Fluid management in surgical patients.pptx

Fluid management in surgical patients

1. FLUID MANAGEMENT IN SURGICAL PATIENTS

2. GENERAL PHYSIOLOGY Total Body Water is between 50-60 % of Total Body Weight. Lean tissues such as Muscles & solid Organs contain more water content than Fat and Bones. An Average young adult male will have 60% of Total Body Weight as Total Body Water .

3. An average young f emale has 50% of Total Body Weight as Water. This difference is mainly because of Adipose tissue and reduced muscle mass. Total Body Water in Newborns is around 80%,By 1 year of age it comes to 65%.

4. In an Average young Male: 1.60% IS Total Body Water 2. 7% BY Minerals 3.15% BY Fat 4.18% BY Proteins.

5. FLUID COMPARTMENTS Total Body Water(TBW) is divided into: Extracellular Fluid Compartment(ECF) Intracellular Fluid Compartment(ICF) Extracellular Fluid Compartment is 1/3 rd of Total Body Water. Intracellular Fluid compartment is 2/3 rd of Total Body Water.

6. ICF consists of 40% of Total Body Weight. ECF consists of 20% of Total body Weight. ECF divided into: Plasma –consists of 5% of Total Body Weight Interstitial Fluid- consists of 15% of Total Body Weight.

7. COMPOSITIONS Chief Cation and Anions ECF: Cations : Sodium Anions: Chlorides And Bicarbonates ICF: Cations : Potassium And Magnesium Anions: Phosphates.

8. OSMOTIC PRESSURE Activity of electrolytes depends on Particles per unit volume ( mmol /L) Electric charges per unit volume ( mEq /L) Osmotically active ions per unit volume ( mOsm /L) Equivalence = atomic weigth (g)/valence

9. OSMOTIC PRESSURE Univalent ions : Na 1 mmol = 1 mEq The movement of water across a cell membrane depends on Osmosis achieve osmotic equilibrium Serum osmolality : sodium, glucose, and BUN Calculated serum osmol = 2Na+glucose/18+BUN/2.8

10. OSMOTIC PRESSURE Serum osmol = 290-310 mOsm Any change in osmotic pressure leads to redistribution of water

11. Normal Exchange of Fluid NORMAL PERSON CONSUMES 2000 ML PER DAY IN AVERAGE 75% FROM ORAL INTAKE REST FROM SOLID FOOD

12. Normal Exchange of Fluid and Electrolytes Daily water losses 800-1200 mL in urine 250 mL in stool 600 mL in insensible losses skin (75%) lungs (25%) ↑ by fever, hypermetabolism , and hyperventilation Kidneys must excrete 500-800 mL of urine/day

13. DISTURBANCES IN FLUID BALANCE ECF volume deficit is the most common fluid disorder Acute deficit cardiovascular and central nervous system signs Chronic deficits tissue signs (↓ skin turgor and sunken eyes) Lab : ↑BUN, Urine osmol > serum osmol , & urine Na ↓, typically <20 mEq /L

14. DISTURBANCES IN FLUID BALANCE Most common cause of volume deficit Loss of GI fluids from NG suction, vomiting, diarrhea , or enterocutaneous fistula In addition secondary to Soft tissue injuries, burns, and intra-abdominal processes such as peritonitis, obstruction, or prolonged surgery

15. SIGNS & SYMPTOMS OF VOLUME DISTURBANCES ADD PIC FROM SCHWARTZ

16. FLUIDS Crystalloids Colloids blood

17. CRYSTALLOIDS

18. CRYSTALLOIDS Isotonic crystalloids - Lactated Ringer’s, 0.9% NaCl - only 25% remain intravascularly Hypertonic saline solutions - 3% NaCl Hypotonic solutions - D5W, 0.45% NaCl

19. Crystalloids Dextrose-5% Indications: Dehydration Pre and post op fluid replacement Prevention from ketosis Provides calories

20. Dextrose -5% Contraindications cerebral edema Neurosurgical procedures acute ischemic stroke Uncontrolled diabetes

21. Crystalloids Normal saline-0.9% NaCl One litre contains: sodium 154mEq chloride 154 mEq 100ml contains 0.90 gms of sodium chloride

