Fluid and Electrolytes in Surgical Patients

Introduction (1)

Fluid and electrolyte management are

paramount to the care of the surgical patient.
Changes in both fluid volume and electrolyte
composition
occur
preoperatively,
intraoperative, and post operatively, as well
as in response to trauma and sepsis.

Balance
Fluid and Electrolytes in
Surgical Patients
Normal
Anatomy
Introduction
(2) and Physiology

Extracellular Fluid (20% body weight)

Total Body Water (60% body weight)

Lesser in
obesity
(Adipose tissues
less water)

Active
NA
Pump

Sodium and
potassium
to maintain
electrical
neutrality

Micropores
allow
escape and
returning of
ALBUMIN
(5%/hr)

Fluid and Electrolytes in Surgical Patients

Introduction (3)
External fluid and electrolyte balance between body and its
environment is defined by intake of fluid & electrolytes with
the output from kidney, GI tracts, skin and lungs (insensible
loss).
Modified and may not be the same, if there are excessive
loss due to diseases, changes in climate and etc.
Intake (in ml)

Output (in ml)

Water from beverages

1200

Urine

1500

Water from solid food

1000

Insensible losses from skin and

lungs

900

Metabolic water from oxidation

300

Faeces

100

2500

2500

Fluid and Electrolytes in Surgical Patients

Introduction (4)
Normal Maintenance Requirement
Calculated approximately from an estimation of insensible
(lungs, skin) and obligatory losses.
Water

25 -35 ml /kg/day

Sodium

0.9 1.2 mmol/kg/day

Potassium

1 mmol/kg/day

Typical daily maintenance fluid regimen consists 5% dextrose with

either Hartmanns or normal saline to a volume of 2 liters.
Replacement fluids required to correct pre-existing deficiencies
and supplemental fluids required to compensate for anticipated
additional intestinal or other loses.

Fluid and Electrolytes in Surgical Patients

Introduction (5)
Solution

NA

Ca

Cl

Lactate

Hartmanns

131

111

29

Normal Saline
(0.9% NaCl)

154

154

Dextrose Saline

30

30

Gelofusine

150

150

Haemcael

145

5.1

Colloid

(4% Dextrose in 0.18% saline)

Hetastarch

Gelatin
in 4 %

<1

145

Polygelin
(75g/L)
Hydroxyet
hyl starch
(6%)

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
INTRODUCTION
Defined as a serum sodium concentration lower than
135 mmol/L.
It can result from a particular laboratory technique or from
improper blood collection, excessively high water intake, or,
most commonly, an inability of the kidneys to excrete free
water.

Causes by
(a) Sodium depletion
(b) Sodium dilution

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
CAUSE 1 : SODIUM DEPLETION
1. Decrease intake
(a) Low Na diet
(b) Enteral feeds
2. Increase loss
(a) Gastrointestinal Losses like vomiting, prolonged NGT
suctioning, and diarrhea
(b) Renal Losses due to diuretics and primary renal disease
3. Dehydration (loss fluids and loss electrolytes)

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
CAUSE 2 : SODIUM DILUTION
1. Due to excess extracellular water
(a) Intentional: excessive oral intake
(b) Iatrogenic: Intravenous
2. Drugs like antipsychotics, Tricyclic antidepressants and
Angiotensin-converting enzyme inhibitors
3. Hyperosmolar like Mannitol and Hyperglycemia

Establishing Type of Hyponatremia

BP, JVP, Skin Turgor

Decreases

BP, JVP, Skin Turgor

Increases

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
Clinical Presentation
CNS symptom show when Na<123 mEq/l and cardiac symptom when Na
<100 mEq/l
Neurologic conditions:
Seizures, coma, encephalopathy
Results from rapid [Na]
Peripheral symptoms:
Cramping, twitches, fasciculations
Results from ion conduction aberrations
Cardiovascular symptoms:
- Hypertension and bradycardia
- Results from significant increases in intracranial pressure

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
Management
Calculate the deficit of Na by the formula below:
Na+ deficit (mEq) = (140 Naserum) x 0.6 x Kg
Correct sodium to above 120 mEq/dl
NaCl + 40 mEq/L KCl
3% Saline
serial electrolytes
be prepared to handle seizures
Replace potassium
Cl should correct itself

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
Treatment Strategies
Hypovolemic Hyponatremia
expand intravascular volume
0.9% NS or 3% Hypertonic Saline
Hypervolemic Hyponatremia
water restriction
treat medical condition
hemodialysis
Euvolemic Hyponatremia
SIADH
restrict fluid: 7-10 ml/kg/d
demeclocycline antagonizes vasopressin

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Sodium Hyponatremia
Central Pontine Myelinosis

Results from overcorrection of sodium

Acute correction limit 25 mEq /day
Chronic correction limit 10 mEq/day
In hyponatremia, brain adjust their osmolytes to fall, then
they will absorb free water from surrounding.
If too rapid correction, causes ECF to be hypertonic, free water
will then move out from cells, brain appear to shrink.
Manifest as paralysis, dysphagia, dysarthria

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Hypernatremia
Hypernatremia
High level of sodium
Due to increase sodium
or decrease in water
Plasma sodium more
than 145 mEq/L
Water moves from ICF
to ECF
Cell dehydrates/shrink

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Hypernatremia
Hypernatremia

Volume Status

Normal
High

Low

Nonrenal water loss

Iatrogenic sodium
administration

Skin

Mineralocorticoid excess

Gastrointestinal

Aldosteronism
Cushings disease
Congenital adrenal
hyperplasia

Renal water loss

Renal disease
Diabetes insipidus

Nonrenal water loss

Skin
Gastrointestinal losses
Renal water losses
Diabetes insipidus
Adrenal failure

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Hypernatremia

Presentation
Thirst
Neurologic symptoms like confusion,
neuromuscular excitability, seizures, coma
due to osmotic shift of water out of brain cells
(brain cell shrinkage)

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Hypernatremia

Diagnosis
Clinically and measuring of serum Na
Determine underlying disorders

Fluid and Electrolytes in Surgical Patients

Electrolytes Imbalance: Hypernatremia
Treatment
Normal saline in hypovolemic patients
Hypotonic fluid (D/w 5%, D/W 5% in or normal saline,

or entral water)
The formula used to estimate the amount of water

required to correct hypernatremia:

Water deficit (L)= Serum sodium - 140 TBW
140