Fluids, Electrolytes and Common Post Operative Problems

Fluids, Electrolytes and

Fluids, Electrolytes and

Common Post Operative

Common Post Operative

Problems

Problems

Chris DeSimone, M.D.

Chris DeSimone, M.D.

Assistant Professor

Assistant Professor

Division of Gynecologic Oncology

Division of Gynecologic Oncology

Overview

Overview

Fluids, electrolytes and trace elements

Fluids, electrolytes and trace elements

Blood products

Blood products

Case presentations of common post

Case presentations of common post

operative complications

operative complications

IV Fluid

IV Fluid

Fluid Replacement

Fluid Replacement

Hourly requirements

Hourly requirements

1

1

st

st

10 kg 4 ml/kg/ hour

10 kg 4 ml/kg/ hour

2

2

nd

nd

10 kg 2 ml/kg/ hour

10 kg 2 ml/kg/ hour

After 20 kg 1 ml/kg/hour

After 20 kg 1 ml/kg/hour

Example 90 kg female


would require

would require

40 ml

40 ml

20 ml

20 ml

70 ml

70 ml

Equals 130 ml/hour

Equals 130 ml/hour

Or 3120 ml/day

Or 3120 ml/day

Daily requirements

Daily requirements

1

1

st

st

10 kg 100 ml/kg/day

10 kg 100 ml/kg/day

2

2

nd

nd

10 kg 50 ml/kg/day

10 kg 50 ml/kg/day

After 20 kg 20 ml/kg/day

After 20 kg 20 ml/kg/day



would require

would require

1000 ml

1000 ml

500 ml

500 ml

1400 ml

1400 ml

Equals 2900 ml/day

Equals 2900 ml/day

Electrolyte Replacement

Electrolyte Replacement

Daily requirements of major electrolytes

Daily requirements of major electrolytes

Sodium 1 mEq /kg/ day

Sodium 1 mEq /kg/ day

Potassium 1 mEq /kg/ day

Potassium 1 mEq /kg/ day

Chloride 1 mEq /kg/ day

Chloride 1 mEq /kg/ day

Calcium 2 g/ day

Calcium 2 g/ day

Magnesium 20 mEq / day

Magnesium 20 mEq / day

Example of a 90 kg woman

Example of a 90 kg woman

90 mEq needed for Na, K, Cl

90 mEq needed for Na, K, Cl

Rational that 1 liter of

Rational that 1 liter of

½

½

NS would cover daily requirements

NS would cover daily requirements

1 liter of

1 liter of

½

½

NS has 77 mEq of Na and Cl

NS has 77 mEq of Na and Cl

Types of Fluid

Types of Fluid

295

295

7.4

7.4

Acetate (27)

Acetate (27)

Gluconate

Gluconate

(23)

(23)

3

3

5

5

98

98

140

140

Normosol

Normosol

273

273

6.4

6.4

Lactate (28)

Lactate (28)

3

3

4

4

109

109

130

130

Lactated

Lactated

Ringers

Ringers

1032

1032

5.7

5.7

516

516

516

516

3.0%

3.0%

NaCl

NaCl

308

308

5.7

5.7

154

154

154

154

0.9%

0.9%

NaCl

NaCl

154

154

5.7

5.7

77

77

77

77

0.45%

0.45%

NaCl

NaCl

Osmolality

Osmolality

pH

pH

Buffers

Buffers

Mg

Mg

Ca

Ca

K

K

Cl

Cl

Na

Na

Fluid

Fluid

IV Fluids

IV Fluids

75

75

-

-

85% of a patients Na is in the

85% of a patients Na is in the

extracellular space

extracellular space

Exogenous fluid administration follows that

Exogenous fluid administration follows that

same distribution

same distribution

If 1 liter of NS is given: 275 ml will remain

If 1 liter of NS is given: 275 ml will remain

within the intravascular system

within the intravascular system

500 ml bolus of NS only places 125 ml in

500 ml bolus of NS only places 125 ml in

the intravascular space

the intravascular space

Lactated Ringers Solution

Lactated Ringers Solution

Calcium binds to anticoagulant factors in packed

Calcium binds to anticoagulant factors in packed

red blood cells thereby causing clotting of donor

red blood cells thereby causing clotting of donor

blood

blood

Calcium also decreases the efficacy of certain

Calcium also decreases the efficacy of certain

drugs :

drugs :

Thiopental

Thiopental

Amicar

Amicar

Amphotericin

Amphotericin

Amoxicillin

Amoxicillin

Doxycycline

Doxycycline

Dextrose

Dextrose

5% dextrose is commonly added to IVF

5% dextrose is commonly added to IVF

Provides 170 kcal per liter (50g)

Provides 170 kcal per liter (50g)

Increases the osmolality by 278

Increases the osmolality by 278

D5NS now has osmolality 560

D5NS now has osmolality 560

D5LR osmolality 525

D5LR osmolality 525

This increased osmolality dehydrates cells and

This increased osmolality dehydrates cells and

can worsen intracellular dehydration in elderly or

can worsen intracellular dehydration in elderly or

insulin resistant women

insulin resistant women

If nutrition needed recommend parenteral or

If nutrition needed recommend parenteral or

enteral feedings

enteral feedings

Question #1

Question #1

Which body fluid has the highest

Which body fluid has the highest

concentration of sodium?

concentration of sodium?

