a&e(vinayaka) fluid & electrolyte emergencies in critically ill dr.patibandla.sowjanya dept...

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Fluid & Electrolyte Emergencies In Critically Ill

Dr.Patibandla.SowjanyaDept Of Accident , Emergency & Critical Care MedicineVinayaka Missions Kirupanandavariyar Medical College

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Introduction

• Total body water (60%)• Two third is intracellular fluid (40%) • One third is extra cellular fluid (20%) - Interstitial fluid (15%) - Intravascular fluid (5%)

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Fluid shifts

INTRACELLULAR 30 LIT40%

INTERSTITIAL 9 LIT15%

IV 5 LIT5%

EXTRACELLULAR

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Electrolyte ComponentsmEq/L ICF ECF

Plasma Interstitial15 142 144150 4 42 5 2.527 3 1.5

1 103 11410 27 30100 2 220 1 1- 5 563 16 6

150

Na+

K+

Ca2+

Mg2+

Cl-

HCO3-

HPO42-

SO42-

Organic acid

Protein

142

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ICF ECF

Major Cation Potassium

Magnesium

Sodium

Major Anion Phosphate

Sulphate

Protein

Chloride

Bicarbonate

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Osmolarity Measurement of the total solutes in a water

solution per liter.

Osmolarity = [sodiumx2

]+urea/2.8+glucose/18

Serum osmolarity is 280-300 mOsm/L

280-300 mOsmol/L- Isotonic

> 300 mOsmol/L – Hypertonic

< 280 mOsmol/L - Hypotonic

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Three categories of fluids

•Isotonic - Fluid has the same osmolarity as plasma

Eg: Normal saline Ringers lactate

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•Hypotonic - Fluid has fewer solutes than plasma

Eg : Water, 1/2 N/S (0.45% NaCl)

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•Hypertonic - Fluid has more solutes than plasma

Eg:5% Dextrose in Normal Saline (D5 N/S) , 3% saline solution.

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2 litres of

blood

3 litres9 litres30 litres

Isotonic Infusion

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30 litres 9 litres 5 litres

Intravascular Volume increases to 5 liters

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2 litres of

colloid

30 litres 9 litres 3 litres

Hypertonic Infusion

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30 litres 9 litres 5 litres

Initially it becomes 5 L

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29 litres 8 litres 7 litres

Hypertonicity of Colloid shifts I/C fluid into I/V

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30 litres 9 litres 3 litres

2 litres of

0.9% saline

If 2 L of Crystalloid infused…

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30 litres 9 litres 5 litres

Initially I/V becomes 5L

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29 litres 10.5 litres 4.5 litres

Isotonicity of Crystalloid shifts I/C & I/V volume into interstitial space

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30 litres 9 litres 3 litres

2 litres of 5%dextrose

Hypotonic Infusion

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31 litres 9.7 litres

3.3 litres

Hypotonicity Shifts the fluid into the I/C space

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Signs of Volume depletion

• Postural hypotension• Tachycardia• Absence of JVP• Dry mucosa• Decreased skin turgor• Oliguria

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Signs of Volume overload

• Hypertension• Raised JVP/gallop• Pedal edema• Pulmonary edema• Ascites• Organ failure

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Basic principles of fluid therapy

Replace Replace

Maintain Maintain

Repair Repair

Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock

Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock

Insensible water loss + urine Insensible water loss + urine

Acid base, electrolyte imbalancesAcid base, electrolyte imbalances

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The rules of fluid replacement

• Replace blood with blood• Replace plasma with colloid• Resuscitate with colloid / crystalloid• Replace ECF depletion with saline• Rehydrate with dextrose

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Case Scenario

45 yr old was brought to ER with h/o loose stools & vomiting since 2 days

Drowsy and lethargic with signs of severe dehydration, BP-80/50 , PR-120

What is initial fluid of choice?

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• Isotonic saline / Ringer’s lactate

• No dextrose containing fluid initially

Why?

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Critically ill

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Case Study #1

• HPI:– A 55 year old man is in the Neuro ICU for acute

non hemorrhagic stroke.

