ir- 027 fluid and electrolytes -2

8/9/2019 Ir- 027 Fluid and Electrolytes -2

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M. Shuja Tahir, M. Abid BashirFaisalabad, Pakistan IR-027

131 April to June, 2010 INDEPENDENT REV IEWS

Insensible loss 900 mlNORMAL DAILY INTAKE Faeces 100 ml(70 Kg person)Total output 2500 mlWater from drinks 1200 ml

Water from food (solids) 1000 mlPatient's output also includesWater from oxidation 300 mlexcessive losses due to;Total intake 2500 ml

Vomiting.Diarrhoea.Patient's intake also includes;Fever.Sweating.I/V fluids infusionFistulae.I/V blood transfusion

Nasogastric aspiration.Absorption from enema fluidDrains.Absorption from irrigation fluids

NORMAL VALUES OF GASTRO-All these are counted in total dailyINTESTINAL-TRACT FLUIDSintake between specified period (24

hours). (70 KG ADULT)Saliva 1500 ml/24 hoursGastric juice 2500 ml/24 hoursNORMAL DAILY OUTPUTBile 500 ml/24 hours(70 Kg person)Pancreatic juice 700 ml/24 hoursNormal daily output includes urine,Succus entericus 3 0 0 0 m l / 2 4

water in faeces and insensible loss hoursfrom respiratory tract and skin.Total 8200 ml/24 hoursUrine output is 1-7 litres depending

upon the weather, fluid intake andCHILDRENdiuretics like coffee, tea and drugs.

Minimum amount of urine to get rid Children may have more demandof solid wastes is 0.5 ml/kg/hour. 1 of fluids because they have;ml/kg/hour of urine output is ! Large surface area in relation toconsidered adequate. Insensible body.loss is usually 500-900 ml/day but ! More metabolic activity.it may exceed 5 litres/day in hot and ! Poor concentrating ability of the

humid weather or in febrile and immature kidneys.hyperventilating patients.Urine 1-7 litres

SURGICAL PATIENTSAverage 1500mlIn surgical patients, fluid loss mayMinimum 0.5ml/kg/houroccur from a number of sitesAdequate 1 ml/kg/hour

FLUID AND ELECTROLYTES -2VOLUME CHANGES

Critical Care


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132April to June, 2010 INDEPENDENT REV IEWS

depending upon the disease and almost same composition as that oftype of surgery such as; extra cellular fluid (Isotonic).! Evaporation during laparo-

tomy. CAUSES! Burns. Hemorrhage! Fluid loss in nasogastric ! Revealed

aspiration. ! Concealed! Fistulae. Gastrointestinal tract! Sequestration into bowel ! Diarrhoea

lumen. ! Vomiting! Sequestration into tissues in ! Nasogastric aspiration

trauma and inflamation. ! FistulaeSequestration

VOLUME STATUS ! Soft tissue injuries

! BurnsASSESSMENT! Infections (peritonitis etc)Following investigations are helpfull! Intra-abdominal or retro-in indirectly assessing the volume

peritoneal inflammationsstatus of a person;(Pancreatitis)! BUN.

! Intestinal obstruction! Creatinine.! Haematocrit.

CLINICAL FEATURES! Urinary osmolality, sodiumconcentration and specific Moderate Deficitgravity. ! Central Nervous System

! Sleepiness

ECF volume can also be directly ! Apathymeasured by isotope tracing but it is ! Slow responsesonly of academic value. ! Anorexia

! RestlessnessMONITORING ! Gastrointestinal TractFollowing clinical parameters help ! Progressive decrease inin assessment and monitoring of food consumptionfluid status of the patient. ! (Anorexia)! Pulse ! Cardiovascular System! Blood pressure ! Orthostatic Hypotention!

Urine output!

Tachycardia! Central Venous Pressure (CVP) ! Collapsed veins

! Low volume pulse! TissuesVOLUME DEFICIT

! Dry tongue, wrinkling of skinIt is the most common fluid disorder! Mild hypothermiain surgical patients. Lost fluid has


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of body water, or output. MinimumSevere Deficitamount of urine to get rid of solid!wastes is 0.5 ml/kg/hr. Insensible!loss is variable but for simple! Anes t he s i a o f d i s t a lcalculation, we may consider 500extremities.ml.! Stupor.

! Coma.So daily fluid requirement would be;! Gastrointestinal Tract

! NauseaCalculated 24 hourly urine output! Vomiting+ Insensible loss + output (fistula,! Anorexianasogastric tube, drain etc) = (body! Silent ileus and distensionweight x 0.5x 24) + 500 +! Cardiovascular Systemdrainage fluid.! Cutaneous lividity

! Hypotension Another method of calculating daily! Distant heart soundsfluid requirement is according to! Absent peripheral pulsesbody weight. It is specially important! Cold extremitiesin children. According to this! Miscellaneousformula;! Atonic muscles

! Sunken eyes100 ml/kg is given for upto 10 kg.! Marked hypothermia50 ml/kg is given for next 10 kg.20 ml/kg is given for 21 kg onward.TREATMENT

The general principles regarding

e.g., for a person of 35 kg, 24volume replacement are as follows;hourly fluid requirement would be;

Volume deficit should be corrected(100x10) + (50x10)+ (20x15) =with isotonic solutions. Ringer1800 ml.lactate is the most commonly used

solution as it contains electrolytes inThis fluid is added to calculated 24almost similar ratio as that ofhourly output other than urineplasma.(fistula, drain, naso-gastric tubeetc).5% dextrose water is an isotonic

solution but it behaves as hypotonicas the glucose is taken up by the VOLUME EXCESScells and utilized. Water also moves CAUSESinto the ICF . ! Iatrogenic

! Renal insufficienciesAmount of fluid to be infused can be ! Cirrhosis of livercalculated on the basis of utilization ! Congestive Cardiac Failure

Central Nervous SystemDecreased tendon reflexes.


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SUMMARY

! TreatmentFluid Balance! Normal daily intake

Volume excess! Normal daily outputCauses

! Clinical featuresVolume status! Treatment! Assessment

! MonitoringWater balance! Water depletion (dehydration)Volume deficit! Water intoxication! Causes

! Clinical features

The author :Muhammad Abid Bashir,FCPS

is associate professor indepartment of Surgery atIndependent MedicalCollege Faisalabad and

instructor of ATLS [email protected]

The author :Muhammad Shuja Tahir

FRCS (Ed), FCPS (Hon)is professor and head of thedepartment of Surgery atI ndependen t Med ica lCollege Faisalabad.

[email protected]

ir- 027 fluid and electrolytes -2

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