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Imbalance of fluid and electrolyte

in surgical patients

外科病人水电解质失衡

Prof. Dr. med Minghui Mei


Key points of this chapter
 Three questions before the lecture
 Introduction
 Metabolic imbalance of body fluid
 Acid-base imbalance
Three questions before the lecture
What does “Surgery” mean in your
mind ?

What is a successful operation?

What is the requirement for a good


surgeon?
Surgery ≠ Operation
It is closely related to other specialties
The history of surgery
From the ancient Inca’s
Through medieval surgery, and
the application of the art of surgery…
To the marriage of science and
surgery in the 19th century…
From the ancient Inca’s

Machu Picchu
Who were the Barber-Surgeons
?
Did you notice my coif (hat)?
I am a member of the guild
of Barber-Surgeons.
I trained for 7 years before starting
work.

I cut the men's hair and


trim their beards. I also
try to heal their wounds,
pull their teeth and cure
their sickness.
理发师外科医生
Chirurgery: ( Latin)
Chirurgia: ( Greek)
cheir = hand
ergon = work
anglicized to Surgery

以手工为主的医疗工作被称之为外科学
The land marks in the history of surgery
in the past century (1840’s)

 Anesthesia 麻醉
 Antisepsis and asepsis 抗菌和无菌
 Stanch bleeding 止血
 Transfusion 输血
Modern surgery

•Micro-surgery
•Interventional
radiology
•Molecular biology
•Minimal invasive
medicine

the marriage of science and surgery


A successful operation
 Precise evaluation pre-operatively

 Skilful performence intra-operatively

 Careful observation and management


post-operatively
A good surgeon

A physician who can perform


operations
Introduction

UFO

Without water
without life
Three important factors
for homeostasis
 Fluid 体液
intra-cellular 40%
extra-cellular 20%
 Electrolyte 电解质
positive ion (+) Na+ K+ Mg2+
negative ion (-) Cl- HCO3- HPO42-
 Osmotic pressure ( OP ) 渗透压
maintain the in/out side of the cells fluid volume
There is a direct ratio between electrolyte concentration and OP
Distribution and amount
of body fluid
 70kg Man Body weight %
3,500ml Plasma Total extracellular
volume 20
10,500 intresticial (Plasma 5
Fluid Int. Fluid 15

28,000 intracellular Total intracellular


volume volume 40

Total 42,000ml Total body fluid 60%


Electrolytes and osmotic pressure
in body fluid

Na+ 142 mmol/L


Cl - 103 mmol/L
Extra- 290-310 mmol/L
HCO3 - 24 mmol/L
OP
K+ 150 mmol/L
Mg+20 mmol/L
HPO42-
290-310 mmol/L
Intra - Protein
OP
Daily volume of digestive fluids and
electrolyte concentration (mmol/L)
volume(ml/24h) Na+ K+ Cl- HCO3-
saliva 1500 10 26 10 30

gastric 1500 60 10 130 0

Small int. 3000 140 5 104 30

pancreatic 100-800 140 5 40 115

bile 800 145 5 100 35


Regulation of fluid balance
and osmotic pressure
 Hypothalamic –posterior pituitary -
antidiuretic hormone (ADH) system:
(下丘脑-垂体后叶-抗利尿激素系统)
Regulating body fluid osmolality

When OP ↑, ADH↑,renal tubule absorption of


water increased ,then urine decreased,the OP
of extra-cellular will be normal again.
Regulation of fluid balance
and osmotic pressure
 Renin – angiotensin-aldosterone system:
(肾素-血管紧张素-醛固酮系统 )
Regulating volume of blood