• Hospital course: – Decreasing urine output (< 0.5 ml/kg/hr) over the

last 24 hours. What is your differential diagnosis?

What diagnostic studies would you order?

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Case Study #1

Differential diagnosis

Oliguria1) Pre-Renal (decreased effective renal blood flow)

Diminished intravascular volume, cardiac dysfunction, vasodilatation

2) Post-Renal

Outlet obstruction (intrinsic vs. extrinsic), foley catheter occlusion

3) Renal

Acute tubular necrosis, acute renal failure, SIADH, ...

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Case Study #1

Laboratory studiesSerum studiesSodium 120 mEq/L BUN 4 mg/dLChloride 98 mEq/L Creatinine 0.4 mg/dLPotassium 3.7 mEq/L Glucose 129 mg/dLBicarbonate 25 mEq/L Osmolality 260

mosmol/kgUrine studiesSpecific gravity 1.025 Sodium 58 mEq/LOsmolality 645 mosmol/kg

What are the primary abnormalities?

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Case Study #1

Laboratory studies

Major abnormalities1) Hyponatremia2) Oliguria (inappropriately concentrated urine)

What is the most likely explanation for these findings?

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In Hyponatremia……

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Case Study #1 Syndrome of Inappropriate Antidiuretic

Hormone (SIADH) Variable etiology

▪ Trauma▪ Infection▪ Psychosis▪Malignancy▪Medications▪ Diabetic ketoacidosis▪ CNS disorders▪ Positive pressure ventilation▪ “Stress”

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SIADH By definition, “inappropriate” implies having excluded

normal physiologic reasons for release of ADH:

▪ 1) In response to hypertonicity.

▪ 2) In response to life threatening hypotension.

Hyponatremia

Oliguria

Concentrated urine

▪ elevated urine specific gravity

▪ “inappropriately” high urine osmolality in face of

hyponatremia

Normal to high urine sodium excretion

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Case Study #1 SIADH

• Diagnosis– Critical level of suspicion.

– Demonstration of inappropriately concentrated urine in face of hyponatremia

urine osmolality, SG, urine sodium excretion

– Be certain to exclude normal physiologic release of ADH

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Case Study #1 SIADH

• Treatment– Fluid restriction

– Avoid hypotonic fluids

– Hypertonic saline / oral sodium chloride

– Frusemide.

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Cerebral Salt wasting Syndrome

• Development of excessive natriuresis with hyponatremic dehydration in patients with intracranial disease

• Seen in Head injury, Brain tumor, Intracranial Surgery or stroke

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CSW vs SIADH

featuresfeatures CSWCSW SIADHSIADH

Volume statusVolume status LowLow NormalNormal

WtWt LossLoss No changeNo change

Orthostatic Orthostatic signssigns

PresentPresent AbsentAbsent

Sr NaSr Na DecreasedDecreased DecreasedDecreased

HematocritHematocrit IncreasedIncreased NormalNormal

Uric acidUric acid Normal or incNormal or inc DecreasedDecreased

Resp to Resp to hydrationhydration

ImprovementImprovement Dec NaDec Na

Resp to fluid Resp to fluid restrest

Possible shockPossible shock improveimprove

Urine NaUrine Na >100>100 >20>20

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Case Study #1

The saga continues….

Hospital course:

Four hours after beginning fluid restriction,

you are called because the patient is having a

generalized seizure. There is no response to

two doses of IV lorazepam and a loading dose

of fosphenytoin

What is the most likely explanation?

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Case Study #1

The saga continuesSeizure

1) Worsening hyponatremia

2) Intracranial event

3) Meningitis

4) Other electrolyte disturbance

5) Medication

6) Hypertension

What diagnostic studies would you order?

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Case Study #1

The saga continues

Stat labs:

Sodium 110 mEq/L

What would you do now?

