Postoperative fluid therapy

Assistant Prof. Sabah Noori

 Postoperative fluid therapy is modified by
the magnitude of surgical trauma Surgery
 and anesthesia are aggressive stimuli.
The body response to these stimuli is
 known as STRESS RESPONSE.
 Stress Response to Surgery: Term used to encompass
metabolic and hormonal changes following surgery,
the same may occur after trauma, burn, &
hemorrhage.
The response has been suggested as being necessary
for survival and recovery after trauma.
Phases of Stress Response
Stress Response has got two phases:
1) The 1st phase of stress response is known as
CATABOLIC Phase.
The Catabolic phase lasts usually 48-72 hours
postoperatively.
2) The 2nd phase of stress response is known as
ANABOLIC Phase.
 The catabolic phase f stress response characterized
by:
① Oliguria (Positive Hydrogen Balance)
② Sodium Retention (Positive Sodium Balance)
③ Loss of Protein ( Negative Nitrogen Balance)

I. Oliguria:
The postoperative oliguria is not due to inadequate
replacement.
The urinary output may be less than 1 Liter even
with an intake as high as 3 liter postoperatively
The Oliguria is due to release of ADH.
 Hypotension and increased Hypervolemia,
osmolarity stimulate osmoreceptor increased serum
osmolarity
in hypothalamus. Nerve impuls
 from hypothalamus stimulate
posterior pituitary gland. Posterior Hypothalamus
 Pituitary gland release the
hormone ADH (Vasopressin). ADH
 Promotes water absorption from
distal tubules of the kidney leading Posterior Pituitary
to Oliguria.
 N.B.: SIADH (Syndrome of
Inappropriate ADH) frequently ADH
occur following surgery even with
adequate water replacement.
H2O Absorption
from distal tubules
 Following a trauma os surgery, there is a period of 24-72
hours of almost NO excretion of Sodium.
-.-

 The output of Na+ can not be increased by supplements of

Na+.
 Aldosterone release responsible for absorption of Na+
from distal renal tubules.

Aldosterone:
Aldosterone is mineralocorticoid hormone secreted by the
cortex of the adrenal gland.
It is secreted in response to:
Reduced renal blood flow (via ACTH).
Hyperkalemia via direct effect on renal cortex.
Hyponatremia via direct effect on renal cortex.
RENIN, ANGIOTENSIN,
ALDOSTERONE System

. .:\r'i r
iu · Il
ANP

- - ----------------- -----

thi ,i.:t
...
' '
l

N + L'pli
11 pro Ii (,.-.1·.al'ion
i. Catabolism of Protien:
➢Catabolism of protien increase urinary excretion of
urea, amonia, amino acids, sulphates, and
accompanying intracellular ions such as K+, Mg++, and
PO+4.
➢ In the presence of Oliguria, these substances may be
appear in the blood in an increased amounts.
➢ Catabolism of protien may reach 500-1000 grams,
which is more than the whole protiens that stored in
the liver.
➢ Protein catabolism may be prevented by
administration of Plasma Proteins.
ii- Fat Catabolism:
Fat breakdown after trauma may reach 500 grams.
When more than 1500 g/day are catabolized, there
is usually accumulation of Keto-acids in the plasma
with Ketonuria.
iii- Glycogen (Carbohydrate Catabolism)
The liver glycogen is used up and there is increased
breakdown of glucose.
Glucose is formed by gluconeogenesis from
aminoacids.
Mechanism of Increased Catabolism:
Most probably due to incraesed release of
CORTISOL.
Trauma ➔ Hypothalamus ➔ ACTH ➔ CORTISOL

Endogenous Water and Hyponatremia:

Water produced by catabolism of protien, fat, and
carbohydrates:
1- responsible for hyponatremia.
2- secondary cause of hyponatremia is shift of Na+
intracellularly.
 Regardless of causes and mechanisms, the
catabolic phase of stress response reduce the
capacity of the kidney to excrete H2O & Na+
during the 1st three days postoperatively.
 Some patients will go into strong positive
water & Na+ balance, when water > 2L & Na+
> 70 mmol given.
 A safe practice is to restrict H2O & Na+ to
its basal requirements.
➢ Adult Basal Requirements:
Na+: 1 mmol/Kg/Day
H2O: 30 ml/Kg/Day

➢ Children Basal Requirements:

