Fluids & ElectrolytesFluids & ElectrolytesDr. Faiez AlhmoudDr. Faiez Alhmoud

Albashir Teaching HospitalAlbashir Teaching Hospital

Why do we care about fluids in the Why do we care about fluids in the body?body?

Fluids factsFluids factsOver half of our body weight is fluid materialOver half of our body weight is fluid material

- Total body water is a function of - Total body water is a function of ageage, , body massbody mass, , and and body fatbody fat..

- Fluids are 60% of an adult’s body weight - Fluids are 60% of an adult’s body weight

- 70 Kg adult male has 60% X 70= 42 Liters- 70 Kg adult male has 60% X 70= 42 Liters

- Infants have more water = 75-80% of BW- Infants have more water = 75-80% of BW

- Elderly have less water = 45-50% of BW- Elderly have less water = 45-50% of BW

- More fat means ↓water (female has 50-55%)- More fat means ↓water (female has 50-55%)

- More muscle means ↑water (male has 55-60%)- More muscle means ↑water (male has 55-60%)

- Infants and elderly are more prone to fluid imbalance- Infants and elderly are more prone to fluid imbalance

- In adults, a loss of just 1/5 of body fluid weight can - In adults, a loss of just 1/5 of body fluid weight can be fatal (Marathon runners). be fatal (Marathon runners). 44

VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT

AGE & GENDERAGE & GENDER

Body Fluid : FunctionBody Fluid : Function

– Transport nutrients to the cells and carries Transport nutrients to the cells and carries waste products away from the cells (cell waste products away from the cells (cell functionfunction

– Maintains blood volumeMaintains blood volume– Regulates body temperatureRegulates body temperature– Serves as aqueous medium for cellular Serves as aqueous medium for cellular

metabolismmetabolism– Assists in digestion of food through hydrolysisAssists in digestion of food through hydrolysis

So where are these So where are these fluids kept?fluids kept?

Compartments of Compartments of Body FluidsBody Fluids

IntercellularIntravascularInterstitial40%

16%

4%

Body Water = 60% of a patient’s body weight

blood

Compartments…Compartments…Intracellular (ICF)Intracellular (ICF)– Fluid within the cells themselves Fluid within the cells themselves – The most stable & least susceptible to fluid The most stable & least susceptible to fluid

shiftsshifts– 2/3 of body fluid2/3 of body fluid– High in KHigh in K , , Phosphors, Mg. & protein Phosphors, Mg. & protein– Located primarily in skeletal muscle massLocated primarily in skeletal muscle mass– Assists in cellular metabolism Assists in cellular metabolism

99

……CompartmentsCompartmentsExtracellular (ECF)Extracellular (ECF)– 1/3 of body fluid1/3 of body fluid– High in Na, Cl, Ca, Glucose, fatty &amino-acids High in Na, Cl, Ca, Glucose, fatty &amino-acids – Comprised of Comprised of 3 major components3 major components

** Intravascular: =4% =3lit., Intravascular: =4% =3lit.,least stable, most least stable, most susceptible to fluid shift (Plasma=90%H2O)susceptible to fluid shift (Plasma=90%H2O)

** Interstitial: =16%=10lit., Interstitial: =16%=10lit., reserve fluid, replacing reserve fluid, replacing intravascular or intracellular as needed (Fluid in intravascular or intracellular as needed (Fluid in and around tissues)and around tissues)

**Transcellular: Transcellular: ~ 1% or up to one Lit.. ~ 1% or up to one Lit.. (Cerebrospinal, pericardial, synovial, (Cerebrospinal, pericardial, synovial, intraocular, pleural fluids..)intraocular, pleural fluids..) 1010

CompartmentsCompartments

Transcellular componentTranscellular component– 1% of ECF1% of ECF– Located in joints, connective tissue, bones, Located in joints, connective tissue, bones,

body cavities, CSF, and other tissuesbody cavities, CSF, and other tissues– Potential to increase significantly in Potential to increase significantly in

abnormal conditions abnormal conditions

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MOVEMENT OF BODY FLUIDS

OsmosisOsmosis-- waterwater moves through semi permeable moves through semi permeable membrane from dilutedmembrane from diluted to concentrated solutionto concentrated solution

DiffusionDiffusion-- dissolved particles.dissolved particles. Eg.gut absorption Eg.gut absorption FiltrationFiltration- - water and dissolvedwater and dissolved. move through . move through membrane from solution having higher hydrostatic membrane from solution having higher hydrostatic pressure Eg. (water and solute move out of the blood at pressure Eg. (water and solute move out of the blood at the arterial end of the capillary to the interstitial fluid by the arterial end of the capillary to the interstitial fluid by filtration filtration Active transport-Active transport- ionsions move from the area of move from the area of lesserlesser concentration to area of concentration to area of greatergreater concentration concentration by energy by energy Eg. Enzymes ,nutritients &potassiumEg. Enzymes ,nutritients &potassiumHydrostatic pressure- Hydrostatic pressure- the pressure created by the the pressure created by the weight of fluid weight of fluid against the wall that contains it.against the wall that contains it.

