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Principals of fluids and electrolytes management Ram Elazary, MD General Surgery Department Hadassah Hebrew University Medical Center Campus Ein-Kerem,

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Presentation on theme: "Principals of fluids and electrolytes management Ram Elazary, MD General Surgery Department Hadassah Hebrew University Medical Center Campus Ein-Kerem,"— Presentation transcript:

1 Principals of fluids and electrolytes management Ram Elazary, MD General Surgery Department Hadassah Hebrew University Medical Center Campus Ein-Kerem, Jerusalem

2 Total Body Water body weight%Total body water% Total60100 Intracellular4067 Extracellular2033 Intravascuar58 Interstitial1525

3 Composition of Fluids plasmainterstitialintracellular Cations Na K44150 Ca5310 Mg217 Anions Cl HCO SO411- HPO Protein16540

4 Control of Volume Kidneys maintain constant volume and composition of body fluids – Filtration and reabsorption of Na – Regulation of water excretion in response to ADH Water is freely diffusible – Movement of certain ions and proteins between compartments restricted

5 Control of Volume Effective circulating volume – Portion of ECF that perfuses organs – Usually equates to Intravascular volume Third space loss – Abnormal shift of fluid for Intravascular to tissues eg bowel obst, i/o, pancreatitis

6 Normal Water Exchange Mean daily (ml)Minimal daily (ml) Sensible Urine Intestinal up to liters Sweat up to liters500 Insensible Lungs/Skin (  10%/1 o rise in Temp)

7 Normal source of water ~2000ml-1300 free water intake 700bound to food additional water from catabolism

8 Water and Eletrolytes Exchange Surgical patients prone to disruption: NPO anaesthesia Trauma (surgery) sepsis

9 Fluid and Electrolytes Therapy Surgical patients need: Maintenance volume requirements On going losses Volume excess/deficits Maintenance electrolyte requirements Electrolyte excess/deficits

10 1. Volume Deficit vital signs changes – Blood pressure – Heart rate – CVP Peripheral temperature and capillary filling time urine output low

11 1. Volume Deficit Decreased skin turgor Sunken eyes Oliguria Orthostatic hypotension High BUN/Creatine ratio Plasma Na may be normal

12 Fluids resusitation Adults: 1000 ml Pediatrics: 20 ml/kg Fluids of crystaloids (NS or RL) Repeated dose

13 2. Maintenance Requirements This includes:insensible loss urinary stool losses Body weightFluid required 0-10Kg100ml/kg/d next 10-20Kg50 ml/kg/d subsequent Kg 20ml/kg/d 15ml/Kg/d for elderly

14 70 Kg Man Needs 1 st 10kg x 100mls = 1000mls 2 nd 10kg x 50mls = 500mls Next 50kg x 20mls= 1000mls TOTAL 2500 mls /d

15 Maintenance Electrolyte Requirements Na 1-2mEq/Kg/d K mEq/Kg/d Usually no K given until urine output is adequate Always give K with care, in an infusion slowly - never bolus (max 0.2% KCL through peripheral IV)

16 Na 1gr = 17 mEq K1gr = 13.6 mEq 70 KgH2O2500ml Na70*2 =140 mEq = ~ 9gr K70*1 =70 mEq = ~ 5gr NS + 0.2%KCl 100ml/h

17 fluids composition

18 3. On Going Losses NGT drains fistulae third space losses

19

20 4. Volume Excess Over hydration Mobilization of third space losses Signs weight gain pulmonary edema peripheral edema S3 gallop

21 Fluid and Electrolyte Therapy Goals normal hemodynamic parameters normal electrolyte concentration Method replace deficits normal maintenance requirements ongoing losses

22 Fluid and Electrolyte Therapy Normal maintenance requirements use BW formula On going losses measure all losses in I/O chart estimate third space losses Deficits estimate using vital signs estimate using U/O

23 Fluid and Electrolyte Therapy The best estimate of the volume required is the patients response After therapy started observe vital signs Urine output (0.5mls/Kg/hr) Central venous pressure

24 Time Frame for Replacement Usually correct over 24 hours For ill patients calculate over shorter period and reassess e.g. 1, 2 hours or 3 hours for e op cases Deficits - correct half the amount over the period and reassess

25 Postoperative Fluid Therapy Check IV regimen ordered in op form Assess for deficits by checking I/O chart and vital signs Maintenance requirements calculated Usually K not started Monitor carefully vital signs and urine output

26 Postoperative Fluid Therapy Urine specific gravity may be used( ) CVP useful in difficult situations (5-15 cm H 2 0) Body weight measured in special situation e.g. burns

27 Concentration Changes changes in plasma Na are indicative of abnormal TBW losses in surgery are usually isotonic hypoosmolar condition usually caused by replacement with free water


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