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FLUID AND FLUID AND ELECTROLYTESELECTROLYTES

IN SURGICAL AND TRAUMA IN SURGICAL AND TRAUMA PATIENTSPATIENTS

By By Dr. Abul Fazal Ali Khan Dr. Abul Fazal Ali Khan Professor of Surgery Professor of Surgery

Allama Iqbal Medical College LahoreAllama Iqbal Medical College Lahore

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SURGICAL AND TRAUMA PATIENTSSURGICAL AND TRAUMA PATIENTS

Unique ChallengesUnique Challenges Critically illCritically ill

Great careGreat care

Body’s Response to StressBody’s Response to Stress

Impact on fluid and electrolytes Impact on fluid and electrolytes homeostasishomeostasis

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ECF DISTURBANCEECF DISTURBANCE

Fluid RestrictionFluid Restriction Diagnostic proceduresDiagnostic procedures Bowel preparationBowel preparation Loss from GITLoss from GIT FeverFever

Acute Loss of ECFAcute Loss of ECF Recognition & TreatmentRecognition & Treatment Prevent Later ComplicationsPrevent Later Complications

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NEUROENDOCRINE RESPONSENEUROENDOCRINE RESPONSE Major SurgeryMajor Surgery TraumaTrauma Different StimuliDifferent Stimuli

HemorrhageHemorrhage HypovolemiaHypovolemia PainPain AnesthesiaAnesthesia HypoxiaHypoxia

EuvolemiaEuvolemia PerfusionPerfusion

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HYPOVOLEMIAHYPOVOLEMIA

Blood LossBlood Loss SequestrationSequestration Various HormonesVarious Hormones

ACTHACTH ADHADH ReninRenin AldosteroneAldosterone CatecholaminesCatecholamines

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HORMONAL RESPONSEHORMONAL RESPONSE

RAA SystemRAA System Increased sympathetic stimulationIncreased sympathetic stimulation Decreased perfusionDecreased perfusion Decreased sodium chlorideDecreased sodium chloride

VasopressinVasopressin HypovolemiaHypovolemia PainPain Head injuryHead injury Water retentionWater retention

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SEQUESTRATIONSEQUESTRATION

Normal Acute injury IV sol. Resolution

ICF

IF

PL

SF

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FLUID LOSSFLUID LOSS

Insensible LossInsensible Loss SweatingSweating StoolsStools External LossesExternal Losses Internal ShiftsInternal Shifts Loss of ElectrolytesLoss of Electrolytes

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DEFICITDEFICIT

FormulaFormula 4 : 2 : 14 : 2 : 1

50 kg/7 Hours50 kg/7 Hours 10 x 4 x 7 = 280ml (first 10 kg)10 x 4 x 7 = 280ml (first 10 kg) 10 x 2 x 7 = 140ml (next 10 kg)10 x 2 x 7 = 140ml (next 10 kg) 30 x 1 x 7 = 210ml (rest 30 kg)30 x 1 x 7 = 210ml (rest 30 kg) Total : 630mlTotal : 630ml

Insensible LossInsensible Loss 0.5ml/kg/hour0.5ml/kg/hour 10% increase10% increase

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CONSEQUENCESCONSEQUENCES

Early PostoperativeEarly Postoperative

Water retentionWater retention HyponatremiaHyponatremia

Late PostoperativeLate Postoperative

HypokalemiaHypokalemia

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MANAGEMENTMANAGEMENT

ECF ReplacementECF Replacement

Provision of ElectrolytesProvision of Electrolytes

Early periodEarly period

Late periodLate period

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FLUID REPLACEMENTFLUID REPLACEMENT

5% D extrose W ater

Intracellular fluid666 m l

Intravascular83 m l

Extravascular250 m l

Extracellular fluid333 m l.

