fluidsandelectrolytes 090912000506 phpapp01

Celso M. Fidel,Celso M. Fidel,

MD,FPCS,FPSGSMD,FPCS,FPSGS

Diplomate Philippine Board Diplomate Philippine Board of Surgeryof Surgery

FLUIDS AND FLUIDS AND ELECTROLYTESELECTROLYTES

INTRODUCTIONINTRODUCTION

HOMEOSTASIS HOMEOSTASIS is determined by:is determined by: Individual’s Intake and outputIndividual’s Intake and output Carefully and precisely regulated by the Carefully and precisely regulated by the body during Healthbody during Health

One of the most critical aspects of One of the most critical aspects of patient’s care is management of the patient’s care is management of the body composition of fluids and body composition of fluids and electrolyteselectrolytes

INTRODUCTIONINTRODUCTION Situations that impose a great impact on Situations that impose a great impact on physiology of body fluid & electrolytes:physiology of body fluid & electrolytes: DiseasesDiseases InjuriesInjuries Operative TraumaOperative Trauma In disease states ---In disease states ---regulatory regulatory

mechanisms mechanisms often becomes impaired & often becomes impaired &

IMBALANCES IMBALANCES occuroccur

•

INTRODUCTIONINTRODUCTION Thorough understanding of the Thorough understanding of the mechanisms of fluids and electrolytes mechanisms of fluids and electrolytes and certain metabolic responses is and certain metabolic responses is essential to the care of surgical essential to the care of surgical patientspatients SURGEONS encounter these PROBLEMS:SURGEONS encounter these PROBLEMS: Additional stress of SURGERYAdditional stress of SURGERY Use of tubes that drain fluidsUse of tubes that drain fluids Patient’s inability to tolerate oral Patient’s inability to tolerate oral intake of fluids and nutrientsintake of fluids and nutrients

BODY WATERBODY WATER

Water constitutes between 50% to Water constitutes between 50% to 70%TB Wt.70%TB Wt. Average Normal ValuesAverage Normal Values Young Adult Male 60% of body Young Adult Male 60% of body wt.wt. Young Young Adult FemaleAdult Female 50% of body 50% of body wt.wt. Total Body Water (% TBW) decreasesTotal Body Water (% TBW) decreases steadily and significantly with age:steadily and significantly with age: 52% in males52% in males 47% in females47% in females

BODY WATERBODY WATER

Highest proportion of TB water : Highest proportion of TB water :

Infants 75% to 80% of body weightInfants 75% to 80% of body weight

One Year Old averages 65% of BWt.One Year Old averages 65% of BWt.

Lean individuals Lean individuals has greaterhas greater proportion proportion of water to TBW than the obeseof water to TBW than the obese

FUNCTIONAL COMPARTMENT OF BODY FLUIDSFUNCTIONAL COMPARTMENT OF BODY FLUIDS

INTRACELLULARINTRACELLULAR

fluid w/in the body’s diverse cell fluid w/in the body’s diverse cell populationpopulation

represent---- 40%represent---- 40%

largest proportion ---- skeletal musclelargest proportion ---- skeletal muscle

principal principal CATION-----CATION-----K (potassium)K (potassium)

principal principal ANION ------ANION ------phosphates & phosphates & proteinsproteins


EXTRACELLULAREXTRACELLULAR

Represents----- 20% of the BWRepresents----- 20% of the BW

Two major subdivisionsTwo major subdivisions

plasma volume----- 5% of BWplasma volume----- 5% of BW

Interstitial( extravascular ) 15% of Interstitial( extravascular ) 15% of BWBW


EXTRACELLULAREXTRACELLULAR

Non-functioning components----1%-2% Non-functioning components----1%-2% B wt.B wt.

