Fluid and Electrolyte Management

of the Surgical Patient

Chapter 3
Ranielle A. Ongoco MD
TOTAL BODY WATER
● 50- 60% of Total Body Weight
● Deuterium Oxide and Titrated water for Measurement
● Muscles and Organs > Fat
○ Males > Elderly/ Obese individuals
○ TBW male = 60%
○ TBW female = 50%
○ Newborns = 80%
○ Downward estimation and Upward estimation
■ 10-20% for Obese - Downward
■ 10% for Malnourished - Upward
Fluid Compartments

The distribution
volumes of NaBr and radioactive
sulfate have been used to measure
ECF in clinical research.
Composition of Fluid Compartments

Concentration Gradient = Na-K

ATPase Pump

Sodium is confined to the ECF

compartment, and because of its
osmotic and electrical properties,
it remains associated with water
Osmotic Pressure

● The physiologic activity of electrolytes in solution depends on the

number of particles per unit volume (mmol/L)

● The concentration of electrolytes = Equivalence

● The number of milliequivalents of cations must be equal to the

milliequivalents of the anions
 Osmotic Pressure
Osmosis - Movement of water across the cell membrane to achieve osmotic equilibrium

Most significant
gains and losses of
body fluid are directly
from the extracellular
compartment

Osmotic Pressure - measured in units of osmoles or milliosmoles that refer to the actual
number of osmotically active particles.
The Osmolality of the intracellular and extracellular fluids is
maintained between 290 and 310 mOsm in each compartment.
Body Fluid Changes

75% lungs
and 25%
2000
skin

75% 500-800 ml

Sweat and GI losses - Isotonic

Classification of Body Fluid Changes

A. Volume
B. Concentration
C. Composition
Disturbances in Fluid Balance
Extracellular volume deficit - most common fluid disorder in surgical patients.

Urine osmolality > Serum osmolality

Urine sodium <20meq/L does not necessarily
reflect volume status of the patient

The most common cause of Volume Deficit in

surgical patients is a loss of GI fluids
Disturbances in Fluid Balance
Volume Control

Osmoreceptors and Baroreceptors

Osmoreceptors - Diuresis and Thirst

E.g. Inc. Plasma Osmolality - Thirst is stimulated and

Hypothalamus secretes vasopressin for water reabsorption

Baroreceptors - Pressure - Pressure sensors in the aortic arch and carotid

sinuses
Concentration changes
Serum Sodium Concentration Total Body Water
Hyponatremia - Sodium Depletion or Dilution
Dilutional
● Excessive Oral Water Intake
● Intravenous Excess
● Postoperative patients = Inc. ADH
● Drug induced water retention
Depletion

● Decreased Intake
● Gastrointestinal Losses
● Renal Losses
 Concentration changes

Hyponatremia due to excess of solute relative to free water

● Hyperglycemia
● Mannitol Administration
● Lipids and protein increase - Pseudohyponatremia

● Hyponatremia in Hyperglycemia
Every 100 mg/dL of plasma glucose above normal = decrease by 1.6 mEq/L
sodium

Correction of Sodium = must be maintained at 1 mEq/L/Hr

 Concentration changes
Serum Sodium Concentration Total Body Water
Hypernatremia - loss of free water / gain of sodium in excess of water

Hypervolemic Hypernatremia - Na >20 mEq/L and urine osmolality > 300 mOsm/L

Normovolemic Hypernatremia

Hypovolemic Hypernatremia - Na <20 mEq/L and urine osmolality <300 mOsm/L

Concentration changes

Symptomatic Changes = >160 mEq/L

Composition Changes
Potassium Abnormalities

● 2% of Total body potassium is in extracellular fluid

● Influenced by number of factors
○ Surgical Stress
○ Injury
○ Acidosis
○ Tissue Catabolism
Composition Changes
Potassium Abnormalities Gastrointestinal
● Nausea
● Vomiting
● Colic
>5.0 mEq/L
● Diarrhea
Neuromuscular
● Weakness
● Paralysis
ECG -> Arrhythmia and Cardiac Arrest
● Peaked T waves
● Widened QRS complex
● Flattened P-wave
● Prolonged PR interval
● Sine wave
● Ventricular Fibrillation
 Composition Changes
Potassium Abnormalities
Gastrointestinal
● Ileus
● Constipation
Neuromuscular
● Weakness
● Fatigue
● Diminished Tendon Reflex
ECG -> Arrhythmia and Cardiac Arrest
● U - waves
● T wave flattening
Alkalosis ● ST-segment changes
Hypomagnesemia -> Hypokalemia