22. Normal saline-0.9% NaCl Indications: Hypovolemic shock Water and salt depletion Alkalosis with dehydration Hyponatremia miscellaneous

23. Normal saline-0.9% NaCl Contraindications: Hypertensive or preeclamptic patients Dehydration with severe hypokalemia

24. Crystalloids 5% dextrose with 0.45% NaCl One litre contains: Sodium 77 mEq Chloride 77 mEq Glucose 50 grms Each 100 ml :50 gm of glucose and 0.45 gm of NaCl

25. 5% dextrose with 0.45% NaCl Indications: hypernatremia Maintenance fluid therapy Paediatric patients

26. 5% dextrose with 0.45% NaCl Contraindications: Hyponatremia

27. crytalloids Dextrose normal saline(DNS) One liter contains: Glucose 50 gm Sodium 154mEq Chloride 154mEq Each 100 ml contains 50gm of glucose and 0.90gm of sodium cholride

28. Dextrose normal saline(DNS) Indications: Salt depletion and hypovolemia Calories Correction of hypochloremia Contraindications: Hypovolemic shock

29. Crytalloids Ringer lactate One litre contains Sodium 130 mEq Chloride 109mEq Potassium 4mEq Bicarbonate 28mEq Calcium 3mEq

30. Ringer lactate Indications: Severe hypovolemia Fluid replacement pre and post op patients Diabetic ketoacidosis Diarrhea induced hypokalemia

31. Crystalloids Ringer lactate Contraindications: Metabolic acidosis Addisons disease Severe CHF Drug interaction

32. Colloids Contain high molecular weight substances retain in the vascular system Better plasma volume expanders Can cause allergic reactions

33. COLLOIDS Albumin 5% Albumin 25% Dextran 40 Dextran 70 Hetastarch Hextend Gelofusine

34. Albumin : indications: Plasma volume expanders Hypoproteinemia Therapeutic plasmapheresis Contraindications: Pulmonary edema and cardiac overlaod Severe anemia

35. Colloids Dextran Indications: Hypovolemia Prophylaxsis for DVT Improve microcirculations

36. Contraindications: Severe oligo-anuria and renal failure CHF Bleeding disorders Severe dehydration

37. Dextran Regimen for thromboembolism Day1: 500-1000 ml over 4 to 6 hrs Day2: 500 ml over 4-6 hrs Upto day 10: 500 ml over 4 -6 hrs on alternate days Surgical prophylaxis: 500ml preop and daily for 3 days postop .

38. Colloids Gelatin polymers ( Haemaccel ) Contains Sodium 145mEq calcium 12.5mEq Chloride 145mEq Potassium 5.1mEq Rapid volume expanders Doesnot interfere with blood group substances Hypersentivity reaction occurs

39. Colloids Hetastarch Antigenic free , anaphylactic reactions are rare Safe and effective plasma expander Avoided in bleeding disorders Increases serum amylase

40. FLUID MANAGEMENT Preoperative FLUID THERAPY Intraoperative FLUID THERAPY Postoperative Fluid Therapy

41. PREOPERATIVE FLUID THERAPY maintenance fluids volume deficit Third space loss

42. MAINTAINANCE FLUIDS

43. VOLUME DEFICET

44. THIRD SPACE LOSS GI obstruction Peritoneal or bowel inflammation Ascites Burns Severe soft tissue infections

45. isotonic crystalloid correction of volume deficit check for vital signs maintenance of adequate urine output correction of base deficit

46. Intraoperative Fluid Therapy induction of anesthesia , compensatory mechanisms are lost and hypotension will develop volume deficits are appropriately corrected prior to the time of surgery

47. Intraoperative Fluid Therapy Hemodynamic instability can be avoided by : correcting known fluid losses, replacing ongoing losses, providing adequate maintenance fluid therapy preoperatively

48. Postoperative Fluid Therapy volume status and projected ongoing fluid losses deficits from either preoperative or intraoperative losses Third-space losses

