FLUID AND ELECTOLYTES ednaadanuniversity.pptx

Introduction
• Knowledge about fluid electrolyte and acid base changes and their
management is basic to the care of the surgical patient.
• Many disease processes result in changes that could result in rapid
deterioration of the patient and death.
• Anyone caring for surgical patients should have a basic knowledge of
fluid, electrolyte, acid and base disturbances, as well as their causes
and their management.

NORMAL DISTRIBUTION OF BODY FLUIDS
Total body water
• The total body water constitutes 50 – 85% of total body weight
depending on age and lean body mass (muscle mass).
• In regard to this, 55% - 60% of body weight for a 70 Kg young man is
water.
• Females have lower body water (45 –60%) because of the high fat
content of their body.
• The total body water in neonates is 80%-85%, which is higher than in
adults.

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Total body water is further divided into two:
1. Intracellular fluid, comprising 2/3 of total body water
2. Extra cellular fluid, comprising 1/3 of total body water.
The extra cellular fluid is sub divided into Intravascular
(plasma) comprising 2/3 of extra cellular fluid and
Interstitial which comprises 1/3 of extra cellular fluid.

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DISTURBANCES OF FLUID AND ELECTROLYTES
CLASSIFICATION
–Disturbances in body fluids can be classified
into three:
i. Disturbance in fluid volume
ii. Disturbance in composition
iii.Disturbance in acid base balance

DISTURBANCE IN FLUID VOLUME
 Volume deficit
• Extra cellular fluid (ECF) volume deficit is the most common fluid
volume disorder in the surgical patient.The lost fluid is not water
alone, but water and electrolytes in approximately the same
proportion as they exist in normal extra cellular fluid.
 Causes
 Losses of gastro-intestinal fluids: e.g. vomiting, gastric tube, diarrhea
and enterocutaneous 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 feature
• Depends on the severity of fluid loss
Moderate (5-10%):
 sleepiness,
 orthostatic hypotension
Severe (more than 15%):
 signs of hypotension,
 stupor or coma,
 sunken eye balls, dry oral mucosa and tongue, poor skin
turgor and decrease in body temperature.

Treatment
• Placement of extra cellular loss with fluid of
similar composition:
• Blood loss: Replace with Ringer’s Lactate,
Normal Saline or Blood, if needed
• Extra cellular fluid: Replace with Ringer’s
Lactate, Normal Saline

Rate of fluid replacement
The Rate depends on the degree of dehydration.
• It should be fast until the vital signs are corrected and adequate urine
output is achieved. One liter over 30 minutes to one hour can be
given for severe dehydration.
Monitoring
• The general condition and the vital signs of the patient should be
followed.
• The urine out put should be monitored hourly.
• Auscultate the chest to follow overload especially in children and the
elderly.

Volume Excess
• Extra cellular fluid volume excess is generally iatrogenic or secondary
to renal insufficiency, cirrhosis, or congestive heart failure.
• Clinical feature
• Subcutaneous edema, basilar rales on chest auscultation, distention of
peripheral veins, and functional murmurs may be detected. Children,
the elderly, patients with cardiac or renal problems are at increased
risk of dangers of fluid replacement.
• Treatment
i. Stop IV fluids (Fluid restriction)
ii. Diuretics: e.g. frusemide

Disturbance of Electrolytes
• Sodium (Na+)
 It is the most abundant caution of the extra cellular fluid
 After trauma and surgery, there is a period of shut down of sodium
excretion for up to 48 hours.
 During this period, it may not be advisable to administer large
quantities of isotonic saline.
 The concentration of serum sodium is not related to the volume status
of extracellular fluid.
 A severe volume deficit may exist with a normal low or high serum
level.
 Daily requirement of sodium is one millimol/kg.
 The excretion of sodium by the kidneys is under the control of
aldosterone.

