fluid & electrolyte balance

the edited version of my previous upload

1. DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY RUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCH KOHKA, BHILAI PRESENTED BY – DR. SHEETAL KAPSE 2 nd YEAR, P.G. STUDENT MODERATORS - DR. SUNIL DUTT C. DR. M. SATISH DR. DEEPAK THAKUR DR. MANISH PANDIT

2. FLUID & ELECTROLYTE BALANCE

3. CONTENTS Introduction Basic physiology Body fluid electrolytes disturbances Parenteral fluid therapy Basic principles I.V. fluids Methods of calculation of fluid transfusion rate Fluid therapy in surgical patients Volume resuscitation – end parameters & goals Conclusion References Total body water Distribution Composition Normal exchange of fluids Salt intake & output

4. Introduction Body is formed with solids & fluids. In human body water content is 45-75% of body weight. Importance : In homeostasis In transport Mechanism In metabolic reactions In maintenance of tissue texture In temperature regulation

5. BASIC PHYSIOLOGY

6. Total body water (TBW) TBW varies with age, gender and body habitus . In adult males= 60-65% of body weight, average = 60% In adult female=45-50% of body weight, average = 50% In infant = 80% of body weight Obese patients have less TBW per Kg than lean body adult.

7. 1= Intracellular fluid (ICF)= 70% TBW or 30%(F) - 40% (M) BW 2= Extracellular fluid (ECF) = 30%TBW or 20% BW Interstitial fluid = 7.5% of body weight ( 15%) Intravascular fluid or plasma volume = 4% of body weight ( 5%) Transcellular fluid = 3.5 % of body weight Body compartment fluid Distribution

8. Composition Organic Inorganic Glucose Amino acids Proteins Fatty acid Lipid Hormones Enzymes Oxygen electrolytes

9. Some important terminologies Osmolarity : It is fluid’s capability to create osmotic pressure. It is concentration of osmotically active substances in solution. Osmolality : It is no. of particles / L of solution. Tonicity : Way of expressing effective osmolarity . 10 Same effective osmolarity as body fluid Greater effective osmolarity than body fluid less effective osmolarity than body fluid Cell in a hypertonic solution Cell in a hypotonic solution

10. Cell Membrane ICF Cell Membrane Na + K + Interstitial H 2 O H 2 O Cell membrane is freely permeable to H 2 0 but Na and K are pumped across this membrane to maintain a gradient! Na + = 10 Urea glucose

11. Normal exchange of fluids Water Gain route Average Daily vol. (ml) Minimum (ml) Maximum (ml) sensible Oral fluids 800 - 1500 1500/h Solid food 500 – 700 1500 insensible Water of oxidation 250 125 800 Water of solution 500 Water loss route average Daily vol. (ml) Minimum (ml) Maximum (ml) sensible Urine 800 - 1500 500 1400 / h Intestine – 250 2500 / h sweat 4000 / h insensible Lungs 400 600 1500 Skin 500 - 1000

12. 13 Daily fluid replacement = 700 + urine output Excess water loss fever : 100 ml / degree fever / day Tracheostomy ( unhumidified air) : >1.5 L / day

13. Salt intake & output Daily salt intake varies 3-5 gm as NaCl Kidneys excretes excess salt: can vary from < 1 to > 200 mEq /day Volume and composition of various types of gastrointestinal secretions Gastrointestinal losses usually are isotonic or slightly hypotonic Should replace by isotonic salt solution

14. Body fluid & electrolytes disturbances Volume Changes : Concentration Changes : Composition Changes : Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities Hypovolemia Hypervolemia Hyponatremia Hypernatremia

15. Volume Changes Hypovolemia Hypervolemia

16. Hypovolemia ECF volume deficit is most common fluid loss in surgical patients, and aggravated by General Anesthesia. Most common causes of ECF volume deficit are: GI losses from vomiting, nasogastric suction , diarrhoea , and fistular drainage Other common causes: soft-tissue injuries and infections, peritonitis, obstruction and burns.

