Subject: Surgery Topic: Body Fluids: Composition, Volume Deficit & Fluid Resuscitation Lecturer: Dr.Jesus L. Versoza Jr.

MD, DPBS, FPCS Date of Lecture: July 26, 2011 Transcriptionist: Maebritt& JC Editor: JC Pages: 10 Case 1: A 27 year old male patient, weighing 65 kg., is admitted due to right upper quadrant pain, with a diagnosis of acute cholecystitis. He undergoes cholecystectomy. After the operation, he was place on NPO. Compute for the following: 1. Total Body Water a. TBW = body wt. (kg) x 60% = 65 kg. x 60% = 39 L 2. Extracellular Fluid Volume a. ECF Volume = body wt. (kg) x 20% = 65 kg. x 20% = 13 L 3. Intracellular Fluid Volume a. ICF Volume = body wt. (kg) x 40% = 65 kg. x 40% = 26 L 4. Intravascular Fluid Volume / Plasma a. Body wt. (kg) x 5% = 65 kg. x 5% = 3.25 L 5. Extravascular Extracellular Fluid Volume / Interstitial a. Body wt. (kg) x 15% = 65 kg. x 15% = 9.75 L Note: In Schwartz s it says that the ECF is 1/3 of the TBW while the ICF is 2/3. This poses no problem when the patient is a male since in males 1/3 of the TBW=20% of Total Body Weight and 2/3 of the TBW=40% of the Total Body Weight. However in females this is not true (as you no doubt have seen in page 52 of Schwartz s); 1/3 of the TBW is not equal to 20% of Total Body Weight and 2/3 of the TBW is not equal to 40% of the Total Body Weight for females. This is why Dr.Versoza advised us to stick to the 20% and 40%/30%. Objectives: 1. To understand fluid distribution in the body according to the various compartments. 2. To understand the clinical features of fluid derangement following various surgical conditions. 3. To understand the concepts of fluid resuscitation in these surgical conditions. Importance: 1. Fluid replacement is one of the things that are ordered first by physicians. 2. One of the most common causes of negligence in hospitals is attributable to a physician not knowing how to compute for the appropriate amount of fluid to give to a patient. This may lead to volume overload, eventually causing cardiac failure. Determinants of TBW: 1. Sex (M/F) 2. Weight

1|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

Table 1.Functional Compartments of Body Fluids Fluid Total Body Water Extracellular Fluid Blood volume Plasma Cell mass Interstitial Intracellular Male 60% 20% 8% 5% 3% 15% 20% Female 50% 20% 8% 5% 3% 15% 30%

Extracellular fluid volume has 2 components: Plasma / Intravascular fluid, which is 5% of the total body weight, and Interstitial fluid, which is 15%. The values of these components are the same for both males and females. The Interstitial fluid compartment is the compartment most often affected by various surgical conditions. Fluid derangements in this compartment are referred to as Third Spacing . Third spacing is given more specific names on the basis of where they occur, e.g. ascites is the abdomen. The volume of the Intracellular fluid compartment is different in males and in females. This is due to males having more muscle mass than females, since most of the Intracellular fluid can be found within muscles. Males are assumed to be more muscular because they secrete more androgens, particularly testosterone; higher testosterone levels usually equates with higher muscle mass in males. Females, on the other hand, secrete more estrogen; estrogen facilitates fat deposition. Blood is made up of Plasma and Formed elements, which includes WBC, RBC and platelets. Since plasma is 5% of the total body weight and fluid volume within the formed elements of blood (i.e. Cell Mass) is 3% of the total body weight, the Blood Volume is 8% of the total body weight. Changes in vital signs are often dependent on the amount of blood a patient will lose. For example, if a girl, who weighs 30kg (2.4 L blood volume) and a man who weighs 100 kg (8L blood volume) got into a car accident and lost 1 L of blood, the girl is more likely to be more compromised than the man because the man has a greater blood volume. Neonates contain more water than adults: 75-80% water with proportionately more extracellular fluid (ECF) than adults. At birth, the amount of interstitial fluid is proportionally three times larger than in an adult. By the age of 12 months, this has decreased to 60% which is the adult value. Total body water as a percentage of total body weight decreases progressively with increasing age. By the age of 60 years, total body water (TBW) has decreased to only 50% of total body weight in males mostly due to an increase in adipose tissue. Table 2.Distribution of Normal Fluid and Electrolyte Losses and Requirements Substance Total Losses Requirement/24 hr( Per kg/BW) Water 2300-2600 ml 35.0 ml Sodium (major extracellular 80-100 mEq 1.0 mEq cation) Potassium (major intracellular 80-100 mEq 1.0 mEq cation) Chloride (major extracellular 100-150 mEq 1.5 mEq anion) Bicarbonate (major intracellular 0.5 mEq anion) Table 3.Sources of Normal Fluid and Electrolyte Losses Sources Insensible or Sensible Losses/24 hrs.? Urine 1200-1500 ml (25 ml./kg BW) Skin 200-400 ml (10 ml./kg BW) Lungs 500-700 ml (10.5 ml./kg BW) Feces 100-200 ml
2|S u r g e r y Body Fl ui ds: C omposi ti on, Vol ume Defi ci t & Fl ui d Resuscitati on

