Fluids and electrolytes ppt

FLUIDS/ ELECTROLYTES IN
SURGICAL PATIENTS
PRESENTER:-
Dr. Rajat Maheshwari,
Resident General surgery
Moderator:-
Dr. Mahim Koshariya (MS, FAMS,FIASGO,FIAGES)
Professor, Dept. of General surgery,
Gandhi medical college & Hamidia hosp., Bhopal

DISTRIBUTION OF FLUIDS IN BODY
• Total body water content is about 60% of body
weight in young adult male and about 50 % in
young adult female.

• Out of this Total Body Water, two-thirds is
intracellular fluid (ICF), whereas remaining
one-thirds is extracellular fluid (ECF).

• ECF is divided into interstitial fluid (three-
fourths of ECF) and intravascular volume (one-
fourth of ECF).

THIRD SPACE
• Acute sequestration of fluid in a body
compartment that is not in equilibrium with ECF.
• Examples:-
 Intestinal obstruction
Severe pancreatitis
Peritonitis
Major venous obstruction
Capillary leak syndrome
Burns

DAILY FLUID BALANCE
• Insensible fluid loss = 500ml through skin
400ml through lung
100ml through stool
• Insensible fluid input = 300ml water due to oxidation
• Normal daily insensible fluid loss = 1000ml- 300ml
= 700ml
Therefore, In a normal person,
Daily fluid requirement = Urine output + 700ml
• Abnormal fluid loss = 500ml through moderate sweating
= 1- 1.5 lit . through severe sweating/ high fever
= 0.5- 3.0 lit. through exposed wound surface
Therefore, higher amount is lost during exercise , abnormal perspiration, burns,
pyrexia and surgery

BASIC PRINCIPLES OF IV FLUID
THERAPY

CLASSIFICATION OF IV FLUIDS
CRYSTALLOIDS
• 5% Dextrose
• Isotonic saline (0.9% NS)
• Dextrose saline
• Ringer’s lactate
• Isolyte - M
• Isolyte - G
COLLOIDS
• Albumin
• Hetastarch
• Pentastarch
• Dextran
• Gelatin polymers
(Haemaccel)

CRYSTALLOIDS
Dext. Na K Cl Acet. Lact. NH4Cl Ca Mg HPO4 Citr
.
mOsm/
L
5% Dextrose 50 - - - - - - - - - -
0.9% Saline - 154 - 154 - - - - - - -
Dextrose
saline
50 154 - 154 - - - - - - -
Ringer’s
Lactate
- 130 4 109 - 28 - 3 - - -
Isolyte- M 50 40 35 40 20 - - - - 15 -
Isolyte- G 50 63 17 150 - - 70 - - - -
Isolyte- E 50 140 10 103 47 - - 5 3 - 8
Isolyte-P 50 25 20 22 23 - - - - 3 3

CLASSIFICATION OF CRYSTALLOIDS
MAINTENANCE FLUIDS
• Provides fluid lost from lungs,
skin, urine and feces.
• Examples:-
5% Dextrose
Isolyte-M
REPLACEMENT FLUIDS
• Formulated to correct fluid
deficit caused by losses such
as gastric drainage, vomiting,
diarrhea, fistula drains,
intestinal edema, oozing from
trauma, infections, burns etc.
• Examples:-
Isotonic saline
DNS
Ringer’s lactate

5% DEXTROSE
COMPOSITION:-
One litre of fluid contains Glucose = 50gm.
Best agent to correct intracellular dehydration. It is given when there is need of water but not
electrolytes.
INDICATIONS:-
1. Pre and post operative fluid replacement.
2. For iv administration of various drugs.
3. Cheapest fluid to provide calories to the body.
4. For treatment and prevention of ketosis in starvation, diarrhea, vomiting and high grade
fever.
5. Prevention and treatment of dehydration due to inadequate water intake or excessive
water loss.
CONTRAINDICATIONS:-
1. Cerebral edema: due to its hypotonic nature, it aggravates cerebral edema.
2. Neurosurgical procedures: increases ICT
3. After acute ischaemic stroke: as hyperglycemia aggravates cerebral ischaemic brain
damage.
4. Hypovolemic shock: It does not increase intravascular volume substantially and could lead
to hyperglycemic osmotic diuresis.
5. Blood transfusion: Due to hypotonicity, infusuion through same iv line can cause hemolysis
6. Uncontrolled diabetes and severe hyperglycemia.

