Presented by: Dr. Mohd Anuar Bin Awang

Dr. Ainin Tasneem Bt Abdul Rafa

Supervised by:Dr. Norhafiza Bt Ab Rahman

1st July 2014

CONTENT

• Introduction• Fluid compartments & distribution• Principle of fluid therapy• Common electrolytes imbalance, causes &

management• Take home messages• References

INTRODUCTION

• Water & electrolyte balance is crucial for body hemostasis & is one of the most protected physiological mechanism in body• A critical role of kidney is to maintain circulating

volume, plasma osmolality & electrolyte hemostasis within relatively narrow limit• Changes in both fluid volume & electrolyte

composition occur preoperatively, intraoperatively & postoperatively, as well response to trauma or sepsis

MOHD ANUAR

FLUID

TOTAL BODY WATER

• Varies with age, gender and body habitus

FLUID COMPARTMENTS

Total body water (TBW)(70kg man )

42L

ECF1/3 of TBW

14 L

ICF2/3 of TBW

28L

Interstitial fluid¾ of ECF

11 L

Plasma¼ of ECF

3L

TBW =0.6X Body Weight

BODY FLUID COMPOSITION

FLUID EXCHANGE

Volume Composition

Disturbance in Fluid Balance

HypovolumiaHypervolumia

SodiumPotassiumCalcium

MagnesiumPhosphate

FLUID THERAPY

PRINCIPLE OF FLUID THERAPY

1. Correction of existing fluid abnormalities • Fluid resuscitation

• Sepsis (sepsis bundle) – 30 ml/kg• Burn = TBSA(%) x 4 x body weight (kg) – Parkland’s

formula

2. Maintenance of daily requirement• Normal ongoing loss – Sensible & insensible3. Replacement of ongoing abnormal losses4. Reassess the patient ( clinical and laboratory

parameter eg. blood pressure, urine output, central venous pressure )

FLUID MAINTENANCE

100/50/10 rule

•100ml/kg for first 10kg•50ml/kg for next 10kg

•20ml/kg for every kg (divided by 24 for hourly rate)

4/2/1 rule

• 4 ml/kg/H for the first 10kg

• 2 ml/kg/H for next 10kg• 1 ml/kg/H every kg

(total is according to/H)

Average: 30-40 ml/kg/day

CASE ILLUSTRATION

• Mr X is a 50 year old man with weight of 70 kg. He has no known comorbids. He was electively admitted for inguinal repair for reducible right inguinal hernia. He was planned to be kept NBM by 12 midnight.

1) HOW TO CALCULATE FOR FLUID MAINTENANCE FOR HIM?

Using 100/50/20 formula:

•100 x 10kg =1000 ml•50 x 10 kg = 500 ml•20 x 50 kg = 1000 ml

Total = 2500 ml

Using 4/2/1 formula:•4 x 10kg =40 ml/H•2 x 10 kg = 20 ml/H•1 x 50 kg = 50 ml/H

Total 110 ml/H x 24 H = 2640 ml

Using average 35 ml/kg/day: 2450 ml

≈ 5 pints

What type of fluid to give?

To be continued……………….

ROUTE OF ADMINISTRATION

• Enteral• Parenteral

• Crystalloids• Colloids• Blood products

CRYSTALLOID COLLOID

DEFINITION Balanced salt solution, administered intravenously

Plasma expander containing larger insoluble molecules

ADVANTAGES • Cheaper • Easily available• More shelf life• Not disturb coagulation

• Less risk of APO• Ratio of replacement 1:1

DISADVANTAGES • Ratio replacement 1:3• More risk of APO

• Expensive• Disturb coagulopathy

CRYSTALLOID

1) Hypotonic• HS , 1/5 NSD5, 2) Isotonic• NS, HM, D5%3)Hypertonic• D10%, mannitol, 3% NS, NSD5

SODIUM CHLORIDE 0.9%(NORMAL SALINE)

• Isotonic solution (150mmol Na + 150 mmol Cl per litre)• Useful for resuscitation• Potential risk of

hyperchloraemic metabolic acidosis & hypernatraemia where large volume are administered

