1. Fluid and Electrolyte Balance during Injury
Zohair Al Aseri. MD. FCEM(UK).FRCPC (EM&CCM) Chairman ,National Emergency Medicine Committee Consultant, ICU Department of Critical Care College of Medicine, King Saud University Medical City. Riyadh, KSA.

2. Fluid and Electrolyte Balance during Injury
Objectives
Understand and inflammatory response to surgery and trauma
Understand normal regulation of fluid balance
Fluid Imbalance In Shock State
Fluid Therapy (Types) & Indication
Electrolyte disturbances in trauma and surgery
Acid base in surgery patients

3. Case 1
39 year old male involved in MVC brought to ED by EMT, he is unconscious, heart rate 120 beat per minute blood pressure of 80/50, intubated in the scene, what is your immediate action
Take further history
Start him on dextrose 5% with NS
Start him in colloid
Start him in Normal saline

4. Case2
A recovery nurse calling you to see a 70 year old male, 7 hours post appendicictomy, because he is drowsy and unresponsive, his vital signs are normal and oxygen saturation 92% on room air? What is the most likely diagnosis?
Intracranial bleeding
Stroke
Acute renal failure
Respiratory failure

5. Case3
70 year old male, admitted for elective hernia repair, kept NPO and started in D5 ½ normal saline 24 hour ago, his current electrolyte showed k of 5 mmol and Na of 128 mmol What is the most likely diagnosis? DI
SAIDH
Acute renal failure
Iatrogenic hyponatremia

6. Fluid and Electrolyte Balance during Injury
May be altered in the surgical patient for several reasons:
Reduced oral fluid intake in the perioperative period
ADH and aldosterone secretion.
Loss from the GI tract (e.g. bowel preparation, ileus, stomas, fistulae).

7. Fluid and Electrolyte Balance during Injury
Insensible losses (e.g. sweating secondary to fever).
Third space losses.
Surgical drains.
Medications (e.g. diuretics).
Underlying chronic illness (e.g. cardiac failure, portal hypertension).

8. Metabolic response to injury, fluid and electrolyte balance and shock
Careful monitoring of fluid balance and thoughtful replacement of net fluid and electrolyte losses is therefore important in the perioperative period.

9. Fluid and Electrolyte Balance during Injury
Normal water and electrolyte balance:
Water forms about 60% of total body weight in men and 55% in women.
Approximately two-thirds is intracellular, one- third extracellular.
Extracellular water is distributed between the plasma and the interstitial space

10. extracellular compartments are separated by water-permeable
Regulation of Fluid Balance
TOTAL BODY FLUID
(40) liters;60%TBW
The intracellular and
extracellular compartments
are separated by
water-permeable
cell membranes.
Plasma volume
(3 liters,5 %)
Red cell volume
(2 liters)
Extracellular
(15 liters,20%)
Intracellular
(25 liters,40%)
Blood volume (5 liters)

11. Fluid & Electrolyte Balance
IC. WATER
ECF
2/3 intrest /3 blood 25
150 15
0.01 2 6 50 Na K Mg Ca Cl
Hco3
Phos
140
4.5
1.2
2.4
100

12. Regulation of Fluid Balance
ECC Osmolarity
ECF Volume
Maintain BP
Prevent swelling or
shrinking of the cells

13. Fluid and Electrolyte Balance during Injury
Osmolality of extracellular fluid
normally mOsmol/kg determined primarily by sodium and chloride ion concentrations.

14. Fluid and Electrolyte Balance during Injury
Normal water and electrolyte balance:
Plasma oncotic pressure is primarily determined by albumin.

15. Fluid and Electrolyte Balance during Injury
Normal water and electrolyte balance:
Aldosterone and ADH facilitate sodium and water retention
Atrial natriuretic peptide (ANP), released in response to hypervolaemia and atria distension stimulates sodium and water excretion.

16. Fluid and Electrolyte Balance during Injury
Normal water and electrolyte balance:
In adults,
Normal daily fluid requirement is 30-35ml / kg (-2500 ml /day).
In newborn babies and children
Contain proportionately more water than adults.
Daily maintenance fluid requirement at birth is about 75ml/ kg, increasing to 150 ml/ kg during the first weeks of life.

