Fluid and Electrolyte TheraphyAndreas Ricky 11.2011.074

Dokter Pembimbing:

Dr. Sjaiful B. SpB

Introduction

Fluid and electrolyte management are paramount to the care of the surgical patient. Changes in both fluid

volume and electrolyte composition occur preoperatively, intraoperatively, and postoperatively,

as well as in response to trauma and sepsis.

Understanding the physiologic mechanisms that regulate the composition and volume of the body fluids and the principles of fluid and electrolyte therapy is essential

for optimal patient management such for nutrient,

apply medicine and maintaining acid base balance.

Definition

• The body fluid is a liquid suspension of cells in the body of multicellular creatures such as humans or animals that have specific physiological functions.

Body Fluid Compartsment

Body Fluid Composition

• Solven: Water (60% male, 55% female)• Solut:

• Electrolyte: associated substance in a solution and will conduct electricity.• Cations (positive charge). Sodium is the major

extracellular cation (Na+), whereas the major intracellular cation is potassium (K+)

• Anions (negative charge). The main extracellular anion chloride (Clˉ), while the main intracellular anion is phosphate ion (PO4ˉ).

• Non Electrolyte: protein, urea, glucose, oxygen, carbon dioxide and organic acids, creatinin, bilirubin

Movement of Body Fluid

• Osmosis• movement of molecules (solutes) through a semipermeable membrane of

lower grade solution towards higher yield solutions to the same levels.• Osmotic pressure of blood plasma was 285 + 5 mOsm / L. Solution with an

osmotic pressure of approximately equal called isotonic (0.9% NaCl, Dextrose 5%, Ringer's lactate).

• Diffusion• movement of molecules through the pores.The solution will move from high

concentration to the low concentration solution. Vascular hydrostatic pressure will push the water inlet diffuses through the pores.• Thus, diffusion depends on the different concentration and hydrostatic

pressure.

Movement of Body Fluid

• Sodium – potassium pump• Transport process that pumps sodium ions out through the cell membrane

and at the same time pumping potassium ions from outside to inside.

The purpose of the sodium potassium pump is to prevent hyperosmolar state in the cell.

Fluid and Electrolyte Imbalance

• Volume DepletionThe most common cause is a loss of fluid in the gastrointestinal tract from

vomiting, nasogastric suction, diarrhea and fistula drainage. Other causes may include loss of fluid in the soft tissue injury, infection, tissue

inflammation, peritonitis, intestinal obstruction, and burns. Acute, rapid fluid loss which will cause signal interference with the CNS and heart.

• Volume OverloadVolume overload is a condition caused by iatrogenic (intravenous fluids such

as saline which causes excess water and sodium chloride or glucose intravenous fluids that cause excess water) or be secondary to renal insufficiency (GFR interference), cirrhosis, or congestive heart failure.

• Isotonic dehidration (135 - 145 mEq/L)– Water loss = sodium, Osmolarity: 275 – 295 mOsm/L– Theraphy:·NaCl 0,9 % or Dekstrosa 5 % in NaCl 0,225 %

20 ml/kg NaCl 0,9 % atau RL

• Hipotonic dehidration (<135 mEq/L) – Water loss < sodium, Osmolarity: < 275 mOsm/L– Theraphy: NaCl 0,9 % followed by Dekstrosa 5 % in NaCl 0,225 % for the rest of fluid

deficit Or fase I: 20 ml/kg 0,9 % NaCl atau RL

fase II: tambahkan defisit natrium

Sodium deficit correction = ( target Na+ - Na+ actual ) x 0,6 x BBcorrection of Na+ were applied in > 24 jam, to prevent CNS injury

• Hipertonic dehidration (>150 mEq/L)– Water loss > sodium, Osmolarity: >295 mOsm/L– Theraphy:·Dekstrosa 5 % in NaCl 0,45 % atau 5 % Dextrose in half RL– {(X-140) x BB x 0,6} : 140. – Applied in 48 hour to prevent brain edema and death– Maximum corection: 2 mEq/L/hour

Sodium Imbalance

Sodium Imbalance

Potassium Imbalance

• Hipokalemia (levels of potassium <3 mEq / L),Signs and symptoms of hypokalemia can be disritmik heart, ECG changes (QRS widening segment, ST segment depression, postural hypotension, skeletal muscle weakness, polyuria, glucose intolerance.

