fluid & electrolytes finalize 2 (2)
TRANSCRIPT
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Fluid & Electrolytes
Presenters:Dr. Nur-Athirah Binti Md.NorDr. Siti Nor Afni Binti Baharum
Supervisor:Dr. Lo
20 January 2014
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Outline
1. Fluid1. Physiology2. Type of IV fluid3. IV Fluid therapy4. IV cannula and rate
2. Electrolytes : causes, clinical features and management
1. Potassium2. Sodium 3. Calcium
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Physiology• 60% of body weight is consist of fluid (42L)• 2/3 of total body fluid is in Intracellular fluid• 1/3 of total body fluid is in Extracellular fluid– 80% is interstitial fluid– 20% is plasma (3L)
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Important Ionic Concentrations (mmol/L)
ICF ECF
NaK CaMgCl
PO4
HCO3
101502.57.5104510
1354
2.51
1001
27
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Daily input and output of water
• Body received fluid by – Ingestion and metabolism (total 2.3L)
• Body remove fluid by– Insensible loss (lung & skin), sweat, feces and
urine (total 2.3L)• Fluid requirement less in CKD and CCF• Fluid requirement more in fever, vomiting,
burn, diarrhea
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Fluid in Surgical Practice
• Fluid balance tend to disturb when pt– Nil orally– Trauma– Sepsis
• In a surgical patient, we must know to calculate – volume and electrolyte requirement– volume and electrolyte excess and deficit
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Crystalloid
ISOTONIC• 0.9% NaCl• Hartmann solutionHYPERTONIC• 10% Dextrose, 20 % Dextrose, 50% Dextrose• 3% Saline, 5% SalineHYPOTONIC• 5% Dextrose• 0.45% Saline
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The most common crystalloid solutionsTypes of isotonic
Composition Notes
NaCl 0.9% NaCl
150 mmol/L150 mmol/L
Use to correct ECF loss and for initial resuscitation of intravascular volume.
Ringer’s Lactate (Haartman)
NaKCaClHCO3
131 mmol/L5mmol/L2mmol/L111mmol/L29mmol/L
It is physiological solution. After administration the lactate is metabolised, resulting in bicarbonate generation. It will decrease the risk of hyperchloraemia
Dextrose 5% dextrose 50g/L200kcal/L
Glucose is rapidly metabolized. The remaining water distributes rapidly throughout the body’s fluid compartments therefore not suitable for resuscitation.
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Colloids
• Colloid solutions contain particles that have oncotic pressure– Natural : Albumin– Synthetic : Gelatins, Hydroxyethyl starches,
Dextrans • It remains largely within the intravascular
space • Half-life is 6 to 24 hours.
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Crystalloid vs. ColloidCrystalloids Colloids
Advantage • Cheap• Accessible
• Longer half life • Smaller volume required to expand intravascular volume
Disadvantage • Short half life• Larger volume required for resuscitation
•Expensive• Risk of allergic reaction
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Assessment and monitoring
Indicators : – Hypotension– Tachycardia – Capillary refill >2s– Urine output <0.5 ml/kg/h
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Resuscitation
• Initial resuscitation– Give high flow O2– 2 large bore IV access– Identify cause of deficit and response
• Bolus of 20ml/kg in adult or 10ml/kg in pt with CKD or CCF
• Burn = TBSA(%) x 4 x body weight (kg)
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Maintenance
• 30-35ml/kg/24h in adult• Paediatrics and Burn– 1st 10kg 100ml/kg– Next 10kg 50ml/kg– Subsequent weight 20ml/kg• Eg: 25kg boy (100x10)+(50x10)+(20x5) • = 1600 ml / 24hours
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Replacement and Redistribution
• On going losses– NG tube, Drains, Fistula, Third space losses
• Concentration is similar to plasma• Can be replace with isotonic fluids
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Complication of over hydration
• Fluid overload• Signs– Weight gain– Pulmonary edema– Peripheral edema– S3 gallop
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IV Cannula and fluid flow rates
• Flow rate is limited by the size of the IV cannula and viscosity of fluid
Cannula size Colour Time to infuse 1000ml Normal saline under ideal circumstances
22 G Blue 22 min
20 G Pink 15 min
18 G Green 10 min
16 G Grey 6 min
14 G Red 3.5 min
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Hyperkalaemia
Causes: ↓ excretion – renal failure↑ load – K sparing diuretic, blood
transfusion Clinical features: Arrhythmias, paralysis Management:
Lytic cocktail Oral Kalimate Dialysis
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Hyponatraemia Causes:
Hypovolaemia – renal failure, diuretics, vomiting, pancreatitis, SBO
Euvolaemia – SIADHHypervolaemia – CCF, liver failure
Clinical features: Na < 120 mmol/L – disturbed mental statusNa < 110 mmol/L – seizure, coma
Management: Treat the u/l causesReplace the lossesNot > 10mmol/L/day - central pontine myelinolysis
[Na req = Na deficit + Na maintenance] & [Na def = 135 – pt’s level x 0.6 x BW]
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Hypernatraemia
Causes: ↑ intake – salt ingestion, hypertonic saline ↑ loss – vomiting, diarrhea, fistula
Clinical features : Irritability, confused, comaManagement:
Allow fluid as tolerated IVD D5%
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Hypocalcaemia
Causes: Surgical – Acute pancreatitisMedical – Vit D def
Clinical features: Cramp, tetany, Chvostek’s sign, Trousseau’s sign
Management: –Iv calcium gluconate–Calcium oral supplement–Vitamin D supplement
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Hypercalcaemia
Causes: Surgical – malignancies, bones metastasisMedical – myeloma, Addison’s disease
Clinical features: ‘Bones, stones, groans, moans’Management:
Rehydration and saline diuresisIv Pamidronate
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Take home messages
1. Crystalloid and colloid are equally effective for the correction of hypovolaemia
2. Use isotonic fluid for fluid resuscitation to maintain wall of cell membrane
3. High volume administration of normal saline produces hyperchloremic acidosis
4. Use at least 16G cannula for fluid resuscitation5. Hypokalaemia & hyperkalaemia need to be treated with caution
– might lead to arrhythmias 6. Na replacement should not > 10 mmol/L/day – risk of central
pontine myelinolysis7. Main treatment for hypercalcaemia is saline diuresis
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Sources
• Textbook of Medical Physiology by Guyton and Hall, 11th Edition
• Principles of Anatomy and Physiology by G.Tortora and B.Derrickson, 12th edition
• Principles and Practice of Surgery by O.J.Garden, A.W.Bradbury, J.L.R. Forsythe and R.W. Parks, 6th edition
• Sarawak Handbook of Medical Emergencies, 3rd Edition