FLUID & ELECTROLYTE

MANAGEMENT IN
SURGICAL PATIENTS
DR. TABISH NISAR
TOTAL BODY WATER

• Water constitutes 50% to 60% of total body water.

• In males, TBW accounts for 60%.
• In females, TBW accounts for 50%.
• In infants, it accounts for 80% which progressivley decreases to 65% by age 1 year.
FLUID COMPARTMENTS

• 2/3rd of TBW is Intracellular (28L), with Sodium as major cation, Bicarbonate &
chloride as major anions.
• 1/3rd of TBW is Extracellular (14L), with Potassium & magnesium as major cations,
Phosphate, sulfate & proteins as anions.
• 2/3rd of ECF is interstitial (10.5L)
• 1/3rd of ECF is plasma (3.5L)
NORMAL PHYSIOLOGY
 PARENTERAL FLUIDS

Commonly used fluids are divided into

• Crystalloids are aqueous solutions of mineral salts & replicate the ionic makeup of plasma. e.g. Hartmann
solution, 0.9% NaCl, 0.45% NaCl, Dextrose saline.
• Colloids are more confined to intrasvascular space due to higher molecular weights & result only in
transient plasma volume expansion. e.g. Blood, Albumin, FFPs, Haemacel, Hetastarch, Gelatin.
isotonic hypotonic hypertonic

Ringer lactate 0.45 % saline 3 % saline

Hartmann 0.2 % saline 5 %saline

Normal saline 0.9 % 25 % D/W

5% D/W 10 % D/W
• RL & NS are isotonic so useful in replacement of GI losses & extracellular deficits.
• Hypertonic saline is used for correction of severe sodium deficits, as treatment modality
in patients with closed head injuries.
• 5% dextrose supplies 200kcal/L to the body & along with 0.45% NaCl, it prevents lysis
of RBCs thus maintaining osmolality.
• Colloids are used as volume expanders.
DISTRIBUTION OF DEXTROSE WATER 5%
DISTRIBUTION OF NORMAL SALINE
 DISTRIBUTION OF RINGER LACTATE
• 1 litre of Hartmanns, 900ml will distribute to the extracellular compartment and 100ml into the intracellular
compartment. Following the 25:75 ratio of intravascular to extravascular spaces, this means about 225ml of
Hartmanns will remain to expand the circulating volume
DISTRIBUTION OF COLLOIDS
 PRINCIPLES OF FLUID THERAPY

MAINTENANCE FLUIDS
• water
• Electrolytes
• Sodium
• Potassium
• Calcium
• Magnesium
REPLACEMENT THERAPY
WHY MAINTENANCE FLUIDS ??

INTAKE = OUTPUT = FLUID BALANCE

SENSIBLE LOSSES
URINATION = 1500 ML
DEFECATION 60-150 ML
WOUND DRAINAGE

INSENSIBLE LOSSES
EVAPORATION FROM SKIN = 600-1000 ML
RESPIRATORY LOSS FROM LUNGS = 400 ML
FLUID THERAPY

Three components are seen when infusing fluid into the body:
I. Resuscitation:
• Needed when there is blood loss, plasma loss due to burns & pancreatitis or GI losses.
• Initially 500ml of NS is given, followed by response to initial fluid.
• Blood transfusion in case of >30% blood loss.
• Avoid NS as it may cause hyperchloremic metabolic acidosis.
II. Maintainence therapy:
• Required in a healthy person to meet the needs in case they were not NPO.
• Water: 35-40ml/kg/day
• Sodium: 1-2 mmol/kg/day
• Potassium: 0.5-1mmol//kg/day
• Calcium: 5mmol/day
• Magnesium: 1mmol/day
• Nitrogen: 0.1-0.15g/kg/day
FLUID CALCULATION

Fluid calculation for fluid replacement 24 hourly

• For first 10kg: Give 100ml/kg/day
• For next 10kg: Give additional 50ml/kg/day
• For weight>20kg: Give additional 20ml/kg/day
• For example, a 60-kg female would receive a total of 2300 mL of fluid daily: 1000 mL
for the first 10 kg of body weight (10 kg × 100 mL/kg per day), 500 mL for the next 20
kg (10 kg × 50 mL/kg per day), and 800 mL for the last 40 kg (40 kg × 20 mL/kg per
day).
MAINTENANCE FLUID

• 40kg 1900ml
• 45kg 2000ml
• 50kg 2100ml
• 55kg 2200ml
• 60kg 2300ml
• 65kg 2400ml
• 70kg 2500ml
4/2/1 RULE

• (4ml/kg/hr for the first 10kg,

• 2ml/kg/hr for the second 10kg,

• 1ml/kg/hr after that , with a maximum of 100ml/hr maintenance)

III. Replacement therapy
• Equal to maintainence fluid plus ongoing losses through NG, drains, fistula, vomiting or
diarrohea.
• A better understanding of fluid composition is needed.
• For example, For every 1 litre of pancreatic fluid or biliary fluid, it should be replaced
with 1 litre of RL along with 50mmol of sodium bicarbonate.
WHICH FLUIDS ???

• For burns
• For gastric outlet obstruction
• For traumatic blood loss
• for sweating
• For diarrhea
• For Pancreatic losses
• For diabetics
• For Post operative
• for intestinal obstruction
FOR BURNS

• Hartmann's (or Lactated Ringer's) solution is the preferred first-line fluid recommended
by the British Burns Association. Its composition and osmolality closely resemble
normal bodily physiological fluids and it also contains lactate which may buffer
metabolic acidosis in the early post- burn phase.
FOR GASTRIC OUTLET OBSTRUCTION

• Normal saline with addition of potassium

• Hypochloremia
• Hyponatremia
• Hyokalemia
Metabolic alkalosis ( paradoxical acidifiaction of urine > na+ -H+ channelsa)aa
PANCREATIC FISTULA

loss of bicarbonates > decrease in PH > metabolic acidosis

best solution =
Ringer lactate + bicarbonates
FOR TRAUMATIC BLOOD LOSS

• Colloid
• Blood
• Crystalloids