Fluid and electrolyte balance

Daily requirements

 For the ‘average’ 70 Kg man

o Total body water is 42 L (~60% of body weight)
o 28 L is in the intracellular and 14 L in the extracellular compartments
o The plasma volume is 3 L
o The extravascular volume is 11 L
o Total body Na+ is 4200 mmol (50% in ECF)
o Total body K+ is 3500 mmol (only about 50-60 mmol in ECF)
o Normal osmolality of ECF is 280 –295 mosmol/kg

Fluid replacement

When calculating fluid replacement for a patients need to consider:

Maintenance requirements

 Daily maintenance fluid requirements vary between individuals.

o 70 Kg male = 2.5 - 3.0L water, 120 – 140 mmol sodium and 70 mmol
potassium
o 40 Kg woman = 2.0L water,70 – 90 mmol sodium and 40 mmol
potassium
 Daily maintenance fluid requirements for children
o 0-10 kg is 100 ml/kg
o 10-20 kg is 1000 ml + 50 ml/kg for each kg > 10
o >20 kg is 1500 ml + 25 ml/kg for each kg > 20

Replacement of losses

 Pre-operative or pre-admission
 Ongoing losses
 Nasogastric aspirate
 Vomit, diarrhoea
 Stoma, drains, fistula etc
 Most ‘surgical ‘ ongoing losses are rich in sodium and should be replaced with 0.9%
saline

Insensible losses

 Faeces approximately 100 ml/ day

 Lungs approximately 400 ml/ day
 Skin approximately 600 ml/ day
Composition of crystalloids

Hartmann’s Normal Dextrose

Solution Saline Saline
Sodium (mmol/l) 131 150 30
Chloride (mmol/l) 111 150 30
Potassium (mmol/l) 5 Nil Nil
Bicarbonate
29 Nil Nil
(mmol/l)
Calcium (mmol/l) 2 Nil Nil
 3L of Dextrose saline is not equivalent to 2L 5% Dextrose and 1L Normal saline
 3L Dextrose Saline = 3L water and 90 mmol sodium
 2L 5% Dextrose saline + 1L Normal saline = 3L water and 154 mmol sodium

Composition of colloids

Volume Average Circulatory

effect (%) MW (kDa) half life
Gelatins (Haemaccel) 80 35 2-3 hours
4% Albumin 100 69 15 days
Dextran 70 120 41 2-12 hours
6% Hydroxyethyl
100 70 17 days
Starch
 Monodispersed = All molecules of similar molecular weight
 Polydispersed = Molecules have spread of molecular weights

Albumin

 Monodispersed
 Expensive
 Long half life
 Accounts for 60-80% of normal plasma oncotic pressure
 No adverse effect on coagulation

Dextrans

 Polysaccharides
 Polydispersed with MW 10-90 kDa
 Reduces plasma viscosity
 Reduces platelet aggregation
  1-5% develop anaphylaxis

Gelatins

 Polypeptides
 Polydispersed with MW ~35 kDa
 Rapidly lost from vascular space
 Hydroxyethyl starch
 Synthetic polysaccharide polymers derived from amylopectin
 Polydispersed with MW 50-450 kDa
 Large molecules engulfed by reticuloendothelial system
 Associated with bleeding diathesis

Assessment of adequacy of resuscitation

 Clinical history and observations – Pulse, blood pressure, skin turgor

 Urine output – oliguria < 0.5 ml/kg/hr
 CVP or pulmonary capillary wedge pressure
 Response of urine output or CVP to fluid challenge
 A fluid challenge should be regarded as a 200-250 ml bolus of colloid
 This should be administered as quickly as possible
 A response in the CVP or urine output should be seen within minutes
 The size and duration of the CVP response rather the actual values recorded is
more important

Bibliography

Choi P T-L, Yip G, Quinonez L G, Cook D J. Crystalloids vs. colloids in fluid

resuscitation: a systematic review. Crit Care Med 1999; 27: 200-210.

Schierhout G, Roberts I, Alderson P. Colloids versus crystalloids for fluid resuscitation in

critically ill patients (Cochrane Review). In: The Cochrane library, Issue 1, 1999. Oxford.

Traylor R J, Pearl R G. Crystalloid versus colloid versus colloid: All colloids are nor
equal. Anaesth Analg 1996; 83; 209-212.