In total, you are losing about 2-2.5 Liters a day. Insensible losses are normal losses. It is from the urine that majority of our fluid losses come from (obviously), however fluid can also be lost from the body through other means like perspiration through the skin, evaporation of fluid found in the respiratory passages (which increases when one is hyperventilating), and the small amount of fluid that is lost whenever we defecate. A patient who is hooked to a mechanical ventilator will have more insensible fluid losses through the lungs, one who is at the desert or is highly febrile through the skin and someone who s diarrheic through the feces. Conditions that cause increased urination, such as Diabetes Insipidus or Diabetes Mellitus, do not contribute to Insensible fluid losses. These cause pathologic fluid losses. Table 4.Electrolyte Composition of Body Fluids Parameters used to determine what type of fluid to give for a particular form of fluid loss. Substance Plasma Gastric Juice Intestinal Juice Bile Pancreatic Juice Na+ K+ 142 45 120 140 130 4.5 30 20 5 15 H+ Cl70 100 120 110 HCO325 25 30 40 80

Ways to determine hydrationstatus of patient: 1) Physical Examination Subjective data 2) Laboratory Findings - Objective data Physical Examination (subjective): a. Skin turgor Assessed by pinching the patient s skin. Loss of elasticity indicates dehydration. b. Moistness of mucous membrane* lips, gingiva andbuccal mucosa, tongue; dryness indicates dehydration. c. Venous filling d. Blood pressure and pulse e. Ocular tension f. Urine output (1-2 ml/kg/hr) most important parameter in determining hydration status g. Weight *This is not 100% reliable. For example, a patient who is talkative is expected to have a dry mouth even though he s not dehydrated. Normal urine output is 1-2ml/kg/hr. Example: A girl weighing 30kg, is expected to void 30cc of urine/hr. In 24 hrs, her normal urine output would be 30cc x 24 = 720cc/day. Note: Bates page 6 says that subjective data is what the patient tells you, which is essentially the History, from the Chief Complaint to the Review of Systems. In contrast objective data is what you detect during the examination and includes all physical examination findings

3|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

Laboratory (objective): a. Hematocrit b. Urine specific gravity c. BUN/Creatinine d. Urine and serum sodium e. Central venous pressure cathether is inserted to the brachial plexus, pass though the vena cava, until to the right side of the heart. f. Pulmonary capillary wedge pressure y Measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch. y Most accurate way of determining hydration because it measures the left side of the heart. Measuring the left side of the heart allows one to measure the cardiac output, giving him an idea of what the total volume of the patient is. If determination of the Pulmonary Capillary Wedge Pressure is no possible, the next best laboratory valuethat should be determined would be the Central Venous Pressure (CVP), which measures the pressure within the right side of the heart. The only problem with CVP is that other conditions (e.gbronchectiasis, corpulmonale)may cause an increase in the CVP. In PCWP results remain constant regardless of the disease of the patient, unless there is a change in body fluid or TBW. Pulmonary Wedge Capillary Pressure: Central Venous Pressure:

a. b. c. d. e. f. g.

Principles of managing fluid, electrolyte, acid-base imbalances Correct shock and restore blood volume to normal: Restore colloid osmotic pressure Correct acid-base imbalance Restore blood osmolality Correct electrolyte deficits Establish F/E daily maintenance Establish daily caloric maintenance Basic categories of fluid and electrolytedisorders: Alterations in volume a. volume excess b. volume deficit more commonly encountered in the surgical setting Alterations in osmolality or solute concentration a. hyponatremia b. hypernatremia Composition abnormalities Alterations in acid-base balance
Body Fl ui ds: C omposi ti on, Vol ume Defi ci t & Fl ui d Resuscitati on

1.

2.

3. 4.
4|S u r g e r y

This is an example of alteration in volume: volume deficit. Rupture of the inflamed appendix, as can be seen here, has led to the edema of the small intestine (as evidenced by its shininess). Fluid that has caused the swelling is from the interstitial fluid compartment resulting in a depletion of the amount of fluid normally present in this compartment.

This is an example of volume deficit resulting from acute blood loss.The patient has a gunshot wound that has resulted in a hemothorax. Blood is being evacuated from the pleural cavity.

This is an example of a volume deficitresulting from a 3rd degree burn. This leads to loss of fluid and colloid through skin.