Oncotic pressure- Oncotic pressure- or colloid osmotic pressure, that usually or colloid osmotic pressure, that usually tends to pull tends to pull waterwater into the circulatory system. into the circulatory system.

osmosis

DiffusionDiffusion

Water ConflictWater Conflict

Sources of Body WaterSources of Body Water-1250cc from drinking-1250cc from drinking -1000 cc-1000 cc from solids (eating) from solids (eating)

-250 cc from oxidation -250 cc from oxidation

OrOr

-Enteral & parenteral support -Enteral & parenteral support

EnteralParenteraleating

drinking

What are the expected losses ?What are the expected losses ?Measurable:Measurable:– urine =1-2lit.urine =1-2lit.

– GI =100-200ccGI =100-200cc

( stool, stoma )( stool, stoma )

Insensible or:Insensible or:

UnmeasurableUnmeasurable

--sweat=up to 1litsweat=up to 1lit

-exhalation=400cc-exhalation=400cc

Fluid shifts / loses

Intracellular 30 litres

Interstitial 9 litres

Intravascular 3 litres

Kidneys Guts Lungs Skin

Extracellular fluid - 12 litres

Regulation of Fluid Balance

Renal regulationRenal regulation

Hypothalamic regulationHypothalamic regulation

Pituitary regulationPituitary regulation

Adrenal cortical regulationAdrenal cortical regulation

Cardiac regulationCardiac regulation

Gastrointestinal regulationGastrointestinal regulation

Insensible water lossInsensible water loss

oror

Regulation of Fluid Balance

Fluid intakeFluid intake

Fluid outputFluid output

Hormonal influenceHormonal influence

Lymphatic influencesLymphatic influences

Neurologic influencesNeurologic influences

Renal influencesRenal influences

↓Blood volume or ↓BP

Volume receptor

Atria and great veins

Hypothalamus

↓

Posterior pituitary gland

Osmoreceptors in hypothalamus

↑Osmolarity

↑ADH Kidney tubules

↑H2O reabsorption

↑vascular volume and ↓osmolarity

Narcotics, Stress, Anesthetic agents, Heat, Nicotine, Antineoplastic

agents, Surgery

ANTIDIURETIC HORMONE ANTIDIURETIC HORMONE REGULATION MECHANISMSREGULATION MECHANISMS

Juxtaglomerular cells-kidney

↓Serum Sodium ↓Blood volume

Angiotensin I

Kidney tubules

Angiotensin II

Adrenal Cortex

↑Sodium resorption

(H2O resorbed with sodium); ↑ Blood volume

Angiotensinogen in plasma

RENIN

Angiotensin-Angiotensin-converting converting

enzymeenzyme

ALDOSTERONE

Intestine, sweat glands, Salivary

glands

Via vasoconstriction of arterial smooth muscle

ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM

ALDOSTERONE-RENIN-ANGIOTENSIN ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMSYSTEM

Renal sympathetic nerves

Renin-angiotensin-

aldosterone system

Atrial natriuretic peptide (ANP)

Fluid Volume ShiftsFluid Volume Shifts

Fluid normally shifts between intracellular Fluid normally shifts between intracellular and extracellular compartments to and extracellular compartments to maintain equilibrium between spacesmaintain equilibrium between spaces

Fluid not lost from body but not available Fluid not lost from body but not available for use in either compartment – for use in either compartment – considered third-space fluid shift (“third-considered third-space fluid shift (“third-spacing”)spacing”)

Enters serous cavities (transcellular)Enters serous cavities (transcellular)

2424

Third SpacingThird SpacingAccumulation and sequestration of trapped Accumulation and sequestration of trapped extracellular fluid in a body spaceextracellular fluid in a body space

This fluid is a volume loss and it’s This fluid is a volume loss and it’s unavailable for normal physiologic functionunavailable for normal physiologic function

Fluid may be trapped in pericardial, pleural, Fluid may be trapped in pericardial, pleural, peritoneal cavities, soft tissue or joints.peritoneal cavities, soft tissue or joints.

e.g.e.g.