17. Fluid and Electrolyte Balance during Injury
Normal water and electrolyte balance:
After first month of life, fluid requirements decrease and the '4/2/1' formula can be used to estimate maintenance fluid requirements:
first l0 kg of body weight requires 4ml /kg/h;
the next 10kg 2ml /kg/ h;
thereafter each kg of body requires 1ml/kg/h.

18. Fluid and Electrolyte Balance during Injury
The estimated maintenance fluid requirements of a 35 kg child would therefore be:
(10 X 4) + (10 X 2) + (15 X 1) = 75 mljh.150 .
The daily requirement for both sodium and potassium in children is about 2-3mmol/kg.

19. Fluid and Electrolyte Balance during Injury
Assessing losses in the surgical patient:

20. Metabolic response to injury, fluid and electrolyte balance and shock
Normal water and electrolyte balance:
ml of fluid is lost via the kidneys, gastrointestinal tract and through evaporation from the skin and respiratory tract
fluid losses are largely replaced through eating and driniking.

21. Fluid and Electrolyte Balance during Injury
Assessing losses in the surgical patient:
Normal Daily Losses and requirements for Fluid and Electrolytes
Volume (ml)
Na+ (mmol)
K+ (mmol)
Urine
2000 80 60
Insensible losses from skin and respiratory tract
700 -
Faeces
300 10
Less water created from metabolism
Total
2700 70

22. Fluid and Electrolyte Balance during Injury
Source of Fluid Loss in Surgical Patients
Typical Losses per 24hrs
Factors Modifying Volume
Insensible Losses ml
Losses associated with pyrexia, sweating and use of non-humidified
Urine ml
With aldosterone and DH secretion;
With diuretic Therapy
Gut ml
Losses with obstruction, ileus, fistulae and diarrhea (may increase substantially)
Third spaces Losses
0-4000ml
Losses with greater extent of surgery and tissue trauma

23. Metabolic response to injury, fluid and electrolyte balance and shock
Normal water and electrolyte balance:
a further ml of water is provided endogenously every 24 hours by the oxidation of carbohydrate and fat.
ln the absence of sweating, almost all sodium loss is via the urine and, under the influence of aldosterone, this can fall to mmol/24 hrs.

24. Metabolic response to injury, fluid and electrolyte balance and shock
Normal water and electrolyte balance:
Potassium is also excreted mainly via the kidney with a small amount (10 mmol / day) lost via the gastrointestinal tract.

25. Metabolic response to injury, fluid and electrolyte balance and shock
Normal water and electrolyte balance:
In severe potassium deficiency, losses can be reduced to about 20 mmol/ day, but increased aldosterone secretion, high urine flow rates and metabolic alkalosis all limit the ability of the kidneys to conserve potassium and predispose to hypokalaemia.

26. Fluid and Electrolyte Balance during Injury
Insensible fluid losses:
Hyperventilation
increases insensible water loss
is not usually large unless the normal mechanisms for humidifying inhaled air (the nasal passages and upper airways) are compromised.
this occurs in intubated patients or in those receiving non­ humidified high-flow oxygen.
In these situations inspired gases should be humidified routinely.

27. Fluid and Electrolyte Balance during Injury
Insensible fluid losses:
Pyrexia
200ml/day for each 1°C rise in temperature.
Sweating
May increase fluid loss by up to 1 litre/hour
Sweat also contains significant amounts of sodium (20- 70mmol/l) and potassium (10mmol/l).

28. Fluid and Electrolyte Balance during Injury
The effect of surgery:
The stress response
ADH leads to water retention and a reduction in urine volume for 2-3days following major surgery.
Aldosterone conserves both sodium and water, further contributing to oliguria.
Urinary sodium excretion falls while urinary potassium excretion increases, predisposing to hypokalaemia.

29. Fluid and Electrolyte Balance during Injury
'Third-space' losses:
if tissue injury is severe, widespread and/or prolonged then the loss of water, electrolytes and colloid particles into the interstitial space can amount to many litres and can significantly decrease circulating blood volume following trauma and surgery.

