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Fluid and Electrolyte Management in Surgical

Patient

Fluid and Electrolyte Fluid and Electrolyte Management in Surgical Management in Surgical

PatientPatientDr.KitiDr.Kiti SiriwatanaSiriwatana

Total body water

• Infant=80• Male=65• Female=55• Thin>Fat

Body fluid compartment• ICF=40%• ECF=20%

– Intravascular fluid(plasma) =5%– Interstitial fluid =15%

Total body water

ICF

Intravascular fluid

Interstitial fluid

140

4

103

24

2

145

4

113

28

2

10

160

2

8

38

Na+

K+

Cl-

HCO3-

PO4-

ICFISFSerum

Na+

K+

Cl-

HC

O3-

PO

4-Serum

ICF020406080

100120140160

Serum

ISF

ICF

Osmolality

• Homeostatic machanism by kidney• Serum Osmolality=(Na+x2)+(BUN/2.8)+(Glucose/18)• Fluid movement:Osmolality• Electrolyte movement:Active

transport

ADH

Aldosterone

Fluid

• Crystalloid– Maintenance type fluid:Hypotonic solution– Replacement type fluid:Isotonic solution– Special type fluid:Hypertonic solution

• Colloid– Albumin– Gelatin(Haemaccel)– Starch(H.E.S.)

Example of crystalloid• D5W:Dilutional hyponatremia• NSS:Normal saline:Isotonic saline• Lactated Ringer’s solution

(LRS):Physiologic solution– Liver-Lactate to bicarbonate and energy

• Acetated Ringer’s solution (ARS)– Acetate metabolite by muscle

NaNa++ KK++ CaCa++++ MgMg++++ ClCl-- HCOHCO33 GlucoseGlucose

ECFECF 142 4 5 3 103 27 1205%5%DD//WW 0 0 0 0 0 0 500.9%0.9%NSSNSS 154 0 0 0 154 0 05%5%DD//NN/2/2 77 0 0 0 77 0 505%5%DD//NN/3/3 51 0 0 0 51 0 505%5%DD//NN/5/5 31 0 0 0 31 0 503%3%NSSNSS 513 0 0 0 513 0 0

LRLLRL 130 4 3 0 109 28 0

ARLARL 130 4 2.7 0 108.7 28 0

Crystalloid VS Colloid

• Crystalloid:2-3 Blood loss• Colloid: ~1:1 Blood loss• Blood replacement: for Oxygen

carrier

Fluid and Electrolyte therapy

• Fluid:Quatity:volume

• Electrolyte:Quality:composition

Replacement for what?

• Daily requirement:Fluid maintenance• Fluid deficit:Already loss• Third space loss from surgery• Fluid for blood replacement

Daily requirement:Fluidmaintenance

• Sensible loss:kidney and GI– Urine:800-1200 cc/day

• Insensible loss:skin and lung– Skin:20-400 cc/day– Lung:400-600 cc/day– Insensible perspiration (cc)=B.W. (kg.)x15

• Total:1600-2000 cc/day• I/O record

Daily requirement:Fluidmaintenance 1

• Holliday and Segar• น้ําหนัก 10 Kg แรก = 100 cc/Kg• 10-20 Kg ตอมา = 50 cc/Kg• >20 Kg = 20 cc/Kg• For 24 Hr. of fluid maintenance

Daily requirement:Fluidmaintenance 2

• Fluid maintenance in 1 Hr.• น้ําหนัก 10 Kg แรก = 4 cc/Kg/Hr• 10-20 Kg ตอมา = 2 cc/Kg/Hr• >20 Kg = 1 cc/Kg/Hr• Rate = cc/Hr• Rate/4= drop/min

Daily requirement:Fluidmaintenance 3

• For NPO pt. before surgery• 5% D/N/2 rate 1.5-2 cc/kg/hr

Daily requirement:Fluidmaintenance

• Composition and concentration• Sodium requirement:

– Adult:2-3 mEq/kg/day=100-150 mEq– Child:4 mEq/kg/day

• Potassium requirement:– Adult:1 mEq/kg/day=40-50 mEq– Child:2 mEq/kg/day

• Glucose :125-150 g for prevent ketosis

NaNa++ KK++ CaCa++++ MgMg++++ ClCl-- HCOHCO33 GlucoseGlucose

ECFECF 142 4 5 3 103 27 1205%5%DD//WW 0 0 0 0 0 0 500.9%0.9%NSSNSS 154 0 0 0 154 0 05%5%DD//NN/2/2 77 0 0 0 77 0 505%5%DD//NN/3/3 51 0 0 0 51 0 505%5%DD//NN/5/5 31 0 0 0 31 0 503%3%NSSNSS 513 0 0 0 513 0 0

LRLLRL 130 4 3 0 109 28 0

ARLARL 130 4 2.7 0 108.7 28 0

Daily requirement:Fluidmaintenance

• 5% D/N/2 1000 cc.+ Water 1000 cc.