This is an example of volume deficit from an acute blood loss.The patient is exhibiting the Grey Turner s Sign i.e., bluish discoloration of the flanks indicating an intra-abdominal hemorrhage.

5|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

This is an example of volume deficit resulting from edema of incarcerated bowels.

Table 5.Volume Deficit (Hypovolemia) Type of dehydration Isotonic hypohydration  Definition Proportionate loss of  water and salt, most common type of  deficit. Results from: Ideal Replacement

 

GI losses without renal Isotonic salt compensation solutions Sweating not compensated by adequate hypotonic fluid replacement Vomiting Losses from gastric tubes Diarrhea (i.e. cholera) Inadequate water intake Corticosteroid therapy Diabetes insipidus Late phase of burns after 48 hours, there is evaporation from the burn area. GI losses Addison s disease Excessive diuretic therapy Extravasation of fluid (ex. Early phase of burns, ascites, peritonitis) Acute blood loss Hypoalbuminemia Hypotonic salt solution (more water but less salt)

Hypertonic hypohydration majority of medicine patients present with this.

Loss of water in excess of salt; more water is lost as compared to salt.

    

Hypotonic  hypohydration majority of surgical patients present with this.

Loss of salt in excess of  water; more salt is lost  as compared to water.   y  

Hypertonic salt solution (more electrolytes than water)

6|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

Degree of hypovolemia: 1. Mild  lose of 4% total body water(TBW),  manifested by thirst 2. Moderate  lose of 8% of the TBW;  manifested by: o marked thirst o no groin or axillary sweat o loss of skin turgor 3. Severe  lose of 10% TBW;  manifested by: o marked hypotension, o confusion o delirium
Signifies decrease in blood volume; not enough blood is getting to the heart to be pumped hence not enough blood reaches the brain.

Degree of hypovolemia (in terms of blood volume): 1. Mild

 lose of 10% total blood volume(TBV),  manifested by thirst 2. Moderate  lose of 20% of the TBV; manifested by  marked thirst  tachycardia 3. Severe  lose of 30% TBV;  manifested by marked hypotension  confusion  delirium Type of fluid deficit correction: 1. Maintenance therapy - normal requirements in the absence of abnormal losses (physiologic losses fromurine, sweat, etc.). In other words, dealing with fluids lost normally. 2. Replacement therapy includes not only those needed to replace insensible fluid losses but also those needed to replace abnormal (continuing) losses from the body (ex. via NGT, GI fistula, diarrhea, febrile etc.). Fluid Correction based on the following criteria: 1. Weight: especially for children (<10) and elderly (>70 y.o) 1st 10 kg. BW = 100 mL/kg. 2nd 10 kg. BW = 50 mL/kg. Additional kg. BW = 20 mL/kg. 2. Temperature: Maintenance therapy + (10% X difference in temperature X Maintenance therapy) Type/amount of losses

3.

7|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

Table 6.Commercially available Intravenous Fluids (IVF and their composition) Solution a. Lactated Ringer s b. Normosol R c. Normosol M d. 0.45 NaCl e. 0.45 NaCl f. 0.9 NSS or NaCl Na+ 130 140 40 51 77 154 K+(in mEq) 4 13 13 Ca++ 3 Mg+ 3 3 Cl109 98 40 51 77 154

 A, B and F arehypertonic solutions or crystalloids while the rest are isotonic solutions.  NOTE: WHAT WILL FOLLOW IS A VERY CONFUSING DISCUSSION ON HOW TO DETERMINE IF A SOLUTION IS HYPOTONIC OR ISOTONIC. To determine the range of Sodium concentrations that is considered isotonic, divide 130 (I think this is from the sodium concentration of Lactated Ringer s above) by 2. This will give you 65. Thus anything having a sodium concentration of 6070 mEq is considered isotonic while those having concentrations of 50 mEq and below are considered hypotonic (I don t know how he was able to make this connection he just said that it was so)  Ideal replacement for acute blood loss (see table 5): hypertonic salt solution  Ideal replacement for GI losses without renal compensation (see table 5): isotonic solution specifically 0.5 Nacl or D5.45 NaCl;  If the patient has diarrhea of cholera type, the ideal IVF would be the hypotonic salt solution D5.3  Remember: D5.9 is hypertonic; D 5.45 is isotonic ; and D5.3 is hypotonic; D means Dextrose  There are instances that you must not give a solution with dextrose, like in patients with Diabetes. Note: This is taken from http://members.efn.org/~nurses/IVF.html

0.9% NaCl (normal saline) 0.25% NaCl 0.45% NaCl 2.5% dextrose Lactated Ringer's solution D5W (acts as a hypotonic solution in body) D5 NaCl D5 in Lactated Ringer's D5 0.45% NaCl

isotonic hypotonic hypotonic hypotonic isotonic isotonic hypertonic hypertonic hypertonic

