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Fluid%20and%20 Electrolyte%20 Management%20in%20 Surgical%20 Patient

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  • 1. Fluid and Electrolyte Management in Surgical Patient Dr.Kiti Siriwatana
  • 2. Total body water • Infant=80 • Male=65 • Female=55 • Thin>Fat
  • 3. Body fluid compartment • ICF=40% • ECF=20% – Intravascular fluid(plasma) =5% – Interstitial fluid =15%
  • 4. Total body water ICF Intravascular fluid Interstitial fluid
  • 5. PO4- 38 2 2 8 HCO3- 28 24 ICF Cl- 2 113 ISF 103 Serum 160 K+ 4 4 10 Na+ 145 140
  • 6. 160 140 120 100 80 Serum 60 ISF 40 20 ICF ICF 0 Na+ Serum K+ Cl- HCO3- PO4-
  • 7. Osmolality • Homeostatic machanism by kidney • Serum Osmolality =(Na+x2)+(BUN/2.8)+(Glucose/18) • Fluid movement:Osmolality • Electrolyte movement:Active transport
  • 8. ADH
  • 9. Aldosterone
  • 10. Fluid • Crystalloid – Maintenance type fluid:Hypotonic solution – Replacement type fluid:Isotonic solution – Special type fluid:Hypertonic solution • Colloid – Albumin – Gelatin(Haemaccel) – Starch(H.E.S.)
  • 11. Example of crystalloid • D5W:Dilutional hyponatremia • NSS:Normal saline:Isotonic saline • Lactated Ringer’s solution (LRS):Physiologic solution – Liver-Lactate to bicarbonate and energy • Acetated Ringer’s solution (ARS) – Acetate metabolite by muscle
  • 12. Na+ K+ Ca++ Mg++ Cl- HCO3 Glucose ECF 142 4 5 3 103 27 120 5%D/W 0 0 0 0 0 0 50 0.9%NSS 154 0 0 0 154 0 0 5%D/N/2 77 0 0 0 77 0 50 5%D/N/3 51 0 0 0 51 0 50 5%D/N/5 31 0 0 0 31 0 50 3%NSS 513 0 0 0 513 0 0 LRL 130 4 3 0 109 28 0 ARL 130 4 2.7 0 108.7 28 0
  • 13. Crystalloid VS Colloid • Crystalloid:2-3 Blood loss • Colloid: ~1:1 Blood loss • Blood replacement: for Oxygen carrier
  • 14. Fluid and Electrolyte therapy • Fluid:Quatity:volume • Electrolyte:Quality:composition
  • 15. Replacement for what? • Daily requirement:Fluid maintenance • Fluid deficit:Already loss • Third space loss from surgery • Fluid for blood replacement
  • 16. Daily requirement:Fluid maintenance • Sensible loss:kidney and GI – Urine:800-1200 cc/day • Insensible loss:skin and lung – Skin:20-400 cc/day – Lung:400-600 cc/day – Insensible perspiration (cc)=B.W. (kg.)x15 • Total:1600-2000 cc/day • I/O record
  • 17. Daily requirement:Fluid maintenance 1 • Holliday and Segar • น้ําหนัก 10 Kg แรก = 100 cc/Kg • 10-20 Kg ตอมา = 50 cc/Kg • >20 Kg = 20 cc/Kg • For 24 Hr. of fluid maintenance
  • 18. Daily requirement:Fluid maintenance 2 • Fluid maintenance in 1 Hr. • น้ําหนัก 10 Kg แรก = 4 cc/Kg/Hr • 10-20 Kg ตอมา = 2 cc/Kg/Hr • >20 Kg = 1 cc/Kg/Hr • Rate = cc/Hr • Rate/4= drop/min
  • 19. Daily requirement:Fluid maintenance 3 • For NPO pt. before surgery • 5% D/N/2 rate 1.5-2 cc/kg/hr
  • 20. Daily requirement:Fluid maintenance • Composition and concentration • Sodium requirement: – Adult:2-3 mEq/kg/day=100-150 mEq – Child:4 mEq/kg/day • Potassium requirement: – Adult:1 mEq/kg/day=40-50 mEq – Child:2 mEq/kg/day • Glucose :125-150 g for prevent ketosis
  • 21. Na+ K+ Ca++ Mg++ Cl- HCO3 Glucose ECF 142 4 5 3 103 27 120 5%D/W 0 0 0 0 0 0 50 0.9%NSS 154 0 0 0 154 0 0 5%D/N/2 77 0 0 0 77 0 50 5%D/N/3 51 0 0 0 51 0 50 5%D/N/5 31 0 0 0 31 0 50 3%NSS 513 0 0 0 513 0 0 LRL 130 4 3 0 109 28 0 ARL 130 4 2.7 0 108.7 28 0
  • 22. Daily requirement:Fluid maintenance • 5% D/N/2 1000 cc.+ Water 1000 cc. • 5%D/N/2 2000 cc. • 5% D/NSS 1000 cc.+ Water 1000 cc.
