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Fluid and Electrolyte Management of the Surgical Patient

Fluid and Electrolyte Management of the Surgical Patient. Dr Abdollahi Afshar Hospital. Fluid therapy is often poorly taught, poorly understood and poorly done.

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Fluid and Electrolyte Management of the Surgical Patient

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  1. Fluid and Electrolyte Management of the Surgical Patient Dr Abdollahi Afshar Hospital

  2. Fluid therapy is often poorly taught, poorly understood and poorly done

  3. ‘Fluid therapy should be directed not only to effective volume expansion of a leaky circulation but also to micro vascular protection’.

  4. Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively, and post operatively, as well as in response to trauma and sepsis.

  5. Total Body Water Who is having higher proportion of body weight as water? And Why? 􀁻Males or Females 􀁻Lean or Obese 􀁻Young or elderly

  6. Body Fluid Compartments: ICF: 55%~75% • Male (55%) > female (45%) • Most concentrated in skeletal muscle • TBW=0.6xBW • ICF=0.4xBW • ECF=0.2xBW 2/3 X 50~70% lean body weight TBW Extravascular Interstitial fluid 3/4 1/3 ECF Intravascular plasma 1/4

  7. Total body water (TBW) • TBW varies with age ,gender and body habitus • In adult males= 55% of body weight • In adult female=45% of body weight • In infant = 80% of body weight • Obese patients have less TBW per Kg than lean body adult.

  8. Body compartment fluid 1= Intracellular fluid (ICF)=55% TBW or 30%-40% BW 2= Extracellular fluid (ECF) =45%TBW or 20% BW • Interstitial fluid =15% of body weight • Intravascular fluid or plasma volume = 5% of body weight.

  9. Example: men with 70kg • TBW= 55%70 =38.5 L • ICF = 55% 38.5 =21.2L • ECF = 45% 38.5=17.3L • ISF = 15%  70 = 10.5L • PV = 5%  70 =3.5L

  10. Fluid compartments ICF

  11. Fluid compartments ICF Plasma Interstitial ECF

  12. Fluid compartments ICF Plasma Interstitial ECF

  13. Fluid compartments Capillary Membrane ICF Plasma Interstitial ECF

  14. Fluid compartments Capillary Membrane ICF Plasma Interstitial ECF

  15. Fluid compartments Capillary Membrane Cell Membrane ICF Plasma Interstitial ECF

  16. Colloid osmotic pressure Capillary Membrane Capillary membrane freely permeable to water and electrolytes but not to large molecules such as proteins (albumin). Plasma Interstitial ECF

  17. Colloid osmotic pressure Capillary Membrane Capillary membrane freely permeable to water and electrolytes but not to large molecules such as proteins (albumin). Plasma Interstitial ECF

  18. Colloid osmotic pressure Capillary Membrane Capillary membrane freely permeable to water and electrolytes but not to large molecules such as proteins (albumin). The albumin on the plasma side gives rise to a colloid osmotic pressure gradient favouring movement of water into the plasma H2O Plasma Interstitial H2O ECF

  19. Colloid osmotic pressure Capillary Membrane Capillary membrane freely permeable to water and electrolytes but not to large molecules such as proteins (albumin). The albumin on the plasma side gives rise to a colloid osmotic pressure gradient favouring movement of water into the plasma This is balanced out by the hydrostatic pressure difference H2O H2O Plasma Interstitial H2O 120/80 H2O ECF

  20. Cell Membrane Cell Membrane H2O ICF H2O Interstitial Cell membrane is freely permeable to H20 but

  21. Cell Membrane Cell Membrane H2O ICF H2O Interstitial Na+ K+ Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient!

  22. Cell Membrane Cell Membrane H2O ICF H2O Interstitial Na- K+ [K+] =4 Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient!

  23. Cell Membrane Cell Membrane H2O ICF H2O Interstitial Na- K+ [K+] =150 [K+] =4 Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient!

  24. Cell Membrane Cell Membrane H2O Na+= 144 ICF H2O Interstitial Na- K+ [K+] =150 [K+] =4 Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient!

  25. Cell Membrane Cell Membrane H2O Na+= 10 Na+= 144 ICF H2O Interstitial Na- K+ [K+] =150 [K+] =4 Cell membrane is freely permeable to H20 but Na and K are pumped across this membrane to maintain a gradient!