AscitesAscites

EffusionEffusion

EdemaEdema

The excess accumulation of fluid in the The excess accumulation of fluid in the interstitial space.interstitial space.

Causes include surgery, accidents, and Causes include surgery, accidents, and trauma.trauma.

Anasarca is generalized body edemaAnasarca is generalized body edema

Save Water, Save LifeSave Water, Save Life

RememberRemember

Fluids and electrolytes Fluids and electrolytes always want to shift from always want to shift from

an area of higher an area of higher concentration to an area of concentration to an area of

lower concentration to lower concentration to equilibrateequilibrate

FLUID IMBALANCES

There are five types of fluid imbalances that There are five types of fluid imbalances that may occur are:may occur are:

Extracellular fluid volume deficitExtracellular fluid volume deficit (EVFVD) (EVFVD)

Extracellular fluid volume excessExtracellular fluid volume excess (ECFVE) (ECFVE)

Extracellular fluid volume shiftExtracellular fluid volume shift

Intracellular fluid vloume excessIntracellular fluid vloume excess (ICFVE) (ICFVE)

Intracellular fluid volume deficitIntracellular fluid volume deficit (ICFVD) (ICFVD)

EXTRACELULLAR FLUID VOLUME DEFICIT

An ECFVD, commonly called as An ECFVD, commonly called as dehydrationdehydration , is a decrease in , is a decrease in intravascular and interstitial fluidsintravascular and interstitial fluids

An ECFVD can result in cellular fluid loss An ECFVD can result in cellular fluid loss if it is sudden or severe if it is sudden or severe

THREE TYPES OF ECFVDTHREE TYPES OF ECFVD

Hyperosmolar fluid volume deficit-Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte water loss is greater than the electrolyte lossloss

Iso-osmolar fluid volume deficitIso-osmolar fluid volume deficit – equal – equal proportion of fluid and electrolyte loss proportion of fluid and electrolyte loss

Hypotonic fluid volume deficitHypotonic fluid volume deficit – – electrolyte loss is greater than fluid losselectrolyte loss is greater than fluid loss

ETIOLOGY AND RISK FACTORS (EVFVD)(EVFVD)

Severe vomiting Severe vomiting DiaphoresisDiaphoresisTraumatic injuriesTraumatic injuriesThird space fluid shifts Third space fluid shifts [ intestinal obst., pleural& [ intestinal obst., pleural& pertonial cavity] pertonial cavity] FeverFeverGatrointestinal suctionGatrointestinal suctionIleostomyIleostomyFistulasFistulasBurnsBurns

HyperventilationHyperventilation

Decresed ADH secretionsDecresed ADH secretions

Diabetes insipidusDiabetes insipidus

Addison’s disease or Addison’s disease or adrenal crisisadrenal crisis

Diuretic phase of acute Diuretic phase of acute renal failurerenal failure

Use of diureticsUse of diuretics

ELDERLY AND CHILDREN AREELDERLY AND CHILDREN AREAT HIGH RISK OF ECFVDAT HIGH RISK OF ECFVD

CLINICAL MANIFESTATION(EVFVD)(EVFVD)

Thirst Thirst Muscle weaknessMuscle weaknessDry mucus membrane; dry Dry mucus membrane; dry cracked lips or dry tongue cracked lips or dry tongue Apprehension , restlessness, Apprehension , restlessness, headache , confusion, coma headache , confusion, coma in severe deficit in severe deficit Elevated temperature Elevated temperature Tachycardia, weak thready Tachycardia, weak thready pulsepulseDecreased number and Decreased number and moisture in stoolsmoisture in stoolsWeight lossWeight loss

Peripheral vein fillingPeripheral vein filling> 5 > 5 Narrowed pulse pressure, Narrowed pulse pressure, decreased CVP&PCWPdecreased CVP&PCWPFlattened neck veins in Flattened neck veins in supine positionsupine positionOliguria<30ml/hOliguria<30ml/hPostural systolic BP falls Postural systolic BP falls >>25mm Hg and diastolic fall 25mm Hg and diastolic fall >> 20 mm Hg , with pulse 20 mm Hg , with pulse increases increases >> 30 30Eyeballs soft and sunken Eyeballs soft and sunken (severe deficit)(severe deficit)

