Expanded ECF: Gain water > Na.
e.g. CHF, NS, ARF, Inappropraite dilution of
formula, PN.
Treatment
1. Restrict water.
2. Hypertonic sodium & fluid extraction.
 Electrolytes After Cardiac
Surgery
C. Normal or near normal ECF__ Impaired water
excretion- SIADH
Treatment
1.Restrict water (40% of maint.)
2. Hypertonic saline 5ml/kg over one hour to get Na > 120
& stop seizures
3. Frusemide.
4. Hourly urine, serum Na & osmolality in acute phase
5. Drug antagonists of ADH e.g. IV phenytoin.
 Electrolytes After Cardiac
Surgery
D. Exclude Pseudohyponatraemia ( due to
hyperlipidaemia & hyperglycaemia).
 Electrolytes After Cardiac
Surgery
E. Cerebral Salt Wasting
 Difficult to distinguish from SIADH
 Weight loss or signs of volume depletion in
the presence of deteriorating
hyponatraemia.
 Electrolytes After Cardiac
Surgery
 Hyponatraemia is resistant to fluid
restriction.
 Etiology appears to be related to
natriuretic factors in serum.
Treatment
 Volume repletion.
 Replace urinary losses of sodium.
 Electrolytes After Cardiac
Surgery
Acute management of symptomatic
hyponataemia:
 3-5 ml/kg 3% saline over one hour to bring
Na>120 mmol/L
 Absolute ↑ over first 2 days should be
below 25 mmol/L to minimise risk of
central pontine myelinosis.
 Electrolytes After Cardiac
Surgery
Management of rapid correction of
sodium:
 IV dextrose 5% +/- DDAVP
 Electrolytes After Cardiac
Surgery
BLOOD LACTATE:
Normal Level is below 2 mmol/L
Causes of high blood lactate:
 Circulatory Failure
 Severe hypoxaemia
 Severe anaemia
 Prolonged seizures
 Intoxification
 Inborn errors of metabolism
 Decompensated D.M.
 Electrolytes After Cardiac
Surgery
 Lactate measurement in the immediate
postoperative period & at 4 hours & 8
hours after surgery are the most reliable
predictors of major adverse events.
 Electrolytes After Cardiac
Surgery
Metabolic Acidosis:
Common Causes:
 Washout acidosis: shortly after bypass
due to reopening of peripheral circulation.
 Low COP
 Low blood glucose
 Septicaemia
 Electrolytes After Cardiac
Surgery
Less Common Causes:
 High aminoacid intake.
 ARF, RTA
 Primary metabolic disorder.
 GI bicarbonate loss.
 Electrolytes After Cardiac
Surgery
Investigations: especially in persistent
metabolic acidosis
 Blood gases, plasma electrolytes
(Na,K,HCO3,Cl), plasma lactate.
 Blood glucose, BUN, Cr, PH & ketones.
 Urine test: Ketones, glucose.
 Ammonia.
 Electrolytes After Cardiac
Surgery
 Calculate the anion gap (Normal 5-15
mmol)
 Renal U/S
 Electrolytes After Cardiac
Surgery
Management:
 Correct cause.
 Consider correcting acidosis if BE > -5
NaHCO3 is given slowly IV, preferably
through a central line.
 Electrolytes After Cardiac
Surgery
 Formula= mmol NaHO3 (ml 8.4%)=
(BE x kg wt)/2 if < 5 kg. OR
(BE x kg wt)/3 if > 5 kg.
 Electrolytes After Cardiac
Surgery
THAM (Tromethamine)
It has 2 advantages over NaHCO3
 It doesn’t contain sodium
 It effectively buffers in a closed system,
unlike bicarbonate where CO2 must first
be eleminated.
 Capillary Leak Syndrome
 This syndrome is thought to arise through
stimulation of inflammatory cascades
which results in damage to the capillary
endothelium.
 Neonates & infants< 1yr are at high risk
after difficult CPB.
 It occurs within 24 hours of CPB
 Capillary Leak Syndrome
Features:
 Unstable circulation with falling systemic
pressure.
 ↑ inotropic requirement.
 ↓ Filling pressures.
 ↑ Colloid requirement.
 Capillary Leak Syndrome
 Absence of bleeding to explain the need
for colloid infusion
 Severe systemic edema, effusions &
ascites.
 Often low diastolic blood pressure.
 Capillary Leak Syndrome
Management:
No Specific ttt
 Keep filling pressure as low as is
compatible with good COP.
 Ventilation: ↑ ventilatory pressures &
↑PEEP
 Capillary Leak Syndrome
 Optimise hemodynamics.
 Keep high normal haematocrit.
 Consider peritoneal drainage of ascitic
fluid +/- P.D. if renal replacement therapy
is indicated.