FLUID & ELECTROLYTE THERAPY IN SURGERY

INTRODUCTION: Body Spaces Intracellular Extracellular Intravascular Total Body Wt (70kg) 50-60% Water (70 x 0.6=42L) / \ 60% Intra ell!lar (25L) 40% "xtra ell!lar (#7L) / \ $0% Inter%t&t&al (#'L) 25% Intra(a% !lar (4L) Plasma Osmolality = 2(Na) + Glucose/18 + BUN/2.8 For Adults: Input /Output 1. Normal Fluid Output / day )r&ne - #500 *l/day +ell!lar ,eta-ol&%* . 400*l/day In%en%&-le lo%%e% . #0*l/kg -ody /t/day Total losses per day =

#500*l 400*l 700*l 2 !!"l

2. Basal Req/d (Adult) = 35 40 ml/Kg/ or 1500ml/msq (2500 3000ml) Basal Req/d (Paediatric): 10 kg = 100ml/kg 10-20 kg = 1000ml + 50ml/kg over 10 kg 20-30 kg = 1500ml + 20ml/kg over 20 kg 3. Electrolyte Requirements / day (Adult) Daily requirement 70kg Sodium 1-2mmol/kg 70-140 mmol/d Potassium 0.5-1 mmol/kg 35-70 mmol/d Calcium 03.-0.5 mmol/kg 10mmol/d Magnesium .35-.45 meq/kg 24.5-31.5 meq/d (Paediatric): Na = 3- 5; K = 2- 3, Cl = 5-7 mmol/kg/d Basal Req /d given as 1L N/S + 2L 5% D + 20 mmol of K to each L

Co"pos#t#o$ o% &ody Fl'#ds So'r(e Da#ly loss ) Na * 0al&(a #000 '0-$0 1a%tr& #000-2000 60-$0 2an rea% #000 #40 B&le #000 #40 0*all 2000-5000 #40 Bo/el +olon 200-#500 75 0/eat 200-#000 20-70

)+* 20 #5 5-#0 5-#0 20 '0 5-#0

)Cl* 70 #00 60-30 #00 #00 '0 40-60

)HCO,* '0 0 40-#00 40 25-50 0 0

Co$te$ts o% (o""o$ly 'sed I- %l'#ds )Na* )+* )Cl* )De.trose* La tated #'0 4 #03 0 4&nger5% 7or*al %al&ne #54 0 #54 0 85L4 #'0 4 #03 50g 8570 #54 0 #54 50g 85.4570 77 0 77 50g 85W 0 0 0 50g 5% 9l-!*&n #45 :2 0 0

Ot/er La tate 2$*e6 La tate 2$*e6

#2.5g ;rote&n

ELECTROLYTES Normal Serum Values: 7a #'5-#45 **ol < '.5-4.$ **ol +l 35-#06 **ol

Principles of Treatment (DCM) 1. Correct Deficits

Na0 de%#(#t=1Des#red Na 2 "eas'red Na #$ ""ol3L4 . !5 . 6e#7/t #$ 87 +0 de%#(#t=1Des#red +2 "eas'red + #$ ""ol3L4 . !529 . 6e#7/t #$ 87 Cl2 de%#(#t=1Des#red Cl 2 "eas'red Cl2 #$ ""ol3L4 . !5:9 . 6e#7/t #$ 87 Free H2O de%#(#t #$ /yper$atre"#( de/ydrat#o$ = : "L387 %or e;ery ""ol t/at ser'" Na <=:9 ""ol3L5

2. Replace Continuing Losses 3. Maintenance Therapy Volume (water) Deficit Water deficit can be estimated clinically from the history, patients body weight and appearance or can be calculated from the serum Na level Haematocrit can also give useful information. MILD DEHYDRATION: Loss of 3% body weight and thirst MODERATE DEHYDRATION: Loss of 6% of the body weight and clinical signs of dehydration apparent, including marked thirst, no groin or axillary sweat and loss of skin turgor. SEVERE DEHYDRATION: Loss of 10% of body weight with marked clinical signs and hypotension, confusion or delirium. Body water = Normal Na (140) X Normal body water (0.6 X body weight) Measured Na Deficit = Normal TBW - Current TBW Sodium Abnormalities Hyponatremia Symptoms: Mental confusion Seizures Ddx: Total body water excess Factitious Hyperglycemia. (Each 100mg/dl rise in glucose above normal will cause a fall in Na 2mmol/l) SIADH Sepsis Renal Failure Treatment: Treat underlying cause Calculating Na deficit