Clinical assessment of degree of Clinical assessment of degree of dehydration(Children)- dehydration(Children)- ((EVFVDEVFVD))

Degree Mild(5-7% ofBW)

Moderate(7-10% ofBW

Severe (>10% ofBW)

1- Fontanella Slightly sunken Very sunken Very sunken

2- Mucous membranes

Slightly sticky dry Very dry

3- Skin turgor Normal Slightly decreased

Markedly decreased

4- Capillary refill time

Normal(<3 seconds)

Normal(<3 seconds)

Delayed(≤ 3 seconds)

5- Urine output Normal Slightly decreased

Decreased or absent

6-Mental status Normal Slightly fussy Irritable or lethargic

Dehydration in ChildrenDehydration in Children

Degrees Of Dehydration in adultsMild=2%of total body water ~ 1-1.4lit

ThirstThirstMarked=5% of total body water ~ 3-3.5lit.

Marked thirst,oliguria,Ht.,pulse,R.R, BP, Dry mucous & Marked thirst,oliguria,Ht.,pulse,R.R, BP, Dry mucous & Low grade fever.Low grade fever.

Severe= 8%Severe= 8% ofof total body water ~ 5-5.5lit.total body water ~ 5-5.5lit.Symptoms of marked dehydration plus:Symptoms of marked dehydration plus:Systolic blood pressure drop (60 mm Hg or below)Systolic blood pressure drop (60 mm Hg or below)Behavioral changes (restlessness, irritability, deliriumBehavioral changes (restlessness, irritability, delirium

& disorientation,)& disorientation,)Fatal 22–30% of total body water loss~ 15lit. or more

Can prove fatalCan prove fatalAnuriaAnuriaComa leading to deathComa leading to death

LABORATORY FINDINGS (EVFVD)(EVFVD)

Increased osmolality(Increased osmolality(>> 295 mOsm/ kg) 295 mOsm/ kg)

Increased or normal serum sodium level Increased or normal serum sodium level ((>> 145mEq/ L ) 145mEq/ L )

Increase BUN (Increase BUN (>>25 mg / L )25 mg / L )

Hyperglycemia ( Hyperglycemia ( >>120 mg /dl )120 mg /dl )

Elevated hematocrit (Elevated hematocrit (>> 55%) 55%)

Increased urine specific gravity ( Increased urine specific gravity ( >> 1.030) 1.030)

MANAGEMENT (EVFVD)(EVFVD)

Mild fluid volume loss can be corrected with Mild fluid volume loss can be corrected with oral fluid replacementoral fluid replacement

-if patient tolerates solid foods advice to take -if patient tolerates solid foods advice to take 1200 ml to 1500ml of oral fluids1200 ml to 1500ml of oral fluids

-if patient takes only fluids, increase the total -if patient takes only fluids, increase the total intake to 2500 ml in 24 hours intake to 2500 ml in 24 hours

MANAGEMENT (EVFVD)(EVFVD)

Estimate Fluid Deficit Estimate Fluid Deficit (% :- Mild, Moderate, Severe).(% :- Mild, Moderate, Severe).

Find Type of Dehydration Find Type of Dehydration (Isonatremic, Hyponatremic, Hypernatremic).(Isonatremic, Hyponatremic, Hypernatremic).Give daily Maintenance.Give daily Maintenance.Give Deficit as follows: Give Deficit as follows:

Half volume over 8 hours, half volume over 16 Half volume over 8 hours, half volume over 16 hourshours(Exception: in Hypernatremic Dehydration, (Exception: in Hypernatremic Dehydration, replace deficit over 48 hours).replace deficit over 48 hours).

If haemorrhage is the cause for ECFVD

Packed red cells followed by hypotonic IV Packed red cells followed by hypotonic IV fluids is administeredfluids is administeredIn situations where the blood loss is less In situations where the blood loss is less than 1 L Normal Saline or Ringer lactate than 1 L Normal Saline or Ringer lactate may be usedmay be usedPatients with severe ECFVD accompanied Patients with severe ECFVD accompanied by severe heart , liver, or kidney disease by severe heart , liver, or kidney disease cannot tolerate large volumes of fluid and cannot tolerate large volumes of fluid and sodium & need monitoring (sodium & need monitoring (CVP)CVP)

EXTRACELLULAR FLUID VOLUME EXCESS

ECFVE is ECFVE is increased fluid increased fluid retention in the retention in the intravasular and intravasular and interstitial spacesinterstitial spaces