Sweat

Sweat

Lasix induced diuresis

Lasix induced diuresis

Diarrhea

Diarrhea

Gastric secretions

Gastric secretions

Small bowel secretions


Hyponatremia

Hyponatremia

Na

Na

+

+

< 136 mmol/L, serious symptoms < 125

< 136 mmol/L, serious symptoms < 125

mmol/L

mmol/L

Symptoms

Symptoms

Weakness

Weakness

Confusion

Confusion

Fatigue

Fatigue

Muscle cramps

Muscle cramps

Headache

Headache

Seizures

Seizures

Coma

Coma

Cerebral edema

Cerebral edema

Hyponatremia

Hyponatremia

Hypovolemic hyponatremia

Hypovolemic hyponatremia

N/V/D

N/V/D

Burn victims

Burn victims

Diuretics

Diuretics

Normovolemic hyponatremia

Normovolemic hyponatremia

SIADH

SIADH

Hypervolemic hyponatremia

Hypervolemic hyponatremia

CHF

CHF

Hepatic failure

Hepatic failure

CRF

CRF

Hyponatremia

Hyponatremia

145

145



80

80

Sweat

Sweat

75

75

Furosemide diuresis

Furosemide diuresis

55

55

Gastric secretions

Gastric secretions

40

40

Diarrhea

Diarrhea

<10

<10

Urine

Urine

Sodium Concentration

Sodium Concentration

mEq/L

mEq/L

Fluids Commonly Lost

Fluids Commonly Lost

Hyponatremia

Hyponatremia

Correction done with NS infusion

Correction done with NS infusion

Can use hypertonic saline (3% NS), rapid

Can use hypertonic saline (3% NS), rapid

correction can lead to central pontine

correction can lead to central pontine

myelinolysis

myelinolysis

Aim for 0.5 mEq/L/hour

Aim for 0.5 mEq/L/hour

Formula Na needed equals (target Na minus

Formula Na needed equals (target Na minus

actual Na)

actual Na)

×

×

0.6 (patients weight in kg)

0.6 (patients weight in kg)

Example 90 kg women with a coma and Na of

Example 90 kg women with a coma and Na of

120

120

(140

(140

-

-

120)

120)

×

×

0.6 (90) = 1080 mEq Na needed

0.6 (90) = 1080 mEq Na needed

Roughly 7 liters of NS

Roughly 7 liters of NS

Hypernatremia

Hypernatremia

Na

Na

+

+

> 143 mmol/L

> 143 mmol/L

Symptoms

Symptoms

Confusion

Confusion

Seizures

Seizures

Ataxia

Ataxia

Hypovolemic hypernatremia

Hypovolemic hypernatremia

N/V/D

N/V/D

Normovolemic hypernatremia

Normovolemic hypernatremia

Diabetes insipidus

Diabetes insipidus

Hypervolemic hypernatremia

Hypervolemic hypernatremia

Hypertonic fluids

Hypertonic fluids

Treatment for hypernatremia

Treatment for hypernatremia

Aim for 0.5 mEq/L/hour correction

Aim for 0.5 mEq/L/hour correction

½

½

NS works well

NS works well

Hypokalemia

Hypokalemia

K

K

+

+

< 3.5 mmol/L

< 3.5 mmol/L

Symptoms

Symptoms

Arrhythmias

Arrhythmias

Increased QT, flattened T waves

Increased QT, flattened T waves

Causes

Causes

N/V/D

N/V/D

Diuretics

Diuretics

Treatment

Treatment

Potassium replacement

Potassium replacement

Rule of thumb: 10 mEq IV replaces 0.1 mmol/L in

Rule of thumb: 10 mEq IV replaces 0.1 mmol/L in

serum

serum

Question #2

Question #2

A 35 year old female is admitted for cervical

A 35 year old female is admitted for cervical

cancer. She is found to have a serum creatinine

cancer. She is found to have a serum creatinine

of 9.6 and a serum potassium of 7.9 mmol/L. All

of 9.6 and a serum potassium of 7.9 mmol/L. All

the following are acceptable management

the following are acceptable management

solutions

solutions

except

except

.

.

