Principles of Fluid &

Electrolyte Management in a
Surgical Patient
Dr. Babangida Sabo Miya
Moderator: Prof. Dauda M. M
ABUTH, Zaria.
30/11/2022
OUTLINE
• Introduction
• Physiology
• Fluid Therapy
• Daily maintenance / requirement
• Dehydration
• Overhydration
• Electrolyte Disorders
• Peri-operative fluid Therapy
• Conclusion
INTRODUCTION
• Fluid & electrolyte management is paramount in the care of
surgical patients.

• Changes in both fluid volume & electrolyte composition occurs

preoperatively, intraoperatively, & postoperatively & as well as in
response to trauma & sepsis
PHYSIOLOGY
Distribution of body fluids
• Total body water = 60% of TBW
• varies with age, sex, body fat
• more in children and lean people
• less in women

• Women=50%; neonates=80%

• Distribution of TBW
• intracellular=40%
• extracellular=20%
• plasma-5%
• interstitial=15%
Control of body fluids
• Thirst center in hypothalamus
• Anti-diuretic hormone (ADH) in posterior pituitary
Fluid sources
• exogenous
• endogenous
Fluid loses:
• insensible loss
• urine
• faeces
• The main cation and anion in the ECF & ICF are Na+ & Cl- ; K+ & Po4

• ECF and ICF contain different types of solute but conc. of solutes
inside and outside the cells are equal

• Concentration difference exists only transiently because they create

an extremely strong force for water movement across cell membranes
• Sodium salts, glucose and urea – responsible for most of the solute particles in
the ECF

• Osmolality – no of milliosmoles of solute particles per litre of solution

• Plasma osmolality

Posm = 2(Plasma Na+)+ (Glucose/18) + (BUN/2.8)

• Two no of anions accompanying Na+ while 18 and 2.8 are correction factors in
converting Glucose and Urea conc. from mg/dl to mmol/L
FLUID THERAPY
• Maintenance i.e. daily requirement

• Deficits

• Ongoing loses
MAINTENANCE
Water Losses Tropics/ml Temperate
• Pulm. & Cutaneous 1,700 1,000
• Urine 1,500
1,500
200
• Faeces 200 2,700
• Total 3,400

Water gain
 Endogenous gain 200 200
• In Adult
- Avg water req. -- 30-40ml/kg

• In Children
-100ml/kg for first 10kg
-50ml/kg for next 10kg
-20ml/kg for each kg over 20kg
Na+ maintenance: Tropics Temperate
• Urine Loss 114mmol 80-110mmol

• Sweat 10-16mmol

• Faeces 10mmol 10mmol

• Net 130-140mmol 90-120mmol

K+ maintenance: Tropics Temperate
• Urine loss 50mmol 60mmol

• Sweat negligible negligible

• Faeces 10mmol 10mmol

• Net 60mmol 70mmol

 Maintenance requirement
• Water - 3.0liters
• Sodium - (1 – 2mmol/kg) 130mmol-140mmols
• Potassium - (1 -2mmol/Kg) 50mmol-60mmol
• Chloride - 1mmol/kg
• Calcium - 0.2-0.3 mEq/kg
• Magnesium - 0.25-0.35mEq/kg
• Phosphate - 7-9mmol/1000kcal
• Glucose/calorie - 100 – 150g/day
CORRECTION
Deficit
• For Cations:
• (Expected –Observed) x Body weight(Kg) x 0.6

• For Anions:
• (Expected –Observed) x Body weight(Kg) x 0.3

• Requirement/correction:
• Deficit + Maintenance

• Fluid will contain glucose and electrolytes (2L dextrose + 1L N/Sal)

 DERRANGEMENTS
DEHYDRATION
• Loss of water (electrolytes)

• Acute - mainly ECF

• Chronic - both ECF and ICF

Causes……
• A)External loses
• GIT:-vomiting, diarrhoea, enterocutaneous fistula, NG tube
drainage
• Renal:-polyuria
• Skin:-excessive sweating

• B) Internal fluid shifts(“Third space” loss)

• mechanical intestinal obstruction or paralytic ileus,
• traumatised or infected tissues as in burns, crush injuries,
• peritonitis
Clinical features……
• mild dehydration
• Thirst
• moderate dehydration
• irritability, loss of skin tugor, dry mucous membranes
• oliguria, tachycardia, lethargy

• severe dehydration
• Sunken eye
• Hypotension/shock, oliguria/anuria, cold-clammy
extremities
Treatment
• Replace loss/deficit

