Fluids and electrolytes in surgical pt [autosaved]
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Transcript of Fluids and electrolytes in surgical pt [autosaved]
Fluids and electrolytes in
surgical patientsPresented by :
Dr.Abdullah j. Al-Qattan
OUTLINE
1. BODY WATER AND FLUIDS VOLUMES2. OSMOTIC PRESSURE3. SIGNS AND SYMPTOMS OF VOLUME DISTURBANCES4. HYPERNATREMIA AND HYPONATREMIA5. HYPERKALEMIA AND HYPOKALEMIA6. TYPES OF FLUIDS
BODY WATER AND FLUIDS VOLUMES
• TBW IS 50%-60% OF BODY WEIGHT
• TBW IN NEWBORNS IS HIGHR (75%-80%) OF BODY WEIGHT
BODY WATER AND FLUIDS VOLUMES
• 2/3 OF TBW IS INTRACELLULAR FLUID (40% BODY WEIGHT)
• 1/3 OF TBW IS EXTRACELLULAR FLUID (20% BODY WEIGHT)
• EXTRA CELLULAR COMPOSITION :PLASMA (1/4 ECF) , (5% OF BODY WEIGHT)INTERSTITIAL FLUID (3/4 ECF) , ( 15% OF BODY
WEIGHT)
OSMOTIC PRESSURE• THE PHYSIOLOGIC ACTIVITY OF ELECTROLYTES IN SOLUTION
DEPENDS ON THE NUMBER OF PARTICLES PER UNIT VOLUME.
• THE OSMOLALITY OF THE INTRACELLULAR AND EXTRACELLULAR FLUIDS IS MAINTAINED BETWEEN 290 AND 310 MOSM IN EACH COMPARTMENT
• HOW TO CALCULATE SERUM OSMOLARITY ??
QUESTION• WHAT IS THE APPROXIMATE SERUM OSMOLARITY FOR A
PATIENT WITH THE FOLLOWING FINDINGS ?? Na 130 CL 94 K 5.2 CO2 14 GLUCOSE 360 BUN 84 CREATININE 3.2
a) 270b) 290c) 310d) 330
Calculated serum osmolality = (2 sodium) + ✖️(glucose 18) + (BUN 2.8) ➗ ➗
SO = (2 130) + (360 18) + (84 2.8)✖️ ➗ ➗
SO = 310
Schwartzs Principles of Surgery: Absite and Board Review. 9TH ED.
SIGNS AND SYMPTOMBS OF VOLUME DISTURBANCESHYPOVOLEMIC HYPRVOLEMIC
GENERALIZED WEIGHT LOSS WEIGHT GAIN
DECREASE SKIN TURGORE PREIPHERAL EDEMA
CARDIAC TACHYCARDIA INCREASE CARDIAC OUTPUT
ORTHOSTASIS HYPOTENSION
INCREASED CENTRAL VENOUS PRESSURE
COLLAPSED NECK VEINS DISTENDED NECK VEINS
RENAL OLIGURIA ……...
GI ILEUS BOWEL EDEMA
PULMONARY …….. PULMONARY EDEMA
HYPERNATREMIA
• HYPERNATREMIA RESULTS FROM EITHER A LOSS OF FREE WATER OR A GAIN OF SODIUM IN EXCESS OF WATER.
• IT CAN BE ASSOCIATED WITH AN INCREASED, NORMAL, OR DECREASED EXTRACELLULAR VOLUME
WHAT ARE THE CAUSES OF
HYPERNATREMIA ??