Calcium gluconate

Calcium gluconate

Sucralfate

Sucralfate

Lasix

Lasix

Insulin

Insulin

Sodium bicarbonate

Sodium bicarbonate

Hyperkalemia

Hyperkalemia

K

K

+

+

> 5.0 mmol/L

> 5.0 mmol/L

Symptoms

Symptoms

Weakness

Weakness

Lethargy

Lethargy

Peaked T waves, widened QRS complex, prolonged

Peaked T waves, widened QRS complex, prolonged

PR interval

PR interval

Leads to V fib or asystole

Leads to V fib or asystole

Causes

Causes

Renal failure

Renal failure

Crush injuries, tumor lysis

Crush injuries, tumor lysis

Adrenal insufficiency

Adrenal insufficiency

Hyperkalemia

Hyperkalemia

Treatment

Treatment

1 amp of calcium gluconate to protect the membrane

1 amp of calcium gluconate to protect the membrane

potential of cardiac cells

potential of cardiac cells

Insulin 10

Insulin 10

-

-

20 units transiently drives K into the cell

20 units transiently drives K into the cell

Sodium bicarbonate increases pH and preferentially

Sodium bicarbonate increases pH and preferentially

drives H

drives H

+

+

out of the cell in exchange for K

out of the cell in exchange for K

+

+

Kayexalate (PO or PR) will bind to K

Kayexalate (PO or PR) will bind to K

+

+

and be

and be

eliminated

eliminated

Dialysis if overwhelming hyperkalemia

Dialysis if overwhelming hyperkalemia

Hypocalcemia

Hypocalcemia

Ca

Ca

++

++

< 8.8 mg/dl

< 8.8 mg/dl

Symptoms

Symptoms

Neuromuscular spasms

Neuromuscular spasms

Tetany

Tetany

–

–

Chvostek’s or Trousseau’s sign

Chvostek’s or Trousseau’s sign

Increased QT interval

Increased QT interval

Depression

Depression

Causes

Causes

CRF

CRF

decreased Vitamin D

decreased Vitamin D

hypoparathyroidism

hypoparathyroidism

Sepsis

Sepsis

Treatment

Treatment

Calcium and Vitamin D replacement

Calcium and Vitamin D replacement

Question #3

Question #3

A 40 year old women treated 8 months ago for a

A 40 year old women treated 8 months ago for a

MMT of the uterus presents to the ED for

MMT of the uterus presents to the ED for

confusion. She is audibly moaning and

confusion. She is audibly moaning and

complaining of pain. Her family states she

complaining of pain. Her family states she

cannot get enough to drink. What electrolyte

cannot get enough to drink. What electrolyte

disturbance is happening?

disturbance is happening?

Hyponatremia

Hyponatremia

Hyperkalemia

Hyperkalemia

Hypercalcemia

Hypercalcemia

Hypomagnesemia

Hypomagnesemia

Hyperphosphatemia

Hyperphosphatemia

Question #4

Question #4

A serum calcium is 14 mg/dl. A CT scan

A serum calcium is 14 mg/dl. A CT scan

confirms multiple lytic lesions of her

confirms multiple lytic lesions of her

vertebral bodies. All of the following are

vertebral bodies. All of the following are

correct

correct

except

except

.

.

IV hydration with NS

IV hydration with NS

Glucocorticoids

Glucocorticoids

Lasix

Lasix

Biphosphonate

Biphosphonate

Calcitonin

Calcitonin

Hypercalcemia

Hypercalcemia

“Stones, bones, groans and mental overtones”

“Stones, bones, groans and mental overtones”

N/V common, ileus, constipation

N/V common, ileus, constipation

Hypovolemia, hypotension

Hypovolemia, hypotension

Shortened QT interval

Shortened QT interval

Polyuria and nephrolithiasis

Polyuria and nephrolithiasis

Confusion, coma

Confusion, coma

Total serum calcium > 10 mg/dl

Total serum calcium > 10 mg/dl

Causes:

Causes:

Hyperparathyroidism

Hyperparathyroidism

Cancer

Cancer

-

-

bony metastases

bony metastases

Above 2 reasons account for 90% of hypercalcemia

Above 2 reasons account for 90% of hypercalcemia

Hypercalcemia

Hypercalcemia

Treatment

Treatment

NS diuresis with or without lasix

NS diuresis with or without lasix

Calcitonin

Calcitonin

Given as 4 U/kg q 12

Given as 4 U/kg q 12

Mild effect (decreases Ca

Mild effect (decreases Ca

++

++

by 0.5 mmol/L)

by 0.5 mmol/L)

