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
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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
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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?
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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
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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
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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
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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
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Na
K
Cl
Bicarb
Urea
Creat
138
2.6
102
29
7.0
0.08
Thank you!
Questions?