DEPARTMENT OF SURGERY

(UPTH)

PRINCIPLES OF FLUID AND ELECTROLYTE THERAPY IN

SURGERY

Dr. Okun P. O
Supervisor: DR C. P Okpani.
12/4/24
OUTLINE
• Introduction
• Statement of Surgical Importance
• Fluid and Electrolyte needs of a Surgical patient.
• Causes of Fluid and Electrolytes Abnormalities
• Clinical Assessment of Fluid and Electrolyte
Abnormalities
• Monitoring of Fluid and Electrolytes in a Surgical patient
• Management of Fluid and Electrolytes problems
• Complications of Managing Fluid and Electrolytes
Abnormalities
• Conclusion
• References
INTRODUCTION
• Fluid and electrolyte management is
paramount to the care of the surgical patient.
• Changes in both fluid volume and electrolyte
composition occur preoperatively,
intraoperatively, and postoperatively, as well
as in response to trauma and sepsis.
BODY FLUIDS
TOTAL BODY WATER (TBW)
• TBW constitute about 50% - 60% of total body weight
• TBW depends on age, sex and obesity
• Young lean individuals have a higher body weight as
water than elderly, obese individual.
• Lean tissues such as muscles and solid organs have
higher water content than fat and bone
• Young adult male: young adult female 60%:50%
• Osmolarity of body fluid 290-300mosm/l
Body fluid compartments and
composition
• TBW - 60%
• 1 Intracellular fluid - 40%
• 2 Extracellular fluid - 20%
• Intravascular (plasma) 4%
• Extravascular 16%
Transcellular 1%
Interstitial 15%
Ionic composition of body fluid

Schwartz
Statement of surgical importance
• Fluid & electrolyte therapy is paramount in
surgical px due to changes that occur
preoperatively, intraoperatively and post
operatively.
• Proper mgt will help facilitate the crucial
homeostasis that allows for cardiovascular
perfusion, organ system function and cellular
mechanisms to respond to surgical illness.
Fluid & Electrolyte requirement
Water exchange
Electrolyte gain & losses
• Normal individual consume 3-5g dietary salt
balanced by the kidneys, sweat, GI losses
• Sodium needed 1-2mEq/kg/day
• Potassium needed 0.5-1mEq/kg/day
• Na+ losses 100-250mEq/day
• k+ losses 15-20mEq/day
CAUSES & CLINICAL ASSESSMENT OF
FLUID & ELECTROLYTES
ABNORMALITY IN SURGICAL PATIENT