 Na deficit = Wt in Kg x 0.6 x[ Normal (140) - Observed Na ] Hypernatremia Symptoms: Lethargy Muscle rigidity, tremors Ddx: High output renal failure Increased urea load Water deficit Excessive diuretics Treatment Treat underlying cause Calculating free water deficit Normal TBW = Nl Wt x TBW fraction (0.6) Current TBW = [Nl Na (140)/ Measured Na] x TBW Water Deficit = Normal TBW - Current TBW If hypernatremia is acute (<7d), correct half of the deficit in 12 hours If hypernatremia is chronic (>7d), correct over at least 48 hours Do not correct hypernatremia too quickly!

Potassium Abnormalities Hypokalemia Symptoms: Weakness Flattened T-waves on ECG Ddx: Metabolic alkalosis causing shift of K+ in exchange for H+ Renal losses from diuretic use GI losses - NG, diarrhea Inadequate supplementation Treatment: No accurate calculation of potassium deficit Decrease of 2mmol/l = 200 meq deficit Decrease of 3mmol/l = 400-500 meq deficit Preferable to replace by enteral route (40-60 mmol p.o./d) Do not give more than 20 mmol/hr by the IV route !

Ensure adequate urine output first Hyperkalemia Symptoms: Nausea, vomiting, abdominal. pain Cardiac arrhythmias Peaked t-waves, wide QRS, ST depression Ddx Renal failure Iatrogenic administration Treatment: Counteract cardiac toxicity Administer Ca gluconate or CaCl Drive K into the cells Administer Na Bicarbonate - raises pH Administer Insulin 25U IV and D50 Administer Albuterol - for resistant hyperkalemia Bind K K binding resins - Kayexalate (25 - 50g) Dialysis as a last resort Calcium Abnormalities Hypocalcemia Symptoms: Circumoral numbness and tingling Abdominal pain Carpopedal spasm Seizures Chvosteks sign Ddx: Acute pancreatitis Hypoparathyroidism ( thyroidectomy or parathyroidectomy) Renal failure Pancreatic and small bowel fistulas Factitious - hypoalbuminemia Treatment: Treat underlying cause IV Ca gluconate or CaCl

Correct Ca value for albumin. For every 1g/dL albumin below normal, add 0.8mg/dl to the measured Ca level Hypercalcemia Symptoms: Intractable nausea, vomiting and dehydration Coma and Death Ddx: Hyperparathyroidism Metastatic malignancy Hyperthyroidism Sarcoidosis Milk-alkali syndrome Prolonged immobilization Treatment Vigorous volume repletion with NS Forced diuresis - Lasix Drug therapy - Slower onset of action Mithramycin - 24-48hrs - directly acts on bones Calcitonin - 24-48hrs - inhibits calcium reabsorption Etidronate - >3days - inhibits bone resorption Magnesium Abnormalities Hypomagnesemia Symptoms Hyperactive tendon reflexes Tremors Ddx: Poor dietary intake Gut losses - NG, fistulas, diarrhoea Chronic alcohol abuse Hyperaldosteronism Hypercalcemia Treatment IV or oral replacement 1g MgSO4 (8meq Mg) will increase serum Mg by 0.1 mg/dl Hypermagnesemia Symptoms: Lethargy and weakness Loss of deep tendon reflexes

 ECG changes Increased PR interval Widened QRS Elevated T waves Ddx: Renal insufficiency Iatrogenic administration Treatment: Correct acidosis IV saline if no renal failure exists Slow infusion of Ca - Antagonized neuromuscular action of Mg Dialysis Phosphate Abnormalities Hypophosphatemia Symptoms: Muscle weakness Seizures Ddx: Poor dietary intake Hyperparathyroidism Antacid administration Treatment: Replete when levels are below 2mg/dl Sodium or potassium phosphate IV 0.08 - 0.24 mmol/kg over 6 hours to reach a level over 2.5 mg/kg Hyperphosphatemia Symptoms: Asymptomatic Occasionally leads to metastatic soft tissue calcification Ddx: Renal Failure Tissue catabolism Excessive intake Cytotoxic therapy for leukemia and lymphoma

 Treatment Diuresis - increase rate of urinary phosphorus excretion Phosphate binding antacids - Amphogel Dialysis