Fluid and electrolyte therapy

• Understand the physiology of fluid distribution throughout the body.

• IV fluids
• Assessment of hypovolaemia
• Managing fluid balance
• Managing electrolyte balance

Physiology of fluid distribution throughout the body

In the average young adult male

• 60% - water
• 18% - protein
• 15% - Fat
• 7% - mineral

Average adult male – 60% is water

Total body water percentage is less in females (45 – 50%) – Due to the presence of relatively greater
amount of subcutaneous fat in female body.
Percentage of total body water decreases with age (Children – 70%) and obesity.

Fluid Compartments
• Around 2/3 (40%) of this distributes in to the intracellular fluid and the remaining 1/3 (20%)
will distribute in to the extracellular fluid.
• Of that fluid in the extracelular space, around 1/5th stays in the intravascular space (5% body
weight) and 4/5th (15% of body weight) of this is found in the interstitium, with a small
proportion in the transcellular space (CSF, Lymph, Synovial, Intraocular, Serous (Pleural,
peritoneal, pericardial)
Bailey and Love - Fluid intake is derived from both exogenous (consumed liquids) and endogenous
(released during oxidation of solid foodstuff) fluids. The average daily water balance of a healthy adult is
shown

Insensible fluid loss is the amount of body fluid lost daily that is not easily measured, from the
respiratory system, skin, and water in the excreted stool. The exact amount is unmeasurable

Fluid losses occur by four routes:

1 Lungs - About 400 mL of water is lost in expired air each 24 hours. This is increased in dry atmospheres
or in patients with a tracheostomy, emphasising the importance of humidification of inspired air.

2 Skin - In a temperate climate, skin (i.e. sweat) losses are between 600 and 1000 mL/day.

3 Faeces -Between 60 and 150 mL of water are lost daily in patients with normal bowel function.

4 Urine - The normal urine output is approximately 1500 mL/ day and, provided that the kidneys are
healthy, the specific gravity of urine bears a direct relationship to volume. A minimum urine output of
400 mL/day is required to excrete the end products of protein metabolism.
 OSMOLALITY
• Normal plasma osmolality -290 mOsm/kg

• Osmolality (mOsm/kg) = 2( Na+ + k+ ) + glucose + urea (mmol/l)

Osmolarity is the number of osmoles of solute per liter solution, which is different than osmolality, which
is the osmoles of solute per kilogram of solution. Osmoles are different from moles in that it takes into
account the dissociation of cations and anions in water.

For example:
If 1 kg of water gets added to 1 mole of NaCl salt, then we observe the salt separate into its ions. As a
result, there will be 1 mol of Na and 1 mol of Cl. Restated, this means there are 2 osmoles of ions in 1 kg of
water which results in a solution with an osmolality of 2osm/1kg.

Components that contribute to plasma osmolality:

Any solute in the plasma will contribute to the osmolality. Examples include proteins, ions, urea, and
sugars. The relative osmoles of each are summed to give the total osmolality per 1 kg of plasma.

How to calculate plasma osmolality?

The Dorwart and Chalmers formula is widely used to estimate plasma osmolality. It utilizes the basic
metabolic panel (BMP) to gain measured values of sodium, glucose, and blood urea nitrogen.

Serum Osmolality=1.86 (Na)+(Glucose)/18 +(BUN)/2.8+9

Normal serum osmolality ranges from 275-295 mmol/kg.

https://www.ncbi.nlm.nih.gov/books/NBK544365/
IV fluids

Crystalloids Colloids
Balanced salt and electrolyte solution High molecular solution
Capable of passing through semipermeable Draw fluid into intravascular compartment via
membrane oncotic pressure

May be isotonic, hypertonic or hypotonic Not able to pass through membrane

Normal saline 0.9% Nacl Albumin
Hypertonic saline – 3,5,7.5% Hexastarch
Ringer lactate/hartmann’s solution/compound Pentastarch
sodium lactate Dextran
5% dextrose Gelafundin

Crystalloids only stay in plasma for 30 or 60 minutes it then moves out into interstitial spaces and into
cells. However colloids will stay in the intravascular volume for few hours to days. (madam during
tutorial)

