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    Fluid Student 2012

    Uploaded by

    Sara Ilyas Khan
    1) The document discusses fluid and electrolyte balance in the human body, focusing on fluid compartments, electrolyte concentrations, fluid movement, and common abnormalities seen in surgical patients. 2) It provides case examples of patients with various fluid and electrolyte imbalances like hypovolemia, hypervolemia, hyponatremia, and hyperkalemia. For each case, it analyzes the abnormalities, identifies likely causes, and outlines treatment approaches. 3) The key lessons are how to classify different fluid and electrolyte disorders, understand their physiologic causes and impacts, and determine appropriate treatment strategies like fluid resuscitation or restriction, electrolyte replacement, and other interventions.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Fluid Student 2012

    Uploaded by

    Sara Ilyas Khan
    16 views43 pages
    1) The document discusses fluid and electrolyte balance in the human body, focusing on fluid compartments, electrolyte concentrations, fluid movement, and common abnormalities seen in surgical patients. 2) It provides case examples of patients with various fluid and electrolyte imbalances like hypovolemia, hypervolemia, hyponatremia, and hyperkalemia. For each case, it analyzes the abnormalities, identifies likely causes, and outlines treatment approaches. 3) The key lessons are how to classify different fluid and electrolyte disorders, understand their physiologic causes and impacts, and determine appropriate treatment strategies like fluid resuscitation or restriction, electrolyte replacement, and other interventions.

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    fluid balance nd electrolytes

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    1) The document discusses fluid and electrolyte balance in the human body, focusing on fluid compartments, electrolyte concentrations, fluid movement, and common abnormalities seen in surgical patients. 2) It provides case examples of patients with various fluid and electrolyte imbalances like hypovolemia, hypervolemia, hyponatremia, and hyperkalemia. For each case, it analyzes the abnormalities, identifies likely causes, and outlines treatment approaches. 3) The key lessons are how to classify different fluid and electrolyte disorders, understand their physiologic causes and impacts, and determine appropriate treatment strategies like fluid resuscitation or restriction, electrolyte replacement, and other interventions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views43 pages

    Fluid Student 2012

    Uploaded by

    Sara Ilyas Khan
    1) The document discusses fluid and electrolyte balance in the human body, focusing on fluid compartments, electrolyte concentrations, fluid movement, and common abnormalities seen in surgical patients. 2) It provides case examples of patients with various fluid and electrolyte imbalances like hypovolemia, hypervolemia, hyponatremia, and hyperkalemia. For each case, it analyzes the abnormalities, identifies likely causes, and outlines treatment approaches. 3) The key lessons are how to classify different fluid and electrolyte disorders, understand their physiologic causes and impacts, and determine appropriate treatment strategies like fluid resuscitation or restriction, electrolyte replacement, and other interventions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 43

    FLUIDS AND

    ELECTROLYTES FOR
    SURGEONS

    Anil S. Paramesh MD, FACS


    Associate Professor of Surgery and Urology
    Why ?
    Essential for surgeons (and all physicians)
    Knowledge can diagnose, treat and prevent
    many of the problems in surgical patients

    Most abnormalities are


    relatively simple, and many
    iatrogenic
    Fluid Compartments

    Total Body Water


    Relatively constant
    Depends upon fat content and varies with age

    Men 60% (neonate 80%, 70 year old 45%)


    Women 50%
    ICF ECF
    1/3
    2/3 (40% BW) (20% BW)
    Predominant solute Predominant solute
    K+ Na+

    75% interstitial

    25% intravascular

    (5% of BW)

    Its All About Balance

    Gains and Losses


    Most individuals ingest approx 2 2.5 L/day
    Losses
    Sensible and Insensible
    Typical adult, typical day
    Skin 600 ml
    Lungs 400 ml
    Kidneys 1500 ml
    Feces 100 ml

    Balance can be dramatically impacted by


    illness and medical care
    How much fluid can a patient lose if
    a patient could lose fluid?

