logging in or signing up fluid and electrlytes in surgical patien zbahli Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 3432 Category: Education License: All Rights Reserved Like it (14) Dislike it (1) Added: February 08, 2009 This Presentation is Public Favorites: 2 Presentation Description Basic understanding of fluids and electrolytes management in surgical patient. Comments Posting comment... By: chihchengwu (8 month(s) ago) excellent! reasonable!!! Saving..... Post Reply Close Saving..... Edit Comment Close By: shibubel (8 month(s) ago) hey its so nice!!!!!!!!!!! Saving..... Post Reply Close Saving..... 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We are approximately two third water Total body water : Total body water %body wt total body water % Total 60 100 Intracellular 40 67 Extra cellular 20 33 Intravascular 5 8 Interstitial 15 25 Normal water exchange : Normal water exchange avrg daily mls min daily mls Sensible urine 700-1600 300 intestinal 0-260 0 sweat 0 0 Insensible lungs/skin 500-900 500-900 8-10 mls/kg/D - ? 10%/ o rise in Temp Normal intake of water : Normal intake of water 2000mls - 1400 free water 600 bound to food additional water comes from catabolism Surgery involves a lot…. : Surgery involves a lot…. Special about surgical patient? : Special about surgical patient? Surgical patients pronto disruption nil orally anesthesia trauma sepsis Fluid and electrolyte therapy : Fluid and electrolyte therapy Surgical patients have Maintenance volume requirements On going losses Volume excess/deficits Maintenance electrolyte requirements Electrolyte excess/deficits Maintenance…. ml/24 hrs : Maintenance…. ml/24 hrs This includes: insensible urinary stool losses Body weight Fluid required0-10Kg 100ml/kg/dnext 10-20kg 50 ml/kg/dsubsequent 20 Kg 20ml/kg/d 15ml/Kg/d for elderly Remember formula 100 , 50, 20 Maintenance … ml/hr : Maintenance … ml/hr Remember formula 4,2,1 4 x first 10 kg 2 x second 10 kg 1 x each subsequent kg So a 60 kg man will have 4 x10 =40 2 x 10 =20 1 x 40 =40 100ml/hr 70 kg man needs : 70 kg man needs 10 x 100 = 1000 4 x 10 =40 10 x 50 = 500 2 x 10 =20 50 x 20 = 1000 1 x 50 = 50 2500 mls / d 110 ml/hr Ohh! Ohh! : Ohh! Ohh! On going losses : On going losses fistulae drains NG third space losses Concentration is similar to plasma Replace with isotonic fluids Volume deficit -acute : Volume deficit -acute vital signs changes Blood pressure Heart rate CVP tissue changes not obvious urine output low Volume deficit-chronic : Volume deficit-chronic Decreased skin turgor Sunken eyes Oliguria Orthostatic hypotension High BUN/creatinine ratio HCT increases 6-8 points per litre deficit Plasma Na may be normal deficit and third space losses : deficit and third space losses NPO deficit = number of hours NPO x maintenance fluid requirement (ml/hr) Bowel prep may result in up to 1 L fluid loss. Superficial surgical trauma: 1-2 ml/kg/hr Minimal Surgical Trauma: 3-4 ml/kg/hr - head and neck, hernia, knee surgery Moderate Surgical Trauma: 5-6 ml/kg/hr - hysterectomy, chest surgery Severe surgical trauma: 8-10 ml/kg/hr (or more) - AAA repair, nehprectomy Are you all with me?? : Are you all with me?? What and how? : What and how? Goal normal haemodynamic parameters normal electrolyte concentration Method replace normal maintenance requirements ongoing losses deficits summary : summary Normal maintenance requirements use BW formula On going losses measure all losses in I/O chart Deficits estimate using vital signs Operative & third space losses estimate using HCT What to monitor? : What to monitor? The best estimate of the volume required is the patients response. After therapy started observe vital signs Urine output (0.5mls/Kg/hr Central venous pressure Time frame for replacements : Time frame for replacements Usually correct over 24 hours For ill patients calculate over shorter period and reassess e.g. 12 hours or 3 hours for e critically ill