Na+ Cl- K+ HCO3- Glucose Calcium Osmolality

(mmol/L) (mmol/L) (mmol/L) (mmol/L) (mmol/L) (mmol/L) mOsm/L
Normal 135 - 145 100 - 3.5 – 5.3 22 - 26 3.5 – 7.8 2.2 to 290
Plasma 110 2.7
0.9% Sodium 154 154 308
chloride
Hartmann’s 131 111 5 29 2 278
solution
5% Dextrose 50g/L 250
Gelofusine 150 150 Gelatin 4% 274
Crystalloids

Normal Saline
▪ The solution is 9 grams of sodium chloride (NaCl) dissolved in water, to a total volume of
1000 ml (weight per unit volume(w/v)).
▪ 0.9% sodium chloride solution (commonly termed “Normal Saline”) is an isotonic
solution containing Na+, Cl–, and water.
▪ It equilibrates throughout both the intra-vascular and interstitial spaces (approximately 25%
volume within the intra-vascular space) and this makes it useful in both resuscitation and
maintenance regimes.
▪ Potassium can be added to the solution too, aiding in electrolyte management. It should not be
used as a lone fluid maintenance however, as excessive saline replacement can result in a
hyperchloraemic acidosis. (Large volume resuscitation with 0.9% normal saline leads to an
overload of chloride ions into the blood. As stated previously, chloride and bicarbonate work
together to maintain an ionic balance of the cellular space. Hyperchlorhydria forces bicarbonate
to move intracellularly to maintain ionic equilibrium, thus reducing the available bicarbonate for
the pH buffering system leading to net acidosis.)
https://www.ncbi.nlm.nih.gov/books/NBK482340/

How much of saline stays in the intravascular compartment?

Because normal saline is isoosmotic with the extracellular fluid, water does not have any osmotic
pressure to shift between compartments, and it distributes itself according to the proportional
distribution of sodium (i.e. about 25% of it stays intravascular and 75% enters the interstitial fluid).

What is isotonic, hypotonic and hypertonic?

The total osmolarity of each of the three fluid compartments is approximately 280 mOsm/1. The
osmotic pressure of a solution is related directly to the number of osmotically active particles it
contains. Thus, about 80% of the total osmolarity of interstitial fluid and plasma is due to sodium and
chloride ions. An isotonic solution (e.g. 0.9% sodium chloride) will have an osmolarity of approximately
280 mOsm/1 and cells placed in it will neither shrink or swell. A cell placed in a hypotonic solution (< 280
mOsm/1) will swell and those placed in a hypertonic solution (> 280 mOsm/1) will shrink. An isotonic
saline solution given intravenously will distribute quickly across most of the extracellular fluid space.
Although capillary pores are highly permeable to sodium and chloride, the cell membrane behaves as if
it were impermeable to these ions, thus keeping the saline solution out of the intracellular space.

Hartmann’s Solution
▪ Hartmann’s solution is a balanced isotonic solution containing Na+ (131), Cl–(111), K+(5), lactate,
Ca2+(2), and water.
▪ Similar to Normal Saline, it distributes in the intra-vascular and interstitial spaces, making it
useful for both resuscitation and fluid maintenance.
▪ Hartmann’s solution is considered to be more “physiological” than Normal Saline as it contains
other electrolytes in concentrations similar to plasma (see Table). It also contains lactate, which
it uses to generate alkalising HCO3– ions.
Dextrose
▪ 5% dextrose solution contains only dextrose and water. Dextrose, the D-isomer of glucose, is
rapidly taken up into cells to be metabolised, leaving the remaining free water component to
equilibrate across all the body compartments.
▪ Only 7% of the fluid therefore stays in the intra-vascular space. This means that 5% dextrose
has no role in fluid resuscitation of a patient, only in fluid maintenance regimes.
▪ The main advantage* of dextrose is being able to maintain hydration without administering an
excess of electrolytes, and it can also be prescribed with supplementary potassium if required.
▪ The energy produced by the metabolism of the dextrose is relatively negligible and should not
be considered to have any substantial calorific or nutritional value, dextrose used only as a
means of hydration.

