Fluid and Electrolyte

AMU,CMHS
Dec, 2023
 Outline
• Introduction
• Composition and Distribution of Body
Fluids
• Regulation of Body Fluid and Electrolytes
• Normal Exchange of Fluid and Electrolytes
• Functions of Electrolytes
• Classifications of Body Fluid Changes
1. Volume Changes,
2. Concentration Changes, and
3. Composition Changes or Acid- base balance
 Introduction
- The knowledge about fluid and electrolyte is paramount for surgical
patient management.

- Changes in both fluid volume and electrolyte composition occur

preoperatively, intraoperative, and postoperatively, as well as in
response to trauma and sepsis.

- Cells should get important substrate and oxygen through modulated

flow of blood, lymph, water and solutes.
 Introduction ctd…
- Survival of an individual is dependent on cells having access to energy
in suitable environment.
- Kidney plays major role in maintaining adequate circulating volume,
osmolality and electrolyte homeostasis.
Composition and Distribution of Body Fluids
- Water constitutes 50-70% of TBWt.

- It depends on age, sex, fat distribution in the body.

- For example:
• Full term infant has 75-80% of TBW(total body weight).
• Young adulthood has 60% of TBWt.
• Old age male has 50% of TBWt.
• Young Female has 50% of TBWt.
• Old age female has 40% of TBWt.
• Obesity has 20% of TBWt.
This implies that:
- Lean individuals have great water volume than obese
individual

- Young age individuals have great water volume than old

individual

- Female has lower water volume than male individuals.

 The body water is divided into two functional compartments:
 ECF:
– It accounts for one third of TBW or 20% of TBWt.
– It composed of plasma (5%) and interstitial fluid
(15%).
– The principal cation is Na+, and main anions are Cl-
and HCO3-.

 ICF:
– It accounts for two third of TBW or 40 % of TBWt.
– It composed of fluid inside the cell.
– The principal cation is K+ and Mg+, while PO4- and
negatively charged proteins are main anions.
 The Electrolyte
distribution with
in a fluid
compartment of
the body.
 Regulation of Body Fluid and Electrolytes
- Volume changes are sensed by both osmoreceptors and
baroreceptors.

- Osmoreceptors are specialized sensors that detect even small

changes in fluid osmolality through osmoreceptor-driven changes in
thirst and diuresis through the kidneys.
For example, when plasma osmolality is increased,
1. Thirst is stimulated and water consumption increases.
2. Additionally, the hypothalamus is stimulated to secrete
vasopressin, which increases water reabsorption in the
kidneys.
Together, these two mechanisms return the plasma
osmolality to normal.
- Baroreceptors also modulate volume in response to changes in
pressure and circulating volume through specialized pressure sensors
located in the aortic arch and carotid sinuses.

- Baroreceptor responses are both

– neural, through ANS, and
– hormonal, including RAAS, ANP, and renal PGs.

- The net result is alterations in renal sodium levels and water

reabsorption in order to restore the volume to normal.
 Normal Exchange of Fluid and
Electrolytes
- The normal person consumes an average of 2000 mL to 3000ml of
water per day, approximately 75% from oral intake and the rest is
extracted from solid foods.

- Daily water losses include

– About 1500m L in urine,
– 250 mL in stool, and
– 600-900 mL as insensible losses through both the skin (75%) and lungs (25%).

N.B:-
To clear the products of metabolism, the kidneys must excrete a
minimum of 500 to 800 mL of urine per day, regardless of the amount
of oral intake.
 Functions of Electrolytes
- Contributes most of the osmotically active particles in body
fluids.

- Provide buffer systems for PH regulation.

- Provide the proper ionic environment for normal neuromuscular

irritability and tissue function.
Classifications of Body Fluid Changes

1. Volume Changes

2. Concentration Changes

3. Composition Changes
1. Volume Changes: it can be either excess or deficit.
 A, Volume Deficit:
- It is the most common fluid disorder in the surgical patient. Mostly it is
ECF lost.

- For example:
• Bleeding;
• GI losses (vomiting, gastric tube, diarrhea, and
entercutaneous fistulas
• Sequestration or loss of fluid in soft tissue injuries and
infections such as burns;
• Intra-abdominal and retroperitoneal inflammatory
processes such as peritonitis, intestinal obstruction…
etc.
Clinical Features: Depends on the severity of fluid loss.
• Mild: up to 5% of TBW

• Moderate: 5-10% of TBW, and may present with prostration

and orthostatic hypotension.

