Trauma & Surgical Critical Care

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Trauma & Surgical Critical Care
Fluids & Electrolytes Scott G. Sagraves, MD, FACS Assistant Professor Trauma & Surgical Critical Care

The recognition and management of fluid, electrolyte, and related acid-base problems are common challenges on the surgical service. Lawrence, Essentials of General Surgery

Goals Review concept of total body fluids Review types of crystalloids
Review electrolytes disturbances & their treatment strategies.

Body Fluids 16% 40% 4% Body Water = 60% of a patient’s body weight

Why do you give D5½NS + 20 mEq/L KCl at 125 cc/hr to a patient?

Fluid Requirements typically 35 mL/kg/day
insensible loss = 700 mL/day or 0.2 cc/kg/day for every 1° C > 37° kg = 100 mL/kg/day {4mL/kg/hr} 11-20 kg = 50 mL/kg/day {2mL/kg/hr} > 21 kg = 20 mL/kg/day {1mL/kg/hr} Trick for hourly maintenance = 40 + weight (kg)

Serum Values of Electrolytes
Cations Concentration, mEq/L Sodium Potassium Calcium Magnesium Anions Chloride CO Phosphate

Daily Requirements for Electrolytes
Sodium: 1-2 mEq/kg/d Potassium: mEq/kg/d Calcium: mg/d Magnesium: mg/d Phosphorus: mg/d

IV Solutions Solution Na+ Cl- K+ Ca+2 HCO3- Glu
Plasma NS D5W G LR Serum Osmolality = [2 x Na] + [BUN/2.8] + [glucose/18]

Replacement Strategies
Sweat: D5¼NS + 5 mEq KCl/L Gastric: D5½NS + 20 mEq KCl/L Biliary/pancreatic: LR Small Bowel: LR Colon: LR 3rd space losses: LR

Resuscitation Crystalloids Replace blood loss at a 3:1 ratio
Initial bolus 1-2 liters, usually normal saline If they have transient response, give additional fluids. Once 3-4 liters of crystalloid has been given consider blood.

INDICATORS OF SUCCESSFUL RESUSCITATION
PULSE bpm URINARY OUTPUT CHILDREN = 1.0 ml/kg/hr ADULT = 0.5 ml/kg/hr Clearance of lactate Resolution of base deficit BLOOD PRESSURE POOR INDICATOR

Fluid Status 140 GI loss 120 140 [Na] 160 low normal high ECV SIADH
Hypothyroid Cortisol GI loss 120 CHF Cirrhosis 140 140 [Na] GI Loss Renal loss Osmotic NaHCO3 3% NaCl Seawater 160 DI Insensible low normal high ECV

Renal Regulatory Mechanisms
Aldosterone distal tubules sodium exchanged for K+ and H+ released by volume reduction Antidiuretic Hormone (ADH) increased tubular water reabsorption posterior pituitary release

Acid/base 7.4 Respiratory Metabolic Acidosis Alkalosis BE = 0
HCO3 = 24 Metabolic Acidosis Respiratory Alkalosis 7.4

ABG Rules Rule 1: An increase or decrease in PaCO2 of 10 mm Hg, respectively, is associated with a reciprocal decrease or increase of 0.08 pH units. Rule 2: An increase or decrease in [HCO3-] or 10 mEq/L respectively is associated with a directly related increase or decrease of 0.15 pH units.

Acidosis pH < 7.2 decreased responsiveness to catecholamines
cardiac dysfunction arrhythmias increased potassium serum levels

Case Studies

What do you think? What do you do?
“Found Down” 45 yo WM, found down, presumed to be assaulted, well known to ED for EtOH CT head - hygromas, small ICH labs: Na = 118 K = 2.4 Cl = 74 What do you think? What do you do?

