IV FLUIDS & ELECTROLYTES in SURGICAL PATIENTS

IV Fluids:
- 60% of Total Body weight is Water
- Out of that 60%, 40% is ICF and 20% is ECF
- ICF is rich in Potassium. About 2l of ICF Fluid is a part of
RBCs
- ECF is rich in Sodium. 11L are a part of ISF and 3L are a
part of Plasma Vol.
- RBC+Plasma = Total Intra Vascular Volume (5L).
- An increase in ECF osmolarity is sensed by osmoreceptors
in hypothalamus.
- This increases ADH release by the posterior pituitary.
- ADH increases the water permeability of late sections of
the nephron
- The resulting fall in excretion of water helps restore ECF
osmolarity.
Plasma Volume Expansion (10 minutes after 250ml IV infusion):
Fluid

Plasm
a Vol.

ISF Vol

ICF Vol

5%D

18ml

70ml

162ml

RL/NS

50ml

200ml

0ml

Colloids

250ml

0ml

0ml

Albumin
25%

1000ml

--750ml

0ml

7.5%
Saline

1750ml

--500ml

--1000ml

7.5%
Saline (at
equi)

250ml

1000ml

--1000ml

Fluid losses occur as:

-

Haemorrhage
GIT Losses
3rd space losses
Burns
Pulmonary Losses
Intraoperative Losses
Polyuria
Heat Exhaustion

Forces controlling Fluid movement in capillaries

Starlings Law of Capillary Filtration: The role of
hydrostatic and oncotic forces (starlings forces) in the
movement of fluids across the capillary membrane.
Q
Q

k A [ (PcPif) + (if p) ]

= Fluid Filtration

k = Capillary Filtration Coefficient

A = Area of Capillary Membrane
Pc = Capillary Pressure (hydrostatic pressure)
Pif = Interstitial Fluid Pressure (hydrostatic Pressure)
= Reflection Coefficient of Albumin
if = Interstitial Fluid Colloid Osmotic Pressure
p = Plasma Colloid Osmotic Pressure
Application of Starlings Equation to fluids:
- Crystalloids increase capillary pressure more leakage in
to ISF
- Interstitial edema Re-entry of fluids in to capillary space
- Colloids tend to retain capillary fluid maintenance of
plasma volume
- Hypo-proteinemia ISF draws fluid from plasma edema

CRYSTALLOIDS:
Crystallos : Clear Ice Eidos

: Appearance

Commonly Used: 5% Dextrose, Ringers Lactate, Normal

Saline, Dextrose Normal Saline
Infrequently Used: 10% Dextrose, Darrows Solution
(lactated pot. Saline), Hypertonic Saline
5% Dextrose:
Indications:
As a Life line
Replacement of Water loss
Part of Postoperative Fluid Therapy
In GIK Infusion Therapy
As a Medium to deliver Drugs
e.g. Dopamine, Deriphyllin, Insulin
Contra-indications:
Head Injuries
Diabetic Coma
Hyponatremia/Hypokalemia
Anasarca
Pulmonary Oedema
Renal Failure

FLUID

GL

Na
+

K
+

Ca+
+

Cl-

HCO3-

Osm

Cal

pH

5%Dex

5Gm

--

--

RL

--

131

05

02

111

29

274

--

6.3

154

--

--

154

--

308

--

07

585

20

07

NS

DNS

-5Gm

154

--

--

--

--

154

--

--

278

20

Properties of Crystalloids:
Ringer lactate:
Indications:
-

Hemorrhagic Shock
Hypovolemia due to GIT Losses
Hypotension
Burns
Postoperative Fluid Therapy
As a Preloading Fluid
As a Hemodiluent in Acute Normovolemic Haemodilution

Contra-indications:
-

Hepatic Failure
Metabolic Acidosis
Hypertension
Hyperkalemia
Head Injuries

Normal Saline:
Indications:
GIT Losses
Head Injuries
Post operative fluid Therapy

07

Maintenance Fluid in NIDDM

Hyponatremia
Water Intoxication
Gastric/Peritoneal Lavage
Contra-indications:
Hypernatremia, Hypertension
Renal failure, Anasarca
Advantages of Crystalloids:
-

Less Expensive
Easy Availability
Greater Urinary Flow
Replace Sequestrated Fluids
Low Incidence of Allergic Reactions
Can Be Given Rapidly
No Interference with Grouping & Cross matching
No Coagulopathy

Disadvantages of Crystalloids:
-

Fluid Reactions
Water Intoxication
Dyselectrolytemia
Pulmonary Oedema
Re-entry from 3rd Space
Increased Cardiac Workload
Dilutional Anaemia Coagulopathy

Colloids:
Kolia : Glue Eidos: Appearance
Commonly Used Colloids: Hemaccel, Hes- steril 3%,6%,10%,
Blood, Mannitol
Infrequently Used Colloids: Plasma, Albumin 5%,25%, Expan,
Lomodex 40,60
Haemaccel:
Indications:

Hemorrhagic Shock
Post-spinal Hypotension
Anaphylactic Shock
Hemodiluent in ANH
Surgical Patients with MS/AS
Contra-indications:
Patients with Atopy
Bronchial Asthma
Septicemia
Pulmonary oedema/ARDS
Hypertension
Patients with unknown Blood Gp
Bleeding Diathesis
Hydroxy Ethyl Starches:
o

Another form of hypertonic synthetic colloids used for

volume expansion

o Contain sodium and chloride and used for hemodynamic

volume replacement following major surgery and to treat
major burns
o

Less expensive than albumin and their effects can last 24

to 36 hours

o Less Incidences of immune reactions compared to

Hemaccel.
Advantages of Colloids:
-

Smaller Infused Volumes

Prolonged Increase in PV
Minimal Oedema (Peripheral/Cerebral)
Higher DO2 (Systemic Oxygen Delivery)
Useful in Preloading before Sub Arachnoid Block

- Useful in Hemodilution
- Fewer Dyselectrolytemias
Disadvantages of Colloids:
-

Greater Expense
Coagulopathy (Dextran>HES)
Interferes in Grouping & Cross matching
Pulmonary Oedema (Septicemia & ARDS)
Decreased GFR
Osmotic Diuresis, Hypocalcemia (with Albumin)

Body Fluid Requirements at Rest:

1. Measurable Losses(Renal + GIT + Drains) + 9OOml
2. 20 to 40 ml/kg/day
3. 1000 ml to1500 ml/M2/Day
4. 01 to 10kg BW=04 ml/kg/hr
+10 to 20kg BW=02 ml/kg/hr
+ For remg BW=01 ml/kg/hr
Fluid Resuscitation:
- Correction of existing abnormalities in volume status or
serum electrolytes (asin hypovolemic shock)
- Parameters used to assess volume deficit?
1. Blood pressure
2. Urine output
3. Jugular venous pressure
4. Urine sodium concentration
How to know that the patient has Hypovolemic Shock?
-

Anxiety, Agitation
Cool Pale Skin, Confusion
Decreased or no urine Output
Rapid breathing
Disoriented, Loss Of Consciousness
Low BP, Cold Extremities
Rapid, Thready Pulse

Rate of fluid repletion:

1- Severe volume depletion or hypovolemic shock:
Rapid infusion of 1-2L of isotonic saline (0.9% NS) as rapidly as
possible to restore tissue perfusion
2- Mild to moderate hypovolemia:
Choose a rate that is 50-100mL/h greater than estimated fluid
losses. calculating fluid loss as follows:
Urine output=

50ml/h

Insensible losses = 30ml/h

Additional loss such as Vomiting or Diarrhoea or high fever
(additional 100- 150 ml/day for each degree of temp >37
C)
Signs and symptoms of Fluid overload:
They are not always typical but most commonly are:
1- Edema (swelling) - particularly feet, and ankles
2- Difficulty breathing while lying down
3- Crackles on auscultation
4- High blood pressure
5- Irritated cough
6- Jugular vein distension
7- Shortness of breath (dyspnea)
8- Strong, rapid pulse
Management:
-

Prevention is the best way

Sodium restriction
Fluid restriction
Diuretics
Dialysis

How to Calculate IV Flow Rate:

What is a drop factor?

Drop factor is the number of drops in one milliliter used in IV
fluid administration (also called drip factor). A number of
different drop factors are available but the Commonest are:
1- 10 drops/ml (blood set)
2- 15 drops / ml (regular set)
3- 60 drops / ml (microdrop, burette)
volume (ml) X drop factor (drops / ml)

= drops / min
(flow rate)

--------------------------------------------time (min)
Recent advancements:
- Interosseous Route tibia, femur, Superior iliac crest, head
of the humerus
- Auto-transfusion Techniques
- Artificial Haemoglobins Perfluoro Carbon based and
Haemoglobin based
- Hypertonic Salines
- Salt-free Albumins
- Tetrastarches (Voluven)

Electrolytes:
Hyponatraemia:
- Def :
<135 mEq/L
- Causes:
- Pseudohyponatremia (high lipid levels)
- Hypovolemic
- Euvolemic

- Hypervolemic
- Clinical Features:
- Majority: Asymptomatic
- GIT (<120 mEq/L): Nausea, Vomiting, Anorexia
- CNS (<120 mEq/L): Confusion, Coma, Seizures
Treatment:
- Management:
- Hypertonic saline with Frusemide
- Management of ICP
- Water Restriction
- Correction of Precipitating factor
- Demeclocycline (reduces responsiveness of CT to ADH)
- Oral Salt Supplementation
- Hourly Na+ Monitoring (till serum Na+ =130mEq/L)
Complications:
- Central Pontine Myelinosis
- Iatrogenic Hypernatremia

Hypernatraemia:
Def:

>145 mEq/L

Causes:
- Iatrogenic
- Inadequate Water Intake
- Water Loss: GIT, Renal, Heat Stroke
- Insensible Loss, Burns

