M. Shuja Tahir, M.

Abid Bashir
Faisalabad, Pakistan IR-027
Critical Care

FLUID AND ELECTROLYTES -2

VOLUME CHANGES

NORMAL DAILY INTAKE Insensible loss 900 ml

(70 Kg person) Faeces 100 ml
Water from drinks 1200 ml Total output 2500 ml
Water from food (solids) 1000 ml
Water from oxidation 300 ml Patient's output also includes
Total intake 2500 ml excessive losses due to;
Vomiting.
Patient's intake also includes; Diarrhoea.
Fever.
I/V fluids infusion Sweating.
I/V blood transfusion Fistulae.
Absorption from enema fluid Nasogastric aspiration.
Absorption from irrigation fluids Drains.

All these are counted in total daily NORMAL VALUES OF GASTRO-

intake between specified period (24 INTESTINAL-TRACT FLUIDS
hours). (70 KG ADULT)
Saliva 1500 ml/24 hours
NORMAL DAILY OUTPUT Gastric juice 2500 ml/24 hours
(70 Kg person) Bile 500 ml/24 hours
Normal daily output includes urine, Pancreatic juice 700 ml/24 hours
water in faeces and insensible loss Succus entericus 3 0 0 0 m l / 2 4
from respiratory tract and skin. hours
Urine output is 1-7 litres depending Total 8200 ml/24 hours
upon the weather, fluid intake and
diuretics like coffee, tea and drugs. CHILDREN
Minimum amount of urine to get rid Children may have more demand
of solid wastes is 0.5 ml/kg/hour. 1 of fluids because they have;
ml/kg/hour of urine output is ! Large surface area in relation to
considered adequate. Insensible body.
loss is usually 500-900 ml/day but ! More metabolic activity.
it may exceed 5 litres/day in hot and ! Poor concentrating ability of the
humid weather or in febrile and immature kidneys.
hyperventilating patients.
Urine 1-7 litres
Average 1500ml SURGICAL PATIENTS
Minimum 0.5ml/kg/hour In surgical patients, fluid loss may
Adequate 1 ml/kg/hour occur from a number of sites

131 April to June, 2010 INDEPENDENT REVIEWS

depending upon the disease and almost same composition as that of
type of surgery such as; extra cellular fluid (Isotonic).
! Evaporation during laparo-
tomy. CAUSES
! Burns. Hemorrhage
! Fluid loss in nasogastric ! Revealed
aspiration. ! Concealed
! Fistulae. Gastrointestinal tract
! Sequestration into bowel ! Diarrhoea
lumen. ! Vomiting
! Sequestration into tissues in ! Nasogastric aspiration
trauma and inflamation. ! Fistulae
Sequestration
VOLUME STATUS ! Soft tissue injuries
ASSESSMENT ! Burns
Following investigations are helpfull ! Infections (peritonitis etc)
in indirectly assessing the volume ! Intra-abdominal or retro-
status of a person; peritoneal inflammations
! BUN. (Pancreatitis)
! Creatinine. ! Intestinal obstruction
! Haematocrit.
! Urinary osmolality, sodium CLINICAL FEATURES
concentration and specific Moderate Deficit
gravity. ! Central Nervous System
! Sleepiness
ECF volume can also be directly ! Apathy
measured by isotope tracing but it is ! Slow responses
only of academic value. ! Anorexia
! Restlessness
MONITORING ! Gastrointestinal Tract
Following clinical parameters help ! Progressive decrease in
in assessment and monitoring of food consumption
fluid status of the patient. ! (Anorexia)
! Pulse ! Cardiovascular System
! Blood pressure ! Orthostatic Hypotention
! Urine output ! Tachycardia
! Central Venous Pressure (CVP) ! Collapsed veins
! Low volume pulse
VOLUME DEFICIT ! Tissues
It is the most common fluid disorder ! Dry tongue, wrinkling of skin
in surgical patients. Lost fluid has ! Mild hypothermia