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Case Study #1 Hyponatremic seizure

• Treatment – Hypertonic saline (3% NaCl) infusion

– To correct sodium to 125 mEq/L, the deficit is equal to

0.6 X weight[kg] X (125 - measured sodium)

0.6 X 60 X (125-110) = 54O mEq

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Newer method• Rate of infusion of 3%NaCl = Na Requirement x 1000 infusate sodium x

time• (Desired-Actual Na) x 0.6.body wt x

1000 513 x no of hours

• As patient is symptomatic, rate of correction is 1 mEq/hr,• Required rate of infusion of 3% NaCl = 1 x 0.6 x 60 x

1000 513 x 1 = 70 ml/hr• Check sodium after 4 hours and correct accordingly

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Hyponatremia

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Case Study # 2

• 60 year old retired engineer presented to ER with

history of inability to speak and move all 4 limbs

since today morning. Detailed history revealed that

he has been on naturopathy diet since 6 months and

had developed GTCS 2 days back. He was treated

outside for GTCS and following the treatment he is

unable to communicate or use his limbs

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• His previous lab reports showed Na is 117 mEq/L and rest of the parameters are within normal Limits

• Repeat Sodium in our hospital showed 145 mEq/L

• What could be the possibility?

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Central Pontine Myelinolysis

• Develops with 1.Aggressive treatment of Chronic

hyponatremia2.Raising Sr.Na >25mEq/L in first 48

hours3.Raising Sr.Na to Normal or Above

normal in 48 hours

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CPM

• Focal demyelination in the Pons & extrapontine areas.

• Causes Mutism / dysarthria Spastic Quadriplegia Pseudobulbar palsy Seizures Altered Mental Status Coma & Death

CPM is

irreversib

le

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Principles of Hyponatremia Management

• Asymptomatic Hyponatremia Use 0.9%NaCl

• Symptomatic Hyponatremia Use 3% NaCl• Correct only 12mEq/L defecit only perday• Chronic Hypernatremia with severe

symptoms should receive hypertonic saline only to arrest the symptoms and followed by slow correction @ 0.5 mEq/L

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Hyponatremia Management is Double Edged Sword

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Case Study #3

HPI:

A 5 month-old girl presents with a one day history of irritability and fever. Mother reports three days of “bad” vomiting and diarrhea.

Home meds:

Paracetamol and ibuprofen for fever

PE:

BP 70/40, HR 200, R 60, T38.3 C. Irritable, sunken eyes and fontanelle.

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Case Study #3

No one can obtain IV access after 15 minutes, what would you do now?

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Case Study #3

Place intraosseous lineBolus 40 ml/kg of isotonic saline

Reassessment (HR 170, RR 40, BP 75/40)

Serum studiesSodium 164 mEq/L BUN 75 mg/dL

Chloride 139 mEq/L Creatinine 3.1 mg/dL

Potassium 5.5 mEq/L Glucose 101 mg/dL

Bicarbonate 12 mEq/L

pH 7.07 pCO2 11

pO2 121 HCO3 8

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Case Study #3

What is the most likely explanation of

this patient’s Condition?

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Case Study #2

Treatment of Hypernatremia

• To stop ongoing fluid loss

• To correct water deficit

= plasma Na – 140 x 0.6 x body wt. in kg

140

• Water deficit can be replaced with water by mouth or IV 5% dextrose or 0.45% NaCl

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Rate Of Correction

• Acute Hypernatremia ½ body water defecit in 24 hours

• Chronic Hypernatremia ½ body water defecit in 48 hours

• Rapid correction cerebral edema & Neurological deterioration

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Case Study #4

• HPI:

– A 50 year old man was involved in a motor vehicle accident two days ago. He sustained an isolated head injury with intraventricular hemorrhage and multiple large cerebral contusions. Three hours ago, he had an episode of severe intracranial hypertension (ICP 90mm Hg, MAP 50mm Hg, requiring volume plus epinephrine infusion for hypotension. Over the last two hours, his urine output has increased to 150 - 200 ml/hour

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What is your differential diagnosis?What test would you order?

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Case Study #4

Differential diagnosisPolyuria

1) Central diabetes insipidusDeficient ADH secretion (idiopathic, trauma, pituitary

surgery, hypoxic ischemic encephalopathy)

2) Nephrogenic diabetes insipidusRenal resistance to ADH (X-linked hereditary, chronic

lithium, hypercalcemia, ...)

