1. Fluid and Electrolyte
Management in Surgical
Patient
Dr.Kiti Siriwatana

2. Total body water
• Infant=80
• Male=65
• Female=55
• Thin>Fat

3. Body fluid compartment
• ICF=40%
• ECF=20%
– Intravascular fluid(plasma) =5%
– Interstitial fluid =15%

4. Total body water
ICF
Intravascular fluid
Interstitial fluid

5. PO4-
38
2
2
8
HCO3- 28
24
ICF
Cl-
2
113 ISF
103
Serum
160
K+ 4
4
10
Na+ 145
140

6. 160
140
120
100
80
Serum
60
ISF
40
20 ICF
ICF
0
Na+
Serum
K+
Cl-
HCO3-
PO4-

7. Osmolality
• Homeostatic machanism by kidney
• Serum Osmolality
=(Na+x2)+(BUN/2.8)+(Glucose/18)
• Fluid movement:Osmolality
• Electrolyte movement:Active
transport

8. ADH

9. Aldosterone

10. Fluid
• Crystalloid
– Maintenance type fluid:Hypotonic solution
– Replacement type fluid:Isotonic solution
– Special type fluid:Hypertonic solution
• Colloid
– Albumin
– Gelatin(Haemaccel)
– Starch(H.E.S.)

11. Example of crystalloid
• D5W:Dilutional hyponatremia
• NSS:Normal saline:Isotonic saline
• Lactated Ringer’s solution
(LRS):Physiologic solution
– Liver-Lactate to bicarbonate and energy
• Acetated Ringer’s solution (ARS)
– Acetate metabolite by muscle

12. Na+ K+ Ca++ Mg++ Cl- HCO3 Glucose
ECF 142 4 5 3 103 27 120
5%D/W 0 0 0 0 0 0 50
0.9%NSS 154 0 0 0 154 0 0
5%D/N/2 77 0 0 0 77 0 50
5%D/N/3 51 0 0 0 51 0 50
5%D/N/5 31 0 0 0 31 0 50
3%NSS 513 0 0 0 513 0 0
LRL 130 4 3 0 109 28 0
ARL 130 4 2.7 0 108.7 28 0

13. Crystalloid VS Colloid
• Crystalloid:2-3 Blood loss
• Colloid: ~1:1 Blood loss
• Blood replacement: for Oxygen
carrier

14. Fluid and Electrolyte
therapy
• Fluid:Quatity:volume
• Electrolyte:Quality:composition

15. Replacement for what?
• Daily requirement:Fluid maintenance
• Fluid deficit:Already loss
• Third space loss from surgery
• Fluid for blood replacement

16. Daily requirement:Fluid
maintenance
• Sensible loss:kidney and GI
– Urine:800-1200 cc/day
• Insensible loss:skin and lung
– Skin:20-400 cc/day
– Lung:400-600 cc/day
– Insensible perspiration (cc)=B.W. (kg.)x15
• Total:1600-2000 cc/day
• I/O record

17. Daily requirement:Fluid
maintenance 1
• Holliday and Segar
• น้ําหนัก 10 Kg แรก = 100 cc/Kg
• 10-20 Kg ตอมา = 50 cc/Kg
• >20 Kg = 20 cc/Kg
• For 24 Hr. of fluid maintenance

18. Daily requirement:Fluid
maintenance 2
• Fluid maintenance in 1 Hr.
• น้ําหนัก 10 Kg แรก = 4 cc/Kg/Hr
• 10-20 Kg ตอมา = 2 cc/Kg/Hr
• >20 Kg = 1 cc/Kg/Hr
• Rate = cc/Hr
• Rate/4= drop/min

19. Daily requirement:Fluid
maintenance 3
• For NPO pt. before surgery
• 5% D/N/2 rate 1.5-2 cc/kg/hr

20. Daily requirement:Fluid
maintenance
• Composition and concentration
• Sodium requirement:
– Adult:2-3 mEq/kg/day=100-150 mEq
– Child:4 mEq/kg/day
• Potassium requirement:
– Adult:1 mEq/kg/day=40-50 mEq
– Child:2 mEq/kg/day
• Glucose :125-150 g for prevent ketosis

21. Na+ K+ Ca++ Mg++ Cl- HCO3 Glucose
ECF 142 4 5 3 103 27 120
5%D/W 0 0 0 0 0 0 50
0.9%NSS 154 0 0 0 154 0 0
5%D/N/2 77 0 0 0 77 0 50
5%D/N/3 51 0 0 0 51 0 50
5%D/N/5 31 0 0 0 31 0 50
3%NSS 513 0 0 0 513 0 0
LRL 130 4 3 0 109 28 0
ARL 130 4 2.7 0 108.7 28 0

22. Daily requirement:Fluid
maintenance
• 5% D/N/2 1000 cc.+ Water 1000 cc.
• 5%D/N/2 2000 cc.
• 5% D/NSS 1000 cc.+ Water 1000 cc.