Biphosphonates

Biphosphonates

Etidronate 7.5 mg/kg in 250 ml NS over 2 hours for

Etidronate 7.5 mg/kg in 250 ml NS over 2 hours for

3 days

3 days

Zometa 4 mg IV infusion over 15 minutes, repeat

Zometa 4 mg IV infusion over 15 minutes, repeat

in 7 days

in 7 days

Hemodialysis

Hemodialysis

Hypophosphatemia

Hypophosphatemia

PO

PO

4

4

< 2.6 mg/dl

< 2.6 mg/dl

Symptoms

Symptoms

Often silent; however

Often silent; however

Exacerbate CHF

Exacerbate CHF

Anemia

Anemia

Decreases 2,3

Decreases 2,3

-

-

diphosphoglycerate (shifts the oxyhemoglobin

diphosphoglycerate (shifts the oxyhemoglobin

dissociation curve to the left)

dissociation curve to the left)

weakness

weakness

Causes

Causes

Glucose loading

Glucose loading

Respiratory Alkalosis

Respiratory Alkalosis

Sepsis

Sepsis

Diabetic ketoacidosis

Diabetic ketoacidosis

Decreased absorption

Decreased absorption

Hypophosphatemia

Hypophosphatemia

Treatment

Treatment

Oral replacement for values less than 2 mg/dl

Oral replacement for values less than 2 mg/dl

Neutra

Neutra

-

-

Phos or K

Phos or K

-

-

Phos recommend 1200

Phos recommend 1200

-

-

1500 mg/day (each tab is 250mg)

1500 mg/day (each tab is 250mg)

IV replacement for values less than 1 mg/dl

IV replacement for values less than 1 mg/dl

0.08

0.08

-

-

0.16 mmol/kg IV over 6 hours

0.16 mmol/kg IV over 6 hours

Hyperphosphatemia

Hyperphosphatemia

PO

PO

4

4

> 4.8 mg/dl

> 4.8 mg/dl

Symptoms

Symptoms

??

Causes

Causes

Renal insufficiency

Renal insufficiency

Tumor necrosis

Tumor necrosis

Treatment

Treatment

Sucralfate

Sucralfate

Hemodialysis

Hemodialysis

Question #5

Question #5

What is the most common laboratory

What is the most common laboratory

finding of

finding of

hypomagnesemia

hypomagnesemia

?

?

Hypokalemia

Hypokalemia

Hypophosphatemia

Hypophosphatemia

Hyponatremia

Hyponatremia

Hypocalcemia

Hypocalcemia

Hypomagnesemia

Hypomagnesemia

Mg++ < 1.5 mg/dl

Mg++ < 1.5 mg/dl

Symptoms

Symptoms

Decreased K

Decreased K

+

+

(40%)

(40%)

Decreased PO4

Decreased PO4

(30%)

(30%)

Decreased Na

Decreased Na

+

+

(27%)

(27%)

Decreased Ca

Decreased Ca

++

++

(22%)

(22%)

Arrhythmias

Arrhythmias

Seizures

Seizures

Causes

Causes

Drugs

Drugs

-

-

Lasix, aminoglycosides, cisplatin

Lasix, aminoglycosides, cisplatin

Diarrhea

Diarrhea

Diabetes

Diabetes

Alcoholism

Alcoholism

Hypomagnesemia

Hypomagnesemia

Treatment

Treatment

Oral replacement

Oral replacement

Magnesium oxide 400 mg

Magnesium oxide 400 mg

Magnesium gluconate 500 mg

Magnesium gluconate 500 mg

IV replacement

IV replacement

1

1

-

-

2 g over 1 hour infusion

2 g over 1 hour infusion

Question #6

Question #6

Hyporeflexia from hypermagnesemia

Hyporeflexia from hypermagnesemia

commonly occurs above what serum

commonly occurs above what serum

level?

level?

2 mg/dl

2 mg/dl

3 mg/dl

3 mg/dl

4 mg/dl

4 mg/dl

5 mg/dl

5 mg/dl

Hypermagnesemia

Hypermagnesemia

Mg > 2.5 mg/dl

Mg > 2.5 mg/dl

Symptoms

Symptoms

Hyporeflexia

Hyporeflexia

4 mg/dl

4 mg/dl

Complete heart block

Complete heart block

10 mg/dl

10 mg/dl

Cardiac arrest

Cardiac arrest

13 mg/dl

13 mg/dl

Causes

Causes

Hemolysis

Hemolysis

Renal insufficiency

Renal insufficiency

Treatment

Treatment

Calcium gluconate 1 g IV over 2

Calcium gluconate 1 g IV over 2

-

-

3 minutes

3 minutes

Volume replacement and lasix

Volume replacement and lasix

hemodialysis

hemodialysis

Question #7

Question #7

What trace element deficiency causes hair

What trace element deficiency causes hair

loss and dry skin?

loss and dry skin?

