2. CONTENTS
• INTRODUCTION
• COMPOSITION OF FLUIDS
• CLASSIFICATION OF BODY FLUIDS
• ELECTROLYTES
• OEDEMA
• HYPONATRAEMIA/HYPERNATRAEMIA
• HYPERKALAEMIA/HYPOKALAEMIA
• HYPOCALCAEMIA/HYPERCALCAEMIA
3. INTRODUCTION
• Fluid and electrolyte management is paramount to the care of the
surgical patient.
• It facilitates crucial homeostasis that allows cardiovascular perfusion,
organ system function, and cellular mechanisms to respond to illness.
• Changes in both fluid volume and electrolyte composition occur
preoperatively, intraoperatively & postoperatively, as well as in
response to trauma and sepsis.
7. OSMOMOLALITY
• The solute or particle concentration of a fluid is known as its osmolality,
expressed as milliosmoles per kilogram of water(mOsm/kg).
• Water easily diffuses across most cell membranes to achieve osmotic
equilibrium.
• The osmolality of the intracellular and extracellular fluids is maintained
between 290 and 310 mOsm in each compartment.
9. ELECTROLYTES
• Electrolytes are chemicals that conduct electricity when mixed with water.
• They regulate nerve and muscle function, hydrate the body, balance blood
acidity and pressure, and help rebuild damaged tissue.
• The muscles and neurons are sometimes referred to as the “electric tissues” of
the body.
• The electrolytes in human bodies include: • sodium • potassium • calcium •
bicarbonate • magnesium • chloride • phosphate
10. COMPONENTS OF THE FLUID
COMPARTMENTS
PLASMA
• Na+,K+ ,Ca+,Proteins
ECF
• Na+,Cl-,HCO3
ICF
• K+,Mg+,Ph-, Sulfate-, Proteins-
12. OEDEMA
• Oedema is the accumulation of excess water in the tissues.
• It is most common in the soft tissues of the extremities.
Causes-
• Damage to the blood vessels/lymphatics
• Disruption of the Hydrostatic pressure
• Changes in the Oncotic pressure
•
13. SIGNS AND SYMPTOMS OF VOLUME
DISTURBANCES
SYSTEM VOLUME DEFICIT VOLUME EXCESS
GENERALISED WEIGHT LOSS, SKIN
TURGOR
WEIGHT GAIN
PERIPHERAL OEDEMA
CARDIAC TACHYCARDIA,HYPOTE
NSION,COLLAPSED
NECK VEINS
RAISED CVP,RAISED
OUTPUT
RENAL OLIGOURIA,
AZOTAEMIA
-
GI ILEUS BOWEL OEDEMA
PULMONARY - PULMONARY OEDEMA
15. HYPONATRAEMIA
• Hyponatraemia = sodium levels less than 130 meq/l
• Hyponatremia occurs when water is given to replace losses of sodium-
containing fluids or when water administration consistently exceeds water
losses.
• TYPES-
1. Hypovolaemic hyponatraemia
2. Hypervolaemic hyponatraemia
3. Normovolaemic hyponatraemia
4. Pseudohyponatraemia
17. HYPOVOLAEMIC HYPONATRAEMIA
• Rapid absorption into intravascular compartment leading to pulmonary and cerebral oedema.
• <100mmol/L = Severe hyponatraemia
• Management
1. Fluid restriction
2. Hypertonic saline
3. Loop diuretics-Furesmide
• Na should be corrected up to above the level of 125 mol/L.
• Correction should be slow and gradual at a rate of 2 meq/L/h with up to 20 meq/L correction in 24 hours with
4th hourly assessment of serum sodium.
• Over correction of sodium should not be done.
• Rapid correction can lead into irreversible myelin lysis of pontine.
18. NORMOVOLAEMIC
HYPONATRAEMIA
• It may be due to renal failure or syndrome of inappropriate ADH(SIADH).
• In mild asymptomatic patients it is corrected by fluid restriction(1L/day will
raise the serum Na).
• Vasopressin antagonist demeclocycline which increases the diluting ability of
kidney is used in severe cases.