23. Fluid deficit,already loss
• Volume deficit assesment from
history taking and physical
examination
• Mild dehydration:3% B.W.
• Moderate dehydration:6% B.W.
• Severe dehydration:9% B.W.

24. STAGE 0-5% 5-10% 10-15%
Dehydration Dehydration Dehydration
Appearance Freshful Restless Semicomatose
Skinturgor Normal or slightly
Eyes Normal or sunken Sunken
Mucous membrane Dry red Very dry Very dry, cyanosis
H.R. 130 160
% B.W. loss 2-5 % 5-10 % > 10 %
Skin temperature Warmer Cold or warm Cold
Fontanelle (in Normal Maybe sunken Sunken
child)

25. อาการ Deficit (% body wt.)
Early Thirst 2%
Moderate 6%
Marked thirst
Dry mouth
Oliguria
Weakness
Malaise
Loss of skin turgor
Mental change
Severe 7-14 %
Severe mental change
Hallucination
Gross weakness

26. Fluid deficit,already loss
• Composition assesment:Fluid loss
from what?
• Vomitting?
• Diarrhea?
• NG-tube?
• T-tube?

27. Na+ K+ Cl HCO3
Stomach 10 26 10 30
Duodenum 140 5 80 0
Diarrhia
stools 120 25 90 45
Pancreas 140 5 75 115
Bile 145 5 100 35

28. Na+ K+ Ca++ Mg++ Cl- HCO3 Glucose
ECF 142 4 5 3 103 27 120
5%D/W 0 0 0 0 0 0 50
0.9%NSS 154 0 0 0 154 0 0
5%D/N/2 77 0 0 0 77 0 50
5%D/N/3 51 0 0 0 51 0 50
5%D/N/5 31 0 0 0 31 0 50
3%NSS 513 0 0 0 513 0 0
LRL 130 4 3 0 109 28 0
ARL 130 4 2.7 0 108.7 28 0

29. Fluid deficit,already loss
• Diarrhea จะเลือกใช N/2+KCl 30 mEq/l
• Vomiting จะเลือกใช N/2+KCl 10 mEq/l
• NG tube ใช N/2+KCl 10 mEq
• T tube (ในการผาตัดทอน้ําดี) ใช LRL

30. Third space loss
• Volume:
– Major surgery:8 cc/kg/hr
– Moderate surgery:6 cc/kg/hr
– Minor surgery:4 cc/kg/hr
– OMFS:2-4 cc/kg/hr
• Composition:LRS,ARS

31. Blood loss therapy
• Acceptable blood loss (ABL)
• (Hct -30) x ปริมาณเลือดในรางกาย x 3/100
• < 1/3 ABL—LRS,ARS 2-3:1 of blood loss
• >1/3 ABL--LRS,ARS 2-3:1 of blood loss or
Albumin 1:1 of blood loss
• = ABL---Packed red cell(PRC) 0.5:1 of
blood loss

32. Fluid therapy during the
operation
• Maintenance
• Preoperative deficit
– ½ in first hour
– ¼ in second hour
– ¼ in third hour
• Third space loss
• Blood loss during the operation

33. Fluid and electrolyte
abnormality
• Volume disturbance
• Concentration disturbance:Sodium
• Composition disturbance:Others
electrolyte

34. Volume disturbance
• Volume excess
• Volume deficit (dehydration)

35. Concentration
disturbance
• Hyponatremia (Water intoxication)
-Water shift to icf:cell swelling esp.brain
• Hypernatremia (Water deficit)
– Dehydration

36. Composition disturbance
• Hypokalemia
– กลามเนือออนแรง,ทองอืด,หัวใจเตนไมเปนจังหวะ
้
• Hyperkalemia
– คลื่นไส อาเจียน ปวดทอง ทองเสีย หัวใจเตนไมเปน
จังหวะ

37. The End