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FLUID AND ELECTROLYTE MANAGEMENT OF calculated base excess, or serum lactate is the most

SURGICAL PATIENT informative measure.


Surgery I Patients whose initial base excess was less than
-6mmol/L and, in some respects more important
than the initial acid-base status, those whose
Pharmacologic Treatment of Shock acidemia did not correct by 24 hours had death rates
The first step in resuscitation of most patients in that exceeded 50%.
shock involves isotonic fluid to expand the plasma Surgeons can use ABG data or consecutive lactate
volume and therefore blood volume, with the measures to monitor patients recovery from the
beneficial consequence that increased return of anaerobic insult of an episode of hemorrhagic
blood to the right-sided cardiac chambers will shock.
increase CO.
Surgeons evaluate the response to volume infusion
Treatment of Hemorrhagic Shock
by monitoring changes in right and left ventricular
filling pressure. After securing a reliable IV access, the first
As a general guideline, full expansion of blood attempts at resuscitation of the patient are made
volume is achieved when CVP exceeds 15mmHg or with balanced electrolyte solutions.
pulmonary artery catheter occlusion pressure Adult patients who do not respond to 2 to 4L of
stabilizes b/n 15 and 20 mmHg. balances electrolyte solution (children are given
Balanced electrolyte solutions are the preferred 20mL/kg) and remain hypotensive usually require
fluids for patients with shock unless they are blood transfusions
anemic with hemoglobin of 7g/dL or less, in w/c
case red cell transfusion is appropriate. Events After Resuscitation From Shock
Ledgerwood demonstrated that those who remain in
Hypovolemic Shock shock after initial isotonic saline infusion are likely
A surgeon treating a patient with shock faces 2 to have ongoing hemorrhage. These patients will
concurrent challenges: require therapeutic procedure that stops the
o 1st Surgeon must restore intravascular bleeding, as well as transfusion of blood.
volume to normal;
o 2nd The surgeon must identify the Initial Evaluation of A Trauma Patient (Circulation)
cause of the patients hypovolemic While steps are being taken to control hemorrhage,
shock and decide whether immediate
at least 2 large-bore IV lines should inserted to
surgical intervention is needed.
allow fluid resuscitation. These lines are generally
Hypotension is the hallmark of sever placed percutaneously in the vessels of the arm.
hypovolemic shock; however, hypotension If the peripheral upper extremity access is
elicits compensatory responses, including
inadequate, alternative routes include placement of
stimulation of neuroendocrine reflexes.
a large-bore venous line in the femoral vein at the
The compensatory response of an individual in groin or cutdown on the greater saphenous vein at
hypovolemic shock parallels the magnitude of the ankle.
the deficit in blood volume The subclavian vein is a poor site of emergency
access in hypovolemic patient and should be used
Clinical Diagnosis of Hemorrhagic Shock only when other sites are not available.
Acidemia is used as a measure in hemorrhagic In small children, intraosseous infusion is the
shock primarily because insufficient oxygen is preferred alternative route if peripheral access
delivered to support aerobic metabolism. cannot be established.
A calculated bicarbonate from an ABG sample that Fluid resuscitation begins with a 1000mL bolus of
is -10 mEq/L or less in a hypovolemic patient is at lactated Ringers solution for an adult and 20mL/kg
risk for death if resuscitation and corrective for a child.
therapies are not implemented. Response to therapy is monitored by clinical
Clinical investigators have already demonstrated indicators, including blood pressure, skin perfusion,
that the severity of hemorrhagic shock in injured urinary output, and mental status. If there is no
patients are related to the patients extent of response or only a transient response to the initial
academia, although it is debated whether pH, bolus, a second bolus should be given. If ongoing
resuscitation is required after 2 boluses, it is likely
that transfusion will be required and should be
initiated early.
It is essential to remember that the primary goal is
control of hemorrhage and that fluid resuscitation is
of value only in active measures to control
hemorrhage in progress.

