FLUID AND ELECTROLYTES

MANAGEMENT IN SURGERY
DR EMMANUEL PAPA KWADWO ACQUAH
SPECIALIST SURGEON
MBCHB, MGCS
 OUTLINE
• INTRODUCTION
• FLUID/ELCTROLYTES DISTRIBUTION IN THE BODY
• FLUID/ELECTROLYTES INPUT-OUTPUT
• TYPES OF IV FLUIDS
• PROBLEM ASSOCIATED WITH BODY FLUID CHANGES
• RECAP/QUIZ
 INTRODUCTION
Fluid and electrolyte management is a major part of junior Dr
prescription:
• Important part of the perioperative management of the surgical
patient
• Critical factor in some patients as a result of the response to trauma,
severe illness and operative procedures.
• Adequate pre operative stabilization essential to prevent
• Hypotension, cardiac arrhythmias, renal failure and other intra operative
complications
FLUID DISTRIBUTION IN THE BODY
FLUID DISTRIBUTION IN THE BODY
 ELECTROLYTE DISTRIBUTION IN BODY FLUIDS
Ion Intravascular Interstitial mmol/L Intracellular
mmol/L mmol/L
Na 140 143 8
K 4 4 140
Ca2+ 1.25 0.625 1
Mg 0.7 – 0.9 0.75 15
Cl 95 – 105 115 8
HCO3- 24 – 27 30 14
PO43- 0.8 – 1.4 1.6 25.8
Protein 2 0 9
SO42- 1 1 20
Organic acids 3 3 -
 FLUID INPUT AND OUTPUT
INPUTS (INTAKE) OUTPUT (LOSSES)

SOURCE VOLUME(ml) SOURCE VOLUME(ml) –

Tropics Temperate

Drinking 1500 Urine 1500) 1500

Food 500 Respiration 1700 1000

&Sweating

Endogenous ≈200 Faeces 200 200

metabolism

TOTAL ≈2200 TOTAL 3400 2700

Net requirement for 3200 2500

NPO
 ELECTROLYTES OUTPUT(LOSSES)

SODIUM (mmol) POTASSIUM (mmol)

Urine 114 50

Stool 10 10

Sweat 10-16 Negl.

TOTAL 130-140 60
 POTENTIAL FLUID AND ELECTROLYTE LOSS
Potassium
Secretions Daily volume (mls) Sodium (mmol/l) (mmol/l)

Saliva 1000 10 25

gastric 1500 60 10

bile 500 140 5

pancreatic 500 140 5

Small bowel 3000 140 5

Colon minimal 60 30
 TYPES OF IV FLUIDS
• TWO MAIN GROUPS – crystalloids and colloids
• BLOOD AND BLOOD PRODUCTS
TYPES OF INTRAVENOUS FLUIDS
 COMPOSITION OF COMMON INTRAVENOUS FLUIDS
Glucose
Fluid Na K Ca Cl HCO3 g/l Osmolality
Normal 154 154 308
saline
Ringer’s 130 4 4 111 27 276
lactate
5% 50 278
dextrose
Badoe’s 43.6 16 1.3 51.7 9 (sorbitol) 100
solution 300g
Dextrose 154 154 50 586
saline
1/5 N/S in 30.8 30.8 43 300
4.3%
dextrose
GIRS 100 12 10 122 50 522
 CRYSTALLOIDS
• Crystalloids are aqueous solutions of low molecular weight ions and
therefore rapidly equilibrate with and distribute throughout the
extravascular space.
• They differ in their composition, tonicity
• May be isotonic , hypotonic or hypertonic .
• Normally only a quarter of the volume of the crystalloid infused remains in
the vascular compartment
• To restore circulating blood volume ( intravascular volume) , crystalloid
solutions should be infused at a volume at least 3 times the blood volume
lost.
 HYPOTONIC CRYSTALLOIDS
• Tonicity lower than the body plasma.
• Hypotonic fluid exerts a lower osmotic force.
• Fluid shifts from the intravascular space to the extravascular space, and into the
tissues and cells.
• Hydrate the cells causing them to swell
• Less than 10% remain intravascular hence inadequate for fluid rescuscitation .
• Used in Diabetic Ketoacidosis , Hypernatremia , Hyperosmolar Hyperglycemic
State
• Eg: 2.5% Dextrose in water (D2.5W), 0.45% NaCl, 0.33NaCl
 ISOTONIC CRYSTALLOIDS