HARTMANN’S SOLUTION

• Contains Na, K, Ca, Cl & lactate• Most physiological

especially when large volume are required• Useful in resuscitation of

burn patient• However contains

excessive Na, lower level of Cl & can cause metabolic acidosis if being use as the sole fluid

DEXTROSE 5%

• Isotonic solution - No electrolytes• 50 g/L of glucose• Provide modest calories

(1L - 200kcal)• Rapidly metabolized &

distribute evenly throughout the all compartments

COLLOID

• Gelatin based• E.g Gelafundin

• Starch based• E.g. Voluven

AININ TASNEEM

ELECTROLYTES

SODIUM

SODIUM

•Normal requirements: 1 - 2 mmol/kg/day•Normal level: 135 – 145 mmol/L• The major cation of the ECF & therefore the osmotic pressure is governed by sodium concentration

HYPONATREMIA

• Vomiting, diarrhea,• burn• bowel obstruction • third space loss • diuretics• dilutional

related to brain cell swelling •Mild Asymptomatic •Moderate Restlessness, confusion,altered mental state

•Severe Seizure,coma

CAUSESCLINICAL

FEATURES

• Rapid correction of Na may cause central pontine myelinolysis; < 10 mmol/24H for chronic

• Correct Na fast (3mmol/L for first 3 hour) for acute

• Modality of treatment 3% NaCl = 513 mmol/L

0.9 % NaCl = 154 mmol/L

• Change in Se Na=‘Infusate Na – Serum Na

(TBW+1)

• Bolus of 100 ml of 3% hypertonic saline which generally raise serum sodium level by 2-3 mmol/L

MANAGEMENT OF HYPONATREMIA

HYPERNATREMIA

CAUSES

Inadequate water intake, Vomiting,

diarhea, Excessive sweating, diuretics,

salt ingestion,

CLINICAL FEATURES

related with cerebral dehydration; Tremor , irritability, dizziness, weakness , mental confusion, coma

MANAGEMENT

Target fall in serum Na concentration of 10

mmol/L/day Modality of treatment: D5% = 0 mmol/L of

sodium 0.45 % NaCl =77 mmol/L of sodium

POTASSIUM

POTASSIUM

• Requirements : 0.5 – 1 mmol/kg/day•Normal level : 3.5 – 5 mmol/L• Potassium is the main cation within the cell• Its high concentration in cell is being maintained by the Na-K ATPase pump

HYPOKALEMIA

• vomiting,• diarhea • Ileostomy • Sweating• Burn• insulin

treatment• beta agonist• Alkalosis• leucocytosis

K < 2.5 mmol/L

Neuromuscular - weakness - cramps, - paraesthesia - paralysis Gastrointestinal - Constipation- ileusCVS – Arrythmias; AF, VT, VF, Heart block

CAUSESCLINICAL

FEATURES

Oral therapy (K > 2.5 mmol/L):- Mist KCl 15 ml TDS - T. Slow K (1 tablet = 600mg = 8 mmol/L) IV therapy (K < 2.5 mmol/L), ECG changes, symptomatic, unable to take orally:IV KCl, rate: <20 mmol/hr

Fast correction1g KCL in 100cc NS over 1 H

1 g K = 13.3 mmol

K deficit:(Desired value – Patient’s value) x body wt (in kg) x 0.4

13.3K maintainance:

Body weight (in kg) 13.3

Done under cardiac monitoring

MANAGEMENT OF

HYPOKALEMIA

HYPERKALEMIA

• Acidosis• insulin

deficiency• Intravascular

haemolysis• tumour lysis

syndrome• crush injury

Usually occur when K > 6.5 mmol/L

Neuromuscular: Weakness, paraesthesia, areflexia, ascending paralysis

Cardiac: Bradycardia, prolongation of AV conduction, complete heart block, wide complex tachycardia, ventricular fibrillation, assystole

CAUSESCLINICAL

FEATURES

Severe lytic coctail-10 mls 10% IV calcium gluconate- 50 mls IVD50% (30 – 60mins)- 10U rapid acting insulin-Then, maintain with D5%

IV salbutamol 0.5 mgSodium Bicarbonate infusionDialysis

MANAGEMENT OF

HYPERKALEMIA

CASE ILLUSTRATION

• Remember Mr X? Overnight, he started to complaint of pain over affected site with persistent vomiting. His blood investigations were repeated & he was reassessed again.

