fluid, electrolyte and acid base balance.ppt

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Fluid, electrolyte andacid base balance

Vijayakumar



Q 1

A child present with diarrhoea and peripheralcirculatory failure. Arterial pH is 7.0, PCO is!" mm H#, PO 7$mmH#. %hat will &e the

most appropriate therapy'( no)*0"+ A+ sodium &icar&onate infusion+ &olus of -in#ers lactate

C+ normal saline infusion+ "/ detrose infusion



Ans*&

Child is ha)in# hypo)olemic shock due to

fluid loss and meta&olic acidosis. 1irst step of mana#ement is fluid

replacement. -2 is preferred since it will

pro)ide fluid for )olume depletion and lactate

Hco3 can &e added after reassessin# the

acid &ase status after correctin# fluid loss



Q 2

-ead this A4 report and comment

paCO3* 30 mm h#, Ph*7.3, 5aHCO3 6

!"m89l, PaO* :" mm9h#, ;ao* :"/ A+ meta&olic acidosis

+ meta&olic alkalosis

C+ respiratory acidosis+ respiratory alkalosis



Ans 6a meta&olic acidosis

5ormal A4 )alues

Ph 6 7.< ( 7.3" 6 7.<"+5aHCO3 6 < ( *$ me892+PaCO 6 <0 ( 3$*<< + mmh#PaO 6 :" (:0*!00+ mmH#;aO 6 := (:"*!00+ /# 6 diarrhoea, >A, A-1



Q 3

A year old child is &ein# e)aluated formeta&olic acidosis. lood tests show 5a !<0me89l, > 6 3 me89l, Ca 6 = m#9dl, ?# 6

m#9dl, Ph 6 7., HCO3 6 !$me89l, Cl 6 !!me89l . Plasma anion #ap is (no)*0"+

A+ :

+ !"C+ + "



Ans* &6 !"

Plasma anion #ap is useful for e)aluatin#

patients with meta&olic acidosis Anion #ap @ (5a > +6( Cl HCO3+

Here 6 (!<0 3+ 6 ( ! !$+ @ !"

5ormal anion #ap is ! m892 (ran#e =*!$+5ormal anion #ap acidosis 6 -BA, A

ncreased anion #ap* >A, 2A,C>



Q 4

-ead this A4 report

Ph 6 7.", PaCO3 6 <" mmH# ,5aHCO3 6 30

me89l ,PaO* :" mmH# ,;aO 6 :"/ dentifythe A4 a&normality

A+ meta&olic acidosis


C+ respiratory acidosis

+ respiratory alkalosis



HCO3

5ormal HCO3 6 < me892

PH low HCO3 low ?et acidosis

PH hi#h HCO3 hi#h ?et alk



Ans &6 meta&olic alkalosis

Cause 6 ecess loss of hydro#en ion, as in

persistent )omitin# or prolon#ed #astricaspiration

ncreased administration of HCO3* oral9V

Hypochloremia and hypokalemia are seen

-espiration is depressed PCO is increased



Q 5

-ead this A4 reportPh 6 7., Pa CO* $0 mmH#, 5aHCO3* 3

m89l, PaO* :0 mmH#, ;aO* :$/ dentify the A4 a&normality A+ meta&olic acidosis+ meta&olic alkalosisC+ respiratory acidosis+ respiratory alkalosis



PaCO2

5ormal PaCO @ <0 mmH#

Hi#h PaCO D <0 PH low -esp acidosis

2ow PaCO E <0 PH hi#h -esp alkalosis



Ans 6c respiratory acidosis

ue to inade8uate pulmonary ecretion of

CO#* 4;,Polio, airway o&struction like forei#n

&ody aspiration, laryn#eal oedema

Plasma &icar&onate is increased due to

compensation



Q 6

-ead this A4PH *7.", PaCO 6 30 mmH#, 5aHCO3* 0

me89l, PaO 6 :" mmH#, ;aO 6 :"/ dentify the A4 a&normality A+ meta&olic acidosis+ meta&olic alkalosisC+ respiratory acidosis+ respiratory alkalosis