Severe Hyponatremia Correct sodium to above 120 mEq/dl
NaCl + 40 mEq/L KCl 3% Saline furosemide diuresis (euvolemic) serial electrolytes be prepared to handle seizures Replace potassium Cl should correct itself

Hyponatremia 1% of hospitalized are hyponatremic
Neurologic conditions: Seizures, coma, encephalopathy Results from rapid  [Na] Peripheral symptoms: Cramping, twitches, fasciculations Results from ion conduction aberrations

Hints… Na+ deficit (mEq) = (140 – Naserum) x 0.6 x Kg
Glucose increase 100 mg/dL or a BUN increase of 30 mg/dL  decrease of 1.5 – 2 mEq/L Sodium

Central Pontine Myelinosis
Results from overcorrection of sodium Correction of > 25 mEq per hrs Concurrent hypoxia Presence of liver disease Acute correction limit 25 mEq /day Chronic correction limit 10 mEq/day

Treatment Strategies Hypovolemic Hyponatremia
expand intravascular volume 0.9% NS or 3% Hypertonic Saline Hypervolemic Hyponatremia water restriction treat medical condition hemodialysis Euvolemic Hyponatremia SIADH restrict fluid: 7-10 ml/kg/d demeclocycline antagonizes vasopressin

HDU Code A Code Blue is called in the HDU.
65 yo male with ESRD has “arrested” awaiting his dialysis treatment. CPR and BVM resuscitation are in progress and an IV has been established. What do you think? What do you do?

Pre-Arrest Rhythm Strip

“Arrest” Strip

Diagnosis? HYPERKALEMIA
Treatment CaCl2 10% - 1 ampule Sodium Bicarbonate - 1 ampule D50 & Insulin 10 U 2 - agonist nebulizer- cellular K  Kayexalate®

Causes of Hyperkalemia
Renal dysfunction Acidemia Hypoaldosteronism Drugs Excessive intake WBC > 100,000 Platelets > 600,000 Cell Death Rhabdomyolysis Tumor lysis Burns Hemolysis

Potassium Metabolism Normal daily intake 100 mEq
Renal filters & reabsorbs prox. Tubule Potassium  1/[aldosterone] Acidosis  [potassium] with H+ out Alkalosis  [potassium] with H+ in

What do you think? What do you do?
Post op patient 42 year old female admitted to the ICU post op after undergoing a thyroidectomy for thyroid cancer. She is complaining of peri-oral numbness and tingling. Her DTRs are hyperactive and her ECG has a prolonged QT interval. What do you think? What do you do?

HYPOCALCEMIA Chvostek’s sign - facial muscle spasm
Trousseau’s sign - carpal spasm Treatment monitor ECG IV calcium follow up labs oral calcium supplements normal is 1 gram/day

What do you think? What do you do?
Blunt Trauma 23 year old male, s/p MVC with blunt abdominal and orthopedic trauma HD#3 develops fever, N/V, abdominal pain, refractory hypotension, with oliguria. Na+ 130, K- 5.5, Glu 65, pH 7.29 What do you think? What do you do?

Treatment fluid and vasopressor support treat precipitating conditions draw baseline cortisol level administer dexamethasone ACTH stimulation test hydrocortisone 100 mg IV q 8

Hydrocortisone Stimulation Test
Baseline cortisol > 20 - no further therapy test < 15 empiric therapy Administer Cortrosyn 250 g IV Obtain levels 30 & 60 minutes post injection

You are called to the Bedside…
55 yo male, s/p fall with isolated, repaired fractured femur. Pt’s LOC decreased and patient began to seize. EKG showed… What Do You Think? What Do You Do?

Hypomagnesemia Mg plays role in energy metabolism, protein synthesis, cell division, & calcium regulation in muscle. Definition < 1.6 mg/dL Causes: poor diet, diuretics, gut losses, & massive diarrhea, resuscitation.

Mg Rx Replacement Magnesium Sulfate 1 gram = 8 mEq
Infuse at rate of 2 gram/hour Emergency: 2 grams over 5 minutes

What do you think? What do you do?
Closed Head Injury 32 year old female, MVC, GCS -7, intubated, with CT scan showing SAH, cerebral edema. ICP monitor shows a pressure of 27. CPP 55. Over the next several days, Na+ > 150. What do you think? What do you do?

