12/9/2007

Fluids & Electrolyte Disorders and Acid Base Disturbances

George G. Lim, MD, FPSGS, FPSCRS, FPCS
Associate Professor 3 UST Department of Surgery Faculty of Medicine & Surgery

Preoperative Fluid Assessment

Preoperative Fluid Assessment

The dehydrated patient Hypotension at the time of induction of anesthesia The over-hydrated patient Edematous tissues Anesthesia interrupts normal baroreceptor reflexes

Preoperative Fluid Assessment

Normal patient Normal vital signs Good skin turgor Moist mucous membranes Adequate urine output Stable body weight

Preoperative Fluid Assessment

Volume deficit Sequestration of extracellular fluid in injured tissues
Intestinal obstruction Peritonitis

Preoperative Fluid Assessment

Detailed history Duration and severity of losses

Gastrointestinal tract

Diarrhea Various enterocutaneous fistulas Other losses

Focused physical signs Sunken eyes, dry tongue Loss of skin turgor Low BP, rapid pulse, low urinary output

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Composition of Gastrointestinal Secretions

TYPE OF SECRETION Saliva Stomach Pancreas Bile Small Intestine Colon VOLUME (ml/24hr) 1000-1500 1000-2000 600-800 300-600 2000-3000 Na mEq/L 5-10 60-90 135-145 135-145 120-140 60 K mEq/L 20-30 10-15 5-10 5-10 5-10 30 Cl mEq/L 5-15 100-130 70-90 90-110 90-120 40 HCO3 mEq/L 25-30 95-115 30-40 30-40
-

Preoperative Fluid Assessment

Loss of 5% of the body weight Depressed skin turgor Sunken eyeballs Dry mucous membranes Decreased urine volume

Preoperative Fluid Assessment

Loss of 10% of body weight or more Markedly depressed urine volume Tachycardia Shortness of breath Labile blood pressure Loss of 5% of body weight (3.5 kg) will require about 3.5 liters to restore homeostasis

Preoperative Fluid Management

Objectives: isotonic fluid infusion Urine volume of 0.5 cc/kg/hr Stabilization of vital signs Reversal of signs of dehydration CVP line or Swan Ganz catheter Urethral Foley catheter

Intraoperative Fluid Losses

Operative site sequestration Tissue edema due to manipulation Magnitude of the surgery Evaporation of water from exposed viscera Length of procedure Blood loss

Intraoperative Fluid Management

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Intraoperative Fluid Management

Clinical approximation 0.5-1 L/hr (<2-3 L in a 4 hr OR) Weight of blood soaked gauze Measuring accurately the amount of blood suctioned out Isotonic fluid replacement Blood transfusion, if necessary

Maintenance Fluid Requirements

Normal Maintenance Requirements

Insensible losses: Lungs & skin: 600-1000 ml Sensible water losses Urine and feces: 1000-1500 ml

Normal Maintenance Requirements

General Rule: weight in kg x 30 ml 70 kg male: 2100 ml/24 hrs Sodium, potassium, chloride ~60-70 mEq/24 hrs each for a 70 kg patient

Postoperative Volume Excess

Intravenous infusion of crystalloids Isotonic fluid replacement Physiologic responses ADH mediated retention of water Aldosterone mediated retention of sodium & water Catabolic response leading to release of water

Postoperative Fluid Excess

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Postoperative Volume Excess

Manifestations of volume excess Increase in BW Increase in CVP High pulse pressure Swollen eyelids Pulmonary edema Hoarseness

Postoperative Fluid Deficit

Water

Sodium 140 mEq/L 140 mEq/L

Postoperative Volume Deficit

Isotonic fluid losses Gastrointestinal losses Other sensible losses

Postoperative Volume Deficit

Manifestations of volume depletion Weight loss Tachycardia Weak pulse Dry mucosa Hypotension Oliguria

Water

NGT output, enterostomies, etc.

Inadequate fluid replacement Inadequate intraoperative replacement

Sodium 140 mEq/L 140 mEq/L

Distribution of Solutes

Distribution of Solutes

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Sodium Abnormalities: Hyponatremia

Sodium Abnormalities: Hyponatremia

Water

Sodium 140 mEq/L 120 mEq/L 120 mEq/L 120 mEq/L

Sodium Abnormalities: Hyponatremia

Hypotonic volume excess Infusion of D5W SIADH Renal disorder Catabolism Water of oxidation

Sodium Abnormalities: Hyponatremia

Manifestations Cellular swelling
Confusion Weakness Nausea & vomiting Convulsions Coma

Water

Sodium 140 mEq/L 120 mEq/L

Sodium Abnormalities: Hyponatremia

Treatment Restrict water intake Serial monitoring of serum sodium

Sodium Abnormalities: Hyponatremia

In a 70 kg patient with a sodium level of 120 mEq/L: Na+ required = (140 - 120) TBW Na+ required = (140 - 120) (0.6 [70])
= 20 42 = 840 mEq

