Fluid and Electrolytes in Surgical Patients Ruth Mitchell, BA, BSc, BMBS Neurosurgical Resident Royal Melbourne Hospital Thursday, March 18, 2010

710 questionnaires to consultant surgeons 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) Bili 19 (<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 138 K 2.6 Cl 102 Bicarb 29 Urea 7.0 Creat 0.08

Thank you! Questions?