This regulation is more susceptible to


volume disorders than OP changes
liver
hypotension Re-absorption of
water and BP to
normal

renin aldosterone
kidney

angiotensin

lung

Adrenal
cortex
Angiotensin II
Contrast
vessels Renin – angiotensin-aldosterone
system
Metabolic imbalance of body fluid
 Volume disorders with sodium
 Potassium imbalance
 Calcium (omitted)
 Magnesium (omitted)
 Phosphorus (omitted)
1)Volume disorders with sodium
Isotonic dehydration
等渗性缺水
Hypotonic dehydration
低渗性缺水
Hypertonic dehydration
高渗性缺水
1、Isotonic dehydration
(acute or mixture dehydration)
Etiology
1)acute loss of digestive
fluids (sever vomiting,
diarrhea or digestive
fistula)
2)water depletion in the
water Na+ area of infection or
tissue(sever infection,
gut obstruction and
burn)
dehydration = sodium loss
serum Na+ & OP are normal
Menifastation
1)common feature of dehydration
(anorexia, nausea, fatigue, sunken eyes,
poor skin elasticity)
2)water loss accounts for 5% BW, may
result in shock, 6-7% in sever shock
3)acid-base imbalance
Diagnosis
 The history of acute and massive
depletion of body fluid
 Hypovolemic pictures clinically
 Lab. exams:concentrated blood
(RBC ↑ HCT ↑ and Hb ↑)
serum Na+&Cl- normal
urine specific gravity↑
Treatment
 Etiological therapy
 Infusion:balanced solution or NS 1
 Rehydration: 2

1、 On degree of dehydration 3

(2%; 4-6%; >6%)


2、 by volume loss
3、2000ml(N.S 500)

1 cumulated 2 continued 3 Phisiol. maintain


Three parts of rehydration
 Cumulative (累计损失)
according to the degree of dehydration
2% BW; 4-6%; >6%
 Continuous (继续损失)
according to the amount of fluid loss
 Physical maintenance (生理维持)
2000ml (incl. 500 NS)
2、Hypotonic dehydration
(chronic or secondary dehydration)
Causes:
•Continue depletion of
digestive fluids (e.g
chronic gut obstruction,
vomiting, gastric
decompression)
water Na+ •Sever wound exudate
•Sodium excretion
diuretics
•Add water is more than
Water Lose  Sodium Lose
+ sodium in isotonic
Serum Na ↓ OP↓
dehydration
 Clinical manifestation
nausea, vomiting, dizziness、fatigue,
unclear vision , apathy, coma, oliguria, etc.
 Classification :
 mild:serum Na+ <135mmol/L
 middle: <130mmol/L
 sever: <120mmol/L
Diagnosis
 Disease history
 Lab. examinations
urine: specific gravity <1.010,
Na+ and Cl- ↓
blood: Na+ < 135mmol/L
RBC, Hb, HCT, BUN increased
Treatment
 Etiological therapy
 Add sodium more than water(N.S or Hypertonic saline)
 Formula
Sodium (g )=[142mmol-Na+measured ] x BW x 0.6
17
1/2 volume will be given on the first day, the rest on the second day 。
 Patient with shock, the first step is fluid
resuscitation ,then treat the hypotonic dehydration
3、hypertonic dehydration
(primary dehydration)
etiology
Insufficient intake
Over-lose of water

