DR BISHWANATH

Understanding physiology controlling fluids and electrolytes. Appreciate difference in surgical patients. Be able to order fluid regimen for a surgical patient.

The osmolalities (reflecting the osmotic pressure) of the ICF and the ECF are similar, although the main cation in the ECF is sodium, whereas in the ICF it is potassium. Fluid distribution between the ECF and the ICF is governed only by changes in the osmotic pressure. Isotonic fluid (which has the same osmolality as plasma) administered into the plasma will not enter the ICF, since there is no difference in the osmolality. In ECF, fluid distribution between the plasma and the ISF is only governed by Starlings forces, i.e. hydrostatic pressure (pushing fluid out of the blood vessels) versus oncotic pressures (sucking fluid back in). Fluid administered into the plasma would increase the hydrostatic pressure and dilute the oncotic pressure until the fluid was evenly distributed throughout the ECF

Infants have low body fat and 73% or more

water

Total water content declines throughout life Healthy males are about 60% water; healthy females are around 50%

 2/3

(65%) of TBW is intracellular (ICF) 1/3 extracellular water

25 % interstitial fluid (ISF) 5- 8 % in plasma (IVF intravascular fluid) 1- 2 % in transcellular fluids CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)
7

Average daily losses in mls urine 700-1600 intestinal 0-260 sweat 0-150 Insensible lungs/skin 500-900 Fever increases insensible loss by 200cc/day for each degree (C) or 10% rise in insensible loss per degree rise in temperature.

Urine Insensible losses Faeces Total

Na+ mmol 100 100

K+ mmol 60 10 70

Surgical patients are prone to disruption nil orally anesthesia trauma sepsis

Surgical patients have Maintenance volume requirements On going losses Volume excess/deficits Maintenance electrolyte requirements Electrolyte excess/deficits

This includes: insensible urinary stool losse Body weight Fluid required 0-10Kg 100ml/kg/d next 10-20kg 50 ml/kg/d Subsequent 20 Kg 20ml/kg/d 15ml/Kg/d for elderly Remember formula 100 , 50, 20

Remember formula 4,2,1 4 x first 10 kg 2 x second 10 kg 1 x each subsequent kg So a 60 kg man will have 4 x10 =40 2 x 10 =20 1 x 40 =40 100ml/hr

So a 60 kg man will have 4 x10 =40 2 x 10 =20 1 x 40 =40 100ml/hr

10 x 100 = 1000 10 x 50 = 500 50 x 20 = 1000 2500 mls / d

4 x 10 =40 2 x 10 =20 1 x 50 = 50 110 ml/hr

fistulae drains NG third space losses Concentration is similar to plasma Replace with isotonic fluids

Acute vital signs changes Blood pressure Heart rate CVP tissue changes not obvious urine output low

Decreased skin turgor Sunken eyes Oliguria Orthostatic hypotension High BUN/creatinine ratio HCT increases 6-8 points per litre deficit Plasma Na may be normal

NPO deficit = number of hours NPO x maintenance fluid requirement (ml/hr) Bowel prep may result in up to 1 L fluid loss. Superficial surgical trauma: 1-2 ml/kg/hr Minimal Surgical Trauma: 3-4 ml/kg/hr head and neck, hernia, knee surgery Moderate Surgical Trauma: 5-6 ml/kg/hr hysterectomy, chest surgery Severe surgical trauma: 8-10 ml/kg/hr (or more) - nehprectomy

Goal normal haemodynamic parameters normal electrolyte concentration Method replace normal maintenance requirements Ongoing losses deficits

Normal maintenance requirements use BW formula On going losses measure all losses in I/O chart Deficits estimate using vital signs operative & third space losses estimate using HCT

The best estimate of the volume required is the patients response

vital signs Urine output (0.5mls/Kg/hr ) Central venous pressure

Usually correct over 24 hours For ill patients calculate over shorter period and reassess e.g. 12 hours or 3 hours for critically ill cases. Deficits - correct half the amount over the period and reassess

62 y/o male, 80 kg, for Hemicolectomy NPO after 2200, surgery at 0800, received bowel prep 3 hr. procedure, 500 cc blood loss What are his estimated fluid requirements?