• OSMOLARITY OF 250 – 375 mOsm/L

• Isotonic fluid contains the same amount of solute as plasma so exerts

an equal osmotic force

• Used for initial volume resuscitation

• Only serves to increase the ECF volume

• Eg: Ringer's lactate and 0.9% NaCl (normal saline)

 HYPERTONIC CRYSTALLOIDS
• Tonicity higher than plasma.
• Shift water from the extravascular spaces , increasing the
intravascular volume.
• Dehydrate the cells causing shrinkage.
• Potential Complications
Hypernatremia
Hyperchloraemic acidosis may occur owing to the large chloride load.
Hemolysis
• Eg: 3% NaCl , 5%Dextrose in Normal Saline ( D5NS)
ADV OF CRYSTALLOIDS
• Less expensive.
• Non-allergic.
• More effective at replacing depleted ECF.
• No infection risk.
• No impairment of coagulation or cross-matching
DISADV
• Short-lived haemodynamic effect.
• Massive use → peripheral oedema and pulmonary oedema.
 COLLOIDS
• Large proteins which provide oncotic pressure in addition
to intravascular volume
• Colloids remain in the blood vessels for long periods of
time
• Increase the intravascular volume (volume of blood).
• Continual use - Cells become dehydrated.
Human Albumin: 5%, 25%
 Dextran 70, Dextran 40
 Gelatin solutions (Haemacel®, Gelafundin®
 hydroxyethyl starches (Hetastarch®)
 COLLOIDS
ADVANTAGE
• Expand plasma volume rather than
interstitial fluid volume.
• Lower fluid requirement.
• Less peripheral / pulmonary
oedema
DISADVANTAGES
• More expensive.
• Allergic reactions (gelatin)
• Infection risk (HAS, albumin)
• Coagulopathy (dextrans and starches)
• Impaired crossmatching (dextran).
• In disease states with ↑ Capillary
permeability colloid may aggravate
 sepsis, ARDS →pulmonary
Oedema
 Head injury → cerebral oedema
and ↑ ICP
 BODY FLUID/VOLUME CHANGES
Classified into three groups
1. Disturbances of volume – due to loss or addition of water from the
ECF

2. Disturbances of concentration – due to addition or loss of solute

3. Disturbances of composition:– Acid – base balance

 VOLUME CHANGES
ECF volume deficit is the most common fluid disorder in surgical
patients.
Seen in :
1. Losses from the GIT due to vomiting, NG suction, diarrhoea and
fistula drainage
2. Sequestration of fluid in soft tissue injuries and infections
3. Intra-abdominal and retroperitoneal inflammatory processes
4. Intestinal obstruction
5. Burns
ASSESSMENT OF HYDRATION STATUS AND
INTRAVASCULAR VOLUME