  26. Composition of Fluid Compartments 200 mEq/L 200 mEq/L 154 mEq/L 154 mEq/L 153 mEq/L 153 mEq/L CATIONS ANIONS K+ 150 HPO4 150 504— HCO3- 10 Mg++ 40 Protein 40 Na+ 10 CATIONS ANIONS Na+ 142 Cl - 103 HC03- 27 504— 3 PO4--- K+ 4 organic Ca++ 5 Acid 5 Mg++ 3 Protein 16 CATIONS ANIONS Na+ 144 Cl - 114 HC03- 30 504— K+ 4 3 PO4--- organic Ca++ 3 Acid 5 Mg++ 2 Protein 1 PLASMA INTERSTITAL FLID INTRACELLULAR FLID

  27. Cations Anions 150 Na+ 100 Cl- ECF 50 HCO3- 0 K+ Protein Ca 2+ Mg 2+ PO43- Organic anion 50 ICF 100 150 Composition of Body Fluids: Osmolarity = solute/(solute+solvent) Osmolality = solute/solvent (290~310mOsm/L) Tonicity = effective osmolality Plasma osmolility = 2 x (Na) + (Glucose/18) + (Urea/2.8) Plasma tonicity = 2 x (Na) + (Glucose/18)

  28. عوامل موثر روی تغییرات آب والکترولیت • نوع عمل جراحی (میزان خونریزی- تبخیر آب – حجم فضای سوم ) • وضعیت آب والکترولیت قبل از عمل • بیماریهای همراه (اندوکرینوپاتی( • اثر داروهای بیهوشی (نسدونال- پروپوفل- MR- RA)

  29. Reasons for fluid therapy • Preserve oxygen delivery to tissues • Correct hypovolaemia • Maintain cardiac output • Optimise gas exchange • Replace electrolytes & water • Maintain urine output Colloids + RBCs Crystalloids Identify what is the goal Choose fluid which best achieves the goal

  30. ارزیابی حجم مایع داخل عروقی • شرح حال بیمار • فشار خون (ایستاده – خوابیده ) • ضربان قلب بیمار • برون ده ادراری • هماتوکریت • نیتروژن خون • الکترولیت ها • ABG • CVP

  31. محلولهای وریدی

  32. Fluids • Crystalloids • Colloids • blood

  33. Which of the following solutions is isotonic? • D5W • 0.45% saline • 0.9% saline • D5 in 0.9% saline

  34. Common parenteral fluid therapy

  35. Crystalloids: • Isotonic crystalloids - Lactated Ringer’s, 0.9% NaCl - only 25% remain intravascularly • Hypertonic saline solutions - 3% NaCl • Hypotonic solutions - D5W, 0.45% NaCl - less than 10% remain intra- vascularly, inadequate for fluid resuscitation

  36. Colloid Solutions: • Contain high molecular weight substancesdo not readily migrate across capillary walls • Preparations - Albumin: 5%, 25% - Dextran - Gelifundol - Haes-steril 10%

  37. رینگر لاکتات • مایع نمکی ایزوتونیک جهت جایگزینی از دست دادنهای GI و کاهش ECF بدون اشکالات عمده در ترکیبات و اجزا رینگر لاکتات است. • ایزوتونیک • Na=130meq/l CL=109meq/l lactat=28meq/l osm=273

  38. 0.9%Nacl • Na=154 • CL= 154 • این مایع جهت جبران کاهش ECF در حضور هیپوناترمی وهیپوکلرمی و آلکالوز متابولیک ایده ال است.PH=5.6

  39. Postoperative (maintenance) 0.45%Nacl +5% dextrose +KCL

  40. Perioperative management of fluid balance include: Preoperative evaluation Intraoperative maintenance Replacement of fluid losses

  41. Preexisting fluid deficits • NPO time and abnormal fluid losses (vomiting-dirreha- asites- infected tissue-fever –sweating- hyperventilation) • Hypotonic fluid (0.5% saline ) or isotonic crystalloids

  42. Maintenance requirements • Up to 10 kg = 4cc/kg/hr • 11-20kg = add 2cc/kg/hr • 21kg and above = add 1cc/kg/hr • Insensible losses = 2cc/kg/hr

  43. Surgical fluid losses Blood loss (measurement) • Suction container • Surgical sponge • Hct and tachycardia not specific • ABG and UO if hypoperfusion occur • Blood loss=3/1 with crystalloid Other losses (third space loss)

  44. Third space loss • Minimal (herniorrapy) =2-4cc/kg/hr • Moderate (cholecystectomy)=4-6cc/kg/hr • Severe (bowel resection) = 6-8cc/kg/hr

  45. Crystalloid solution • The main solutions is either glucose or saline • Hypotonic or isotonic or hypertonic. • Safe , nontoxic, reaction free ,inexpensive. • Complication is edema if large volumes are needed. • During surgery isotonic solution favored (normal saline - lactate ringer and plasma lyte)

  46. Colloids • Albumin • Hydroxyethyl starch • Dextran

  47. Complications • Hypersensitivity reactions (anaphylaxis ) • Pruritis (hetastarch) • Couglopathy (dextran 70 and hetastarch) > 1 litter • Dextran ( platelet aggregation , adhesive) • Hetastarch (reduction in factor vlll and VOB factor ) These colloid is best avoided in patients with coagulopaty.

  48. The Influence of Colloid & Crystalloid on Blood Volume: Blood volume Infusion volume 200 600 1000 1000cc Lactated Ringers 500cc 5% Albumin 500cc 6% Hetastarch 500cc Whole blood

  49. Colloid versus crystalloid solutions

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