• Water intoxication
• Dehydration
• Shock
• Disturbances in Sodium, Potassium, Calcium,
Magnesium
• Changes in Acid-base balance
 VOLUME OVERLOAD
• Parenteral administration of more fluids than
the kidneys can excrete, especially in the
presence of hypo-proteinaemia, renal or
hepatic disease and CCF, leads to retention of
large volumes of fluid
 TREATMENT OF FLUID OVERLOAD
• Stop IVF immediately and give IV frusemide .
• IV Mannitol
• In cases with severe renal impairment,
removal of excessive volume by
haemodialysis or peritoneal dialysis.
Dehydration
• DEHYDRATION– common fluid loss
associated with loss of electrolytes.
• It may be rapid (acute dehydration).
• It can be slow over a period of many days or
weeks as in gastric outlet
obstruction(chronic dehydration).
• ECF Volume deficit is the most common fluid
loss in surgical patients.
CAUSES OF dehydration
• Vomiting or Nasogastric aspiration
• Diarrhoea
• Intestinal fluid shifts
• Burns
• Entero-cutaneous fistula
• Excessive sweating
• Polyuria
SHOCK
• It ensues with ECF loss ≥ 3.5L
• It is a life threatening condition which results
from failure of the circulatory system to supply
sufficient blood, oxygen (O₂) & nutrients to
peripheral tissues.
• Types of shock –
• Low volume shock – (hypovolemic and
haemorrhagic shock), Cardiogenic shock,
Septic Shock, Neurogenic Shock, Anaphylactic
Shock
Principle of fluid and electrolyte
therapy in surgical px
• Correction of deficit
• Maintenace fluid
• Correction of ongoing loss
• Monitoring of treatment
 Preoperative Correction of
dehydration (deficit)
• Mild dehydration - liberal fluid intake.
• IV access secured, blood samples taken for U/ECr, PCV
• Crystalloid are started ; ringers lactate, N/S IL for 30-
45min
• Pass urethral catheter, empty the urinary bladder, then
monitor urine output
• Then re-assess patient, if parameters (PR,BP, urine
output ) inadequate, repeat IV fluid IL over 30-45min
• and reassess as appropriate upto 4L, then give
frusemide. Otherwise if adequate, place on
maintenance of 1L 8hrly.
• During resuscitation, the following parameters are
checked for;
•  Hourly urine output 30-50ml/hr (0.5-1ml/kg/min)
•  Half-hourly P.R and BP
• Skin tugor, moistness of tongue , fill of
subcutaneous veins
•  Frequent auscultation of the lungs and
monitoring of JVP to prevent overhydration or
quickly diagnose and treat if occur.
•  CVP 10-15mmHg
 TREATMENT OF SHOCK (SEVERE DEHYDRATION)
• O₂ supplementation
• IV fluids about 3.5L on the average
• Passive leg raising
• Treat hypokalemia
• Avoid hypothermia
• Treat the underlying cause
Maintenance
• With correction of deficit and patient is
making adequate urine, PR,BP,CVP all within
normal limit, patient is placed on daily
maintenance. 1L 8hrly, 2L of 5%DW,1L of N/S
and 3g of KCL added to the fluid. However,
ongoing loss is taken into consideration and
added to the total maintenance fluid.
• Maintenance IV Fluid Calculation-
• 100ml/kg/day for first 10kg
• 50ml/kg/day for next 10kg
• 20ml/kg/day for every kg over 20kg
Ongoing loss
• Ongoing GI losses such as N-G tube drainage,
drainage from enterocutenous fistulae,
diarrhea, vomiting are estimated and added
into maintenance fluid.
Intraoperative fluid therapy
• With the induction of anesthesia, compensatory
mechanisms are lost, and hypotension will develop if
volume deficits are not appropriately corrected before
the time of surgery.
• In addition to measured blood loss, third space losses
must be considered in the OR.
• Although no accurate formula can predict
intraoperative fluid needs, replacement of ECF during
surgery often requires 500 to 1000 mL/h of a balanced
salt solution to support homeostasis.
Monitoring
•  Input –out put chart
•  Serum U/ECr must be checked daily and
deficiency corrected,12hly for critically ill patient.
•  Repeat Hb/PCV after rehydration and correct if
depleted.
•  State of hydration assessed daily; urine output of
≥ 1000ml is indicative of good hydration
•  Monitoring for overload
• Frequent auscultation
• CVP
Monitoring
• It can be : Clinical and Laboratory
• Clinical
• Non-invasive
• Invasive
• a. Non-invasive
• The following parameters are observed during rehydration-
• Half hourly PR, RR & BP
• Skin turgor, moistness of the tongue, capillary refill
• Frequent auscultation of the lungs to avoid Severe Fluid
Overload.
• Daily weighing
• b. Invasive
• Central venous catheter.
• Urethral Catheter - Hourly urine output – 30-
50mls/hr or (1000ml/day or more) - a mirror
of tissue perfusion.
• Strict input/output chart must be kept.
• Oesophageal doppler monitoring
• Arterial wave form analysis
• Pulmonary artery catheter
• 2. Laboratory
• Daily S/E/U/CR
• S/Ca++, S/Mg++
• PCV/Hb
• Urinalysis
• S/Albumin
• Arterial blood gases -
• Electrocardiogram
ELECTROLYTE
DISTURBANCE
HYPONATREMIA
• Hyponatraemia<135MMOL/L: Mild- 130-
134mm0l/L, Moderate -120-129mmol/L,
Severe- <120mmol/L
• Manifest clinically when serum Na+
<125mmol/l
• convulsion is seen in severe hyponatremia <
120mmol.
 CAUSES
• vomiting or N-G aspiration, diarrhea,
internal fluid shift, enterocutenous fistulae,
excessive sweating, renal disease, diuretics
TREATMENT OF HYPONATREMIA

• Treat underlying condition (Free water restriction

for Euvolemia, IV N/Saline for Hypovolemia,
Diuretic for Hypervolemia)
• Correction of Na+ deficit =[ {0.6 x wt (kg) x Na
deficit } mEq/l
• acute hyponatremia-1-2mEq/L/hr.
• Hypertonic saline
• 3.5% & 5% saline – symptomatic severe
hyponatremia,
• 7.5% saline - treatment of closed head injury
 HYPERNATREMIA
• Hypernatremia results from either a loss of free water or a
gain of sodium in excess of water. Like hyponatremia, it
can be associated with an increased, normal, or decreased
extracellular volume.
• Hypernatremia->145MMOL/L: Mild- >145mmol/L,
Moderate- 146-159mmol/L, Severe- >160mmol/L