    Sensible losses
    Blood (most pts can tolerate 500 cc BL)
    Sweat (up to 4 L /day)
    Tears (diarrhea)

    Insensible losses
    Skin 250 cc/day/degree fever
    Trach/vent upto 1500 cc/day
    Peritoneum - > 1/day
    Third spacing
    The image part with relationship ID rId2 was not found in the file.

    I LOVE SALT WATER!



    Electrolytes

    (mEq/L) Plasma Intracellular


    Na 140 12
    K 4 150
    Ca 5 0.0000001
    Mg 2 7
    Cl 103 3
    HCO3 24 10
    Protein 16 40
    Fluid Movement

    Is a continuous process
    Diffusion
    Solutes move from high to low concentration
    Osmosis
    Fluid moves from low to high solute concentration.
    Active Transport
    Solutes kept in high concentration compartment
    Requires ATP
    Movement of Water

    Osmotic activity

    Normal around 300 mOsm/L

    Osmolality determined by concentration of


    solutes

    Plasma (mOsm/L)
    2 X Na + Glc + BUN
    18 2.8
    Fluid Status

    Blood pressure
    Check for orthostatic changes
    Physical exam
    Invasive monitoring
    Arterial line
    CVP
    PA catheter
    Foley
    Volume Deficit

    Most common surgical disorder


    Signs and symptoms
    CNS: sleepiness, apathy, reflexes, coma
    GI: anorexia, N/V, ileus
    CV: orthostatic hypotension, tachycardia with
    peripheral pulses
    Skin: turgor
    Metabolic: temperature
    Hypovolemia
    Acute Volume Depletion

    Determine etiology
    Hemorrhage,
    NG, fistulas,
    Aggressive diuretic therapy
    Third space shifting, burns, crush injuries
    Ascites
    What kind of fluid are we losing?

    Sweat hypotonic (low sodium)


    Insensible loss is pure water
    GI loss is usually isotonic
    Stomach acid, high CL
    Pancreas/bile high HCO3
    Saliva high K
    IV fluids a la carte

    NaCl
    Normal saline (0.9%) has 154 mEq/L Na, 154
    mEq Cl
    Normal has 77 mEq Na/Cl
    Lactated Ringers
    Has 130 Na, 109 Cl (also has some K, Ca,
    lactate)
    D5Water
    Good replacement for insensible losses
    Case 1

    6 month old boy, born full-term


    Developed worsening vomiting during the
    past week
    Today he is listless, irritable, not tolerating
    oral intake
    Pulse 145, BP 70/50
    Diaper is dry, anterior fontanel depressed
    Case 1 Labs

    134 92 12
    2.8 40 0.8

    15
    12.3
    200

    45
    Case 1 F & E Problem List
    134 92 12
    2.8 40 0.8

    Hypovolemia
    Hypochloremia

    Hypokalemia

    Alkalosis
    Treatment Patient weight is 12 kg

    Fluid choice?
    Replace volume
    Replace K/Cl
    How to order
    Bolus
    Think about rate over time
    Adequate access important
    What would maintenance fluid choice and
    rate be?
    4-2-1 rule
    Acid Base Balance

    Acidosis
    May result from decreased perfusion i.e. decreased
    intravascular volume
    K will move out of cells (K+ - H+ exchange)

    Alkalosis
    Complex physiologic response to more chronic
    volume depletion
    i.e. vomiting, NG suction, pyloric stenosis, diuretics
    K will move intracellular
    Paradoxical Aciduria

    Hypochloremic

    Na
    H

    Hypovolemia

    Aldosterone
    activation
    Na

    Loop of Henle

    Case 1 When should we operate?

    Need to wait until adequately resuscitated


    Why

    Monitor by:
    Normalized vital signs
    Good urine output
    Normalized labs
    Case 2

    64 year old, 50 kg, had colon resection 5


    days ago
    doing well .until.
    Suddenly develops atrial fibrillation with rapid
    ventricular response
    P 120, irregular; BP 115/70; RR 20
    Temp 38.7
    Confused, anxious
    Case 2 Labs

    128 100 12
    3.0 22 0.8
    Mg 1.1

    8.9
    16.3
    180

    28
    Case 2
    Diagnoses?

    New onset A fib, why?