Connective tissue waterConnective tissue water

Cerebrospinal fluidCerebrospinal fluid

Joint fluidsJoint fluids

The principal The principal CATION-----CATION-----Na+( Sodium)Na+( Sodium)

The principal The principal ANION-------ANION-------Cl (Chloride Cl (Chloride andand

bicarbonatesbicarbonates


Gibbs-Donnan Equilibrium-----Gibbs-Donnan Equilibrium-----The The

product of concentration of any pair of product of concentration of any pair of

diffusable diffusable cation cation and and anionanion on one side on one side

of a semi-permeable membrane will of a semi-permeable membrane will

equal the product of the same pair of equal the product of the same pair of

ions on the other sideions on the other side


TWO THIRDS RULETWO THIRDS RULE

Determination of the exact size of Determination of the exact size of

any one of the 3 compartments is any one of the 3 compartments is

virtually impossiblevirtually impossible

Total Body Compartment is Total Body Compartment is

approximately 2/3 of BODY Weightapproximately 2/3 of BODY Weight

FUNCTIONAL COMPARTMENT OF BODY FUNCTIONAL COMPARTMENT OF BODY FLUIDSFLUIDS

TWO THIRDS RULETWO THIRDS RULE

Of this 2/3; 2/3 is INTRACELLULAR Of this 2/3; 2/3 is INTRACELLULAR

& 1/3 is & 1/3 is EXTRACELLULAREXTRACELLULAR

Of the extracellular portion Of the extracellular portion

2/3 is INTERSTITIAL &2/3 is INTERSTITIAL &

1/3 intravascular1/3 intravascular

REPLACEMENT OF WATERREPLACEMENT OF WATER By IngestionBy Ingestion

By Metabolism-----combustion of foodstuff:By Metabolism-----combustion of foodstuff:

Each 100 calories ofEach 100 calories of

FATFAT

CARBOHYDRATESCARBOHYDRATES

PROTEINSPROTEINS

VITAL NEEDS W/C DEMANDS continuous VITAL NEEDS W/C DEMANDS continuous

water EXPENDITUREwater EXPENDITURE Removal of Body Heat ----800cc Removal of Body Heat ----800cc ((SKIN AND SKIN AND

LUNGS) 600-1000 >>>> RANGE DAILYLUNGS) 600-1000 >>>> RANGE DAILY

RELEASES 14 CC OF WATER


water EXPENDITUREwater EXPENDITURE

Excretion of UREA, METABOLIC Excretion of UREA, METABOLIC PRODUCTSPRODUCTS

& MINERAL SALTS& MINERAL SALTS

1200 mOsm of solute have to be 1200 mOsm of solute have to be excreted excreted

daily daily

A good kidney can CONCENTRATE A good kidney can CONCENTRATE urine up urine up

to 1400 mOsm soluteto 1400 mOsm solute


water EXPENDITUREwater EXPENDITURE

Average Adult excretes 900 cc Average Adult excretes 900 cc H20/dayH20/day

Normal H20 loss in Urine----800-Normal H20 loss in Urine----800-1500cc/ day1500cc/ day

Normal Na+ loss-----10-100 mEq/ liter Normal Na+ loss-----10-100 mEq/ liter of of

urineurine

Normal Daily LossesNormal Daily Losses

1. GIT 100-200 ml loss in stools1. GIT 100-200 ml loss in stools

2. GUT 1000- 1500 ml loss in urine2. GUT 1000- 1500 ml loss in urine

3. Insensible 600-800 ml in adults (divided equally3. Insensible 600-800 ml in adults (divided equally between lungs and skin) a better term wouldbetween lungs and skin) a better term would be imperceptible lossbe imperceptible loss

Abnormal Losses of WaterAbnormal Losses of Water

1. Fever - 10% increase insensible loss per 1. Fever - 10% increase insensible loss per degree above 37 C.degree above 37 C. 2. Tachypnea –doubling RR 50% increase resp. L2. Tachypnea –doubling RR 50% increase resp. L 3. Evaporation- Sweating, ventilator, open wounds3. Evaporation- Sweating, ventilator, open wounds 4. GI –Fistula, Diarrhea, Tube drainage4. GI –Fistula, Diarrhea, Tube drainage 5. Third space – Interstitium of lungs, bowel, soft5. Third space – Interstitium of lungs, bowel, soft tissuestissues 6. Intraoperative losses6. Intraoperative losses