cases. Deficits - correct half the amount over the period and reassess We are getting there??? : We are getting there??? Example 1 : Example 1 62 y/o male, 80 kg, for hemicolectomy NPO after 2200, surgery at 0800, received bowel prep 3 hr. procedure, 500 cc blood loss What are his estimated fluid requirements? Solution…easy : Solution…easy Fluid deficit: 120 ml/kg/hr x 10 hrs = 1200 ml + 1000 ml for bowel prep = 2200 ml total deficit: (Replace 1/2 first hr, 1/4 2nd hr, 1/4 3rd hour). Maintenance: 120 ml/kg/hr x 3hrs = 360mls Third Space Losses: 6 ml/kg/hr x 3 hrs =1440 mls Blood Loss: 500ml x 3 = 1500ml Total = 2200+360+1440+1500=5500mls Example 2 – fluids therapy in ward : Example 2 – fluids therapy in ward 62 year old, 80 kg 2nd POD urine out put 40 mls/hr NG 1.5 L drains 500 mls Example 3 – fluids therapy in ward : Example 3 – fluids therapy in ward 62 year old, 80 kg 2nd POD urine out put 40 mls/hr NG 1.5 L drains 500 mls BP 90/60 Post operative fluid therapy : Post operative fluid therapy Check i/v regime ordered in op form Assess for deficits by checking I/O chart and vital signs Maintenance requirements calculated Usually K not started Monitor carefully vital signs and urine output Maintenance electrolytes requirements : Maintenance electrolytes requirements Na 1 - 2 mEq/Kg/d K 0.5 - 1 mEq/Kg/d Usually no K given until after urine output is adequate and U/E done. Always give K with care, in an infusion slowly - never bolus Ca, PO4, Mg not required for short term Composition of crystalloids : Composition of crystalloids Hartmann's solution normal saline dextrose saline Sodium (mmol/l) 131 150 30 Chloride (mmol/l) 111 150 30 Potassium (mmol/l) 5 nil nil Bicarbonate (mmol/l) 29 nil nil Calcium (mmol/l) 2 nil nil 3L of dextrose saline is not equivalent to 2L of 5% dextrose and 1L on normal saline 3L of dextrose saline = 3L of water and 90 mmol of sodium 2L of 5% dextrose plus 1L of normal saline = 3L of water and 154 mmol of sodium Its not so simple….. : Its not so simple….. intravenous fluids in children : intravenous fluids in children Whenever possible the enteral route should be used for fluids.These guidelines only apply to children who cannot receive enteral fluids. These guidelines apply to children beyond the newborn period. The safe use of IV fluid therapy in children requires accurate prescribing of fluid and careful monitoring Always check orders that you have written, and ensure that you double check on orders written by other staff when you take over the child's care incorrectly prescribed or administered fluids are potentially very dangerous. More adverse events are described from fluid administration than for any other individual drug. If you have any doubt about a child's fluid orders - ask an expert's help. Well children with normal hydration require only maintenance fluids : Well children with normal hydration require only maintenance fluids For 24 hr fluids Remember 100,50,20 100ml/kg for first 10 kg 50ml/kg for next 10 kg 20ml/kg for remaining Adding all will give you mls for 24 hrs. OR Mls for 24 hrs/24=ml/hr For mls/hr Remember 4,2,1 4 x first 10 kg 2 x next 10 kg 1 x remaining kgs Adding all will give you ml/hr of maintenance fluid For 24 hr fluids Remember 100,50,20 100ml/kg for first 10 kg 50ml/kg for next 10 kg 20ml/kg for remaining Adding all will give you mls for 24 hrs. OR mls for 24 hrs/24=ml/hr For mls/hr Remember 4,2,1 4 x first 10 kg 2 x next 10 kg 1 x remaining kgs Adding all will give you ml/hr of maintenance fluid Which fluid???? : Which fluid???? The recommended fluid to be infused as maintenance for well children with normal hydration is: 0.45% NaCl with 2.5% dextrose at Altnagelvin. Do not use this solution: If the serum sodium is low For volume resuscitation For replacement of fluid deficit in dehydrated children For initial treatment of children with acute neurological conditions (e.g. meningitis) Unwell children (+/- abnormal