Zinc

Zinc

Copper

Copper

Manganese

Manganese

Selenium

Selenium

Molybdenum

Molybdenum

Trace Elements

Trace Elements

ZincZinc

(10

(10

-

-

15 mg/day)

15 mg/day)

Alopecia, decreased immune system, dermatitis

Alopecia, decreased immune system, dermatitis

CopperCopper

(2

(2

-

-

6 mg/day)

6 mg/day)

Anemia, decreased hair pigmentation, hypothermia

Anemia, decreased hair pigmentation, hypothermia

ManganeseManganese

(2.5 mg/day)

(2.5 mg/day)

Bleeding disorder, decreased MMP’s

Bleeding disorder, decreased MMP’s

SeleniumSelenium

(0.05

(0.05

-

-

0.2 mg/day)

0.2 mg/day)

CHF, cardiomyopathy, decreased glutathione

CHF, cardiomyopathy, decreased glutathione

Blood Products

Blood Products

Blood products

Blood products

Packed red blood cells pRBC’s

Packed red blood cells pRBC’s

Platelets

Platelets

Fresh frozen plasma (FFP)

Fresh frozen plasma (FFP)

Cryoprecipitate

Cryoprecipitate

Albumen

Albumen

Hetastarch

Hetastarch

Question #8

Question #8

What is the

What is the

least

least

likely to occur during a

likely to occur during a

blood transfusion?

blood transfusion?

CMV transmission

CMV transmission

Hepatitis C transmission

Hepatitis C transmission

Hepatitis B transmission

Hepatitis B transmission

HIV transmission

HIV transmission

Transfusion reaction


Question #9

Question #9

What product is

What product is

least

least

likely to transmit

likely to transmit

hepatitis?

hepatitis?

Platelets

Platelets

FFP

FFP

pRBC

pRBC

Whole blood

Whole blood

Albumen

Albumen

pRBC’s

pRBC’s

Colloid of choice for anemia/ hypovolemia

Colloid of choice for anemia/ hypovolemia

Raises hematocrit by 2 to 3% per unit

Raises hematocrit by 2 to 3% per unit

250

250

-

-

300 ml

300 ml

Comprised of RBC’s, plasma,

Comprised of RBC’s, plasma,

nonfunctioning WBC’s and platelets

nonfunctioning WBC’s and platelets

Adverse effects:

Adverse effects:

Blood borne illnesses (HIV, Hep B, C, D,

Blood borne illnesses (HIV, Hep B, C, D,

CMV)

CMV)

Transfusion reactions

Transfusion reactions

CDC 2005

CDC 2005

Transmission Rates

Transmission Rates

Hepatitis B

Hepatitis B

1/60,000

1/60,000

Hepatitis C

Hepatitis C

1/120,000

1/120,000

HIV

HIV

1/500,000

1/500,000

CMV

CMV

1/2 to 3

1/2 to 3



1/100 to 1/1000

1/100 to 1/1000

Platelets

Platelets

Administer when platelet count < 10,000

Administer when platelet count < 10,000

(prophylaxis) or if < 20,000 and clinically

(prophylaxis) or if < 20,000 and clinically

hemorrhaging

hemorrhaging

Comprised of platelets, nonfunctioning WBC’s,

Comprised of platelets, nonfunctioning WBC’s,

few RBC’s and plasma

few RBC’s and plasma

50

50

-

-

70 ml per unit

70 ml per unit

1 six pack raises count by 36,000 to 48,000

1 six pack raises count by 36,000 to 48,000

A single unit increases count by 6,000 to 8,000

A single unit increases count by 6,000 to 8,000

Awareness of antibody exposure (ITP not an

Awareness of antibody exposure (ITP not an

indication for platelet transfusion)

indication for platelet transfusion)