TonicityTonicity Body Fluids ---- composed of water and Body Fluids ---- composed of water and

substances dissolved in itsubstances dissolved in it

Total number of particles in solution areTotal number of particles in solution are

constant throughout the body, constant throughout the body, although the although the

nature of the individual solute varies nature of the individual solute varies inin

different parts of the bodydifferent parts of the body

Tonicity( property derived from the Tonicity( property derived from the number ofnumber of

particles in solution) Normal----300 particles in solution) Normal----300 mOsm/L mOsm/L

TonicityTonicity In PLASMA 280 is due to ELECTROLYTESIn PLASMA 280 is due to ELECTROLYTES

1/2 --- 140 mOsm is coming from Na+1/2 --- 140 mOsm is coming from Na+

1/2 --- 140 mOsm from Chlorides & 1/2 --- 140 mOsm from Chlorides &

BicarbonatesBicarbonates

Crystalloids:Crystalloids:

SugarSugar

Urea 10-20 mOsmUrea 10-20 mOsm

CreatinineCreatinine

Protein ------ 2 mOsmProtein ------ 2 mOsm

Electrolytes, What are TheyElectrolytes, What are They??

Group of compounds-----DISSOCIATES in Group of compounds-----DISSOCIATES in solution to form solution to form “IONS’“IONS’ after the greek after the greek

for for “ “ GOING”GOING” These ions each carry an electrical These ions each carry an electrical

charge; charge; example; NaCl -----dissolved in water example; NaCl -----dissolved in water providesprovides Na+ ---- carries a positive chargeNa+ ---- carries a positive charge Cl- -----carries a negative chargeCl- -----carries a negative charge

Electrolytes, What are TheyElectrolytes, What are They?? Those IONS carrying a (+) charge Those IONS carrying a (+) charge

migrated to migrated to FARADAY’s (-)FARADAY’s (-) electrode electrode

or “CATHODE” were called or “CATHODE” were called ”Cations””Cations”

after the Greek for after the Greek for “DOWN”“DOWN”

Those IONS carrying a (-) charge Those IONS carrying a (-) charge

migrated to migrated to FARADAY’s (+)FARADAY’s (+) electrode electrode

or “ANODE” were called or “ANODE” were called ”anions””anions” after after

the Greek for “UP”the Greek for “UP”

Electrolytes, What are TheyElectrolytes, What are They?? Cations in the body; Na+, K+, Ca++, Cations in the body; Na+, K+, Ca++,

Mg++Mg++

Anions in the body include ; Cl-, HCO3-, Anions in the body include ; Cl-, HCO3-,

HPO4=, SO4=; ions of inorganic acids HPO4=, SO4=; ions of inorganic acids such such

as:as:

LactateLactate

PyruvatePyruvate

Aceto-AcetateAceto-Acetate

ProteinatesProteinates


Each of the water compartments of Each of the water compartments of the the

body contains electrolytes. body contains electrolytes. However However

the composition and concentration the composition and concentration of of

these electrolytes in the water of these electrolytes in the water of each each

compartment differ from that of compartment differ from that of the the

others.others.


Physiologic and Chemical Activity of Physiologic and Chemical Activity of electrolytes are proportional to:electrolytes are proportional to: Number of particles present per unit Number of particles present per unit

volumevolume ( MOLES or MILLIMOLES)( MOLES or MILLIMOLES)

No. of electrical charges per unit No. of electrical charges per unit volumevolume

( Equivalents or Milliequivalents per ( Equivalents or Milliequivalents per liter)liter)

Electrolytes, What are TheyElectrolytes, What are They?? mEq/L=mgs./L X val. divided by the atomic mEq/L=mgs./L X val. divided by the atomic

Wt.Wt. ==mgs/ 1000cc X Valencemgs/ 1000cc X Valence Atomic WeightAtomic Weight OSMOLARITY OSMOLARITY >>>expression of concentration >>>expression of concentration of ions and proteins in solution in body water.of ions and proteins in solution in body water.