• Types of Hypernatremia;
• Euvolemic (pure water loos)
• Hypovolaemic (among the loss of water and sodium,
more water is lost than sodium)
• Hypervolaemic (both sodium and water gain but
sodium gain is more than water gain).
 Causes
• Hypernatremia could either be hypervolemic (caused
either by iatrogenic administration of sodium-
containing fluids, including sodium bicarbonate,
Urine Na conc. > 20mEq/L),
• normovolemic (result from renal causes, including
diabetes insipidus, diuretic use, and renal disease)
• hypovolemic (nonrenal water loss from the GI tract
or skin, although the same conditions can result in
hypovolemic hypernatremia<20mEq/L)
TREATMENT OF
HYPERNATREMIA
• Stop sources of sodium
• Treat underlying cause
• Hypovolemic Hypernatremia- volume should be
restored with IV N/S first before correcting conc
abnormality. adequate vol achieved then 5%
dextrose.
• Water deficit (L) = serum sodium -140÷140 x TBW
• Hypervolemic Hypernatremia- Use diuretics
• Correction of Na+ excess =[ {0.6 x wt (kg) x (X-145)}
mEq/l
ALTERATIONS IN
POTASSIUM
• Normal value is 3.5 - 5.6mmol/L
• K+ is important in cardiac and neuromuscular functions
Hypokalemia
• , mild hypokalemia – 3- 3.4mmol/L, moderate
hypokalemia – 2.5 – 2.9mmo/L, severe hypokalemia -
<2.5mmol/L
Can occur suddenly in a diabetic coma patient treated with
insulin and saline.
Gradual loss is seen in;
• Diarrhoea of any causes, villous tumour of the rectum,
ulcerative colitis.
• After trauma or surgery.
• Pyloric stenosis with gastric outlet obstruction.
• Duodenal fistula, ileostomy.
• After uretero sigmoidostomy
• Insulin therapy.
• Poisoning.
• Drugs like beta agonists
Clinical features

• Slurred speech.
• Muscular hypotonia.
• Depressed reflexes.
• Paralytic ileus.
• Weakness of respiratory muscles.
• Cardiac arrhythmias, flattened T waves, depressed
ST segment, prolonged QT interval.
• Inability to produce concentrated urine and so
causes nocturia and polyuria
 TREATMENT OF HYPOKALEMIA

• Potassium rich foods and slow K+ 600mg for

mild hypokalemia
• IV KCL at 10-20mmol/hr for moderate and
severe cases.
• K+ correction = [ {body weight(kg) x deficit x
0.4} + ongoing losses + maintenance]
• Correction of alkalosis result with correction
of k+ and adequate rehydration.
Hyperkalemia
Serum K+ > 6mmol/L
CAUSES OF HYPERKALEMIA
• Increased intake – K+ supplementation
• Increased release – DKA, transfusion of old
haemolysed blood, endogenous destruction
(haemolysis, rhabdomyolysis, crush injury, major
burns, limb ischaemia, gastrointestinal
haemorrhage).
• Impaired excretion – K+ sparing diuretics, renal
failure, Aminoglycosides, ᵦ-Blockers, Angiotensin
converting enzyme inhibitors.
CLINICAL FEATURES
• GI: Nausea, vomiting, diarrhea, muscle
weakness
• CVS; Peaked T waves, widened QRS complex
& depressed ST segment > disappearance T
waves, Heart block, diastolic cardiac arrest
TREATMENT OF
HYPERKALEMIA
• Stop sources of K+
• Give 10 units of soluble insulin and 50ml of 50%
D/W
• 10ml of 10% Calcium gluconate / 10ml of 10%
Calcium chloride
• IV NaHCO₃ - metabolic acidosis
• Cation exchange resins
• Peritoneal dialysis or haemodialysis - renal failure
• Treat underlying cause
ALTERATIONS IN CALCIUM
• Ionized Ca++ 45% responsible for NM
stability
• Acidosis - increased ionized fraction
• Alkalosis - decreased ionized fraction
• Normal value 8.5-10.5mEq/l; ionized ca 4.2-
4.8mEq/dl
HYPOCALCEMIA <8.5mEq/L
(<4.2mg/dl)
CAUSES
o Acute pancreatitis
o massive soft tissue infections such as necrotizing fasciitis,
o renal failure,
o pancreatic and small bowel fistulas,
o hypoparathyroidism,
o toxic shock syndrome,
o abnormalities in magnesium levels,
o tumor lysis syndrome
o malignancies associated with increased osteoclastic activity eg breast
and prostate ca.
o massive blood transfusion with citrate toxicity
• Asymptomatic hypocalcemia may occur when
hypoproteinemia results in a normal ionized calcium
level. Conversely, symptoms can develop with a
normal serum calcium level during alkalosis, which
decreases ionized calcium. neuromuscular and cardiac
symptoms do not occur until the ionized fraction falls
below 2.5 mg/d.
Clinical feature
• Paresthesias of the face and extremities, muscle
cramps, carpopedal spasm, stridor, tetany, and
seizures.
• Hyperreflexia
• Positive Chvostek's sign
• Trousseau's sign +ve
• Decreased cardiac contractility and heart failure.
• ECG changes, prolonged QT interval, T wave
inversion, heart block and VF
 TREATMENT OF HYPOCALCEMIA
• Asymptomatic hypoCa++: oral or IV calcium.
• With gastric access and tolerating enteral nutrition:
Calcium carbonate suspension 1250 mg/5 mL q6h
per gastric access; recheck ionized calcium level in 3
d
• Without gastric access or not tolerating enteral
nutrition: Calcium gluconate 2 g IV over 1 h × 1 dose;
under ECG Monitoring. Recheck ionized calcium level
in 3 d
• Treat the underlying cause
• For blood induced hypoca++: 2mls of cacl2/500mls of
blood if the rate of transfusion is 100mls/min.
• 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.
• Hypocalcemia will be refractory to treatment if
coexisting hypomagnesemia is not corrected first
Hypercalcemia >12mEq/l or
ionized ca++ >4.8mg/dl
CAUSES
• Primary hyperparathyroidism
• malignancy in hospitalized patients, from either
bony metastasis or secretion of parathyroid
hormone–related protein, account for most cases
of symptomatic hypercalcemia.
• Vitamin D overdose
• Thiazide diuretics-HCT, Indapamide
• Milk Alkali syndrome
Clinical features
• Anorexia, nausea/vomiting, abdominal pain,
Weakness, confusion, coma, bone pain,
• Hypertension, arrhythmia, polyuria,
Polydipsia.
• ECG changes shortened QT interval,
prolonged PR and QRS intervals, increased
QRS voltage, T-wave flattening and widening,
and cardiac arrest.
TREATMENT OF
HYPERCALCEMIA
• Treat the underlying cause
• Stop sources of calcium and antacid ingestion
• Fluid replacement & diuretics
• Bisphosphonates to inhibit true resorption.
Contraindicated in CRF
• IV Nasulphate for CRF
• Haemodialysis- renal failure
• Exogenous SC Calcitonin 4u/kg 12hrly
• Steroids/mithramycin
Hypomagnesemia <1.5mEq/l
Causes
• Malnutrition, alcohol.
• Large GI fluid loss.
• Patients on total parenteral nutrition.