hydration) : Unwell children (+/- abnormal hydration) How much fluid? Firstly administer an Initial bolus of fluid to correct hypovolaemia if so, (10-20 ml/kg)0.9%Nacl. Do not use this amount in any subsequent calculations. Then Maintenance plusDeficit plusOngoing losses deficit : deficit A child's water deficit in mls can be calculated following an estimation of the degree of dehydration expressed as % of body weight. (e.g. a 10kg child who is 5% dehydrated has a water deficit of 500mls. Mild/No dehydration (<4%) - No clinical signs Moderate dehydration (4-6%) - Some physical signs Severe dehydration (>7%) - Multiple physical signs present and child may also have acidosis and hypotension On going losses : On going losses Catheters Drains NG tubes Ongoing losses are usually replaced with normal saline (keep an eye on K.) Calculation should be base upon each previous hour or last 4 hours depending upon the situation. monitoring : monitoring All children on IV fluids should be weighed prior to the commencement of therapy, 6 - 8 hours after the infusion is commenced, and then at least daily. Ensure you request this on the treatment orders. All children on IV fluids should have serum electrolytes and glucose checked before commencing the infusion (typically when the IV is placed) and again within 24 hours if IV therapy is to continue. For sick children, check the electrolytes and glucose 4-6 hours after commencing, and then according to results and the clinical situation but at least daily. Get ready for prescribing fluids ! : Get ready for prescribing fluids ! QUESTIONS : QUESTIONS You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
fluid and electrlytes in surgical patien zbahli Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 3432 Category: Education License: All Rights Reserved Like it (14) Dislike it (1) Added: February 08, 2009 This Presentation is Public Favorites: 2 Presentation Description Basic understanding of fluids and electrolytes management in surgical patient. Comments Posting comment... By: chihchengwu (8 month(s) ago) excellent! reasonable!!! Saving..... Post Reply Close Saving..... Edit Comment Close By: shibubel (8 month(s) ago) hey its so nice!!!!!!!!!!! Saving..... Post Reply Close Saving..... Edit Comment Close By: anaesthesia1973 (12 month(s) ago) very goog work-thank you Saving..... Post Reply Close Saving..... Edit Comment Close By: folinka (18 month(s) ago) nice presentation# Saving..... Post Reply Close Saving..... Edit Comment Close By: chefchenko (18 month(s) ago) download Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Fluids and electrolytes in a surgical ward : Fluids and electrolytes in a surgical ward Zahid mehmood bahli SHO surgery 30/9/2005 objectives : objectives Understanding physiology controlling fluids and electrolytes. Appreciate difference in surgical patients. Be able to order fluid regimen for a surgical patient. Under hydrated or over hydrated? : Under hydrated or over hydrated? Are we drowning???? : Are we drowning???? We are approximately two third water Total body water : Total body water %body wt total body water % Total 60 100 Intracellular 40 67 Extra cellular 20 33 Intravascular 5 8 Interstitial 15 25 Normal water exchange : Normal water exchange avrg daily mls min daily mls Sensible urine 700-1600 300 intestinal 0-260 0 sweat 0 0 Insensible lungs/skin 500-900 500-900 8-10 mls/kg/D - ? 