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Principals of fluids and electrolytes management. Ram Elazary , MD General Surgery Department Hadassah Hebrew University Medical Center Campus Ein-Kerem , Jerusalem. Total Body Water. body weight% Total body water% Total 60 100 I ntracellular 40 67 E xtracellular 20 33

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principals of fluids and electrolytes management

Principals of fluids and electrolytes management

Ram Elazary, MD

General Surgery Department

Hadassah Hebrew University Medical Center

Campus Ein-Kerem, Jerusalem

total body water
Total Body Water

body weight% Total body

water%

Total 60 100

Intracellular 40 67

Extracellular 20 33

Intravascuar 5 8

Interstitial 15 25

composition of fluids
Composition of Fluids

plasma interstitial intracellular

Cations

Na 140 146 12

K 4 4 150

Ca 5 3 10

Mg 2 1 7

Anions

Cl 103 104 3

HCO 24 27 10

SO4 1 1 -

HPO4 2 2 116

Protein 16 5 40

control of volume
Control of Volume

Kidneys maintain constant volume and composition of body fluids

  • Filtration and reabsorption of Na
  • Regulation of water excretion in response to ADH

Water is freely diffusible

  • Movement of certain ions and proteins between compartments restricted
control of volume1
Control of Volume

Effective circulating volume

  • Portion of ECF that perfuses organs
  • Usually equates to Intravascular volume

Third space loss

  • Abnormal shift of fluid for Intravascular to tissues eg bowel obst, i/o, pancreatitis
normal water exchange
Normal Water Exchange

Mean daily (ml) Minimal daily (ml)

SensibleUrine 800-1500 600Intestinal up to liters Sweat up to liters 500

InsensibleLungs/Skin 600-900 600-900

( 10%/1 o rise in Temp)

normal source of water
Normal source of water

~2000ml - 1300 free water intake

700 bound to food

additional water from catabolism

water and eletrolytes exchange
Water and Eletrolytes Exchange

Surgical patients prone to disruption:

  • NPO
  • anaesthesia
  • Trauma (surgery)
  • sepsis
fluid and electrolytes therapy
Fluid and Electrolytes Therapy

Surgical patients need:

  • Maintenance volume requirements
  • On going losses
  • Volume excess/deficits
  • Maintenance electrolyte requirements
  • Electrolyte excess/deficits
1 volume deficit
1. Volume Deficit
  • vital signs changes
    • Blood pressure
    • Heart rate
    • CVP
  • Peripheral temperature and capillary filling time
  • urine output low
1 volume deficit1
1. Volume Deficit
  • Decreased skin turgor
  • Sunken eyes
  • Oliguria
  • Orthostatic hypotension
  • High BUN/Creatine ratio
  • Plasma Na may be normal
fluids resusitation
Fluids resusitation
  • Adults:

1000 ml

  • Pediatrics:

20 ml/kg

Fluids of crystaloids (NS or RL)

Repeated dose

2 maintenance requirements
2. Maintenance Requirements

This includes: insensible loss

urinary

stool losses

Body weight Fluid required0-10Kg 100ml/kg/dnext 10-20Kg 50 ml/kg/dsubsequent Kg 20ml/kg/d15ml/Kg/d for elderly

70 kg man needs
70 Kg Man Needs

1st 10kg x 100mls = 1000mls

2nd 10kg x 50mls = 500mls

Next 50kg x 20mls= 1000mls

TOTAL 2500 mls /d

maintenance electrolyte requirements
Maintenance Electrolyte Requirements

Na 1-2mEq/Kg/d K 0.5 - 1 mEq/Kg/d

  • Usually no K given until urine output is adequate
  • Always give K with care, in an infusion slowly - never bolus (max 0.2% KCL through peripheral IV)
slide16

Na 1gr = 17 mEq

  • K 1gr = 13.6 mEq
  • 70 Kg H2O 2500ml

Na 70*2 =140 mEq = ~ 9gr

K 70*1 =70 mEq = ~ 5gr

2500 0.45NS + 0.2%KCl 100ml/h

3 on going losses
3. On Going Losses
  • NGT
  • drains
  • fistulae
  • third space losses
4 volume excess
4. Volume Excess
  • Over hydration
  • Mobilization of third space losses

Signs

    • weight gain
    • pulmonary edema
    • peripheral edema
    • S3 gallop
fluid and electrolyte therapy
Fluid and Electrolyte Therapy

Goals

  • normal hemodynamic parameters
  • normal electrolyte concentration

Method

replace deficits

normal maintenance requirements

ongoing losses

fluid and electrolyte therapy1
Fluid and Electrolyte Therapy

Normal maintenance requirements

  • use BW formula

On going losses

  • measure all losses in I/O chart
  • estimate third space losses

Deficits

  • estimate using vital signs
  • estimate using U/O
fluid and electrolyte therapy2
Fluid and Electrolyte Therapy

The best estimate of the volume required

is the patients response

After therapy started observe

  • vital signs
  • Urine output (0.5mls/Kg/hr)
  • Central venous pressure
time frame for replacement
Time Frame for Replacement
  • Usually correct over 24 hours
  • For ill patients calculate over shorter period and reassess e.g. 1, 2 hours or 3 hours for e op cases
  • Deficits - correct half the amount over the period and reassess
postoperative fluid therapy
Postoperative Fluid Therapy
  • Check IV regimen ordered in op form
  • Assess for deficits by checking I/O chart and vital signs
  • Maintenance requirements calculated
  • Usually K not started
  • Monitor carefully vital signs and urine output
postoperative fluid therapy1
Postoperative Fluid Therapy
  • Urine specific gravity may be used (1.010 - 1.012)
  • CVP useful in difficult situations (5-15 cm H20)
  • Body weight measured in special situation e.g. burns
concentration changes
Concentration Changes
  • changes in plasma Na are indicative of abnormal TBW
  • losses in surgery are usually isotonic
  • hypoosmolar condition usually caused by replacement with free water
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