fluid electrolytes

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FLUID AND ELECTROLYTES MANAGEMENT IN THE SURGICAL PATIENT: 

FLUID AND ELECTROLYTES MANAGEMENT IN THE SURGICAL PATIENT By Dr Rabia Gul

Fluid compartments : 

Fluid compartments

Water Steady State: 

Water Steady State

NORMAL DAILY LOSSES of FLUIDS AND ELECROLYTES : 

NORMAL DAILY LOSSES of FLUIDS AND ELECROLYTES Volume Na+ K+ ML mmol mmol Urine 2000 80-130 60 Faeces 300 - - Insensible 400 - - Total 2700 80-130 60

Fluid and electrolyte regulation : 

Fluid and electrolyte regulation

sodium: 

sodium Normal range 136 -145 mmol / L 90 % of total ECF cations Regulation of Sodium Aldosterone Renin / angiotensin

AETIOLOGY OF HYPER AND HYPONATRAEMIA : 

AETIOLOGY OF HYPER AND HYPONATRAEMIA Hypernatraemia (greater than 145mmol/l) Low extracellular fluid volume diarrhea vomiting Osmotic diuresis Normal extracelluler fluid volume *Sweating ( pyrexia,hot environment) *respiratory tract loss(increased ventilation) *burns Diabetes inspidus (pituitary or nephrogenic ) Diabetes mellitus Increased extracelluler fluid volume Excessive Sodium load (hypertonic fluid,parenteral nutrition Hyponatraemia (less than 136 mmol /l) - Low extracellular fluid volume * Volume depletion ( vomiting,diahrrhoea,burns,decreased fluid intake) * Hypoadrenalism *diuretic use - Normal extracelluler fluid volume hypothyroidism SIADH Increased extracellular fluid volume excessive water administration excessive mannitol use cardiac failure cirrhosis nephritic syndrome renal failure

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Hypernatremia

Clinical manifestations of Hypernatremia: 

Clinical manifestations of Hypernatremia Thirst Lethargy Neurological dysfunction due to dehydration of brain cells Decreased vascular volume

Treatment of Hypernatremia: 

Treatment of Hypernatremia Lower serum Na+ level via Isotonic salt-free IV fluid Loop diuretic(frusamide)

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HYPONATREMIA

Clinical manifestations of Hyponatremia: 

Clinical manifestations of Hyponatremia Neurological symptoms Lethargy, headache, confusion, apprehension, depressed reflexes, seizures and coma Muscle symptoms Cramps, weakness, fatigue Gastrointestinal symptoms Nausea, vomiting, abdominal cramps, and diarrhea

treatment: 

treatment limit water intake Salt containing solutions(normal saline)

potassium: 

potassium Major intracellular cation Normal levels 3.5 – 5.0 mEq /L Hypokalemia < 3.5 mEq /L Hyperkalemia > 5.0 mEq /L Regulation of Potassium Aldosterone Insulin

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HYPOKALEMIA

causes: 

causes Inadequate dietary intake IV fluids without potassium Loss of GI secretions vomiting diarrhea enemas Renal losses Renal tubular acidosis hyperaldosteronism

CLINICAL MANIFESTATIONS: 

CLINICAL MANIFESTATIONS Neuromuscular Skeletal muscle effects( Malaise, Muscular weakness,Fatigue ) Gastrointestinal effects ( Decreased motility ,Constipation , Paralytic ileu s ) Cardiac Ectopic beats Arrythemias

treatment: 

treatment Replacement via Oral route( bananas,tablets,syrup ) Intravenous route RATE OF REPLACEMENT Generally 10 mEq /hour Urgent settings 40 mEq /hour Cardiac monitoring

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Hyperkalemia

causes: 

causes Burns Renal failure Addision’s disease Excressive intake of potassium tablets Drugs(spironolactone)

Clinical manifestations of Hyperkalemia: 

Clinical manifestations of Hyperkalemia Early – hyperactive muscles , paresthesia Late - Muscle weakness, flaccid paralysis Change in ECG pattern Dysrhythmias Bradycardia , heart block, cardiac arrest

Treatment of Hyperkalemia: 

Treatment of Hyperkalemia Calcium gluconate 10% intravenous dil in 10ml given over period of 10 min (reduced risk of ventricular fibrillation) 4 ampules of 25%dextrose plus 10 units short acting insulin over 2-3min(Monitor plasma glucose and K+ over next30-60 min) Salbutomol nebulizers Resonium (ion exchange resin) Haemodialysis for persistent hyperkalemia

Acid-base Imbalance: 

Acid-base Imbalance Alkalosis Respiratory Metabolic Acidosis Respiratory Metabolic Normal range Ph 7.3-7.4 PCO2 35-45 mm hg HCO3 22-31 mm hg

Respiratory Alkalosis: 

Respiratory Alkalosis Deficiency of carbon dioxide Too much carbon dioxide is released pH high (>7.45) pCO2 low (< 35) Causes: Hyperventilation Hypoxemia High altitudes Salicylate overdose Treatment treat the cause

Respiratory Acidosis: 

Respiratory Acidosis excess of PCO2 Lungs are unable to excrete carbon dioxide effectively pH low (< 7.35) PCO2 high (>45) Causes Lung parenchymal pathology Opioid overdose Weakness of respiratory muscle Treatment Treat cause Ventilatory support

Metabolic Alkalosis: 

Metabolic Alkalosis Excess of base pH high (> 7.45) HCO3 high (>26) Causes: Vomiting Antacids Hyperaldosteronism Treatment: Replace fluids and electrolytes Acetazolamide enhances excretion of bicarbonate

Metabolic Acidosis: 

Metabolic Acidosis Acid excess or base deficit pH low (< 7.35) HCO3 low (< 22) Causes: Metenol Uremia DKA Lactic acidosis Treatment: Treat cause Administer bicarbonate in extreme cases & replace fluids and electrolytes

Electrolyte content of I/V fluids: 

Electrolyte content of I/V fluids i /v sol. Na+ mmol /l Cl - mmol /l K+ mmol /l HCO3- mmol /l Ca2+ mmol /l Normal plasma 140 103 4.5 26 2.5 Normal saline 150 150 _ _ _ Dextrose saline 30 30 _ _ _ Ringer lactate 131 111 5 29 2

Fluid therapy: 

Fluid therapy Preoperative Fluid loss + maintenance fluid Maintenance fluid: For first 0-10 kg 100ml/kg/day For next 10-20 kg 50ml/kg/day For wt >20 kg 20ml/kg/day Intraoperative Fluid loss + ongoing loss Postoperative Fluid loss + maintenance fluid (Initial isotonic sol. After 24-48 hrs fluid and electrolyte replacement)

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Thank you