• Provide for maintenance

• Replace on going loss

• drains, fistula, abnormal loses from urine and faeces

 IVF=Ringer’s lactate, 0.9% saline, paediatric saline

• Pass urethral catheter (0.5 – 1ml/kg/hr)

• Monitoring
• level of consciousness,
• state of hydration of the tongue or skin,
• hourly urine output,
• vital signs including capillary refill
• auscultation of lungs,
• JVP
• CVP monitoring
• Serial U & E
OVERHYDRATION
• Commonly found in fluid administration
• without monitoring
• more than what kidneys can excrete
• renal/hepatic disease
• Congestive heart failure

• Clinical features are that of Hyponatraemia

• Added breath sounds, elevated CVP, symptoms of
elevated ICP

• Investigation-Chest X-ray shows pulmonary

congestion.
TREATMENT
• Regular interval auscultation

• Discontinue infusion

• IV diuresis (eg furosemide, mannitol,)

• Morphine
Hypokalaemia
• Most body K is in the ICF

• However, serum K+ - less than 3.5mmols

• Grading
• Mild: 3 – 3.5
• Moderate: 2.5 – 3
• Severe: < 2.5
• Causes
• Inadequate potassium intake
• Excessive renal potassium excretion
• GIT - diarrhea, fistulas, vomiting, or high nasogastric output, typhoid
perforation
• Intracellular shifts from metabolic alkalosis or insulin therapy
• Drugs - amphotericin, aminoglycosides, foscarnet, cisplatin,
• Features:

• related to failure of normal contractility of GI

smooth muscle, skeletal muscle, and cardiac
muscle

• paralytic ileus, constipation, weakness, fatigue,

diminished tendon reflexes, paralysis, cardiac
arrhythmias, cardiac arrest
• Raised p wave
• ECG- flat or inverted T-waves,
• depressed S-T segment,
• prolonged QT interval
• Presence of U wave
Treatment
• Correction depends severity and presence symptoms

• Could be via oral or parenteral

• Mild:
• Diet e.g. milk, fruit juice, coconut water
• Oral K+ supplement

• Moderate to severe:
• Darrows soln
• Potassium chloride infusion
CAUTION DURING THERAPY
• Never inject it as a bolus
• Adequate urine output
• Under ECG monitoring

• Safe rules for giving potassium are:

• Urine output at least 30 mls
• Not more than 40 mmol added to 1 litre
• No faster than 20mmol/h
• Not > 120mmol/day
 HYPERKALAEMIA
• K+ >5.2mmols

CAUSES
• Increased intake
• Potassium supplementation
• Multiple Blood transfusions
• Endogenous load/destruction: hemolysis, crush injury
• Increased release
• Acidosis
• Rapid rise of extracellular osmolality
• Impaired excretion
• Potassium-sparing diuretics
• Renal insufficiency/failure
CLINICAL FEATURE
• GI :- Nausea/vomiting, colic, diarrhea
• Neuromuscular :- Weakness, paralysis, respiratory
failure
• Cardiovascular :- Arrhythmia, arrest

• ECG Finding
• high peaked T waves (early)
• widened QRS complex
• flattened P wave
• prolonged PR interval (first-degree block)
• sine wave formation, and ventricular fibrillation
Treatment
• Stop all K-containing fluid medications
• Counteract cardiac effects
• Calcium: iv 10mls of 10% calcium gluconate or calcium
chloride over 3-5minutes
• Potassium removal
• Ion-exchange resins e.g. Calcium resonium or kayexalate
• Oral administration is 15–30 g in 50–100 ml of 20% sorbitol
• Rectal administration is 50 g in 200 ml of 20% sorbitol

• Shift potassium
• 50% dextrose and regular insulin 5–10 units iv
• Bicarbonate : iv 8.4% nahco3 1-2mmols/kg over 10-15 mins
• Dialysis
CALCIUM
• majority is within the bone matrix
• <1% found in the ECF.

• Serum calcium is distributed among three forms

• protein found (40%),
• complexed to phosphate and other anions (10%), and
• ionized (50%)

• ionized fraction - neuromuscular stability

• When total serum calcium levels are measured

• albumin conc
• changes in pH

• Daily calcium intake is 1 to 3 g/d.

HYPERCALCEMIA
• serum calcium level > 8.5 to 10.5 mEq/L
• increase in the ionized calcium >4.2 to 4.8 mg/dL.

CAUSE
• Primary hyperparathyroidism
• malignancy
• bony metastasis
• secretion of parathyroid hormone
SYMPTOMS
• neurologic impairment, musculoskeletal weakness and
pain

• renal dysfunction

• GI symptoms of nausea, vomiting, and abdominal pain.