1000 m l

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HYPONATREMIAHYPONATREMIA

Water Used to Replace Salt LossesWater Used to Replace Salt Losses GI lossesGI losses ElderlyElderly

Salt-wasting kidneysSalt-wasting kidneys

Water Administration Exceeds Water Water Administration Exceeds Water LossesLosses ADH SecretionADH Secretion

Post-op periodPost-op period Head injuryHead injury

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FLUID REPLACEMENTFLUID REPLACEMENT

Balanced Sa lt So lu tion

Intrace llular fluid0 m l

Extravascular750 m l.

Intravascular250 m l.

Extracellular fluid1000 m l.

1000 m l

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RINGOLACT-DRINGOLACT-D

Initial TherapyInitial Therapy Composition Quite Similar to Extracellular Composition Quite Similar to Extracellular

FluidFluid Dextrose is Added as an Energy SourceDextrose is Added as an Energy Source Prevents GluconeogenesisPrevents Gluconeogenesis

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COMPARISONCOMPARISON

Electrolytes (mEq/L)Electrolytes (mEq/L) ECFECF Ringolact-DRingolact-D

NaNa 142142 130130 KK 44 44 ClCl 103103 108.7108.7 CaCa 55 2.72.7 HCOHCO33 2727 2828 Dex.Dex. VarVar 50(g/L)50(g/L)

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HYPOKALEMIAHYPOKALEMIA

Most Common AbnormalityMost Common Abnormality Renal ExcretionRenal Excretion IV SolutionsIV Solutions Inadequate IntakeInadequate Intake GI LossesGI Losses

VomitingVomiting Nasogastric tubeNasogastric tube DrainageDrainage

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HYPOKALEMIAHYPOKALEMIA

SecretionSecretion AmountAmount

(mEq/L)(mEq/L)

GastricGastric 10 10

DuodenalDuodenal 15 15

BiliaryBiliary 5 5

PancreaticPancreatic 5 5

JejunalJejunal 6 6

IlealIleal 8 8

ColonicColonic 90 90

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HYPOKALEMIAHYPOKALEMIA

Clinical ManifestationsClinical Manifestations Depend on SeverityDepend on Severity

FatigueFatigue MyalgiasMyalgias Muscular WeaknessMuscular Weakness ECG ChangesECG Changes Respiratory Muscle FatigueRespiratory Muscle Fatigue ArrhythmiasArrhythmias Decreased GI MotilityDecreased GI Motility Paralytic IleusParalytic Ileus

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HYPOKALEMIAHYPOKALEMIA

Intracellular CationIntracellular Cation Decrease of 1 mEq/LDecrease of 1 mEq/L

Deficit of 200-400 mEqDeficit of 200-400 mEq Decrease of 0.27 mEq/LDecrease of 0.27 mEq/L

Deficit of 100 mEqDeficit of 100 mEq Daily RequirementsDaily Requirements

40 mEq for baseline renal loss40 mEq for baseline renal loss 20 mEq for GI losses20 mEq for GI losses Total 60 mEq/dayTotal 60 mEq/day

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HYPOKALEMIAHYPOKALEMIA

IV AdministrationIV Administration Maximum ConcentrationMaximum Concentration

40 mEq/L (peripheral)40 mEq/L (peripheral) Maximum RateMaximum Rate

10 mEq/hour10 mEq/hour Cardiac MonitoringCardiac Monitoring

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PLABOLYTE-MPLABOLYTE-M

Maintenance SolutionMaintenance Solution

Replaces Lost Potassium in Late Post-Replaces Lost Potassium in Late Post-operative Periodoperative Period

Potassium : Potassium : 20 mEq/L20 mEq/L

Low Sodium ContentLow Sodium Content

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PLABOLYTE-MPLABOLYTE-M

Elec.(mEq/L)Elec.(mEq/L) NaNa :: 6060 KK :: 2020 ClCl :: 6060 CaCa :: 33 HCOHCO33 :: 2323 Dextrose:Dextrose: 50(g/L)50(g/L)

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CONCLUSIONCONCLUSION

Ringolact-DRingolact-D Immediate Post-operative PeriodImmediate Post-operative Period

Plabolyte-MPlabolyte-M Late Post-Operative PeriodLate Post-Operative Period

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