30. Regulation of Fluid Balance Q=K[(Pc-Pi)-@(Oc-Oi)]
Arteriole
Venule
Pnet =(37-1)+(0-25)=11 17
Mm Hg 37
mm Hg
Oncotic P=25
Interstitial
Hydrostatic P=1
Pnet =(17-1)+(0-25)=-9

31. Fluid and Electrolyte Balance during Injury
'Third-space' losses:
Colloid oncotic pressure throughout the lumen of the capillary is 25mmHg.
The hydrostatic pressure is 1 mmHg in the interstitium.
Hydrostatic pressure on the arteriolar side of the capillary falls from 37 mmHg to 17 mmHg on the venular side.
net outward pressure on the arteriolar side ( = 11)
net inward pressure ( = 9) on the venular side.

32. tending to keep fluid within the capillaries
tending to move fluid out of the capillaries
tending to keep fluid within the capillaries
Regulation of Fluid Balance
Oncotic
pressure
Hydrostatic
pressure
Excess fluid filtered is collected through the lymphatic circulation and returned to the Systemic circulation
THE STARLING EQUATION

33. Fluid and Electrolyte Balance during Injury
Third-space' losses:
Oedema is formed if
hydrostatic pressure increases on the venu­ lar side as in heart failure or
colloid oncotic pressure falls due to liver or kidney disease or
permeability is increased as in sepsis and /or injury.

34. Fluid and Electrolyte Balance during Injury
Loss from the gastrointestinal tract
The magnitude and content of fluid losses depends on the site of loss or lntestinal obstruction.
ln general, the higher an obstruction occurs in the intestine, the greater the fluid loss

35. The approximate daily volumes (ml) and electrolyte concentrations (mmol/l) of various gastrointestinal fluids.
Volume
Na+ K+
Cl-
HCO3
Plasma -
140 5
100 25
Gastric Secretions
2500 50 10 80 40
Intestinal Fluid (Upper)
3000
Bile and Pancreatic secretions
1500 60
Mature ileostomy
500 20
Diarrhoea (Inflammatory)
110
Mixed Gastric Aspirate
120
*If gastrointestinal loss continues for more than 2-3days, samples of fluid and urine should be collected regularly and sent to the laboratory for measurement of electrolyte content. For calculation of electrolyte replacement mixed gastric aspirate composit on can be used for ease of calculation. For example replacement of 2 of nasogastric aspirate would require an additional supply of 240mEg of Na+ and 20 mEq of K+ in addition to the daily requirement.*

36. Fluid and Electrolyte Balance during Injury
Loss from the gastrointestinal tract
Paralytic ileus.
Propulsion in the small intestine ceases, has numerous causes.
Resolves within 1-2days of the operation.

37. Fluid and Electrolyte Balance during Injury
Loss from the gastrointestinal tract:
Intestinal fistula
associated with the greatest fluid and electrolyte losses.

38. Fluid and Electrolyte Balance during Injury
Loss from the gastrointestinal tract:
Diarrhoea.
Patients may present with diarrhoea or develop it during the perioperative period.
Fluid and electrolyte losses may be considerable.

39. Fluid and Electrolyte Balance during Injury
Intravenous fluid administration:
When choosing and administering intravenous fluids it is important to consider:
what fluid deficiencies are present.
fluid compartments requiring replacement.
electrolyte disturbances present .
which fluid is most appropriate.

40. Fluid and Electrolyte Balance during Injury
Types of intravenous fluid:
Dextrose
After the IV administration of 1000 ml 5% dextrose solution, about 670ml of water will be added to the lFC and about 330 ml of water to the EFC, of which about 70ml will be intravascular.
therefore
Dextrose solutions are of little value as resuscitation fluids to expand intravascular volume

42. Fluid and Electrolyte Balance during Injury
Crystalloids
Sodium chloride 0.9%(NS) and Hartmann' s solution (Ringer) are isotonic solutions
Sodium chloride NS 0.9 contains 9g of sodium chloride dissolved in l000ml of water.
(Ringer's lactate) has a more composition, containing lactate, potassium and calcium addition to sodium and chloride ions.

