Body fluid,electrolytes :In

surgical perspective
Dr.Ahmed Sami-Al-Hasan
MBBS(DMC),FCPS,MRCS(Edinburgh)
Assistant Professor
Kurmitola General Hospital samidmc@gmail.com
01819431787
• TBW -72% of lean body mass
• Highest in infant-80%
• Lowest in female due to increased adipose
tissue
 Body Fluid compartment
• ICC-ICF
• ECC-ECF
• ISS-ISF
• IVC- Plasma
• TBW=42 L
• ICF=2/3 =28 L
• ECF=1/3= 14 L (3 L plasma + 11 L
ISF)
• Lymph and trans cellular fluid
kind of ISF
 Trans cellular fluid
• A part of ECF
• Actively secreted from cells
• Rich in mucopolysaccharide or
glycoprotein-so it is slippery
• Eg.- CSF,Synovial fluid,pleural
fluid,peritoneal fluid,pericardial
fluid,Intra ocular fluid,GI secretions
Measurement of Fluid compartment volume

• ICF=TBW-ECF
• ISF=ECF-Plasma
• For TBW= D20
• For ECF=inulin,mannitol
• For plasma=Radio iodinated Serum
albumin
 Ionic composition
• ECF =total cation=total anion=150 meq/l
• ICF=total cation=total anion=200 meq/l
• So every fluid comp.is electrically neutral
• ECF chief Cation Na+(135-145) and anion
Cl-100 and bicarbonate
• ICF Chief cation K + 150 and anion
phosphate 140 and protein
• So, ECF rich in Na and Cl
• ICF rich in K ,phosphate and protein
 Law of osmotic equilibrium
• ICF,ECF,ISF,Plasma …..osmotic pressure all the
same= 280-300 mosm/l
 Plasma Osmotic pressure
• 280-300mosm/l
• 92% of OP contributed by NaCl
• Plasma protein contributed only 0.5%(Colloid
osmotic pressure 25 mm of Hg)
• Plasma OP is the direct function of
Plama NaCl conc.
• ECF OP=ICF OP
• ECF hyperosmolarity ICF water comes
out of cell cellular dehydration
• ECF Hypoosmolarity water enters into
ICF cellular swelling/edema
Consequence of osmotic disequilibrium

• ECF OP< ICF OP(Infusion of hypotonic

solution)

What Happened?
 Clinical problem solving
• A 30-yr-old man with presented to A & E
department with features of Hypovolemic
Shock after fracture rt.femur without any
evidence of head injury .His GCS was 15/15 on
admission.Patient had been resuscitated by
5% DA (3L) in first 2 hour.After 2 hr his GCS
became 12/15.The most possible mechanism
for deteriorating GCS in this condition-
• A) Cerebral Concussion
• B)Cerebral dehydration
• C)Cerebral edema
• D)Cerebral hypoxia
• E)Cerebral hypoperfusion
• ECF OP> ICF OP(Infusion of hypertonic
solution)
What happened?????
cerebral dehydration
 Colloid osmotic pressure(COP) and Colloid
solution
• COP tends to retain fluid within intravascular
space
• Increased COP of plasma promotes fluid
translocation from ECF to intravascular space
• IV administration of colloid expands plasma
volume
• Plasma volume expander-clinical use
 Clinical Problem solving
• A 35 year old man presented to emergency
with pelvic bone fracture following fall from
the height with rapid thready
pulse,hypotension and oliguria.Patient’s blood
is sent for grouping and cross
matching.Patient had been resuscitated
initially by Hartmann’s soln and
Hexaethylstarch(HES) solution.The explanation
behind the use of HES Solution-
• A) It decreases intravascular hydrostatic
pressure
• B) It increases intravascular colloid osmotic
pressure
• C)It retains the fluid within intracellular
compartment
• D)It expels fluid from intravascular
compartment
• E) it expands the intravascular compartment.
 Water retaining solute
• ECF- Na,cl,HCO3
• ICF-K,Phosphate,Protein
• IV- Plasma protein
 Important equations
• ICF Vol 1/ECF osmolarity

• ECF osmolarity ECF Na conc

• ECF Na conc 1/water balance

(Positive/negetive)
• ECF vol body Na content

• Body Na content Na balance

(Positive,negetive)