-------------------------------------------------------------------------------------------------------------------------------------Case no. 2 65 kg. male with elective cholecystectomy, nonasogastric tube, placed on NPO TBW = wt. (kg.) X 60% = 65 kg. X .60 = 39 liters ECF= wt. (kg.) X 20% = 65 kg. X .20 = 13 liters ICF = wt. (kg.) X 30% = 65 kg. X .40 = 26 liters TBV = wt. (kg.) X 8 % = 65 kg. X .08 = 5.2 liters

CONSTANT IF COMPUTING FOR MAINTENANCE THERAPY

Maintenance therapy: 35 ml./kg. X 65 kg. = 2275 ml./day Electrolyte replacement: Na = 1 meq/kg. K = 1meq/kg. Cl = 1.5 meq/kg

8|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

-----------------------------------------------------------------------------------------------------------------------------------------Case no. 3 Same patient in Case no. 1 but develops ileus w/ NGT output of 1600 mL bile stained Compute for the following: 1. Replacement and maintenance therapy: = maintenance + output =2275 ml. ( see above answer for maintenance) + 1600 ml. (replacement) = 3875 mL/day; because you need to maintain the fluid loss normally and at the same timeyou need to replace what is abnormally lost!

2. Electrolyte replacement: Na = 1 meq/kg

K = 2-3 meq/kg

Cl = 1.5 meq/kg

-----------------------------------------------------------------------------------------------------------------------------------------Case no. 4 Same patient but develops atelectasis, with temperature a 39.0 C Compute for the following: 1. Replacement and maintenance therapy: = Maintenance therapy + 10% [temp. difference X maintenance therapy] = 2275 ml. (maintenance) + 10% [(39.0 C - 37.0 C) x 2275] =2275 ml + [10% (2x 2275)] = 2275 + 455 = 2730 mL/ 24 hrs. Note: Patients that have abnormal loss of fluid through the lungs (i.e. from ventilator use) are given a constant volume of 1 Liter in addition to their maintenance therapy volume. This 1 Liter is good for 24 hours. -----------------------------------------------------------------------------------------------------------------------------------------Case no. 5 50 y/o male, 60 kg., (+) Peptic Ulcer Disease, w/ continuous vomiting. ml./24 hr. Compute for the following: 1. 2. 3. 4. TBW: wt.(kg.) X 60% = 60 x .60 = 36 liters ECF: wt.(kg.) X 20% = 60 X .20 = 12 liters ICF: wt.(Kg.) X 40% = 60 X .40 = 24 liters Replacement and maintenance therapy: =2100 ml. (maintenance) + 2500 ml. (replacement) = 4600 ml./day 5. Electrolyte Imbalance : hypochloremic, hypokalemic, metabolic alkalosis due to loss of HCl(if there is closure of the pylorus, a.k.a gastric outlet obstruction) In PUD, if the patient s pylorus is not closed and he vomits a lot, there is an equal loss of electrolytes. But, if patient s pylorus closes (as a result of fibrosis) andhe vomits a lot, he loses a lot of gastric juices, particularly HCl acid. Loss of acid results in alkalosis. In order to prevent death due to severe alkalosis the body will try to save H+ in exchange for K+. Thus in addition to hypochloremia, patient will also exhibit hypokalemia.

NGT

output

2500

9|S u r g e r y

Body

Fl ui ds: C omposi ti on, Vol ume Defi ci t &

Fl ui d Resuscitati on

The IVF needed is D5 NSS ( D5.9NaCl ).You cannot give KCl to the patient because KCl (bolus), which incidentallyis given for lethal injection, causes cardiac stand still. Thus, to correct the electrolyte derangement you need to give NaCl. The Cl- portion of NaCl will correct the hypochloremia. And by giving Na+ in excessive amounts, the kidneys will spare K+ by expelling Na+ in its place. Thus hypochloremia, hypokalemia and metabolic alkalosis are corrected ---------------------------------------------------------------------------------------------------------------------------------------RULE OF NINES IN ESTIMATING TBSA Rule of nines is used for burns. This will be lectured next semester but Dr.Versoza asked us to still take note of this. Replacement depends on the burned area.

(Doc didn t explain this thoroughly)

PARKLAND FORMULA FOR ESTIMATINGFLUID RESUSCITATION TOTAL FLUID REQUIREMENT : WT.(Kg.) x %BURNS x3-4 ml. 1st 24 hours: Lactated Ringer s solution half of total fluid requirement during first 8 hours, half of remaining fluid during last 16 hours Colloid solution at 250 ml. For each 10% burns over 20% D5 Water to maintain sodium at 140 meq/L
End of Transcription

2nd 24 hours:

10 | S u r g e r y

Body Fl ui ds: C omposi ti on, V ol ume Deficit & Fl ui d Resusci tati on