• Cardiac : hypertension, cardiac arrhythmias

• ECG changes : shortened QT interval, prolonged PR and

QRS intervals, increased QRS voltage, T-wave flattening
and widening, and atrioventricular block
TREATMENT
• required when symptomatic
• exceeds 12 mg/dL
• critical level is 15 mg/dL

• initial treatment is aimed

• repleting the associated volume deficit
• inducing a brisk diuresis with normal saline

• In malignancy
HYPOCALCEMIA
• serum calcium level below 8.5 mEq/L or
• ionized calcium level below 4.2 mg/dL.

CAUSES
• Pancreatitis, renal failure, pancreatic and small bowel fistulas,
hypoparathyroidism, toxic shock syndrome, Massive blood transfusion
and tumor lysis syndrome

CLINICAL FINDINGS
• paresthesias of the face and extremities,
• muscle cramps, carpopedal spasm, stridor, tetany, and seizures
• hyperreflexia
• positive Chvostek's sign
• Trousseau's sign
• ECG changes prolonged QT interval, T-wave inversion, heart block, and
ventricular fibrillation.
TREATMENT
• Asymptomatic
• oral or IV calcium

• Acute symptomatic
• IV 10% calcium gluconate .
• 10ml of 10% Calcium gluconate over 5-10mins
• corrected Ca2+
• measured serum Ca2+ + 0.8 (4- measured serum Alb)

• Associated deficits in magnesium, potassium, and pH

must also be corrected
MAGNESIUM
• fourth most common mineral in the body

• primarily in the ICF

• one third is bound to serum albumin(ECF).

• The normal dietary intake is approximately 20 mEq/d

• The kidneys conserve magnesium
• Essential for proper function of many enzyme systems
HYPERMAGNESEMIA

• Hypermagnesaemia is rare
CAUSE
• severe renal insufficiency
• Excess intake - TPN, Magnesium-containing antacids and
laxatives
• massive trauma, thermal injury, and severe acidosis
CLINICAL EXAMINATION
• nausea and vomiting
• neuromuscular dysfunction - weakness, lethargy,
hyporeflexia
• impaired cardiac conduction
• ECG changes :-Prolonged PR interval, widened QRS
complex, and elevated T waves.
TREATMENT
• Eliminate exogenous sources

• Correct volume deficits

• Correct acidosis

• Calcium chloride (5 to 10 mL)

• Haemodialysis
HYPOMAGNESEMIA

• a common problem
• Causes
• Poor intake - starvation, alcoholism, prolonged IV fluid therapy
• Renal losses - alcohol abuse, diuretic use, amphotericin B, and
primary aldosteronism
• GI losses - diarrhea, malabsorption, and acute pancreatitis.

• characterized by neuromuscular and CNS hyperactivity.

• Hyperactive reflexes, muscle tremors, tetany, and positive
Chvostek's and Trousseau's signs
• Delirium and seizures.

• ECG:- prolonged QT and PR intervals, ST-segment depression,

flattening or inversion of P waves, and arrhythmias.
TREATMENT

• oral - asymptomatic and mild.

• IV - severe deficits (<1.0 mEq/L) and symptomatic

• 1 to 2 g of magnesium sulfate over 15 minutes.
• if under ECG monitoring, can be given over 2 minutes

• Simultaneous administration of Ca gluconate will

counteract the adverse side effects and correct
hypocalcemia
PREOPERATIVE FLUID THERAPY

• Fluid replacement depends -concentration and compositional abnormalities

• Acute volume deficit corrected.

• Electrolyte derrangement corrected.

INTRAOPERATIVE FLUID THERAPY

• Inadequate ECF Volume replacement - hypotension under

anaesthesia

• Restore obligate ECF loss - Third space

• For HTNsive ( permissive hypotension can be done to reduce blood

loss)
INTRAOPERATIVE FLUID THERAPY
• Routes of intraoperative fluid losses

• Blood loss

• Oedema from extensive dissection

• Fluid collection within the lumen

• Accumulation of fluid in the peritoneal cavity

• Fluid loss from the wound – very small

INTRAOPERATIVE FLUID THERAPY

• Guidelines
• Blood should be replaced as lost
• Fluid replacement should begin during
the operative procedure
POSTOPERATIVE THERAPY
• Immediate postoperative period
-Correct existing deficit in addition to daily
maintenance
-Hourly urinary monitor
-Strict Input/Output chart
CONCLUSION
• Fluid therapy must include replacement of deficits, administration of
daily requirements & replacement of ongoing loss.

• Great deal of complications may accompany fluid and electrolyte

therapy in surgical practice.

• Adequate evaluation and monitoring of patient is paramount