Water moves freely in the body to prevent Water moves freely in the body to prevent the development of any compartmentalizedthe development of any compartmentalized osmolar concentration difference.osmolar concentration difference.

Electrolytes, What are TheyElectrolytes, What are They?? Electrolyte Concentration in SerumElectrolyte Concentration in Serum

Na+ -------- 135-145 mEq/ literNa+ -------- 135-145 mEq/ liter

K+ -------- 3.5-5.5 mEq/literK+ -------- 3.5-5.5 mEq/liter

Cl- ----- 85-115 mEq/literCl- ----- 85-115 mEq/liter

HCO3- ---- 22-29 mEq/literHCO3- ---- 22-29 mEq/liter

Mg++ ---- 1.5-2.5 mEq/literMg++ ---- 1.5-2.5 mEq/liter

Ca++ ---- 4-5.5 mEq/literCa++ ---- 4-5.5 mEq/liter

ELECTROLYTE COMPOSITION OF BODY FLUIDSELECTROLYTE COMPOSITION OF BODY FLUIDS

Na+ K+ H+ Cl- HCO3 Proteins PO4 SO4- Na+ K+ H+ Cl- HCO3 Proteins PO4 SO4- Plasma 142 4.5 Plasma 142 4.5 100 25 16 2 1 100 25 16 2 1

GastricGastric

Low Acid Low Acid 45 45 30 70 120 25 30 70 120 25

High Acid High Acid 100 45 0.015 115 30100 45 0.015 115 30

Intestinal Juice 120 20 30Intestinal Juice 120 20 30

Bile 140 5 40Bile 140 5 40

Pancreatic Juice 130 15 80Pancreatic Juice 130 15 80

Intracellular 10 150 5 10 60 100 20Intracellular 10 150 5 10 60 100 20

NORMAL DAILY FLUID& ELECTROLYTE LOSSES NORMAL DAILY FLUID& ELECTROLYTE LOSSES AND REQUIREMENTS AND REQUIREMENTS

LOSSES/ 24 hoursLOSSES/ 24 hours SubstancesSubstances Urine Urine SkinSkin LungsLungs Feces Feces TotalTotal WATER WATER 1200-1500 200-400 500-700 100-200 2300-26001200-1500 200-400 500-700 100-200 2300-2600

SODIUM SODIUM 100 mEq 40 mEq/liter 80-100 mEq100 mEq 40 mEq/liter 80-100 mEq

POTASSIUM POTASSIUM 100 mEq100 mEq 80- 80-100mEq100mEq

CHLORIDES CHLORIDES 150 mEq 40 mEq/ liter150 mEq 40 mEq/ liter 100-150 100-150 mEq mEq

REQUIREMENTSREQUIREMENTS WATER 35 ml/ kg. body weightWATER 35 ml/ kg. body weight

PEDIATRICS 100 ml/kg first 10 kg. body weightPEDIATRICS 100 ml/kg first 10 kg. body weight 50 ml/kg next 10 kg. “ “50 ml/kg next 10 kg. “ “

20 ml/kg for each additional body weight20 ml/kg for each additional body weight

SODIUM 1 mEq/kg body weight SODIUM 1 mEq/kg body weight

POTASSIUM “ “ “ “POTASSIUM “ “ “ “

CHLORIDE 1.5 mEq/ kg. body weightCHLORIDE 1.5 mEq/ kg. body weight

HCO3 0.5 “ “ “ “HCO3 0.5 “ “ “ “

THE IONSTHE IONS

SODIUMSODIUM

Principal Principal CationCation of extracellular fluid of extracellular fluid

Normal requirement is met by the average dietNormal requirement is met by the average diet

Average intake----- 100 mgs dailyAverage intake----- 100 mgs daily

Sweat conc. -----27mEq/ L isSweat conc. -----27mEq/ L is to 100mEq /L to 100mEq /L Total secretion---Alimentary Tract Total secretion---Alimentary Tract 1000-12001000-1200mEqmEq

ADH of Pituitary promotes Na+ excretion from ADH of Pituitary promotes Na+ excretion from

the kidney to some extent & to markedly the kidney to some extent & to markedly

favor water resorption from the distal favor water resorption from the distal tubules. tubules.

