Fluid & electrolytes

Objectives:
Revision of fluid compartments
Osmotic/oncotic pressure /
osmolality
Fluid shifts in disease
Prescribing fluids

We are
approximately twothirds water

Fluid shifts / intakes

Kidneys

Guts

Lungs

Intracellular
30 litres
Interstitial
9 litres

IV 3
litres

Extracellular fluid - 12 litres

Skin

Osmotic / oncotic pressure

Na+

Na+

PP

Intracellular

Interstitial

Intravascular

Calculation of osmolality
Difficult: measure & add all active
osmoles
Easy = [ sodium x 2 ] + urea +
glucose
Normal = 280 - 290 mosm / kg

The role of ADH:

ADH = urinary concentration
ADH = secreted in response to
osmo;
= secreted in response to vol;
ADH acts on DCT / CD to reabsorb water
Acts via V2 receptors & aquaporin 2
Acts only on WATER

Fluid shifts in disease

Fluid loss:

GI: diarrhoea, vomiting, etc.

renal: diuresis
vascular: haemorrhage
skin: burns

Fluid gain:
Iatrogenic:
Heart / liver / kidney failure:

Prescribing fluids:
Crystalloids:
0.9% saline
5% dextrose
Ringer lactate

Colloids:
blood
plasma / albumin
synthetics

The rules of fluid

replacement:

Replace blood with blood

Replace plasma with colloid
Resuscitate with colloid
Replace ECF depletion with saline
Rehydrate with dextrose

Crystalloids & colloids

2 litres of
blood
30 litres

9 litres

3 litres

Crystalloids & colloids

30 litres

9 litres

5 litres

Crystalloids & colloids

2 litres of
colloid
30 litres

9 litres

3 litres

Crystalloids & colloids

30 litres

9 litres

5 litres

Crystalloids & colloids

29 litres

8 litres

7 litres

Crystalloids & colloids

2 litres of
0.9% saline
30 litres

9 litres

3 litres

Crystalloids & colloids

30 litres

9 litres

5 litres

Crystalloids & colloids

29 litres

10.5 litres

4.5 litres

Crystalloids & colloids

2 litres of
5% dextrose
30 litres

9 litres

3 litres

Crystalloids & colloids

31 litres

9.7 litres

3.3
litres

How much fluid to give ?

What is your starting point ?
Euvolaemia ?
( normal )
Hypovolaemia ? ( dry )
Hypervolaemia ?
( wet )

What are the expected losses ?

What are the expected gains ?

Signs of hypo /
hypervolaemia:
Signs of
Volume depletion Volume overload
Postural hypotension
Tachycardia
Absence of JVP @ 45o
Decreased skin turgor
Dry mucosae
Supine hypotension
Oliguria
Organ failure

Hypertension
Tachycardia
Raised JVP / gallop rhythm
Oedema
Pleural effusions
Pulmonary oedema
Ascites
Organ failure

What are the expected

losses ?
Measurable:
urine ( measure hourly if necessary )
GI ( stool, stoma, drains, tubes )

Insensible:
sweat
exhaled

What are the potential

gains ?
Oral intake:
fluids
nutritional supplements

IV intake:
colloids & crystalloids
drugs

Approach to fluid
calculations

Maintenance fluid
requirement
WEIGHT

FLUID/hr

0 10 Kg

4 ml/kg/hr

10 20 Kg

2 ml/kg/hr

> 20 Kg

1 ml/kg/hr

REGIMEN
5% DEXTROSE 2 LITRES
ISOTONIC SALINE 500ml
KCL 5ml IN EACH FLUID

Fluid therapy in surgical

patients
Why special consideration?
1.Acute stress
2.Increased ACTH /ADH
3.Fluid deficit due to NPO
4.Abnormal blood and fluid loss

Can be divided into..

PRE OPERATIVE
INTRA OPERATIVE
POST OPERATIVE

Pre operative
Maintenance fluid replacement
Replacement of defecit
Replacement of ongoing losses

Intra operative
Maintenance fluid replacement
Replacement of ongoing losses
Replacement of deficit if already
not done

Post operatively
Day

Dextrose

Isotonic saline

First 24 hrs

2 litres

500ml

Second day

2 litres

1000ml

Third day

Similar fluid + 40-60 mEq k /day

Special situations
Vomiting or NG drainage
Causes dehydration with hypokalemia,
hypochloremic metabolic alkalosis
Regimen
Isolyte G
Isotonic saline with 30-40mEq/l KCL

Diarrhea / ileostomy losses

Causes hypokalemia ,hyperchloremia,
metabolic acidosis
Treatment
ORS
None is ideal

Nuerosurgical disorder
Isotonic to hyperosmolar is preferred
to avoid brain edema

Burns
First 24 hrs
Adult ringer lactate without dextrose
Children 5% D RL
Half in first 8 hrs
And other half in next 16 hrs

Burns continued.
24 48 hrs
5 % dextrose
Maintain urine output
After 48 hrs
Maintenance 4-2-1 rule

Examples:
What follows is a series of simple and some more complex fluidbalance problems for you

Case 1:
A 62 year old man is 2 days postcolectomy. He is euvolaemic, and is
allowed to drink 500ml. His urine output is
63 ml/hour:
1. How much IV fluid does he need today ?
2. What type of IV fluid does he need ?

Case 2:
3 days after her admission, a 43 year old
woman with diabetic ketoacidosis has a blood
pressure of 88/46 mmHg & pulse of 110 bpm.
Her charts show that her urine output over the
last 3 days was 26.5 litres, whilst her total
intake was 18 litres:
1. How much fluid does she need to regain a
normal BP ?
2. What fluids would you use ?

Case 3:
An 85 year old man receives IV fluids for 3
days following a stroke; he is not allowed
to eat. He has ankle oedema and a JVP of
+5 cms; his charts reveal a total input of 9
l and a urine output of 6 litres over these 3
days.

1. How much excess fluid does he carry ?

2. What would you do with his IV fluids ?

Case 4:
5 days after a liver transplant, a 48 year old
man has a pyrexia of 40.8oC. His charts for the
last 24 hours reveal:
urine output: 2.7 litres
drain output: 525 ml
nasogastric output:
1.475 litres
blood transfusion: 2 units (350 ml each)
IV crystalloid:
2.5 litres
oral fluids: 500 ml

Case 4 cont:
On examination he is tachycardic; his
supine BP is OK, but you cant sit him up
to check his erect BP. His serum [ Na+ ] is
140 mmol/l.
How much IV fluid does he need ?
What fluid would you use ?