COLLOIDS
• Three times more potent in increasing vascular
volume.
• So, helpful in hemorrhagic shock, however to
maintain adequate capacity to carry oxygen,
blood transfusion is required subsequently.
TYPE OF FLUID EFFECTIVE PLASMA
VOLUME EXPANSION
DURATION OF EXPANSION
5% Albumin 70- 130 ml 16 hrs
10% Dextran-40 100-150 ml 6 hrs
6% Hetastarch 100- 130 ml 24 hrs
10% Pentastarch 150ml 8 hrs

HETASTARCH (HYDROXYETHYL
STARCH)
COMPOSITION:-
It is a synthetic esterified colloid available as 6% solution in isotonic saline.
Esterification retards degradation which leads to longer plasma expansion.
ADVANTAGE:-
1) Non- antigenic (as compared to dextran)
2) Does not interfere with blood grouping and cross matching (as compared to
dextran)
3) Less expensive than albumin
4) Plasma volume expansion greater than 5%albumin.
5) Expands plasma volume for longer period (about 24 hrs)
DISADVANTAGE:-
1) Increase in serum amylase concentration during and 3-5 days after discontinuation
of hetastarch (unable to diagnose accute pancreatitis during this period).
2) Like other colloids, no oxygen carrying capacity

ADVERSE EFFECTS:-
Although non antigenic, allergic or sensitivity reactions
can occur (incidence <0.0004%).
INDICATIONS:-
Safe and effective plasma expander, which maintains
plasma volume for a longer period.
Indications are same as that of Dextran.
CONTRAINDICATIONS:-
Same as that of dextran.
ADMINISTRATION:-
Usual adult dose is 500ml to 1 litre. Total daily dose
should not exceed 20ml/kg.

PREOPERATIVE FLUID THERAPY
• Can be discussed under following 3 headings:-
1) Correction of hypovolemia
2) Correction of anemia
3) Corection of other disorders

CORRECTION OF HYPOVOLEMIA
For correction of hypovolemia. First we need to decide the
severity of dehydration, which could be estimated as follows:-

• Now on the basis of severity of dehydration,
following guidelines provide as to how much
amount of fluid deficit is present:

• Replacements fluids eg: Isotonic saline,
ringer’s lactate, colloids whole blood can be
given.
• In case of severe deficit, initial rate of fluid
replacement may be 1000ml/hr and gradually
reducing the rate as fluid status improves.
• Improvement in tachycardia, blood pressure
and achieving urine output >30-50ml/hr (in
absence of diuretics) suggests correction of
fluid deficit.

FLUID LOSS IN DIFF. TYPES OF
SURGERY

INTRAOPERATIVE BLOOD
TRANSFUSION

FACTORS TO BE CONSIDERED FOR
INTRAOPERATIVE BLOOD
TRANSFUSION

WHEN TO GIVE BLOOD TRANSFUSION
INTRAOPERATIVELY

MAXIMUM ALLOWABLE BLOOD LOSS
(MABL)

TO ESTIMATE INTROPERATIVE Hb
STATUS AFTER INTRAOPERATIVE
BLOOD LOSS

• In major surgeries, where handling of intestine
is not required, i.v. fluid is required only for 24-
48 hrs eg: cardiac surgeries, coronary bypass
surgery, total hip replacement etc.

