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Fluid and Electrolytes in Surgical Patients

Fluid and Electrolytes in Surgical Patients. Ruth Mitchell, BA, BSc, BMBS Neurosurgical Resident Royal Melbourne Hospital Thursday, March 18, 2010.

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Fluid and Electrolytes in Surgical Patients

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  1. Fluid and Electrolytes in Surgical Patients Ruth Mitchell, BA, BSc, BMBS Neurosurgical Resident Royal Melbourne Hospital Thursday, March 18, 2010

  2. Peri-operative fluid and electrolyte management: a survey of consultant surgeons in the UK. D. N. Lobo, M. G. Dube, K. R. Neal, S. P. Allison, and B. J. Rowlands Ann R Coll Surg Engl. 2002 May; 84(3): 156–160. • 710 questionnaires to consultant surgeons • junior staff given written guidelines 22% of cases • 16% felt their interns were adequately trained before joining the firm • only 30% felt postoperative patients were given appropriate amounts of water, sodium and potassium

  3. What you need to know • Patients need fluid • Patients need electrolytes • Surgical patients are at your mercy

  4. How much?

  5. How much? In a 65kg man • Fluid: 2.5-3L water • Sodium: 100-150mmol • Potassium: 60-90mmol • Fluid requirements increase in fever

  6. 65 year old man • Admitted for severe and constant lower abdo pain, began on L side • Vomiting, unwell • 24 hours ago he had a colonoscopy and polypectomy (x2) • Febrile 38.5, dry coated tongue and loss of skin turgor, thirsty • Tachycardic 110pbm • BP 110/70 lying, 90 systolic sitting up • Mildly distended abdo, rigid, no bowel sounds

  7. What’s going on?

  8. What’s going on? • Likely perforated colon • Peritonitis • Risk post polypectomy is 0.5-1% • R colon more common • Immediate or delayed

  9. What’s your management plan?

  10. What’s your management plan? • IV Cannula • IV therapy –1L over 1hour of normal saline • Oxygen via face mask • Analgesia • Take blood • CXR and AXR • Broad spectrum antibiotics • Call a surgeon

  11. Hb 164 (130-170) Plt 350 (140-400) WCC 13.6 (4.0-11.0) Na 149 (135-145) K 3.4 (3.5-5.5) Cl 112 (95-110) Bicarb 29 (22-30) Glucose 4.4 Chol 3.6 LDH 110 Amylase 65 Ca 2.16 (2.10-2.60) Phos 1.15 (0.8-1.5) TP 65 (60-82) Alb 38 (35-50) Bili 19 (<19) Alt, ast, ggt, alp - nad Blood Results

  12. Blood results • Elevated WCC – inflammation and infection • High haemoglobin – dehydration • Biochemical values: high urea, sodium and chloride – dehydration

  13. What fluid to give?

  14. What fluid to give? • Replace lost fluid with normal saline (isotonic) • Start with 2L of normal saline over 1 hour • Estimate fluid loss and make a plan to replace it

  15. Maintenance Fluid • 2.5-3L/day • Normal saline • Dextrose • Hartmanns/CSL

  16. Replacement Fluid • Calculate and replace frequently • Consider loses through increased temperature, NGT, vomitus, ileostomy • Replace like with like

  17. Update… • Exploratory laparotomy shows purulent peritonitis, perforated transverse colon • Transverse colon resected, defunctioning ileostomy performed

  18. Fluid output Urine 800mL Urine last 4 hours 15/13/9/8mL NGT 2500mL Wound drain 300mL Ileostomy 3000mL Fluid balance 24 hours later • Fluid input • IV fluid 4500mL

  19. Electrolytes • Na 138 • K 2.6 • Cl 102 • Bicarb 29 • Urea 7.0 • Creat 0.08

  20. Thank you! Questions?

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