Sodium depletion (Hyponatremia):
• Na+ less than 130 milliequivalent/liter
• Hyponatremia can be associated with
1. Volume depletion, sodium and water depletion. Most frequent cause
of sodium and water depletion in surgery is small intestinal
obstruction.
Duodenal, Biliary, pancreatic and high intestinal fistula are also causes of
hyponatremia.
2.Water intoxication with excess volume and edema, over-prescribing of
intravenous 5% D/W and colorectal washouts with plain water

Clinical feature
• It can present with signs and symptoms of either fluid excess or fluid
overload depending on the primary cause.
• Laboratory:
• Serum sodium and other electrolytes, hematocrit drops
• Treatment
• Ringer’s Lactate or Normal Saline In cases of volume depletion.
• Fluid restriction and sodium sparing diuretics In case of fluid excess.

Sodium Excess (Hypernatremia):
• Na+ more than 145 mmol
• Causes
• Excessive water loss in burns or sweating, insensible losses through
the lungs.
• Excess amount of 0.9% saline solution is given IV during the early
operative period where there is some degree of retention of sodium.
• Depending on the cause it can be of fluid excess or fluid deficit.
• Treatment
• 5% D/W can be infused slowly

Potassium (K+)
• Potassium is the most abundant intracellular
cation.
• 98% of potassium is found intracellular with ¾
of the total body potassium in skeletal
muscles.
• The average daily requirement is 1mmol/kg.

Potassium depletion (Hypokalemia):
• K + less than 3.5 millimol
• Causes
1. Loss in gastrointestinal secretions such as vomiting in GOO or
diarrhea
2. Movement of potassium into cells e.g. in alkalosis
3. Prolonged administration of potassium free parenteral fluids with
continued obligatory renal loss of potassium
4. Excessive renal excretion – e.g. Diuretic use.

Clinical features
• Most patients are asymptomatic. Clinical symptoms and signs such as
listlessness, slurred speech, muscular hypotonia, and depressed reflexes are
presenting features.
• Abdominal distention results due to paralytic ileus.
• Treatment
• Oral potassium in the form of milk, meat extracts, fruit juices, honey and
KCl tablets
• 40 mmol KCl IV added to 1 liter of fluid run over 6 -8 hours. Never
directly IV.
• Correct the underlying cause
• N.B.:- Administration should be properly controlled, the level of potassium
should be checked daily and the urine out put must be adequate.

Potassium Excess (Hyperkalemia):
• K + more than 5 mmol
• Significant quantity of intracellular potassium is released into the
extra cellular space in response to severe injury, surgery, acidosis and
a catabolic state.
• A significant rise in serum potassium concentration may occur in
these states in the presence of oliguric or anuric renal failure.
• A renal insufficiency with hypoaldosteronism can cause hyperkalemia.

Clinical features
• Nausea, vomiting, intermittent intestinal colic and diarrhea are the
presenting pictures.
• Cardiovascular signs are apparent on ECG with high peakedT waves,
widened QRS complex and depressed ST segment. Disappearance of
T waves,
• heart block and cardiac arrest may develop with increasing levels of
potassium.

Treatment
• Measures to reduce K+ level:
• Administration of bicarbonate and glucose with insulin.
• 10 to 20 units of regular insulin and 25 to 50 g of glucose can be
used.
• 10 ml of 10% calcium gluconate to suppress the myocardial effect
• Enteral administration of cation exchange resign (Kayexalate).
• Dialysis
• Avoid exogenous potassium

Calcium (Ca++)
• Normal serum level is 8.5 to 10 .5 mg/dl.
• An increase in pH causes a fall in the ionized proportion of calcium.
• Calcium imbalance is not frequently encountered.
• Hypocalcaemia (serum level below 8mg/dl)
• Common causes include:
• Hypoparathyroidism after thyroid surgery
• Acute pancreatitis
• Massive soft tissue infection (necrotizing fascitis) and
• Pancreatic and small bowel fistulas

Clinical feature
• Latent hypocalcemia: Positive Chovestek’s andTrousseu’s sign.
• Symptomatic: Numbness and tingling, hyperactive tendon reflexes,
muscle and abdominal cramp, tetany with carpopedal spasm and
convulsions.
• Treatment
• IV Calcium gluconate (10ml of 10% solution over 10 minute) or
calcium chloride.
• Calcium lactate may be given orally with or withoutVitamin D.

