PRINCIPLES OF FLUID & ELECTROLYTE BALANCE IN SURGICAL PATIENTS

NORMAL DAILY LOSSES AND REQUIREMENTS FOR FLUIDS AND ELECROLYTES

Volume ML 2000 700 300 300 2700 Na+ mmol 80 80 K+ mmol 60 10 70

Urine Insensible losses Faeces Minus endogenous Water Total

ASSESSING LOSSES IN THE SURGICAL PATIENT

INSENSIBLE FLUID LOSSES

EFFECT OF SURGERY
The stress response Third-Space losses Loss from the gastrointestinal tract

INTRAVENOUS FLUID

5% DEXTROSE 0.9% NaCl RINGERS LACTATE (HARTMANNS SOLUTION) HAEMACCEL (SUCCINYLATED GELATIN) GELOFUSINE (POLYGELINE GELATIN) HETATARCH HUMAN ALBUMIN SOLUTION 4.5% (HAS;PPF)

PROVISION OF NORMAL 24-HR FLUID & ELECTROLYTE REQUIREMENTS BY INTRAVENOUS INFUSION

Intravenous fluid 500 ml 0.9% NaCl 500 ml 5% Dextrose 500 ml 5% Dextrose 500 ml 0.9%Dextrose 500 ml 5% Dextrose 500 ml 5% Dextrose Additive 20mmol KCl 20 mmol KCl 20 mmol KCl Duration 4hr 4hr 4hr 4hr 4hr 4hr

AETIOLOGY OF HYPER AND HYPONATRAEMIA

Hypernatraemia ------------------Reduced intake fasting nausea and vomiting ileus reduced conscious level Increased loss *Sweating (pyrexia,hot environment) *respiratory tract loss(increased ventilation, administration of dry gases) *administration of dry gases *burns Inappropriate urinary water loss Diabetes inspidus(pituitary or nephrogenic) Diabetes mellitus Excessive Sodium load (hypertonic fluid, parenteral nutrition)

Hyponatraemia ------------------- Low extracellular fluid volume * Volume depletion (vomiting,diahrrhoea,burns,de creased fluid intake) * salt losing renal disease * Hypoadrenalism *diuretic use - Normal extracelluler fluid volume hypothyroidism SIADH Increased extracellular fluid volume excessive water administration excessive mannitol use cardiac failure cirrhosis nephritic syndrome renal failure

CONSEQUENCES OF HYPER AND HYPOKALEMIA

HYPERKALEMIA Arrythmias(broad-complex rhythms,bradycardia,heart block,ventricular fibrillation) Muscle heart block Ileus Hypokalemia ECG changes Ectopic beats Muscle weakness

MANAGEMENT OF SEVERE ACUTE HYPERKALAEMIA (K+ > 7mmol/L)

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 next3060 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

ACID BASE BALANCE

METABOLIC ACIDOSIS METABOLIC ALKALOSIS RESPIRATORY ACIDOSIS RESPIRATORY ALKALOSIS MIXED PATTERN OF ACID-BASE IMBALANCE

COMMON CAUSES OF METABOLIC ACIDOSIS IN THE SURGICAL PATIENT

LACTIC ACIDOSIS Shock (any causes) Severe hypoxaemia Severe haemorrhage/anaemia ACCUMULATION OF OTHER ACIDS Diabetic Ketocaidosis Acute Renal Failure INCREASED BICARBONATE LOSS Diahrroea Intestinal Fistulae Ureterosigmoidostomy

COMMON CAUSES OF METABOLIC ALKALOSIS

LOSS OF SODIUM AND WATER Vomiting Aspiration of gastric secretions Diuretic administration
HYPOKALEMIA

CAUSES OF RESPIRATORY ACIDOSIS

Excessive opiate administration

Pulmonary complications e.g Pneumonia

CAUSES OF RESPIRATORY ALKALOSIS ENCOUNTERED IN SURGICAL PRACTICE

Hyperventilation during mechanical ventilation Pain Apprehension/hysterical hyperventilation Pneumonia Central nervous system disorders(meningitis,encephalopathy) Septicaemia

Principles of fluid and electrolyte balance in surgical patients

Discussions

1. What are the normal values or serum sodium, potassium, creatinine and urea? 2. What are the normal basal requirements for water, sodium and potassium? 3. How can this be provided in a patient who is fasting? 4. How is fluid retained in the intravascular compartment? 5. What might cause it to leak out? 6. In clinical practice, it is often desirable to "expand" the intravascular compartment. Why might this be desirable and how could it be done? 7. What are the clinical symptoms and signs of fluid depletion? How can the severity of fluid depletion be assessed? 8. How can clinicians assess the patients response to resuscitation in severe fluid depletion? 9. What biochemical disturbance might you expect in a patient with gastric outlet obstruction who has been vomiting for several days before admission? 10. What biochemical abnormalities might you expect in a patient who has had excessive diarrhoea and who has been drinking large amounts of water because of thirst? (If a house officer inadvertently prescribed too much 5% dextrose and not enough N Saline, you would find the same effect) In patients with massive burns, fluid losses are impossible to measure. How might you assess fluid requirements?