Na+ required (in mEq) = (desired serum sodium - actual serum sodium) TBW

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Sodium Abnormalities: Hypernatremia

Sodium Abnormalities: Hypernatremia

Water

Sodium 140 mEq/L 160 mEq/L 160 mEq/L 160 mEq/L

Sodium Abnormalities: Hypernatremia

Hypertonic volume deficit insensible loss of water Renal disease CNS trauma Hyperosmolar dehydration Solute loading (tube feeding)
120 mEq/L

Sodium Abnormalities: Hypernatremia

Manifestations Severe thirst CNS manifestations
Restlessness, irritability Spasms, stupor, coma Fever

Water

Sodium 140 mEq/L

Sodium Abnormalities: Hypernatremia

Treatment Water requirement =

Sodium Abnormalities: Hypernatremia

In a 70 kg patient with Na+ of 170 mEq/L TBW = 60% x BW = 0.60 x 70 = 42 Maximum change of sodium per day

des ired changeins erumNa x TBW des ired s erumNa

16 mEq (0.7 mEq/L/hr)

Water requirement =
des ired changeins erumNa x TBW des ired s erumNa

16 x 42 4.3 L 154

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Potassium Abnormalities
Release of K+ in immediate postoperative period Tissue catabolism Operative trauma Blood transfusion Normal neurohormonal response leads to loss of K+ in urine

Potassium Abnormalities

Potassium Abnormalities
K+ deficiency Prolonged K+ free IV fluids infusion Inappropriate replacement of daily K+ losses Unsuspected / neglected GI losses + K excess Renal dysfunction / disease

Potassium Abnormalities
Manifestations Cardiac
Bradycardia Hypotension Ventricular fibrillation / Cardiac arrest

Muscular

Weakness Paresthesia

Potassium Abnormalities
Hyperkalemia Acute MI

Potassium Abnormalities
Treatment of hypokalemia Ensure adequate renal function Replacement should not exceed 150-200 mEq/day or 10-15 mEq/hr

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Potassium Abnormalities
Treatment of hyperkalemia 50 ml D50W + insulin 10-25 units IV infusion over 30 minutes (GIK) Sodium bicarbonate 5-10 ml 10% Ca gluconate slow IV

Postoperative Acid Base Disorders: Acidosis

Postoperative Acidosis
Metabolic acidosis Primary decrease in [HCO3-] Respiratory acidosis Primary increase in pCO2

Postoperative Acidosis
Cardiovascular effects Decreased myocardial contractility Decreased responsiveness of the peripheral vasculature to circulating catecholamines Increased refractoriness of the fibrillating myocardium to defibrillation

Postoperative Acidosis
Metabolic effects O2-Hgb dissociation curve shifts to the right Decreased affinity of Hgb for O2

Postoperative Acidosis
Common postoperative causes Pulmonary insufficiency Poor tissue perfusion Impairment of renal function Diabetes mellitus Loss of alkali via gastrointestinal secretions Inadequate ventilation

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Postoperative Acidosis
Respiratory causes of postoperative acidosis Inadequate ventilation
Depression of respiratory center Impaired thoracic excursion Airway obstruction COPD Inappropriate ventilatory settings

Postoperative Acidosis
Anion Gap Change in unmeasured anions or cations

Anion gap Increases in endogenously produced acids Decreases in renal excretion of acids Ingestion of toxins

Postoperative Acidosis
Anion Gap = [Na+] ([Cl-] + [HCO3-])

Postoperative Acidosis
Treatment Correct tissue perfusion Use of IV bicarbonate Correct alveolar ventilation
Deep breathing and coughing Suction of retained secretions Humidification of air Avoidance of over-sedation

Normal value: 12 2 mEq/L

Postoperative Alkalosis
Metabolic alkalosis Primary increase in [HCO3-] Respiratory alkalosis Primary decrease in PCO2

Postoperative Acid Base Disorders: Alkalosis

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Postoperative Alkalosis
Metabolic causes Post-traumatic aldosteronism

Postoperative Alkalosis
Respiratory causes Hyperventilation secondary to apprehension or pain Inappropriate respiratory therapy

Renal inhibition of bicarbonate excretion & excessive K+ excretion Removing H+ ions along with Cl-

Nasogastric suction

Transfused blood with citrate being oxidized to bicarbonate

Postoperative Alkalosis
Manifestations Insidious onset CNS: decreased cerebral blood flow

Postoperative Alkalosis
Treatment Correction of the underlying cause
Correction of potassium depletion Volume depletion Cl- containing solutions Acid infusion NH4Cl, arginine HCl, lysine HCl, or dilute HCl acid (0.1 N).

Dizziness, nervousness, confusion, obtundation, stupor, coma Tetany & neuromuscular irritability

Muscular: decreased ionized Ca++

Postoperative Alkalosis
Treatment Correction of respiratory alkalosis

Hyperventilation Rebreathing CO2 Adjustment of tidal volume or respiratory rate

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