Fluid therapy

and
Surgical nutrition
Supervisor:
- Dr. Kamal abdul-hussein
Presented By:
- Zainab Mustafa
- Aveen Adil
- Basma Falah
- Rand Salim
 Learning objects
1.To describe fluid, electrolytes and acid base disturbances.
2. To be able to calculate fluid and electrolytes maintenance
requirements.
3. To be able to calculate fluid and electrolytes deficit requirements.
4. To be able to supplement postoperative parenteral fluid therapy; its
routes and types, restrictions and complications.
5.To describe different types of acid base disturbances.
 Introduction
• Body is formed of:
- Solids;
- Fluids.
• Water forms most of the fluid part
• The fluid forms more than 2/3 of the whole body.
Body fluid is distributed between
two major compartments:
– Intracellular compartment = 2/3;
this is the fluid contained within cells,
and bound by cell membranes.
– Extracellular compartment = 1/3;
this is the fluid that bathes cells, and is
outside of the cell membrane.
The extracellular fluid is further
subdivided:
– Eighty percent is in the interstitial
fluid, which is the fluid that "bathes"
the non-blood cells of the body.
– The remaining twenty percent is in
the plasma, which is the fluid that
suspends the blood cells; it is bound by
capillary walls.
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
- patients with a tracheostomy (here the humidification of inspired air is very important).
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.
Chemical composition of body fluid compartments
daily requirements of some electrolytes in adults:
• sodium: 50–90 mM/day;
• potassium: 50 mM/day;
• calcium: 5 mM/day;
• magnesium: 1 mM/day.
- Estimation of losses already incurred and their
nature: for example, vomiting, ileus, diarrhea,
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.
 Basic terminology
Osmolarity
is the number of particles of solute per liter of the solution, its units of measurement are
mosmol/Liter or mmol/Liter.
Osmosis
Osmosis is the transport of a solvent through a semipermeable membrane that separates
two solutions of different solute concentration from the solution that is lower in solute
concentration to the solution that is higher in solute concentration.
So:
1. Hypertonic
used to refer to the solution with higher concentration or more solute.
2. Hypotonic
used to refer to the solution with lower concentration or less solute.
3. Isotonic
 Types of fluids :-
-Crystalloid
-Colloid
Crystalloids
- IV solutions of low molecular weight ions with or without glucose or
only contains glucose.
- Could be:
• Isotonic
• Hypertonic
• Hypotonic
Advantages:
- Enter all body compartments.
- Non-allergic.
- Inexpensive.
- Easy to store for long time.
- No coagulation impairment.
- No transmission of infection.
Disadvantages:
- Short-lived hemodynamic effect (half-life 30-60 min).
- Peripheral and pulmonary edema (excessive use).
- 3 times the volume needed for replacement (1 ml loss needs 3
ml crystalloid to replace it).
Important crystalloid indications:
1. Dehydration of any cause.
2. Hypoglycemia.
3. Hypochloremia and hyponatremia.
4. Interoperative/postoperative maintenance fluid.
 Colloids
- High molecular weight.
- Could be:
• Natural: Albumin.
• Artificial: gelatin, dextran and HES.
Advantages:
1. Less volume needed for replacement (1 ml loss needs 1 ml
colloid to replace it)
2. Less edema
3. Long time effect (half life several hours to days)
Disadvantages:
4. Allergic reaction (anaphylactoid reaction)
5. Expensive
6. Difficult to store for long time
7. Renal toxicity
8. Coagulopathy (gelatinous probertites → platelet dysfunction and
interfere with fibrinolysis and and coagulation factor VIII).
Important indications of colloids:
1. Fluid resuscitation prior to arrival of blood.
2. Severe hypoalbuminemia.
3. Burns.
 General principles of fluid therapy

1. All the fluids that are given parenteral should be isotonic .

2. All fluids should be pyrogen free (does not cause fever on parenteral
administration).

3. All fluids should be sterile ( contains no microorganisms including bacteria,

spores, fungi, monilia & viruses)