ROUTINE POST-OP I.V. FLUIDS FOR
FIRST 3 DAYS IN NPO PATIENTS

PARENTRAL NUTRITION IN SURGICAL
PATIENTS
• PREOPERATIVE PARENTRAL NUTRITION:-
 Indicated in severly malnourished patients with weight loss >10-15%,
serum albumin <2.8g/dl.
 Preoperative PN reduces non- infectious complications (eg: pulmonary
emboli and delayed wound healing) and is therefore recommended in
moderate to severe malnourished patients.
 Effective restoration of malnutrition requires PN to be started at least 7-14
days prior to surgery and should be continued postoperatively.
 Patients with mild malnutrition may not be benefited from PN , instead
have more risk of infectious complications like pneumonia and wound
infection.

• POST-OPERATIVE PARENTERAL NUTRITION:-
 Indicated in :
a) Patients unlikely to resume oral feeds within 10 days
after surgery. PN should be started within 3 days after
surgery (due to postoperative paralytic ileus and
concern of disruption of bowel anastomosis) .
b) Immediate nutritional support may be appropriate in
patients as a continuation of preoperative nutritional
support for malnutrition.

NORMAL ELECTROLYTE DISTRIBUTION

SODIUM REGULATION
• Major ECF cation
• Normal serum concentration = 135-145mEq/l
• Major function is to maintain ECF volume and
thereby control the blood pressure.
• Daily requirement is about 100mEq or 6 gm of
sodium chloride

HYPONATREMIA
• Defined as plasma sodium <135 mEq/l.
• Etiology:-
On the basis of ECF volume can be classified as:
HYPONATREMIA WITH ECF VOLUME
DEPLETION
HYPONATREMIA WITH
HYPERVOLEMIA(increase
d ECF volume)
HYPONATREMIA WITH
NORMAL ECF VOLUME
Patient dehydrated Patient edematous Patient normovolemic,
increased total body
water
1. Extra-renal loss (urinary
Na<15mEq/l)
Vomiting, diarrhea, peritonitis
2. Renal loss(urinary Na >20mEq/l )
Excessive diuretics, diabetic
ketoacidosis, salt losing
nephropathy
1. Urinary Na <20mEq/l
CHF, cirrhosis,
nephrotic syndrome
2. Urinary Na >20mEq/l
Renal failure
SIADH, Post operative
pain, psychogenic
polydypsia,
hypothyroidism,
glucocorticoid def.,
drug induced

Clinical features:
Mild Moderate Severe
Anorexia Personality changes Drowsiness
Headache Muscle cramps Diminished reflexes
Nausea Muscular weakness Convulsions
Vomiting Confusion Coma
Lethargy Ataxia Death

TREATMENT:-
Treatment
Clinical features
HYPONATREMIA
Hypovolemia
Salt and water
supplementation
Oedema
Salt restriction
Water restriction
Loop diuretcs
Normovolemia
Water restriction

jabj
When to treat?
Acute (<48hrs) / Symptomatic
(severe neurological symptoms) /
Severe hyponatremia (<120mEq/l)
Rapid correction with hypertonic saline
at rate 1.5-2mEq/L/hr for first 3-4 hrs or
until symptoms subside. Besides this
initial correction, rise should not exceed
10-12mEq in 24 hrs.
Chronic(>48 hrs) /Mild
hyponatremia with minimal
neurological symptoms
Targeted rate of correction should not
be > 0.5- 1 mEq/l/hr and should not
exceed 8mEq/l in 24 hrs.

• Correction should be interrupted once any of the
3 end points are reached:
i. Patient’s symptoms are abolished.
ii. Safe plasma Na level(120-125mEq/L) is
achieved.
iii. Total magnitude of correction of 20mEq is
achieved.
• 0.9 % Saline is preferred in cases of hypovolemic
and normovolemic hyponatremia. Whereas
Hypertonic saline is preferred in cases where fluid
restriction is required along with salt
supplementation( Hypervolemic hyponatremia).