• Severe: >/= 10% of TBW, and may present with signs of

hypotension; stupor or coma; sunken eye balls; dry oral
mucosa and tongue; poor skin turgor; and hypothermia.
 Treatment:
- Replacement of ECF losses with fluid of similar composition.
• Blood loss: replace with RL, NS or Blood if needed.
• ECF loss: replace with RL, NS.

- The rate of fluid replacement depends on the degree of dehydration.

o Mild: 30ml per loss of ORS.
o Moderate: 75ml/kg over 4 hours ORS.
o Sever: 100ml/kg, (30ml/kg over 1hour/30min, and then 70ml/kg the next 5hour/2 and
1/2hour).

- It should be fast until the V/S are corrected and adequate urine output is
achieved.

- Follow up chart: to look for response

– V/S;
– Urine output; and
– Auscultate the chest to follow fluid overload especially in children and elderly.
 B. Volume Excess:
- It is also called water intoxication .
- It is generally, iatrogenic (mostly due to over administration
of 5% D/W) or
- Secondary to renal insufficiency, cirrhosis or CHF.

Clinical Features:
• Subcutaneous edema;
• Basilar rales on chest auscultation;
• Distention of peripheral veins; and
• Functional murmurs.
Treatments:
- stop IV fluids or fluid restriction;

- Diuretics e.g.:- Furosemide

- Follow the clinical conditions

- Treat the underlying condition

 2. Concentrations Changes
A. Sodium Balance
– It is the most abundant cation of the ECF.
– After trauma and surgery, there is a period of shut down of Na+
excretion for up to 48 hrs.
– During this period, it may not be advisable to administer large
quantities of isotonic saline.
– The concentration of serum Na+ is not related to the status of
ECF.
– Daily requirement of Na+ is 1mmol/kg(2.5meq/kg).
– The excretion of Na+ by the kidneys is under the control of
aldosterone.
I. Hyponatremia:
Na+<135mmol/l.
- Normal: 135-140mmol/l.
- Severe<120mmol/l.
- Can be associated with volume depletion(Na+ and H20 depletion)
- Due to decreased Na+ intake, GI losses, diuretics and primary renal
d/se.
- Most frequent cause in surgery is SBO.
- Other causes are duodenal, biliary, pancreatic and high intestinal
fistula.

Clinical features: can present with sign and symptoms of

either fluid excess or fluid overload.
- Depending on the primary cause.
- Laboratory: Na+ and other electrolytes drops; and Hct drops.
- Post Op hyponatremia due to increased and prolonged
administration.
- Increased ICP due to brain edema secondary to hyponatremia.
 Hyponatremia Ctd…
Management:
- RL or NS in case of volume depletion.
- Fluid restriction and Na+ sparing diuretics in
cases of fluid excess.
- Correct no more than 8meq/day.
- NS, 3-24%hypertonic saline can be used.
- Na+(required)=Na+(desired)-Na+(actual)*TBW.
 II. Hypernatremia: Na+>145mmol/l. Severe>160mmol/l.

Causes:
- Excessive water loss in burns or sweating, insensible losses
through lungs

- Excessive administration of 0.9%NS solution after trauma and

early post op period where there is some degree of retention of
Na+.

- Mineralocorticoid excess(aldosteronism and Cushing d/se).

- Congenital Adrenal hyperplasia.

 Hypernatremia Ctd…
Clinical features: Depends on the cause it can be
of fluid excess or fluid deficit.
• CNS- restlessness, lethargy, ataxia, irritability, spasms,
delirium, seizure, come.
• MSK-weakness
• CVS- tachycardia, syncope, hypotension.
• Tissue- dry sticky mucus membranes, red swollen tongue,
decrease saliva and tears.
• Renal-oliguria
• Metabolic-fever
 Hypernatremia Ctd…
Management:
– Correct volume deficit with isotonic solution
– Na+ free eternal or parenteral fluid.
– Correct no more than 8meq/day. B/cs has risk
of cerebral edema
– Desmopressin
– 5%DW can be infused slowly.
 B. Potassium Balance
- It is the most abundant ICF cation.

- 98% of it is ICF with ¾ are found in the skeletal muscle.

- Normal value is 3.5-5.3mmol/l.

- Daily requirement is 1mmol/kg.

- Founds abundantly in fruits, milk, and honey.

