This document discusses fluid and electrolytes, including physiology, types of IV fluids, fluid therapy, and electrolyte abnormalities. It provides the following key points: - Total body water is 60% of body weight, with 2/3 intracellular and 1/3 extracellular fluid divided between interstitial and plasma. - Crystalloids like NaCl 0.9% and Ringer's lactate are commonly used IV fluids. Colloids remain intravascularly but are more expensive. - Initial resuscitation of fluid deficit uses 20mL/kg boluses while maintenance is 30-35mL/kg/day. Losses are replaced as needed. - Electrolyte abnormalities can cause arrhythm

1. Fluid & Electrolytes
Presenters:
Dr. Nur-Athirah Binti Md.Nor
Dr. Siti Nor Afni Binti Baharum
Supervisor:
Dr. Lo
20 January 2014
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2. Outline
1. Fluid
1. Physiology
2. Type of IV fluid
3. IV Fluid therapy
4. IV cannula and rate
2. Electrolytes : causes, clinical features and
management
1. Potassium
2. Sodium
3. Calcium
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3. Physiology
• 60% of body weight is consist of fluid (42L)
• 2/3 of total body fluid is in Intracellular fluid
• 1/3 of total body fluid is in Extracellular fluid
– 80% is interstitial fluid
– 20% is plasma (3L)
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4. Important Ionic Concentrations
(mmol/L)
ICF ECF
Na
K
Ca
Mg
Cl
PO4
HCO3
10
150
2.5
7.5
10
45
10
135
4
2.5
1
100
1
27
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5. Daily input and output of water
• Body received fluid by
– Ingestion and metabolism (total 2.3L)
• Body remove fluid by
– Insensible loss (lung & skin), sweat, feces and
urine (total 2.3L)
• Fluid requirement less in CKD and CCF
• Fluid requirement more in fever, vomiting,
burn, diarrhea
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6. Fluid in Surgical Practice
• Fluid balance tend to disturb when pt
– Nil orally
– Trauma
– Sepsis
• In a surgical patient, we must know to
calculate
– volume and electrolyte requirement
– volume and electrolyte excess and deficit
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7. Crystalloid
ISOTONIC
• 0.9% NaCl
• Hartmann solution
HYPERTONIC
• 10% Dextrose, 20 % Dextrose, 50% Dextrose
• 3% Saline, 5% Saline
HYPOTONIC
• 5% Dextrose
• 0.45% Saline
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8. The most common crystalloid
solutions
Types of
isotonic
Composition Notes
NaCl 0.9% Na
Cl
150 mmol/L
150 mmol/L
Use to correct ECF loss and for initial resuscitation of
intravascular volume.
Ringer’s Lactate
(Haartman)
Na
K
Ca
Cl
HCO3
131 mmol/L
5mmol/L
2mmol/L
111mmol/L
29mmol/L
It is physiological solution. After administration the
lactate is metabolised, resulting in bicarbonate
generation. It will decrease the risk of
hyperchloraemia
Dextrose 5% dextrose 50g/L
200kcal/L
Glucose is rapidly metabolized. The remaining water
distributes rapidly throughout the body’s fluid
compartments therefore not suitable for
resuscitation.
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9. Colloids
• Colloid solutions contain particles that have
oncotic pressure
– Natural : Albumin
– Synthetic : Gelatins, Hydroxyethyl starches,
Dextrans
• It remains largely within the intravascular
space
• Half-life is 6 to 24 hours.
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10. Crystalloid vs. Colloid
Crystalloids Colloids
Advantage • Cheap
• Accessible
• Longer half life
• Smaller volume required to
expand intravascular volume
Disadvantage • Short half life
• Larger volume required for
resuscitation
•Expensive
• Risk of allergic reaction
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11. Assessment and monitoring
Indicators :
– Hypotension
– Tachycardia
– Capillary refill >2s
– Urine output <0.5 ml/kg/h
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12. Resuscitation
• Initial resuscitation
– Give high flow O2
– 2 large bore IV access
– Identify cause of deficit and response
• Bolus of 20ml/kg in adult or 10ml/kg in pt
with CKD or CCF
• Burn = TBSA(%) x 4 x body weight (kg)
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13. Maintenance
• 30-35ml/kg/24h in adult
• Paediatrics and Burn
– 1st 10kg 100ml/kg
– Next 10kg 50ml/kg
– Subsequent weight 20ml/kg
• Eg: 25kg boy (100x10)+(50x10)+(20x5)
• = 1600 ml / 24hours
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14. Replacement and Redistribution
• On going losses
– NG tube, Drains, Fistula, Third space losses
• Concentration is similar to plasma
• Can be replace with isotonic fluids
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15. Complication of over hydration
• Fluid overload
• Signs
– Weight gain
– Pulmonary edema
– Peripheral edema
– S3 gallop
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16. IV Cannula and fluid flow rates
• Flow rate is limited by the size of the IV
cannula and viscosity of fluid
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Cannula size Colour
Time to infuse 1000ml Normal
saline under ideal circumstances
22 G Blue 22 min
20 G Pink 15 min
18 G Green 10 min
16 G Grey 6 min
14 G Red 3.5 min