FFP

FFP

Acute correction of coagulopathy

Acute correction of coagulopathy

Comprised of II, V, VII, VIII, IX, XII, XIII and 500

Comprised of II, V, VII, VIII, IX, XII, XIII and 500

mg fibrinogen

mg fibrinogen

180 to 250 ml

180 to 250 ml

Increases factor levels by 3%

Increases factor levels by 3%

Adequate clotting occurs with factors above 30%

Adequate clotting occurs with factors above 30%

Short lived, must use 1

Short lived, must use 1

-

-

2 hours prior to

2 hours prior to

procedure

procedure

Not indicated after multiple units of pRBC’s

Not indicated after multiple units of pRBC’s

Cryoprecipitate

Cryoprecipitate

Treatment of Hemophilia A, von

Treatment of Hemophilia A, von

Willebrand’s and hypofibrinogenemia

Willebrand’s and hypofibrinogenemia

Compromised of VIII, XIII, von

Compromised of VIII, XIII, von

Willebrand’s factor, fibronectin and 200 mg

Willebrand’s factor, fibronectin and 200 mg

fibrinogen

fibrinogen

5 to 15 ml

5 to 15 ml

Generally give 10 units at a time

Generally give 10 units at a time

Good for coagulopathic patients who

Good for coagulopathic patients who

cannot withstand added fluid volume

cannot withstand added fluid volume

Albumen

Albumen

It composes 75% of the oncotic pressure in plasma

It composes 75% of the oncotic pressure in plasma

Available in 5% solution or 25% solution in 100 ml NS

Available in 5% solution or 25% solution in 100 ml NS

Molecular weight of 69 kd


Half life of 16 hours

Half life of 16 hours

5% albumen has a plasma volume expansion of 0.7 to

5% albumen has a plasma volume expansion of 0.7 to

1.3

1.3

25% albumen has a volume expansion of 4 to 5

25% albumen has a volume expansion of 4 to 5

Therefore 100 ml of 25% albumen will increase the

Therefore 100 ml of 25% albumen will increase the

vascular volume by 400 to 500 ml

vascular volume by 400 to 500 ml

No risk of Hepatitis transmission

No risk of Hepatitis transmission

Hetastarch

Hetastarch

Synthetic colloid of amylopectins

Synthetic colloid of amylopectins



Half life of 24 hours although excretion can

Half life of 24 hours although excretion can

take up to 17 days

take up to 17 days

Plasma volume expansion of 1 to 1.3

Plasma volume expansion of 1 to 1.3

500 mg given over 8 hours

500 mg given over 8 hours

Anaphylaxis does occur in < 1%

Anaphylaxis does occur in < 1%

Parasite #1

Parasite #1

Case #1 (Mrs. Clonorchis Sinensis)

Case #1 (Mrs. Clonorchis Sinensis)

This is a delightful 74 year old woman,

This is a delightful 74 year old woman,

widowed, with endometrial cancer.

widowed, with endometrial cancer.

She has HTN, DM, COPD and a CVA

She has HTN, DM, COPD and a CVA

with minimal deficits two years ago.

with minimal deficits two years ago.

She smokes 2 ppd and weighs 230

She smokes 2 ppd and weighs 230

lbs. Her medications include Toprol XL

lbs. Her medications include Toprol XL

100 mg BID, Accupril 20 mg QD, Lasix

100 mg BID, Accupril 20 mg QD, Lasix

40 mg BID, Glucophage 500 mg BID,

40 mg BID, Glucophage 500 mg BID,

Glyburide 5 mg BID, Plavix 75 mg QD,

Glyburide 5 mg BID, Plavix 75 mg QD,

Advair, Combivent, ASA 325 mg QD

Advair, Combivent, ASA 325 mg QD

and a multivitamin. She is scheduled

and a multivitamin. She is scheduled

for a TAH/BSO/LNS. What

for a TAH/BSO/LNS. What

preoperative testing would you order?

preoperative testing would you order?

CBC

CBC

BMP

BMP

CMP

CMP

PT/PTT

PT/PTT

T & H

T & H

T & C 2 units

T & C 2 units

T & C 4 units

T & C 4 units

ABG

ABG

PFT

PFT

ECHO

ECHO

EKG

EKG

Carotid Doppler

Carotid Doppler

Cardiac Consult

Cardiac Consult

Exercise stress echo

Exercise stress echo

Dobutamine stress echo

Dobutamine stress echo

Coronary angiography

Coronary angiography

Hemoglobin A1c

Hemoglobin A1c

TSH

TSH

Mrs. Clonorchis Sinensis


Her surgery went without complications. What

Her surgery went without complications. What

maintenance fluid would you start?

maintenance fluid would you start?

A)

A)

NS @ 125 ml/hr

NS @ 125 ml/hr

B)

B)

½

½

NS @ 125 ml/hr

NS @ 125 ml/hr

C)

C)

LR @ 125 ml/hr

LR @ 125 ml/hr

D)

D)

NS @ 150 ml/hr

NS @ 150 ml/hr

E)

E)

½

½

NS @ 150 ml/hr

NS @ 150 ml/hr

F)

F)

LR @ 150 ml/hr

LR @ 150 ml/hr

G)

G)

D5NS @ 125 ml/hr

D5NS @ 125 ml/hr

H)

H)

D5

D5

½

½

NS @ 125 ml/hr

NS @ 125 ml/hr

I)

I)

D5LR @ 125 ml/hr

D5LR @ 125 ml/hr

J)

J)

D5NS @ 150 ml/hr

D5NS @ 150 ml/hr

K)

K)

D5

D5

½

½

NS @ 150 ml/hr

NS @ 150 ml/hr

L)

L)

D5LR @ 150 ml/hr

D5LR @ 150 ml/hr



The night of surgery her urine output is 30

The night of surgery her urine output is 30

ml/hr, her pulse is 114.

ml/hr, her pulse is 114.

1) Is this adequate urine output?

1) Is this adequate urine output?

50 ml/hour

50 ml/hour

2) What testing is needed?

2) What testing is needed?