ETIOLOGY AND RISK FACTORS(EVFVE)

Heart failureHeart failureRenal failureRenal failureCirrhosis of liverCirrhosis of liverIncreased ingestion of high sodium foodsIncreased ingestion of high sodium foodsExcessive amount of IV fluids containing Excessive amount of IV fluids containing sodiumsodiumElectrolyte free IV fluidsElectrolyte free IV fluidsSepsisSepsisDecreased colloid osmotic pressureDecreased colloid osmotic pressureLymphatic and venous obstruction Lymphatic and venous obstruction Cushing’s syndrome & glucocorticoids Cushing’s syndrome & glucocorticoids

CLINICAL MANIFESTATION (EVFVE)(EVFVE)

Constant irritating coughConstant irritating coughDyspnoea & crackles in lungsDyspnoea & crackles in lungsCyanosis, pleural effusionCyanosis, pleural effusionNeck vein distention Neck vein distention Bounding pulse &elevated BPBounding pulse &elevated BPS3 gallopS3 gallopPitting & anasacra edemaPitting & anasacra edemaWeight gainWeight gainIncreased CVP& PCWPIncreased CVP& PCWPChange in level of consciousnessChange in level of consciousness

LAB INVESTIGATION (EVFVE)

serum osmolality <275mOsm/ kgserum osmolality <275mOsm/ kg

Low , normal or high sodiumLow , normal or high sodium

Decreased hematocrit [ < 45%]Decreased hematocrit [ < 45%]

Urine specific gravity below 1.010Urine specific gravity below 1.010

Decreased BUN [< 8mg/ dl] Decreased BUN [< 8mg/ dl]

MANAGEMENT (EVFVE)(EVFVE)

Diuretics [combination of potassium Diuretics [combination of potassium sparing and potassium depleting sparing and potassium depleting diuretics]diuretics]

In people with CHF: ACE inhibitors and In people with CHF: ACE inhibitors and low dose of beta blockers are used low dose of beta blockers are used

A low sodium diet A low sodium diet

EXTRACELLULAR FLUID VOLUME SHIFT: THIRD

SPACING(shift)

Fluid that shifts into nonfunctioning Fluid that shifts into nonfunctioning spaces and remain there is called as spaces and remain there is called as third space fluid third space fluid

Common sites are abdomen , pleural Common sites are abdomen , pleural cavity, peritoneal cavity and GI lumen cavity, peritoneal cavity and GI lumen

RISK FACTORS(shift)

Crushing injuries, major tissue traumaCrushing injuries, major tissue traumaMajor surgeryMajor surgeryExtensive burnsExtensive burnsPancreatitisPancreatitisPerforated peptic ulcers - peritonitisPerforated peptic ulcers - peritonitisIntestinal obstructionIntestinal obstructionLymphatic obstruction Lymphatic obstruction HypoalbumenemiaHypoalbumenemia

CLINICAL MANIFESTATION(shift)

skin pallorskin pallorCold extremitiesCold extremitiesWeak and rapid pulseWeak and rapid pulseHypotension Hypotension OliguriaOliguria

Decreased levels of consiousness Decreased levels of consiousness LAB INVESTIGATION

Elevated hematocrit & BUN levelElevated hematocrit & BUN levelAs in the iso-osmolarAs in the iso-osmolar

MANAGEMENT(shift)Treat the cause

• For burns and tissue injuries large volume For burns and tissue injuries large volume of isosmolar IV fluid is administeredof isosmolar IV fluid is administered

• Albumin is administered for protein deficitAlbumin is administered for protein deficit• IV fluid intake is maintained after major IV fluid intake is maintained after major

surgery to maintain kidney perfusion surgery to maintain kidney perfusion • Paracentesis or tapping for ascitis or Paracentesis or tapping for ascitis or

pleural effusion pleural effusion

INTRACELLULAR FLUID VOULME EXCESS:WATER

INTOXICATION

ICFVE is increase in amount of water ICFVE is increase in amount of water inside the cellsinside the cells

ETIOLOGY (ICFVE)

Administration of excessive amount of Administration of excessive amount of hyposmolar IV fluids[0.45%saline or hyposmolar IV fluids[0.45%saline or 5%dextrose in water]5%dextrose in water]Consumption of excessive amount of tap Consumption of excessive amount of tap water without adequate nutritional intakewater without adequate nutritional intake