DIABETES INSIPIDUS Signs Treatment [Na+]  150
Urine specific gravity 1.007 polyuria, clear urine dDAVP 1g sq raises urine osmolality in 2 hours Treatment free water deficit = (0.6) x (Kg) x ([Naserum/140] -1) dDAVP 2g sq every 12 hours for every L water deficit [Na+] will rise 3 mEq above 140

What do you think? What do you do?
The transfer 50 year old obese female, transferred for critical care management after a bowel resection. Presents with obtundation, hypotension, tachypnea, and emesis. C/O abdominal pain and has fruity breath amylase, lipase are elevated, Na+ 127 What do you think? What do you do?

Work up? ABG Electrolyte panel urine analysis CBC Serum Ketones

Hyperglycemia Characteristic DKA NKHC Glucose 400-800 > 1000
Acidosis Severe min. Ketones High low Dehydration Mod. High Na  1.6 for every 100  glucose above 200

Treatment Adequate fluid replacement narrowing of anion gap
crystalloids: LR, NS, ½ NS Insulin bolus units/kg infusion 0.1 units/kg/hour goal reduce plasma glucose mg/dL/hr Electrolytes K replacement mEq/hour after UOP OK Mg, PO4 replacement

What do you think? What do you do?
The drunk 37 year old male, h/o EtOH abuse fell from a deer hunting tree stand. C5 fracture without cord involvement. HD #2 develops delirium tremors moved from SIU to ICU. Librium started. HD#4, dobhoff placed and tube feeds started. That night, the patient’s respiratory status worsens and he is intubated. What do you think? What do you do?

HYPOPHOSPHATEMIA “Refeeding Syndrome” Hypophosphatemia malnutrition
alcoholism Hypophosphatemia limits oxygen unloading immunocompromise muscle weakness  failure to wean

Treatment IV supplementation in emergent cases
sodium or potassium phosphorous PO supplementation routinely Keep (phosphorous x calcium) ratio < 60 Magnesium should be replenished simultaneously

The burn patient 25 year male, caught fire after his lawnmower exploded as he was filling it with gasoline while smoking a cigarette. The patient sustained second and third degree burns estimated at 40 % total body surface area.

Parkland Formula 4 cc x WEIGHT (kg) x (% TBSA)

Parkland Example 25 year old male weight = 220 pounds
40% TBSA 2° - 3° burns How much fluid do you need to give? During the first 8 hours? During the next 16 hours?

first 8 hours = 16,000/2 =8,000/8 = 1,000cc/hr
Parkland Example 4 cc x weight x %TBSA 4 x 100 x 40 = 16,000 cc/24 hours first 8 hours = 16,000/2 =8,000/8 = 1,000cc/hr next 16 hours = 8,000/16 = 500cc/hr

What do you think? What do you do?
Diarrhea Dysrhythmia 68 yo female on digoxin for chronic CHF, presents to the SIU for colitis as evidenced by copious diarrhea. The patient is weak and lethargic and ectopic beats are noted on her ECG. What do you think? What do you do?

Hypokalemia Deficits Treatment Serum K =
3-4 is a mEq deficit 2-3 is a mEq deficit Treatment replacement 10 mEq/hr via peripheral IV 10 mEq  0.1 mEq/L increase in serum K Remember to check the Mg level too

Paradoxical Aciduria A rule:  0.1 pH   0.4 - 0.5 mEq [K+]
pathophysiology loss of K, severe alkalosis, [Na+] load hydrogen exchanged for K independent of alkalosis remaining requires emergent replacement

What do you think? What do you do?
Cancer 72 yo female with stage 4, metastatic breast cancer. Patient is confused, cachetic, and nauseated Na+= 147, Ca+2 = 14mg/dl What do you think? What do you do?

HYPERCALCEMIA Treatment Cancers associated with hypercalcemia
bone breast kidney colon thyroid multiple melanoma Treatment hydration diuretics-lasix mithramycin corticosteroids calcitonin- osteoclast resorption phosphate

What do you think? What do you do?
Labor and Delivery 32 year old P3G3 being treated by OB for eclampsia. You are called for a somnolent patient in second-degree heart block and paralysis. What do you think? What do you do?

Hypermagnesemia Signs Treatment Prolonged PR interval
Hypotension, hyporeflexia, paralysis Treatment Calcium gluconate Normal saline Loop diuretics dialysis

Questions?