Hematocrit

Hematocrit

Spot urine sodium

Spot urine sodium

FeNa

FeNa

Recorded Ins and Outs

Recorded Ins and Outs

Fractional Excretion of Sodium

Fractional Excretion of Sodium

(FeNa)

(FeNa)

Urine

Urine

na

na

Plasma

Plasma

na

na

×

×

100

100

Urine

Urine

cr

cr

Plasma

Plasma

cr

cr

Values < 1 are prerenal

Values < 1 are prerenal

Values > 2 are renal

Values > 2 are renal



How would you improve her urine output?

How would you improve her urine output?

Lasix 20 mg IV

Lasix 20 mg IV

Increase maintenance fluid to 200 ml/hour


NS 500 ml bolus

NS 500 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

×

×

2

2

Hespan 500 mg over 8 hours


2 units of pRBC’s

2 units of pRBC’s

5% albumen over 1 hour






During the course of the night Mrs. S’s hematocrit is

During the course of the night Mrs. S’s hematocrit is

stable (34 from 38). She has a spot urine sodium of <

stable (34 from 38). She has a spot urine sodium of <

10. You have given 7 liters of fluid from 7 pm to 4 am.

10. You have given 7 liters of fluid from 7 pm to 4 am.

She has no signs of pulmonary edema. What do you do

She has no signs of pulmonary edema. What do you do

next?

next?

Lasix 20 mg

Lasix 20 mg



NS 500 ml bolus

NS 500 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

×

×

2

2



2 units of pRBC’s

2 units of pRBC’s







The morning arrives and

The morning arrives and

Mrs. S’s urine out put

Mrs. S’s urine out put

remains above 70 ml/hr.

remains above 70 ml/hr.

She however has

She however has

persistent tachycardia,

persistent tachycardia,

110 to 120. She is

110 to 120. She is

lethargic and complains

lethargic and complains

of a headache, chest pain

of a headache, chest pain

and SOB. You are

and SOB. You are

rightfully concerned about

rightfully concerned about

what?

what?

MI

MI

Pulmonary embolis

Pulmonary embolis

Pulmonary edema

Pulmonary edema

Anemia

Anemia

How would you evaluate

How would you evaluate

for these complications?

for these complications?

Troponin, CK

Troponin, CK

-

-

MB, EKG

MB, EKG

Spiral CT of the chest

Spiral CT of the chest

CXR, JVD, Lung exam

CXR, JVD, Lung exam

Hematocrit

Hematocrit



After ruling out MI, PE, pulmonary edema

After ruling out MI, PE, pulmonary edema

and acute blood loss; Mrs. S feels great. It

and acute blood loss; Mrs. S feels great. It

is POD 2. She has just started to tolerate

is POD 2. She has just started to tolerate

clears. Her urine output has climbed to

clears. Her urine output has climbed to

120 ml/hr. After evening rounds, however,

120 ml/hr. After evening rounds, however,

she again complains of SOB. A pulse

she again complains of SOB. A pulse

oximeter reads 88%.

oximeter reads 88%.



What’s happening?

What’s happening?

Pulmonary edema and

Pulmonary edema and

mobilization of fluid

mobilization of fluid

Management

Management

1) Lasix 40

1) Lasix 40

-

-

80 mg with

80 mg with

assessment by

assessment by

pulmonary exam and

pulmonary exam and

urine output every

urine output every

eight hours

eight hours

2) DECREASE FLUID

2) DECREASE FLUID

RATE

RATE

Still Mrs. Clonorchis Sinensis

Still Mrs. Clonorchis Sinensis

POD 4 arrives. Mrs. S is tolerating regular diet.

POD 4 arrives. Mrs. S is tolerating regular diet.

She has diuresed 8 liters of fluid. Before

She has diuresed 8 liters of fluid. Before

discharge she complains of a bloody discharge /

discharge she complains of a bloody discharge /

drainage from her incision. What is your

drainage from her incision. What is your

management?

management?

Assessment with q

Assessment with q

-

-

tip reveals copious amount

tip reveals copious amount

of serosanguinious fluid.

of serosanguinious fluid.

Fascia is intact

Fascia is intact

Packing wet to dry TID. No antibiotics. Home

Packing wet to dry TID. No antibiotics. Home

health

health

Parasite #2

Parasite #2

Case #2 (Mrs. Ascaris

Case #2 (Mrs. Ascaris

Lumbricoides)

Lumbricoides)

Mrs. A is referred for ascites and a pelvic mass

Mrs. A is referred for ascites and a pelvic mass

(12

(12

×

×

10 cm). She is in pain, has nausea and

10 cm). She is in pain, has nausea and

vomiting. Her past medical history is significant

vomiting. Her past medical history is significant

for HTN, DM, CAD and cirrhosis from alpha 1

for HTN, DM, CAD and cirrhosis from alpha 1

antitrypsin disease. She is expedited to the O.R.

antitrypsin disease. She is expedited to the O.R.

Preoperative labs reveals a HCT 28, Cr 1.5, AST

Preoperative labs reveals a HCT 28, Cr 1.5, AST

60, ALT 70, PT 15 with INR 1.5.