• History
• Physical examination
• Labs
• Haemodynamic measurements
PHYSICAL EXAMINATION
HISTORY
 Period of nil per os • Skin turgor
 Vomiting, diarrhea • Dry mucous membrane
 Haemorrhage • Sunken eyes
Diuretic Therapy • Capillary refill time
• BP & pulse
• Urine
 LEVEL OF Fluid Deficit in the ml/kg (%
DEHYDRATION body weight)
INFANTS ADULTS SIGNS
MILD 50 (5%) 20 (2%) Alert ,CRT=2s
Slight dry mucus membrane,
increased thirst,
slight decreased urine output
MODERATE 100 (10%) 40 (4%) Lethargic, CRT= 2-4s
Dry mucous membrane,
Tachycardia,
Oliguria/anuria
Sunken eyes/fontanelles
Loss of skin turgor
SEVERE 150 (15%) 60 (6%) Obtunded, CRT >4s
Same as moderate dehydration PLUS
Rapid thread pulse
Cold extremities
No tears
Rapid breathing
Hypotension
Mottled skin
Coma
 LABORATORY INVESTIGATIONS
• Unexplained high Hb
• High haematocrit
• High urea
• Arterial blood gases
• Urine: high specific gravity (>1.010)
 FLUID THERAPY PRINCIPLES
Before prescribing any fluid, consider the characteristics of the
individual patient:
1. Reason for the fluid prescription:
• Replacement of pre-existing deficits (resuscitation).
• Maintenance requirements.
• Replacement of on-going losses
2. Patient’s wt & size: eg frail 45kg 80yr f. vs healthy 100kg 40yr m.
3. Underlying reason for admission
4. Co-morbidities : HF, CKDx
5. Most recent electrolytes
 FLUID REPLACEMENT (RESUSCITATION)
• Replace ECF losses with Ringers lactate, normal saline or dextrose saline
i. Dehydration formula =(2:4:6%-adults; 5:10:15% - infants)
ii. Hypovolemic shock = 1L (infant=20ml/kg) over 30-45min (reassess and repeat 1L
over 1hr if needed)
• Continue till U/O= 30-50ml (0.5ml/kg/hr), subcut vein are filled and skin and tongue
are moist.
• Reduce infusion rate to 1L over 8hrs and then approp. maintenance solution
commenced.
• Gastric outlet obstruction
• Normal saline or dextrose saline with added potassium
• NB: DO NOT GIVE R/L
 MONITORING DURING RESUSCITATION
1. Hourly urine output= 30-50ml/h (0.5-1.0ml/kg/hr) (infant- 1-2ml/kg/hr)
• In very ill patients, a urethral catheter should be inserted under aseptic conditions for the
accurate measurement of the hourly urine.
2. Skin turgor, moistness of tongue. filling of subcutaneous veins
3. Half-hourly pulse and BP
4. Frequent auscultation of the lungs and monitoring JVP so that overhydration is
prevented or quickly diagnosed and treated if it occurs.
5. Central venous pressure = 10-15cmH2O
 The most reliable parameter is the hourly urine output which is a mirror of
tissue perfusion.
Fluid Intake-Output Chart and Daily weight chart.
Serum electrolyte and BUN are checked after 12hrs and any def. esp. ↓K
corrected
 DAILY FLUID AND ELECTROLYTE
MAINTENANCE
BAJA CURRENT NICE GUIDELINES
• Water = 3000ml = 3L/d SUGGEST THE FOLLOWING:
• Sodium = 130 mmol/d(2-3mmol/kg) • Water: 25-30mL/kg/day
• Potassium = 50 – 60 mmol/d
(1-2mmol/kg) • Na+: 1.0 mmol/kg/day
• Glucose (calories) = 100gm/d
(2g/kg/d) • K+: 1.0 mmol/kg/day
• Multivitamins vit c , vit b co , zinc etc
• Glucose: 50-100g/day