- Near Drowning in Sea Water

- Malfunctioning Hemodialysis
Clinical Features:
- GIT: Anorexia ,Nausea ,Vomiting ,Thirst
- CNS: Lethargy ,Irritability ,Drowsiness
- Renal: Oliguria, Pre-renal Failure
- Other: Pyrexia, Hypertonia, Postural Hypotension
Management:
- Correction of Hypotension
- Oral Water
- IV Distilled Water --X
- 0.45% Saline + 5% Dextrose
- DDAVP (Desmopressin acetate 0.1-0.8mg divided doses
(BD) )
- Rate of Reduction: 02 mEq/L per Hr
Hypokalemia:
Def: <3.5 mEq/L
Causes:
-

Inadequate Intake
GIT Losses: Diarrhoea, Vomiting, Nasogastric Suction
Renal Losses
Diuretics: Most Common
Compartment Shift

Clinical Features:
-

Weakness -> Quadriplegia

Hypotonicity -> Postural Hypotension
Adynamic Ileus -> Vomitings
Hypoventilation -> Respiratory Failure
Atrial / Ventricular Tachycardia -> Arrest
Rhabdomyolysis in Chronic Cases

ECG Changes:

Prolonged PR Interval
Depression of ST Segment
T Wave Flattening -> Inversion
Prominent U Waves
Apparent Prolongation Of QT Interval
Hypokalemia Potentiates Digitalis Action

Treatment:
- Potassium Supplementation
- Oral: Food, Potchlor, Delayed Release Formulations
- IV: KCL, Acetate, Citrate, Gluconate, Bicarbonate,
Phosphate
- Rate Of Correction not > 10 mEq/L per Hr
- Ensure Renal Function
- ECG Monitoring Bolus Effect on Heart
- Stop Loop Diuretics
- Use Potassium Sparing Diuretics
Hyperkalemia:
Def: > 5.0 mEq/L
Causes:
- Pseudohyperkalemia
- Excessive Intake (Exogenous):
- Oral, IV, Blood Transfusion,
- GI Bleeding, TPN, K Penicillin
- Excessive Release (Endogenous):
- Tissue Damage, Tumour Lysis, Burns,
Rhabdomyolysis, Haemolysis, Septicemia
- Decreased Renal Excretion: Drugs, RF
- Compartment shift: Acidosis, Insulin Defi,
- Digoxin Over Dosage, Scoline, B Blockers
Management:
- Treat if K > 6.5 mEq/L
- Membrane Stabilization:

- 1 or 2 amp of CaCl2 IV Stat (onset in sec, lasts 30 mins)

- Shift Of Potassium into Cells:
- IV Insulin + Glucose (onset 2 or 3 mins, lasts few Hrs)
- Asthalin Nebulization
- IV Sodium Bicarbonate 2 amp Stat
- Removal of Potassium:
- Loop Diuretics
- GI Potassium Binding Resin: Kayexalate 30gmsPO or
50gms PR
- Acute Hemodialysis:
- In Life Threatening Hyperkalemia
Hypocalcaemia:
Def: Serum Ca++ < 8 mg%
Causes:- GIT:
Fistulae
- Renal:

Acute Pancreatitis, Pancreatic / Enteric

Acute / Chronic RF

- Endocrinal:Hypo PTH, Excision of PTH, Hypothyroidism

- Necrotizing Fasciitis
- Severe Alkalosis, Hypo Magnesenemia
- Rapid Blood Transfusion
Symptoms:
-

Petechiae, Parasthesias
Hyperreflexia, Carpopedal Spasm, Chvosteks Sign
Muscle / Abdominal Cramps
ECG: Prolongation of QT Interval
Life threatening: Laryngospasm, cardiac arrhythmias

Management:
- Correction of Underlying Cause
- Correction of Deficit:

- Acute: Inj CaCl2 / Ca Gluconate IV

- Chronic: Calcium Lactate, Milk Orally
- During Massive Blood Transfusion: 02 ml of 10% CaCl2 IV
per Every 500 ml of blood Through a Separate Line
- Monitor Serum Ca++ Levels: Watch for Hypocalcemia and
nephrolithiasis after long term calcium therapy.
- Monitor QT Intervals
Hypercalcaemia:
-

Def: Serum Ca++ > 11 mg %

Causes:
Pseudohypercalcemia
PTH Mediated: Hyperparathyroidism, Ca Parathyroid
Gland -> 45%

PTH Nonmediated:
-

Other Malignancies, MEN Type I & II

Vitamin A & D Intoxication,
Milk-Alkali Syndrome,
Ortho: Pagets Disease, Rheumatoid Arthritis
Renal: Renal Transplant, Diuretic phase of RF
Granulomatous Diseases: TB, Sarcoidosis

Clinical Features:
- Asymptomatic
- GIT: Anorexia, Nausea, Constipation
- CNS: Irritability, Weakness, Fatigue, Photophobia,
Stupor, Coma
- Renal: Nephrocalcinosis, Nephrolithiasis
- ECG: Prolonged PR Interval, Shortened QT
Management:
-

Calciuretic Diuresis -> Saline + Lasix

Inj Calcitonin 4 to 8 IU / Kg sc q 6-12 Hrs
Diphosphonates: Didronel 7.5 mg / Kg
Gallium Nitrate 100200 mg/M2 BSA/24 Hrs
IV Phosphate, IV EDTA, Haemodialysis