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FLUIDS AND
ELECTROLYTES
IN SURGICAL PATIENT
SUPERVISOR : DR
ALIFF
PRESENTER :
MOHD RIFAIE
CHAN XIN HUI
NORMAZIAH

OUTLINES

BASIC PHYSIOLOGY
FLUID
RESUCITATION
COLLOID VS
CRYSTALLOIDS
ELECTROLYTE
IMBALANCE
TAKE HOME
MESSAGE

BASIC
PHYSIOLOGY

TOTAL BODY WATER (TBW)

Water constitutes appraximately 5060% of TBW
It varies according to age, gender
and BMI

Fluid compartments

Water and electrolyte

exchange
Surgical patients prone to
disruption
Nil orally
Anaesthesia
Trauma
Sepsis
Major surgeries

Fluid and electrolyte

therapy
Surgical patients need:
Maintenance volume
requirements
On going losses
Maintenance electrolyte
requirements

FLUID
RESUSCITATION

Fluid resuscitation
Definition
Medical practice of replenishing
bodilyfluidlost through sweating,
bleeding,fluidshifts or other pathologic
processes.
Aim
To restore adequate blood pressure and
perfusion by using
Colloids
crystalloids

Clinical features of
dehydration
Key point to note
History

Mental status

Blood
pressure

Skin turgor

Capillary refill
time

Sunken eyes

Respiratory
rate

Mucosa/toung
e

Urine output

Pulse volume

Limb
warmness

Serum
electrolyte

Total fluid requirement

Fluid requirements vary between
individuals
Maintenance + deficit
Adult :30-40cc/kg/24hr
Deficit : Sweat, saliva, urine, bleeding from
surgical procedure
Children: holliday segar formula
First 10 kg : 100 ml/ kg/day or 4ml /kg/hr
Second 10 kg : 50 ml/kg/day or 2 ml/kg/hr
Subsequent kgs : 20 ml /kg/day or 1 ml/kg/hr

Crystalloids
Balanced salt solution
Contain electrolytes (e.g sodium,
potassium, calcium, chloride)
classified according to their
tonicity.

Solution

Osmolarity
(mOsm/L)

Na
(mmol/
L)

Cl
(mmol/
L)

K
(mmol/L)

Ca
(mmol/L)

Glucose
(g/L)

Lactate
(mmol/L
)

NS

154

77

77

Dextrose
5%

278

50

Hartmann
s

278

131

111

29

NS D5%

296

30.8

30.8

42.3

Normal
Saline

308

154

154

Dextrose
Saline

586

154

154

50

Sodium
Chloride3
%

1027

513

Normal osmolarity(isotonic)
275300(mOsm/L)

513

Hypotonic <250 (mOsm/L)

Hypertonic >375 (mOsm/L)

Colloids
Solution that contain electrolytes (e.g
sodium, potassium, calcium, chloride)
with higher molecular size solution
compared to crystalloid
higher oncotic pressure. (30k
dalton)
longer duration of action (6h) : the
molecules remain within the
intravascular space longer.

types of colloid
Starch
Non starch
Type

Advantage

Disadvantag
e

Type

Advantage

Disadvantage

Human
albumin
solution

Expensive
overload

Hetastarch

Higher
degree of
plasma
expender

Renal
impairment
Anyphylactic
Coagulapthy

Gelatins
(gelafusine)
& Polygeline
(Haemaccel)

No effect on
renal
impairment

Anyphylact
ic
Coagulapt
hy

Pentastarch

Higher
degree of
plasma
expender

Renal
impairment
Anyphylactic
Coagulapthy

Hydroxyethyl
Starch
(VOLUVEN
6% )

Hypoallergeni
c
Less effect on
coagulopathy

Overload
Renal
impairmen
t

Dextran

Improve
periphery
perfusion as
well

Anyphylactic
Coagulapthy
Interference
with crossmatch
Precipitation
of acute
renal failure

Hypoallerge
nic
Higher
degree of
plasma
expender

Summary of
Crystalloid vs Colloid
Compariso
n
Advantages

Crystalloid
Cheap
Accessible

Disadvantag Short half life

es
Larger volume
required for
resusitation

Colloid
Longer half life
Smaller volume
required to expand
intravascular volume
Expensive
Risk of allergic
reaction
Disturb coagulation
cascade
Interfere the cross
match

ELECTROLYTES
IMBALANCES

HYPOKALEMIA
Defined as potassium level less than 3.5mmol/L
Causes : increased K loss, decreased K intake,
redistribution into cells
Symptoms:

Weakness ,hyporeflexia, paralysis

Constipation, ileus
Metabolic acidosis
Arythmia
Ecg changes

Correction of K
Daily requirement : 1 mmol/kgBB/day
Total requirement: maintanance + deficit
Eg :
A 60kg man with K 2.8mmol/L
1. Deficit : (3.5-2.8) X 60 X 0.4 = 16.8mmol
2. Maintenance : 1 x 60 = 60 mmol/L/day
3. Total = 16.8 mmol/L + 60 mmol/L= 76.8mmol/L