2) He was put on NBM. What fluid regime to start?

• Fluid maintenance =(100 x 10) + (50 x 10) + (20 x 50) = 2500 ml

• Na maintenance = 1-2 mmol/kg = 70-140 mmol/day

• K maintenance = 0.5-1 mmol/kg = 35-70 mmol/day• Therefore =

• 2 pints NS (0.9% NaCl) = 150 mmol Na + 1 L water

• 3 pints D5% = 1.5 L water + 150 g glucose• 70 mmol KCl = 5.26 g

3) After persistent vomiting, he was noted to be confused. His Na level came back as 111 mmol/L. How to correct his Na level?

• Total body water = 70 x 0.6 = 42 L• He is severely symptomatic Correct Na fast• Correct 3 mmol/L in 3 hour with 3% NaCl• Change in serum Na = Infusate Na – Serum Na

Total body water + 1 = 513 – 111

42 + 1 = 9.35 mmol/L

• To aim for 3 mmol/L elevation = 3 ÷ 9.35 = 0.32 L of 3% NaCl

= 320 ml 3% NaCl over 3 hour

4) His K level came back as 3.0 mmol/L. How to correct his K level?

•K deficit = (4.0 – 3.0) X 70 X 0.4

13.3= 2.1 g•Solution = Fast correction 2 g KCl in 200 ml NS over 2 hours

CALCIUM

CALCIUM

• Requirements : 0.1 mmol/kg/day• Normal level: 8.5 – 10.6 mg/dL; 2.1-2.65 mmol/L• Functions:• Bone density• Muscle contraction• Second messenger for hormones & neurotransmitters• Blood coagulation pathway (intrinsic pathway)

HYPOCALCEMIA

• Hypoparathyroidism• post thyroidectomy• vitamin D deficiency• severe sepsis• Burn• phosphate therapy

• Paraesthesia• circumoral numbness• cramp• Tetany• Dystonia• Convulsion• psychosis

SIGN• Chvostek’s sign• Trousseau’s sign• Dry skin(long standing)

CAUSESCLINICAL

FEATURES

Acute:•10-20ml of IV Ca gluconate 10% dilute in 100 ml NS over 10 min•±IVI at 0.5-2mg/kg/hour (10-50ml of Cal gluconate in 500ml D5% over 4-8 hours)

Long term:•1-2 elemental Cal (Cal lactate/Ca carbonate) TDS•Calcitriol 0.25mcg daily

MANAGEMENT OF HYPOCALCEMIA

HYPERCALCEMIA

CAUSESHyperparathyroidism, . Humoral hypercalcemia of malignancy (Breast ca, SCC, RCC, ovarian

ca),

CLINICAL FEATURES “Stones, bones, abdominal moans, psychic groans”

MANAGEMENT Rehydration & saline diuresis 0.45-0.9% saline, about (3-4 L) for 2-3 daysIV frusemide

Biphosphonates - Pamidronate 30 mg stat dose

Dialysis

• Water constitute 50-60% of body weight• The principal extracellular cation is Na and

principal anion are Cl and HCO3.

• In contrast principal intracellular cation is K and Mg and principal anion is PO4

• In normal individual, fluid balance is achieved through water intake and loss.• Water loss can be divided to insensible and

sensible loss• Extracellular volume deficit is most common fluid

disorder in surgical patient

TAKE HOME MESSAGES

• Most acute surgical illness are accompanied by some degree volume loss or redistribution, thus isotonic fluid administration is most common initial IV fluid given.

• The most important type of hyponatraemia in surgical patients is due to hypovolumia thus management is directed towards replacement of water volume & Na level.

• Symptoms of hypernatraemia are related to hyperosmolarity effect of Na which results in cellular dehydration

• Hypokalaemia is one of the important cause of ileus

REFERENCES

• Schwartz’s Principle of Surgery (9th edition), G. Tom Shires 111, 2010• The Washington Manual of Surgery (6th edition),

Klingensmith et al, 2012• Maintainance and replacement fluid therapy in

adult, H Stern, Uptodate.com, 2014• Sarawak Handbook of Medical Emergencies, 3rd

edition, Soo et al, 2011• Surgicall Recall, 6th edition, Blackbourne, 2012