This document provides an overview of fluids and electrolytes in surgical patients. It discusses body water volumes, osmotic pressure, signs and symptoms of volume disturbances, and various electrolyte abnormalities including hypernatremia, hyponatremia, hyperkalemia, and hypokalemia. Common causes and clinical manifestations of each electrolyte imbalance are presented. The document also reviews intravenous fluid types, including crystalloids like lactated Ringer's solution and normal saline, as well as colloid solutions. Fluid and electrolyte requirements in surgical patients are discussed. References utilized include Schwartz's Principles of Surgery and Sabiston Textbook of Surgery.

1. Fluids and electrolytes in
surgical patients
Presented by :
Dr.Abdullah j. Al-Qattan

2. OUTLINE
1. BODY WATER AND FLUIDS VOLUMES
2. OSMOTIC PRESSURE
3. SIGNS AND SYMPTOMS OF VOLUME DISTURBANCES
4. HYPERNATREMIA AND HYPONATREMIA
5. HYPERKALEMIA AND HYPOKALEMIA
6. TYPES OF FLUIDS

3. BODY WATER AND FLUIDS VOLUMES
• TBW IS 50%-60% OF BODY WEIGHT
• TBW IN NEWBORNS IS HIGHR (75%-80%) OF BODY WEIGHT

4. BODY WATER AND FLUIDS VOLUMES
• 2/3 OF TBW IS INTRACELLULAR FLUID (40% BODY WEIGHT)
• 1/3 OF TBW IS EXTRACELLULAR FLUID (20% BODY WEIGHT)
• EXTRA CELLULAR COMPOSITION :
PLASMA (1/4 ECF) , (5% OF BODY WEIGHT)
INTERSTITIAL FLUID (3/4 ECF) , ( 15% OF BODY WEIGHT)

5. OSMOTIC PRESSURE
• THE PHYSIOLOGIC ACTIVITY OF ELECTROLYTES IN SOLUTION
DEPENDS ON THE NUMBER OF PARTICLES PER UNIT VOLUME.
• THE OSMOLALITY OF THE INTRACELLULAR AND EXTRACELLULAR
FLUIDS IS MAINTAINED BETWEEN 290 AND 310 MOSM IN EACH
COMPARTMENT
• HOW TO CALCULATE SERUM OSMOLARITY ??

6. QUESTION
• WHAT IS THE APPROXIMATE SERUM OSMOLARITY FOR A PATIENT
WITH THE FOLLOWING FINDINGS ??
Na 130 CL 94 K 5.2 CO2 14
GLUCOSE 360 BUN 84 CREATININE 3.2
a) 270
b) 290
c) 310
d) 330
Calculated serum osmolality = (2 ✖️sodium) + (glucose➗18) + (BUN➗2.8)
SO = (2✖️130) + (360➗18) + (84➗2.8)
SO = 310
Schwartzs Principles of Surgery: Absite and Board Review. 9TH ED.

7. SIGNS AND SYMPTOMBS OF VOLUME DISTURBANCES
HYPOVOLEMIC HYPRVOLEMIC
GENERALIZED WEIGHT LOSS WEIGHT GAIN
DECREASE SKIN TURGORE PREIPHERAL EDEMA
CARDIAC TACHYCARDIA INCREASE CARDIAC OUTPUT
ORTHOSTASIS
HYPOTENSION
INCREASED CENTRAL
VENOUS PRESSURE
COLLAPSED NECK VEINS DISTENDED NECK VEINS
RENAL OLIGURIA ……...
GI ILEUS BOWEL EDEMA
PULMONARY …….. PULMONARY EDEMA

8. HYPERNATREMIA
• HYPERNATREMIA RESULTS FROM EITHER A LOSS OF FREE
WATER OR A GAIN OF SODIUM IN EXCESS OF WATER.
• IT CAN BE ASSOCIATED WITH AN INCREASED, NORMAL, OR
DECREASED EXTRACELLULAR VOLUME

