Presented by:

Dr. Mohd Anuar Bin Awang

Dr. Ainin Tasneem Bt Abdul Rafa
Supervised by:
Dr. Norhafiza Bt Ab Rahman
1st July 2014

CONTENT

Introduction
Fluid compartments & distribution
Principle of fluid therapy
Common electrolytes imbalance, causes &
management
Take home messages
References

INTRODUCTION
Water & electrolyte balance is crucial for body
hemostasis & is one of the most protected
physiological mechanism in body
A critical role of kidney is to maintain circulating
volume, plasma osmolality & electrolyte
hemostasis within relatively narrow limit
Changes in both fluid volume & electrolyte
composition occur preoperatively,
intraoperatively & postoperatively, as well
response to trauma or sepsis

FLUID
MOHD ANUAR

TOTAL BODY WATER

Varies with age, gender and body habitus

FLUID COMPARTMENTS

TBW =0.6X Body Weight

Total body water (TBW)
(70kg man )
42L

ECF
1/3 of TBW
14 L

Interstitial fluid
of ECF
11 L

ICF
2/3 of TBW
28L

Plasma
of ECF
3L

BODY FLUID COMPOSITION

FLUID EXCHANGE

Disturbance in Fluid
Balance

Volume

Composition

Hypovolumia
Hypervolumia

Sodium
Potassium
Calcium
Magnesium
Phosphate

FLUID THERAPY

PRINCIPLE OF FLUID THERAPY

1. Correction of existing fluid abnormalities
Fluid resuscitation
Sepsis (sepsis bundle) 30 ml/kg
Burn = TBSA(%) x 4 x body weight (kg) Parklands
formula

2. Maintenance of daily requirement

Normal ongoing loss Sensible & insensible
3. Replacement of ongoing abnormal losses
4. Reassess the patient ( clinical and laboratory
parameter eg. blood pressure, urine output,
central venous pressure )

FLUID MAINTENANCE

100/50/10 rule
100ml/kg for first 10kg
50ml/kg for next 10kg
20ml/kg for every kg (divided
by 24 for hourly rate)

4/2/1 rule
4 ml/kg/H for the first
10kg
2 ml/kg/H for next 10kg
1 ml/kg/H every kg
(total is according to/H)

Average: 30-40 ml/kg/day

CASE ILLUSTRATION
Mr X is a 50 year old man with weight of 70 kg.
He has no known comorbids. He was electively
admitted for inguinal repair for reducible right
inguinal hernia. He was planned to be kept NBM
by 12 midnight.

1) HOW TO CALCULATE FOR FLUID MAINTENANCE

FOR HIM?
Using 100/50/20
formula:
100 x 10kg =1000
ml
50 x 10 kg = 500 ml
20 x 50 kg = 1000
ml

Using 4/2/1 formula:

4 x 10kg =40 ml/H
2 x 10 kg = 20 ml/H
1 x 50 kg = 50 ml/H
Total 110 ml/H x 24 H = 2640
ml

Total = 2500 ml

5
pints
Using average 35 ml/kg/day:

2450 ml

What type of fluid to give?

To be continued.

ROUTE OF ADMINISTRATION
Enteral
Parenteral
Crystalloids
Colloids
Blood products

CRYSTALLOID
DEFINITION

ADVANTAGES

DISADVANTAGES

Balanced salt solution,

administered
intravenously

Cheaper
Easily available
More shelf life
Not disturb coagulation

Ratio replacement 1:3

More risk of APO

COLLOID
Plasma expander
containing larger insoluble
molecules
Less risk of APO
Ratio of replacement 1:1

Expensive
Disturb coagulopathy

CRYSTALLOID

1) Hypotonic
HS , 1/5 NSD5,
2) Isotonic
NS, HM, D5%
3)Hypertonic
D10%, mannitol, 3% NS, NSD5

SODIUM CHLORIDE 0.9%

(NORMAL SALINE)
Isotonic solution (150mmol
Na + 150 mmol Cl per litre)
Useful for resuscitation
Potential risk of
hyperchloraemic metabolic
acidosis & hypernatraemia
where large volume are
administered

HARTMANNS SOLUTION
Contains Na, K, Ca, Cl &
lactate
Most physiological
especially when large
volume are required
Useful in resuscitation of
burn patient
However contains
excessive Na, lower level
of Cl & can cause
metabolic acidosis if
being use as the sole
fluid