10%/ o rise in Temp Normal intake of water : Normal intake of water 2000mls - 1400 free water 600 bound to food additional water comes from catabolism Surgery involves a lot…. : Surgery involves a lot…. Special about surgical patient? : Special about surgical patient? Surgical patients pronto disruption nil orally anesthesia trauma sepsis Fluid and electrolyte therapy : Fluid and electrolyte therapy Surgical patients have Maintenance volume requirements On going losses Volume excess/deficits Maintenance electrolyte requirements Electrolyte excess/deficits Maintenance…. ml/24 hrs : Maintenance…. ml/24 hrs This includes: insensible urinary stool losses Body weight Fluid required0-10Kg 100ml/kg/dnext 10-20kg 50 ml/kg/dsubsequent 20 Kg 20ml/kg/d 15ml/Kg/d for elderly Remember formula 100 , 50, 20 Maintenance … ml/hr : Maintenance … ml/hr Remember formula 4,2,1 4 x first 10 kg 2 x second 10 kg 1 x each subsequent kg So a 60 kg man will have 4 x10 =40 2 x 10 =20 1 x 40 =40 100ml/hr 70 kg man needs : 70 kg man needs 10 x 100 = 1000 4 x 10 =40 10 x 50 = 500 2 x 10 =20 50 x 20 = 1000 1 x 50 = 50 2500 mls / d 110 ml/hr Ohh! Ohh! : Ohh! Ohh! On going losses : On going losses fistulae drains NG third space losses Concentration is similar to plasma Replace with isotonic fluids Volume deficit -acute : Volume deficit -acute vital signs changes Blood pressure Heart rate CVP tissue changes not obvious urine output low Volume deficit-chronic : Volume deficit-chronic Decreased skin turgor Sunken eyes Oliguria Orthostatic hypotension High BUN/creatinine ratio HCT increases 6-8 points per litre deficit Plasma Na may be normal deficit and third space losses : deficit and third space losses NPO deficit = number of hours NPO x maintenance fluid requirement (ml/hr) Bowel prep may result in up to 1 L fluid loss. Superficial surgical trauma: 1-2 ml/kg/hr Minimal Surgical Trauma: 3-4 ml/kg/hr - head and neck, hernia, knee surgery Moderate Surgical Trauma: 5-6 ml/kg/hr - hysterectomy, chest surgery Severe surgical trauma: 8-10 ml/kg/hr (or more) - AAA repair, nehprectomy Are you all with me?? : Are you all with me?? What and how? : What and how? Goal normal haemodynamic parameters normal electrolyte concentration Method replace normal maintenance requirements ongoing losses deficits summary : summary Normal maintenance requirements use BW formula On going losses measure all losses in I/O chart Deficits estimate using vital signs Operative & third space losses estimate using HCT What to monitor? : What to monitor? The best estimate of the volume required is the patients response. After therapy started observe vital signs Urine output (0.5mls/Kg/hr Central venous pressure Time frame for replacements : Time frame for replacements Usually correct over 24 hours For ill patients calculate over shorter period and reassess e.g. 12 hours or 3 hours for e critically ill cases. Deficits - correct half the amount over the period and reassess We are getting there??? : We are getting there??? Example 1 : Example 1 62 y/o male, 80 kg, for hemicolectomy NPO after 2200, surgery at 0800, received bowel prep 3 hr. procedure, 500 cc blood loss What are his estimated fluid requirements? Solution…easy : Solution…easy Fluid deficit: 120 ml/kg/hr x 10 hrs = 1200 ml + 1000 ml for bowel prep = 2200 ml total deficit: (Replace 1/2 first hr, 1/4 2nd hr, 1/4 3rd hour). Maintenance: 120 ml/kg/hr x 3hrs = 360mls Third Space Losses: 6 ml/kg/hr x 3 hrs =1440 mls Blood Loss: 500ml x 3 = 1500ml Total = 2200+360+1440+1500=5500mls Example 2 – fluids therapy in ward : Example 2 – fluids therapy in ward 62 year old, 80 kg 2nd POD urine out put 40 mls/hr NG 1.5 L drains 500 mls Example 3 – fluids therapy in ward : Example 3 – fluids therapy in ward 62 year old, 80 kg 2nd POD urine out put 40 mls/hr NG 1.5 L drains 500 mls BP 90/60 Post operative fluid therapy : Post operative fluid therapy Check i/v regime ordered in op form Assess for deficits by checking I/O chart and vital signs Maintenance requirements calculated Usually K not started Monitor carefully vital signs and urine output Maintenance electrolytes requirements : Maintenance electrolytes requirements Na 1 - 2 mEq/Kg/d K 0.5 - 1 mEq/Kg/d Usually no K given until after urine output is adequate and U/E done. Always give K with care, in an infusion slowly - never bolus Ca, PO4, Mg not required for short term Composition of crystalloids : Composition of crystalloids Hartmann's solution normal saline dextrose saline