HYPERNATREMIA
• Defined as plasma Na conc. >145mEq/L.
• Etiology:-

• Clinical features:-
Dry sticky mucous membrane
Elevated body temprature
Nausea
Muscular weakness
Altered mental status
Neuromuscular irritability
Focal neurological deficits
Seizures
Coma

• Treatment:-
Therapeutic goals:
i. To stop ongoing fluid loss (by treating underlying cause)
ii. To correct water deficit
 Rate of correction: In Acute hypernatremia, water deficit can be replaced relatively rapidly
with a targeted rate of 1mEq/L, whereas in chronic hypernatremia, safe rate of reduction in
serum Na is 1mEq/L every 2 hrs or 10mEq over first 24 hrs.
 Goal of treatment: Goal is to reduce serum Na concentration to 145mEq/L
 Acute hypernatremia is treated vigorously with D5% infusion. If required hyperglycemia can be
combated with insulin therapy.
 In Hypernatremia with ECF volume contraction (i.e. hyotension, azotemia), Isotonic saline is
given initially until ECF volume is restored. Subsequently water deficit can be replaced by water
by mouth or i.v. 5% Dextrose
 In Hypernatremia with incresed ECF volume, patients are usually volume overloaded.
Therefore, loop diuretic is administered along with water to facilitate Na excretion. In patients
with massive overload or renal failure, Dialysis may be necessary.

POTASSIUM
• Chief intracellular cation
• Normal serum level = 3.5 – 5.0 mEq/L
• Normal daily requirement of K is 50-80mEq/L

HYPOKALEMIA
• Defined as serum K <3.5mEq/L
• Etiology:-

CLINICAL FEATURES:-
 Fatigue, myalgia, muscular weakness
 Constipation, ileus, urinary retention(due to smooth muscle
involvement)
 More severe hypokalemia hypoventilation due to respiratory
muscle paralysis
 Arrythmias
 Can precipitate hepatic encephalopathy in patients with hepatic
failure
ECG Changes:
Flattening of T wave
Prominent U wave
Prolonged PR interval
Widening of QRS complex
Ventricular arrythmia

• TREATMENT:-
1. Prevention of hypokalemia
2. To prevent life threatening complications
3. To correct potassium deficit
4. To minimize ongoing losses
5. To treat underlying etiology

• PREVENTION OF HYPOKALEMIA:-
Normal K intake of about 60mEq/ day is
sufficient to prevent hypokalemia
 Post-operative patients on parentral fluid
therapy should receive 40-50mEq/day of K to
prevent hypokalemia.

• CORRECTION OF POTASSIUM DEFICIT

ORAL POTASSIUM SUPPLEMENTATION:-
 Safer mode of correction of hypokalemia
 In mild to moderate hypokalemia, avg. dose of
potassium chloride is 60- 80 mEq/ day (20mEq, 3-4
times a day).
IV POTASSIUM THERAPY:-
 Reserved for severe symptomatic hypokalemia or for
patients who cannot ingest oral potassium.
 100mEq of K (5amp of 10ml, 15% KCl ampules) mixed
in 1 litre of isotonic saline @ 100ml/ hr will deliver
10mEq/ hr.
 1 ampule of 15% KCl = 10ml = 20mEq of potassium

• PRECAUTIONS:-
• Continuous ECG monitoring and frequent
potassium estimation is required.
• Avoid i.v. potassium till urine output is
established.
• Dose should not exceed > 10-20 mEq/ hr
> 40 mEq/ hr
> 250ml / day
• Treatment with acidosis with i.v. NaHCO3 may
aggravate or precipitate hypokalemia.

HYPERKALEMIA
• Serum potassium level >5.5 mEq/L.
• ETIOLOGY:-

• CLINICAL FEATURES:-
• Hypokalemia is often asymptomatic until plasma K
concentration is > 6.5 mEq/L.
• Vague muscular weakness is usually the first symptom
of hyperkalemia.
• Severe hyperkalemia can lead to hyporeflexia, gradual
paralysis affecting initially legs. Then trunks and arms
at last face and respiratory muscles.
• ECG findings:
Tall T waves
Loss of P waves
QRS merges with T waves
Ventricular fibrillation nad cardiac standstill

• EMERGENCY TREATMENT OF
HYPERKALEMIA:-
In potentially fatal hyperkalemia (serum K >7.5mEq/L, profound
weakness, absence of P wave, QRS widening or ventricular
arrythmias).

