Transcript Hello
Fluid and Electrolytes in
Surgical Patients
Ruth Mitchell, BA, BSc, BMBS
Neurosurgical Resident
Royal Melbourne Hospital
Thursday, March 18, 2010
Peri-operative fluid and electrolyte management: a survey of
consultant surgeons in the UK.
D. N. Lobo, M. G. Dube, K. R. Neal, S. P. Allison, and B. J.
Rowlands Ann R Coll Surg Engl. 2002 May; 84(3): 156–160.
710 questionnaires to consultant surgeons
junior staff given written guidelines 22% of
cases
16% felt their interns were adequately
trained before joining the firm
only 30% felt postoperative patients were
given appropriate amounts of water,
sodium and potassium
What you need to know
Patients need fluid
Patients need electrolytes
Surgical patients are at your mercy
How much?
How much? In a 65kg man
Fluid: 2.5-3L water
Sodium: 100-150mmol
Potassium: 60-90mmol
Fluid requirements increase in fever
65 year old man
Admitted for severe and constant lower
abdo pain, began on L side
Vomiting, unwell
24 hours ago he had a colonoscopy and
polypectomy (x2)
Febrile 38.5, dry coated tongue and loss of
skin turgor, thirsty
Tachycardic 110pbm
BP 110/70 lying, 90 systolic sitting up
Mildly distended abdo, rigid, no bowel
sounds
What’s going on?
What’s going on?
Likely perforated colon
Peritonitis
Risk post polypectomy is 0.5-1%
R colon more common
Immediate or delayed
What’s your management plan?
What’s your management plan?
IV Cannula
IV therapy –1L over 1hour of normal saline
Oxygen via face mask
Analgesia
Take blood
CXR and AXR
Broad spectrum antibiotics
Call a surgeon
Blood Results
Hb 164 (130-170)
Plt 350 (140-400)
WCC 13.6 (4.0-11.0)
Na 149 (135-145)
K 3.4 (3.5-5.5)
Cl 112 (95-110)
Bicarb 29 (22-30)
Glucose 4.4
Chol
3.6
LDH
110
Amylase 65
Ca 2.16 (2.10-2.60)
Phos 1.15 (0.8-1.5)
TP 65 (60-82)
Alb 38 (35-50)
Bili19 (<19)
Alt, ast, ggt, alp - nad
Blood results
Elevated WCC – inflammation and
infection
High haemoglobin – dehydration
Biochemical values: high urea,
sodium and chloride – dehydration
What fluid to give?
What fluid to give?
Replace lost fluid with normal saline
(isotonic)
Start with 2L of normal saline over 1
hour
Estimate fluid loss and make a plan to
replace it
Maintenance Fluid
2.5-3L/day
Normal saline
Dextrose
Hartmanns/CSL
Replacement Fluid
Calculate and replace frequently
Consider loses through increased
temperature, NGT, vomitus, ileostomy
Replace like with like
Update…
Exploratory laparotomy shows
purulent peritonitis, perforated
transverse colon
Transverse colon resected,
defunctioning ileostomy performed
Fluid balance 24 hours later
Fluid input
IV fluid 4500mL
Fluid output
Urine 800mL
Urine last 4 hours
15/13/9/8mL
NGT 2500mL
Wound drain 300mL
Ileostomy 3000mL
Electrolytes
Na
K
Cl
Bicarb
Urea
Creat
138
2.6
102
29
7.0
0.08
Thank you!
Questions?