Postoperative Management

1. FLUID & ELECTROLYTE
MANAGEMENT IN
POSTOPERATIVE PATIENTS
DR. ISHTIAK AHMED
MBBS, MS- PHASE A (CVTS)
ASSISTANT REGISTRAR
SURGERY UNIT 2
KHULNA MEDICAL COLLEGE HOSPITAL,
KHULNA

2. WHY FLUID THERAPY IN SURGICAL
PATIENTS NEED SPECIAL ATTENTION ?
• After surgery maintenance of normal physiology of fluid & electrolytes.
• Acute stress > increased sympathetic stimuli > tachycardia,
vasoconstriction
• Increased ACTH > adrenal gland stimulation > large amount of
HYDROCORTISONE to fight acute stress & ALDOSTERONE which
leads to Na+ retention & urinary loss of K+

3. • Increased ADH secretion causes water retention, reduction of urine
output to as low as 500 ml in 1st POD
• NPO status leads to hypovolumia prior to surgery, Patient becomes
hypotensive during surgery & anaesthesia.
• Fluid loss
• Surgical stress or direct damages of kidney, lung, brain, skin or GIT

4. GOAL OF FLUID THERAPY
• BP >100/70 mm of Hg
• Pulse <120 bpm
• Urine output 30-50ml/hour
• Normal temperature, warm skin, normal respiration & sensorium

5. WHEN & HOW LONG TO GIVE FLUID
THERAPY ?
• Short operative surgery (No handling of intestines or visceras)-
Maintenance of IV fluid to correct deficit due to NPO state. After 4-5
hours, oral fluid restarted & there is no need of IV fluid.
• Major Surgeries (Handling of intestinal viscera)-Requires post
operative fluid for few days,after ensuring normal movement of
intestines, oral fluid intake restarted.
• Major Surgeries (Handling of intestinal viscera not done) –Most OBG
surgery – IV fluid is required for 24-48 hours.

6. FACTORS TO BE CONSIDERED BEFORE IV
FLUID CHOOSING
• Age, Weight, Vital data, Hydration status, Urinary output
• Nature of surgery, blood loss, nature & volume of Fluid & Blood
replaced intraoperatively.
• Drain output, Fluid lost in operative site.
• Renal status, associated illness eg. DM, HTN, Acid Base Disorder.
• Intestinal loss due to atmospheric temperature, pyrexia, hyperventilation
etc.

7. POST OPERATIVE FLUID FOR 1ST 3 DAYS
• 1st 24 hours of surgery – 2L of 5% DA or 1.5L 5%DA + 500ml
isotonic saline
• 2nd POD – 2L 5% DA + 1L 0.9% N/S
• 3rd POD – Similar fluid + 40-60 mEq K+ per day.
• Guideline may required modification considering clinical
condition.

8. WHY LESS SALT & LESSER VOLUME IN 1ST
POD ?
• Increased ADH & ALDOSTERONE > Salt & Fluid retention in kidney.

9. BUT WHEN SALINE CONTAINING FLUID
GIVEN IN 1ST POD ?
• Elderly patients ē salt losing nephropathy.
• Head injury or Neurosurgical patients.
• Patients on diuretics & mannitol.
• To replace nasogastric aspiration & drain output.
• In most of the major surgery, saline is given to replace 3rd space
losses.

10. K+ IS AVOIDED IN FIRST 2 POST OPERATIVE
DAYS
• Patient may have oliguria or azotemia.
• Post operative trauma > release of K+ from intracellular to
extracellular compartment > Hyperkalemia.
• Intra or post operative stored blood transfusion.
• Post operative metabolic acidosis (Shifts intracellular K+
extracellularly).

11. HOW TO INFUSE IV FLUID
POSTOPERATIVELY ?
• Maintenance fluid should be given at a steady rate over an 18-24
hours period.
• If given over a short period, renal excretion of excess salt & water may
occur. But as the normal losses continues over 24 hours, body will be
deprived of their fluid needed during the remaining period.

12. VOLUME EXCESS
• BLOOD Excess – Pulmonary congestion.
• Saline Excess – Weight gain, Periorbital puffiness, Dyspnea on
exertion.
• Hypotonic Fluid Excess (5% DA) – Hyponatremia (Confusion,
drowsiness, rarely coma & convulsions).