Ans 6d respiratory alkalosiscessi)e pulmonary loss of COin the

presence of normal production# 6 psycho#enic hyper)entilation results in

primary fall of PaCO and secondary relati)edecrease in plasma HCO3

5euromuscular irrita&ility and paresthesia ofetremities are due to decreasedconcentration of ioniFed calcium



Q 7

n meta&olic acidosis

A+ PH decrease, HCO3 increase

+ PH increase, HCO3 increaseC+ PH decrease, HCO3 decrease

+ PH increase, HCO3 decrease



Ans-c

A4 a&normality PH HCO3

?eta&olic

acidosis

decrease decrease

-espiratoryalkalosis

increase decrease

?eta&olic

alkalosis

increase increase

-espiratoryacidosis

decrease increase



HCO3!"A#$H

PaCO2 $H

%a&e direction

O$$osite direction

%a&e direction

RES

P



Q '

deal mana#ement of respiratory acidosis

A+ re&reathin# of ehaled CO

+ administration of V salineC+ impro)in# the )entilation

+ administration of sodium &icar&onate



Ans c 6 impro)in# the )entilation

-e&reathin# of ehaled CO is used in rapid

correction of respiratory alkalosis.



Q (

A !0 day old neonate is posted for sur#ery for

pyloric stenosis. Bhe in)esti#ation report shows a

serum calcium le)el of $ m#9dl. %hat information

would you like to know &efore you supplementcalcium' (no)0<+

A+ &lood #lucose

+ serum protein

C+ serum &iliru&in

+ oy#en saturation



Ans 6 & serum protein

5ormal total calcium le)el is =* !0 m#9dl

$0/ of total Ca eists in free ( ioniFed+ form,remainder is &ound to protein

ach ! #m9dl decrease in serum al&umin

decreases &ound and there fore total calcium

&y ! m#9d2. oniFed Ca le)el is not affected

&y hypo al&uminemia.



Q 1)

Oral rehydration miture contains #lucoseand sodium &ecause &oth of them (no)0<+

A+ are needed to maintain plasma osmolality+ are prominent ener#y sources for the &odyC+ facilitate the transport of each other from

the intestinal mucosa to the &lood

+ re8uired for acti)ation of 5a,>,ABP ase



Ans 6c &oth facilitate transport of each other Carrier mechanism for the transport of

#lucose and 5a across the cell mem&rane

are interlinked. As #lucose is a&sor&ed, 5a isalso a&sor&ed. ;odium a&sorption promotesa&sorption of water, this will pre)entdehydration 6 this is the physiolo#ical &asisof O-B



Q 11

Calculate the plasma osmolality of a child

with plasma sodium 6 !" me89l , #lucose 6

!0= me89l, and &lood urea nitro#en 6 !<0

me89l. (no)*03+

A+ 300 mosm9k#

+ 30$ mosm9k#

C+ 3! mosm9k#

+ 3!= mosm9k#



Ans* & ***** 30$ mosm9k#

plasma osmolality @ G 5a #lucose9 !=

59.=

G !" !0=9!= !<09.=

"0$"0 @ 30$ mosm9k#

f &lood urea is #i)en then calculation is 6&lood urea9$



Q 12

?eta&olic deran#ement in con#enital pyloric

stenosis is (no)*0+

A+ hyperchloremic alkalosis

+ hypochloremic alkalosis

C+ hyperchloremic acidosis

+ hypochloremic acidosis



Ans & 6 hypocholemic alkalosis

n CHP; main symptom is non &ilious

)omitin#. Bhere is loss of H,Cl, alon# with

fluids resultin# in meta&olic alkalosis and

hypochloremia



Q 13

A child sufferin# from acute diarrhoea is&rou#ht and dia#nosed as ha)in# se)eredehydration with pH of 7.3, serum 5a* !",