Colloids

Colloids are rarely used in most routine surgical practice. Colloids are solutions containing proteins with
large molecular weights, aiming to maintain a high plasma oncotic pressure to keep fluid within the
intravascular compartment(in theory an advantage during fluid resuscitation)
However, clinical trials have shown their limited benefit in resuscitation*, and they also come with a
small risk of anaphylaxis.
*This is likely due to loss of tight endothelial junctions in critically ill patients, with the proteins
subsequently leaching into the interstitium

Human albumin solution (HAS) is still routinely used in patients who are unable to produce sufficient
protein (such as decompensating liver disease).
▪ By temporarily increasing the plasma oncotic pressures, HAS allows intravascular volumes to be
maintained.
▪ For the general maintenance of hydration, it is necessary for fluid to distribute into all
compartments. However, if the aim is to fluid resuscitate a patient (improving tissue perfusion
by raising the intravascular volume), it is more important these fluids stay within
the intravascular space. This concept will help us understand why different fluids are available
and for what purpose they might be used.

In which compartments fluid will end up when administered to the patient depends on the type of fluid
administered
Assessment of hypovolaemia

Being able to assess the hydration status of a patient is an important skill that you’ll use regularly in
clinical practice. It involves assessment of whether a patient is hypovolaemic (dehydrated), euvolaemic
or hypervolaemic (fluid overloaded) to inform ongoing clinical management.

Hypovolaemia refers to an overall deficit of fluid in the body. Causes include poor fluid intake, excessive
fluid loss (e.g. vomiting, diarrhoea, haemorrhage or excessive diuretic therapy) and third space loss of
fluid (where fluid remains within the body but has shifted from the intravascular space to another
compartment within the body).

Hypervolaemia refers to an excess of fluid in the body. Colloquially it is often referred to as fluid
overload. Hypervolaemia is common in the elderly and those with renal or cardiac failure. It can be
caused by excessive fluid intake or inappropriate fluid retention (e.g. heart failure, renal failure).

Patient factors
• Patient’s age
• Reasons for admission that can increase fluid requirements:
o Trauma
o Febrile illness and sepsis
o Burns
o Surgical patients may need additional volume secondary to:
o Bleeding
o Drainage
o Third-space fluid losses
o Gastrointestinal losses (vomiting, diarrhoea)
o Polyuric patients

• Medical conditions that can affect fluid balance (e.g. renal disease, congestive cardiac failure)
• Medications (e.g. diuretics can increase fluid losses)

The nature and volumes of these fluids are determined by:

● A careful assessment of the patient including
o Pulse – low volume rapid thready pulse in hypovolemia
o Blood pressure – low in hypovolemia
o Capillary refill – it will be more than 2S. As peripheral perfusion is reduced capillary refill is
increased.
o Increased respiratory rate – >20 breaths per minute
o Central venous pressure, if available.

Clinical examination to assess hydration status

o Peripheries – In hypovolemia there is hypotension leading to poor peripheral perfusion – cold
and clammy extremities.
o Skin turgor – reduced in hypovolemia
o urine output and specific gravity of urine - usually urine output is about 0.5 – 1 ml/kg/h. If its
less than 0.5ml/kg/h is of concern. In hypovolemia specific gravity is increased.
o serum electrolytes and haematocrit.
Bailey and love - In addition to maintenance requirements, ‘replacement’ fluids are required to correct
pre-existing deficiencies and ‘supplemental’ fluids are required to compensate for anticipated additional
intestinal or other losses. The nature and volumes of these fluids are determined by:

• A careful assessment of the patient including pulse, blood pressure and central venous pressure,
if available. Clinical examination to assess hydration status (peripheries, skin turgor, urine
output and specific gravity of urine), urine and serum electrolytes and haematocrit.

• Estimation of losses already incurred and their nature: for example, vomiting, ileus, diarrhoea,
excessive sweating or fluid losses from burns or other serious inflammatory conditions.

• Estimation of supplemental fluids likely to be required in view of anticipated future losses from
drains, fistulae, nasogastric tubes or abnormal urine or faecal losses.