Therapy:• infusion of potassium chloride to 10 mEq / hour (for mild hypokalemia;> 2 mEq / L) or• intravenous potassium chloride and 40 mEq / h with monitoring by ECG (for severe

hypokalemia; <2mEq / L with ECG changes, severe muscle weakness) . • Counting Formula Potassium Deficit:

K = K1 - K0 x 0.3 x BB

K = potassium neededK1 = the desired serum potassiumK0 = measured serum potassiumB = weight (kg)

• Hiperkalemia (potassium levels> 5 mEq / L,

Often due to renal insufficiency or drug that limits the excretion of potassium (NSAIDs, ACE-inhibitors,

cyclosporin, diuretics).

Signs and symptoms primarily involve the central nervous system (paresthesias, muscle weakness) and

cardiovascular system (disritmik, ECG changes).

Therapy for hyperkalemia may include intravenous calcium chloride 10% in 10 min, 50-100 mEq of sodium bicarbonate in 5-10 minutes, or diuretics, hemodialysis.

Respiratory Acidosis

• (pH <3.75 and PaCO2> 45 mmHg)This condition is associated with CO2 retention secondary to decrease alveolar ventilation in surgical patients.

Acute events are the result of inadequate ventilation include airway obstruction, atelectasis, pneumonia, pleural effusion, upper abdominal pain from the incision, abdominal distension and excessive use of narcotics.

Management involves adequate correction of the defect pulmonary, endotracheal intubation and mechanical ventilation if necessary.

Respiratory Alkalosis

(pH> 7.45 and PaCO2 <35 mmHg)

This condition is caused by fear, pain, hypoxia, CNS injury, and assisted ventilation.

In the acute phase, normal serum bicarbonate concentration, and alkalosis occurs as a result of the

rapid decrease in PaCO2.

Therapy: sedation, analgesia, mechanical ventilators, and correction of potassium deficits that occur

Metabolic Acidosis

• (pH <7.35 and bicarbonate <21 mEq / L• This condition is caused by the retention or addition of acid

or loss of bicarbonate. The most common causes include diarrhea, kidney failure, small bowel fistulas, diabetic ketoacidosis, and lactic acidosis, shock.

Initial compensation that occurs is increased ventilation and PaCO2 depression.

Therapy should be directed toward correction of the underlying disorder. Bicarbonate therapy is only for handling severe acidosis and respiratory alkalosis only after compensation is used.

Metabolic Alkalosis

• (pH> 7.45 and bicarbonate> 27 mEq / L)

This disorder is a result of the loss or addition of acid and bicarbonate exacerbated by hypokalemia.A common problem in surgical patients is hipokloremik (hypokalaemic effect of extracellular volume deficit).

The therapy used was isotonic sodium chloride and potassium deficiency replacement. Alkalosis should be gradual correction over during the period of 24 hours by measuring pH, PaCO2 and serum electrolytes often.

Fluid Theraphy

• Fluid therapy is action to maintain, replace fluids within physiological limits with crystalloid fluids (electrolyte) or colloid (plasma expanders) intravenously

Fluid therapy serves to replace the fluid deficit during fasting before and after surgery, during surgery

routine needs replacing, replace bleeding occurred, and replace fluids move into the third cavity.

Resucitation Fluid Theraphy

• Objective: Acute replace lost body fluids or rapid expansion of

intravascular fluid to improve tissue perfusion.For example in the state of shock and burns.

Resuscitation fluid therapy can be performed with the infusion Normal Saline (NS), Ringer Acetate (RA), or Ringer's lactate (RL) of 20 ml / kg for 30-60 minutes.In hemorrhagic shock can be given 2-3 L in 10 minutes.

Maintenance Therapy

• Objective: maintain the balance of body fluids and nutrients.Average adult requires:liquid ± 40 ml / kg / dayThe main electrolyte:

Na + = 1-2 mmol / kg / dayK + = 1 mmol / kg / day.

The need for replacement fluid is lost due to the formation of urine, gastrointestinal secretion, sweating and expenditures through the lungs, known as Insensible Water Losses.

Strategies for rehydration should take into account: a deficit of fluids, fluid maintenance and ongoing fluid losses.