17. Signs Diminished skin turgor Dry oral mucus membrane Dry axilla Oliguria - < 500ml/day (normal: 0.5~1ml/kg/h) Flat neck veins Tachycardia Orthostatic Hypotension Hypoperfusion  cyanosis (hypothermia) Sunken eye Altered mental status Clinical Diagnosis Thorough history taking: poor intake, GI bleeding…etc glucocorticoid therapy BUN : Creatinine > 20 : 1 Increased specific gravity Increased hematocrit Electrolytes imbalance Acid-base disorder

18. Hypervolemia Iatrogenic or Secondary to renal insufficiency, cirrhosis, or CHF. Signs CNS: none CVS: elevated JVP, venous distension – pulmonary edema, S3, Respiratory : shortness of breath even in rest. GI: edema of bowel Tissue: pitting edema – anasarca , ascites , weight gain Clinical Diagnosis Electrolytes imbalance Decreased specific gravity Decreased hematocrit Cholesterol Liver enzymes Bilirubin Creatinin clearance

19. Management of Hypervolemia: Prevention is the best way Guide fluid therapy with CVP level or pulmonary wedge pressure Diuretics Increase oncotic pressure: FFP or albumin infusion (may followed by diuretics) Dialysis

20. Concentration Changes Hyponatremia <135 mEq /l. Hypernatremia > 145 mEq /l.

21. Hyponatremia Na + is the most abundant positive ion of ECF compartment and is critical in determining the ECF and ICF osmolality . Normal amount 135-145 mEq /l. Sign & symptoms : <120 mEq /l. Signs & symptoms CNS: confusion, lethargy, stupor, headache, seizure, coma GI: nausea, vomiting Skeletal system : muscle twiches

22. Etiology & treatment of hyponatremia

23. Hypernatremia Asymptomatic Symptomatic (Na>160 meq /L ) >145 mEq /l. CNS manifestations : due to dehydration of brain cells Body system Signs & symptoms Central nervous system Restlessness, lethargy, ataxia, irritability, tonic spasms, delirium, seizures, coma Musculoskeletal Weakness Cardiovascular Tachycardia, hypotension, syncope Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears Renal Oliguria Metabolic Fever

24. Etiology & treatment of hypernatremia Aggressive correction : central pontine myelinolysis

25. Composition Changes Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities

26. Potassium Abnormalities Normal daily dietary intake of K+ is approx. 50 to 100 mEq /day, & The normal range of serum potassium: 3.5-5.1 meq /L. Majority of K+ is excreted in the urine (0-700 meq /day). 98 % of the potassium in the body is located in ICF at 150 mEq /L and it is the major cation of intracellular water. Intracellular K + is released into the extracellular space in response to severe injury or surgical stress, acidosis, and the catabolic state. K+ has an important role in the regulation of acid-base balance.

27. Hypokalemia Etiology : Inadequate intake Dietary, potassium-free intravenous fluids, potassium-deficient Total parenteral nutrition Excessive potassium excretion Hyperaldosteronism Medications Gastrointestinal losses Direct loss of potassium from gastrointestinal fluid (diarrhea), (gastric fluid, either as vomiting or high nasogastric output) Renal loss of potassium Intracellular-shift (metabolic alkalosis or insulin therapy) Potassium decrease by 0.3 meq /L for every 0.1 increase in pH above normal Serum K + < 3.5 mEq /L

28. Treatment : KCl 10 mEq/L/hr IV - pripherally KC1 20 mEq/L/hr IV - centrally Body system Signs & symptoms Gastrointestinal Paralytic Ileus , constipation Neuromuscular Decreased reflexes, fatigue, weakness, paralysis, rhabdomyolysis , hyporeflexia Cardiovascular U-waves T-wave flattening ST-segment changes Arrhythmias Tissue Dry sticky mucous membranes, red swollen tongue, decreased saliva and tears Renal Polyuria & polydypsia

29. Hyperkalemia Serum K + > 5.1 mEq /L Etiology : Increased intake : Potassium supplementation & Blood transfusions Endogenous load/destruction: hemolysis , rhabdomyolysis , cruch injury, gastrointestinal hemorrhage Increased release : Acidosis Rapid rise of extracellure osmolality (hyperglycemia or mannitol ) : Impaired excretion of potassium & Renal insufficiency/failure.