49. Initial postoperative period, an isotonic solution should be administered After the initial 24 to 48 hours, fluids can be changed to 5% dextrose in 0.45% saline If normal renal function and adequate urine output are present, potassium may be added to the intravenous fluids

50. Volume excess is a common disorder in the postoperative period administration of isotonic fluids in excess earliest sign of volume overload is weight gain Volume deficits also can be encountered in surgical patients

51. Electrolyte Imbalance Hyponatremia Plasma sodium less than 135mEq/L

52. Hyponatremia treated by free water restriction administration of sodium neurologic symptoms : 3% normal saline not more than 1 mEq /L per hour asymptomatic hyponatremia not more than 0.5 mEq /L per hour to 12 mEq /L per day

53. Hyponatremia Correction Na required=(desired Na-serum Na) xTBW

54. Rapid correction of hyponatremia Pontine myelinolysis Seizures Weakness Paresis Akinetic movements Unresponsiveness Permanent brain damage Death

55. Hypernatremia Plasma sodium greater than 145mEq Less frequent disorder Indicates lack of water

56. Hypernatremia ethiology Hypernatremia ethiology

57. Hypernatremia usually treatment of water deficit Water deficit (L)= serum sodium – 140 x TBW 140

58. rate of fluid administration should be titrated to achieve a decrease in serum sodium concentration of no more than 1 mEq /h and 12 mEq /day

59. The normal range of serum potassium: 3.5-5 meq /L Factors that influence serum potassium: surgical stress Injury Acidosis Tissue catabolism

60. Hyperkalemia Serum potassium more than 5.5mEq/L

61. ethiology

62. Hyperkalemia   Increased intake    Potassium supplementation    Blood transfusions    Endogenous load/destruction: hemolysis , rhabdomyolysis , crush injury, gastrointestinal hemorrhage Increased release    Acidosis    Rapid rise of extracellular osmolality ( hyperglycemia or mannitol ) Impaired excretion    Potassium-sparing diuretics    Renal insufficiency/failure

63. Hyperkalemia GI :nausea, vomiting, intestinal colic, and diarrhea Neuromuscular : weakness to ascending paralysis to respiratory failure CVS :electrocardiogram (ECG) changes ,cardiac arrhythmias , arrest.

64. Hyperkalemia ECG changes Peaked T waves (early change) Flattened P wave Prolonged PR interval (first-degree block) Widened QRS complex Sine wave formation Ventricular fibrillation

65. Hypokalemia Serum potassium less than 3.5mEq/L

66. etiology

67. Hypokalemia Etiology : inadequate Dietary intake potassium-free intravenous fluids, potassium-deficient total parenteral nutrition Excessive potassium excretion Hyperaldosteronism Medications Gastrointestinal losses Direct loss of potassium from gastrointestinal fluid (diarrhea) Renal loss of potassium (gastric fluid, either as vomiting or high nasogastric output) Intracellular-shift (metabolic alkalosis or insulin therapy)

68. Hypokalemia GI : ileus , constipation Neuromuscular:weakness , fatigue, diminished tendon reflexes, paralysis CVS : cardiac arrest (PEA or asystole ).

69. Hypokalemia ECG changes • U waves • T-wave flattening • ST-segment changes • Arrhythmias (especially if patient is taking digitalis)

70. Hypokalemia Oral supplimentation Serum potassium(3-3.5) dose of KCl is 60-80 mEq /day . Serum potassium less than 2mEq/l dose of KCl upto 40mEq 6 hourly with ECG monitoring

71. Hypokalemia I.V. Potassium therapy Correction Not > 10-20mEq/Hour Correction not > 40mEq/ Litre Correction not > 240mEq/day

72. Calcium Abnormalities 3 forms: Protein-bound (40%), Complexed to phosphate and other anions (10%) Ionized (50%). Normal range of 8.5 to 10.5 mEq /L Ionized calcium level range of 4.2 to 4.8mg/ dL

73. Etiologies Primary hyperparathyroidism Malignancy (bony metastasis or due to secretion of parathyroid hormone–related protein)

74. Hypercalcemia Clinical features neurologic musculoskeletal renal gastrointestinal. Cardiac

75. ECG changes Shortened QT interval Prolonged PR and QRS intervals Increased QRS voltage T-wave flattening and widening AV block (can progress to complete heart block, then cardiac arrest with severe hypercalcemia )

76. Treatment is required when serum level exceeds 12 mg/ dL initial treatment is aimed: Repleting the associated volume deficit. I nducing a brisk diuresis with normal saline.