 I. Hypokalemia
• K+<3.5 mmol/l and more common in surgical patients.
• Causes are
-Loss in GI secretions such as vomiting in GOO or diarrhea,
high output fistulas.
-Mov.t of K+ into cells(In Alkalosis).
-Prolonged administration of K+ free Iv fluid with
continued obligatory renal loss of K+.
-Excessive renal excretion e.g:- Diuretic use
-Inadequate intake due to dietary deficiency.
 Hypokalemia Ctd…
• Clinical features: are
-Mostly asymptomatic,
-Restlessness, slurred speech, hypotonia, and
depressed reflexes.
-Abdominal distension due to paralytic ileus.
-Arrhythmia
-ECG: prolonged QT, depressed ST segment, flatter or
inverted T-wave.
 Hypokalemia Ctd…
Managements are
-Oral potassium in the form of milk, meat extracts,
fruit juices, honey and KCl tablets(20mmol IV with
in 500ml of fluid run over 6-8 hrs).

-Correct the underlying cause.

-Administration should be properly controlled, the

level of K+ should be checked daily and urine out
put must be adequate.
 II. Hyperkalemia
-K+ > 5.3 mmol/l.
-Causes are
-Significant quantity of ICF K+ is released into ECF in
response to severe injury, surgery, acidosis, and a
catabolic state.

-May occur in the presence of oliguria or anuric renal

failure.

-A renal insufficiency with hypoaldosteronism can

cause hyperkalemia.
 Hyperkalemia Ctd….

Clinical features: are

-Nausea, vomiting, intermittent intestinal colic,
and diarrhea are present.

-ECG: high peaked T-waves, Widened QRS

complex, depressed ST- segment.

-Disappearance of T- waves, heart block and

cardiac arrest.
 Hyperkalemia Ctd….
Managements are
-Administration of HCo3- and glucose with insulin.
o 10 to 20 Us of regular insulin and 25 to 50 gm of
glucose can be used.
o 10 ml of 10% calcium gluconate to suppress the
myocardial effect.

-Promotion of renal kaluresis by loop diuretic.

-Immediate hemodialysis

-Avoid exogenous K+
 C. Calcium Balance
- Normal serum level: 8.5 to 10.5 mg/dl.

- An increase in PH causes fall in the ionized proportion of

Ca2+.

- Ca2+ imbalance is not frequently encountered.

 I. Hypocalcaemia
-Ca2+<8mg/dl.

-Common causes are

 Hypoparathyriodism after thyriodsurgery
 Acute pancreatitis
 Massive soft tissue infection(Necrotizing fasciitis).
 Pancreatic and small bowel fistulas.

Clinical features:
Latent hypocalcaemia: +ves Chvostek's sign and Trousseau's sign.
 Symptomatic: Numbness and tingling; hyperactive tendon reflexes;
muscle and abdomenial cramp; tetany with carpopedal spasm and
convulsions.
 Hypocalcaemia Ctd…
Managements are
- IV Calcium glucate(10ml of 10% solution over
10min) .

- Calcium carbonate may be given over orally with or

without Vit D.
 II. Hypercalcemia
-Ca2+> 10.5mg/dl.
-Occurs with hyperparathyroidism, vit.D
intoxication, cancer, and prolonged
immunization.
-It is uncommon in surgical pts.

Clinical features: Most are asymptotic,

 Symptoms can include fatigue, lassitude,
weakness of varying degree, anorexia, nausea,
and vomiting.
 Hypercalcemia Ctd…
Managements are
-A Level> 15mg/dl requires emergency treatment.
-Vigorous volume depletions with salt solutions.
-Oral or IV inorganic phosphate.
3. Acid-Base Balance/Disturbances
- It is also called composition change.

General Concepts:
-Acid-base homeostasis represents equilibrium among
the concentration of H+, partial pressure of Co2(Pco2),
and HCo3-.

-Clinically H+ concentration is represent/expressed as

PH.

-Normal PH is 7.35-7.45.
 General Concepts Ctd…
- The PH of body fluid is maintained with in a narrow range.

- The control of this tight balance is accomplished By:

-Blood Buffer/Buffer of the body(includes ICF, ECF, &
RBCs/Meth-HgB).

-The Lung: excrete acid in the form of Co2.

-Kidney: The ultimate organ to maintain imbalance to

near normal by its capacity to excrete both acid and
base.
Terminologies
-Acidemia: refers to PH<7.35,
-Alkalemia: refers to PH> 7.45.
-Acidosis and alkalosis describe processes that
cause the accumulation of acid or alkali
respectively.