How rehydration:Calculate the degree of dehydration (Dehydration = D)The degree of dehydration

Adults Infants and ChildrenMild dehydration 5% 4% Medium 6% 10% Severe 8% 15%

The amount of fluid given = degree of dehydration (%) x BB x 1000 ml

2. Calculate maintenance fluid. (Maintenence = M)              Infants and Children: formula 4, 2, 1 (Holliday Segar)

Adults: 40 ml/kg/24 hours

3. Fluid (Guillot).First 6 hours = ½ D +¼ MNext 18 hours = ½ D + ¾M

To calculate the number of drops/minute infusion should be given:

Type of infusion:Macro: 15 drops / 60 minutesMicro: 60 drops / 60 min

maintenence----------------- X (X drops / Y min)

        Σ hours

=. . . . . DPM

Intraoperative Fluid Therapy• With the induction of anesthesia, compensatory mechanisms are lost and hypotension

will develop if volume deficits are not appropriately corrected• Blood loss during surgery, open abdominal surgeries, Large soft tissue wounds,

complex fractures with associated soft tissue injury, and burns all have additional third-space losses that must be considered in the operating room.

Postoperative Fluid Therapy• Postoperative fluid therapy should be based on the patient's current estimated volume

status and projected ongoing fluid losses. Fluids can be changed to 0.45% saline with added dextrose in patients unable to tolerate enteral nutrition.

• Daily fluid orders should begin with assessment of the patient's volume status and assessment of electrolyte abnormalities. In general, there is no need to check electrolyte levels in the first few days, because all known losses are replaced with the appropriate parenteral solution.

Before surgery patients will be fasted for 6 hours (adults) or 4 hours (infantsand children)

Substances lost during fasting, every hour:Water 60 ml2.6 g KHNa + 1.8 mEqFat 5.6 gK + 2.4 mEqProtein 6.4 g

Fluids ongoing operations:· Substitute fasting 2 ml / kg / hour· Maintenance of 2 ml / kg / hour· Stress operation:

Adults ChildrenMinor surgery 4 ml / kg / hour 2 ml / kg / hourMild surgery 6 ml / kg / hour 4 ml / kg / hourMajor surgery 8 ml / kg / hour 6 ml / kg / hour

Combustion Fluid Theraphy Evans’s Method

Within first 24 hours NaCl 0.9%: 1 x BB x% burnColloids: 1 x BB x% burnDextrose 5%: 2000 ml (for replacement insessible water loss)

The first 8 hours ½ total requirement The next 16 hours remaining needs

Within 24 hours II ½ the amount of liquid the first dayWithin 24 hours III ½ the amount of fluid second day

Combustion Fluid Theraphy Baxter’s Method

• Within first 24 hours Ringer lactate: 4 x BB x% burnThe first 8 hours ½ total requirement The next 16 hours remaining needs

• Within 24 hours of IIRinger lactate: ½ x 4 x BB x% burn

Variabel Grade I Grade II Grade III Grade IV

Systole (mmHg) > 110 > 100 < 90 << 90HR (x/menit) < 100 >> 100 >>120 >> 140RR (x/menit) 16 16-20 21-26 > 26

Mental anxious agitated confused lethargy

Blood Lost 750ml 750-1500ml 1500-2000ml >2000ml< 15 % 15-30% 30-40 % > 40 %

Theraphy Crystaloid Crystaloid Crystaloid Crystaloid Blood Blood Surgery

Hemmorrhage

• WHOLE BLOOD transfusion may use or PACKED RED CELLS. For acute bleeding, use Whole Blood.

Criteria for transfusion with Packed Red Cells:• Hb <7 g / dL• Hb 7-10 g / dL, normovolemik accompanied by signs       myocardial disorders, cerebral and respiratory• Bleeding great: 10 ml / kg in the first 1 hour       or> 5 ml / kg in the first 3 hours

• To increase Hb, transfusion with:• Whole blood: (HBX - Hb patients) x BB x 6 =. . . ml• Packed red cells: (HBX - Hb patients) x B x 3 =. . . ml

Hipovolemic Shock

• The body loses intravascular and interstitial fluid, there was extensive burns, severe vomiting and diarrhea, severe sepsis, diabetes, use of diuretics strong, ileus obstruction.