Fluid deficit: 120 ml/hr x 10 hrs = 1200 ml + 1000 ml for bowel prep = 2200 ml total deficit: (Replace 1/2 first hr, 1/4 2nd hr, 1/4 3rd hour). Maintenance: 120 ml/hr x 3hrs = 360mls Third Space Losses: 6 ml/kg/hr x 3 hrs =1440 mls Blood Loss: 500ml x 3 = 1500ml Total = 2200+360+1440+1500=5500mls

The metabolic response to the stresses of surgery involves a rise in various hormones, including circulating catecholamines, ADH , cortisol and aldosterone. The overall result of these is the renal conservation of salt and water, with somewhat increased losses of potassium and hydrogen ions. These effects usually last for about 2448 h. Despite the high potassium losses in the urine, the serum potassium is usually maintained or may even transiently rise, through release of cellular contents by damaged tissues.

Therefore, unless serum potassium levels are very low, it is probably best to avoid potassium supplements in the first day or two postoperatively. since water is being retained it is usual to reduce the fluid replacements to about 2 l in the first postoperative day, especially in patients prone to heart failure
Urine output is the best indicator, aiming for greater than 50 ml/h. The minimum urine output is about 30 ml/h (60 kg adult) or 0.5 ml/kg/hrs

A patient who has undergone abdominal surgery is likely to have a transient ileus postoperatively, due to mechanical handling of the bowel or due to an electrolyte disturbance or even the effects of anaesthesia. When an ileus is present, the fluid secreted into the bowel simply lies there, and is not reabsorbed completely. These third space losses mean that the patient effectively has a reduced volume of the ECF, and hence is fluid depleted. In such patients, extra fluid needs to be given to allow for the third space losses. Unfortunately, we donot know how much extra fluid is needed and so must rely on urine output as an indicator.

There will be sudden diuresis on day 2 or 3 postoperatively, explained by recovery of the ileus and reabsorption of the fluids from the bowel. Similarly, in pancreatitis, patients can lose several litres of fluids rich in electrolytes and plasma proteins into the peritoneal cavity. Really, the only way to effectively gauge these losses is by vigorous replacement to maintain their urine output and correcting any electrolyte disturbances according to daily U & Es. If after 2 days 10 l have been put in with only. 3 l of urine produced, then assuming 12 l of insensible losses, this equates to about 5 or 6 l of fluid sequestered into the peritoneal cavity.

Check i/v regime ordered in op form Assess for deficits by checking I/O chart and vital signs Maintenance requirements calculated Usually K not started Monitor carefully vital signs and urine output

Three main types of IVF: Isotonic fluids Hypotonic fluids Hypertonic Fluids

Osmolarity is similar to that of serum. These fluids remain intravascularly mommentarily, thus expanding the volume. Helpful with patients who are hypotensive or hypovolemic. Risk of fluid overloading exists. Therefore, be careful in patients with left ventricular dysfunction, history of CHF or hypertension. Avoid volume hyperexpansion in patients with intracranial pathology or space occupying lesions.

Less osmolarity than serum (meaning: in general less sodium ion concentration than serum) These fluids DILUTE serum thus decreasing osmolarity. Water moves from the vascular compartment into the interstitial fluid compartment interstitial fluid becomes diluted osmolarity descreases water is drawn into adjacent cells. These are helpful when cells are dehydrated from conditions or treatments such as dialysis or diuretics or patients with DKA (high serum glucose causes fluid to move out of the cells into the vascular and interstitial compartments). Caution with use because sudden fluid shifts from the intravascular space to cells can cause cardiovascular collapse and increased ICP in certain patients.

These have a higher osmolarity than serum. These fluids pull fluid and sometimes electrolytes from the intracellular/interstitial compartments into the intravascular compartments. Useful for stabilizing blood pressure, increasing urine output, correcting hypotonic hyponatremia and decreasing edema. These can be dangerous in the setting of cell dehydration.

Crystalloids Colloids

Clear solutions fluids- made up of water & electrolyte solutions; small molecules. These fluids are good for volume expansion. However, both water & electrolytes will cross a semi-permeable membrane into the interstitial space and achieve equilibrium in 2-3 hours. Remember: 3mL of isotonic crystalloid solution are needed to replace 1mL of patient blood. This is because approximately 2/3rds of the solution will leave the vascular space in approx. 1 hour. In the management of hemorrhage, initial replacement should not exceed 3L before you start using whole blood because of risk of edema, especially pulmonary edema.