features
mild:thirsty,2-4% lost
water Na+
middle:extreme thirsty,
4- 6% lost
water lose > sodium lose sever:mind disorders,
Serum Na+,OP 、cellular dehydration over 6% lost
Diagnosis
Disease history
Clinical manifestation
Specific gravity of urine increased
RBC、HB、HCT↑
Serum sodium >150mmol/L
Managements
 Primary disease therapy
 Oral or intravenous supplements:
5%G.S or hypotonic saline (0.45%)
 Every 1% dehydration of BW add 400-
500ml
 Under the serum Na+ value to treat the case
 Maintain the physiologic requirement
2)Potassium imbalance
Hypokalemia (<3.5mmol/L)
Hyperkalemia ( ommited )
Hypokalemia
 Etiology
-Insufficient eating for a long time;
-over excretion of potassium (e.g diuretic
drugs)
-inadequately supplement of K+
-extensive lose of K+ from digestive tract
- K+ transfer to inside of cells ( e.g alkalosis,
massive transfusion of Glucose or Insulin)
Clinical features
 Myasthenia (muscle contractility↓) :limb mus.、
respiratory mus. 、heart (conduction block ,arrhythmia)
 Digestive symptoms: nausea, vomiting, bloating,
paralytic ileus;
 CNS: Irritability, drowsiness, unconsciousness,
coma
 Abnormal ECG : lower T wave and lower ST
segment, or Q-T intervel prolongation; and U wave;
Alkalosis related to hypokalemia :
Mechanism :
1、the cellular exchange between k+ and Na+ H+
increases (3 k+ out of cell, 2 Na+ 1 H+ into cell)
2、 in renal distal tubule the exchange of k+ and
Na+↓; but Na+ and H+↑;
that resulted in hydrogen ion decreased in serum
Treatment
 Etiological thetapy
 Principles for potassium supplement
-amount:based on the degree of K+ lose
usually 40-80mmol/d(3-6g),
-velocity:< 20mmol/h (1.5g /500ml )
-standard :10% potassium chloride
-indication:urine 40ml/h
-time: normally it needs 3-5 days to recover
Acid-base imbalance
Normal physiology
Respiratory acidosis (omitted)
Respiratory alkalosis (omitted)
Metabolic acidosis
Metabolic alkalosis (omitted)
Normal physiology for acid-base balance
 Buffer system: HCO3-/H2CO3=20:1
 Lung: inspiration of O2 & Expiration of
co2
 Kidney :
re-sorption Na+, HCO3-
secretion H+and acidized urine
The most important buffering
 HCO3-/H2CO3=20:1
 Calculate formula :

PH=PK+log* [HCO3-]/[H2CO3]
=6.10+log27/1.35
=6.10+log20
= 7.40
PH is depended on the ratio of [HCO3-]/[H2CO3]
* Logarithm
Metabolic acidosis 代谢性酸中毒
the most common kind of
acid-base imbalances
clinically
Etiology
 Excessive bicarbonate losses:digestive juice contains
rich HCO3-(small intestine、pancreas and bile )
 Increased production of hydrogen ion:
shock, diabetes and drugs (Hydrochloric acid,Chloride)
 Renal dysfunction:
decreased discharge of H+ of renal distal
convoluted tubule;
and decreased re-absorption of HCO3- in proximal
convoluted tubule;
Clinical manifestations
 Fast deep breathing (40-50/min.)
 Cheeks flushing、quick HR
 Tendon reflexes weakened and mental
alteration
 Concomitant dehydration or
shock(hypotension)
Diagnosis

 Disease history;
 Clinical pictures;
 Gas analysis: PH、HCO3-、BE (base
excess);
Treatment
 Etiological treatment (underlying diseases :e.g
shock , intestinal fistula);
 Supplement of body fluid and improve
microcirculation( based on the degree of
dehydration);
 When HCO3- <10mmol/L, sodium bicarbonate
is required under guide of gas analysis
 The formula :
NaHCO3(ml)=[normal val. HCO3--measured val]
× BW × 0.4×20÷12
For example
 A male patient , BW 70kg,with metabolic acidosis,
measured serum HCO3-was 10mmol/L. The needed
amount of HCO3-was calculated as follows:
 NaHCO3(ml)=[24-10] ×70 × 0.4×20÷12
=14 ×70 ×0.4 ×20÷12
=7840÷12 =653ml
 Half of the calculated volume(≈320) given to the patient
within 12 h. According to the gas analysis to determine
if the rest should be transfused to him again.
Summary
 There is a direct ratio (正比)between electrolyte
concentration and OP
 Different type of dehydration with sodium is
depended on the lost amount of water and
electrolyte
 Hypokalemia is a common complication in critical
cases
 Metabolic acidosis is the commonest disorder of
acid-base imbalance clinically
Questions for this chapter
1.What are the three factors to regulate
homeostasis of our body?
2.What is the etiology of metabolic acidosis and
how to diagnose and treat it?
3.What kind of acid-base imbalance will occur in
hypokalemia? Why ?
4.Definition of the three types of dehydration
with sodium?