Initial Treatment of Burns (Resuscitation)


Lactated Ringers solution w/o dextrose is the fluid
of choice , except in children younger than 2 years,
should receive lactated Ringers solution with
5%dextrose.
The initial rate can be rapidly estimated by the
TBSA burn multiplied by the patients wt. in kg and
then dividing by 8. Thus the rate of infusion for an
80kg man with 40% TBSA burn would be:
o (80kg x 40% TBSA) / 8 = 400mL/hour

Rationale for Enteral Nutrition


Initiation if enteral nutrition should occur
immediately after adequate resuscitation, most
readily determined by adequate U/O
The presence of bowel sound and the passage of
flatus or stool are not absolute prerequisites for
initiation of enteral nutrition.
CONCEPTS OF BODY FLUIDS AND C4
ELECTROLYTES The concentration gradient is maintained by ATP-driven
C1 NaK pumps.
Water constitutes approximately 50 to 60% of
TBW.
Lean tissues have higher water content than fat and
bone.
C2
The extracellular (EC) water comprises 20% of
TBW and is divided b/n plasma and interstitial
fluid.
Intracellular (IC) water makes up 40% of an
individuals TBW.

C5
The healthy person consumes an average of 2L of
water/day, 75% from oral intake and the rest is
extracted from solid foods.
Daily water losses include stool and other losses
C3 (sensible and insensible).
To clear the products of metabolism, the kidneys
The EC fluid compartment is balanced b/n Na
must excrete a minimum of 500-800mL or urine per
(main cation), and chloride and bicarbonate (main day.
anion).
The IC fluid compartment is comprised primarily of
K and Mg (cations), and phosphate and proteins
(anions).

EC fluid volume deficit is the most common fluid


disorder in surgical patients.
The most common cause of volume deficit in
surgical patients is a loss of gastrointestinal fluids
sequestration secondary to soft tissue injuries,
burns, and intra-abdominal processes, and can lead
to massive volume deficits.
Hemolysis and crush injuries can disrupt cell
membranes and release intracellular K in the EC
fluid compartment.
Cell Lysis Causes Increase Extracellular Potassium
Concentration.
As cells are destroyed, the large amounts of K
contained in the cells are released into the
C6 extracellular compartment. This can cause
Post-operative patients are particularly prone to significant hyperkalemia if large amount of tissue
increased secretion of ADH w/c increases are destroyed, as occurs with severe muscle injury.
reabsorption of free water from the kidneys w/ C9
subsequent volume expansion and hyponatremia. Acidosis and a rapid rise in EC osmolality from
hyperglycemia or IV mannitol can raise K levels
by causing a shift of K to the EC compartment.
Acid-Base Abnormalities Can Cause Changes in
Potassium Distribution.
Metabolic acidosis increases extracellular K
concentration, in part by causing loss of K from
the cells, whereas metabolic alkalosis decrease
extracellular fluid K concentration. Although the
mechanisms responsible for the effect of hydrogen
ion concentration on K internal distribution are not
completely understood, one of the effect of
increased hydrogen ion concentration is to reduce
the activity of the Na- K ATPase pump. This in
turn decreases cellular uptake of K and raises
C7 extracellular K concentration.
Symptomatic hypernatremia usually occurs only in
patients with impaired thirst or restricted access to
fluid because thirst will result in increased water
intake.
Symptoms are rare until serum Na concentration
exceeds 160mEq/L.
Hypernatremia
Treatment of hypernatremia usually consist of
treatment of the associated water deficit. In
hypovolemic patients, volume should be restored w/
normal saline before the concentration abnormality
is addressed. Once adequate volume has been
achieved, the water deficit is replaced using a
hypotonic fluid such as 5% dextrose, 5% dextrose
in ??? ??? normal saline, or enterally
administered water. The formula used to estimate
the amount of water required to correct C10
hypernatremia is as follows:
Hypokalemia is much more common than
serum sodium140 hyperkalemia in surgical patient.
Water deficit= 140 x TBW It may be caused by inadequate K intake,
excessive K excretion, K loss in pathologic GI
Estimate TBW as 50% in men and 40% in women. secretions, or IC shifts from metabolic alkalosis or
C8 insulin therapy.
C11
The change in K that is associated with alkalosis
can be calculated as: K decrease by 0.3mEq/L
for every 0.1 increase in pH above normal