1.) Calcium gluconate :-
• Calcium gluconate injection available as 10%
solution in 10ml ampules.
• Usual dose is 10-20 ml infused over 5 to 10 min.
• Most rapid treatment available and effect begins
within minutes. The dose can be repeated if no
change in ECG seen after 5 -10 min.
• Calcium administration decreases membrane
excitability and protects the myocardium.
• Calcium not alter K level, so definite treatment
should be planned.
• Calcium can excerbate digitalis toxicity.

• Insulin and Glucose:-
 Fast way to lower serum potassium
 Insulin causes potassium to shift inside cells. Glucose
is administered with insulin to prevent hypokalemia
 Administer 25 to 50 gm glucose alongwith 10-20
units of regular insulin(50% of regular dose in case of
severe renal impairment) as bolus.
 Initial bolus of insulin to be followed by continuous
infusion of 5% dextrose @ 100ml/hr to prevent late
hypoglycemia.
 May help in reducing plasma K concentration by 0.5-
1.5 mEq/L.

• Sodium bicarbonate infusion:-
 Shifts K into the cells.
 Sod. Bicarboante 7.5% given as bolus dose of 50-100ml (45-90
mEq = 2-4 ampules) i.v. slowly over 10-20 min.
 Injudicious use of large amount of alkali can cause excessive
Ca binding leading to tetany.
 Most effective in severe hyperkalemia with metabolic
acidosis.
• Beta adrenergic agonists(Salbutamol):-
 Promtes cellular uptake of potassium and effectively loers
serum potassium level.
 Dose is 20mg in 4ml of saline by nasal inhalation over 10 min.,
or 0.5mg by i.v. infusion.
 Lowers serum K level by 0.5-1.5 mEq/L.
 Insulin and beta agonists exert additive effects.

PERMANENT MEASURES
• LOOP AND THIAZIDE DIURETICS:-
 Promotes K excretion, if renal function is inadequate.
• CATION EXCHANGE RESINS:-
 Promotes exchange of Na for K in GI tract.
 Given orally as 25-30g mixed with 100ml of 20% sorbitol 3-4 times daily
(sorbitol helps in preventing constipation)
 Can also be given as enema in which 50gm of resin and 50ml of 70% sorbitol
is given with 150ml of water every 4-6 hrly. Washed with water after 60 min.
• DIALYSIS:-
 Most effective and rapid way of lowering plasma K concentration (@
35mEq/hr)
 Reserved for patients with life threatening hyperkalemia (>7mEq/L)
unresponsive to conservative measures.

NON- EMERGRNCY TREATMENT OF
HYPERKALEMIA
In mild to moderate hyperkalemia and for prevention of
recurrence of severe hyperkalemia.
1. Dietary potassium restriction
2. Loop and thiazide diuretics
3. Cation exchange resins(15-20g 2-4 times a day)
4. Avoid medications like:
i. Potassium sparing diuretics, NSAIDS, Ace inhibitors
(reduce renal excretion of K).
ii. Beta blockers- decreases (decrease ECF ti ICF shift
of K.)

Calcium(Ca)
• Essential for bone formation nd neurouscular
function.
• Normal serum levels = 8.5- 10.5mg/dl

 Weakness
 Circumoral and distal extremity parasthesia
 Muscle spasm, carpopedal spasm and tetany
 Mental changes such as irritability, depression and psychosis.
 Chovstek’s sign- Facial twitch elicited by tapping the facial nerve just
ant. to earlobe, just below the zygomatic arch with mouth slightly
open.
 Trousseau’s sign- Development of wrist flexion,
metacarpophalengeal joint extension and interphalangeal joint
extension and thumb flexion when BP cuff is kept inflated over
systolic BP for > 3min.