• When an estimate of the volumes required has been made, the appropriate replacement fluid
can be determined from a consideration of the electrolyte composition of gastrointestinal
secretions. Most intestinal losses are adequately replaced with normal saline containing
supplemental potassium
Fluid management in surgery (colombo uni long case book)
Fluid management is important at 3 stages of a patient
• Preoperative
• Intraoperative
• Post operative

Amount of fluid to = replace existing + obligatory losses (UOP + Ongoing losses (intestinal fluid
be given Deficit +insensible loss ) blood)

Therefore when calculating the amount of fluid the following 3 aspects should be taken into
consideration
• Existing deficit
• Maintenance requirement – obligatory losses (urine out put + insensible loss (lung, skin, feaces)
• Ongoing losses

Ideally replacement should be done with fluids with the same volume and composition

Existing deficit

Calculation of the existing deficit

Level of Percentage of loss Symptoms and signs Fluids to be
dehydration given
(10ml/%/kg)
Adults Children Adults
Mild 4% 5% Thirst 40ml/kg
Moderate 6% 10% Dry mucous membrane 60ml/kg
Sunken eyes
Reduced skin turgor
Severe 8% 15% Altered sensorium 80ml/kg
Decreased UOP
Impaired vital signs – Increased PR and
decreased BP

Mild and moderate – calculate the total amount – Give half in 1st 8 hours, next half in next 16 hours.
Half volume as 0.9% saline other half as 5 % dextrose

Severe – First replace IV compartment – Bolus 20ml/kg – over 30 minutes. Can be repeated.
Replace the remaining deficit as in mild and moderate dehydration.

Maintenance fluid requirements

Calculation can be done in 2 ways

1.
• Adults - 1.5 ml/kg/h
• Paediatrics - For the first 10kg – 4ml/kg/h next 10kg - 2ml/kg/h Other – 1ml/kg/h
 2. Maintenance fluid for 24 hours = Previous day’s urine output + insensible loss (500ml)

Maintenance Electrolytes
• Sodium – 2mmol/kg/day
• Potassium – 1 mmol/kg/day

Remember that the administered fluid should cover the above stated fluid and electrolyte requirements.

Example: for a 60kg

Total maintenance fluid – (considering 1.5ml/kg/h) = 90 ml/h = for 24 hours 2160 ml
Electrolytes – Sodium – 120mmol/day Potassium – 60mmol/day

Type of fluid – 0.9% saline 1L gives 154 mmol/l of sodium – completes the daily requirement
Give rest of the fluid as 5% dextrose.
Add potassium 20 mmol into 500ml of 5% dextrose

Losses

Calculation of the losses and replacement

There are 3 types of losses that can be considered in surgery

• Blood loss at surgery
• Drains
• Evaporation
• 3rd space loss

The following table gives a guide to the calculation and replacement of fluids during surgery.

Loss Calculation Replacement

Blood loss Based on the amount of soaked gauze towels, If <15% can replace with
drain and sucker fluid crystalloids at a ratio of 3:1 OR
colloids at a ratio of 1:1
Total blood volume 70ml/kg (Blood volume
can be estimated as approximately 70 mL/kg
for adults, 80 mL/kg in children and 100 mL/kg
in neonates. )
Express the loss as a percentage of the total
blood volume
Drains Measure Replace with hartmann’s
Evaporation
3rd space losses Depends on the surgery
Questions

1. What are the types of shock?

• Cardiogenic(acute HF, MI)
• Hypovolemic(blood loss, dehydration)
• Obstructive
• Distributive (septic shock (vasodilatation )comes under here, Neurogenic )

2. How much blood is lost in a femur fracture and pelvic fracture?

• Femur fracture – 0.5 – 1.5L
• Pelvic fracture – 2 – 4L
• Tissue damage – 500ml (within 48 hours) 250 ml during injury

Blood volume loss in

o one fully soaked towel – 80ml
o one fully soaked one swab – 20ml
When estimating the blood loss during surgery sucker bottles volume and these towel and swabs can be
calculated

3. Peadiatric patient weighing 10kg What is his blood volume?

(70%) About 700 ml. (you can only allow 10% of blood to be lost without any problems – only about 70
or 80ml – if there are 2 towels soaked that’s significant.