>*3, HCO3 6 !$,which of the followin# V fluidwill you prefer '(no)*0!+

A+ detrose saline (5;+

+ "/ detoseC+ normal saline+ half normal saline



Ans 6 c normal saline

Child is ha)in# hyponatremic dehydration

5ormal serum sodium le)el* !3"* !<" me89l. hyponatremia E !30 me89l, hypernatremia D

!"0 me89l

etrose solution should not &e used forcorrection of fluid deficit



Q 14

-e8uirement of potassium in a child is(ai*0$+

A+ !* me89k#

+ <*7me89k#C+!0*! me89k#

+ !3*!<me89k#



Ans a (!* m89k#+

Potassium is seen in plenty in food, and is

a&sor&ed in small intestine. Hence dietary

deficiency is rare

5ormal C1 > le)els 6 < m892

C1 > le)els ** !"0m892

Hyperkalemia ** D "." m892



Q 15

year old &oy passed != loose stools in the

last < hours and )omited in the last < hours.

He is irrita&le &ut drinkin# fluids. Bhe optimal

therapy for this child is (A*03+

A+ V -in#er lactate

+ O-; one #lass per each loose stool

C+ ;tart with -2 followed &y O-;

+ O-; 7" ml9k# in < hours



Ans 6 dChild is ha)in# features of some dehydration

and needs mana#ement accordin# to plan*Plan A 6 O-; after each loose stoolsPlan 6 O-; 7"ml9k# in < hours 6

super)ised

Plan*C 6 V1 ,-2 *30 ml9k# in 30 minutes and70 ml9k# in I hours . (n infants it is in onehour and " hours respecti)ely+



Q 16

Amount of sodium in normal saline

A+ !<" me89l

+ !"< me89lC+ !"0 me89l

+ !<0 me89l



Co&$osition o* + solution $er

litre

solution etrose(#+

5a

me8

> Cl lactate

calorie

mOsm

5 saline o !"< 0 !"< :

"/5; "0 !"< 0 !"< 00 ""=

-2 * !30 < !0: = $!

solyteP "0 " 0 00 3"0"/ "0 00 $$

!0/ !00 <00 "3



Q 17

A year old child wei#hin# $ k# presents with)omitin# and diarrhoea for the last days.o9e skin tur#or is delayed and took 3 seconds

to re#ain its normal position. How you willinterpret this findin#'

A+ no dehydration

+ some dehydrationC+ se)ere dehydration+ it is not a relia&le si#n



Ans* d

;kin pinch is not a relia&le si#n to interpret in

the presence of malnutrition

n a well nourished child, skin pinch #oes

&ack 8uickly, if there is no dehydration, #oes

&ack slowly ( less than seconds+ in some

dehydration and )ery slowly in se)eredehydration



Q 1'

Hypokalemia in an infant may &e due to all of

the followin# ecept (A* 0<+

A+ adrenal tumor

+ acute renal failure

C+ thiaFide therapy

+ diarrhoea



Ans 6& acute renal failureHypokalemia 6 serum > E 3." m89lCauses 6iarrhoea 6 commonest?ineralocorticoid secretin# adrenal tumor ?alnutrition 6 decreased storeru#s 6 thiaFide;hift to intracellular compartment * insulin



Q 1(

A 3 month old female infant wei#hin# < k# isha)in# diarrhea. amination re)ealedfeatures of some dehydration. Bhe amount of

O-; to &e #i)en to her in the first < hours will&e.

A+ !00 ml

+ 00 mlC+ 300 ml+ <00 ml



Ans 6c 300ml

Bhe amount of O-; in some dehydration is

7" m#9k# in < hours



Q 2)

A " month old formula fed infant is &rou#ht with

complaints of watery diarrhoea of days and

irrita&ility of one day duration. He is on %HO O-; at

home. amination re)eals irrita&le child withdou#hy skin and rapid pulse. ia#nosis

A+ menin#itis

+ encephalitis

C+ hyponatremic dehydration

+ hypernatremic dehydration



Ans 6d hypernatremic dehydration

Cause of hypernatremia in A is

replacement with hypertonic saline

%e may underestimate dehydration



Q 21

4lucose is included in O-;