Fever (for 1oC rise in temperature, add 12% of the daily fluid requirement)
 DAILY FLUID AND ELECTROLYTE
MAINTENANCE
• Maintenance fluid (TROPICS) • Temperate region requirement
i. Water -2.5L
i. 1L R/l, ii. Na : 80-100mmol
ii. 2L 5% dextrose, iii. K - 60mmmol
iii. 50mmol KCl iv. Carbohydrate -100gm
v. Vit C and B complex added
OR
i. 3L of Badoe’s solution • Maintenance fluid (TEMPERATE)
• (Na=43.6; K=16; Ca=1.3; Cl=51.7; i. ½ litre Normal Saline
HCO3=9 ; (sorbitol) 300g ; Osm=100 ii. 2L 5% dextrose
iii. 60 mmol KCl
MAINTENANCE IV FLUID CALCULATION
ONGOING LOSSES
• During surgery and anaesthesia
• Gastric aspirate from NG tube
• Obstructed bowel
• Loss into paralysed bowel, vomiting and NG aspirate
• Diarrhoea
• From drainage tubes and drains
• Bleeding, and weeping from burns etc
• Excessive diuresis
• Stoma/fistula
 OVERHYDRATION
• 67 ml/kg/day (4L/day/in a 60 kg adult)
Features:
i. Added breath sounds, raised JVP, Peripheral or sacral edema, pulmonary edema.
ii. Intracranial pressure
iii. Congestive cardiac failure
iv. CVP >15cm
TREATMENT
i. Stop infusion immediately
ii. Emergency treatment to reduce cerebral edema with hypertonic saline or mannitol
iii. In Inappropriate ADH secretion, limit water intake to 500ml/day
 CONCENTRATION CHANGES

1. Hyponatremia and Hypernatremia

2. Hyperkalaemia and Hypokalaemia

3. Hypomagnesaemia and Hypermagnesaemia

4. Hypocalcaemia and Hypercalcaemia

HYPONATREMIA
• Serum sodium < 130mmol/l

• Symptoms
• CNS- headaches, confusion, seizures, increased ICP
• MS- weakness, fatigue, muscle cramps
• GIT-anorexia, vomiting, watery diarrhoea
• CVS- hypertension and bradycardia with↑ICP
• Renal- oliguria

• May be divided into hypovolaemic, isovolaemic and hypervolaemic

hyponatremia
Hypovolaemic hyponatremia
• is a state in which the total body water • Na maintenance=2-4mmol/kg
and sodium content are decreased and
the relative decrease in total body • Na = Na deficit + Na maintenance
sodium is greater than the decrease in
total body water. • Acute hyponatremia (<48hrs) can be safely
• Causes include corrected more quickly than chronic
• GIT –diarrhoea, vomiting , fistulae hyponatremia.
• Third space shift – burns, peritonitis,
pancreatitis, ascites
• Hypoaldosteronism • Replace with NS no faster than
0.5mmol/L/hour or 10mmol/l/24hrs to
CORRECTION avoid central pontine myelinolysis
• Na deficit= 0.6*weight*(ideal Na- (Osmotic demyelination syndrome)
patient’s Na)
HYPONATREMIA
• EUVOLEMIC HYPONATREMIA
• It occurs when there is an increase in
total body water without a
corresponding increase in total body
sodium though the increase in body
water is not sufficient to promote
clinically evident edema
• Causes include Syndrome of
inappropriate ADH secretion,
psychogenic polydipsia
• Treatment- free water restriction to
1L dly
• HYPERVOLEMIC HYPONATREMIA
• Characterized by an increase in
both total body sodium and total
body water with a relatively
greater increase in total body
water
• Renal failure, cirrhosis, chronic heart
failure ,
• Treatment – salt and fluid
restriction, diuretics, control of
underlying condition
HYPERNATREMIA
• Serum sodium >145mmol/l

• Symptoms
• CNS-restlessness, lethargy, tonic spasms, delirium, seizures, coma
• MS- weakness
• CVS- tachycardia, hypotension, syncope
• Tissue – dry sticky mucus membranes, red swollen tongue, decreased saliva
and tears
• Renal- oliguria
 HYPERNATREMIA CORRECTION
• TBW deficit=correction factor * premorbid wt * (1- 140/Na)
• Correction factor in children is 0.6