(Schizophrenia[compulsive water (Schizophrenia[compulsive water consumption])consumption])SIADH results from innapropriate ADH SIADH results from innapropriate ADH secretion resulting in innapropriate secretion resulting in innapropriate retention of ingested/infused water retention of ingested/infused water

CLINICAL MANIFESTATIONS (ICFVE)

HeadachesHeadachesBehavioral changes Behavioral changes ApprehensionApprehensionIrritability, disorientation and confusionIrritability, disorientation and confusionIncreased ICP – pupillary changes and Increased ICP – pupillary changes and decreased motor and sensory functiondecreased motor and sensory functionBradycardia, elevated BP, widened pulse Bradycardia, elevated BP, widened pulse pressure & altered respiratory patterns, pressure & altered respiratory patterns, Babinski’s response flaccidity, projectile Babinski’s response flaccidity, projectile vomiting, papilledema, delirium, convulsions vomiting, papilledema, delirium, convulsions &coma&coma

LABORATORY FINDINGS (ICFVE)

Low serum sodium level- 125 mEq/L Low serum sodium level- 125 mEq/L

decreased hamatocritdecreased hamatocrit

MANAGEMENT (ICFVE)

Early administration of IV fluids containing Early administration of IV fluids containing sodium chloride can prevent SIADHsodium chloride can prevent SIADHoral fluids such as juices or soft drinks can be oral fluids such as juices or soft drinks can be given orally every hourgiven orally every hourPerform neurologic checks every hour to see if Perform neurologic checks every hour to see if cranial changes are presentcranial changes are presentMonitor fluid intake , IV fluids and fluid output Monitor fluid intake , IV fluids and fluid output hourly and weight dailyhourly and weight dailyAdminister antiemetics for food and fluid Administer antiemetics for food and fluid retention retention

INTRACELLULAR FLUID VOLUME DEFICIT

Severe hypernatremia and dehydration Severe hypernatremia and dehydration can cause ICFVDcan cause ICFVDRelatively rare in healthy adultsRelatively rare in healthy adultsCommon in elderly people and in those Common in elderly people and in those conditions that result in acute water lossconditions that result in acute water lossSymptoms include confusion, coma, and Symptoms include confusion, coma, and cerebral hemorrhagecerebral hemorrhage

Assessment of fluid and Assessment of fluid and Electrolytes Imbalance;Electrolytes Imbalance;

Observation of general condition of the patient, Observation of general condition of the patient, including including vital signsvital signs, , neck veinsneck veins, , skinskin, and , and mucous membranesmucous membranes, , weightweight, , presence of presence of edemaedema and and appetite.appetite.Type of fluid lost.Type of fluid lost.Character and volume of urine & specific gravity Character and volume of urine & specific gravity Assessment of blood electrolytes level.Assessment of blood electrolytes level.Blood urea nitrogen and creatinine level.Blood urea nitrogen and creatinine level.Frequency and character of stool.Frequency and character of stool.Measuring and recording intake and output.Measuring and recording intake and output.

The rules of fluid replacement:The rules of fluid replacement:

Replace blood with bloodReplace blood with blood

Replace plasma with colloid or LRReplace plasma with colloid or LR

Resuscitate with colloid or LRResuscitate with colloid or LR

Replace ECF depletion with salineReplace ECF depletion with saline

Rehydrate with dextroseRehydrate with dextrose

Hyponatremic pt. needs Hyponatremic pt. needs NSS or hypertonic salineNSS or hypertonic saline

Hypernatremic pt. needsHypernatremic pt. needs– D5W or hypotonic salineD5W or hypotonic saline

Hypo versus HyperHypo versus Hyper

INDICATORS OF SUCCESSFULRESUSCITATION

URINARY OUTPUTURINARY OUTPUT– CHILDREN = 1.0 ml/kg/hrCHILDREN = 1.0 ml/kg/hr

– ADULT = 0.5 ml/kg/hrADULT = 0.5 ml/kg/hr

BLOOD PRESSURE BLOOD PRESSURE POORPOOR INDICATOR INDICATOR

How much fluid to give ?How much fluid to give ?What is your starting point ?What is your starting point ?– Euvolemia ?Euvolemia ? ( normal )( normal )– Hypovolemia ? ( dry )Hypovolemia ? ( dry )– Hypervolemia ? ( wet )Hypervolemia ? ( wet )

What are the expected losses ?What are the expected losses ?

What are the expected gains ?What are the expected gains ?

MAINTENANCE THERAPY..