4. What is the colour of 14G cannula - Orange 17G – White 16G – grey

5. What are the types of IV fluids you know? – Colloids and crystalloids

6. What are the differences between the 2?

Crystalloids can diffuse through the semipermeable membrane. Colloids are high molecular weight they
are retained in plasma.
Crystalloids – non expensive no allergic reactions. Colloids – costly allergic reactions possible.
 7. Tell me the crystalloids and colloids available
Crystalloids – normal saline, 5%b dextrose, Hartmanns
Colloids – Dextran (used for Dengue hemorrhage) gelofundin hexastarch, albumin

If there is a blood loss of 500ml have to give about 1500ml of crystalloids as they move from
intravascular compartment to interstitial fluid. (Isnt it 2000ml?)

8. What are the constituents in normal saline 0.9% saline? what is the osmolality? 308

9. What are the newer crystalloids you know? plasmalite Na+ 140 K+ 5

PlasmaLyte is a family of balanced crystalloid solutions with multiple different formulations available
worldwide according to regional clinical practices and preferences. It closely mimics human plasma in its
content of electrolytes, osmolality, and pH. One liter has an ionic concentration of 140 mEq sodium, 5
mEq potassium, 3 mEq magnesium, 98 mEq chloride, 27 mEq acetate, and 23 mEq gluconate.

10. What are the complications or problems which can occur when giving crystalloids?
• Peripheral and pulmonary oedema
• Hypercholeremic acidosis – risk when giving normal saline

11. What is the percentage of total body water?

Child – 70% adult male – 60% Female – 55%

70kg man – 42L - ICF (2/3) ECF (1/3) – part in interstitial fluid rest in plasma

12. How do fluids move?

• 1L of normal saline – 250ml in plasma and 750ml in interstitial fluid
• 1L of 5% dextrose – dextrose gets metabolized – majority will move into intracellular
compartments. Only 80ml will remain in plasma. (cannot be used as a resuscitation fluid)
• Colloids – almost all will remain in plasma.

Input of water – water, food, metabolism (about 350ml per day)

Output of water – urine + insensible loss (skin, lung, feaces)

13. What are the electrolyte requirements of an adult per day?

Na+ - 1 – 2 mmol/kg/day K+ - 1 mmol/kg/day

14. What are the aims of IV fluids

resuscitation (for deficits) + maintenance fluid (supply daily requirements)+ losses (drains)

15. What are the maintenance requirements of adults and paediatrics?

Normal maintenance requirement of an adult – 1.5 ml/kg/h

Paediatrics - For the first 10kg – 4ml/kg next 10kg - 2ml/kg Other – 1ml/kg
 16. If your patient is hypovolemic what are the causes
• Blood loss
• excessive vomiting and diarahoea
• excessive diuresis
• High fever will also increase loss
• Leaky capillaries – loss into 3rd space
• metabolic derangements – diabetes insipidus, diabetes mellitus.
• Restricted intake and no IV fluids given

17. What are the degrees of dehydration ?

Mild – dry mucous membrane, thirst, UOP normal or reduced, skin turgor normal, BP and HR normal
Moderate – disinterest of surroundings, postural hypotension (dizzy when getting up), tachycardia,
tachypnea, decreased skin turgor, reduced UOP
Severe – unconscious, low BP, tachycardia, oliguria/anuria, respiratory distress

ICU – intraarterial blood pressure monitoring, CVP monitoring, CO monitoring

Composition of electrolyte loss depends on site

Stomach - K+ loss is higher, acid loss is higher
Bile – 150 of Na+

Giving K+ through a peripheral canula is painful therefore it should be given in a diluted form. Maximum
is 40mmol/h. ECG monitoring is needed if its >20mmol/h is being given. (20 is what is usually given)
High potassium can precipitate cardiac arrhythmias.
If potassium level is more than 3 can give oral potassium tablets – it is a GIT irritant– have to give
antacids
If potassium level is less than 3 – IV is preferred
Patient after bowel surgery – to prevent paralytic ileus – best thing is to maintain potassium as 4 – 4.5
(same in cardiac patients)

Burn patient – parklands formula – 4ml/%body surface area/kg – half the volume in 8 hours other half in
next 16 hours.
70kg patient with 25% surface area burn - 7 L of fluids. Patient should be assessed.