  • 23. Fluid deficit,already loss • Volume deficit assesment from history taking and physical examination • Mild dehydration:3% B.W. • Moderate dehydration:6% B.W. • Severe dehydration:9% B.W.
  • 24. STAGE 0-5% 5-10% 10-15% Dehydration Dehydration Dehydration Appearance Freshful Restless Semicomatose Skinturgor Normal or slightly Eyes Normal or sunken Sunken Mucous membrane Dry red Very dry Very dry, cyanosis H.R. 130 160 % B.W. loss 2-5 % 5-10 % > 10 % Skin temperature Warmer Cold or warm Cold Fontanelle (in Normal Maybe sunken Sunken child)
  • 25. อาการ Deficit (% body wt.) Early Thirst 2% Moderate 6% Marked thirst Dry mouth Oliguria Weakness Malaise Loss of skin turgor Mental change Severe 7-14 % Severe mental change Hallucination Gross weakness
  • 26. Fluid deficit,already loss • Composition assesment:Fluid loss from what? • Vomitting? • Diarrhea? • NG-tube? • T-tube?
  • 27. Na+ K+ Cl HCO3 Stomach 10 26 10 30 Duodenum 140 5 80 0 Diarrhia stools 120 25 90 45 Pancreas 140 5 75 115 Bile 145 5 100 35
  • 28. Na+ K+ Ca++ Mg++ Cl- HCO3 Glucose ECF 142 4 5 3 103 27 120 5%D/W 0 0 0 0 0 0 50 0.9%NSS 154 0 0 0 154 0 0 5%D/N/2 77 0 0 0 77 0 50 5%D/N/3 51 0 0 0 51 0 50 5%D/N/5 31 0 0 0 31 0 50 3%NSS 513 0 0 0 513 0 0 LRL 130 4 3 0 109 28 0 ARL 130 4 2.7 0 108.7 28 0
  • 29. Fluid deficit,already loss • Diarrhea จะเลือกใช N/2+KCl 30 mEq/l • Vomiting จะเลือกใช N/2+KCl 10 mEq/l • NG tube ใช N/2+KCl 10 mEq • T tube (ในการผาตัดทอน้ําดี) ใช LRL
  • 30. Third space loss • Volume: – Major surgery:8 cc/kg/hr – Moderate surgery:6 cc/kg/hr – Minor surgery:4 cc/kg/hr – OMFS:2-4 cc/kg/hr • Composition:LRS,ARS
  • 31. Blood loss therapy • Acceptable blood loss (ABL) • (Hct -30) x ปริมาณเลือดในรางกาย x 3/100 • < 1/3 ABL—LRS,ARS 2-3:1 of blood loss • >1/3 ABL--LRS,ARS 2-3:1 of blood loss or Albumin 1:1 of blood loss • = ABL---Packed red cell(PRC) 0.5:1 of blood loss
  • 32. Fluid therapy during the operation • Maintenance • Preoperative deficit – ½ in first hour – ¼ in second hour – ¼ in third hour • Third space loss • Blood loss during the operation
  • 33. Fluid and electrolyte abnormality • Volume disturbance • Concentration disturbance:Sodium • Composition disturbance:Others electrolyte
  • 34. Volume disturbance • Volume excess • Volume deficit (dehydration)
  • 35. Concentration disturbance • Hyponatremia (Water intoxication) -Water shift to icf:cell swelling esp.brain • Hypernatremia (Water deficit) – Dehydration
  • 36. Composition disturbance • Hypokalemia – กลามเนือออนแรง,ทองอืด,หัวใจเตนไมเปนจังหวะ ้ • Hyperkalemia – คลื่นไส อาเจียน ปวดทอง ทองเสีย หัวใจเตนไมเปน จังหวะ
  • 37. The End