FLUID AND ELECTROLYTE

MANAGEMENT OF THE
SURGICAL PATIENT

Dr Tewodros
Outline
 Objectives
 Introduction
 Normal body fluids physiology
 Body fluid changes
 Fluid and electrolyte therapy
 Objectives

 Know the normal body fluid and electrolyte

homeostasis.
 Identify fluid and electrolyte derangement in surgical
patient.
 Know the different options in the management of this
clinical conditions.
 Introduction
 The vast majority of our body weight is fluid by composition
 Body fluid is the place where the metabolism of our body function
 Homeostasis of water and electrolyte in the body fluid is very
important to normal cell function
 Fluid and electrolytes derangement is a common problem
encountered on daily basis
 Proper treatment require a sound understanding and knowledge in
the assessment and prompt intervention
 Normal anatomy and physiology of body fluid

 Water constitutes approximately 50% to 60% of total body

weight in adult.
 The proportion of water in the body various with age, sex and body
weight
 Females higher % of adipose tissue, lower % of muscle mass
 The highest is in newborn 80%.... By 1yr

 However the r/s b/n total body weight and total body water is constant.
 Estimate of %age of TBW should be adjusted
 Obese individual 10-20% downward
 Malnourished individual 10% upward
A physiologic adult person
Body Fluid Compartments

 TBW is divided in to two functional fluid compartments

 Intracellular fluid (ICF)
 Extracellular fluid(ECF)
 Interstitial fluid (IF)
 Intravascular(plasma) fluid
 Trans cellular fluids

 2/3rd of the TBW is ICF(40% of wt) and 1/3rd ECF(20%)

 15% is IF and 5% is the plasma
 Fluid compartments are separated by membranes
with especial features
 Cell membrane
 Capillary membranes

 The constant interaction b/n the different fluid

compartments of the body is responsible for the
existence of normal homeostasis.
 Composition of Fluid Compartments

 Electrolyte

 Cations – positively charged

 Na+, K+ , Ca2+, H+

 Anions – negatively charged

 Cl-, HCO3- , PO43-

 Non-electrolytes

 Proteins, urea, glucose, O2 , CO2

 ICF and ECF are different in ionic composition.
 ECF
 balanced b/n , Na+ and Cl-, HCO3-
 ICF
 Balanced b/n K+, Mg+ and PO43- , SO43- and protein
 The concentration gradient is maintained by Na/K ATPase
 The ionic composition of plasma and IF differ slightly
 slight higher protein content in plasma
 Body fluid osmolality
 Osmosis
 movement of water or solvent across a semi permeable membrane
along conc. gradient
 Osmotic pressure
 Pull that draws solvent through the membrane to the more
concentrated side
 Determined by the number of particles instead of the mass
of the solute in the solution.
 Can be divided in two types:
 Crystal osmotic pressure: formed by a lot of small molecular
weight materials, such as electrolyte, Glucose, BUN
 Colloid osmotic pressure: formed by large molecular weight
materials such as proteins
Under normal physiology
 Plasma protein remain intravascular
 Responsible for the oncotic pressure which counter act the
hydrostatic pressure
 Water move evenly b/n compartments till electrical
equilibrium is achieved
 A given volume of water increases the volume of any one
compartment little
 Na+ confined to the ECF
 b/c of osmotic and electrical properties is associated with water
 Na+ containing fluid are distributed throughout the ECF
 Increase the IF 3x as much as the plasma.
 In normal condition, the osmolality of plasma
= interstitial fluid = intracellular fluid =
280-310 mOsm/ kg or 280-310 mmol/L
 The osmolality is determined mainly by:
 in ECF: Na+ and Cl- (80%)
 In clinical practice, serum osmolality can be estimated
by doubling serum sodium
 in ICF: K+ (50%)
Relation ship
 Fluid and Electrolyte balance

 Fluid and electrolyte gain is equal to the lose

 Mechanism for regulating body fluid and electrolyte balance
 The sensation of thirst
 Antidiuretic hormone
 Aldosterone
 The natriuretic peptide family
Table 2: Normal maintenance requirements