• Acute symptomatic hypernatremia(<24hr) should be corrected rapidly

while chronic hypernatremia (>48hrs) should be corrected more
slowly due to risk of cerebral oedema.
 HYPERNATREMIA CORRECTION
• In the acute setting, Na is corrected at a rate of 2-3mmmol/L/hr for
2-3hr (max total 12mmol/L/d)
• In the chronic setting, with no or mild symptoms, serum Na
correction should not exceed 0.5mmol/L/hr or 8-10mmol/L/d
• If both volume deficit and hypernatremia are present, restore
intravascular volume with normal saline before free water
administration.
 HYPOKALEMIA
• Normal range of potassium 3.5-5.0mmol/l
• Hypokalemia < 3.5 mmol/l
• Symptoms
• GIT- ileus, constipation
• Neuromuscular- fatigue, weakness, paralysis
• CVS- arrythmias, cardiac arrest
• ECG, flat T waves and depressed ST segments
HYPOKALEMIA
• Loss of GIT secretions = vomiting, diarrhea
• Peritonitis
• High output fistulae
• Due to excessive renal excretion of K+
• Movement of K+ into the cells
• Prolonged administration of K+ free parenteral fluids with continued
obligatory renal loss of K+ (>20mEq/day)
• Parenteral nutrition with inadequate K+ replacement
 TREATMENT
Potassium deficit in mmol is calculated as:
• K+ deficit= 0.4x weight x (ideal K+ - patient’s K+) : ADD TO
• Daily K+ maintenance= 1-2mmol/kg
• KCl solution in either 5% Dextrose or 0.9% saline

Common Guidelines
• Prevention i.e. replace GIT fluid loss volume for volume
• Give K+ not more than 40mEq/L of fluid (can put 20mmol in 500ml of iv fluids and
run over 3-4hrs)
• Rate not exceeding 20mEq/hour ((typically 0.5mmol/kg/hr)
• Don’t give oliguric patients and within 24hrs post operatively
• Continuous ECG monitoring
 HYPERKALEMIA (K+ > 5.5mmol/L)
• Chronic renal failure
• Metabolic acidosis
• Massive crush injury
• Rhabdomyolysis
• Limb ischemia
• Major burns
• Massive blood transfusion
CLINICAL FEATURES
 Muscle weakness  hyporeflexia  paralysis affecting legs, trunk and arms (in that
order) and last respiratory muscles.

GIT symptoms – nausea, vomiting, intermittent intestinal colic and diarrhoea

Cardiac Arrythmia
• EGC FINGDINGS
• ECG changes are very tall, slender peaked T waves,
• Absent P waves, widened QRS and ventricular arrhythmias and
• fibrillation and finally cardiac arrest.
 CORRECTION
SHORT ACTING REMEDIES
• 10% Calcium gluconate 1ml/kg IV
• Nebulized Salbutamol
4microgram/kg
• Insulin 1unit/kg with 4ml/kg of
25% Dextrose
• NaHCO3 2mmol/kg at 1-
2mmol/min
LONG ACTING REMEDIES
• Remove source of potassium
• Calcium resonium 0.5-1g/kg
PO/PR in divided doses
• Dialysis
• Exchange transfusion
PERMANENT REMEDY
• Treat underlying cause
 Calcium
• Has a vital role in the body
• Structural function. Present as calcium phosphate in bones. (99% is in
skeleton in this form)
• Enzymatic function – coenzyme for clotting factors
• Muscle contraction
• Neurotransmitter release
• Signalling function