For OSCE – IV fluids can be given

Practical things you should know - How to connect and change IV bags? how to set a drip?
1ml = 20 drops.
Tutorial

Case 1
A 35 year old motor cyclist was brought to A & E following a RTA. On admission he was
conscious with a patent airway and complained of severe abdominal pain. He was noted to
have bruises over left upper abdomen and left thigh. His Heart Rate was 120 bpm and blood
pressure was 90/60.

1. What are the possible causes for his hypotension and tachycardia?
Blood loss due to solid abdominal organ injury and femur fracture– hypovolemic shock
2. How would you assess the degree of blood loss?
a. blood pressure - reduced
b. heart rate – increased Pulse will be low volume and thready
c. capillary refill time (increased (more than 2S) when BP is low body is trying to
compensate. It is increased due to poor peripheral perfusion)
d. urine output – will reduce Expected urine output – 0.5 – 1 ml/kg/hour.
e. CNS – Poor cerebral perfusion will lead to cerebral hypoxemia can cause
drowsiness and reduced level of consciousness .
f. Extremities – cold and clammy

4 classes of hemorrhage – class 1 – 15% (compensated by the patient) class 2 – 15 – 30% class 3
– 30 – 40% severed Class 4 - >40% dying patient. She also explained about HR BP pulse pressure
(becomes narrowed) respiratory rate urine output class 1 and 2 – crystalloids

3. How would you fluid resuscitate this patient?

This is class 2 hemorrhage may go into class 3. Have to start with crystalloids.

Prompt action required - Detection assessment and control bleeding. Aim - Rapid restoration of
circulatory volume to prevent irreversible changes in microcirculation which will lead to multi organ
failure. This cannot be done alone. Apply direct pressure if there is bleeding. Pelvic binders if there is a
pelvic fracture. Insert 2 wide bore cannulas and take blood for grouping and cross matching. If it is a
major trauma – cross match for about 6 units of blood. Blood bank should be informed. Rapid infusion
of crystalloids. 20ml/kg initial bolus should be given. If normalized with 2 litres - loss less than 20%. Aim
is not to get a very high BP. Then patient can start bleeding again. SBP – 90 for a major bleeding.
Surgeons can then take actions to stop bleeding.

What is the colour of 14G? orange

Rapid crystalloid infusion – 20ml /kg . Aim is not to get a very high BP.
Case 2
You are called to see a 60 year old patient 18 hrs after a laparotomy for hemicolectomy. She
has low BP 90/60 mmHg, HR 110 / minute with a gradually falling UOP over last 3 hrs.

1. Comment on the clinical findings.

This patient is likely to have comorbidities. There can be large fluid losses due to the surgery. This can be
due losses( NG tube, drains, active bleeding), inadequate fluids given after surgery in the
ward(hypovolemic shock). Cardiogenic shock may also be a cause. Epidural catheter– (generally
bupivacaine) vasodilatation and hypotension possible. Sepsis unlikely as it has only being 18 hours.
There is a possibility of pulmonary embolism also due to long term immobilization. (malignant patients
are at a higher risk of thromboembolism)

2. How would you assess his volume status?

Repeated answer same as before(question 1). Additionally check the drain output. NG tube. Go back to
anesthetic records and check the input, blood loss and other losses during the surgery. Check the lung
bases – fluid overload pulmonary edema. Continually assess the patient.

3. Comment on the initial steps in fluid resuscitation of this patient?

Inform the seniors if you are the HO. Arrange the patient to be shifted to HDU or ICU.. Check if crossed
matched blood is available if not make sure if it ready. Try to find the cause. Start crystalloids. Look for
ongoing bleeding. (may need to take the patient back to theatre) Blood gas can be done – lactate levels
rising if there is poor peripheral perfusion. Hartman’s solution can be given if there are NG losses,
ascetic fluid – hartmans or colloid. (if oncotic pressure in the fluid we give is low fluid will keep going
back to interstitial spaces)

Case 3

5 year old child was brought to the A &E with diarrohea and vomiting for 2 days.
1. How would you assess his level of hydration?
2. 2. Outline the principles of fluid resuscitation of this child.