Clinical Features
• Hypereflexia.
• Muscle spasm.
• Parasthesia.
• Tetany.
• Chvostek's sign +ve
• Trousseau's sign +ve
• Delirium and seizure
• ECG: prolonged QT & PR interval, ST Segment depression, flattened p
waves
 TREATMENT OF
HYPOMAGNESAEMIA
• Oral magnesium salts for asymptomatic & mild
• Magnesium level <1.0 mEq/L:
• Magnesium sulfate 1 mEq/kg in normal saline 250 mL
infused IV over 24 h × 1 d, then 0.5 mEq/kg in normal
saline 250 mL infused IV over 24 h × 2 d
• Recheck magnesium level in 3 d
• Note – when hypokalemia or hypocalcemia coexists
with hypomagnesaemia, Mg should be aggressively
replaced to assist in restoring K+ or Ca++ haemostasis.
Hypermagnesemia >2.5mEq/l
Causes
• Advanced renal failure treated with magnesium
containing antacids
• Severe acidosis.
• Intentionally produced hypermagnesaemia while
treating pre-eclampsia.
 Clinical Features
• Loss of tendon reflexes (commonest).
• Neuromuscular depression.
• Flaccid quadriplegia.
• Respiratoty paralysis.
• Somnolence.
• Hypotension.
• Increase P-R interval, widened QRS complex &
elevated T waves.
 TREATMENT OF HYPERMAGNESAEMIA
• CaCl2 (5-10ml) is given to antagonize cardiovascular
effect
• IV N/S for concurrent volume deficit
• Diuretics to hasten renal excretion
• Hemodialysis in severe cases
COMPLICATIONS
• Thrombophlebitis
• Local sepsis
• Endothelial injury
• Septicaemia
• Fluid Overload
• Air embolism
• Pyrogenic reactions
• Arrhythmia & Cardiac arrest
• Respiratory failure
• Cerebral oedema , Seizures, Brain damage
• Death
Conclusion
• Knowledge of the guidelines for managing fluid and
electrolytes abnormalities perioperatively by a
surgeon is vital in the care of a surgical patient
• It is necessary to recognize the fluid and electrolyte
problems timely, corrections should be
individualized.
References
• Schwartz’s Principles of Surgery, 10th Edition
• Baja’s Principles and Practice of Surgery (including
Pathology in the Tropics), 5th Edition
• Sabiston Textbook of Surgery, the Biological Basis of
Modern Surgical Practice, 20th Edition.
• Medscape