THE IONSTHE IONS

POTASSIUM (cation)POTASSIUM (cation)

Major exchangeable portion lies within the cellMajor exchangeable portion lies within the cell

Daily turnover of K+ requirement represents Daily turnover of K+ requirement represents

1.5 to 5% of the total K+ content of the body.1.5 to 5% of the total K+ content of the body.

Normal 70 kg. man----- 3,200 mEqNormal 70 kg. man----- 3,200 mEq

Average woman--------- 2,300mEqAverage woman--------- 2,300mEq

Normal requirement met by average dietNormal requirement met by average diet

Gastric Juice Content----15-40mEq/literGastric Juice Content----15-40mEq/liter

Healthy cell maintains high K+ & low Na+ conc.Healthy cell maintains high K+ & low Na+ conc.

Patient under stress of disease or in the postop.Patient under stress of disease or in the postop. period>> Normal Kidney excretes 80-90 period>> Normal Kidney excretes 80-90 mEq/daymEq/day

THE IONSTHE IONS

POTASSIUM (cation)POTASSIUM (cation) At 7 mEq/L in Serum----- elevation of T waves onAt 7 mEq/L in Serum----- elevation of T waves on Electro Cardio GramElectro Cardio Gram At 8-10 mEq/L ------Arrhythmia & Heart BlockAt 8-10 mEq/L ------Arrhythmia & Heart Block

CHLORIDE (ANION)CHLORIDE (ANION) Na+ to Cl- ratio is 3:2 in serum & extracellularNa+ to Cl- ratio is 3:2 in serum & extracellular compartmentcompartment

It follows changes in Na+ concentration EXCEPTIt follows changes in Na+ concentration EXCEPT in GASTRIC OBSTRUCTION;in GASTRIC OBSTRUCTION; Chloride is lowChloride is low Na+ is normalNa+ is normal Alkalosis is severe Alkalosis is severe

DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES

It is the center of any scheme of FLUID It is the center of any scheme of FLUID

and ELECTROLYTE Balanceand ELECTROLYTE Balance

Nature of imbalances and approximate Nature of imbalances and approximate

magnitude are based on:magnitude are based on:

HistoryHistory

Clinical Signs and SymptomsClinical Signs and Symptoms

Certain Laboratory StudiesCertain Laboratory Studies

Past Clinical ExperiencePast Clinical Experience


CLUES FROM THE HISTORYCLUES FROM THE HISTORY

In Gastric Outlet Obstruction present inIn Gastric Outlet Obstruction present in

Duodenal Ulcer will produce Duodenal Ulcer will produce

Pyloric Stenosis alkalosis (loss ofPyloric Stenosis alkalosis (loss of

Chloride & K+; Hypokalemia; loss of H20 & Chloride & K+; Hypokalemia; loss of H20 & Na+)Na+)

Vomiting secondary to a cause other than Vomiting secondary to a cause other than gastric gastric

Outlet Obstruction:Outlet Obstruction:

Loss of H2O If there is a shift in ACIDLoss of H2O If there is a shift in ACID

Loss of Na+ BASE balance, it is Loss of Na+ BASE balance, it is towardstowards

Loss of K+ METABOLIC ACIDOSISLoss of K+ METABOLIC ACIDOSIS

vomiting


CLUES FROM THE HISTORYCLUES FROM THE HISTORY

Diarrhea secondary to:Diarrhea secondary to:

Cholera Loss of Cholera Loss of

Ulcerative Colitis H20, K+, Ulcerative Colitis H20, K+, ACIDOSISACIDOSIS

Ileostomy dysfunction Na+Ileostomy dysfunction Na+

Burns produces acute loss of PLASMA & Burns produces acute loss of PLASMA & Extra-Extra-

cellular fluid (Water, Proteins, and Na+)cellular fluid (Water, Proteins, and Na+)