1g KCl : 13.4 mmol/L

So
76.8 mmol/13.4 = 5.7 g

Treatment
Treat the cause (eg correction of alkalosis)
Oral therapy : (mild and moderate
hypokalemia)
MIST KCL 15mls : 13mmol = 1g K * give in 2-3 divided
dose
T. Slow K (1 tab : 8mmol) = 600mg K* can give 1-2 tablet
in 2-3 divided dose
IV Therapy (severe)
1g KCL in 100cc over 1hour or 2g KCL in 200cc over 2
hour
Make sure take ecg /cardiac monitoring
To repeat BUSE 1 hour post correction
Maintanance of KCL In IVD

HYPERKALEMIA
Defined as potassium level > 5.5 mmol/L
Causes : decrease K excretion, tissue breakdown,
shift of K out of cells.
Symptoms :

Weakness, paraesthesia
Nausea or vomiting
Frank paralysis
Dyspnea
Bradycardia

Treatment
Moderate hyperkalemia + no
ECG changes
Oral kalimate 15-30mg daily in 2-3 divided
dose
Remove drug induced hyperkalemia
Severe hyperkalemia
Lytic cocktail (with cardiac monitoring)
IV 10cc of 10% calcium gluconate
IV 50cc of D50%
IV 10u actrapid
Dialysis in refractory hyperkalemia

HYPOCALCEMIA
Defined as serum Calcium <2.1
mmol/L
Causes :
o Hypoparathyroidism
o Acute severe pancreatitis
o Hypoalbuminemia
o Severe sepsis
o Burn
o Chronic renal failure

Manifestation

Numbness of fingertip
Perioral paraesthesiae
Chovsteks sign
Trousseaus sign
Irritable
Seizures
Colic , dysphagia
Perioral paraesthesiae
Impaired orientation
Cardiomyopathy

Treatment
Asymptomatic
Calcium carbonate
Vitamin D
Symptomatic

Iv calcium gluconate
- bolus 10-20ml IV calcium gluconate 10%
- Followed by infusion at 0.5-2mg/kg/hr
*correct Magnesium if low
*cardiac monitor during Ca infusion

HYPERCALCEMIA
Defined as Calcium level >2.65mol/L
Causes:
Hyperparathyroidism
Malignant disease
Other endocrine disease eg : thyrotoxicosis,
addisons disease

Symptoms :
Nausea, vomitting,constipation
Polyuria, hypertension
Bone pain
Depression, headache, confusion,coma

Management
Rehydration and saline diuresis
o Iv drip 4-6L NS
o Iv frusemide

Biphosponates
o IV Pamidronate
o Single dose 30-90 mg in 1L of 0.9%
saline infused over 4hrs

HYPONATREMIA
Serum sodium < 135mmol/L

CAUSES
- Drugs
- Sodium loss
- SIADH
- Kidney, liver
and
heart disease
- Dehydration

SYMPTOMS
Mild

asymptomatic
Moderate Nausea
headache
Vomitting
Severe
- Respiratory
distress
Somnolen
Confusion
Seizures

Management
Asymptomatic hyponatremia
Oral sodium replacement
Mist Sodium Chloride 5-10ml in 2 to 3 divided
dose
All NS IV drip
Severe/Symptomatic hyponatremia
USE HYPERTONIC SALINE 3% (256.5mmol Na in
each pint)
Aim is to increase sodium level by 1.0 to 1.5 mmol
in 3 hours (0.5-1mmol/H)
100cc of hypertonic saline 3% will increase sodium
level by 1mmol
Infuse 100cc over 4-6 hour
Repeat until patient asymptomatic or Na > 125

HYPERNATREMIA
Defined as sodium level >
145mmol/LInadequate water intake
Causes :
Fluid loss

GI : vomiting, diarrhea, fistula

Skin : excesscive sweating
Renal : D.I , diuretic therapy

Salt gain
Excessive Na intake
Mineralocorticoid excess :
hyperaldosteronsim, Cushings
syndrome

Manifestation

Thirst
Lethargy
Sign of dehydration
Neurological dysfunction due to
dehydration of brain cells eg
fasciculation, seizure, coma

Management
Give water orally if possible
D5% IV slowly guided by urine output
and plasma Na
Avoid hypertonic solution

Take home message

Start fluid resuscitation with 20cc/kg/BW
(bolus then reassess max 3x) if pediatrics
use holliday segar formula
Normal saline is more preferable as
maintanance: prolonged used of hartman
lactate acidosis
Hartman is more preferable as fluid
resuscitation in acute fluid loses : contains
lactate prevent acidosis by mitigates
changes inblood PH (Alexis Hartmann)

Reference
1) Intraoperative Fluid Management
and Blood Transfusion Essentials.
Glenn P. Gravlee, M.D. Department
of Anesthesiology University of
Colorado Denver and Health
Sciences Center
2) Sarawak HandBook of Medical
Emergencies
3) Guidelines for the rational use of
blood and blood product. National