30. Body system Signs & symptoms Gastrointestinal Nausea/vomiting ,colic diarrhea Neuromuscular weakness, paralysis, respiratory failure Cardiovascular Arrhythmia, arrest ECG changes Peaked T waves (early change) Flattened P wave Prolonged PR interval (first-degree block) Widened QRS complex Sine wave formation Ventricular fibrillation Treatment of hyperkalemia

31. Calcium Abnormalities Majority of the 1000 to 1200g of calcium in the average-sized adult is found in the bone . Normal daily intake of calcium is 1 to 3 gm. Normal serum level = 8.8-10.5 mg/dl Albumin Bound = 40-60% Ionized portion (1.2 mg/dl) is responsible for neuromuscular stability Most is excreted via the GI tract Corrected calcium = 4 – albumin x 0.8 + serum calcium

32. Hypocalcemia Hypercalcemia Serum calcium level <8.8 mg/dl Causes: acute pancreatitis, massive soft-tissue infections (necrotizing fasciitis), acute and chronic renal failure, pancreatic and small-bowel fistulas, hypoparathyroidism Serum calcium level >10.5 mg/dl Causes: hyperparathyroidism cancer PTH-like peptide in malignancies

33. Hypocalcemia S/S Hypercalcemia S/S Hypotension Anxiety Psychosis Paresthesia Laryngeal spasm Numbness and tingling of the circumoral region and the tips of the fingers and toes tetany with carpopedal spasm, convulsions (with severe deficit), Chvosteck & trousseau’s signs Hypertension Bradycardia Constipation Anorexia nausea, vomiting Nephrolithiasis Pain Psychosis Pruritis weight loss, thirst, polydipsia , and polyuria easy fatigue, weakness, stupor, and coma Treatment : IV calcium for acute -1gm in D5 or NS Oral calcium and vitamin D for chronic

34. Magnesium Abnormalities Total body content of magnesium 2000 mEq , about half of which is incorporated in bone. Normal daily dietary intake of magnesium is approximately 240 mg Normal serum level = 1.5- 2.4 mg/dl Deficiency causes impaired repletion of Na + & Ca 2+

35. Hypomagnesemia causes: starvation, malabsorption syndromes, GI losses, prolonged IV or TPN with magnesium-free solutions signs & symptoms: similar to those of calcium deficiency

36. Hypermagnesemia Symptomatic hypermagnesemia , although rare, is most commonly seen with severe renal insufficiency signs & symptoms: CNS : lethargy and weakness with progressive loss of DTR’s – somnolence, coma, death CVS: increased P-R interval, widened QRS complex, and elevated T waves (resemble hyperkalemia ) – cardiac arrest

37. Basic principle Should have knowledge of 1. Etiology of fluid deficit 2. Type of electrolyte deficit 3. Associated illness 4. Clinical status Rationale 1. When to give or avoid 2. Which fluid 3. How much 4. Drop rate 5. Contraindication of specific fluid 6. How to correct the imbalance 7. How & when to use specific fluids

38. Oral route is always preferred. Intravenous therapy should be started in critical situations. indications Oral intake is not possible Severe vomiting, diarrhoea , Dehydration & shock hypoglycemia Vehicle for some medication Nutrition Treatment of critical problems (poisoning) contraindications Ability to take oral fluid Avoid in CHF & volume overload

39. Advantages Acute, controlled, predictable way Immediate response Prompt correction Disadvantages Require strict asepsis Skilled supervision Improper selection of fluid - dangerous Improper volume – life threatening Improper technique - complications complications Local : hematoma, infusion phlebitis, infiltration Systemic : circulation overload, rigors, septicemia, air embolism Others : fluid contamination, I.V. set & catheter problem Human error

40. Parenteral fluid therapy Para = other than , enteron (Gk) = intestine Ways to approach i.v . route – venepuncture venesection