• Urinary Na excretion ECF volume not

ECF Na conc.
Biochemical consequence of IV fluid infusion
Fluid ECF Osmo ICF TBW ECF ICF Plasm Urinar Body
Osmol sis Osmol Vol Vol a Na y Na Na
arity directi arity Conc Conc conte
on nt
Hyper I ICF to I I I D I I I
ECF
Hypo D ECF to D I I I D I I
ICF
ISo N No N I I N N I I
 Clinical Problem solving
• A 80 –year-old lady patient is brought
emergency with unconsciousness…her
electrolyte profile shows-
Na- 100 meq\l
CL-70 meq/l
K- 3.8 meq/l
She had been treated with 3% Nacl solution.
• Comment regarding following parameter
A. ECF Osmolarity decreases
B. ICF Osmolarity decreses
C. TBW increases
D. ECF Volume increases
E.Urniary Na excretion Decrease
• A –F, B-F, C-T, D- T,E-F
 Common infusions
• Hypertonic soln-5% DNS, 3% NaCl
• Hypotonic-0.45% NaCl
• Isotonic-0.9% NaCl,Hartmann’s soln.
• Maintenance- 5% DA,NS
• Replacement,Resuscitation-
Hartmann’s,Ringer’s lactate
• 3 times volume deficit should be infused
 Head injury and infusion
• Normal Saline
 Hypovolemic shock and infusion

• Not 5% DA
 Post operative fluid
• Initial estimated loss-replaced ml by ml with
isotonic soln.If blood loss >15% BT
• Ongoing loss- NG aspirtion,drain,replaced by
isotonic saline NS ,Ringer’s lactate for GI Loss
• For 1000 ml loss 20 mmol K added
• Maintenance-
• 1st POD- 2000 ml 5% DA
• 2nd POD 2 L 5% DA + 1L Isotonic
soln(Hartmann)
• 3rd POD-20 mmol K added at each 1L soln
 Colloid solution
• Limited use
• Plasma volume expander
• Gelatin(Hemaccel),Dextran,HES-synthetic
• Needs smaller volume-equal with volume
deficit
 Water homeostasis
• Intake and out put 2600ml
• 25-30 ml/kg/day
• Child 100 ml/kg/day
 Water balance regulation
• 1.Thirst mechanism -stimulated by plasma
hyper osmolarity(2-3%) and hypovolemia
• ADH mechanism –same stimulation but
hyperosmolarity(1-2%)
• ADH escape- if plasma osmolarity more than
300 mosm ADH mechanism fails.Thirst
mechanism override.
 Mechanism
• RAAS
• SNS
• Renin
• Angiotensin 2
 Hypovolumia

Baroreceptor inhibition RAAS Stimulation

SNS stimulation

Increased Renin and Angiotensin

• Increased thirst and ADH Secretion

Increased water intake and water

retention
• Water deficit
Increased ECF OP

OR stimulation

Increased thirst and ADH Secretion

• Hypovolemia (10-15%) is less sensitive
stimulus than hyperosmolarity(1-3%)
• Thirst centre less senitive than osmoreceptor
 Water intoxication

• Water intake is more than maximum renal

water excretion capacity
• Consequence-cerebral edema
 Clinical Problem solving
• A 60-yr-old man had been undergone TURP with
continuous irrigation. 2 hours after surgery patient
becomes drowsy,disoriented.His vitals are within normal
limit.Most probable explanation of the scenario-
a)Reactionary hemorrhage
b) Cardiogenic shock
c) DIC
d)DVT with embolism
e) Cerebral edema
 Sodium homeostasis
• more than 90% at ECF
• Intake-100-200 mmol/day(1-2 mmol/kg)
• Output-same …..150 through urine
• ECF vol is direct control over body Na content
• Afferent limb-baroreceptor at atria,carotid
sinus,aortic arch etc stimulated by
hypervolemia
• Effector organ-kidney
Mechanism
 Hormanal regulation of Na
• Aldosterone- DCT
• Renin-Angiotensin 2 –PCT
• Catecholamines-PCT
• ANP-inhibit reabsoption (Hypervolemic
hormone)
 Aldosterone escape
• Excessive urinary sodium excretion inspite of
maximum aldosterone activity at CD

• Conn’s syndrome
 Volume disorder
• Isotonic volume contraction- Isotonic fluid
loss
• severe hemorrhage,acute severe
diarrhoea,Enterocutaneous fistula ,Intestinal obstruction
• ECF Vol. decrease
• ECF Osmolarity .no change
• ICF vol. no change
• Hct increase
• Na ..no change
 Isotonic volume expansion
• -Excess infusion of normal saline
• ECF volume increase
• ICF Vol no change
• ECF osmolarity no change
• Hct decrease
• Na conc…no change
 Hyperosmotic vol.contraction

• Fever,sweating DI
• Fluid loss is more than Na
• ECF vol. …..Decrease
• ECF osmolarity….Increase
• ICF vol Decrease
• Na conc…increase
• Hct…..normal
 Hyperosmolar volume expansion

• Conns cushing,sea water intake,Nacl intake

high
• ECF vol Increase
• ECF osmolarity…Increase
• ICF Vol….decrease
• Hct decrease
• Na Increase
 Hypoosmolar vol.expansion
• CCF,NS,CLD,SIADH
• ECF Vol increase
• ECF osmolarity decrease
• Icf vol increase
• Na…decrease
• Hct N
 Hypoosmolar vol.contraction
• Treatment of hypovolemia with 5%DA
• Adrenal insufficiency
• ECF Vol decrease
• ECF Osmolrity-Increase
• ICF vol-Increase
• HCT Increase
• Na conc
 Hyponatremia
• Cause……..
• Surgical- intestinal obs
• Burn
• post operative
• Enterocutaneous fistula
• GOO
• Endocrine cause-Addisons SIADH
• Renal loss-CRF,,Diuretic Phase of ATN
• Water retention with Less Na retention
-CLD,NS,CCF
• Only water retention-SIADH

