Fluids and Electrolytes

Dr. Delos Reyes

Group TENtacles
Learning Objectives:
Overview of body fluid homeostasis
Control of body fluid volumes
Disorders of water and sodium balance
Fluid and electrotype therapy
Preoperative
Intraoperative
Postoperative
Acid-base balance
I.BODY FLUID HOMEOSTATIS

Water constitutes about 50-60% of the body

weight
Lean tissues such as muscle and solid organs have
higher water content than fat and bone Muscle
cells contain more H20
o Young lean males have higher
proportion of percentage of water
to its body weight as compared to
elderly or obese individuals. Which
means that Young people tolerate
stress/injury than elderly people
e.g. long durations of surgery
o Newborn
has
the
highest
percentage (80%)
REVIEW OF BODY FLUID COMPARTMENTS

Extracellular (1/3%) of total body water (TBW)

Plasma or intravascular or 5% of body
weight
Interstitial or 15% of body weight
Intracellular (2/3%) of the TBW or 40% of body
weight
o Internal environment of the body

PRINCIPLES OF OSMOTIC PRESSURE

Basically it is the movement of water across a cell

membrane in order to achieve osmotic equilibrium
It is governed by:
Concentration of solutes/ electrolytes/ or any
particles which exerts osmotic pressure (ability
to draw water)
o Example if the concentration of
sodium
in
the
extracellular
compartment increases, then water
will be drawn from the intracellular to
the extracellular to achieve osmotic
equilibrium.
o Proteins can also cause movement of
fluid across membrane eg. Albumin
NORMAL BODY FLUID EXCHANGES
(Physiologic Balance Sheet)
Intake
1800 -2000mL (coming from oral intake of
water and from solid foods)
Obligatory intake - caused by human need to
replenish water to withstand stress/injury
Output

*A rough calculation based on a 70 kg adult male

counts for about 42 liter of fluid.

ELECTROTYPE COMPOSITION

Sodium together with chloride is the principal

cation and anion respectively in the extracellular
fluid compartment.
Potassium and magnesium together phosphate
and proteins are the principal cations and anions
respectively in the intracellular fluid.

Sodium because of its osmotic and electrical properties is

always associated with water.

1000 ml thru urine

o 500-800 ml is the minimum obligatory
output ie, force to excrete regardless
of the amount of water intake
250 ml thru stools
600 ml thru insensible loses (skin and lungs)*
but can be altered **in case of sweating, fever,
hyper metabolic states and hyperventilation.
cannot be measured, and should be considered
in delivery of fluids

REGULATION AND CONTROL OF BODY FLUIDS

Extracellular fluid
Any control systems (hormonal and nonhormonal) primarily affecting SODIUM is
involved such as: rennin-angiotensinaldosterone system, arginine vasopressin,
sympathetic nervous system which includes

the baroreceptors and atrial volume

receptors. Fluid volume/concentration
levels stimulate hormonal and nonhormonal
control system
Intracellular fluid
Mediated thru the arginine vasopressin
mechanism
which
determines
its
hypertonicity and hypotonicity respectively.

COMPOSITION OF GI SECRETIONS
Secretio
ns
Stomac
h
Small
Bowels

Volume
/day
1-2
liters
2-3
liters

Colon
CONTROL OF BODY FLUID VOLUMES
Electrolyte-free
Water
Balance
Saltwater Balance
Emergenc
Day to Day
y Backup
Regulated
Variable

Extracellular volume
Vascular fullness

Cell Volume

Clinical
Indicator

Blood Pressure
Edema

Plasma
Sodium
concentratio
n

Blood
pressure
Edema

Sensors

Baro and atrial

volume receptors

Hypothalamic
osmorecepto
rs

Baro and
atrial
volume
receptors

Mediators

Renin- angiotensin
aldosterone ADH,
sympathetic,
starling forces at
tubular capillaries

ADH
or
arginine
vasopressin
Thirst

ADH
Thirst

Urinary
excretion

Urine
osmolality
Water intake

Urine
osmolality
Water
intake

Affected
variable

sodium

Arterial
Filling

MANIFESTATIONS OF VOLUME DISTURBANCES

System

Volume Deficit*

Generalized

Weight Loss
Decreased skin turgor

Cardiac

Tachycardia,
collapsed neck veins,
orthostatic
hypotension

Renal

Oliguria
Azotemia

Gastrointestinal

Ileus

Volume Excess
Weight gain
Peripheral
edema
Increased cardiac
output
Increased CVP,
murmur
Distended neck
veins

Bowel edema
Pulmonary
edema

Sodium

Potassiu
m

Chlorid
e
100130

Bicarbon
ate

60-90

10-30

120-140

5-10

90-120

30-40

60

30

40

Pancrea
s

600-800

135-145

5-10

70-90

95-115

Bile

300-800

134-145

5-10

90-110

30-40

Saliva

1-1.5
Liters

5-10

20-30

5-15

25-30

II.ELECTROLYTE DISTURBANCES
Generally divided into EXCESS and DEFICITS
o EXCESS may be iatrogenic and DEFICIT is more
common
Disturbances in Sodium
Hyponatremia
Hypernatremia
Disturbances in Potassium more common in surgery
Hypokalemia
Hyperkalemia
DISTURBANCES IN SODIUM
Hyponatremia
Excess of extracellular water relative to
sodium eg. Excessive oral water intake
(deliberate or self-induced) marathoners,
electrolyte
free
dextrose
solution,
hyperglycemia, ecstasy, post op patients*
Manifestations may range from CNS to GIT
to muscular weakness to confusion to
seizures, fatigue and cramps. Lacrimation
and salivation.
Manifestations of increase intracranial
pressure.
*Due to ADH secretion due to stress
Hypernatremia
Loss of free water or increase in sodium
relative to water
Administration of high sodium containing
fluids
like
sodium
bicarb,
hyperaldosteronism, gastrointestinal loses.
Diuretics, diabetes insipidus and osmotic
diuretics.
Manifestations
include
tachycardia,
hypotension, CNS manifestations like
restlessness, irritability hyperactive DTRs to
coma
Dry sticky mocusa, decrease saliva and tears.