A+ as a source of ener#y

+ as a sweetenin# a#entC+ to help in the a&sorption of sodium

+ to add to the osmolar stren#th of the

solution



Ans c



Q 22

!= yr old &oy with h9o PV ful#rated at the a#e of

3 yrs, now presented with se)ere &reathlessness

followin# B J A4 K PH 7.!, HCO3 !0, PCO3, 5a !30, > $, Cl !0$, HCO3 !0, !30m#,

s.cr ".= m#. He is ha)in#

A+ hi#h anion #ap meta&olic acidosis

+ normal anion #ap meta&olic acidosis

C+ compensated respiratory acidosis

+ partially compensated meta&olic alkalosis

.



Ans a

PH 7.! Kacidosis,

HCO3 !0 K ?et acid

A4P K (!30 $+ 6 (!0$ !0+ @ 0

;o hi#h A4P ?A



Q 23

Concentration of chloride in etra cellular fluid

is

A+ !00 m89l

+ 7 m89l

C+ !<0 m89l

+ " m89l



Ans*a

Concentration in C1 in m89l

;odium* !<0Potassium* "

Chloride* !00

icar&onate* 7



Q 24

Hypokalemia is associated with all of the

followin# ecept

A+ rha&domyolysis

C+ muscle hypotonia

C+ prolon#ed LB inter)al

+ hypertension



Ans 6d

Hypokalemia produce orthostatic hypotension

Produce decreased neuromuscular ecita&ility

resultin# in weakness and decreased &owel

motility.

%eakness is first noticed in lim& muscles

Paralytic ileus and #astric distension reflects

smooth muscle dysfunction



Q 25

5ormal anion #ap acidosis is seen in

A+ dia&etic ketoacidosis

+ renal tu&ular acidosisC+ salicylate poisonin#

+ uremia



Ans*&

-BA due to renal &icar&onate wastin# and

diarrhea due to intestinal &icar&onate wastin#

produce normal anion #ap meta&olic acidosis



Q 26

Hypercalcemia is seen in all of the followin#

conditions ecept

A+ hyperparathyroidism

+ pseudohypoparathyroidism

C+ thiaFide therapy

+ supra )al)ular aortic stenosis



Ans &

Hypo parathroidism and pseudo hypo

parathyroidism produce hypo calcemia and

hyper phosphatemia.



Q 27

A !0 month old child with )omitin# and

diarrhea has tachycardia, deep respiration,

irrita&ility, dry mucous mem&rane, normal

&lood pressure, capillary refill time of seconds. %hat is the percenta#e of

dehydration'

A+ E !/ + !*</C+ "*:/ + !0*!"/



Ans*c "*:/ * he is ha)in# moderate

dehydration since P is preser)ed.



Q 2'

A serious complication of treatment of

hypernatremic dehydration is

A+ cere&ral throm&osis

+ cere&ral edema

C+ hypo#lycemia

+ hypochloremia



Ans & 6 cere&ral edema

f usin# hypo osmolar solutions for treatment

there is a chance of cere&ral edema



Q 2(

An != year old #irl is presented with croup

like )oice, painful fleion of wrist joint and

etension of fin#ers. Bhe most likely

a&normality is A+ hypo#lycemia

+ hyponatremia

C+ hypokalemia

+ hypocalcemia



Ans*d hypocalcemia

Other conditions producin# tetany and

laryn#ospasm are hypoma#nesaemia and

alkalosis.