Hypercalcaemia (serum calcium over10.5mg/dl)
• Hypercalcaemia occurs with hyperparathyroidism,Vitamin D
intoxication, cancer and prolonged immobilization.
• It is uncommon in surgical patients.
• Most are asymptomatic. Symptoms can include fatigue, lassitude,
weakness of varying degree, anorexia, nausea and vomiting.
• Other symptoms include severe headaches, pain in the back and
extremities, thirst, polydypsia and polyuria.

Treatment
• A serum level of calcium of 15 mg/dl or higher
requires emergency treatment.
• Vigorous volume repletion with salt solutions.
• Oral or IV inorganic phosphate or
mithramycin.

ACID – BASE BALABCE
• Normally, the blood pH lies within the range of 7.36-7.44.
• The control of this tight balance is accomplished by:
• Blood buffer:- which includes the bicarbonate and carbonic acid,
phosphates ,serum proteins and meth-hemoglobin( play a greatest
role from the blood buffers)
• The lung:- excretes acid(CO2 )
• Kidney :- the ultimate organ to maintain imbalance to near normal by
its capacity to excrete both acid and base.

Alkalosis (accumulation of Base or loss of acid)
• Metabolic Alkalosis
Causes
• Loss of acid from the stomach by repeated vomiting or aspiration
• Excessive ingestion of absorbable alkali
• Hypokalemic alkalosis in patients with pyloric stenosis: potassium loss
due to repeated vomiting.
Clinical Features
• Cheyne-stokes respiration with periods of apnea
• Tetany sometime occurs.
Treatment
• Repletion of volume + potassium (check urine output )
• Use of 0.1 N or 0.2 N HCl is also effective in treatment of resistant
metabolic alkalosis.

Respiratory Alkalosis (PCO2 below the
normal range of 31 – 42 mmHg)
• Causes
• Most common cause is excessive pulmonary ventilation by
anesthetized patients in surgical practice.
• It can also be caused by hyperventilation due to severe pain, hyper
pyrexia and high altitude.

Clinical Features
• The dangers of a severe respiratory alkalosis are those related to
potassium depletion and include the development of ventricular
arrhythmias and fibrillation.
• Treatment
• Can be corrected by breathing into a plastic bag, or insufflation of
carbon dioxide.

Acidosis (accumulation of acid or loss of base)
• Metabolic Acidosis
• Causes
• Increase in fixed acids due to:
• Anaerobic tissue metabolism (shock, infection, tissue injury)
• Retention of metabolites in renal insufficiency
• Formation of ketone bodies in diabetes or starvation
• Loss of bases in:
• Chronic diarrhea, gastro colic or high intestinal fistula, excess
intestinal aspiration

• Besides signs and symptoms of the primary etiology like shock and
infection, rapid, deep, noisy breathing is found.
• The urine becomes strongly acidic.
• Treatment
• Tissue hypoxia should be treated by reperfusion
• Sodium bicarbonate can be given where bases have been lost or where
the degree of acidosis is so severe that myocardial function is
compromised.

Respiratory Acidosis
• Causes
• Impaired alveolar ventilation due to:
- Airway obstruction
-Thoracic and upper abdominal incisions, abdominal distention in ileus
- Pulmonary diseases (pneumonia, atelectasis especially post operative
- Inadequate ventilation of the anesthetized patient

• Clinical Features
• Restlessness, hypertension and tachycardia may indicate inadequate
ventilation with
• hypercapnia.
• 14
• Treatment
• 􀂃 Must focus on relieving the primary cause.
• 􀂃 Relieving airway obstruction, adequate analgesia, and draining
pleural effusion are
• some of the definitive measures.
• 􀂃 Intubation and mechanical ventilation may be used in severe cases.

FLUID AND ELECTOLYTES ednaadanuniversity.pptx

FLUID AND ELECTOLYTES ednaadanuniversity.pptx

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