Table 3: Approximate electrolyte content of gastrointestinal and skin

secretions
Disturbances in Fluid and Electrolytes Balance

 Volume
 Concentration, and
 Composition
 Disturbances in Fluid Volume

 Extracellular volume deficit is the most common fluid disorder

in surgical patients
 can be either acute or chronic
 Acute volume deficit is associated with CVS and CNS signs, whereas
 chronic deficits display tissue signs,
 decrease in skin turgor and sunken eyes, in addition to CVS and CNS signs

 Lab exam may reveal

 An elevated BUN level if the deficit is severe enough to reduce glomerular filtration and
 Hemoconcentration .
 Urine osmolality usually will be higher than serum osmolality, and
 Urine sodium will be low, typically <20 mEq/L.
 The most common cause of volume deficit in surgical patients

 Loss of GI fluids

 nasogastric suction, vomiting, diarrhea, or enterocutaneous fistula.

 sequestration secondary

to soft tissue injuries, burns, and intra-abdominal processes such

as peritonitis, obstruction, or prolonged surgery

 Extracellular volume excess may be
 Iatrogenic or
 Secondary to renal dysfunction, congestive heart failure, or cirrhosis.

 Symptoms are primarily pulmonary and cardiovascular.

 In fit patients, edema and hyperdynamic circulation are common and well tolerated
 Elderly, pt with cardiac ds… CHF,PE
Clinical features of body fluid disturbances
Concentration Changes

 Hyponatremia <135mEq/l
 Due to dilution or depletion
 Dilutional hyponatremia frequently results from excess extracellular water
 Causes
 Excessive oral water intake or iatrogenic IV fluid administration
 Patients particularly prone to increased secretion of ADH
 Drugs ..ACEI, tricyclic antidepressant

 Depletional causes decreased intake or increased loss of sodium-containing fluids.

 A concomitant ECF volume deficit is common
 Causes
 consumption of a low-sodium diet

 GI losses from vomiting, prolonged nasogastric suctioning, or

diarrhea; and
 Renal losses due to diuretic use or primary renal disease, hyperglycemia
Clinical manifestations
 Signs and symptoms of hyponatremia depend on the degree and the rapidity with
which it occurred
 primarily have a central nervous system origin due to increased ICP

 Hypernatremia >145mEq/l

 Due to loss of free water or a gain of sodium in excess of water

 Cause
 iatrogenic administration of sodium-containing fluids, or
 mineralocorticoid excess as seen in hyperaldosteronism,
Cushing’s syndrome, and congenital adrenal hyperplasia .
 Urine sodium concentration is typically >20 mEq/L and urine osmolarity is >300 mOsm/L

 Renal causes, including diabetes insipidus, diuretic use, and renal disease,
 Nonrenal water loss from the GI tract or skin.
 With nonrenal water loss, the urine sodium concentration is <15 mEq/L and the urine osmolarity is >400 mOsm/L
 Clinical feature

 Symptomatic hypernatremia usually occurs only in pts with impaired thirst or

restricted access to fluid.
 Symptoms are rare until the serum sodium concentration exceeds 160 mEq/L

 Central nervous system effects predominate resulting in cellular dehydration

 Potassium (3.5-5.0mEq/L)

 Average dietary intake of 50 to 100 mEq/d,

 Extracellular potassium is maintained within a narrow range,
principally by renal excretion of potassium
 Only 2% of the total body potassium 63 mEq is located within the ECF
 Is critical to cardiac and neuromuscular function
 Distribution of potassium is influenced by a number of factors,
including surgical stress, injury, acidosis, and tissue catabolism
Hyperkalemia

 Etiology
Clinical feature
 primarily GI, neuromuscular, and cardiovascular
Hypokalemia
 Much more common than hyperkalemia in the surgical patient
Calcium
 Daily calcium intake is 1 to 3 g/d
 The vast majority of the body’s calcium is contained within
the bone matrix,<1% in the ECF
 Distribution of serum calcium take three forms:
 Protein bound (40%),
 Complexed to phosphate and other anions (10%),
 Ionized (50%)
 Responsible for neuromuscular stability
 Total body calcium balance is under complex hormonal
control
Hypercalcemia >10.5 mEq/L,4.8mg/dl