Q 3)

%hich of the followin# is considered

insensi&le water loss

A+ pulmonary loss

+ stool water loss

C+ )omitin#

+ urinary loss to ecrete o&li#atory solute



Ans 6a pulmonary loss

O&li#atory water loss include 3 components

!+nsensi&le water loss* which are mainlye)aporati)e water loss from lun#s and skin

+rinary water loss 6amount of water

necessary to ecrete a solute load &y the

kidneys

3+ stool water loss



Q 31

Bhe &est method to decrease potassium le)el

in hyperkalemia &y reducin# the &ody &urden

of potassium is

A+ #lucose and insulin infusion

+ V sodium &icar&onate administration

C+ sal&utamol ne&ulisation

+ keelate enema



Ans 6d

Others will shift potassium from etra cellular

to intracellular space



Q 32

All of the followin# can &e used in acute

mana#ement of hyperkalemia ecept

A+ calcium #luconate

+ sal&utamol

C+ sodium &icar&onate

+ captopril



Ans 6d

Captopril will raise serum potassium le)el



Q 33

n which of the followin# conditions

respiratory alkalosis occur'

A+ Pickwikian syndrome

+ hyper)entilation syndrome

C+ kyphoscoliosis

+ 4uillian arreM syndrome



Ans &

All others produce hypo)entilation resultin#

in CO retention and respiratory acidosis



Q 34

est way to monitor initial impro)ement in a

child with se)ere dehydration is

A+ wei#ht #ain

+ assessin# urine output

C+ monitorin# &lood pressure

+ measure CVP



A5; 6

Assessin# urine output



Q 35

PH of )enous &lood is

A+ 7.<

+ 7.3$

C+7.$

+ 7

or&al acid-base conc in



or&al acid base conc in

.arious body *luids

Art )ein C;1 C1

H <0 << <= !00

pH 7.<0 7.3$ 7.3 7.0

HCO3 < = !

PCO <0 <$ << "0



Arterial / enous sa&$le 0

n )enous sampleK*

PO E <0 mmH#

pH 0.03 lower PCO $ mm H# hi#her

NHCO3* * < me8 hi#her



Q 36

?ention the amount of #lucose in reduced

osmolarity O-;

A+ !!! mmol9l

+ :0 mmol9l

C+ 7" mmol9l

+ "0 mmol9l

Ansc 75 &&ol/l



Ans c 75 &&ol/l

contents %HO O-; (inmillimol9 2+

-educedosmolarity O-;

;odium :0 7"

Chloride =0 $"

Potassium 0 0

Citrate !0 !0

4lucose !!! 7"

Osmolarity 3!! <"



Q 37

-ead this A4 reportJ

PH 7., HCO3 0,PaCO "" mmH#

a+ ?eta&olic acidosis

&+ -espiratory acidosis

c+ Compensated meta&olic acidosis

d+ ?eta&olic acidosis with respiratory acidosis



Ans d

pH 7. K acidosis PaCO K -esp acidosis pected HCO3 K < (!" 0.!+ @ "." Actual HCO3 K 0

;o -esp acidosis ?et acidosis



Q 3'

ncreased anion #ap occurs in all of the

followin# ecept

A+ dia&etic ketoacidosis

+ lactic acidosis

C+ renal tu&ular acidosis

+ renal failure



Ans 6 csual unmeasured anions are or#anic acids,

phosphates, sulphates, and proteins 6 anion

#ap increases if their le)els are increased-enal failure * phosphates, sulphates>A* *hydroy &utyrate and aceto acetate

2actic acidosis 6 lactateOr#anic acedemia 6 or#anic acidsecreased anion #ap 6 nephrotic syndrome



Q 3(

lectrolyte a&normality producin# peakin# of

B wa)es

A+ hypokalemia

+ hyperkalemia

C+ hypocalcemia

+ hypercalcemia



Ans -b

lectrolyte a&normality C4 findin#s

hyperkalemia Peaked B,prolon#ed P-,wide L-;

hypokalemia 1lat B, wa)e, LBprolon#ation

Hyper calcemia ;hort LB inter)al

hypocalcemia LB prolon#ation



Q 4)

Hypochloremia is usually seen in

A+ meta&olic acidosis


C+ respiratory acidosis

+ respiratory alkalosis



Ans & 6 meta&olic alkalosis



Q 41

Calculate the maitenance fluid re8uirement of

a &oy with $ k#

A+ $00 ml

+ !300 ml

C+ !$0 ml

+ !30 ml



Ans* cHoliday and ;e#arMs formulapto !0 k#* !00 ml9k#, !!* 0 k# 6 !000 ml

"0 ml9k# , a&o)e 0 k# 6 !"00 ml 0 ml9k# n this child , !"00 0G $ @ !$0 ml *< m8 of 5a and > for e)ery !00 calories

epended. !93 of this water re8uirement is for insensi&le

water loss and 93 for renal water loss



Q 41

%hich of the followin# element is not an

in#redient in -;O?A2 '