Maintenance therapy is usually undertaken Maintenance therapy is usually undertaken when the individual is not expected to eat or when the individual is not expected to eat or drink normally for a longer time (eg, drink normally for a longer time (eg, perioperatively or on a ventilator).perioperatively or on a ventilator).Big picture: Most people are “NPO” for 8-12 Big picture: Most people are “NPO” for 8-12 hours each day.hours each day.

Patients who won’t eat for > one to two weeks Patients who won’t eat for > one to two weeks should be considered for parenteral or enteralshould be considered for parenteral or enteralnutrition.nutrition.

..MAINTENANCE THERAPY

water requirements increase with:water requirements increase with:fever, sweating, burns, tachypnea, surgical fever, sweating, burns, tachypnea, surgical drains, polyuria, or ongoing significant drains, polyuria, or ongoing significant gastrointestinal lossesgastrointestinal losses..

For example, water requirements For example, water requirements increase by increase by 100 to 150 mL/day100 to 150 mL/day for each C degree of body for each C degree of body temperature elevation.temperature elevation.

..MAINTENANCE THERAPY

4/2/1 rule4/2/1 rule4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24h4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24hthen 2 ml/kg/hr for next 10 kg (=20ml/hr)=50ml/kg/24hthen 2 ml/kg/hr for next 10 kg (=20ml/hr)=50ml/kg/24hthen 1 ml/kg/hr for any kgs over that=20ml/kg/24hthen 1 ml/kg/hr for any kgs over that=20ml/kg/24h

This always gives 60ml/hr for first 20 kgThis always gives 60ml/hr for first 20 kgthen you add 1 ml/kg/hr for each kg over 20 kgthen you add 1 ml/kg/hr for each kg over 20 kg

This boils down to: This boils down to: Weight in kg + 40 = Maintenance IV Weight in kg + 40 = Maintenance IV rate/hourrate/hour..For any person weighting >20kg &<100kg.For any person weighting >20kg &<100kg.

Daily fluid maintenance in pediatrics:Daily fluid maintenance in pediatrics:

0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc

Electrolytes

WHAT DO ELECTROLYTES DO?WHAT DO ELECTROLYTES DO?

Serum Values of ElectrolytesCations (+)Cations (+) ConcentrationConcentration

SodiumSodium 135 – 145 mEq/L135 – 145 mEq/LPotassiumPotassium 3.5 - 4.5 mEq/L 3.5 - 4.5 mEq/LCalciumCalcium 9-10.5 mg/dL 9-10.5 mg/dLMagnesiumMagnesium 1.5 - 2.5 mEq/L 1.5 - 2.5 mEq/L

Anions (-)Anions (-)ChlorideChloride 95 – 107 mEq/L 95 – 107 mEq/LCO2CO2 24 – 30 mEq/L 24 – 30 mEq/LPhosphatePhosphate 2.5 - 4.5 mEq/L 2.5 - 4.5 mEq/LHCOHCO33 22 – 26 mEq/LmEq/L

Location of Ions

Intracellular Ions

Mg++ K+ Ph-Cl-

Na+

Ca++

Extracellular Ions

Daily Requirements for Electrolytes

Sodium: 1-2 mEq/kg/dSodium: 1-2 mEq/kg/d

Potassium: 0.5-1 mEq/kg/dPotassium: 0.5-1 mEq/kg/d

Calcium: 800 - 1200 mg/dCalcium: 800 - 1200 mg/d

Magnesium: 300 - 400 mg/dMagnesium: 300 - 400 mg/d

Phosphorus: 800 - 1200 mg/dPhosphorus: 800 - 1200 mg/d

Sodium imbalances

Definition

Risk factors/ etiology

Clinical manifestation

Laboratory findings

management

Hyponatraemia

  It is defined as a plasma sodium level below 135 mEq/ L

•Kidney diseases

• Adrenal insufficiency

• Gastrointestinal losses

• Use of diuretics (especially with along with low sodium diet)

• Metabolic acidosis

•Weak rapid pulse•Hypotension•Dizziness•Apprehension and anxiety •Abdominal cramps •Nausea and vomiting•Diarrhea•Coma and convulsion•Cold clammy skin•Finger print impression on the sternum after palpation •Personality change

•Serum sodium less than 135mEq/ L

• serum osmolality less than 280mOsm/kg

•urine specific gravity less than 1.010

•Identify the cause and treat •Administration of sodium orally, by NG tube or parenterally•For patients who are able to eat & drink, sodium is easily accomplished through normal diet•For those unable to eat,Ringer’s lactate solution or isotonic saline [0.9%Nacl]is given•For very low sodium 3%Nacl may be indicated •water restriction in case of hypervolaemia