41. Sites for venepuncture - Median cubital vein Long Saphenous vein In obese, female & infants Risk of thrombophlebitis & pulmonary imbolism Rare in infants / children Cephalic vein in deltopactoral groove Subclavian vein Internal jugular vein External jugular vein Neonates / small children

42. I.V. fluids Based on use Maintenance fluids Replacement fluids Special fluids 5% D 5% D with 0.45% NaCl NS, DNS, RL, ISOLYTE -G, ISOLYTE-E, ISOLYTE-M, ISOLYTE-P Inj. Sod.bicarbonate , mannitol , NS 1.6%, 3%, 5% Inj. KCl 25% Dextrose

43. I.V. fluids Based on property Crystalloids (solution of electrolytes) Colloids (solution of large molecules) Life saving RL NS DNS D-5% ISOLYTES 5% Albumin 25% Albumin 10% Pentastarch 10% Dextran -40 6% Dextran -70 10% Hetastarch

44. 5 % dextrose Composition : Glucose 50 gms Pharmacological basis : Corrects dehydration and supplies energy( 170Kcal/L) Indications : Prevention and treatment of dehydration P re and post op fluid replacement IV administration of various drugs P revention of ketosis in starvation, vomiting, diarrhea Adequate glucose infusion protects liver against toxic substances Correction of hypernatremia

45. Contra indications C erebral edema , neuro surgical procedures A cute ischaemic stroke H ypovolemic shock H yponatremia , water intoxication Same iv line blood transfusion – hemolysis , clumping occurs U ncontrolled DM , severe hyperglycemia Rate of adminstration – 0.5 gm / kgBW / hr or 666ml/ hr 5 % D or 333ml/ hr 10 %D

46. INVERTED SUGAR SOLUTION Composition : inverted sugar 100 gms Pharmacological basis : half dextrose + half fructose Indications : Prevention and treatment of dehydration (specially pregnancy ) Liver diseases (prevents glycogen depletion) Adverse effects : Lactic acidosis Hyperurecemia hypophosphatemia Contra indications hereditory fructose intolerance Caution in renal & hepatic impairment >25gm fructose should be avoided more expansive

47. Isotonic saline(0.9 % NS) C omposition : Na + 154 mEq , Cl - 154 meq Pharmacological basis : provide major ECF electrolytes.. corrects both water and electrolyte deficit. increase the iv volume substantially C ontra indications Avoid in pre eclamptic patients, CHF, renal disease and cirrhosis Dehydration with severe hypokalemia – deficit of ICF potassium Large volume may lead to hyperchloremic acidosis.

48. Indications Water and salt depletion – diarrhoea, vomiting, excessive diuresis Hypovolemic shock Alkalosis with dehydration Severe salt depletion and hyponatremia I nitial fluid therapy in DKA Hypercalcemia Fluid challenge in prerenal ARF I rrigation – washing of body fluids Vehicle for certain drugs

49. DNS Pharmacological basis : Supply major EC electrolytes, energy and fluid to correct dehydration Indications : Conditions with salt depletion , hypovolemia Correction of vomiting or NGT aspiration induced alkalosis and hypochloremia Compatible with blood transfusion Contra indications : A nasarca – cardiac, hepatic or renal S evere hypovolemic shock (osmotic diuresis ) >25gm/hr should be avoided

50. DNS with half strength saline Pharmacological basis : Supply major EC electrolytes, energy and fluid to correct dehydration more water with less salt. Indications : paediatric & very elderly Maintenance fluid in early post operative periods Treatment of hypernatremia Compatible with blood transfusion Contra indications : hyponatremia S evere dehydration

51. Ringer’s lactate Pharmacological basis : M ost physiological fluid , rapidly expand s iv volume.. Lactate metabolised in liver to bicarbonate providing buffering capacity Acetate instead of lactate advantageous in severe shock.