PE Loss of skin turgor, Dry tongue, cardiovascular

status (Tachy/bradycardia), low urine output,
Labs
- Hematocrit level checks the degree of
hemoconcentration
- Urine specific gravity
- Elevated Blood urea Nitrogen
- Serum electrolytes value is dependent
upon tonicity/osmolality of fluid loss
FLUID AND ELECTROLYTE MANAGEMENT

Basic calculation: (Based on kg body weight)

First 10 kg x 100 ml/kg/day
Next 10-20 kg x 50 ml/kg/day
>20kg x 20 ml/kg/day

POTASSIUM DISTURBANCE
Hypokalemia
Common problem in the post operative
period
Most often due to GIT losses as in nasogastric
suction and vomiting use of diuretics, drugs
that result to renal excretion of potassium
(penicillin)
Ileus is a significant manifestation of
hypokalemia
Fatal cardiac arrhythmia

Hyperkalemia
Iatrogenic potassium administration*
Transfusion using banked blood of several days
old
Hemolysis or increased cell destruction
Acidosis
Potassion sparing diuretics
Renal insufficiency or failure
Manifestations of colic, diarrhea, arrhythmia
and arrest

OTHER DISTURBANCES
Hypo or hypercalcemia
Hypo or hypermagnesemia
Hypo or hyperphosphatemia
CLINICAL EVALUATION
History Will oftern reveal the duration and
severity of fluid loss
- Eg. External losses like Vomiting and
rd
diarrhea and Internal losses such as 3
spaces loss/ Fluid shifting

Therefore, for a 60 kg adult female the computed

maintenance fluid per day is approximately 2400 ml. This
is based on the premise that surgical patients are placed
on NPO.
Preoperative
Maintenance + deficit (if there is any) / 24
hrs.
Intraoperative
Fluid replacement based on vital signs and
adecuacy of urine output
Also consider the length of surgery and
extent of dissection (edema or third space
losses)
Postoperative
Guided primarily by urine output (0.5 to 1
ml/kg/hr), vital sign plus calculation of
maintenance and deficit.
III.PARENTERAL FLUIDS
The plasma (extracellular fluid) is considered as the basis
for categorizing parental fluid as:
Isotonic
o Lactated
Ringers

most
physiologic
o 0.9 NaCI

Hypotonic
o Dextrose water or D5W or D 0.45%
NaCI
Hypertonic
o 3% NaCI

OTHER TYPES OF FLUIDS BEING USED

Belong to the category of colloids of plasma expanders
(high molecular weight) other than blood of blood
products:
Human albumin 5%, 25%
Dextran

Starch solution (popular among religious groups

who dont want to receive blood transfusion)
Gelatin based
These products holds fluids in the intravascular
space; used for correction of fluid and blood volume
ELECTROLYTE THERAPY

CLINICAL APPLICATIONS
Metabolic Acidosis
Primary decrease in plasma bicarbonate (HCO3 )
The use of the Anion Gap is useful in the
differential diagnosis (Anion Gap = Sodium-[
HCO3 + Cl]

Basically in a surgical patient the most common electrolyte

abnormality is:
Hypokalemia
Hypochloremia
Dilutional hyponatremia
Hypocalcemia

Causes:
o
o
o
o

Renal failure
Lactic acidoses
Ketoacidosis
Poisoning

COMPARISON OF VARIOUS PARENTERAL FLUIDS

Electrolyte composition (mEq/l)
Solutions

IV.ACID-BASE BALANCE
Acid-Base homeostasis- based on normal buffers of the
body maintains blood pH to 7.32-7.38. any deviation from
this range indicate a change in the H ion (pH=-log10*H+
Intracellular
o Proteins and phosphates
Extracellular
o Bicarbonate-Carbonic Acid System
(Henderson-Hasselbach Formula)

ACID-BASED COMPENSATORY MECHANISM

Respiratory- immediate compensation via the lungs
Hydrogen sensitive chemoreceptors in the
carotid body and brain stem
o Increase ventilation for acidosis=
blows off carbon dioxide*
o Decrease
ventilation
for
alkalosis=retains carbon dioxide
Metabolic- delayed via kidneys
Bicarbonate reabsorption/secretion

Na

Cl

HC03

mOsm

Extracellular fluid
(plasma)

142

10
3

27

280-310

Lactated Ringers

130

10
9

28

273

0.9% NaCl

154

15
4

308

D5 0.45% NaCl

77

77

407

D5W
3% NaCl

253
513

51
3

1056

Mebaloic Acidoses
Hydrogen ion loss- NGT suction, pyloric
obstruction
Hydrogen movement into the cell- hypokalemia
Bicarbonate retention-administration of alkali,
massive blood transfusion, acidosis
Contraction alkalosis-diuretics, gastrointestinal
losses

Respiratory Acidosis
Medullary center suppression-sedative, CP
arrest, sleep apnea
Reduced respiratory muscle function- paralysis,
poliomyelitis, GB syndrome
Upper airway obstruction- aspiration of foreign
body, laryngospasm
Pulmonary gas exchange disorder*-severe
asthma, pneumothorax, ARDS, pneumonia
Inadequate mechanical ventilation

Respiratory Alkalosis- as a general rule respiratory alkalosis is the initial disorder but will later result to metabolic acidosis
Hypoxemia
Respiratory center (medullary) conditions
Excessive mechanical ventilation

Crystalloids