13. VOLUME DEFICIT
• Decreased Urine output < 30 ml/hr
• Postural hypotension
• Tachycardia
• Diminished skin turgor
• Decreased capillary refill time
• Increased BUN out of proportion to creatinine
TREATMENT
(Depends on the type of fluid lost, can be done ē isotonic fluid eg. 0.9% N/S or Ringers Lactate).

14. COMPLICATIONS
• Hyponatremia
• Hypernatremia
• Hypokalemia
• Hyperkalemia

15. HYPONATREMIA
• Excess ADH – Retention of water in exchange of Na+
• Excess 5% DA
• Water administration consistently which exceeds water loss
• Signs & Symptoms – Nausea without vomiting, Drowsiness,
Weakness, Confusion, Convulsion
TREATMENT
• Avoid using hypotonic solutions. Avoid excessive use of electrolyte
free fluid during first 2-4 postoperative days. Serum Na+ should be
kept between 130-135 mEq/ml.

16. HYPERNATREMIA
• Uncommon
• Excess isotonic saline
• Diabetes Insipidus
• Excess pure water loss in severe hyperglycemia due to osmotic
diuresis.
TREATMENT
• 0.45% N/S – Half strength saline

17. HYPOKALEMIA
• Most common
• Lost through urine or GIT
• Postoperative infusion of Diuretics or Mannitol
• Prolonged administration of K+ free IV fluids
• C/F- Extreme weakness, Muscular hypotonia, Paralytic Ileus
• Patient on Digitalis therapy – Develop cardiac arrhythmia due to hypokalemia
TREATMENT
• Daily supplement 60-100mEq QD

18. HYPERKALEMIA
• Uncommon
• Cardiovascular symptoms – Bradyarrhythmias, Hypotension, Diastolic cardiac arrest
• ECG changes - wide QRS complex, Peaked T waves
TREATMENT
• Inj. Ca Gluconate
• Inj. Sodium bicarbonate
• Glucose – Insulin
• Potassium sparing oral or rectal solution eg. Calcium Resonium Powder

19. HYPERKALEMIA is more Dangerous than
HYPOKALEMIA

20. FLUID MANAGEMENT IN HYPERTENSIVE
PATIENTS
• Fluid overload can cause pulmonary oedema & cardiac failure in
hypertensive patient, so ensure that fluid should be administered over
strict 24 hours & not faster.
• Na+ containing fluids will cause water retention > increase BP
• Strict BP monitoring on 1st POD
• Lasix will drop the BP, increase urine output but can cause electrolyte
imbalance.

21. FLUID MANAGEMENT IN DIABETES
• High chances of developing Diabetic Ketoacidosis in
postoperative period.
• Avoid using Dextrose in 1st POD as already due to excess
glucocorticoids, the level of glucose is on higher side.
• With 5%DNS, INSULIN should be added ( Neutralizing Drip - 10
unit short acting insulin on 1L DNS is a good option).
• RBS CHART – 2 hourly on 1st & 4 hourly on 2nd day.
• Come back to usual regimen when patient stabilized & diet
become oral.

22. BLOOD TRANSFUSION
ADVANTAGES
• Most physiological way to replace blood loss.
• Corrects hypotension secondary to blood loss.
• Adequate tissue oxygen.
• Effective than crystalloids & cheaper than colloids to correct
hypotension.

23. WHEN BLOOD TRANSFUSION IS NOT
NEEDED ?
• Blood loss less than 500ml in adult ē normal preoperative Hb.
• Loss of 10% of estimated blood volume is well tolerated, such losses
are usually replaced ē Ringer’s Lactate or 0.9% N/S.
As a rule blood loss needs to be replaced ē 3 times
volume of crystalloids.

24. WHEN BLOOD TRANSFUSION IS NEEDED ?
• Blood loss >20% of blood volume.
• Replacement of blood loss between 10-20% is a matter of clinical
discretion. If Hb <10gm/dl, Blood Transfusion is given.
• 500ml – 1000ml blood loss required 1 unit Blood Transfusion.
• Blood transfusion is mandatory if Hb falls below 8gm/dl after blood
loss.

25. Thank You