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Gastrointestinal tract
Focused physical signs Sunken eyes, dry tongue Loss of skin turgor Low BP, rapid pulse, low urinary output
12/9/2007
12/9/2007
12/9/2007
Water
Water
Distribution of Solutes
Distribution of Solutes
12/9/2007
Water
Na+ required (in mEq) = (desired serum sodium - actual serum sodium) TBW
12/9/2007
Water
Water requirement =
des ired changeins erumNa x TBW des ired s erumNa
16 x 42 4.3 L 154
12/9/2007
Potassium Abnormalities
Release of K+ in immediate postoperative period Tissue catabolism Operative trauma Blood transfusion Normal neurohormonal response leads to loss of K+ in urine
Potassium Abnormalities
Potassium Abnormalities
K+ deficiency Prolonged K+ free IV fluids infusion Inappropriate replacement of daily K+ losses Unsuspected / neglected GI losses + K excess Renal dysfunction / disease
Potassium Abnormalities
Manifestations Cardiac
Bradycardia Hypotension Ventricular fibrillation / Cardiac arrest
Muscular
Weakness Paresthesia
Potassium Abnormalities
Hyperkalemia Acute MI
Potassium Abnormalities
Treatment of hypokalemia Ensure adequate renal function Replacement should not exceed 150-200 mEq/day or 10-15 mEq/hr
12/9/2007
Potassium Abnormalities
Treatment of hyperkalemia 50 ml D50W + insulin 10-25 units IV infusion over 30 minutes (GIK) Sodium bicarbonate 5-10 ml 10% Ca gluconate slow IV
Postoperative Acidosis
Metabolic acidosis Primary decrease in [HCO3-] Respiratory acidosis Primary increase in pCO2
Postoperative Acidosis
Cardiovascular effects Decreased myocardial contractility Decreased responsiveness of the peripheral vasculature to circulating catecholamines Increased refractoriness of the fibrillating myocardium to defibrillation
Postoperative Acidosis
Metabolic effects O2-Hgb dissociation curve shifts to the right Decreased affinity of Hgb for O2
Postoperative Acidosis
Common postoperative causes Pulmonary insufficiency Poor tissue perfusion Impairment of renal function Diabetes mellitus Loss of alkali via gastrointestinal secretions Inadequate ventilation
12/9/2007
Postoperative Acidosis
Respiratory causes of postoperative acidosis Inadequate ventilation
Depression of respiratory center Impaired thoracic excursion Airway obstruction COPD Inappropriate ventilatory settings
Postoperative Acidosis
Anion Gap Change in unmeasured anions or cations
Anion gap Increases in endogenously produced acids Decreases in renal excretion of acids Ingestion of toxins
Postoperative Acidosis
Anion Gap = [Na+] ([Cl-] + [HCO3-])
Postoperative Acidosis
Treatment Correct tissue perfusion Use of IV bicarbonate Correct alveolar ventilation
Deep breathing and coughing Suction of retained secretions Humidification of air Avoidance of over-sedation
Postoperative Alkalosis
Metabolic alkalosis Primary increase in [HCO3-] Respiratory alkalosis Primary decrease in PCO2
12/9/2007
Postoperative Alkalosis
Metabolic causes Post-traumatic aldosteronism
Postoperative Alkalosis
Respiratory causes Hyperventilation secondary to apprehension or pain Inappropriate respiratory therapy
Renal inhibition of bicarbonate excretion & excessive K+ excretion Removing H+ ions along with Cl-
Nasogastric suction
Postoperative Alkalosis
Manifestations Insidious onset CNS: decreased cerebral blood flow
Postoperative Alkalosis
Treatment Correction of the underlying cause
Correction of potassium depletion Volume depletion Cl- containing solutions Acid infusion NH4Cl, arginine HCl, lysine HCl, or dilute HCl acid (0.1 N).
Dizziness, nervousness, confusion, obtundation, stupor, coma Tetany & neuromuscular irritability
Postoperative Alkalosis
Treatment Correction of respiratory alkalosis
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