Some of the advantages of crystalloids are that they are inexpensive, easy to store with long shelf life, readily available with a very low incidence of adverse reactions, and there are a variety of formulations that are available that are effective for use as replacement fluids or maintenance fluids. A major disadvantage is that it takes approximately 2-3 x volume of a crystalloid to cause the same intravascular expansion as a single volume of colloid.

Colloids are macormolecular substance do not readily cross semi-permeable membranes or form sediments. Because of their high osmolarities, these are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries. These work well in reducing edema because they draw fluid from the interstitial and intracellular compartments into the vascular compartments. Initially these fluids stay almost entirely in the intravascular space for a prolonged period of time compared to crystalloids. These will leak out of the intravascular space when the capillary permeability is deranged or leaky.

The general problems with colloid solutions are: Much higher cost than crystalloid solutions Small but significant incidence of adverse reactions Because of gelatinous properties, these can cause platelet dysfunction and interfere with fibrinolysis and coagulation factors thus possibly causing coagulopathy in large volumes. These fluids can cause dramatic fluid shifts which can be dangerous if they are not administered in a controlled setting.

0.9% Normal Saline Basically Salt and Water Principal fluid used for IV resuscitation and replacement of salt loss . Contains: Na+ 154 mmol/l, K+ - Nil, Cl- - 154 mmol/l; But K+ is often added Isoosmolar compared to normal plasma Distribution: Stays almost entirely in the Extracellular space Of one liter approx 750ml stays Extracellular fluid; 250ml moves Intravascular fluid So for 100ml blood loss need to give 300-400ml NS[only -1/3 remains intravascular

5% Dextrose (often written D5W) Sugar and Water Primarily used to maintain water balance in patients who are not able to take anything by mouth; Commonly used post-operatively in conjuction with salt retaining fluids ie saline. Often prescribed as 2L D5W: 1L N.Saline [Physiological replacement of water and Na+ losses] Provides some calories [ approximately 10% of daily requirements] Regarded as electrolyte free contains NO Sodium, Potassium, Chloride or Calcium

Distribution: <10% Intravascular; > 66% intracellular When infused, is rapidly redistributed into the intracellular space; Less than 10% stays in the intravascular space therefore it is of limited use in fluid resuscitation. For every 100ml blood loss need 1000ml dextrose replacement [10% retained in intravascular space Common cause of iatrogenic hyponatraemia in surgical patient

Dextrose saline Think of it as a bit of salt and sugar Similar indications to 5% dextrose; Provides Na+ 30mmol/l and Cl- 30mmol/l Ie a sprinkling of salt and sugar! Primarily used to replace water losses postoperatively Limited indications outside of post-operative replacement Neither really saline or dextrose; Advantage doesnt commonly cause water or salt overload

What is your goal for therapy? Maintenance Rehydration Volume resuscitation Any baseline electrolyte abnormalities? ALWAYS look at basic chemistry prior to ordering fluids. Where is the fluid going to go?

How much volume expansion per liter of fluid. Concepts: Free water is distributed evenly throughout the TBW compartment Essentially 100% of sodium if confined to the extracellular space Normal saline contains essentially no free water.

2/3 to intracellular space = 660cc 1/3 to extracellular space = 330cc 2/3 to interstitial space = 220cc 1/3 to intravascular space = 110cc 110/1000 = 11 %

Essentially all confined to extracellular compartment 2/3 to interstitial space = 660 cc 1/3 to intravascular space = 340 cc Approximately 33 %

Na 1 - 2 mEq/Kg/d K 0.5 - 1 mEq/Kg/d Usually no K given until after urine output is adequate. Always give K with care, in an infusion slowly - never bolus Ca, PO4, Mg not required for short term

Hartmanns solution

Normal saline

Dextrose saline

Sodium (mmole/l) chloride potassium bicarbonate calcium

131

150

30

111 5 29 2

150 nil nil nil

30 nil nil nil

Whenever possible the enteral route should be used for fluids. These guidelines only apply to children who cannot receive enteral fluids. These guidelines apply to children beyond the newborn period. incorrectly prescribed or administered fluids are potentially very dangerous.

