Fluids
Normal Requirements per day (75 kg)
2500ml water
2-3mmol/kg Na+ = 70-150mmol
1 mmol/kg K+ = 70 mmol
other ions (Mg++ Ca++ Cu++ I- F- Fe++etc)
trace elements (eg Mn, Selenium etc),
vitamins (water: BC, Fat Soluble: ADEK)
fat/carbohydrate/ nitrogen ie calories
Fluid Types
Crystalloids
1litre has…mmol
Colloid
most in saline
saline,
glucose (‘dextrose’) glucose-saline
Na+ 150 Cl- 150
=0.9%
5% glucose
Hartmann’s
Na+ 30/Cl 4%glucose
Na+ 131 K+ 5 Ca++ 2
Cl- 111 Lac 27
gelatins
starches
Dextrans
‘gelofusin’ ‘geloplasma’
‘elo-haes’ ‘voluven’
‘Dextrans 40 / 70’
Na+ 150 K+ 5 Cl- 100 Mg++ 1.5 Lac 30
Blood
Products
packed cells
FFP
Platelets ‘cryoprecipitate’
Albumin
Approach 1: Calculating how much
Normal requirements +ongoing losses + deficit (amount to catch up)
Think about vomiting / fistulae-stomas / obstruction / peritonitis
Approach 2: Have they had enough fluid ?
Look at
Hx ‘feel thirsty’ ?post op?
Exam heart rate BP postural drop JVP cool periphery
capillary refill Urine output
Ix Urea:Creatinine (Cr should be 10x urea)
Urinary Na+
?CXR overload –much less common than dry
Examples: Trauma and preop resusitation
Calculate as above or Try and see (Caution in Ht Failure)
Big venflons ‘endpoints of resusitation’
Try fluid bolus: 250ml colloid and see response
Analgesia
The point of Analgesia is to relieve pain

? give more / Ix
The pathway of pain
Peripheral receptorsNerveSpinal cord Up CordBrain
Types of analgesia:
Systemic or local /regional
Local + Regional Anaesthesia Eg postop epidural (local + opioid = LDM)
NO SYSTEMIC opioids with epidural opioids
Systemic:  simple analgesia: Paracetamol 1g QDS
Combination: codydramol TT QDS
Systemic:  NSAIDS Eg Diclofenac (‘Volterol’) 150 mg/day
Ibuprofen (‘Brufen’) 400mg TDS
? Which route PO/ PR / i/v
side effects: renal / ulcers / asthma / CCF
Systemic:  Opioids
Morphine 3-10mg/3 hourly
Pethidine 25-100mg/3 hourly
Diamorphine 2.5-5mg /3 hourly
Tramadol 50- 100mg / TDS
I/V slow I/M S/C Oral (2x dose)
PCA (1mg morphine /5 mins)
Side effects: resp BP nausia itching
Systemic: Others Eg Nitrous Oxide ‘Entonox’ for dressings, reassure
Example
Laparotomy:
Morphine PCA 1mg/5 mins iv + paracetamol i/v 1g QDS
Caution NSAIDS- renal s/e – not if unwell/24 hrs postop
Then
paracetamol + weaker opioid
+\-diclofenac 50mg po tds when eating
If still in pain consider:
 Another route eg I/V
dose
PCA (call Anaesthetist)
 Add NSAID or another group of drugs
 Regular not PRN
 Other pathology ie investigate…(adhesions/ bleeding / ischaemia
etc).