 Primary hyperparathyroidism in the outpatient setting and

 malignancy in hospitalized patients,
 From bony metastasis or
 Secretion of parathyroid hormone–related protein
 Clinical feature
 Hypocalcemia <8.5mEq/l, 4.2mg/dl

 causes
 pancreatitis, massive soft tissue infections such as necrotizing fasciitis,
 Parathyroidectomy
 renal failure, pancreatic and small bowel fistula hypoparathyroidism,
abnormalities in magnesium levels, and tumor lysis syndrome
 Clinical features
 ionized fraction falls below 2.5 mg/dL
 neuromuscular and cardiac symptoms predominate
 paresthesias of the face and extremities,
muscle cramps, carpopedal spasm, stridor, tetany, and seizures.
 Positive Chvostek’s sign and Trousseau’s sign
 Decreased cardiac contractility and heart failure.
 ECG changes include prolonged QT interval, T-wave inversion, heart
block, and ventricular fibrillation.
 FLUID AND ELECTROLYTE THERAPY

 Types of IV fluid and electrolyte

 Crystalloid fluid
 Colloid fluid

 Can be accomplished in three ways

 Deficit fluid therapy
 Maintenance fluid therapy
 Ongoing fluid loss therapy

 Route of administration
 Parenteral route
 Enteral route
Types of IV fluids
 Points to note
 Both lactated Ringer’s solution and normal saline are considered isotonic
and are useful in replacing GI losses and correcting extracellular volume
deficits
 0.45% NS for maintenance fluid therapy in the postoperative period, are useful
for replacement of ongoing GI
 The addition of 5% dextrose to maintenance fluid supplies 200 kcal/L
 Ongoing loss need to be replaced by fluid with comparable concentration
 Blood loss need to be replaced 1:3 ratio for losses < 30% of blood loss
 Frequent clinical monitoring is vital for successful treatment outcome
 Deficit
 Already Lost fluid before the pt seek treatment
 Can be assessed from pre illness wt
 Need to be replaced by isotonic fluid

 Replacement fluid
 Like for like

 Maintenance
 Fluid to provide the physiologic process
 Rule of 4,2,1 or 100,50,20
 Hypernatremia
 Correct volume deficit with NS then correct water deficit by hypotonic fluid

 Rate of fluid administration titrated to decrease serum conc of no more than 1mEq/h and 12mEq/d to
avoid complications
 slower correction should be undertaken for chronic hypernatremia (0.7 mEq/h)
 Enteral or IV routes 0.45 NS,1/4 NS…
 Hyponatremia
 Most cases can be treated by free water restriction and, if severe, the administration of sodium
needed
 Types of fluid 3% NS,
 Rate of correction 1mEq/l/h till serum Na increase to 130mEq/l
 Asymptomatic pt 0.5mEq/l/h
 The rapid correction of hyponatremia can lead to pontine myelinolysis
 Hyperkalemia
 The goals of therapy include
 reducing the total body potassium,
 shifting potassium from the ECF to ICF space, and
 protecting the cells from the effects of increased potassium

 Hypokalemia
 Oral repletion is adequate for mild, asymptomatic hypokalemia.
 If IV repletion is required, usually no more than 10 mEq/h
 increased to 40 mEq/h when accompanied by continuous ECG monitoring
 Hypercalcemia
 Treatment is required when hypercalcemia is symptomatic exceeds 12 mg/dL
 The initial treatment is aimed at repleting the associated volume deficit
 inducing a brisk diuresis with normal saline

 Hypocalcemia
 Asymptomatic hypocalcemia can be treated with oral or IV calcium
 Acute symptomatic hypocalcemia should be treated with IV 10% calcium gluconate to
achieve a serum concentration of 7 to 9 mg/dL
 Associated deficits in magnesium, potassium, and pH must also be corrected.
Assignment
 Acid base balance
 Other electrolyte balance
Practical case.
 Woman with ECF volume= 15 L, ICF volume =25
L, and plasma osmolarity = 300 mOsm/L runs a
marathon on a hot day. She loses 3 L of sweat that
has an osmolarity of 200 mOsm/L, and replaces all
volume lost by drinking pure water. Calculate
 Her plasma osmolarity in new steady state?
 New ECF volume?
 New ICF volume?
 New TBW?
 Hct inc, dec, or unchanged?
 New plasma Na concentration (inc, dec, or unchanged)?
Reference
 Schwartz’s principles of surgery 10th ed
 Basic concepts of fluid and electrolyte therapy
 Baily and love principles of surgery
 Up to date 21.4