52. I ndications Correction in severe hypovolemia Replacing fluid in post op patients, burns Diarrhoea induced hypokalemic metabolic acidosis Fluid of choice in diarrhoea induced dehydration in paediatrics DKA , provides water, correct metabolic acidosis and supplies potassium Maintaining normal ECF fluid and electrolyte balance Contra indications Liver disease, severe hypoxia and shock Severe CHF , lactic acidosis takes place Addison’s disease Vomiting or NGT induced alkalosis Simultaneous infusion of RL and blood Certain drugs – amphotericin , thiopental, ampicillin , doxycycline

53. Isolyte fluids Isolyte G Isolyte M Isolyte P Isolyte E dextrose 50 50 50 50 Na K Cl 63 17 150 40 35 40 25 20 22 140 10 103 Acetate Lactate NH4Cl --- --- 70 20 --- --- 23 --- --- 47 --- --- Ca Mg --- --- --- --- --- --- 5 3 HPO4 --- 15 3 --- Citrate --- --- 3 8 Mosm /L 580 410 368 595

54. Isolyte G : V omiting or NGT induced hypochloremic , hypokalemic metabolic alkalosis NH4 gets converted to H+ and urea in liver Treatment of metabolic alkalosis Contraindications : Hepatic failure, renal failure, metabolic acidosis Isolyte M Richest source of potassium (35 mEq ) Ideal fluid for maintenance Correction of hypokalemia Contraindications : Renal failure, burns, adrenocortical insufficiency

55. Isolyte P M aintenance fluid for children – as they require less electrolytes and more water E xcessive water loss or inability to concentrate urine Contraindications : hyponatremia , renal failure I solyte E Extracellular replacement solution, additional K and acetate (47mEq) Only iv fluid to correct Mg deficiency Treatment of diarrhoea, metabolic acidosis Contraindications – metabolic alkalosis

56. Effects of large volume crystalloid infusion. Extravascular accumulation in skin, connective tissue , lungs and kidney I nhibition of GI motility D elayed healing of anastomosis L arge volume ,rapid infusion crystalloids causes hypercoagulability.. Ruttmann TG, James MF. Effects on coagulation due to intravenous crystalloid or colloid in patients undergoing vascular surgery. Br J Anesth 2002 ; 89 : 999 - 1003

57. Crystalloids …

58. Colloids Colloids : large molecular wt substances that largely remains in the intravascular compartment thereby generating oncotic pressure 3 times more potent 1 ml blood loss = 1ml colloid = 3ml crystalloids

59. colloids…

60. Type of fluid Effective plasma volume expansion/100ml duration 5% albumin 70 – 130 ml 16 hrs 25% albumin 400 – 500 ml 16 hrs 6% hetastarch 100 – 130 ml 24 hrs 10% pentastarch 150 ml 8 hrs 10% dextran 40 100 – 150 ml 6 hrs 6% dextran 70 80 ml 12 hrs

61. Albumin Maintain plasma oncotic pressure – 80 % Heat treated preparation of albumin – 5%, 20% and 25% commercially available Pharmacalogical basis : 5% albumin – COP of 20 mmHg 25% albumin – COP of 70mmHg ,expands plasma volume to 4-5 times the volume infused Rate of infusion : A dults – initial infusion of 25 gm 1 to 2 ml/min – 5% albumin 1 ml/min - 25% albumin

62. Indications : Plasma volume expansion in acute hypovolemic shock , burns, severe hypo albuminemia Hypo proteinemia – liver disease, Diuretic resistant nephrotic syndrome In therapeutic plasmapheresis , as an exchange fluid Contra indications : S evere anaemia, cardiac failure H ypersensitive reaction

63. Dextran Dextran are glucose polymers produced by bacteria ( leuconostoc mesenteroides ) 2 forms : dextran 70(MW 70,000) and dextran 40(40,000) Pharmacological basis : Effectively expand iv volume Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapid renal excretion Anti thrombotic , inhibits platelet aggregation Improves micro circulatory flow

64. Indications : H ypovolemia correction P rophylaxis of DVT and post operative thromboembolism I mproves blood flow and micro circulation in threatened vascular gangrene Myocardial ischemia, cerebral ischemia, PVD and maintaining vacular graft patency Priming in ECC A dverse effects Acute renal failure Interfere with blood grouping and cross matching Hypersensitive reaction