The recommended fluid to be infused as maintenance for well children with normal hydration is: 0.45% NaCl with 2.5% dextros. Do not use this solution: If the serum sodium is low For volume resuscitation For replacement of fluid deficit in dehydrated children For initial treatment of children with acute neurological conditions (e.g. meningitis)

How much fluid? Firstly administer an Initial bolus of fluid to correct hypovolaemia if so, (10-20 ml/kg)0.9%Nacl. Do not use this amount in any subsequent calculations. Then Maintenance plus Deficit plus Ongoing losses

All children on IV fluids should be weighed prior to the commencement of therapy, 6 - 8 hours after the infusion is commenced, and then at least daily. All children on IV fluids should have serum electrolytes and glucose checked before commencing the infusion (typically when the IV is placed) and again within 24 hours if IV therapy is to continue. For sick children, check the electrolytes and glucose 4-6 hours after commencing, and then according to results and the clinical situation but at least daily.

Normal Plasma K+ level 3.5 - 5mmol/L Normal plasma Na+ level 135-145mmol/L

Low levels of potassium in post-operative patients are common but hypokalaemia is rarely so severe as to produce muscle weakness, ileus or arrhythmias. Patients with large and continuous fluid loss from the gastrointestinal tract are prone to develop hypokalaemia. If potassium supplements are required they may be given either orally or intravenously. If by the latter route, the rate of infusion should not exceed 10mmol/h. Faster rates may precipitate arrhythmias and should only be undertaken on a unit where the patient can be monitored for any ECG changes

Decrease 1 meq/L means deficient 200~400 meq K Check the Osmolarity and Acid-base status, especially DKA and acidosis will mask the K deficient condition Dont use sugar content IVF Cl Every bottle< 20 meq KCl, except femoral line is available

Estimate the deficit

For every 100 mEq below normal, serum K+ usually drops by 0.3 mEq/L
Highly variable from patient to patient, however!!

In nearly all situations, ORAL replacement is PREFERRED over IV replacement

Oral is quicker Oral has less side effects (IV burns!) Oral is less dangerous

Choose route to replace K+

Choose IV therapy ONLY in patients who are npo or who have severe depletion low serum magnesium often accompanies hypokalaemia and needs to be corrected to enable recovery of serum potassiumn)

IV therapy Adjunct to maintenance fluids (10-20 meq/l) IV rider/piggyback

Generally 40-60 mEq KCl is PREFERRED AGENT again Avoid dextrose solution (trigger insulin, shift K+)

Choose K+ prep

Choose dose/timing
Mild/moderate hypokalemia
3.0 to 3.5 mEq/L 60-80 mEq PO (or IV) QDay divided doses Sometimes will require up to 160 mEq per day (refeeders, lots of diarrhea, IV diuretics) Avoid too much PO at once
GI upset or just poor response

Usually divide as BID or TID dosing

Choose dose/timing
Severe hypokalemia (< 3.0 mEq/L)
Can use combination of IV and PO, again with PO preferred if at all possible Avoid more than 60-80 mEq PO in a single dose Avoid IV infusion rates faster than 20 mEq/hourcan cause arrhythmia!!!
Most protocols wont allow more than 10 mEq/hour rates on the floors (ICUs too?)

S.K
(mEq/L)

3.5

<2

TOTAL K deficit
(mEq/L,70 kg)

125 -250 150-400 300-600 500 -750

Give in a normal saline infusion, as dextrose may exacerbate the hypoglycaemia by provoking insulin production. The rate via a peripheral line should not exceed 10 mmol/hour to avoid discomfort and phlebitis. Careful monitoring is required both of clinical condition and bloods (1-3 hourly). Once ECG abnormalities, muscle weakness or paralysis are resolving, slow the rate of replacement or switch to oral replacement.

