Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Resusciation and Anaesthesia
Resuscitation and Preparation for Anaesthesia and Surgery
Management of emergencies and cardiopulmonary resuscitation
Other conditions requiring urgent attention
Intravenous access
Fluids and drugs
Drugs and resuscitation
Preoperative assessment and investigations
Anaesthetic issues in the emergency situation
Important medical conditions for the anaesthetist
Practical Anaesthesia
General anaesthesia
Anaesthesia during pregnancy and for operative  delivery
Pediatric anaesthesia
Conduction anaesthesia
Specimen anaesthetic techniques
Monitoring the anaesthetized patient
Postoperative management
Anaesthetic infrastructure and supplies
Equipment and supplies for different level hospitals
Anaesthesia and oxygen
Fires, explosions and other risks
Care and maintenance of equipment
Postoperative Management



Postoperative management, especially in emergency cases, poses a complex problem in finding the right fluid balance. Not all the volumes that have been lost and replaced will be known.

In terms of input and output, consider:
:: Replacement of the preoperative deficit:
The patient may have been dehydrated for several days
The longer the history of illness before operation, the more fluids you should give postoperatively
This may result in a 5–10 litre positive fluid balance in the first 24 hours postoperatively
:: Replacement of losses during the operation plus other fluids given in the course of anaesthesia; again, input will greatly exceed output, resulting in a positive fluid balance
:: Expected further losses: e.g. from nasogastric drainage, other drains, bleeding
:: Hypothermic patient warming up: as the peripheries become warm, more circulating volume is needed
:: Normal maintenance requirement.

Your decision on how to give the fluid will be determined by three factors:
The need to correct a residual deficit from the preoperative state – as
estimated above: this should ideally be given fast as a fluid bolus, under
your direct supervision
A maintenance schedule

The patient’s response, including:

Slowing of tachycardia
Urine output
Increased blood pressure
Rising jugular venous pressure
Return of skin turgor to normal
Sunken eyes returning to normal.


Maintenance fluids

:: Give 3 litres a day to an adult (125 ml/hour); rotate 1 litre bags over 8 hours
:: With normal body electrolytes, give normal saline followed by 5% dextrose (glucose) followed by Ringer’s lactate; 5% glucose is suitable only as replacement for water in patients who cannot drink

Replace other fluid losses with solutions containing sodium: normal saline or Hartmann’s solution, with added potassium 20 mmol/litre, if necessary.


When deciding on your fluid regime, use all the variables above to enable you to write down what must be given. If you are unsure how much to give, write up a regime for the next hour only, and then come back and check the patient’s response.

It is useful to have laboratory estimations of sodium and potassium after a few days of fluid therapy to adjust the input accordingly. Normal values are:
Sodium: 125–145 mmol/litre
:: Potassium: 3.5–5.5 mmol/litre
Additional potassium supplements may be required if hypokalaemia is demonstrated (K+ less than 3.5 mmol/litre)
Potassium must be diluted and given slowly at not more than 20 mmol/hour
The average adult will need about 100 mmol to increase plasma levels by 1 mmol/litre.

See also The Clinical Use of Blood (WHO, 2000) for further information on fluid regimens.

Only give blood if absolutely necessary because of the risk of acute or delayed reactions and of transfusion-transmissible infection.

Fluid balance chart

The fluid balance chart measures the patient’s hourly fluid intake and output over a 24 hour period. At the end of 24 hours, the total measured output (urine, drains, nasogastric drainage) is subtracted from the total measured intake (intravenous infusion, oral intake). The result is called the fluid balance.

A “positive” fluid balance means that there is more intake than output: that is, the patient is accumulating water. In fact, a positive fluid balance is not really positive because there are certain outputs that are not measured very accurately (e.g. faeces) and others that are not possible to measure at all (in sweat and respiration – so called “insensible” losses). Thus a normal healthy adult will appear to have a positive fluid balance of about 1–1.5 litres a day.

For these reasons, in the first 24 hours, the fluid balance chart will usually show a big positive balance, perhaps as high as 10 litres. In succeeding days, fluid balance should revert to the normal 1–1.5 litre positive per day.

In general, if a severely ill patient, such as a septic surgical case, shows a persistent positive fluid balance each day, it means an ongoing illness that is not resolving.

Care of the infusion site

Postoperative infusions are life saving. Loss of the drip and failure to
correct hypotension is the commonest cause of death during the first postoperative night after major surgery.

All patients having major surgery will need a postoperative infusion to correct any deficit and for maintenance. Secure placement of the intravenous cannula is very important:

:: Use a vein in a position that will last a long time in the wards
:: Secure the cannula and giving set carefully; you should be able to lift the arm with the giving set

Use tape that sticks to the skin and use the wings or other large part of the IV cannula for attachment.




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