4. All fluids should be clear (not cloudy).

5. The Fluid container (bottle) should not show any sign of leakage.
what happen (During exposure to injury):-
The patients will pass into an obligatory catabolic phase of physiological
response to injury( trauma ) this will lead to increase in the secretion of
cortisol from adrenal cortex .
The cortisol will results in :
Sodium & water retention.
Potassium excretion .
Break down of intracellular proteins into amino acids which is converted by
the liver into glucose by the process of gluconeogenesis.
It had been found that the break down of proteins could be reduced by
addition of glucose from external source this is called protein sparing action of
glucose.
It had been found also that the 50% reduction in the protein breakdown could
be achieved by giving 100 gm of glucose to 70 kg body weight patient.
In the day of trauma ( within the first 24
hours after trauma or day 0 )
-There is sodium retention due to the effect of cortisol.
-The serum potassium level will be either normal or increased due
to catabolism & cell injury which lead to liberation of intracellular
potassium to the plasma.
-The fluid formula in this day :
-No sodium supplement is needed.
-No potassium supplement is needed.
-Need glucose 100gm ( protein sparer).
-Need the daily requirement of fluid (urinary loss+ insensible loss).
-If there is any other loses it should be replaced accordingly.
 In day 1 (First post trauma day)

 The level of cortisol will usually decrease as the effects of trauma will subside so
the patient will loose sodium in urine in a mean value of 90 meq /day(obligatory
sodium loss in urine).
 The formula of fluid in this day will be:
1. Daily requirement of sodium is given = obligatory loss of sodium in urine ( 90
meq / day)
2. Daily requirement of fluid –urine volume + insensible loss)
3. No potassium is needed.
4. 100 gm of glucose ( protein sparer).
5. If there is any other loses it should be replaced accordingly.
In the Second post trauma day (Day 2)

• The fluid formula is the same as in first post trauma day + potassium level should
be estimated
• ( blood sample is aspirated from the patient and send for serum potassium
estimation) + daily requirement of potassium should be given.
• The daily requirement of potassium should be given = obligatory potassium loss in
urine (20-60 meq/day)
In the third post trauma day ( Day 3)

• Serum potassium level will decline in most of the cases due to

obligatory loss of potassium in urine
• The same formula should be given as in day 2 + potassium
deficit should be added.
• Potassium deficit (meq/day) = (Normal level of potassium –
measured level of potassium) x body weight x 0.3

Formula of fluid replacement

 Classification of changes in body fluids

Volume change
Concentration change
Compositional change
Redistributional change
 Volume change

• Is the loss or gain of Isotonic salt solution (volume of fluid with its cations &
anions from one compartment).
• No shift of fluid from one compartment to the other.
• Decrease in extracellular fluid volume might be compensated by stimulation of
sympathatico-adrenal axis (increase in cardiac output + vasoconstriction of
peripheral blood vessels).
 Concentration change
• Sodium constitute 90% of the osmotically active particles in the extracellular
fluid.
• It generally reflects the tonicity of body fluid compartment.
• If the extracellular fluid is depleted of its sodium content as in hyponatremia
water will be transferred from extracellular fluid to intracellular fluid by
osmosis to equalize the effective osmotic pressure across the cell membrane &
vise versa.
Hyponatremia
Hypernatremia
 Compositional change
Is change in the rest of osmotically active particles which is present in small
concentration that its change will not affect the effective osmotic pressure.
 These elements are important for the functions of vital structures like heart
( potassium & calcium) , smooth muscle activity (potassium) , neuromuscular
transmission (Calcium).
is no shift of fluids from one compartment to the other as there is little change
in the effective osmotic pressure.
The normally functioning kidney minimize these changes particularly if it
occur gradually.
 Distributional change
There is internal loss of extracellular fluid into non functional compartment
(third space loss) e.g. sequestration of Isotonic fluid in burn ,
peritonitis ,ascetis ,trauma to the muscle.
This fluid loss could be:
Extracellular fluid as in peritonitis.
Intracellular fluid as in hemorrhagic shock,.
Both as in burn.
Acid Base Balance
Normal PH in the body is from 7.35-7.45
Acidosis: physiological state result from abormally low PH
Alkalosis : physiological state results from abnormally high PH