Monitor IV K ECG & S.K levels Never give IV push Never add KCl to Iso M
DONT GIVE MORE THAN 10-20mEq/hr 40 mEq/L 240 mEq/L/day

REMEMBER THAT HYPOKALEMIA IS SAFER THAN HYPERKALEMIA

AVOID OVERENTHUSIASM in Rx

Clinical feature
Asymptomatic Generalised fatigue Paralysis Palpitations

Mild Hyperkalemia(5.5-6.5mmol/L)-Tall peaked T waves with narrow base Moderate hyperkalemia(6.5-8 mmol/L)-Peaked T waves Prolonged PR interval Decreased amplitude of P waves Widening of QRS complex Severe HyperkalemiaAbsence of P waves Intraventricular blocks,BBB, Progressive widening of QRS complex Sine wave pattern ventricular fibrillation,asystole

The severity of Hyperkalemia is determined by Symptoms Plasma K+ concentration Electrocardiographic abnormalities

Continuous cardiac monitoring and serial electrocardiograms are warranted in patients with hyperkalemia on rapidly acting therapies. The serum potassium should be measured at one to two hours after the initiation of therapy.

Identify and treat cause 10 20 mL intravenous 10% calcium chloride over 10 min in patients with ECG abnormalities (reduced risk of ventricular fibrillation) 50 mL 50%dextrose plus 10 units short acting insulin over 2-3min Monitor plasma glucose and K+ over next30-60 min) Regular Salbutomol nebulizers Consider oral or rectal calcium Resonium (ion exchange resin),although this is more effective for non-acute hyperkalaemia. Haemodialysis for persistent hyperkalemia

Defined as sodium concentration < 135 mEq/L Generally considered a disorder of water as opposed to disorder of salt Results from increased water retention Normal physiologic measures allow a person to excrete up to 10 liters of water per day which protects against hyponatremia Thus, in most cases, some impairment of renal excretion of water is present

Hyponatremia can be asymptomatic and found by routine lab testing It may present with mild symptoms such as nausea and malaise (earliest) or headache and lethargy Or it may present with more severe symptoms such as seizures, coma or respiratory arrest

If severe symptoms are present, hypertonic saline needs to be administered to prevent further decline If severe symptoms are not present, can start by initiating fluid restriction and determining cause of hyponatremia Oral fluid restriction is good first step as it will prevent further drop in sodium NOTE: This does not mean that you cant give isotonic fluids to someone who is truly volume depleted

Patients with serum sodium above 120 are generally asymptomatic Symptoms tend to occur at serum sodium levels lower than 120 or when a rapid decline in sodium levels occur Patients can have mild symptoms at sodium concentrations of 110-115 mEq/L when this level is reached gradually

As stated earlier, symptoms dictate treatment If severe symptoms are present, starting bolus of 100 ml of 3% hypertonic saline which generally raise serum sodium level by 2-3 mEq/L Goals for correction:
1.5 to 2 mEq/L per hour for first 3-4 hours until symptoms resolve Increase by no more than 10 mEq/L in first 24 hrs Increase by no more than 18 mEq/L in first 48 hrs

Oral fluid restriction is the first step

No more than 1500 mL per day NOTE: This only pertains to oral fluid, isotonic IV

fluids do not count towards fluid intake

If volume depletion is present, isotonic (0.9%) saline can be given intravenously Careful monitoring should be used whether symptoms are present or not
Serum sodium levels should be drawn every 4-6 hours or more frequently if hypertonic saline is used

Sodium deficit = Total body water x (desired Na actual Na)

Total body water is estimated as lean body weight x 0.5 for women or 0.6 for men

60 kg woman with sodium level of 116 How much sodium will bring him up to 124 in the next 24 hours? Sodium needed = 0.5 x 60 x (124-116) = 240 Hypertonic saline contains 500 mEq/L of sodium Normal saline contains 150 mEq/L of sodium

The patient needs 240 mEq in next 24 hours That averages to 10 mEq per hour or 20 mL of hypertonic saline per hour However, this will only raise the serum sodium by 0.33 per hour therefore, increasing the rate 60 mL to 90 mL will produce the desired rate of serum sodium increase of 1.0 to 1.5 mEq per hour until symptoms resolve

The dreaded complication of increasing sodium too fast is Central Pontine Myelinolysis which is a form of osmotic demyelination Symptoms generally occur 2-6 days after elevation of sodium and usually either irreversible or only partially reversible Symptoms include: dysarthria, dysphagia, paraparesis, quadriparesis, lethargy, coma or even seizures

Rate of correction over 24 hours more important than rate of correction in any one particular hour More common if sodium increases by more than 20 mEq/L in 24 hours Very uncommon if sodium increases by 12 mEq/L or less in 24 hours CT but preferably MRI to diagnose demyelination if suspected, though imaging studies may not be positive for up to 4 weeks after initial correction