• Skin loss-excessive sweating ,third degree burn

• Acute dilutional hyponatremia-
• excessive hypotonic fluid infusion
• Post opeartive period(Due to ADH)
• Psychogenic polydipsia
 Rapid correction of Na-Danger?
• Osmotic demyelination syndrome or central
pontine myelinolysis
 Hypernatremia
• Mostly due to water imbalance rather than
sodium
• DI, Reduced water intake
• Tube hyperosmolar enteral feeding
 Clinical problem solving
• A hemiplegic patient sustained head injury
following falling over the floor.The following
electrolyte imbalance may be encountered-
A) Hypercalcemia
B) Hypocalcemia
C)Hypernatremia
D)Hyponatremia
E)Hypomagnesemia
• C,D -T
 K homeostasis
• Intake- 50-100 mmol/day
• Trans membrane regulation K flux
• Influx-Insulin,aldosterone, beta
agonist,alpha blocker,acute k
excess,alkalosis
• Efflux-glucagon,acidosis,beta blocker alpha
agonist
• Renal control –aldosterone-excretion
 Hyperkalaemia
• More than 5 mmol/l
• Tissue break
down..hemolysis,tumorolysis,rhabdomyolysis,burn,crus
h syndrome etc
• Impaired renal excretion-Renal failure, Obstructive
uropathy ,Renal Tubular Acidosis
• Spurious hyperkalemia-Hemolysis after collection of
blood
• Cosequence-arrythmia, cardiac arrest in
asystole,tingling,paresthesia etc.
• Spurious hyperkalemia-Hemolysis after
collection of blood
• Cosequence-arrythmia.cardiac arrest in
asystole,tigling,paresthesiaetc
 DM and Hyperkalemia
• Insulin Deficiency
• ECF Hyperosmolarity due to hyperglycemia
• Ketoacidosis
• Osmotic diuresis due to hyperglycemia
 Hypokalemia-K <3.5
• GI causes-diarrhoea,ileostomy,GOO,NG
suction,biliary fistula
• Renal cause-renal tubular acidosis,diuretic
phase of ARF,Post obstructive diuresis
• Cushing,Conns
• C/F cardiac arrythmia,paralytic ileus,muscle
cramp
 Calculation of Na, K deficit
• Na deficit= (140-pt’s Na) * 0.6* wt in kg
• K deficit=(4.5-Pt’s K)* 0.4* wt in kg
 Vomiting and diarrhoea
Vom Na K H2O Cl
iting
Diar Na K H2O HC0
rhoe 3
a
 Changes in GOO
• Hyponatremia
• Hypochloridemia
• Hypokalemia
• Hypocalcemia
• Hypomagnesemia
• Metabolic alkalosis
• Paradoxical aciduria
 Changes in intestinal obstruction
• Third space fluid loss
• Isotonic Hypovolumia
• Hyponatremia
• Hypokalemia
• Loss of HCO3
• Metabolic acidosis
 Clinical problem solving
• A 60-yr-old diabetic man underwent right
hemicolectomy in a district hospital.At 3rd
postoperative day follow up patient
complained of abdominal pain and mild
distension.On examination,Abdomen is soft
and bowel sound absent.Which one of the
following ion is responsible?
• a) calcium b)magnesium c) potassium d)
sodium e)chloride
 Clinical problem solving
• A 46-year-old lady admitted to surgery indoor
with recurrent episodes of vomiting.
Endoscopy of Upper GI revealed severely
stenosed pylorus.The chemical substance
primarily responsible for biochemical change
in this patient
a) Cl- b) H+ c) K+ d) Na+ e)Mg+
 Clinical problem solving
• A 25 years old lady presented to colorectal
surgery OPD with chronic diarrhoea for last 3
months.She had been diagnosed as a case of
tubular villous adenoma.Regarding
biochemical change-
A) Hypochloridaemia B) Hyponatremia
C)Hypocalcemia D) Hyperkalemia E)metabolic
acidosis
• B,E-----T
 Clinical problem solving
• A 12 yr boy brought to emergency after falling
from the roof of a two storied building 6 hr
back.Patient is oliguric with intact spinal cord
functional status.The expected biochemical
findings-
A) Hyponatremia B)Hyperkalemia C)
Hypocapnia D) Hypermagnesemia E)blood ph
increased.
 For any enquiries contact
Dr.Ahmed Sami-Al-Hasan
Assistant Coordinator,FCPS Part 1 orientation
Course Surgery, 2020
samidmc@gmail.com
mobile- 01819431787 (also at Whats app)