April to June, 2010 INDEPENDENT REVIEWS 132

 Severe Deficit
! Central Nervous System
! Decreased tendon reflexes.
! Anesthesia of distal
extremities.
! Stupor.
! Coma.
! Gastrointestinal Tract
! Nausea
! Vomiting
! Anorexia
! Silent ileus and distension
! Cardiovascular System
! Cutaneous lividity
! Hypotension
! Distant heart sounds
! Absent peripheral pulses
! Cold extremities
! Miscellaneous
! Atonic muscles
! Sunken eyes
! Marked hypothermia
TREATMENT
The general principles regarding
volume replacement are as follows;
Volume deficit should be corrected
with isotonic solutions. Ringer
lactate is the most commonly used
solution as it contains electrolytes in
almost similar ratio as that of
plasma.
5% dextrose water is an isotonic
solution but it behaves as hypotonic
as the glucose is taken up by the
cells and utilized. Water also moves
into the ICF .
Amount of fluid to be infused can be
calculated on the basis of utilization
133 April to June, 2010
of body water, or output. Minimum
amount of urine to get rid of solid
wastes is 0.5 ml/kg/hr. Insensible
loss is variable but for simple
calculation, we may consider 500
ml.
So daily fluid requirement would be;
Calculated 24 hourly urine output
+ Insensible loss + output (fistula,
nasogastric tube, drain etc) = (body
weight x 0.5x 24) + 500 +
drainage fluid.
Another method of calculating daily
fluid requirement is according to
body weight. It is specially important
in children. According to this
formula;
100 ml/kg is given for upto 10 kg.
50 ml/kg is given for next 10 kg.
20 ml/kg is given for 21 kg onward.
e.g., for a person of 35 kg, 24
hourly fluid requirement would be;
(100x10) + (50x10)+ (20x15) =
1800 ml.
This fluid is added to calculated 24
hourly output other than urine
(fistula, drain, naso-gastric tube
etc).
VOLUME EXCESS
CAUSES
! Iatrogenic
! Renal insufficiencies
! Cirrhosis of liver
! Congestive Cardiac Failure
INDEPENDENT REVIEWS
! Endocrine (hypo or hyper
thyroidism)
CLINICAL FEATURES
Moderate Excess
! Visceral edema as seen during
surgery
! Raised jugular venous pressure
! Distended Veins
! Increased cardiac output
! Loud heart sounds
! Gallop rhythm
! Functional murmurs
nd
! Increased Pulmonary 2 sound.
! High pulse pressure
! Bounding pulse
! Subcutaneous pitting edema
! Crepitations at lung bases
REFERENCES
1. Shires III, GT, Borber AB, Shires GT. Fluid &
Electrolyte management of the surgical
patient, In Shwortze I, Shires GT, Spencer
FC, Doly JM, Fisher JE, Galloway AC. (Ed).
Principles of surgery 7th Ed. 1999. Mc
Grath Hills New York PP 53-76.
2. Shires GT, Canizoro PC. Fluid, Electrolyte
management of surgical patient. In
sabiston DC (Ed). The text book of surgery.
The biological bases of modern surgical
practice 14th Ed. 1991. W.B Sanden Co.
Philadelphia PP 57-76.
3. Doly JM, Barie PS, Dudnch SI. Preparation
of the patient. In Nylium (Lm), Baker RJ,
April to June, 2010 INDEPENDENT
Severe
! Vomiting
! Diarrhoea
! Anasarca
! Moist rales in lungs
! Pulmonary edema
TREATMENT
The main stay of treatment is to get
rid of extra water. Diuretics are given
to increase water excretion. It is
important to prevent electrolyte
imbalance at the same time. In
acute emergency and in renal
failure dialysis may have to be
performed.
Fischer JE. (Ed) Mastery of surgery 3rd Ed.
1997, Little Drown, Co. Boston. PP. 22-49.
4. Gnerlich JL, Buchman TA. Fluid,
Electrolyte, Acid base disorders. In
Klingensmith ME, Chen LE, Glasgow SC,
Goer TA, Melby SJ, (Eds) Washington
Manual of surgery 5th Ed. 2008. Lippincott
Williams & Wilkins, Philadelphia. PP 71-
91.
5. Steele RJC, Patients with metabolic
disorders. In Cuschieni A, Steelw RJC,
Moosa AR (Ed). Essential surgical practice
4th Ed. 2000. Butterworth Heinmann
Oxford PP. 205-14.
REVIEWS 134
 SUMMARY

Fluid Balance ! Treatment

! Normal daily intake
! Normal daily output Volume excess
Causes
Volume status ! Clinical features
! Assessment ! Treatment
! Monitoring
Water balance
Volume deficit ! Water depletion (dehydration)
! Causes ! Water intoxication
! Clinical features

The author :
Muhammad Shuja Tahir
FRCS (Ed), FCPS (Hon)
is professor and head of the
department of Surgery at
Independent Medical
College Faisalabad.
shuja@iu-hospital.com

The author :
Muhammad Abid Bashir,
FCPS
is associate professor in
department of Surgery at
Independent Medical
College Faisalabad and
®
instructor of ATLS .
abidbashir@hotmail.com

135 April to June, 2010 INDEPENDENT REVIEWS