Sweating if excessive causes appreciable Sweating if excessive causes appreciable loss ofloss of

both Na+ & H20------ Shrinkage of both Na+ & H20------ Shrinkage of ExtracellularExtracellular

Fluid Volume -------VASCULAR COLLAPSEFluid Volume -------VASCULAR COLLAPSE


P.E. should give attention to: P.E. should give attention to:

BODY WEIGHTBODY WEIGHT

Weight gain >>>H20 retentionWeight gain >>>H20 retention

Weight loss 300-500 gms./day expected in Weight loss 300-500 gms./day expected in

postoperative Patients.>>>> In excess of postoperative Patients.>>>> In excess of 300- 300-

500 gms/ day indicates H20 loss.500 gms/ day indicates H20 loss.

Tissue TurgorTissue Turgor >>Decrease in T T in volume >>Decrease in T T in volume of of

the Interstitial Fluid compartment of ECFthe Interstitial Fluid compartment of ECF

( Na+ dependent)( Na+ dependent)

Skin Turgor>> useful indicator of diminishedSkin Turgor>> useful indicator of diminished

interstitial fluid volumeinterstitial fluid volume


P.E. should give attention to: P.E. should give attention to:

Tissue turgorTissue turgor

Tongue>> most reliable indicator forT.TTongue>> most reliable indicator forT.T Normally it has a single “Median Furrow”Normally it has a single “Median Furrow”

Additional furrows parallel to the median furrowAdditional furrows parallel to the median furrow

appears with decrease interstitial volume and appears with decrease interstitial volume and aa

need for Na+need for Na+

Moisture of the axilla and groinMoisture of the axilla and groin. Dry but . Dry but other-other-

wise normal axilla----H20 deficit, at least wise normal axilla----H20 deficit, at least 150cc150cc

Jugular VeinsJugular Veins ------Normally it fills to the ------Normally it fills to the anterioranterior

border of the sternocleidomastoid muscle border of the sternocleidomastoid muscle whenwhen

the patient is supine.the patient is supine.


P.E. should give attention to: P.E. should give attention to: Blood Pressure and PulseBlood Pressure and Pulse

Tachypnea>> earliest sign of decrease Tachypnea>> earliest sign of decrease BVolume BVolume

Postural Hypotension Need for Blood & Postural Hypotension Need for Blood & NaNa

Hypotension when Supine containing fluidHypotension when Supine containing fluid

Edema and RalesEdema and Rales

Pitting Edema>>> Na+ increase >> 400 Pitting Edema>>> Na+ increase >> 400 mEqmEq

Rales>> Acute increase in Volume by at Rales>> Acute increase in Volume by at least least

1500cc 1500cc


LABORATORY TESTS & Other LABORATORY TESTS & Other PARAMETERS PARAMETERS

HematocritHematocrit

Urine Specific GravityUrine Specific Gravity

Na+ levels in serum and urineNa+ levels in serum and urine

CVP monitoringCVP monitoring

Pulmonary Wedge PressurePulmonary Wedge Pressure


LABORATORY TESTS & Other PARAMETERSLABORATORY TESTS & Other PARAMETERS

HematocritHematocrit

Urine Specific GravityUrine Specific Gravity

Na+ levels in serum and urineNa+ levels in serum and urine

CVP monitoringCVP monitoring

Pulmonary Wedge PressurePulmonary Wedge Pressure

Determining the Amount of the DeficitDetermining the Amount of the Deficit

A Vol(H2O) deficit---- Estimate from patient’s A Vol(H2O) deficit---- Estimate from patient’s Body Body

Wt.& appearance or from the serum Sodium Wt.& appearance or from the serum Sodium level.level.

The hematocrit gives also useful information.The hematocrit gives also useful information.