SYSTEM BODY HYPERNATREMIA
CENTRAL NERVOUS SYSTEM
RESTLESSNESS, LETHARGY, ATAXIA, IRRITABILITY, TONIC SPASMS, DELIRIUM, SEIZURES, COMA
MUSCULOSKELETAL WEAKNESS
CARDIOVASCULAR TACHYCARDIA, HYPOTENSION, SYNCOPE
TISSUE DRY STICKY MUCOUS MEMBRANES, RED SWOLLEN TONGUE, DECREASED SALIVA AND TEARS
RENAL OLIGURIA
METABOLIC FEVER
CLINICAL MANIFESTATIONS OF HYPERNATREMIA
HYPONATREMIA
• A LOW SERUM SODIUM LEVEL OCCURS WHEN THERE IS AN EXCESS OF EXTRACELLULAR WATER RELATIVE TO SODIUM, EXTRACELLULAR VOLUME CAN BE HIGH, NORMAL, OR LOW
• HYPONATREMIA IS ALWAYS ASSOCIATEDN WITH HYPOOSMOLALITY , IN CASE OF HYPONATREMIA WITHOUT HYPOOSMOLALITY NAMED “PSEUDOHYPONATREMIA”
WHAT ARE THE CAUSES OF
HYPONATREMIA ??
CLINICAL MANIFESTATIONS OF HYPONATREMIA
BODY SYSTEM HYPONATREMIA
CENTRAL NERVOUS SYSTEM HEADACHE, CONFUSION, HYPERACTIVE OR HYPOACTIVE DEEP TENDON REFLEXES, SEIZURES, COMA, INCREASED INTRACRANIAL PRESSURE
MUSCULOSKELETAL WEAKNESS, FATIGUE, MUSCLE CRAMPS
GI ANOREXIA, NAUSEA, VOMITING, WATERY DIARRHEA
CARDIOVASCULAR HYPERTENSION AND BRADYCARDIA IF INTRACRANIAL PRESSURE INCREASES SIGNIFICANTLY
TISSUE LACRIMATION, SALIVATION
RENAL OLIGURIA
HYPERKALEMIA
• HYPERKALEMIA IS DEFINED AS A SERUM POTASSIUM CONCENTRATION ABOVE THE NORMAL RANGE OF 3.5 TO 5.0 MEQ/L.
• IT IS CAUSED BY EXCESSIVE POTASSIUM INTAKE, INCREASED RELEASE OF POTASSIUM FROM CELLS, OR IMPAIRED POTASSIUM EXCRETION BY THE KIDNEYS
CAUSES OF HYPERKALEMIA• INCREASED INTAKE :
POTASSIUM SUPPLEMENTATIONBLOOD TRANSFUSION
• INCREASED RELEASE :ACIDOSISHYPERGLYCEMIA
• IMPAIRED EXCRETION :RENAL FAILURE
CLINICAL MANIFESTATIONS OF HYPERKALEMIA
SYSTEM HYPERKALEMIA
GI NAUSEA/VOMITING, COLIC, DIARRHEA
NEUROMUSCULAR WEAKNESS, PARALYSIS, RESPIRATORY FAILURE
CARDIOVASCULAR ARRHYTHMIA, ARREST
RENAL …..
ECG CHANGES IN HYPERKALEMIA
ECG changes progress as follows :
peaked T – wave >> widening of QRS complex >> prolongation of P-R interval >> loss of P wave >> ST segment depression >> ventricular fibrillation and asystole.