Acidemia : plasma PH < 7.35

Alkalaemia : plasma PH > 7.45
ACID – BASE BALANCE

•The PH is maintained within a narrow limit in spite of large load of acids which mainly produced
by metabolism .
•These acids are neutralized effectively by buffer system& subsequently excreted by lungs &
kidneys.
•These buffers could be:
1.Intracellular buffers which includes proteins, phosphates & hemoglobin in the red blood cells.
2.Extracellular buffers includes HCO3-H2CO3 mainly while proteins and hemoglobin plays a minor
role in the extracellular buffer system.
3.These buffers consist of weak acids ,weak base & their salts.
Surgical nutrition

• Malnutrition is the cellular imbalance between the supply of nutrients

and energy and the body’s demands for them to ensure growth,
maintenance and specific functions.
• Malnutrition is common
• 30% in surgical patients with GIT disease
• 60% in surgical patients with prolonged hospital stay due to post-op
complications.
Nutritional requierments
• Carbohydrates 50%
• Fat 30-40%
• Protein 20-10%
• Energy for hospitalized patients is approximately 1300-1800 kcal/day
• Vitamins
• Minerals
• Trace elements
• Fluid and electrolytes
Nutritional assessment
• There isn’t a direct way to measure protein and energy stores so we
resort to the following:
1. Anthropometry : mid arm circumference, skinfold thickness
2. Biochemical : albumin, prealbumin, transferrin, retinol binding
protein
3. Clinical : BMI, body weight change, GI symptoms, wasting …
Methods of nutrition support
1-Enteral nutrition
Delivery of nutrients into the gastrointestinal tract This
can be achieved with
oral supplements (sip feeding)
Sip feeds provide 200 kcal and 2 g protein per 200ml
carton
Given in patients who can drink but whose appetite is
impaired
variety of tube-feeding techniques (NG, ND,NJ tubes)
Surgical techniques
A variety of nutrient formulations are available for
enteral feeding
 Indications for enteral feeding
• 1) protein - energy malnutrition with inadequate oral intake
• 2) dysphagia, except for fluids
• 3) major trauma (including surgery) when return to required dietary
intake is prolonged
• 4) inflammatory bowel disease
• 5) distal, low output (<200ml) enterocutaneous fistula
• 6) To enhance adaptation after massive enterectomy.
CONTRAINDICATIONS

1. Intractable vomiting/ diarrhoea

2. Paralytic ileus
3. GI Obstruction
4. Diffuse peritonitis
5. Severe GI haemorrhage, GI malabsorption
6. Short bowel syndrome(<100cm)
7. Severe shock
8. Distal high output fistula
9. Severe pancreatitis
10. Low cardiac output
11. Multi-organ dysfunction syndrome
2-parenteral nutrition
• Defined as infusion of a nutrient
hyperosmolar solution containing
carbohydrates, proteins, fat, and other
essential nutrients through an intravenous
route delivered via an indwelling intravenous
catheter.
• Components are in elemental or “pre-
digested” form
• Protein as amino acids
• CHO as dextrose
• Fat as lipid emulsion
• Electrolytes, vitamins and minerals
Indications of Parenteral nutrition
1. Contraindications of enteral feeding
2. Enteral feeding is not possible
3. Enteral nutrition has failed

Routes of parenteral nutrition

1- central vein
2- peripheral vein
Contraindications of parenteral nutrition
• Heart failure
• Blood disorders
• Altered fat metabolism
complications
Reference :-Bailey & love textbook.

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