C14
Lactated Ringers solution is slightly hypotonic in
that it contains 130 mEq/L of lactose.
C12 Lactate is used rather than bicarbonate because it is
Hypercalcemia is defined as a serum Ca level more stable in IV fluids during storage.
above normal range of 8.5 to 10.5mEq/L It is converted into bicarbonate by the liver after
or an increase in ionized Ca level above infusion.
4.2 to 4.8mg/dL. C15
C13 Sodium chloride is mildly hypertonic, containing
In general, neuromuscular and cardiac 154mEq of Na that is balanced by 154
symptoms do not occur until the ionized mEq of Cl.
fraction falls below 2.5mg/dL The Cl concentration imposes significant
Clinical findings may include positive Cl load on the kidneys and may lead to
Chvosteks and Trousseaus signs. hypochloremic metabolic acidosis.
Calcium C16
Normalized Ca level is <4.0mg/dL: The addition of 5% dextrose (50g of
o With gastric access and tolerating dextrose/L) supplies 200kcal/L.
enteral nutrition: Ca carbonate Dextrose is always added to solutions
suspension 1250mg/5mL q6h per containing <0.45% NaCl solution to
gastric access, recheck ionized Ca maintain osmolality and prevent the lysis
level in 3d. of RBC with rapid infusion of hypotonic
o Without gastric access or not fluids.
tolerating enteral nutrition: Ca Alternative resuscitive fluids
gluconate 2g IV over 1h x 1 dose,
-colloid solutions derived from
recheck ionized Ca level in 3d.
carbohydrates and proteins
-have less free water, larger particles
FLUID AND ELECTROLYTE THERAPY IN over electrolyte components of
SURGICAL PATIENT crystalloids
Parenteral solutions -confined to the intravascular space as
-crystalloid fluids with a high volume of plasma expanders
distribution -have four major types with varying
-mainly composed of water with molecular weights: albumin, dextran,
electrolytes and/or glucose hetastarch, and gelatin(plus whole blood
-primary solutions for resuscitation and or PRBCs)
maintenance
C17
The four major types of colloids are
albumin, dextran, hetastarch and
gelatins.
Colloid solutions with smaller particles -addition of albumin or other colloid-containing
and lower molecular weights (MW) exert solutions to inta-opertaive fluid therapy is not
greater oncotic effect but are retained necessary
within the circulation for a shorter period Post-operative fluid requirements
of time than higher MW colloids.
-initial administration of an isotonic solution,
C18 followed by 5% dextrose in 0.45% saline in patients
Hypertonic saline (7.5%) has been used unable to tolerate enteral nutrition
as treatment in patients with closed head -adequacy of resuscitation should be guided by
injuries increases cerebral perfusion restoration of acceptable values of vital signs, U/O,
and decreases ICP. and CVP.

Preoperative fluid requirements


- frequently used formula for calculating the volume
of maintenance of fluids in the absence of pre-
existing abnormalities:
References:
For the first 0 to
10kg Give 100mL/kg/day
For the next 10 to Give an additional
20kg 50mL/kg/day
Give an additional
For wt >20kg 20mL/kg/day
-For example, a 60kg female would receive a total
of 2,300mL of fluid daily:
-1000mL for the 1st 10kg BW (10kg x
100mL/kg/day)
-500mL for the next 20kg (10kg x 50mL/kg/day)
-800mL for the last 40kg (40kg x 20mL/kg/day)
Intra-operative fluid requirements
-replacement of ECF during surgery often requires
500 to 1000mL/hr of balanced NaCl solution to
support homeostasis