Fluids & Electrolytes

in Surgical Patients

Objectives
Review physiology controlling fluid/elec balance Appreciate differences in surgical patients Be able to order fluid regime for surgical patients

Total Body Water

body wt% total intracellular extracellular intravas interstitial 60 40 20 5 15 Total body water% 100 67 33 8 25

Composition of Fluids
plasma Cations Na K Ca Mg Anions Cl HCO SO4 HPO4 Protein 140 4 5 2 103 24 1 2 16 interstitial 146 4 3 1 104 27 1 2 5 intracellular 12 150 10 7 3 10 116 40

Osmotic Activity of Fluids

Osm or mOsm unit for number of particles

1 mol of NaCl - 2 osm Osmolarity - mOsm/L Osmolality - mOsm/Kg water

Osmolality defines concentration of solution

Tonicity defines effect of fluid on cell volume

Osmolality
Plasma osmolality Posm - measure of body osmolality Usually Posm(mOsm/l) = 2x serum [Na]

Osmolality
Posm(mOsm/l) = 2x serum [Na] + glocose/18 + BUN/2.8 Look for osmolar gap

Control of Volume
Effective circulating volume
Portion of ECF that perfuses organs Usually equates to Intravascular volume

Third space loss

Abnormal shift of fluid for Intravascular to tissues eg bowel obst, i/o, pancreatitis

Volume Control

osmoreceptors - day to day control baroreceptors - respond to pressure change neural output hormonal mediators

Osmoregulation
osmolality 289 mOsm/kg H20
osmoreceptor cells in paraventricular/

supraoptic nuclei
osmoreceptors control thirst and ADH
small changes in Posm - large response

Osmoregulation
Excess free water (Posm 280)
thirst inhibited

ADH declines
urine dilutes to Uosm 100

Osmoregulation
Decreased free water (Posm 295)
thirst increased ADH increases

urine concentrates to Uosm 1200

Osmoregulation
Change in uOsm = 95 x change in Posm

Volume Control

osmoreceptors - day to day control baroreceptors - respond to pressure change neural output hormonal mediators

Baroreceptors

Neural mechanism stretch - tachycardia and increased renal blood flow and decreased Na reabsorption

Baroreceptors

Hormonal mediators renin aldosterone ANP dopamine

Hormonal effect ECF Na and water reabsorption

Renin-angiotensin
Renin secreted when

drop BP drop Na delivery to kidney

increased sympathetic tone

Angiotensin II
Increases vascular tone

increases catecolamine release

decrease renal blood flow

increases Na reabsorption

stimulates aldosterone release

Aldosterone
Release stimutlated by

Angiotensin II increased K ACTH

Effect

Na and water absorption in distal tubular segments

Normal Water Exchange

Avg daily ml Min daily ml

Sensible urine 800-1500 300 intestinal 0-250 0 sweat 0 0 Insensible lungs/skin 600-900 600-900 8-10 mls/kg/D - 10%/ o rise in Temp

Normal Intake of Water

2000mls - 1300 free water 700 bound to food additional water comes from catabolism

Water and Eletrolyte Exchang

Surgical patients prone to disruption nil orally anesthesia trauma sepsis

Fluid and Electrolyte Therapy

Surgical patients have

Maintenance volume requirements On going losses Volume excess/deficits Maintenance electrolyte requirements Electrolyte excess/deficits

Maintenance Requireme
This includes: insensible urinary stool losses

Body weight Fluid required 0-10Kg 100ml/kg/d next 10-20kg 50 ml/kg/d subsequent 20 Kg 20ml/kg/d
15ml/Kg/d for elderly

70 Kg Man Needs
10 x 100 = 1000 10 x 50 = 500 2500 mls / d 50 x 20 = 1000

On Going Losses

NG
drains fistulae third space losses

Concentration is similar to plasma Replace with isotonic fluids

Volume Deficit - Acute

vital signs changes

Blood pressure Heart rate CVP

tissue changes not obvious

urine output low

Volume Deficit - Chronic

Decreased skin turgor Sunken eyes Oliguria

Orthostatic hypotension
High BUN/Creatine ratio

HCT increases 6-8 points per litre deficit

Plasma Na may be normal

Volume Excess

Over hydration
Mobilisation of third space losses Signs
weight

gain pulmonary edema peripheral edema S3 gallop

Fluid and Electrolyte Therapy

Goal normal haemodynamic parameters normal electrolyte concentration Method replace

normal maintenance requirements ongoing losses deficits

Fluid and Electrolyte Therapy

Normal maintenance requirements

use BW formula

On going losses

measure all losses in I/O chart estimate third space losses

estimate using vital signs estimate using HCT

Deficits

Fluid and Electrolyte Therapy

The best estimate of the volume required is the patients response After therapy started observe
vital signs Urine output (0.5mls/Kg/hr Central venous pressure

Time Frame for Replacement

Usually correct over 24 hours

For ill patients calculate over shorter period and reassess e.g. 12 hours or 3 hours for e op cases Deficits - correct half the amount over the period and reassess

Fluid therapy in the ward Example 1

65 year old, 75 kg 2nd POD urine out put 40 mls/hr NG 1.5 L drains 500 mls

Fluid therapy in the ward Example 2

65 year old, 75 kg 2nd POD

urine out put 40 mls/hr

NG 1.5 L
drains 500 mls HCT 55 BP 90/60

Maintenance Electrolyte Requirement

Na 1-2mEq/Kg/d
K

0.5 - 1 mEq/Kg/d

Usually no K given until after urine output is adequate and U/E done.

Always give K with care, in an infusion slowly - never bolus Ca, PO4, Mg not required for short term

Postoperative Fluid Therapy

Check i/v regime ordered in op form

Assess for deficits by checking I/O chart and vital signs

Maintenance requirements calculated

Usually K not started Monitor carefully vital signs and urine output

Postoperative Fluid Therapy

Urine specific gravity may be used (1.010 - 1.012) CVP useful in difficult situations (5-15 cm H2) Body weight measured in special situation e.g. burns

Concentration Changes

changes in plasma Na are indicative of abnormal TBW losses in surgery are usually isotonic hypoosmolar condition usually caused by replacement with free water

Hyponatremia Usually Excess Free Water

Free water replacement of isotonic losses Increased ADH secretion

Low intravascular volume states like cirrhosis /low albumin Excess solute e.g. glucose - intracellular water shifts to ECF

Hyponatremia Usually Excess Free Water

Features - depends on rapidity acute drop below 120 weakness fatigue confusion cramps nausea/vomiting headache/delirium/seizures/coma permanent CNS damage

Diagnosis of Hyponatremia

assess circulating volume

exclude hyperosmolar states check for losses check for excess free water replacement In difficult situations measure urine Na (> <20mEq/L)

Treatment of Hyponatremia

replace volume deficits in dehydration

restrict free water in overload
TBW = 0.6xWt

Na required = [desired Na] - [actual Na] x (TBW) Correct half the deficit over 12 hours and reassess

UESTIONS