PRINCIPLES OF FLUID &

ELECTROLYTE BALANCE IN
SURGICAL PATIENTS
 NORMAL DAILY LOSSES AND
REQUIREMENTS FOR FLUIDS AND
ELECROLYTES

Volume Na+ K+
ML mmol mmol
 Urine 2000 80 60
 Insensible losses 700 - -
 Faeces 300 - 10
 Minus endogenous 300 - -
 Water
 Total 2700 80 70
 ASSESSING LOSSES IN THE
SURGICAL PATIENT
 INSENSIBLE FLUID LOSSES

 EFFECT OF SURGERY

The stress response

‘Third-Space’ losses
Loss from the gastrointestinal tract
 INTRAVENOUS FLUID
 5% DEXTROSE
 0.9% NaCl
 RINGER’S LACTATE (HARTMANN’S
SOLUTION)
 HAEMACCEL (SUCCINYLATED GELATIN)
 GELOFUSINE (POLYGELINE GELATIN)
 HETATARCH
 HUMAN ALBUMIN SOLUTION 4.5%
(HAS;PPF)
PROVISION OF NORMAL 24-HR FLUID &
ELECTROLYTE REQUIREMENTS BY
INTRAVENOUS INFUSION

Intravenous fluid Additive Duration

 500 ml 0.9% NaCl 20mmol KCl 4hr

 500 ml 5% Dextrose - 4hr

 500 ml 5% Dextrose 20 mmol KCl 4hr

 500 ml 0.9%Dextrose - 4hr

 500 ml 5% Dextrose 20 mmol KCl 4hr

 500 ml 5% Dextrose - 4hr

AETIOLOGY OF HYPER AND HYPONATRAEMIA
 Hypernatraemia
 -------------------
 Reduced intake
• fasting
• nausea and vomiting
• ileus
• reduced conscious level
 Increased loss
 *Sweating (pyrexia,hot
environment)
 *respiratory tract
loss(increased ventilation,
administration of dry gases)
 *administration of dry
gases
 *burns
 Inappropriate urinary water loss
• Diabetes inspidus(pituitary
or nephrogenic)
• Diabetes mellitus
 Excessive Sodium load
(hypertonic fluid, parenteral
nutrition)
 Hyponatraemia
 -------------------
 - Low extracellular fluid volume
 * Volume depletion
(vomiting,diahrrhoea,burns,decrease
d fluid intake)
 * salt losing renal disease
 * Hypoadrenalism
 *diuretic use

 - Normal extracelluler fluid volume
 hypothyroidism
 SIADH
 Increased extracellular fluid volume
• excessive water administration
• excessive mannitol use
• cardiac failure
• cirrhosis
• nephritic syndrome
• renal failure
 CONSEQUENCES OF HYPER
AND HYPOKALEMIA
 HYPERKALEMIA
Arrythmias(broad-complex
rhythms,bradycardia,heart block,ventricular
fibrillation)
Muscle heart block
Ileus

 Hypokalemia
ECG changes
Ectopic beats
Muscle weakness
MANAGEMENT OF SEVERE ACUTE
HYPERKALAEMIA (K+ > 7mmol/L)
 Identify and treat cause
 10 – 20 mL intravenous 10% calcium chloride
over 10 min in patients with ECG abnormalities
 (reduced risk of ventricular fibrillation)
 50 mL 50%dextrose plus 10 units short acting
insulin over 2-3min
 Monitor plasma glucose and K+ over next30-
60 min)
 Regular Salbutomol nebulizers
 Consider oral or rectal calcium
 Resonium (ion exchange resin),although this is
more effective for non-acute hyperkalaemia.
 Haemodialysis for persistent hyperkalemia
 ACID BASE BALANCE
 METABOLIC ACIDOSIS
 METABOLIC ALKALOSIS
 RESPIRATORY ACIDOSIS
 RESPIRATORY ALKALOSIS
 MIXED PATTERN OF ACID-BASE
IMBALANCE
COMMON CAUSES OF METABOLIC
ACIDOSIS IN THE SURGICAL
PATIENT
 LACTIC ACIDOSIS
Shock (any causes)
Severe hypoxaemia
Severe haemorrhage/anaemia

 ACCUMULATION OF OTHER ACIDS

Diabetic Ketocaidosis
Acute Renal Failure

 INCREASED BICARBONATE LOSS

Diahrroea
Intestinal Fistulae
Ureterosigmoidostomy
COMMON CAUSES OF METABOLIC
ALKALOSIS

 LOSS OF SODIUM AND WATER

Vomiting
Aspiration of gastric secretions
Diuretic administration

 HYPOKALEMIA
 CAUSES OF RESPIRATORY
ACIDOSIS

 Excessive opiate administration

 Pulmonary complications e.g

Pneumonia
 CAUSES OF RESPIRATORY
ALKALOSIS ENCOUNTERED IN
SURGICAL PRACTICE
 Hyperventilation during mechanical
ventilation
 Pain
 Apprehension/hysterical hyperventilation
 Pneumonia
 Central nervous system
disorders(meningitis,encephalopathy)
 Septicaemia
Principles of fluid and
electrolyte balance in
surgical patients

Discussions
 1. What are the normal values or serum sodium, potassium,
creatinine and urea?
 2. What are the normal basal requirements for water, sodium and
potassium?
 3. How can this be provided in a patient who is fasting?
 4. How is fluid retained in the intravascular compartment?
 5. What might cause it to leak out?
 6. In clinical practice, it is often desirable to "expand" the
intravascular compartment. Why might this be desirable and how
could it be done?
 7. What are the clinical symptoms and signs of fluid depletion? How
can the severity of fluid depletion be assessed?
 8. How can clinicians assess the patient’s response to resuscitation
in severe fluid depletion?
 9. What biochemical disturbance might you expect in a patient with
gastric outlet obstruction who has been vomiting for several days
before admission?
 10. What biochemical abnormalities might you expect in a patient
who has had excessive diarrhoea and who has been drinking large
amounts of water because of thirst? (If a house officer inadvertently
prescribed too much 5% dextrose and not enough N Saline, you
would find the same effect)
 In patients with massive burns, fluid losses are impossible to
measure. How might you assess fluid requirements?