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

2. 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

3. What you need to know Patients need fluid Patients need electrolytes
Surgical patients are at your mercy

4. How much?

5. How much? In a 65kg man Fluid: 2.5-3L water Sodium: 100-150mmol
Potassium: 60-90mmol
Fluid requirements increase in fever

6. 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

7. What’s going on?

8. What’s going on? Likely perforated colon Peritonitis
Risk post polypectomy is 0.5-1%
R colon more common
Immediate or delayed

9. What’s your management plan?

10. 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

11. Blood Results Hb 164 (130-170) Plt 350 (140-400) WCC 13.6 (4.0-11.0)
Na 149 ( )
K 3.4 ( )
Cl 112 (95-110)
Bicarb 29 (22-30)
Glucose 4.4
Chol 3.6
LDH 110
Amylase 65
Ca 2.16 ( )
Phos 1.15 ( )
TP 65 (60-82)
Alb 38 (35-50)
Bili 19 (<19)
Alt, ast, ggt, alp - nad

12. Blood results Elevated WCC – inflammation and infection
High haemoglobin – dehydration
Biochemical values: high urea, sodium and chloride – dehydration

13. What fluid to give?

14. 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

15. Maintenance Fluid
2.5-3L/day
Normal saline
Dextrose
Hartmanns/CSL

16. Replacement Fluid Calculate and replace frequently
Consider loses through increased temperature, NGT, vomitus, ileostomy
Replace like with like

17. Update…
Exploratory laparotomy shows purulent peritonitis, perforated transverse colon
Transverse colon resected, defunctioning ileostomy performed

18. 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

19. Electrolytes
Na 138
K 2.6
Cl 102
Bicarb 29
Urea 7.0
Creat 0.08

20. Thank you!
Questions?