9. WHAT ARE THE CAUSES OF
HYPERNATREMIA ??

11. SYSTEM BODY HYPERNATREMIA
CENTRAL
NERVOUS
SYSTEM
RESTLESSNESS, LETHARGY, ATAXIA, IRRITABILITY, TONIC
SPASMS, DELIRIUM, SEIZURES, COMA
MUSCULOSKEL
ETAL
WEAKNESS
CARDIOVASCUL
AR
TACHYCARDIA, HYPOTENSION, SYNCOPE
TISSUE
DRY STICKY MUCOUS MEMBRANES, RED SWOLLEN
TONGUE, DECREASED SALIVA AND TEARS
RENAL OLIGURIA
METABOLIC FEVER
CLINICAL MANIFESTATIONS OF HYPERNATREMIA

12. HYPONATREMIA
• A LOW SERUM SODIUM LEVEL OCCURS WHEN THERE IS AN
EXCESS OF EXTRACELLULAR WATER RELATIVE TO SODIUM,
EXTRACELLULAR VOLUME CAN BE HIGH, NORMAL, OR LOW
• HYPONATREMIA IS ALWAYS ASSOCIATEDN WITH
HYPOOSMOLALITY , IN CASE OF HYPONATREMIA WITHOUT
HYPOOSMOLALITY NAMED “PSEUDOHYPONATREMIA”

13. WHAT ARE THE CAUSES OF
HYPONATREMIA ??

15. CLINICAL MANIFESTATIONS OF HYPONATREMIA
BODY SYSTEM HYPONATREMIA
CENTRAL NERVOUS SYSTEM
HEADACHE, CONFUSION, HYPERACTIVE OR
HYPOACTIVE DEEP TENDON REFLEXES,
SEIZURES, COMA, INCREASED INTRACRANIAL
PRESSURE
MUSCULOSKELETAL WEAKNESS, FATIGUE, MUSCLE CRAMPS
GI
ANOREXIA, NAUSEA, VOMITING, WATERY
DIARRHEA
CARDIOVASCULAR
HYPERTENSION AND BRADYCARDIA IF
INTRACRANIAL PRESSURE INCREASES
SIGNIFICANTLY
TISSUE LACRIMATION, SALIVATION
RENAL OLIGURIA

16. HYPERKALEMIA
• HYPERKALEMIA IS DEFINED AS A SERUM POTASSIUM
CONCENTRATION ABOVE THE NORMAL RANGE OF 3.5 TO 5.0
MEQ/L.
• IT IS CAUSED BY EXCESSIVE POTASSIUM INTAKE, INCREASED
RELEASE OF POTASSIUM FROM CELLS, OR IMPAIRED
POTASSIUM EXCRETION BY THE KIDNEYS

17. CAUSES OF HYPERKALEMIA
• INCREASED INTAKE :
POTASSIUM SUPPLEMENTATION
BLOOD TRANSFUSION
• INCREASED RELEASE :
ACIDOSIS
HYPERGLYCEMIA
• IMPAIRED EXCRETION :
RENAL FAILURE

18. CLINICAL MANIFESTATIONS OF
HYPERKALEMIA
SYSTEM HYPERKALEMIA
GI
NAUSEA/VOMITING, COLIC,
DIARRHEA
NEUROMUSCULAR
WEAKNESS, PARALYSIS,
RESPIRATORY FAILURE
CARDIOVASCULAR ARRHYTHMIA, ARREST
RENAL …..

19. ECG CHANGES IN HYPERKALEMIA
ECG changes progress as follows :
peaked T – wave >> widening of QRS complex >>
prolongation of P-R interval >> loss of P wave >> ST
segment depression >> ventricular fibrillation and asystole.

21. TREATMENT OF HYPERKALEMIA
• POTASSIUM REMOVAL :
 KAYEXALATE
 DIALYSIS
• SHIFT POTASSIUM :
 GLUCOSE 1 AMPULE OF D5 AND REGULAR INSULIN 5–10 UNITS IV
 BICARBONATE 1 AMPULE IV
• DECREASE CARDIAC EFFECTS :
 CALCIUM GLUCONATE 5–10 ML OF 10% SOLUTION

22. HYPOKALEMIA
• HYPOKALEMIA IS MUCH MORE COMMON THAN
HYPERKALEMIA IN THE SURGICAL PATIENT
• IT MAY CAUSED BY INADEQUATE POTASSIUM
INTAKE, EXCESSIVE RENAL POTASSIUM EXCRETION,
POTASSIUM LOSS IN PATHOLOGIC GI SECRETIONS