TREATMENT OF HYPERKALEMIA
• POTASSIUM REMOVAL : KAYEXALATE DIALYSIS
• SHIFT POTASSIUM : GLUCOSE 1 AMPULE OF D 5 AND REGULAR INSULIN 5–10 UNITS IV BICARBONATE 1 AMPULE IV
• DECREASE CARDIAC EFFECTS : CALCIUM GLUCONATE 5–10 ML OF 10% SOLUTION
HYPOKALEMIA
• HYPOKALEMIA IS MUCH MORE COMMON THAN HYPERKALEMIA IN THE SURGICAL PATIENT
• IT MAY CAUSED BY INADEQUATE POTASSIUM INTAKE, EXCESSIVE RENAL POTASSIUM EXCRETION, POTASSIUM LOSS IN PATHOLOGIC GI SECRETIONS
CAUSES OF HYPOKALEMIA
• INADEQUATE INTAKE : DIETARY , POTASSIUM FREE INTRAVENOUS FLUID
• EXCESSIVE POTASSIUM EXCRETION : HYPERALDOSTERONISM
• GL LOSSES : DIRECT LOSS OF POTASSIUM FROM GI FLUID “DIARRHEA” RENAL LOSS OF POTASSIUM
CLINICAL MANIFESTATIONS OF HYPOKALEMIA
SYSTEM HYPOKALEMIA
GI ILEUS, CONSTIPATION
NEUROMUSCULAR DECREASED REFLEXES, FATIGUE, WEAKNESS, PARALYSIS
CARDIOVASCULAR ARREST
TREATMENT OF HYPOKALEMIA
• SERUM POTASSIUM LEVEL <4.0 MEQ/L: ASYMPTOMATIC, TOLERATING ENTERAL NUTRITION: KCL 40 MEQ
PER ENTERAL ACCESS OD ASYMPTOMATIC, NOT TOLERATING ENTERAL NUTR. : KCL 20 MEQ
IV Q2H BID SYMPTOMATIC: KCL 20 MEQ IV Q1H × 4 DOSES
RECHECK POTASSIUM LEVEL 2 H AFTER END OF INFUSION; IF <3.5 MEQ/L AND ASYMPTOMATIC, REPLACE AS PER ABOVE PROTOCOL
IV replacement shouldn’t exceed 240mEq/day
IV FLUIDS
FLUID & ELECTROLYTE REQUIREMENTS
The 1st 10 kg >>> 100 ml/kg/day The 2nd 10 kg >>> 50 ml/kg/day Wt. above 20kg >> 20 ml/kg/day
TYPE OF FLUIDS
• IV FLUID MAY CONSIST OF INFUSIONS OF CRYSTALLOID , COLLOID , OR A COMPINATION OF BOTH.
• Crystalloids : Aqueous solutions of LMW salts with or without glucose. most common useing
• Colloids : contain high MW substances such as proteins or large glucose colloids have been shown to improve oxygen transport, myocardial
contractility and cardiac output
CRYSTALLOID SOLUTIONS
• Intravascular half life is 20 – 30 minutes.• The most commonly used fluid is lactated Ringer’s solution: - Generally it has the least effect on ECF composition, and it is the most physiologic solution when large volumes are needed. - Lactate is converted by the liver into bicarbonate.
CRYSTALLOID SOLUTIONS• Normal Saline:
- When given in large volumes, it produces dilutional hyperchloremic acidosis bec. Of its high Na+ & Cl- contents ( Plasma bicarbonate conc. decreases as Cl- conc. Increases). - NS is a preferred solution for hypochloremic metabolic alkalosis and for diluting PRBCs prior to transfusion.
CRYSTALLOID SOLUTIONS• D5W: - Used for replacement of pure water deficits and as a maintenance fluid for patients on sodium restriction.
• Hypertonic 3% saline: - Treatment of severe symptomatic hyponatremia.
COLLOID SOLUTIONS• Intravascular half life 3 – 6 hours.• The substantial cost and occasional complications tend to limit their use.• Generally accepted indications for use: 1- Severe intravascular fluid deficits ( hemorrhagic shock) prior to arrival of blood for transfusion. 2- Severe hypoalbuminaemia or conditions associated with large protein losses such as burns.
COLLOID SOLUTIONS
• Several colloid solutions are generally available.
• They are derived from either plasma proteins or synthetic glucose polymers, and they are supplied in isotonic electrolyte solutions.
REFERENCES
• SCHWARTZS PRINCIPLES OF SURGERY: ABSITE AND BOARD REVIEW. 9TH ED.
• SCHWARTZS PRINCIPLES OF SURGERY 10TH ED• SABISTON TEXTBOOK OF SURGERY 19TH EDITION• KUWAITI BOARD LECTURE , DR.KHAJA
FOR YOUR OPINION AND CONTACTED
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