CLINICAL MANIFESTATIONS OF HYPONATREMIACLINICAL MANIFESTATIONS OF HYPONATREMIA

Muscle Weakness Apathy

Postural hypotension

Nausea andAbdominal Cramps

Weight Loss

In severe hyponatremia: mental confusion, delirium, shock and coma

Sodium imbalan-ce

Definition

causes Clinical

manifestation

Lab findings

management

Hypernat-remia

It is defined as plasma sodium level greater than 145mEq/L

*Ingestion of large amount of concentrated salts*Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion

* Low grade fever Postural hypertension*Dry tongue & mucous membranes

* Agitation

* Convulsions

*Restlessness

 *Excitability·*Oliguria or anuria·*Thirst

*Dry &flushed skin

*high serum sodium 145mEq/L  *high serum osmolality295mO sm/kg *high urine specificity 1.030

*Administration of hypotonic sodium solution [0.3 or 0.45%] 

*Rapid lowering of sodium can cause cerebral edema

*Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk

*Diuretics are given in case of sodium excess

*In case of Diabetes insipidus desmopressin acetate nasal spray is used 

*Dietary restriction of sodium in high risk clients

CLINICAL MANIFESTATIONS of HYPERNATREMIA

Thirst Dry & sticky mucous membranesThirst Dry & sticky mucous membranes Firm, rubbery Firm, rubbery tissue turgortissue turgor

Manic excitementManic excitement

TachycardiaTachycardia

DEATHDEATH

Potassium imbalances

Definition

Causes Clinical manifestation

Lab findings Management

Hypokalemia

It is defined as plasma potassium level of less than 3.0 mEq/L

*Use of potassium wasting diuretic

*diarrhea, vomiting or other GI losses

*Alkalosis

*Cushing’s syndrome

*Polyuria

*Extreme sweating

*excessive use of potassium free Ivs

*weak irregular pulse

*shallow respiration

*hypotesion

*weakness, decreased bowel sounds,

heart blocks , paresthesia, fatigue,

decreased muscle tone

intestinal obstruction

* K – less than 3mEq/L results in ST depression , flat T wave, taller U wave

* K – less than 2mEq/L cause widened QRS, depressed ST, inverted T wave

Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement

Moderate hypokalemia*K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/

Severe hypokalemia K- less than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day]

Definition Causes Clinicalmanifestation

Lab findings Management

Hyperkalemia

It is defined as the elevation of potassium level above 5.0mEq/L

Renal failure ,  Hypertonic dehydration,  Burns& trauma Large amount of IV administration of potassium, Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood

Irregular slow pulse,  hypotension,  anxiety,  irritability,  paresthesia,  weakness

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad P- wave *serum potassium levels of 8mEq/L results in no arterial act ivi ty[no p-wave]

•Dietary restriction of potassium for potassium less than 5.5 mEq/L •Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics• Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema

Calcium imbalances

Definition

Causes Clinical manifestation

Lab findings

Management

hypocalcemia

It is a plasma calcium level below 8.5 mg/dl

•Rapid administration of blood containing citrate,

•hypoalbuminemia,

•Hypothyroidism ,  •Vitamin deficiency,

•neoplastic diseases,

•pancreatitis

•Numbness and tingling sensation of fingers,

•hyperactive reflexes,• Positve Trousseau’s sign, positive chvostek’s sign ,

•muscle cramps,

•pathological fractures,

•prolonged bleeding time

Serum calcium less than 4.3 mEq/L and ECG changes

1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

TESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCYTESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCY

Calcium imbalance

Definition Causes Clinical manifestation

Lab findings Management

Hypercalcemia

It is calcium plasma level over 5.5 mEq/l or 11mg/dl

•Hyperparathyroidism, •Metastatic bone tumors,  •paget’s disease,

•osteoporosis ,

•prolonged immobalisation

•Decreased muscle tone,

•anorexia,  •nausea, vomiting,

•weakness , lethargy,  •low back pain from kidney stones,

•decreased level of consciousness & cardiac arrest

•High serum calcium level 5.5mEq/L,

• x- ray showing generalized osteoporosis,

•widened bone cavitation,

•urinary stones,

•elevated BUN 25mg/100ml,

•elevated creatinine1.5mg/100ml

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium  2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same

ANY QUESTION?ANY QUESTION?ANY QUESTION?ANY QUESTION?

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