43. Fluid and Electrolyte Balance during Injury
Crystalloids
Both normal saline and Ringer solution
have an osmolality similar to extracellular fluid (about 300m0sm/l)
distribute rapidly to ECF compartment after venous administration .

44. Fluid and Electrolyte Balance during Injury
One liter of isotonic saline contains 154 meq of sodium and an equivalent number of chloride ions.

45. Fluid and Electrolyte Balance during Injury
Balanced solutions, such as Ringer's lactate
closely match the composition of extracellular fluid by providing physiological concentrations of sodium and lactate in place of bicarbonate.
After administration the lactate is metabolized, resulting in bicarbonate generation.

46. Fluid and Electrolyte Balance during Injury
Balanced solutions, such as Ringer's lactate
Decrease the risk of hyperchloraermia, which can occur following large volumes of fluids NS.

47. Fluid and Electrolyte Balance during Injury
Hypertonic saline solutions
Induce a shift of fluid from the IFC to the EFC
Reducing brain water and increasing intra­ vascular volume and serum sodium concentration.
Potential indications
cerebral oedema
raised intracranial pressure
hyponatraemic seizures
'small volume' resuscitation of hypovolaemic shock.

48. Fluid and Electrolyte Balance during Injury
Dextrose saline solutions
Commercially available 5% dextrose with 0.9% normal saline is a hypertonic solution (twice the osmolarity of plasma) and should be used with caution.

49. Fluid and Electrolyte Balance during Injury
Colloids:
albumin or be synthetically modified (e.g. gelatins, hydroxyethyl starches [HES], dextrans).
When administered, colloid remains largely within the intravascular space until the colloid particles are removed by the reticuloendothelial system.

50. Fluid and Electrolyte Balance during Injury
Colloids:
The intravascular half-life is usually between 6 and 24 hours and such solutions are therefore appropriate for fluid resuscitation.
Electrolyte-containing solution distributes throughout the EFC.
But No Evidence

51. Fluid and Electrolyte Balance during Injury
Colloids:
Synthetic colloids are more expensive than crystalloids and have variable side effect profiles.
Recognized risks
Coagulopathy
Reticuloendothelial system dysfunc­tion
Pruritus and anaphylactic reactions
Renal failure when used for resuscitation in patients with septic shock.

52. Fluid and Electrolyte Balance during Injury

53. Fluid and Electrolyte Balance during Injury
Maintenance fluid requirements
under normal conditions, adult daily sodium requirements (80mmol) may be provided by the administration of ml of 0.9% sodium chloride.
The remaining requirement to maintain fluid balance ( ml).., typically provided as 5% dextrose.

54. Fluid and Electrolyte Balance during Injury
Maintenance fluid requirements
Daily potassium requirements (60-80mmol) are usually met by adding potassium chloride to maintenance fluids, but the amount added can be titrated to measured plasma concentrations.
“potassium should not be administered at a rate greater than mmol/h except in severe potassium deficiency.

55. Fluid and Electrolyte Balance during Injury
Maintenance fluid requirement:
The provision of total parenteral nutrition should also be considered in this situation.

56. Fluid and Electrolyte Balance during Injury
Treatment of postoperative hypovolaemia and/or hypotension:
Hpovolaemia is common in the postoperative period and may present with one or more of the following:
tachycardia,
pallor, clammy skin,
collapsed peripheral pulses
oliguria and / or hypotension.

57. Fluid and Electrolyte Balance during Injury
Treatment of postoperative hypovolaemia and/or hypotension:
Intravascular volume should be rapidly restored with a series of fluid boluses (e.g ml) with the clinical response being assessed after each bolus.

58. Crystalloids or colloids in fluid therapy??
Crystalloids Versus Colloids
Crystalloids or colloids in fluid therapy??

59. Fluid and Electrolyte Balance during Injury

60. Fluid and Electrolyte Balance during Injury

61. Thank you ??