The document discusses fluid and electrolyte balance in surgical patients. It begins by explaining the concepts of extracellular and intracellular volume. It then recommends daily water intake of 2000-2500 ml to replace daily losses through urine, stool, and insensible losses. The document presents four case studies of different surgical patients and asks how pre-op, intra-op, and post-op fluid requirements would be managed in each case. Key factors discussed include maintenance fluids, replacing blood and third space losses during surgery, and giving low-sodium fluids without potassium in the immediate post-op period.

1. FLUID AND
ELECTROLYTE
BALANCE IN A
SURGICAL PATIENT

2. FLUID BALANCE
Before going into detail of fluid balance; do you have any idea of
EXTRA CELLULAR VOLUME & INTRA CELLULAR VOLUME??

4. So we will discuss only the practical application of fluid balance
in a surgical patient..

5. Any idea how much
water should be
taken daily??

6. The simpleansweris
that the equal amount
whichis excreted out
of the body

7. • So we must know the daily water excretion:
• in urine: 1000-1500 ml
• in stool: 250 ml
• insensible losses (skin+respiration): 750 ml
• total: 2000 – 2500 ml
• so the daily water intake should be around 2000 – 2500 ml (equal
to 8-10 glasses of water)

8. Make sure you are not using the
smaller one…
OTHERWISE YOU WILL REMAIN DEHYDRATED EVEN AFTER 10 GLASSES

9. Now we will discuss the
PRE-OP, INTRA OP &
POST OP FLUID
Management in
different scenarios

10. CASE 01: MINOR PROCEDURE
• A 70 kg 50 yr old male presented to you with right sided
reducible indirect incomplete inguinal hernia. He wants it
repaired. You plan mesh hernioplasty. How will you manage
his pre-op , intra-op and post-op fluid requirements?

11. CASE 02 (MODERATE
PROCEDURE)
• A 50 yr old female weighing 60 kg presents to you in OPD with
an abdominal ultrasound showing gall stones. There is no
evidence of obstructive jaundice and She wants her gall
bladder removed. You plan open cholecystectomy. How will
you manage her fluid requirements?

12. CASE 03 (MAJOR PROCEDURE)
• A 45 yr old male weighing 50 kg presents with an abdominal
mass. Radiological n biochemical investigations confirm it to
be a carcinoma head of pancreas. You plan pancreatico
duodenectomy. How will you manage his fluid requirements?

13. CASE 04 ( POLYTRAUMA
PATIENT)
• You receive a young patient in emergency who has suffered
from RTA 45 minutes back. Pulse is 120, BP 90/60, urine
output is negligible. He has been referred from other hospital
with multiple radiographs showing 1 rib fracture & right femur
fracture. How will you manage his fluid requirements?

14. REMEMBER SOME OF THE CONCEPTS!

15. MAINTENANCE FLUIDS
• Maintenance fluids are the ones which when administered maintain
the urine output to 0.5-1 ml/kg/hr (35-70 ml/hr for a 70 kg pt)
• Maintenance fluids are calculated on the basis of body weight as
follows:
• 100 ml/kg/day for first 10 kg
• 50 ml/kg/day for second 10 kg
• 20 ml/kg/day for each subsequent 10 kg
• For a 70 kg pt; it becomes 1000+500+1000 =2500 ml/day (about 100
ml/hour)
• Maintenance fluids should contain Na (1-2 mmol/kg/day) & K (0.5-1
mmol/kg/day). (if parenteral maintenance fluid is to be given then
it can be D5/0.45% NaCl + 20-30 mmol K/litre

16. PRE-OP FLUID MANAGEMENT
• Pre-op fluid abnormalities (Hb, hydration status, electrolytes)
should be corrected before operation WHENEVER POSSIBLE.
• Hb: 1 pack cell will raise Hb by 0.8-1gm/dl
• Hydration status: monitor with CVP & Urine output.
• Electrolytes:
• K: 0.6 × weight(kg) (desired K – Pt K).
• Na: Total body water x Weight(Kg) (desired Na – Pt Na)
• Total body water: 0.6 for males, 0.5 for females.
• K replacement: 40 mEq in 1000ml @ 10 mEq/hr

17. INTRA-OP FLUID
MANAGEMENT
• Pre Operative fluid management:
• Maintenance fluids:
• Blood loss: 1 ml blood or colloid per 1 ml blood loss or 3 ml
crystalloid per 1 ml blood loss.
• Third space losses:
• 1-3 ml/kg/hr for minor procedures..small incision
• 3-7 ml/kg/hr for moderate procedures..medium incision
• 9-11 ml/kg/hr for major procedures..large incisions
• On going losses: NG, Stool, bile, pancreatic

18. POST OPERATIVE FLUID
MANAGEMENT:
• Pre operative Fluid management:
• Nature of surgery.
• Intra operative fluid management:
• On going losses:
• Drain output, NG losses, insensible losses
• Maintenance Requirement.

20. Peri-op day fluids:
• Should be less in salt n low total volume
• Stress response release ADH & aldosterone.
• But salt rich solutions can be used if
• After major surgeries.
• To replace nasogastric n drain output.
• patients with simultaneous diuretics.

21. Peri-op day fluid:
• No potassium should be given:
• Tissue trauma releases K
• Blood transfusion.

22. Major surgeries post operative
fluid:
• Day 1:
• Requirements:
• Pre operative status.
• Intraoperative status.
• Age & weight.
• Nature of surgery.
• Fluid requirements:
• Low salt, low water, no potassium

23. Major surgeries
• Day 2 & onwards:
• Requirements:
• Age & weight.
• Nature of surgery.
• NG & drain losses.
• Hb & Electrolytes report
• Fluid requirements:
• Maintenance fluids PLUS losses

24. Now calculate fluid regimen

25. Post operative fluid:
• CASE 1:
A 70 kg 50 yr old male presented to you with right sided
reducible indirect incomplete inguinal hernia. He wants it
repaired. He underwent mesh hernioplasty.

26. Post operative fluid:
• Data available:
• 70 Kg man
• Hernia repair done in 1.5 hrs.
• Data required:
• Pre operative status:
• Intraoperative fluid management:
• On going losses:

27. Post operative fluid:
• Maintenance fluid:
• 40 ml/Kg/day plus 1-2 mEq Na/Kg and K 1mEq/Kg
• 1000 ml plus 50 mEq Na and 25 mEq K
• BUT
• Perioperative day????
• Low Na, Low Volume and NO K….

28. Post operative fluid:
• So fluid of choice should be:
• N/S or R/L @ 33 drops/Min

29. Post operative fluid:
• CASE 2:
A 50 yr old female weighing 60 kg presents to you in OPD
with an abdominal ultrasound showing gall stones. There
is no evidence of obstructive jaundice and She wants her
gall bladder removed. She underwent open
cholecystectomy.

30. Post operative fluid:
• CASE 3:
A 45 yr old male weighing 50 kg presents with an
abdominal mass. Radiological n biochemical
investigations confirm it to be a carcinoma head of
pancreas. You plan pancreatico duodenectomy. He
underwent Whipple’s Procedure.

31. Post operative fluid:
• CASE 4:
You receive a young patient in emergency who has
suffered from RTA 45 minutes back. Pulse is 120, BP
90/60, urine output is negligible. He has been referred
from other hospital with multiple radiographs showing 1
rib fracture & right femur fracture. How will you manage
his fluid requirements?

32. RIGHT NOW….
• SOME ARE LIKE… • SOME ARE LIKE…