20. HYPERNATRAEMIA
• Primary sodium excess/potassium excess/primary water deficit
• The only state in which dry, sticky mucous membranes are characteristic
• sign does not occur with pure ECF deficit alone
• signs & symptoms:
• CNS: restless, weak - delirium
• CVS: tachycardia - hypotension
• Tissue: dry/sticky mucous membranes – swollen tongue,puffiness of face, pitting edema
• Renal: oliguria ,increased urination
• Metabolic: fever – heat stroke
21. TREATMENT OF HYPERNATRAEMIA
• In hypovolemic patients, volume should be restored with normal saline
before the concentration abnormality is addressed.
• Once adequate volume has been achieved, the water deficit is replaced
using a hypotonic fluid
• such as 5% dextrose, 5% dextrose in normal saline, or enterally
administered water.
22. HYPOKALAEMIA
• Sudden Hypokalaemia->3.5 mEq/L. It occurs in patients in diabetic coma treated by
insulin and saline infusion.
• Gradual Hypokalaemia
Causes
1. Diarrhoea of any causes, villous tumour of the rectum
2. Ulcerative colitis; After trauma or surgery.
3. Pyloric stenosis with gastric outlet obstruction.
4. Duodenal fistula, ileostomy; After ureterosigmoidostomy.
5. Insulin therapy; Poisoning;
23. HYPOKALAEMIA
• Slurred speech; Muscular hypotonia-physical sign.
• Depressed reflexes; Paralytic ileus.
• Weakness of respiratory muscles; Cardiac arrhythmias.
• Inability to produce concentrated urine and so causes nocturia and polyuria.
• ECG shows prolonged QT interval, depression of the ST segment and
inversion of T wave, prominent U wave.
• Often hypokalaemia is associated with alkalosis.
24. TREATMENT
• Oral potassium 2 g 6th hourly, 15 ml potassium chloride syrup (20 mmol of K).
• IV KCI 40 mmol/L given in 5% dextrose or normal saline slowly, often under
ECG monitoring [Total dose is 40 mmol (0.2 mmol/kg/hour). Maximum dose
per hour is 20 mmol].
25. HYPERKALAEMIA
• Normal range of potassium is 4.0 to 4.5 mEq/L.
• Hyperkalaemia manifests when potassium exceeds 6 mEq/L.
• Renal failure; Rapid infusion of potassium.
• Transfusion of stored blood;
• Diabetic ketoacidosis, Adrenal insufficiency; Metabolic acidosis.
• Potassium sparing diuretics, cyclosporine, beta blockers.
• Insulin deficiency.
• Tissue destruction, burns, trauma, tumour necrosis, crush
• injury.
• In vitro haemolysis, thrombocytosis, tourniquet application,
• exercise-pseudohyperkalaemia.
• Familial hyperkalaemic periodic paralysis.
• High serum potassium level. Peak 'T' wave in an ECG.
26. TREATMENT OF
HYPERKALAEMIA
1. Potassium removal- Kayexalate, Oral administration is 15–30 g in 50–100 mL
of 20% sorbitol, Rectal administration is 50 g in 200 mL of 20% sorbitol,
2. Dialysis
3. Shift potassium-Glucose 1 ampule of D50 and regular insulin 5–10 units IV,
Bicarbonate 1 ampule IV
4. Counteract cardiac effects-Calcium gluconate 5–10 mL of 10% solution
33. CAUSES OF HYPERCALCAEMIA
• Hyperparathyroidism
• Malignancy
• Excessive vit D
• Pagets disease of the bone
• Granulomatous diseases
• Milk alkali syndrome
• Adrenal insuffiency
Plasma osmolality is mainly achieved by serum Na; but small proportion, I.e.25% of osmolality is due to other solutes like glucose ,lipids, plasma proteins ,urea will not move easily between intracellular and extracellular spaces.
When concentration of these molecules raise due to some pathology ,proportionately relative concentration of sodium will drop causing pseudo hyponatraemia
The rapid correction of hyponatremia
can lead to pontine myelinolysis,39 with seizures, weakness,
paresis, akinetic movements, and unresponsiveness, and may
result in permanent brain damage and death.
The rate of fluid administration should be titrated to
achieve a decrease in serum sodium concentration of no more
than 1 mEq/h and 12 mEq/d for the treatment of acute symptomatic
hypernatremia. Even slower correction should be undertaken
for chronic hypernatremia (0.7 mEq/h), because overly
rapid correction can lead to cerebral edema and herniation.