CLINICAL ESTIMATES CLINICAL ESTIMATES

MILD Dehydration----- Patient losses 3% of MILD Dehydration----- Patient losses 3% of the the

Body Weight ----- Body Weight ----- THIRSTYTHIRSTY

MODERATE Dehydration ------ Patient losses MODERATE Dehydration ------ Patient losses 6%6%

of the Body Wt. Clinical signs of of the Body Wt. Clinical signs of dehydrationdehydration

are Evident:are Evident:

Marked Thirst and Dry MouthMarked Thirst and Dry Mouth

No groin and axillary SweatNo groin and axillary Sweat

Loss of Skin TurgorLoss of Skin Turgor

..


CLINICAL ESTIMATESCLINICAL ESTIMATES

SEVERE Dehydration------Patient losses 10% SEVERE Dehydration------Patient losses 10% ofof

Body Weight:Body Weight:

Clinical signs of Dehydration are marked.Clinical signs of Dehydration are marked.

Hypotension may be presentHypotension may be present

Patient may be confused & delirious.Patient may be confused & delirious.

BODY WATER CALCULATIONSBODY WATER CALCULATIONS

Body H20 = Body H20 = Normal Serum Na+Normal Serum Na+ X normal B X normal B H20H20

Measured Na+ valueMeasured Na+ value


Electrolyte deficits.Electrolyte deficits. They are They are calculatedcalculated

after the lab results for Na+. K, Cl, and after the lab results for Na+. K, Cl, and NaHC03 are in.NaHC03 are in.

NaCl & HCO3 deficit are calculated NaCl & HCO3 deficit are calculated using foll:using foll:

DEFICIT= DEFICIT= NORMAL VOLUME –OBSERVED BODY VOLUME x ELECTROLYTE NORMAL VOLUME –OBSERVED BODY VOLUME x ELECTROLYTE

DISTRIBUTIONDISTRIBUTION IN BODY COMP% x BODY WT(KG)IN BODY COMP% x BODY WT(KG) WHERE: NA DISTRIBUTION = 60 %WHERE: NA DISTRIBUTION = 60 % CL “ 20 %CL “ 20 % HCO3 “ 5O%HCO3 “ 5O%


Electrolyte deficits.Electrolyte deficits.

The K+ deficit is figured differently w/normalThe K+ deficit is figured differently w/normal

Blood pH:Blood pH:

For every 1.0 mEq/L decrease in For every 1.0 mEq/L decrease in concentrationconcentration

at or above 3.0 mEq----consider the total at or above 3.0 mEq----consider the total bodybody

deficit as 100-200 mEq.deficit as 100-200 mEq.

For every1.0 mEq/L decrease in the K+ For every1.0 mEq/L decrease in the K+ conc. conc.

below 3.0 mEq/L -----consider the total below 3.0 mEq/L -----consider the total bodybody

deficit as another 300-400 mEq.deficit as another 300-400 mEq.


ABNORMAL PATTERNS in Fluids & ElectrolytesABNORMAL PATTERNS in Fluids & Electrolytes

Disorders of composition & concentrationDisorders of composition & concentration

Disorders of VolumeDisorders of Volume

Disorders of Acid-Base BalanceDisorders of Acid-Base Balance

CLINICAL STATESCLINICAL STATES

HYPONATREMIA HYPONATREMIA HYPERCLOREMIA HYPERCLOREMIA

HYPERNATREMIA HYPERNATREMIA ACID BASE BALANCE ACID BASE BALANCE

ISOTONIC DEHYDRATIONISOTONIC DEHYDRATION

HYPOKALEMIAHYPOKALEMIA

HYPERKALEMIAHYPERKALEMIA


HYPONATREMIAHYPONATREMIA

PathophysiologyPathophysiology

Hypovolemic or IsovolemicHypovolemic or Isovolemic

Mechanism:Mechanism:

Loss of Na+ containing fluid and Loss of Na+ containing fluid and replacementreplacement

with salt free fluid( isovolemic)with salt free fluid( isovolemic)

Salt free fluid and administration in excess Salt free fluid and administration in excess inin

the absence of salt loss the absence of salt loss ((dilutional Hyponatremia)dilutional Hyponatremia)