77. Hypocalcemia serum calcium level below the normal range of 8.5 to 10.5 mEq /L decrease in the ionized calcium level below the range of 4.2 to 4.8 mg/ dL

78. Hypocalcemia Etiologies • Pancreatitis( chelation with free fatty acids) • Massive soft tissue infections:necrotizing fasciitis • Renal failure • Pancreatic and small bowel fistulas • Hypoparathyroidism • Toxic shock syndrome • Abnormalities in magnesium

79. Malignancies : breast and prostate cancer(increased osteoclastic activity ) Tumor lysis syndrome Removal of a parathyroid adenoma(transient) massive blood transfusion (citrate)

80. Clinical features Hyperactive reflexes paresthesias carpopedal spasm Seizures Chvostek's sign Trousseau's sign stridor tetany

81. heart failure following ECG changes: Prolonged QT interval T-wave inversion Heart blocks Ventricular fibrillation

82. Treatment of hypocalcemia Acute symptomatic hypocalcemia : intravenous 10% calcium gluconate given to achieve a serum concentration of 7 to 9 mg/ dL deficits in magnesium, potassium, and pH must also be corrected

83. Ppicture from schwartz

84. Magnesium Abnormalities fourth most common mineral in the body intracellular compartment Excreted in both the feces and urine normal dietary intake is approximately 20 mEq daily Normal value 1.4-2.2mEq/L

85. Hypermagnesemia Etiologies Impaired renal function Excess intake Parenteral nutrition Mg-containing laxatives and antacids

86. Clinical features Nausea/vomiting Weakness, lethargy, decreased reflexes Hypotension, arrest

87. ECG changes Increased PR interval Widened QRS complex Elevated T waves

88. treatment withhold exogenous sources of magnesium correct volume deficit, and correct acidosis if present. Calcium gluconate calcium chloride dialysis

89. Hypomagnesemia Etiologies Poor intake Total parenteral nutrition with inadequate supplementation of magnesium Increased renal excretion Gl losses Acute pancreatitis, DKA Primary aldosteronism .

90. Symptoms are similar calcium deficiency Positive Chovstek's sign Severe deficiencies can lead to delirium and seizures

91. ECG changes includes: Prolonged QT and PR intervals ST-segment depression Flattening or inversion of P waves Torsades de pointes Arrhythmias

92. Treatment: Oral replacements Intravenous suppliments severe deficits (<1.0 mEq /L) or those who are symptomatic, administer 1 to 2 g of magnesium sulfate intravenously over 15 minutes. 1mEq/kg/day slow infusion

93. Phosphorous Normal value 3.0-4.5 mg/dl Mainly present in intracellular Main regulatory factors are PTH and Insulin

94. Hypophosphatemia Etiology Decreased GI absorption Increased renal excreation Shifting into intracellular fluid

95. Clinical features Muscular abnormality Neurological abnormality Hematological abnormality

96. Treatment Serum phosphate >1.0mg/dl and asymptomatic ,oral suppliments of phosphorous Serum level <(0.5-1.0mg/dl) I.V phosphate therapy.

97. Hyperphosphatemia Levels greater than 5mg/dl Etiology Decreased renal excreation Acute tissue destruction Increased renal absorbtion

98. Clinical features Mostly asymptomatic Ectopic calcification of soft tissuse Renal osteodystropy

99. Treatment Treat underlying cause Restrict dietary phosphates Phosphate binders ( sucralfate or aluminum -containing antacids ) Calcium acetate and calcium carbonate Saline diuresis