Na+ : 2 mmol/Kg/Day
H2O: 60 mmol/Kg/Day

N.B.
K+ administration is not necessary for the 1st three
days postoperatively, because the serum K+ is kept
normal in spite of the overall deficit, an this is due to
increase catabolism of protein.
K+ administration is necessary if Serum K+ estimation
shows hypokalemia During anabolic phase after 3 days.
 In addition to daily requirements, fluid must be
supplied volume for volume to replace losses by
vomiting, gastric suction, intestinal drainage,
fistulae, and diarrhea.
 Allowance my also have to be made for
 Any internal losses of fluid such as pooling of
fluid in the gut in paralytic Ileus.
 Insensible Losses: Excessive sweating, Hot
(warm) ambient tenperature, fever, and
tachypnea.
 For FEVER, 250 ml of 1/5 G/S is required for
each 10C rise of body temperature above
normal.
Thank You
Fluid & Electrolyte Balance

ASSISTANT PROF. SABAH NOORI

Definitions:

 Homeostasis: Uniformity or Stability, i.e. the state

of equilibrium of internal environment.
 Electrolytes: compounds that when placed in
solution will conduct an electric current.
 Ions: are dissociated particles of electrolytes that
carry either Positive charge (CATion) or Negative
charge (ANion)
 Concentration of Solution may be expressed either as
quantity of solute per volume of solution, or
quantity of solute per weight of solvent.
 Quantity expressed in Grams, Moles (mol), or
Equivalent.
 One Mole of substance represents 6.02 x 1023
molecules. The weight of this quantity in grams
referred as Gram Molecular Weight.
 Equivalent: No. of Moles multiplied by the
Valence (charge)
 Molarity: (is the SI unit of concentration)= No. of
Moles of solute / Liter of Solution.
 Molality: No. of Moles of Solute / Kg weight of
Solvent.
➢ Osmosis: the movement of water across a
semipermeable membrane as a result of difference in
non-diffusible solute concentrations between the two
sides.
➢ Osmotic Pressure: the pressure that must be
applied to side with more solute to prevent a net
movement of water down its concentration gradient.
➢ Osmole: unit of osmotic pressure
One Osmole = 1 Mole (for non-dissociated Substances).
One Osmole = 1 Mole x No. of ions produced (for ionized
substances).
➢ Osmolarity of solution is equal to No. of Osmole
per liter of solution.
➢ Osmolality: No. of Osmole per Kg of solvent.
Total Body Fluids:

❖ Water when expressed as percentage of the body

weight, the corresponding mean values:
❖ Men 60%, Women 50%, Infant 70%

Interstitial
ICS
Space 16%
40% Plasma
ECS 20%
Fluid Water 4%
Compartment
Of the Body
Distribution and Fixation of Body Water:

Total Body Water

ECS ICS
290 mosmol/Kg 290 mosmol/Kg
Na-Ions K-Ions

IVS
COP 25 mmHg Interstitial
Space
80% Albumin
Fluid Movement in Capillaries:
Water Balance (WB):

Defined as the ratio of water taken in (H2O input)

through all routes over water leaving the body through
all routes.
W.B. = H2O gained/ H2O loss = 1
The same definition is applied for Na+ , K+ , N2 and
other electrolyte balances.
 Water Balance
Water Gained Water Loss
3L 3L

Fluids 1500 ml Urine 1500 ml

Skin 500 ml & Lung 500 ml

Food 1000 ml (Insensible Loss)

H2 + O2 300 ml Feces 300 ml

Daily Water requirement of an adult male basal condition is:

40 ml/Kg BW / Day = 40 x 70 = 2800 ml ≅ 3000 ml
 Electrolytes Composition
in various body fluid compartments

ECF
IONS (meq/L) ICF
Plasma Interstitial
Na+ 142 140 10
(CATion)
Positive

K+ 5 5 150
Ions

Ca++ 5 5 0.0001
Mg++ 3 3 40
Cl- 100 + 5 115 4
Negative Ions

HCO3- 30 + 2 30 10
(ANion)

HPO4-- 2 4 142
SO4— 1 2 5
Protien (Pr-) 16 1 40
pH 7.4 7.4 7.0
Osmolality 300 ≈300 ≈300
Types of IV Fluids:

Crystalloids Colloids

Normal (0.9%) Saline Human Albumin

Riger’s Lactate Solution Gelatin Solution

(Hartmann’s (Haemacel, Gelafusin)
Solution)
5% Dextrose Dextran

Plasma-Lyte 148 Hydroxethyl Starches

(Hetastarch)
Thank You