The response of the body against bleeding depends on the volume, speed, and duration of bleeding. When intravascular volume is reduced, the body will always try to maintain perfusion of vital organs (heart and brain) at the expense of perfusion of other organs such as the kidneys, liver, and skin.

The goal of therapy: normalize the intravascular and interstitial volume.

Marked with the unstable vital signs and urine output is less. Returns plasma and interstitial volume is only possible when given a combination of colloidal fluids (blood, plasma, dextran, etc.) and saline balance.

Management of Hypovolemic Shock

Attach two large abocath infusion line.

With rapid infusion of crystalloid solution or a combination of crystalloid and colloid solutions to the vein (v. jugular) fully collapsed.

Meanwhile, when the alleged shock due to bleeding, take blood samples and ask for blood.

When it is clear there is an increase in the content of the pulse and blood pressure, the infusion should be slowed. The danger of rapid infusion is pulmonary edema, especially elderly patients.

• Monitoring needs to be done in determine the speed of infusion:

Pulse: rapid pulse indicates hypovolemia.

Blood pressure: when blood pressure <90 mm Hg in normotensive patients or drop in blood pressure> 40 mmHg in hypertensive patients, suggesting the need for transfusion is still fluid.

Installation urine production was measured with catheters.  Urine Output = ... cc: {(BB x ... hour catheter inserted)}Urine output should be maintained at least 1/2 ml / kg / hour. If less, indicate the presence of hypovolemia.

Given until clear fluid filled veins and arteries clearly palpable. When the intra-vascular volume enough, good blood pressure, urine output <1/2 ml / kg / h, can be given Lasix 20-40 mg to maintain urine output.

Dopamine 2-5 ug / kg / min can also be used after measurement of central venous pressure (normal 8-12 cmH2O), and if there are common symptoms of patients such as anxiety, thirst, spasms, pale, and cold extremities, showed still need transfusion fluids .

• Crystalloid Group: is isotonic, so effective in filling a volume of fluid (volume expanders) into a blood vessel in a short time, and is useful in patients who need liqiud soon

1. Ringer's Lactate (RL)Most physiological fluids if necessary volumes.Widely used as a replacement fluid therapy (resuscitation or replacement therapy), for example: hypovolemic shock, diarrhea, trauma and burns.

Lactate in the RL will be metabolized by the liver to bicarbonate to improve the situation, such as metabolic acidosis.

Potassium in RL is not enough for their daily needs, especially in the case of potassium deficit.

Does not contain glucose, so that as fluid maintenance (maintenance) should be added glucose to prevent ketosis.Giving maximum 2000 ml per day.

2. NaCl 0.9% (normal saline)

Used as fluid resuscitation (replacement therapy), especially in the case of:• low levels of Na +• if RL does not match (alkalosis, retention of K +)• fluid selected for head trauma• to dilute eritosit before transfusion

Has shortcomings:• does not contain HCO3-• does not contain K +• levels of Na + and Cl-are relatively high, so it can Hyperchloraemia acidosis, dilutional acidosis, and hypernatremia

  Giving maximum 1500 ml per day.

3. Dextrose 5%

Used as fluid maintenance (maintenance) in patients with limiting sodium intake or as a substitute for the pure liquid water deficit.

Perioperative Use:• ongoing metabolism• provide for water• prevent hypoglycemia• maintaining existing protein; required at least 100 g of carbohydrate to prevent katabolism of body protein content• reduce levels of free fatty acids and ketone• prevent ketosis, it takes a minimum of 200 g carbohydrate

Dextrose 5% should not be given to patients with head trauma (neuro-trauma) as dextrose and water will move freely into the brain cells. In the brain cells (intracellular), dextrose will be metabolized which causes brain edema.

• Colloids Group molecular size (typically a protein) is large enough so it will not come out of the capillary membrane, and remain in the blood vessels, the hypertonic nature, and can draw fluid from outside the blood vessels.

1. HES (Hydroxyethyl Starch)a. Solvent NaCl 0.9%: Wida HES, HES sterileb. Solvent Electrolyte balanced: FIMAHES

2. gelatin3. dextran4. albumin

Advantages HES:• plug leaks (sealing effect)• It has anti-inflammatory effects, by inhibiting the production of    inflammatory mediators NF-kappa β, so it can be used on    cases of inflammation (sepsis)

KA - EN