A+ Finc

+ copper

C+ ma#nesium

+ iron



Q 43

;odium content of -e;O?al ( rehydration

solution for malnourished children+ is

A+ :0 mmol92

+ $0 mmol92

C+ <" mmol92

+ 30 mmol92



Ansc 45 &&ol/

Component -e;o?al ;tandard O-;

4lucose !" !!!

;odium <" :0

Potassium <0 0

Chloride 70 =0

Citrate 7 !0

?a#nesium 3 *inc 0.3 *

Copper 0.0<" *

Osmolarity 300 3!!



Q 44

Hypernatremic dehydration is characteriFed

&y

A+ serum sodium D !"0 mmol92

+ si#ns of dehydration are more marked

C+ C1 )olume is decreased

+ rapid correction is re8uired



Ans * a



Q 45

Bhe most common neurolo#ical complication

of hyperkalemia is

A+ con)ulsions

+ ascendin# paralysis

C+ cranial ner)e palsies

+ distal paresthesia



Ans *&



Q 46

?ajor contri&ution of anion #ap is from

A+ proteins

+ sulfates

C+ lactic acid

+ phosphates



Ans 6 a



Q 47

A patient with PCO of $0 and HCO3 of " is

likely to ha)e

A+ acute meta&olic acidosis

+ acute respiratory acidosis

C+ acute meta&olic alkalosis

+ acute respiratory alkalosis



Ans 6 & respiratory acidosis



Q 4'

A patient with meta&olic acidosis is likely to

ha)e

A+ PCO * ", HCO3 * !0

+ PCO * $0, HCO3 * !=

C+ PCO * ", HCO3 * 30

+ PCO * $0, HCO3 * <0



Ans * a



Q 4(

Calculate the &ody surface area of this child

wei#ht 6 30 k#, hei#ht 6 !0 cm

a+ 0."

&+ 0.7"

c+ !

d+ !."



Ans c

ody surface area is calculated &y ?osteller

formula

;8uare root of 6 Q%ei#ht (in k#+ G hei#ht (in

cm+R 9 3$00;8uare root of Q 30G !0R9 3$00

;8uare root of 3$0093$00

!



L "0

!0 year old with insulin*dependent. On room air A4

pH *7.!", PCO** mmH# ,PO**: mmH#, HCO3*:

mmol92.He is ha)in#

a+Pure meta&oic acidosis

&+ partially compensated meta&olic acidosis

c+ fully compensated meta&olic acidosis

d+Com&ined meta&olic acidosis with respiratory acidosis



Ans b

A$$ro$riate co&$ensation in si&$le Acid base disorders

?eta&olic acidosis PCO @ Q (!."G hco3+ =R 9*

?eta&olic alkalosis PCO increases &y 7 mm9h# for each

!0 me89l increase in serum HCO3

-espiratory acidosis HCO3 increase &y! for each !0mm9h# increase in PCO

-espiratory alkalosis HCO3 falls &y for each !0 mm9h#decrease in PCO



Bhank you



ncreased anion #ap in urine

si#nifiesncreased ammonium

ncreased HA

ncreased >A

ncreased ?#A

Ans !



-aised anion #ap in &lood is seen in all the

followin# eceptia&etic ketoacidosis

-enal failure

Chronic respiratory failure

AntifreeFe in#estion

Ans 3



. n a case of hypertrophic pyloric stenosis,

the meta&olic distur&ance is

-espiratory alkalosis

?eta&olic acidosis

?eta&olic alkalosis with paradoical aciduria

?eta&olic alkalosis with alkaline urine

Ans 3

fluid, electrolyte and acid base balance.ppt

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