• TREATMENT:-
1. Acute management:-
 Sympomatic hyperglycemia is treated with 10% calcium gluconate (90mg of
elemental Ca/ 10ml) 10-20ml i.v. slowly over 10min.
 Severe symptomatic hypocalcemia may require infusion of 60ml (540gm)of
calcium gluconate in 500ml D5%, to make the concentration of 1mg/ml and is
infused @ 0.5-2 mg/kg/hr.
2. Long term management:-
 Treatment of underlying etiology.
 An asymptomatic hypocalcemic pt., oral elemental Ca is given 1-3 gm/day.
 Best absorbed when taken between meals.
3. Vitamin D supplementation:-
 Calcitriol is the most potent, with fastest onset and shortest duration of action

 Mild hypercalcemia is generally asymptomatic.
 Features of severe hypercalcemia include:
 CNS symptoms: Weakness, fatigue, depression, confusion,
stupor or coma.
 GI symptoms: Constipation, anorexia, nausea, vomiting,
abd pain (due to hypercalcemia induced peptic ulcer
disease or pancreatitis)
 Renal symptoms: Polyuria, nocturia and stone formation.
 Cardiac abnormalities: Shortened QT interval, more prone
to digoxin toxicity

TREATMENT
MEASURES TO INCREASE
URINARY EXCRETION
Isotonic saline(2-
4l/day) : To correct
dehydration, volume
expansion and
natriuresis, which leads
to urinary excretion of
calcium.
Frusemide(20-
160mg/8h): Forced
diuresis after volume
expansion.
Haemodialysis: In
severe hypercalcemia
with little or no renal
function
MEASURES TO INHIBIT
BONE RESORPTION
Bisphosphonates: Most
potent Pamidronate
90mg i.v. over 4 hrs
causes fall in Ca which
is maximal at 2-3 days.
Calcitonin(4IU/kg/12h
s.c.): Rapid acting ,
useful for urgent
therapy of life
threatening
hypercalcemia
alongwith rehydration
and saline diuresis.
MEASURES TO DECREASE
INTESTINAL ABSORPTION
Glucorticoids: Effective
in hypercalcemia due to
Vit.D intoxication,
sarcoidosis and
malignancies.
Oral Phosphate: Should
be used only if serum
phosphorus level is
<3mg/dl and renal
function is normal.
SPECIFIC ETIOLOGICAL
TREATMENT
Discontinue responsible
drugs
Surgical treatment of
primary
hyperparathyroidism
Specific treatment for
Malignancy,
thyrotoxicosis etc.

MAGNESIUM
• Fourth most important cation in body.
• Normal serum Mg level = 1.4- 2.2 mEq/L (1.8-
3 mg/dl).
• Plays an important role in neuromuscular
function and maintenance of cardiovascular
tone.

HYPOMAGNESEMIA
• Defined as serum magnesium concentration <1.5mEq/L or <1.8 mg/dl.
• ETIOLOGY:-

 Rarely occurs as a single deficiency. Often causes
hypocalcemia and hypokalemia, which contributes to
clinical picture.
 Neuromuscular manifestations: Similar to hypocalcemia
and include lethargy, confusion, tremor, fasciculations,
ataxia, tetany and seizures.
 Cardiovascular manifestations: Prolonged PR and QT
intervals
 Leads to hypocalcemia and hypomagnesemia.

• TREATMENT:-
 Correct underlying etiology and co-existing hypocalcemia and
hypomagnesemia.
 Mild hypomagnesemia( 1-1.5mEq/L or 1.2–1.8mg/dl):- Oral supplementation
of 2gm Mg three times a day
 Severe hypomagnesemia(<1 mEq/L or <1.2 mg/dl):- 2gm (16mEq or 4ml of
50%MgSO4) is given slowly i.v. over 10min.; followed by 1mEq/kg of body
weight over 24 hrs as slow continuous infusion. After first day, dose required is
0.5mEq/kg/day for the next 3 days to correct intracellular deficit.
 CAUTION AND MONITORING OF MgSO4 therapy:-
a) Check deep tendon reflexes every 15min. Disappearance of patellar reflex is
usually a sign of Mg intoxication.
b) Periodic monitoring of serum Mg is essential during Mg therapy.
c) Contraindicated in patients with heart block and severe myocardial damage.
d) If over infusion, treat with10% cal. Gluconate, 10-20ml followed by fluid
loading and diuretics

Fluids and electrolytes ppt

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