65. Precautions/CI : S evere oligo -anuria CHF, circulatory overload Bleeding disorders like thrombocytopenia. Severe dehydration Anticoagulant effect of heparin enhanced Hypersensitive to dextran Administration : Adult patient in shock – rapid 500 ml iv infusion First 24 hrs – dose should not exceed 20ml/kg Next 5 days – 10 ml/kg/ day

66. Gelatin polymers( haemaccel ) Sterile, pyrogen free 3.5 % solution P olymer of degraded gelatin with electrolytes 2 types Succinylated gelatin (modified fluid gelatin ) Urea cross linked gelatin ( polygeline ) Composition : Na Cl 145 mEq , Ca 12.5 mEq , potassium 5.1 mEq Indications : Rapid plasma volume expansion in hypovolemia Volume pre loading in regional anesthesia Priming of heart lung machines

67. Advantages : D oes not interfere with coagulation, blood grouping Remains in blood for 4 to 5 hrs Infusion of 1000ml expands plasma volume by 300 to 350 ml Side effects : Hypersensitivity reaction Should not be mixed with citrated blood

68. Hydroxyethyl starch Hetastarch : It is composed of more than 90% esterified amylopectine . E sterification retards degradation leading to longer plasma expansion 6% starch - MW 4,50,000 Pharmacological basis : Osmolality – 310 mosm /L Higher colloidal osmotic pressure LMW substances excreted in urine in 24 hrs

69. Physiochemical characteristics : Substitution of hydroxy ethyl groups at C2, C3 and C6 Concentration : low( 6%), high(10%) MW : Low( <70kDa), med and high(>450kDa) Degree of substitution : low(0.45 – 0.58), high( 0.62 – 0.70) C2/C6 : low(<8) , high(>8) Metabolism : Rapid amylase dependent breakdown and renal excretion upto 50% in 24 hrs

70. Advantages : Non antigenic Does not interfere with blood grouping Greater plasma volume expansion Preserve intestinal micro vascular perfusion in endotoxaemia Duration – 24 hrs Disadvantages : I ncrease in S amylase concentration upto 5 days after discontinuation A ffects coagulation by prolonging PTT, PT and bleeding time by lowering fibrinogen Decrease platelet aggregation , VWF , factor VIII

71. Contra indications : B leeding disorders , CHF Impaired renal function Administration : Adult dose 6% solution – 500ml to 1 lit Total daily dose should not exceed 20ml/kg

72. Pentastarch : LMW derivative (2,64,000) 3 %, 6% and 10% solution Lower degree of esterification Lesser effect on coagulation 10% solution can increase plasma volume 1.5 times of infused volume

73. Special fluids Inj KCl 10 ml amp – 20mEq 25%D (25 mi amp or 100 ml infusion bottle)– in hypoglycemic shock Inj. Sodium bicarbonate (25 ml amp. 22.5mEq Na + & 22.5mEq HCO3 - ) dose = 10-15 mEq /L : in metabolic acidosis Mannitol 10% & 20% : osmotic diuretic

74. Goals Maintenance of normovolemia and hemodynamic stability Acceptable plasma colloid osmotic pressure Correction of electrolyte imbalance C orrection of acid base imbalance A dequate urine output( 0.5 to 1 ml/kg/ hr )

75. Crystalloids or colloids…??? Crystalloids – recommended as the initial fluid of choice in resuscitating patients from hemorrhagic shock Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 - 141 COCHRANE Collaboration in critically ill patients – “ No evidence from RCT that resuscitation with colloids reduces the risk of death, compared with crystalloids in patients with trauma or burns after surgery ” Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD 000567, 2004

76. Indication of blood therapy Goal : the oxygen carrying capacity of blood. Indications Hb <6 gm% (normal =10 gm%) 2. age 3. Medical status 4. Major surgical procedure 5. Anticipation of ongoin blood loss >100ml/min 6. Acute blood loss > 40% (2L crystalloid 3:1 ---  colloid 1:1 )

77. AMERICAN COLLEGE OF SURGEONS (2001), Classification of acute hemorrhage Committee on Trauma. Advanced Trauma Life Support Student manual. 6 th ed. Chicago. American College of Surgeons. 2001: 87-107.