Laboratory Studies that are necessary for the initial

evaluation of acid-base disturbances include
– Arterial PH,
– Arterial Pco2 normal is 35 to 45mmHg, and
– Serum electrolytes(Hco3 normal is 22 to 31 mmHg)
Types of Acid-Base Disturbance
• Disorders that Initially Alter PaCo2(Normal is 35 to 45mmHg):
a. Respiratory Acidosis
b. Respiratory Alkalosis

• Disorders that initially Affects Plasma Hco3(normal is 20 to

31mmHg):
a. Metabolic Acidosis
b. Metabolic Alkalosis

N.B:
- Compensation for Acid- Base Derangements are either respiratory
for metabolic
derangements or metabolic for respiratory derangements.
 A. Respiratory Acidosis
- Causes are impaired alveolar ventilation due to
Respiratory center depression(Morphine, CNS injury),

Airway obstruction,

Thoracic & upper abdomen incisions,

Abdominal distention in ileus,

Pulmonary D/se such as pneumonia, atelectasis.

Inadequate ventilation of anesthetized patients.

 Respiratory Acidosis Ctd…

- Clinical Features are

 Restlessness, HTN & tachycardia may indicate
inadequate ventilation with hypercarpnia.

- Managements are
 Must focus on relieving the primary cause,
 Relieving airway obstruction, adequate analgesia,
& drain pleural effusion,
 Intubation & mechanical ventilation my be used in
severe cases.
 B. Respiratory Alkalosis
- Causes are due to excessive ventilation by anesthesia(most
case) and also caused by hyperventilation due to
hypothalamic lesion, severe pain, hyper pyrexia, high altitude,
and hysteria.

- Clinical Features
 Dev.t of ventricular arrhythmia and fibrillation due
to potassium depletion during sever respiratory
alkalosis.

- Management
 Can be controlled by breathing into a plastic, or
 C. Metabolic Acidosis
- It is a condition with either in deficit of base or an excess of
acid other than carbonic acid.

- Causes are
 Increased fixed acids due to
 Anaerobic tissue metabolism during shock, infection,
tissue injury.
 Retention of metabolites in renal insufficiency.
 Formation of ketone bodies in DM or starvation.
 Loss of Bases in
 Chronic diarrhea,
 Gastrocolic or high intestinal fistula, and
 Excessive intestinal aspiration.
 Metabolic Acidosis Ctd…
- Clinical Features are
 Besides sign and symptoms of primary etiology like
shock, infection, rapid, deep, noisy breathing is found.
 The urine become strongly acidic.

- Managements are
 Tissue hypoxia should be treated by reperfusion.

 NaHCo3 can be given where bases have been lost or

where the degree of acidosis is so severe than
myocardial function is compromised.
 D. Metabolic Alkalosis
- It is a condition of base excess or deficit of any acid
other than carbonic acid.

- Causes are
 Loss of stomach acid in vomiting or aspiration(the
most common),

 Excessive ingestion of absorbable alkali,

 Hypokalemic alkalosis in patients with pyloric

stenosis or GOO due to loss of K+ and acid.
 Metabolic Alkalosis Ctd…
- Clinical Features are
Cheynestrokes respiration with periodic apnea,
Tetany sometime occurs.

- Managements are
Repletion of volume plus potassium(check UOP),

Use 0.1N or 0.2N HCl is also effective in Rx of resistant

metabolic alkalosis.
 Fluid and Electrolyte Therapy
- Choice aims on
a. Deficit/Excess: diarrhea, vomiting, bleeding, sepsis….
b. Maintenance: NPO
c. Ongoing Loss: pre-, Intra-, and post- operative
procedure.

- Correct the abnormalities but imposes minimal demand on the

kidney.
 A. Deficit:
- Replace with crystalloid/blood either enteral or parenteral(IV).
- Classifications are
• Mild if deficit <5% of body wt,

• Moderate if it is b/n 5-10% of the body wt,

• Severe if it is >/= 10% of the body wt, and

• If in shock should be replaced on 10 to 20ml/kg over

30min.
 B. Ongoing Loss
- Replacement of continuing loss estimated by the previous
24hrs loss.

- It is measured from NG tube, drainage tube, stoma bags, and

suctions.

- Estimated from Gauzes and packs.

- Replaced on ml to ml bases.
 C. Maintenance Fluid
- It is calculated maintenance fluid requirement of day.
- Adults& older Children:
100ml/kg/d(4ml/kg/hr) for the first 10kg,
50ml/kg/d(2ml/kg/hr) for the next 10kgs, and
20ml/kg/d(1ml/kg/hr) for each subsequent/ the
remaining kg.
Eg. For 40kg child needs 40+20+20=80ml per hour free fluid

-Child: 150-200ml/kg/d.
- Electrolyte requirement
Na+: 1.5-2mmol/kg/day
K+ :1mmol/kg/day
Electrolyte solutions for parenteral
administration (common)
Why Children are not
small adults?