CPM is associated with poor prognosis Prevention is key

Small studies have shown that plasmapharesis done immediately after diagnosis may improve clinical outcomes

Produced by either administration of hypertonic fluids or much more frequently, loss of thirst Because of extremely efficient regulatory mechanisms such as ADH and thirst, hypernatremia generally occurs only in people with prolonged lack of thirst mechanism Patients with loss of ADH (Diabetes Insipidus) usually can compensate with increased fluid intake

Same labs as workup for hyponatremia: Serum osmolality, urine osmolality and urine sodium Urine sodium should be lower than 25 mEq/L if and water and volume loss are cause. It can be greater than 100 mEq/L when hypertonic solutions are infused or ingested If urine osmolality is lower than serum osmolality then DI is present
Administration of DDAVP will differentiate
Urine osmolality will increase in central DI, no response in nephrogenic DI

First, calculate water deficit Water deficit = CBW x ((plasma Na/desired Na level)-1) CBW = current body water assumed to be 50% of body weight in men and 40% in women So lets do a sample calculation:
60 kg woman with 168 mEq/L How much water will it take to reduce her sodium to 140 mEq/L

Water deficit = 0.4 x 60 ([168/140]-1) = 4.8 L But how fast should I correct it? Same as hyponatremia, sodium should not be lowered by more than 12 mEq/L in 24 hours So what does that mean for our patient?
Overcorrection can lead to cerebral edema which can lead to encephalopathy, seizures or death

The 4.8 L which will lower the sodium level by 28 should be given over 56-60 hours, or at a rate of 75-80 mL/hr Typical fluids given in form of D5 water

Loss of thirst usually has to occur to produce hypernatremia Rate of correction same as hyponatremia D5 water infusion is typically used to lower sodium level Same diagnostic labs used: Serum osmolality, Urine osmolality and Urine sodium Beware of overcorrection as cerebral edema may develop

Patients who are malnourished are prone to many complications, such as delayed wound healing, muscle weakness and an increased tendency to infection. There is evidence that patients with poor nourishment prior to surgery will benefit from preoperative supplementation and do better after their operation. There are a lot of reasons why hospital patients become malnourished. They may have a decreased appetite due to the illness itself. They may have increased nutritional demands or their digestion may be impaired. Another reason could be due to the hospital stay itself, i.e. dislike of hospital food, being rushed off for an X-ray or ultrasound at noon, or being nil by mouth.

If oral intake is not anticipated within 710 days of surgery, then nutritional support is indicated (perhaps 5 days in a previously malnourished patient). The main indication for preoperative nutritional support is severe malnourishment (greater than 10% weight loss). Nutritional support can vary from mere supplementation of vitamins,or protein in a high-protein diet, to a complete replacement of all essential foodstuffs.

Enteral diets are those given via the gut, including oral intake. The ideal situation is one where the patient takes in all the required nutrition orally. If this is not possible, then enteral feeding is the

next option.

This involves passing the food into the gut, allowing it to be absorbed normally, either through a nasogastric tube or, if required for longer periods, via a gastrostomy or jejenostomy. The commonest indication for enteral feeding is where there is a problem with swallowing, caused by a stroke or oesophageal obstruction

Parenteral nutrition bypasses the gut and involves a specialised feed directly into the patients bloodstream.

Parenteral nutrition may be used as a supplement to enteral feeding when it is usually given through a cannula in a peripheral vein. Alternatively, total parenteral nutrition (TPN) can be used to deliver the complete nutritional requirements. As TPN has a high osmolality it is toxic to veins and is usually given via a central line. Unfortunately, parenteral feeding has some complications, including an increased risk of infection, due to CVP line

Another complications are villous atrophy in the gut. This makes the gut wall more permeable to bacterial flora and increases the risk of translocation of bacteria into the bloodstream. Electrolyte imbalances are likely and, therefore, the urea and electrolytes should be checked daily and adjusted accordingly. Hyperglycaemia is another problem and the patient may need to be given insulin temporarily while on TPN. Other disturbances of liver function are common (possibly because of fatty infiltration of the liver) and a cholestatic picture may be seen with raised alkaline phosphatase,and hence LFTs should be measured every few days.