DEXTROSE 5%
Isotonic solution - No
electrolytes
50 g/L of glucose
Provide modest calories
(1L - 200kcal)
Rapidly metabolized &
distribute evenly
throughout the all
compartments

COLLOID
Gelatin based
E.g Gelafundin

Starch based
E.g. Voluven

ELECTROLYTES
AININ TASNEEM

SODIUM

SODIUM
Normal requirements: 1 - 2
mmol/kg/day
Normal level: 135 145 mmol/L
The major cation of the ECF &
therefore the osmotic pressure is
governed by sodium concentration

HYPONATREMIA
CAUSES

Vomiting, diarrhea,
burn
bowel obstruction
third space loss
diuretics
dilutional

CLINICAL
FEATURES

related to brain cell

swelling
Mild
Asymptomatic
Moderate Restlessness,
confusion,altered
mental state
Severe
Seizure,coma

 Rapid correction of Na may cause

central pontine myelinolysis; < 10
mmol/24H for chronic
Correct Na fast (3mmol/L for first 3
hour) for acute

MANAGEMENT OF
HYPONATREMIA

Modality of treatment
3% NaCl = 513 mmol/L
0.9 % NaCl = 154 mmol/L
Change in Se Na=
Infusate Na Serum Na
(TBW+1)
Bolus of 100 ml of 3% hypertonic saline
which generally raise serum sodium
level by 2-3 mmol/L

CAUSES
Inadequate water
intake, Vomiting,
diarhea, Excessive
sweating, diuretics,
salt ingestion,

CLINICAL FEATURES
related with cerebral
dehydration; Tremor ,
irritability, dizziness,
weakness , mental
confusion, coma

MANAGEMENT

HYPERNATREMI
A

Target fall in serum Na

concentration of 10
mmol/L/day
Modality of treatment:
D5% = 0 mmol/L of
sodium
0.45 % NaCl =77
mmol/L of sodium

POTASSIUM

POTASSIUM
Requirements : 0.5 1 mmol/kg/day
Normal level : 3.5 5 mmol/L
Potassium is the main cation within
the cell
Its high concentration in cell is being
maintained by the Na-K ATPase pump

HYPOKALEMIA
CAUSES

vomiting,
diarhea
Ileostomy
Sweating
Burn
insulin
treatment
beta agonist
Alkalosis
leucocytosis

CLINICAL
FEATURES
K < 2.5 mmol/L
Neuromuscular
- weakness
- cramps,
- paraesthesia
- paralysis
Gastrointestinal
- Constipation
- ileus
CVS
Arrythmias; AF, VT, VF,
Heart block

Oral therapy (K > 2.5 mmol/L):

- Mist KCl 15 ml TDS
- T. Slow K (1 tablet = 600mg = 8 mmol/L)
IV therapy (K < 2.5 mmol/L), ECG changes,
symptomatic, unable to take orally:
IV KCl, rate: <20 mmol/hr

MANAGEMENT
OF
HYPOKALEMIA

Fast correction
1g KCL in 100cc NS over 1 H
1 g K = 13.3 mmol
K deficit:
(Desired value Patients value) x body wt (in kg) x
0.4
13.3

K maintainance:
Body weight (in kg)
13.3
Done under cardiac monitoring

HYPERKALEMIA
CAUSES

CLINICAL
FEATURES
Usually occur when K > 6.5
mmol/L

Acidosis
insulin
deficiency
Intravascular
haemolysis
tumour lysis
syndrome
crush injury

Neuromuscular:
Weakness, paraesthesia,
areflexia, ascending
paralysis
Cardiac: Bradycardia,
prolongation of AV
conduction, complete heart
block, wide complex
tachycardia, ventricular
fibrillation, assystole

MANAGEMENT
OF
HYPERKALEMIA

Severe lytic coctail

-10 mls 10% IV calcium
gluconate
- 50 mls IVD50% (30
60mins)
- 10U rapid acting insulin
-Then, maintain with D5%
IV salbutamol 0.5 mg
Sodium Bicarbonate infusion
Dialysis

CASE ILLUSTRATION
Remember Mr X? Overnight, he started to
complaint of pain over affected site with
persistent vomiting. His blood investigations were
repeated & he was reassessed again.