78. Blood component therapy Transfusion with whole blood is indicated very rarely. Advantages : Preservation of remaining whole blood components Longer storage Decreases the risk of transfusion reaction

79. Methods of calculation of fluid transfusion rate

80. Holiday Segar Method 4 ml/kg/hr = 4x10/hr = 40 ml/hr 2ml/kg/hr = 2x20/hr = 40 ml/hr So, for > 20 kg patient = body wt + 40 ml Eg . For 70 kg. pt = 70+40 = 110 ml

81. Fluid therapy in surgical patients Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively , and post operatively, as well as in response to trauma and sepsis. Proper fluid & electrolyte state is helpful in reducing morbidity & mortality in certain surgical procedures, hence it is important.

82. Need for correction Acute stress : sympathetic stimuli, tachycardia & vasoconstriction. Stress : corticosteroids secretion (up to 48 hrs) Stress : ADH (up to 2-3 post op days)  water retention NPO require consideration & replacement. Pre, intra & post operative blood / fluid loss require consideration & replacement. Na + retention, K + depletion Intracellular K + depletion  hyperkalemia Requirement of maintenance fluid is less on1 st post op day.

83. 6. Hypovolemia should be corrected preoperatively  hypotension intraoperatively 7. Surgical stress / direct damage to kidney, brain, lungs, skin, GIT should be considered as they play important role in fluid & electrolyte balance.

84. Preoperative fluid therapy Very important for better outcome in surgical patients. 3 parameter are important Correction of hypovolemia (GA diminishes the compensatory reflexes ) Correction of anemia (48 hours prior to surgery) Correction of other disorders ( eg . hypo & hyperkalemia )

85. Intraoperative fluid therapy Volume to be replaced – Correction of fluid deficit due to starvation : Maintenance volume for intraop period : Correction of intraop loss : Duration of starvation (in hr) x 2 ml / kg ; 5% D Duration of surgery (in hr) x 2 ml / kg ; 5% D Suction container Surgical sponge Third space Blood loss =3/1 with crystalloid Blood / blood products if indicated Decrease in Hb by 2gm% can be tolerated by patient with pre op Hb = 10gm% Type of trauma Requirement of fluid Least trauma nil Minimal trauma 4 ml /kg / hr Moderate trauma 6 ml /kg / hr severetrauma 10 ml /kg / hr

86. Postoperative fluid therapy First 24 hrs of surgery (total = 2 L) 2 nd post op day (total = 3 L) 3 rd post op day (total = 3 L) 2L 5% D or 1.5 L 5% D + 500ml 0.9% NS 2L 5% D + 1L 0.9% NS 2L 5% D + 1L 0.9% NS + 40-60 mEq K + / day

87. Volume resuscitation – end parameters & goals End parameters Goals Achieve primary goal (0xygen supply) Good level of Hb % & cardiac output Test for – ABG CVP Pulmonary pressure BP heart rate Urine output > 1ml/kg/hr CVP = 15 mmHg Pulmonary capillary wedge pressure 10-12 mmHg Cardiac index >3L/min/sq meter Oxygen uptake >100 ml /min/sq meter Blood lactate < 4 mmol /l Basic deficit

88. Conclusion ‘Fluid therapy should be directed not only to effective volume expansion of a leaky circulation but also to micro vascular protection’.

89. Books Gyton & hall textbook of medical physiology,10 th edition. Sembulingam  K.  Sembulingam Prema . K Sembulingam - Essentials of Medical Physiology, 6th Edition  Concise Textbook of Surgery – Das S.3 rd ed References

90. Others Ruttmann TG, James MF. Effects on coagulation due to intravenous crystalloid or colloid in patients undergoing vascular surgery. Br J Anesth 2002 ; 89 : 999 – 1003. Svensen C, Ponzer S. Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 – 141. Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD 000567, 2004 Committee on Trauma. Advanced Trauma Life Support Student manual. 6th ed. Chicago. American College of Surgeons. 2001: 87-107 References

91. Thank you