FLUID AND ELECTROLYTE MANAGEMENT
IN A SURGICAL PATIENT
DEBRA C. OLEA
SECOND YEAR RESIDENT
ISAH SHAMUEL V. CENTINO, MD
LEA MARIE D. MAGNO, MD
FIRST YEAR RESIDENTs
Schwartz Principles of Surgery 11th Ed
Current Surgical Therapy 12th Ed
PCS Handbook of Critical Care and Surgical Nutrition 1st Ed
OBJECTIVES
• Know the different fluids and its uses
• Know how to compute and correct the electrolyte deficit and excess
• How to compute and manage fluid excess and deficit
CORRECTION OF LIFE
THREATENING
ELECTROLYTE
ABNORMALITIES
HYPERNATREMIA
• Water deficit
• Hypovolemic patients
• Restore volume with normal saline
• Address the concentration abnormality
• Replace water deficit with hypotonic fluid
• 5% dextrose, 5% dextrose in one- quarter saline, or enterally
administered water.
HYPERNATREMIA
HYPERNATREMIA
• Acute symptomatic hypernatremia
• decrease in serum sodium concentration of no more than 1 mEq/h
and 12 mEq/d
• Chronic hypernatremia
• Slower correction (0.7 mEq/h)
• Overly rapid correction cerebral edema and herniation
HYPERNATREMIA
• If central diabetes insipidus suspected as cause, check urine and
serum osmolarity.
• (+) DI if urine osmolarity <200 mOsm and serum osmolarity >320 mOsm.
• If diabetes insipidus: give DDAVP (Desmopressin), an ADH analogue
• Minirin 100 mcg tablet every 12 hrs
• DDAVP nasal spray 1μg/spray, 2-4 μg BID
• One half of the water deficit should be given over the first 24 hours,
with the remainder given over the next 24 to 48 hours
HYPONATREMIA
• Free water restriction; severe = administration of sodium
• If w/ neurologic symptoms, use 3% Normal Saline
• no more than 1 mEq/L per hour until the serum sodium level
reaches 130 or neurologic symptoms have improved
• Asymptomatic
• increase the sodium level by no more than 0.5 mEq/L per hour to
a maximum increase of 12 mEq/L per day, and even more slowly
in chronic hyponatremia.
HYPONATREMIA
HYPONATREMIA
• Rapid correction pontine myelinolysis, seizures, weakness, paresis,
akinetic movements permanent brain damage and death
HYPONATREMIA
ANDORGUE MADIAS FORMULA
Change in serum Na (mmol/L)=[(Infusate Na + K) – serum Na]/ TBW +1
TBW= (0.6 x BW)
Amount of fluid (mL) = change in Na desired/ estimated change in Na
Drip rate (mL/hr) = amount of fluid/ target no. of hours
HYPERKALEMIA >5.5
• TREATMENT
• Cardiac monitoring indicated
• Renal excretion can be enhanced by the administration of loop diuretics
• K+ binding resins: ex. Kalimate 5g/sachet 3 sachets in 1/2 glass of water BID
• Hemodialysis in renal failure
HYPERKALEMIA >5.5
• TREATMENT
• Calcium gluconate 10% soln, 10mL IV over 2 to 5 minutes
• to decrease myocardial excitability. Does not decrease K levels
• NaHCO3 44 to 132 mEq (1 to 3 amps of 7.5%) IV over 5 min, given
after calcium in a separate line, repeat in 10 to 15 minutes, ff by
infusion of 2 to 3 amps in D5W titrated over 2 to 4 hours
• Insulin 10 to 20 U regular in D10W 500 mL over 1 hour, or 10 U IV
push with 1 amp 50% glucose (25 gm) over 5 mins.
HYPOKALEMIA
K deficit = [(desired K – actual K)/ 0.27] x 100
Desired K = 3.5 (4 if cardiac patients)
• Oral repletion- mild asymptomatic hypokalemia
• IV repletion
• No more than 10 mEq/h in an unmonitored setting
• May be increased to 40 mEq/H by continuous ECG monitoring
HYPOKALEMIA
• Correction:
• No reliable equation to compute for K deficit
• Estimate of K+ deficit:
• If serum K+: 3.0 to 4.0 mEq/L → total deficit: 100 to 200 mEq
• If serum K+: 2.0 to 3.0 mEq/L → total deficit: 200 to 400 mEq
HYPERCALCEMIA
• Symptomatic >12mg/dL; critical level 15 mg/dL
• Repleting the associated volume deficit and then inducing a brisk
diuresis with normal saline.
• Treatment
• Hydration with normal saline
• Diuretics (except thiazide diuretics)
• Chronic therapy
• Bone metastases: biphosphonate therapy
• Paresthesias
HYPOCALCEMIA <2.2
• Artifact of hypoalbuminemia: serum calcium predominantly bound
• to albumin.
For every 1 g /L decrease in albumin, serum Ca decreases by 0.02
mmol/L.
HYPOCALCEMIA <2.2
HYPOCALCEMIA <2.2
• Calcium gluconate 10% soln, 10 – 20 mL IV bolus over 10 to 15
minutes.
• Followed by 6-8 10mL ampules of 10% calcium gluconate in 1L D5W
• Maintenance: Calcium carbonate 1-2g P.O. TID with Vitamin D3
(Calcitriol; brand name: Rolcaltrol) 0.25 mcg capsule/day
HYPERPHOSPHATEMIA
• Phosphate binders
• Sucralfate or aluminum containing antacids
• With hypocalcemia- calcium acetate tablets
HYPOPHOSPHATEMIA
• Serum phosphate < 2.5mg/dl
(Normal levels 2.5-4.5 mg/dl or 0.80- 1.45 mmol/L)
• Classified as
• Moderate: 0.32 – 0.65 mmol/L
• Severe: < 0.32 mmol/L
HYPOPHOSPHATEMIA
HYPERMAGNESEMIA
• Eliminate sources of Mg, correct concurrent volume deficits, and
correct acidosis if present.