60, ALT 70, PT 15 with INR 1.5.

The surgery reveals an extensive ovarian

The surgery reveals an extensive ovarian

carcinoma. It is optimally debulked. Ascites

carcinoma. It is optimally debulked. Ascites

measured 6 liters and blood loss of 400 cc

measured 6 liters and blood loss of 400 cc

Intraoperative resuscitation was 2 units pRBC

Intraoperative resuscitation was 2 units pRBC

’

’

s,

s,

3000 cc of NS.

3000 cc of NS.

Mrs. Ascaris Lumbricoides


NOS is as expected. Mrs. A has been bolused

NOS is as expected. Mrs. A has been bolused

with 4 liters of crystalloid. Her urine output is

with 4 liters of crystalloid. Her urine output is

suboptimal. What next…?

suboptimal. What next…?

Lasix 20 mg

Lasix 20 mg



NS 500 ml bolus

NS 500 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

×

×

2

2



2 units of pRBC’s

2 units of pRBC’s







Despite further hydration and colloid, her urine output is disma

Despite further hydration and colloid, her urine output is disma

lly low

lly low

10 ml/hour. She has a decreased O2 saturation 84%. What next…?

10 ml/hour. She has a decreased O2 saturation 84%. What next…?

CXR

CXR

EKG

EKG

Troponin, CK

Troponin, CK

-

-

MB

MB

Echo

Echo

Call fellow

Call fellow

Call attending

Call attending

Swan

Swan

-

-

ganz

ganz

Spiral CT of chest

Spiral CT of chest

CBC

CBC

Nebulizer

Nebulizer

Intubation

Intubation

ICU

ICU



An ICU admission later, Mrs. A has a swan

An ICU admission later, Mrs. A has a swan

-

-

ganz

ganz

catheter. Her

catheter. Her

wedge pressure is 24 mm, her CVP is 16 mm. She continues to

wedge pressure is 24 mm, her CVP is 16 mm. She continues to

have minimal urine output: < 10 ml/hour. Her serum Cr has risen

have minimal urine output: < 10 ml/hour. Her serum Cr has risen

to

to

2.3. What can be done to improve her urine output and spare her

2.3. What can be done to improve her urine output and spare her

kidneys from ATN?

kidneys from ATN?

Lasix 20 mg

Lasix 20 mg



NS 500 ml bolus

NS 500 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

×

×

2

2



2 units of pRBC’s

2 units of pRBC’s





Parasite #3

Parasite #3

Case #3 (Mrs. Diphyllobothrium

Case #3 (Mrs. Diphyllobothrium

Latum)

Latum)

Mrs. L is an unfortunate woman. She had

Mrs. L is an unfortunate woman. She had

an extensive frozen pelvis from an MMT of

an extensive frozen pelvis from an MMT of

the uterus. Her SB mesentery was

the uterus. Her SB mesentery was

tethered necessitating a proximal

tethered necessitating a proximal

ileostomy. It is POD 3 and she continues

ileostomy. It is POD 3 and she continues

to have a prolific amount of succus. Your

to have a prolific amount of succus. Your

nurse points out to you that her respiratory

nurse points out to you that her respiratory

rate is close to 40.

rate is close to 40.

Mrs. Diphyllobothrium Latum


What key electrolytes and vitamins are

What key electrolytes and vitamins are

being lost?

being lost?

Na

Na

Cl

Cl

K

K

Mg

Mg

Bicarbonate

Bicarbonate

Vitamin A, D, E, K

Vitamin A, D, E, K

Vitamin B12

Vitamin B12



The daily loss of succus is 5 liters. How is this

The daily loss of succus is 5 liters. How is this

best replaced?

best replaced?

Lasix 20 mg

Lasix 20 mg



NS 500 ml bolus

NS 500 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

NS 1000 ml bolus

×

×

2

2



2 units of pRBC’s

2 units of pRBC’s







An ABG reveals a pH of 7.21 and a CO

An ABG reveals a pH of 7.21 and a CO

2

2

of

of

20. What is the acid

20. What is the acid

-

-

base disturbance?

base disturbance?

Metabolic acidosis

Metabolic acidosis

Metabolic alkalosis

Metabolic alkalosis

Mixed

Mixed

Respiratory alkalosis

Respiratory alkalosis

Respiratory acidosis

Respiratory acidosis



How would you best manage her high out

How would you best manage her high out

put?

put?

Somatostatin (Octreotide)

Somatostatin (Octreotide)

Cholestyramine

Cholestyramine

Omeprazole

Omeprazole

Decreased lipid diet

Decreased lipid diet

High calorie, protein diet

High calorie, protein diet

Pepcid

Pepcid

Fluids, Electrolytes and Common Post Operative Problems

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Transcript of Fluids, Electrolytes and Common Post Operative Problems