This presentation is the final assignment of my placement in Surgery Ward during my internship at Dhaka Medical College & Hospital.

1. Fluid and Nutrition
Dr. Lisanul Hasan , Intern Doctor , SU-3, DMCH

2. The body
A finely balanced osmometer

3. Anatomy of body water and electrolytes
• Body mass= Body fat+ Fat free mass
• Fat = Anhydrous , major energy reservoir ,has major role while considering
fluid therapy
• Fat free mass- 72-80% of it is composed of water
• Total body water= (Extra cellular +intra cellular) water
• ICW – All enzymatic reactions and metabolic processes occur here

4. Intra-cellular Water
• Subdivided into five compartments
1. Plasma
2. Interstitial fluid/lymph
3. Connective tissue and cartilage water
4. Bone water
5. Transcellular water

5. Water
• Average daily intake is 1500 ml as fluid, rest as water content of food
• Loss- 100ml in stool
- 1500ml in urine
- 500ml from skin & some insensible loss
* Water requirements 30-70ml/kg, vary from person to person
* Water requirements increase with fever , hyperventilation & hypermetabolism

6. Sodium
• 4200 mmol sodium in a healthy adult male , 70% of it is exchangeable
• Sodium is primarily extra-cellular cation
• Daily requirement for sodium is 80-120 mmol/day
• Regulation of sodium balance is primarily done by kidney
• Approximately 100-150 mmol/day lost in urine
• Fun fact – western meal contains more sodium than our requirements

7. Potassium
• 3500 mmol of within the body ,almost all is exchangeable
• Primarily intra-cellular , only 2% extra-cellular
• Serious surgical illness causes changes in membrane potential and thus changes in
intracellular potassium content .
• Daily requirement is 60-80 mmol
• 60 mmol lost in urine and some stool
• Small intestinal content has low potassium content with more being seen in colonic
content

8. Chloride , magnesium , calcium & zinc
• Healthy adult- 2300 mmol chloride, index of ECF volume
-1000 mmol magnesium , role in functioning enzymes
-1200 mmol calcium, 1% responsible for biological action, 50%
of serum calcium is bound to proteins

9. Acid-base balance
• Body cells function better in-between 7.2-7.5 pH
• Acidosis -produced from metabolism of carbohydrate, protein & fat
-ischemic gut-hypoperfusion-anaerobic metabolism- more lactate
-diabetic ketoacidosis
• Alkalosis-pyloric obstruction
-respiratory alkalosis due to hyperventilation in anxious pt.

10. Compensatory mechanism
• Various buffer systems play role in the compensatory mechanism
• Lungs and kidney play a vital role
• Immediate response by lungs , then by kidney

11. ECF depletion ( Surgical dehydration)
• Due to – blood loss, vomiting , diarrhea, fistulae , burns ,sepsis or shock
• Mild deficit- less than 2 liters
• Moderate deficit- 2-4 liters
• Severe deficit – Greater than 5 liters
ECF Excess
Commonest cause – excessive sodium containing fluid administration
Congestive cardiac failure , liver and kidney failure

12. Hyponatremia & Hypernatremia
• Sodium less than 130 mmol/l – signs of excess ECF
• Sodium less than 120mmol/l- CNS signs including convulsion
• Treated with water restriction and in exceptional cases with hypertonic
solution with diuretics
• Hypernatremia is usually the result of pure water depletion , corrected by
increasing water intake

13. Hyperkalemia
• Causes – Severe injury culminating cell death , renal failure , metabolic
acidosis
• Rx- withhold further potassium supplementation
• -if less than 6 mmol/l – administer cation exchange resin
-if ECG changes – dextrose infusion
- if metabolic acidosis in ABG – administer bicarbonate

14. Hypokalemia
• Causes – prolonged use of potassium-losing diuretics, alkalosis, replacement
of gastric losses with saline without added potassium
• Rx- potassium replacement , ensure good renal output
- infusion rate should not exceed 20 mmol/l , urethral catheterization and
cardiac monitoring should be considered

15. Fluid therapy
• Maintenance therapy + replacement of pathological losses + repair of
deficits
• Maintenance therapy= 500ml Normal saline+2L 5% Dextrose /day+ 1
mmol/kg/day potassium
• In the first 24 hours of surgery potassium may not be required

16. Abnormal GI loss
• Upper GI loss should be replaced with 0.9% Sodium chloride
• Loss from stomach should be replaced with (Normal saline + 15 mmol KCl
/ liter saline )
• Other GI loss from lower down should be replaced with Hartmann’s
solution

18. Cont.
• Prolonged ongoing losses- zinc and trace elements should be supplemented
• Fever / tachypnea – extra 500 ml dextrose /day
• Sequestration-small intestinal obstruction, site of an operation especially if
extensive dissection has been done- intraoperative fluid requirements up to
500ml/hour
Repair of deficit: Plasma volume should be replaced rapidly, interstitial space
fluid should be replaced at a slower rate . Patient monitoring is crucial here.

19. Nutritional Support
• Enteral route and parenteral route
• Daily requirements : Water 30-70 ml/kg , calories 30-50kcal/kg, protein: 1.5-
2 g/kg, sodium 50-90mmol/L, potassium 50 mmol/L, calcium 5mmol/L,
magnesium 1 mmol/L.
• Enteral nutritional support through fine-bore NG tube, jejunostomy or
gastrostomy, needle jejunostomy , combined endoscopic /percutaneous
placement of feeding gastrostomy/jejunostomy tubes : route of choice for
patients with intact and functional GIT .

22. Cont.
• Parenteral nutrition: Seriously ill patient with GIT that is blocked , short ,
fistulated or can not cope .
• Indication for total parenteral nutrition (TPN):
Problem Example
Gut short Volvulus with infarction
Gut blocked Anastomotic edema
Gut unable to cope Radiation enteritis
Gut fistulated Crohn’s disease

24. Cont.
• Patients with short gut syndrome usually require TPN for first 2 months while gut
adaptation is occurring .
• If less than 1 meter of gut remains, permanent home TPN may be necessary for
survival
• TPN was administered into a central vein as it is hypertonic , the line should be
dedicated solely to TPN , dressing over insertion site should be changed thrice a
week , chest radiograph should be done to check the position of the line.
• Development of new solutions allowed using peripheral vein.

26. Cont.
• Apart from protein and calories , potassium must be added at
40mmol/1000kcal and phosphate at 20mEq/1000 kcal
• One ampule of multivitamin infusion( both fat and water soluble vitamin) is
added to TPN each day
• Folate and vitamin k given weekly
• Vitamin B12 once a week by IM injection

27. Fluid management is of
utmost importance in
surgical practice .It can
make difference in between
life and death .
Picture credit : Dr. Promita Kundu , k-71