3) Primary polydipsia (psychogenic)Primary increase in water intake (psychiatric), occasionally

hypothalamic lesion affecting thirst center

4) Solute diuresisDiuretics (lasix, mannitol,..), glucosuria, high protein diets,

post-obstructive uropathy, resolving ATN, ….

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Laboratory studies

Serum studies

Sodium 155 mEq/L BUN 13 mg/dL

Chloride 114 mEq/L Creatinine 0.6 mg/dL

Potassium 4.2 mEq/L Glucose 86 mg/dL

Bicarbonate 22 mEq/L Serum osmolality: 320 mosmol/kg

Other

Urine specific gravity 1.005, no glucose.

Urine osmolality: 160 mosmol/kg

What are the main abnormalities?

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Case Study #4

Laboratory studies

Major abnormalities

1) Hypernatremia2) Polyuria (inappropriately dilute urine)

What is the most likely explanation?

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Case Study #4

Diabetes Insipidus

Diagnosis

Central Diabetes insipidus

1) Polyuria2) Inappropriately dilute urine (urine osmolality < serum

osmolality)

May be seen with midline defectsFrequently occurs in brain dead patients

What should you do to treat this patient?

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Case Study #4

Diabetes Insipidus• Treatment

– ADH preparations - dDAVP nasal spray 2-4 μg/dl

– Potentiate ADH effect – chlorpropamide, carbamazepine, NSAID’s.

– Increase ADH release – Clofibrate

Warning

– Closely monitor for development of hyponatremia

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Hypernatremia

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Case Study #4

• HPI:

– An 35 year old lady with Chronic kidney disease presents with irritability. She is on nightly peritoneal dialysis at home. The lab calls a panic potassium value of 7.1 meq/L. The tech says it is not hemolyzed.

What do you do now?

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Case Study #4

Hyperkalemia

Treatment

Immediately repeat serum potassium. Do not wait for confirmatory labs especially if ECG changes present.

Anticipatory Stop potassium administration including feeds

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ECG

• What is this rhythm?• What is your immediate treatment?

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Case Study #5

HyperkalemiaControl effects

Antagonism of membrane actions of potassium▪10% Calcium gluconate 10-20 ml over 5 - 10 minutes; may repeat x2

Shift potassium intracellularly▪Glucose 1 gm/kg plus 0.1 unit/kg regular insulin▪Alkali therapy - Sodium bicarbonate 1 mEq/kg IV▪ Inhaled 2 adrenergic agonist

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– Removal of potassium from the body

–Loop / thiazide diuretics–Cation exchange resin: sodium polstyrene sulfonate (Kayexelate) 1 gm/kg PO or PR (or both)

–Dialysis

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Hyperkalemia Rx

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Case Study #5

• HPI:

– A three year old boy is recovering from septic shock. He received 150 ml/kg in fluid boluses in the first 24 hours and has anasarca. You begin him on a frusemide infusion for diuresis. He develops severe weakness and begins to hypoventilate. You notice unifocal premature ventricular beats on his cardiac monitor.

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What is your differential diagnosis?

What tests would you order?

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Case Study #6

Laboratory studies

Serum studiesSodium 134 mEq/L BUN 11 mg/dLChloride 98 mEq/L Creatinine 0.4 mg/dLPotassium 2.4 mEq/L Calcium 9.2 mg/dLBicarbonate 27 mEq/L Phosphorus 3.2 mg/dL

OtherECG: Unifocal PVC’s

What is the main abnormality?

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Case Study #6

Laboratory studies

Major abnormality

1) Hypokalemia

What would you do now?

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Case Study #6

Hypokalemia Treatment

Oral

▪ Safest, although solutions may cause diarrhea

IV

▪ do not exceed 40 mEq/L or 10 – 20 mEq/hr potassium.

- never give inj.Kcl directly never give inj.Kcl directly intravenously.intravenously.

Replace magnesium also if low

▪ (25-50 mg/kg MgSO4)

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Summary

• Disorders of sodium, water, and potassium regulation are common in critically ill.

• Diagnostic approach must be considered carefully for each patient

• Strict attention to detail is important in providing safe and effective therapy

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