2) He was put on NBM. What fluid regime to start?

Fluid maintenance =
(100 x 10) + (50 x 10) + (20 x 50) = 2500 ml
Na maintenance = 1-2 mmol/kg = 70-140
mmol/day
K maintenance = 0.5-1 mmol/kg = 35-70 mmol/day
Therefore
=
2 pints NS (0.9% NaCl) =
=
3 pints D5%
70 mmol KCl
=

150 mmol Na + 1 L water

1.5 L water + 150 g glucose
5.26 g

3) After persistent vomiting, he was noted to be confused. His Na

level came back as 111 mmol/L. How to correct his Na level?

Total body water = 70 x 0.6 = 42 L

He is severely symptomatic Correct Na fast
Correct 3 mmol/L in 3 hour with 3% NaCl
Change in serum Na = Infusate Na Serum Na
Total body water + 1
= 513 111
42 + 1
= 9.35 mmol/L
To aim for 3 mmol/L elevation = 3 9.35
= 0.32 L of 3% NaCl
= 320 ml 3% NaCl over 3 hour

4) His K level came back as 3.0 mmol/L. How to

correct his K level?
K deficit =
(4.0 3.0) X 70 X 0.4
13.3
= 2.1 g
Solution = Fast correction 2 g KCl in 200 ml NS
over 2 hours

CALCIUM

CALCIUM
Requirements : 0.1 mmol/kg/day
Normal level: 8.5 10.6 mg/dL; 2.1-2.65 mmol/L
Functions:

Bone density
Muscle contraction
Second messenger for hormones & neurotransmitters
Blood coagulation pathway (intrinsic pathway)

HYPOCALCEMIA
CLINICAL
FEATURES

CAUSES

Hypoparathyroidism
post thyroidectomy
vitamin D deficiency
severe sepsis
Burn
phosphate therapy

Paraesthesia
circumoral numbness
cramp
Tetany
Dystonia
Convulsion
psychosis

SIGN
Chvosteks sign
Trousseaus sign
Dry skin(long standing)

MANAGEMENT OF
HYPOCALCEMIA

Acute:
10-20ml of IV Ca gluconate
10% dilute in 100 ml NS over
10 min
IVI at 0.5-2mg/kg/hour (1050ml of Cal gluconate in 500ml
D5% over 4-8 hours)
Long term:
1-2 elemental Cal (Cal
lactate/Ca carbonate) TDS
Calcitriol 0.25mcg daily

CAUSES
Hyperparathyroidism, .
Humoral hypercalcemia
of malignancy (Breast
ca, SCC, RCC, ovarian
ca),

HYPERCALCEMIA

CLINICAL FEATURES
Stones, bones,
abdominal moans,
psychic groans

MANAGEMENT
Rehydration & saline
diuresis
0.45-0.9% saline, about
(3-4 L) for 2-3 days
IV frusemide
Biphosphonates Pamidronate 30 mg
stat dose
Dialysis

TAKE HOME MESSAGES

Water constitute 50-60% of body weight
The principal extracellular cation is Na and
principal anion are Cl and HCO3.
In contrast principal intracellular cation is K and
Mg and principal anion is PO4
In normal individual, fluid balance is achieved
through water intake and loss.
Water loss can be divided to insensible and
sensible loss
Extracellular volume deficit is most common fluid
disorder in surgical patient

 Most acute surgical illness are accompanied by some

degree volume loss or redistribution, thus isotonic
fluid administration is most common initial IV fluid
given.
The most important type of hyponatraemia in surgical
patients is due to hypovolumia thus management is
directed towards replacement of water volume & Na
level.
Symptoms of hypernatraemia are related to
hyperosmolarity effect of Na which results in cellular
dehydration
Hypokalaemia is one of the important cause of ileus

REFERENCES
Schwartzs Principle of Surgery (9th edition), G.
Tom Shires 111, 2010
The Washington Manual of Surgery (6th edition),
Klingensmith et al, 2012
Maintainance and replacement fluid therapy in
adult, H Stern, Uptodate.com, 2014
Sarawak Handbook of Medical Emergencies, 3rd
edition, Soo et al, 2011
Surgicall Recall, 6th edition, Blackbourne, 2012