• Serum levels
• Total calcium- 2.2-2.6 mmol/l
• Ionized calcium -1.1-1.4
 HYPOCALCEMIA ( serum ca:< 2.2mmol/l)
• causes:
• acute pancreatitis
• acute and chronic renal failure
• pancreatic and small-bowel fistulas,
• hypoparathyroidism
• Clinical features
• Circum-oral numbness
• Numbness of fingers and toes
• Hyperactive tendon reflexes, TETANY
• Seizures (severe deficit)
• Refractory hypotension
• Chvostek sign
• Trousseau sign
CHOVSTEK’S SIGN
TROUSSEAU’S SIGN
 HYPOCALCEMIC CORRECTION
• Mild/ chronic: oral Calcium supplement
• Severe: Calcium containing infusion
• 10ml of Calcium gluconate = 90mg of elemental Ca
• 10ml of Calcium chloride = 272mg of elemental Ca
• Start with 0.5mg/kg/hr and increase up to 2mg/kg/hr as needed
• 100-300mg of elemental Ca in 50-100ml of 5% Dextrose is given over
5-10mins which raises the ionized Ca level to 0.5-1.5mmol/L
 HYPERCALCEMIA
(Serum calcium > 2.7 mmol/l)
• Causes
• Primary hyperparathyroidism
• Malignancies
• Prolonged immobilization
• Renal failure with secondary hyperparathyroidism
 HYPERCALCEMIA
• Easy fatigability
• Lassitude
• Weakness
• Anorexia, nausea and vomiting
• Weight loss
In severe cases
- lassitude, somnambulism, stupor, coma
- Headaches, skeletal pains, thirst, polydipsia, polyuria
 CORRECTION
• Rehydration- isotonic saline used. Up to 8L/24hrs to
promote diuresis and calciuria.
• Diphosphonates – disodium pamidronate 15-60mmg
• Calcitonin blocks bone resorption and increases urinary
calcium excretion by inhibiting renal calcium reabsorption.
Dose-4units/kg IM/SC
• Dialysis my be required
 HYPOMAGNESEMIA
• Serum magnesium <0.5mmol/l

• Causes
• Poor dietary intake
• Starvation
• Prolonged use of intravenous fluids
• Total parenteral nutrition with inadequate Mg
• Gastrointestinal losses eg diarrhoea
 HYPOMAGNESEMIA CORRECTION
• Magnesium sulphate in 25 % or 50% solution is used. 1 m1 of 50%
solution contains 2mmol of magnesium and 0.25mmol/kg is given
daily until the serum concentration becomes normal.

• In a severe case, l mmol/kg is administered in 0.5L of 5 % dextrose

infusion in 4-8h.
 HYPERMAGNESAEMIA
• Generally rare
• Causes
• Impaired renal function
• Excess intake

• Symptoms
• GIT- nausea / vomiting
• Neuromuscular- weakness, lethargy, decreased reflexes
• CVS-hypotension and arrest
 TREATMENT
• Withhold exogenous magnesium
• Calcium chloride (5-10ml) to antagonize cardiovascular
effects
• Dialysis may be required
 POST-COURSE QUIZ
1. Which of the following intravenous solutions is a
colloid solution?
A. 5% Dextrose

B. 0.9% Sodium Chloride

C. Hartmanns Solution

D. Human albumin solution (HAS)

• A 27-year-old man is involved in a car crash while traveling in excess of
70 mi/h. He sustains an intra-abdominal injury and a fracture of the femur.
The BP is 60/40 mm Hg, and the hematocrit is 16%.
• Initial resuscitation is best done by administration of which of the
following?
A. D5W
B. D5W and 0.45% normal saline
C. Ringer’s lactate solution
D. 5% plasma protein solution
E. 5% hydroxyethyl starch solution
• Identify the eletrolytes
abnormality
• Management (50kg)
• A30-year-old man who weighs 60 kg has the following laboratory
values: Hb= 10 g/dL; Na=120 mEq/L; K=4 mEq/L; Cl=90 mEq/L; and
serum CO2 content=30 mEq/L.
• What is his sodium deficit approximately?
(A) 20 mEq
(B) 200 mEq
(C) 400 mEq
(D) 720 mEq
(E) 120 mE
 REFERENCES
• Principles and Practice of Surgery in the Tropics .5th edition
• Sabiston textbook of surgery. 7th Edition
• Schwartz/s Principles of Surgery 8th edition
• MEDSCAPE
THANK YOU