Every 0.1 increase in pH level there will be decrease of 0.3 mEq/L of Potassium
Composition Changes
Calcium Abnormalities

<1% Found in the ECF

3 Forms
Ionized 50% - Neuromuscular stability and can be measured directly
Complexed to phosphate 10%
Protein found 40%

Every 1g/dL decrease in albumin there is 0.8 decrease in serum calcium

Composition Changes
Calcium Abnormalities
Hypercalcemia - >10.5 mEq/L serum calcium or increased ionized calcium level
> 4.2 - 4.8 mg/dL

Most common causes

● Primary Hyperparathyroidism
● Malignancy
Composition Changes
Composition Changes
Calcium Abnormalities

ECG
● Shortened QT interval
● Prolonged PR interval
● Prolonged QRS interval
● T - wave flattening and widening
Composition Changes
Calcium Abnormalities
Hypocalcemia - Serum calcium below 8.5 mEq/L and ionized calcium
4.2mg/dL
Common causes:

Pancreatitis
Massive soft tissue infections
Necrotizing fasciitis
Renal Failure
Fistulas
Hypoparathyroidism
Toxic Shock Syndrome
Removal of parathyroid adenoma
Malignancies
Composition Changes
Calcium Abnormalities

< 2.5 mg/dl ionized calcium = Neuromuscular and cardiac symptoms

Chovstek’s sign - Spasm from tapping the facial nerve
Trousseau sign - Spasm resulting from pressure of the upper extremity nerves

ECG findings :
Prolonged QT interval
T wave inversion
Heart Block
Ventricular Fibrillation
 Composition Changes
Phosphorus Abnormalities

Hyperphosphatemia - Impaired Renal Function (Most are asymptomatic)

Prolonged - Calcium phosphorus complexes

Hypophosphatemia - Chronic cases- Decreased GI uptake

Acute Cases - Respiratory Alkalosis

Cardiac Dysfunction and Muscle Weakness

Composition Changes
Magnesium Abnormalities

Intracellular
½ of Mg body content is in the bone
In extracellular space ⅓ is bound to plasma
Composition Changes
Magnesium Abnormalities
Hypermagnesemia

Severe Renal Insufficiency

Parallel Changes in potassium excretion
TPN
Composition Changes
Magnesium Abnormalities
Hypomagnesemia

Starvation
Alcoholism Neuromuscular and Central
nervous system hyperactivity.
Prolonged IV fluid therapy
Diuretic ECG findings same with
Diarrhea hypocalcemia + Torsades
Malabsorption de pointes
Pancreatitis
Composition Changes
Magnesium Abnormalities
Acid- Base Balance
Acid-Base Homeostasis

35-45 mmhg 22-28 mEq/L

7.35-7.45
Acid- Base Balance
Acid-Base Homeostasis
Acid- Base Balance
Metabolic Derangements

Metabolic Acidosis

● increased intake of acids

● increased generation of acids
● increased loss of bicarbonate
Anion Gap - Index of unmeasured anion ( Normal <12 mmol/L )

AG = (Na) – (Cl + HCO3)

Corrected AG = actual AG – [2.5(4.5 – albumin)]
Acid- Base Balance
Metabolic Derangements
Acid- Base Balance
Metabolic Derangements

A low urinary [NH4 +] in the face of

hyperchloremic acidosis would indicate that
the kidney is the site of loss
Acid- Base Balance
Metabolic Derangements

Sepsis/Injury HYDRATE
Acid- Base Balance
Metabolic Derangements

Metabolic alkalosis

Treatment includes replacement

of the volume deficit with isotonic saline
and then potassium replacement once
adequate urine output is achieved.
Acid- Base Balance
Respiratory Derangements
Respiratory Acidosis - retention of CO2 secondary to decreased alveolar
ventilation

Treat the underlying cause

Bilevel positive airway pressure
Endotracheal intubation
Increase minute ventilation
Acid- Base Balance
Respiratory Derangements

Respiratory Alkalosis - secondary to alveolar hyperventilation.