• 5%D/N/2 2000 cc.

• 5% D/NSS 1000 cc.+ Water 1000 cc.

Fluid deficit,already loss

• Volume deficit assesment from history taking and physical examination

• Mild dehydration:3% B.W.• Moderate dehydration:6% B.W.• Severe dehydration:9% B.W.

STAGE 0-5%Dehydration

5-10%Dehydration

10-15%Dehydration

Appearance Freshful Restless SemicomatoseSkinturgor Normal or slightly

Eyes Normal or sunken Sunken

Mucous membrane Dry red Very dry Very dry, cyanosisH.R. 130 160

% B.W. loss 2-5 % 5-10 % > 10 %Skin temperature Warmer Cold or warm ColdFontanelle (inchild)

Normal Maybe sunken Sunken

อาการ Deficit (% body wt.)Early Thirst 2 %Moderate

Marked thirstDry mouthOliguriaWeaknessMalaiseLoss of skin turgorMental change

6 %

SevereSevere mental changeHallucinationGross weakness

7-14 %

Fluid deficit,already loss

• Composition assesment:Fluid loss from what?

• Vomitting?• Diarrhea?• NG-tube?• T-tube?

Na+ K+ Cl HCO3

Stomach 10 26 10 30

Duodenum 140 5 80 0Diarrhiastools 120 25 90 45Pancreas 140 5 75 115Bile 145 5 100 35

NaNa++ KK++ CaCa++++ MgMg++++ ClCl-- HCOHCO33 GlucoseGlucose

ECFECF 142 4 5 3 103 27 1205%5%DD//WW 0 0 0 0 0 0 500.9%0.9%NSSNSS 154 0 0 0 154 0 05%5%DD//NN/2/2 77 0 0 0 77 0 505%5%DD//NN/3/3 51 0 0 0 51 0 505%5%DD//NN/5/5 31 0 0 0 31 0 503%3%NSSNSS 513 0 0 0 513 0 0

LRLLRL 130 4 3 0 109 28 0

ARLARL 130 4 2.7 0 108.7 28 0

Fluid deficit,already loss

• Diarrhea จะเลือกใช N/2+KCl 30 mEq/l• Vomiting จะเลือกใช N/2+KCl 10 mEq/l• NG tube ใช N/2+KCl 10 mEq• T tube (ในการผาตัดทอน้ําดี) ใช LRL

Third space loss

• Volume:– Major surgery:8 cc/kg/hr– Moderate surgery:6 cc/kg/hr– Minor surgery:4 cc/kg/hr– OMFS:2-4 cc/kg/hr

• Composition:LRS,ARS

Blood loss therapy• Acceptable blood loss (ABL)• (Hct -30) x ปริมาณเลือดในรางกาย x 3/100• < 1/3 ABL—LRS,ARS 2-3:1 of blood loss• >1/3 ABL--LRS,ARS 2-3:1 of blood loss or

Albumin 1:1 of blood loss• = ABL---Packed red cell(PRC) 0.5:1 of

blood loss

Fluid therapy during the operation

• Maintenance• Preoperative deficit

– ½ in first hour– ¼ in second hour– ¼ in third hour

• Third space loss• Blood loss during the operation

Fluid and electrolyte abnormality

• Volume disturbance• Concentration disturbance:Sodium• Composition disturbance:Others

electrolyte

Volume disturbance

• Volume excess

• Volume deficit (dehydration)

Concentration disturbance

• Hyponatremia (Water intoxication)-Water shift to icf:cell swelling esp.brain

• Hypernatremia (Water deficit)– Dehydration

Composition disturbance

• Hypokalemia– กลามเนือ้ออนแรง,ทองอืด,หัวใจเตนไมเปนจังหวะ

• Hyperkalemia– คลื่นไส อาเจียน ปวดทอง ทองเสีย หัวใจเตนไมเปนจังหวะ

The End