    Hypervolemia

    Hyponatremia

    Hypokalemia

    Hypomagnesemia

    Anemia
    Case 2
    Why does patient have hypervolemia?
    Increased Antidiuretic Hormone
    (ADH)

    Causes
    Surgical stress (physiologic)
    Cancers (pancreas, oat cell)
    CNS (trauma, stroke)
    Pulmonary (tumors, asthma, COPD)
    Medications
    Anticonvulsants, antineoplastics, antipsychotics,
    sedatives (morphine)
    Hyponatremia how to classify

    Na loss
    True loss of Na
    Dilutional (water excess)
    Inadequate Na intake
    Classified by extracellular volume
    Hypovolemic (hyponatremia)
    Diuretics, renal, NG, burns
    Isovolemic (hyponatremia)
    Liver failure, heart failure, excessive hypotonic
    IVF
    Hypervolemic (hyponatremia)
    Glucocorticoid deficiency, hypothyroidism
    Patient was receiving maintenance fluids

    D5 0.45NS at 125 ml/hr



    Case 2 - How to treat

    A fib: ACLS protocol


    Correct electrolytes
    Replace Mg and K
    Decrease volume, fluid restriction
    Case 3

    23 year old with jejunostomy


    Had colon and ileum resected due to injury
    Tolerates some oral nutrition, but has high
    output from jejunostomy (2.5 liters per day),
    therefore requires TPN
    P 118, BP 105/60
    Case 3 Labs

    154 114 28
    3.2 16 2.4
    Glucose 213

    Mg 1.4

    9.7
    10.3
    380

    28
    Current Problems

    Hypovolemia
    Increased plasma osmolarity
    2 X 154 + (213/18) + (28/1.8) = 335
    Hypernatremia
    Renal insufficiency
    Acidosis
    Case 3 - Hypovolemia

    Fistula output
    High volumes can rapidly lead to dehydration
    Electrolyte composition can be difficult to
    estimate
    Can send aliquot to laboratory
    May need to be replaced separately from
    maintenance (TPN) fluids
    Hyperglycemia
    Hypernatremia

    Relatively too little H2O


    Free water loss (burns, fever, fistulas)
    Diabetes insipidus (head trauma, surgery,
    infections, neoplasm)
    Dilute urine (Opposite of SIADH)
    Osmotic diuresis
    Nephrogenic DI
    Kidney cannot respond to ADH
    Too much Na, usually iatrogenic
    Hypernatremia

    Free water deficit:


    [0.6 X wt (kg)] X [Serum Na/140 - 1]



    Example:

    Na 154, 60 kg person

    (0.6 X 60) X [(154/140) - 1]



    36 X [1.1 -1]

    36 X 0.1 = 3.6 Liters

    154 114 28
    Case 3 How to Treat 3.2 16 2.4

    Correct hyperglycemia
    Replace pre-existing volume deficits
    Reduce ostomy output if possible
    What to do with:
    Acidosis?
    Hypokalemia?
    Case 4

    58 year old, had a recent kidney transplant


    Laboratory calls with critical value:
    Potassium 5.9

    What to do?
    Case 4

    Evaluate the patient


    Exam
    ECG
    Order repeat labs
    Hyperkalemia - Common Causes

    Hemolyzed specimen

    Underlying disease
    Renal failure
    Rhabdomyolysis

    Associated medications
    Too much K+, ACE inhibitors, beta-blockers,
    antibiotics, chemotherapy, NSAIDS,
    spironolactone
    Potassium and Ph

    Normally 98% intracellular


    Acidosis
    Extracellular H+ increases, H+ moves
    intracellular, forcing K+ extracellular
    Alkalosis
    Intracellular H+ decreases, K+ moves into cells
    (to keep intracellular fluid neutral)
    Hyperkalemia - Treatment

    Emergency (> 6 mEq/l)


    Monitor ECG, VS
    Calcium gluconate IV (arrhythmias)
    Insulin and glucose IV
    Kayexalate, Lasix + IVF, dialysis
    Mild to Moderate
    Mild: dietary restriction, assess medications
    Moderate: Kayexalate
    Severe: dialysis

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