Sodium (mmol/l) 131 150 30 Chloride (mmol/l) 111 150 30 Potassium (mmol/l) 5 nil nil Bicarbonate (mmol/l) 29 nil nil Calcium (mmol/l) 2 nil nil 3L of dextrose saline is not equivalent to 2L of 5% dextrose and 1L on normal saline 3L of dextrose saline = 3L of water and 90 mmol of sodium 2L of 5% dextrose plus 1L of normal saline = 3L of water and 154 mmol of sodium Its not so simple….. : Its not so simple….. intravenous fluids in children : intravenous fluids in children Whenever possible the enteral route should be used for fluids.These guidelines only apply to children who cannot receive enteral fluids. These guidelines apply to children beyond the newborn period. The safe use of IV fluid therapy in children requires accurate prescribing of fluid and careful monitoring Always check orders that you have written, and ensure that you double check on orders written by other staff when you take over the child's care incorrectly prescribed or administered fluids are potentially very dangerous. More adverse events are described from fluid administration than for any other individual drug. If you have any doubt about a child's fluid orders - ask an expert's help. Well children with normal hydration require only maintenance fluids : Well children with normal hydration require only maintenance fluids For 24 hr fluids Remember 100,50,20 100ml/kg for first 10 kg 50ml/kg for next 10 kg 20ml/kg for remaining Adding all will give you mls for 24 hrs. OR Mls for 24 hrs/24=ml/hr For mls/hr Remember 4,2,1 4 x first 10 kg 2 x next 10 kg 1 x remaining kgs Adding all will give you ml/hr of maintenance fluid For 24 hr fluids Remember 100,50,20 100ml/kg for first 10 kg 50ml/kg for next 10 kg 20ml/kg for remaining Adding all will give you mls for 24 hrs. OR mls for 24 hrs/24=ml/hr For mls/hr Remember 4,2,1 4 x first 10 kg 2 x next 10 kg 1 x remaining kgs Adding all will give you ml/hr of maintenance fluid Which fluid???? : Which fluid???? The recommended fluid to be infused as maintenance for well children with normal hydration is: 0.45% NaCl with 2.5% dextrose at Altnagelvin. Do not use this solution: If the serum sodium is low For volume resuscitation For replacement of fluid deficit in dehydrated children For initial treatment of children with acute neurological conditions (e.g. meningitis) Unwell children (+/- abnormal hydration) : Unwell children (+/- abnormal hydration) How much fluid? Firstly administer an Initial bolus of fluid to correct hypovolaemia if so, (10-20 ml/kg)0.9%Nacl. Do not use this amount in any subsequent calculations. Then Maintenance plusDeficit plusOngoing losses deficit : deficit A child's water deficit in mls can be calculated following an estimation of the degree of dehydration expressed as % of body weight. (e.g. a 10kg child who is 5% dehydrated has a water deficit of 500mls. Mild/No dehydration (<4%) - No clinical signs Moderate dehydration (4-6%) - Some physical signs Severe dehydration (>7%) - Multiple physical signs present and child may also have acidosis and hypotension On going losses : On going losses Catheters Drains NG tubes Ongoing losses are usually replaced with normal saline (keep an eye on K.) Calculation should be base upon each previous hour or last 4 hours depending upon the situation. monitoring : monitoring All children on IV fluids should be weighed prior to the commencement of therapy, 6 - 8 hours after the infusion is commenced, and then at least daily. Ensure you request this on the treatment orders. All children on IV fluids should have serum electrolytes and glucose checked before commencing the infusion (typically when the IV is placed) and again within 24 hours if IV therapy is to continue. For sick children, check the electrolytes and glucose 4-6 hours after commencing, and then according to results and the clinical situation but at least daily. Get ready for prescribing fluids ! : Get ready for prescribing fluids ! QUESTIONS : QUESTIONS