• Acute symptoms, calcium chloride (5 to 10 mL)
• Hemodialysis
HYPOMAGNESEMIA
Magnesium deficit = Desired Mg – Actual Mg
1 mg MgSO4 given per 0.1 mmol deficit
Desired Mg = 0.8 (1.0 cardiac)
MANAGING FLUID
EXCESS AND DEFICIT
FLUID STATUS AND THE
MANAGEMENT OF VOLUME
REPLETION AND MAINTENANCE
ASSESSMENT OF FLUID STATUS
• Low effective circulatory volume
• include abnormal mentation
• excessive thirst
• dry mucous membranes
• poor skin turgor
• Tachycardia
• Hypotension
• orthostatic changes in heart rate and blood pressure
• and oliguria
ASSESSMENT OF FLUID STATUS
• Daily weights, serum and urine electrolyte levels, acid-base balance,
and invasive monitoring
• Urine output is an excellent measure of volume status
• adults should produce at least 0.5 mL/kg/hr
• small children should produce nearly 1 to 2 mL/kg/hr
• Indicators of intravascular depletion
• elevated hematocrit, a low serum bicarbonate level with associated base
deficit, a BUN/creatinine (Cr) ratio greater than 20:1 (prerenal azotemia), or a
fractional excretion of sodium (FENa) of less than 1%.
• Renal dysfunction or use of diuretics FENa is not a useful indicator of
volume status.
• Fractional excretion of urea (FEUrea)
• FEUrea less than 35% is suggestive of a prerenal condition.
IDEAL FLUIDS TO USE
• TYPE OF FLUID ADMINISTERED DEPENDS ON:
• PATIENT’S VOLUME STATUS
• TYPE OF CONCENTRATION OR COMPOSITIONAL ABNORMALITY PRESENT
ISOTONIC FLUIDS
• PlasmaLyte, Lactated Ringer’s, and normal saline
• Replacing GI losses and correcting extracellular volume deficit
Lactated Ringer’s Solution
• Slightly hypotonic (130 mEqs lactate)
• Lactate more stable than bicarbonate
• Lactate converted to bicarbonate by the liver
• Preferential in setting of acidosis; for pancreatic, biliary, or small
intestinal losses
• + 20 mEq/L KCl: Large intestinal losses
0.9% Sodium Chloride
• 154 mEq sodium and 154 mEq chloride
• Hyperchloremic metabolic acidosis
• For correcting volume deficits associated with hyponatremia,
hypochloremia, and metabolic alkalosis
Plasma-Lyte
• Closely resembles the electrolyte composition of human plasma +
buffers
• Can address acidosis
• Popular fluid used in surgery
D5 0.45% Sodium Chloride
• For ongoing GI losses and maintenance fluid therapy in the
postoperative period
• Provides free water for insensible losses and enough sodium to aid
the kidneys in adjustment of serum sodium levels
• 5% dextrose
• 200kcal/L
• Maintain osmolality – prevent lysis of RBCs
• Can add potassium if with adequate renal function
HYPERTONIC SALINE (3.5%, 5%, 7.5%)
• Correction of severe sodium deficits
• Closed head injuries
• Increase cerebral perfusion
• Decrease intracranial pressure
• Increased bleeding
• Arteriolar vasodilator
PEDIATRIC FLUID MGT
1. DEFICIT THERAPY
2. MAINTENANCE THERAPY
3. REPLACEMENT THERAPY
FLUID MGT
1. Correction of preexisting deficits: RESUSCITATION
a. Past: unreplaced volume losses
b. Delivered rapidly
c. Example: px given a 2L bolus as initial treatment
2. Replacement of ongoing losses: pay as you go
a. Present: as they are incurred
b. Fluid given based on composition, tonicity of fluid lost
c. Ex: ileostomy losses replaced volume per volume every 4hrs with LR solution
3. Maintenance requirements
a. Future: normal physiologic reqs
b. Ex: daily fluid reqt= kg BW x 30cc/kg/day
ROLE OF COLLOIDS
Colloids for fluid resuscitation: what is
their role in patients with shock?
D Orbegozo Cortes 1, C Santacruz, K Donadello, L Nobile
, F S Taccone
Colloids versus crystalloids for fluid resuscitation
in critically ill people
Sharon R Lewis, Michael W Pritchard, David JW Evans, Andrew R Butler
, Phil Alderson, Andrew F Smith, Ian Roberts, and Cochrane Injuries
Group
Crystalloids and colloids in critical patient
resuscitation
J. Garnacho-Monteroa,
E. Fernández-Mondéjarb, R. Ferrer-Rocac,d, M.E. Herrera-Gutiérreze, J.A.
Lorentef,g,h, S. Ruiz-Santanai, A. Artigasd,j
Haemodynamic response to
crystalloids or colloids in shock: an
exploratory subgroup analysis of a
randomised controlled trial
Nicholas Heming1,2, Souheil Elatrous3, Samir Jaber4
, Anne Sylvie Dumenil5, Joël Cousson6, Xavier
Forceville7, Antoine Kimmoun8, Jean Louis Trouillet9
, Jérôme Fichet10, Nadia Anguel11, Michael Darmon
12, Claude Martin13, Sylvie Chevret14, Djillali Annane
1,2
for the CRISTAL Investigators
Critical Care Alert: Crystalloids vs Colloids for Fluid
Resuscitation in the Intensive Care Unit: A
Systematic Review and Meta-analysis
5/17/2019 Omid Manoochehri, MD , Sean M. Hickey, MD
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