1. Fluid and Electrolyte Management

2. Suggested Reading Schwartz's Principles of Surgery, 9e Schwartz's Principles of Surgery, 9e F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock Copyright © 2010, 2005, 1999, 1994, 1989, 1984, 1979, 1974, 1969 by The McGraw-Hill Companies, Inc. Chapter 3. Fluid and Electrolyte Management of the Surgical Patient

3. What is the electrolyte composition of the following fluid compartments? Plasma Interstitial Fluid Intracellular Fluid Medical Student Small Group Discussion Topics Fluid and Electrolyte Management

4. What is the composition of the following IV fluids? D5W Normal Saline Solution (0.9% NaCl) D5 ½ NSS (0.45% NaCl) D5 ¼ NSS (0.22% NaCl) Lactated Ringer’s Medical Student Small Group Discussion Topics Fluid and Electrolyte Management

5. What is the electrolyte composition and daily volume for the following gastrointestinal secretions? Gastric Juice Pancreatic Juice Bile Small bowel drainage Distal ileum and cecum drainage Diarrheal stools Medical Student Small Group Discussion Topics Fluid and Electrolyte Management

6. What are the findings for each of the following: ≤15% Volume Deficit 15-30% volume loss 30-40% volume loss >40% volume loss Medical Student Small Group Discussion Topics Fluid and Electrolyte Management

7. A 23 year old female weighing 55 kg is admitted to the hospital after a fall in which she suffered a fractured wrist.

8. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 23 year old female weighing 55 kg is admitted to the hospital after a fall in which she suffered a fractured wrist. Based on her weight, what is her total body water?

9. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 23 year old female weighing 55 kg is admitted to the hospital after a fall in which she suffered a fractured wrist. How does obesity effect body water volume?

10. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management She is maintained NPO while awaiting availability of an operating room. A 23 year old female weighing 55 kg is admitted to the hospital after a fall in which she suffered a fractured wrist.

11. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management How would you calculate the patient’s maintenance IV fluid infusion rate and electrolyte composition? A 23 year old female weighing 55 kg is admitted to the hospital after a fall in which she suffered a fractured wrist.

12. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management What would you write as a maintenance IV fluid order for this patient? A 23 year old female weighing 55 kg is admitted to the hospital after a fall in which she suffered a fractured wrist.

13. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management Problem 1 A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

14. His operative procedure was performed two years previously. His ileostomy usually drains about 800 cc per day. Two days before coming to the hospital he developed crampy abdominal pain, bloating, and began draining large quantities of liquid from his ileostomy. Because of the nausea and two episodes of vomiting, he did not take any food or liquids over the past 24 hours. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

15. What is the usual amount of ileum output into the colon each day? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

16. What are the electrolytes of ileostomy output? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

17. What would be physical examination evidence to estimate the degree of water deficit? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

18. What laboratory tests might you order to assess the degree of dehydration and what alterations would you expect? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

19. What intravenous fluid would you administer to replace the ileostomy output? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 36-year-old man has undergone a total colectomy and proctectomy for ulcerative colitis

20. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management Problem 1 A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

21. The vomit is clear-looking and acidic in taste. He has no abdominal pain. Prior to the vomiting, he had difficulty with solid foods causing a fullness in the stomach and he had been taking only liquids for one week. His heartburn had been aggravated at the time of the fullness, but antacids did not help, he did not seek medical attention until today. He complains of being dizzy when he stands up. His blood pressure changes from 120/90 when lying to 105/75 when standing, his pulse changes from 100 to 130. Serum Sodium is 155 meq/L. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

22. What is the electrolyte composition of gastric contents? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

23. What is the likely acid-base disturbance in this patient? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

24. What is the mechanism for this acid-base disturbance? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

25. What would be the sodium, potassium, and hydrogen ion concentration in the urine (normal, high, low for each)? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

26. What are goals of therapy when attempting to correct this abnormality? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

27. The patient normally weighs 70 Kg. Based on his weight, what is his total body water volume? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

28. Based on his serum Na + level (155 meq/L), what is your estimate of the patients total body water deficit? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

29. What is your strategy for correction of his expected acid base disturbance? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

30. What is your strategy for correction of his likely cation abnormality? Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours.

31. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 45-year-old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours. Based on the previous questions, what IV fluid(s) might you order to correct the patient’s fluid and electrolyte abnormality?

32. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management An 18-year-old man was in a motorcycle collision.

33. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management The patient was not wearing his helmet. He suffered a severe closed head injury with diffuse swelling of both cortices. He remains comatose three days after injury and is noted to have urine output of 500 cc per hour. His serum electrolytes demonstrate a sodium of 155, chloride of 125, potassium of 4.5, and TCO2 of 25.

34. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management An 18-year-old man was in a motorcycle collision. What is the differential diagnosis of hypernatremia?

35. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management An 18-year-old man was in a motorcycle collision. What tests would you order to establish the diagnosis?

36. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management An 18-year-old man was in a motorcycle collision. What is the most likely etiology in this patient?

37. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management An 18-year-old man was in a motorcycle collision. How would you treat this patient?

38. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.

39. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management Upper endoscopy reveals gastritis which is not actively bleeding. She is admitted and given an intravenous of 5% dextrose and 0.2% NACl at 125 cc/hr. Over the next 24 hours her abdomen becomes tense and her urine output is 15 to 20 cc per hour. Her serum sodium has decreased from 132 on admission to 122 and she is less responsive to verbal stimuli. A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.

40. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management What are the possible etiologies of hyponatremia? A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.

41. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management What happens to urine sodium concentrations with the several etiologies listed above? A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.

42. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management What is the most likely etiology is this patient? A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.

43. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management What is the treatment of hyponatremia in this patient? A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.

44. Medical Student Small Group Discussion Topics Fluid and Electrolyte Management Discuss the action of anti-diuretic hormone (ADH) on the kidney A 55-year-old woman with alcoholic cirrhosis and ascites is admitted for upper gastrointestinal bleeding.