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Principals of fluids and electrolytes management

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Presentation on theme: "Principals of fluids and electrolytes management"— 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% Total 60 100
Intracellular 40 67 Extracellular 20 33 Intravascuar 5 8 Interstitial 15 25

3 Composition of Fluids plasma interstitial intracellular Cations
Na K Ca Mg 2 1 7 Anions Cl HCO SO HPO Protein

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 Third space loss
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 liters 500 Insensible Lungs/Skin ( 10%/1 o rise in Temp)

7 Normal source of water ~2000ml - 1300 free water intake
700 bound 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 weight Fluid required 0-10Kg 100ml/kg/d next 10-20Kg 50 ml/kg/d subsequent Kg ml/kg/d 15ml/Kg/d for elderly

14 70 Kg Man Needs 1st 10kg x 100mls = 1000mls 2nd 10kg x 50mls = 500mls
Next 50kg x 20mls= mls TOTAL 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 K 1gr = 13.6 mEq 70 Kg H2O 2500ml Na 70*2 =140 mEq = ~ 9gr K 70*1 =70 mEq = ~ 5gr NS %KCl 100ml/h

17 fluids composition

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


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 H20) 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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