● Pain
● Anxiety
● Neurologic disorders
Hypokalemia
Hypocalcemia
Hypophosphatemia

Treatment should be directed at the underlying cause, but direct

treatment of the hyperventilation using controlled ventilation may
also be required.
Fluid and Electrolyte Therapy
Parenteral Solutions

To maintain osmolality and accounts for 200 kcal/L

 Fluid and Electrolyte Therapy
Alternative Resuscitative Fluids

Closed head
injuries

Acute kidney injury

Pulmonary edema
Intravascular
Postoperative Space
bleeding
Correction of Life-Threatening Electrolyte
Abnormalities
Hypernatremia
Volume should be restored with normal saline before the
concentration abnormality is addressed
Correction of Life-Threatening Electrolyte
Abnormalities
Hypernatremia
Acute symptomatic Hypernatremia = 1 mEq/h and 12 mEq/d
Cerebral edema and Herniation

Hypernatremia is less common than hyponatremia, but has a worse

prognosis, and is an independent predictor of mortality in critical illness
Correction of Life-Threatening Electrolyte
Abnormalities
Hyponatremia
Free water restriction and, if severe, the administration of sodium
Symptoms appear at <120 mEq/L

Symptomatic = 1 mEq/L per hour until Asymptomatic = no more than 0.5

the serum sodium level reaches 130 mEq/L per hour to a maximum
mEq/L increase of 12 mEq/L per day

The rapid correction of hyponatremia

can lead to pontine myelinolysis
Correction of Life-Threatening Electrolyte
Abnormalities
Hyperkalemia
Correction of Life-Threatening Electrolyte
Abnormalities
Hypokalemia

Asymptomatic - Oral Repletion

Symptomatic - 10 mEq/hr if NO ECG monitoring If monitored

can increase up to 40mEq/hr
Correction of Life-Threatening Electrolyte
Abnormalities
Hypercalcemia

Symptomatic at 12 mEq/L

Repleting the associated volume deficit and

then inducing a brisk diuresis with
normal saline.
Correction of Life-Threatening Electrolyte
Abnormalities
Hypocalcemia

Acute symptomatic
hypocalcemia should be treated with IV 10% calcium
gluconate
Correction of Life-Threatening Electrolyte
Abnormalities
Hyperphosphatemia

● Sucralfate
● Aluminum-containing antacids
● Dialysis
Correction of Life-Threatening Electrolyte
Abnormalities
Hypophosphatemia
Correction of Life-Threatening Electrolyte
Abnormalities
Hypermagnesemia

Acute symptoms = calcium chloride (5 to 10 mL)

If elevated levels or symptoms persist, hemodialysis

may be necessary.
 Correction of Life-Threatening Electrolyte
Abnormalities
Hypomagnesemia

Oral - Asymptomatic or Mild

Severe - 1-2 g magnesium sulfate IV 15 min if with monitoring can give over 2
minutes
+
Simultaneous calcium gluconate 10%
 Preoperative Fluid Therapy

Acceptable values for vital signs,

Tachycardia and Orthostasis - Acute signs of volume loss Adequate urine output (½–1 mL/kg
per hour in
an adult)
Intraoperative Fluid Therapy
Induction of anesthesia Hypotension

To prevent:

Correcting fluid losses

Replacing ongoing losses

Parasitic losses
Sequestration Requires 500 to 1000 mL/h
of a balanced salt solution
Third-space edema
Postoperative Fluid Therapy

Based current estimated volume status and projected ongoing fluid

losses

Guided by the restoration of acceptable values for vital signs and urine
output

After 24 - 48 hours 5% dextrose in 0.45% saline

Postoperative Fluid Therapy

Volume Excess Weight Gain

Tachycardia
Volume Deficit Orthostasis
Oliguria
Thank You