17. Hyperkalaemia
Causes:
↓ excretion – renal failure
↑ load – K sparing diuretic, blood
transfusion
Clinical features: Arrhythmias, paralysis
Management:
 Lytic cocktail
 Oral Kalimate
 Dialysis
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18. Hyponatraemia
 Causes:
Hypovolaemia – renal failure, diuretics, vomiting,
pancreatitis, SBO
Euvolaemia – SIADH
Hypervolaemia – CCF, liver failure
 Clinical features:
Na < 120 mmol/L – disturbed mental status
Na < 110 mmol/L – seizure, coma
 Management:
Treat the u/l causes
Replace the losses
Not > 10mmol/L/day - central pontine myelinolysis
18[Na req = Na deficit + Na maintenance] & [Na def = 135 – pt’s level x 0.6 x BW]

19. Hypernatraemia
Causes:
 ↑ intake – salt ingestion, hypertonic saline
 ↑ loss – vomiting, diarrhea, fistula
Clinical features : Irritability, confused, coma
Management:
Allow fluid as tolerated
IVD D5%
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20. Hypocalcaemia
Causes:
Surgical – Acute pancreatitis
Medical – Vit D def
Clinical features: Cramp, tetany, Chvostek’s sign,
Trousseau’s sign
Management:
–Iv calcium gluconate
–Calcium oral supplement
–Vitamin D supplement
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21. Hypercalcaemia
Causes:
Surgical – malignancies, bones metastasis
Medical – myeloma, Addison’s disease
Clinical features: ‘Bones, stones, groans, moans’
Management:
Rehydration and saline diuresis
Iv Pamidronate
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22. Take home messages
1. Crystalloid and colloid are equally effective for the
correction of hypovolaemia
2. Use isotonic fluid for fluid resuscitation to maintain wall of
cell membrane
3. High volume administration of normal saline produces
hyperchloremic acidosis
4. Use at least 16G cannula for fluid resuscitation
5. Hypokalaemia & hyperkalaemia need to be treated with
caution – might lead to arrhythmias
6. Na replacement should not > 10 mmol/L/day – risk of
central pontine myelinolysis
7. Main treatment for hypercalcaemia is saline diuresis
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23. Sources
• Textbook of Medical Physiology by Guyton and
Hall, 11th Edition
• Principles of Anatomy and Physiology by
G.Tortora and B.Derrickson, 12th edition
• Principles and Practice of Surgery by
O.J.Garden, A.W.Bradbury, J.L.R. Forsythe and
R.W. Parks, 6th edition
• Sarawak Handbook of Medical Emergencies,
3rd Edition
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