23. CAUSES OF HYPOKALEMIA
• INADEQUATE INTAKE :
 DIETARY , POTASSIUM FREE INTRAVENOUS FLUID
• EXCESSIVE POTASSIUM EXCRETION :
 HYPERALDOSTERONISM
• GL LOSSES :
 DIRECT LOSS OF POTASSIUM FROM GI FLUID “DIARRHEA”
 RENAL LOSS OF POTASSIUM

24. CLINICAL MANIFESTATIONS OF
HYPOKALEMIA
SYSTEM HYPOKALEMIA
GI ILEUS, CONSTIPATION
NEUROMUSCULAR
DECREASED REFLEXES, FATIGUE,
WEAKNESS, PARALYSIS
CARDIOVASCULAR ARREST

25. TREATMENT OF HYPOKALEMIA
• SERUM POTASSIUM LEVEL <4.0 MEQ/L:
 ASYMPTOMATIC, TOLERATING ENTERAL NUTRITION: KCL 40 MEQ PER
ENTERAL ACCESS OD
 ASYMPTOMATIC, NOT TOLERATING ENTERAL NUTR. : KCL 20 MEQ IV Q2H BID
 SYMPTOMATIC: KCL 20 MEQ IV Q1H × 4 DOSES

RECHECK POTASSIUM LEVEL 2 H AFTER END OF INFUSION; IF <3.5 MEQ/L AND
ASYMPTOMATIC, REPLACE AS PER ABOVE PROTOCOL
 IV replacement shouldn’t exceed 240mEq/day

26. IV FLUIDS

27. FLUID & ELECTROLYTE
REQUIREMENTS
 The 1st 10 kg >>> 100 ml/kg/day
 The 2nd 10 kg >>> 50 ml/kg/day
 Wt. above 20kg >> 20 ml/kg/day

28. TYPE OF FLUIDS
• IV FLUID MAY CONSIST OF INFUSIONS OF CRYSTALLOID , COLLOID ,
OR A COMPINATION OF BOTH.
• Crystalloids :
 Aqueous solutions of LMW salts with or without glucose.
 most common useing
• Colloids :
 contain high MW substances such as proteins or large glucose
 colloids have been shown to improve oxygen transport, myocardial contractility and cardiac
output

29. CRYSTALLOID SOLUTIONS
• Intravascular half life is 20 – 30 minutes.
• The most commonly used fluid is lactated Ringer’s solution:
- Generally it has the least effect on ECF composition,
and it is the most physiologic solution when large
volumes are needed.
- Lactate is converted by the liver into bicarbonate.

30. CRYSTALLOID SOLUTIONS
• Normal Saline:
- When given in large volumes, it produces dilutional
hyperchloremic acidosis bec. Of its high Na+ & Cl-
contents ( Plasma bicarbonate conc. decreases as Cl-
conc. Increases).
- NS is a preferred solution for hypochloremic
metabolic alkalosis and for diluting PRBCs prior to
transfusion.

31. CRYSTALLOID SOLUTIONS
• D5W:
- Used for replacement of pure water deficits and as a
maintenance fluid for patients on sodium restriction.
• Hypertonic 3% saline:
- Treatment of severe symptomatic hyponatremia.

33. COLLOID SOLUTIONS
• Intravascular half life 3 – 6 hours.
• The substantial cost and occasional complications tend to limit their use.
• Generally accepted indications for use:
1- Severe intravascular fluid deficits
( hemorrhagic shock) prior to arrival of
blood for transfusion.
2- Severe hypoalbuminaemia or conditions
associated with large protein losses such
as burns.

34. COLLOID SOLUTIONS
• Several colloid solutions are generally available.
• They are derived from either plasma proteins or synthetic glucose polymers,
and they are supplied in isotonic electrolyte solutions.

35. REFERENCES
• SCHWARTZS PRINCIPLES OF SURGERY: ABSITE AND BOARD
REVIEW. 9TH ED.
• SCHWARTZS PRINCIPLES OF SURGERY 10TH ED
• SABISTON TEXTBOOK OF SURGERY 19TH EDITION
• KUWAITI BOARD LECTURE , DR.KHAJA

36. FOR YOUR OPINION AND
CONTACTED