CausesCauses

Loss of fluid with high Na+ content:Loss of fluid with high Na+ content:

Fistula Fistula Ngt Drainage Ngt Drainage

Vomiting Vomiting Diarrhea Diarrhea

Excessive URINE Na+ wastageExcessive URINE Na+ wastage

Diuretics Diuretics Chronic Nephritis Chronic Nephritis

Adrenal Cortical Insufficiency as in Adrenal Cortical Insufficiency as in Addison’sAddison’s

diseasedisease Over infusion of salt free fluid (Over infusion of salt free fluid (dilutional dilutional

Hyponatremia)Hyponatremia)



Causes cont’dCauses cont’d

Loss of Extracellular Fluid:Loss of Extracellular Fluid:

Externally:Externally:

Burns Burns Marked Sweating Marked Sweating

Internally as in Third Space loss:Internally as in Third Space loss:

Peritonitis Peritonitis Ascites Ascites

Ileus Ileus Pancreatitis Pancreatitis



Clinical PresentationClinical Presentation

Accumulation of intracellular fluid could causeAccumulation of intracellular fluid could cause

CNS symptoms:CNS symptoms:

Serum Na+ below 130 mEq/Liter ( Mild)Serum Na+ below 130 mEq/Liter ( Mild)

“ “ “ “ “ “ 113 “ “ (Severe)113 “ “ (Severe)

CNS depression, Confusion, Somnolence CNS depression, Confusion, Somnolence

Signs of Increase Intracranial pressureSigns of Increase Intracranial pressure

OLIGURIC Renal Failure in Severe OLIGURIC Renal Failure in Severe HyponatremiaHyponatremia



ManagementManagement

Repeated Na+ determination; other Repeated Na+ determination; other ElectrolytesElectrolytes

H20 deprivation, Use diureticsH20 deprivation, Use diuretics

Administer Na+ containing FluidsAdminister Na+ containing Fluids

Sodium must be Titrated slowly back to Sodium must be Titrated slowly back to

NormalNormal


HYPONATREMIAHYPONATREMIA “ “ Sample CASE”Sample CASE” A muscular 50 year old man with A muscular 50 year old man with

polycysticpolycystic kidney disease presents w/ hypotension, confusion, oliguria, and kidney disease presents w/ hypotension, confusion, oliguria, and

no axillary sweat. Past medical record reveals that he has no axillary sweat. Past medical record reveals that he has polyuria has been eating a low salt diet because of mild polyuria has been eating a low salt diet because of mild hypertension. BUN has beenhypertension. BUN has been

stable at 40mgs/dL;Blood CO2 is 15mmol/L (Metabolic Acidosis) stable at 40mgs/dL;Blood CO2 is 15mmol/L (Metabolic Acidosis) andand

Na+ level of 120mEq/L.Body Weight is 90kgs; Urine output- Na+ level of 120mEq/L.Body Weight is 90kgs; Urine output- 170ml/day170ml/day

GIVEN:GIVEN: Na+ deficit =140mEq – 120mEq = 20mEq/L Na+ deficit =140mEq – 120mEq = 20mEq/L Total Body H20 = 90kgs X 60 = 54 LTotal Body H20 = 90kgs X 60 = 54 L Fluid Loss = 10% (Clinical Findings)Fluid Loss = 10% (Clinical Findings)

First Step:First Step: COMPUTE for Hypotonic Na+ deficitCOMPUTE for Hypotonic Na+ deficit Hypotonic Na+ deficit = Na+ deficit X TBWHypotonic Na+ deficit = Na+ deficit X TBW = 20mEq X 54 L =1080(Hypotonic Na+ = 20mEq X 54 L =1080(Hypotonic Na+

def.)def.)


HYPONATREMIAHYPONATREMIA “ “ Sample CASE”Sample CASE” 22ndnd Step Step: : COMPUTE for the isotonic Na+ deficitCOMPUTE for the isotonic Na+ deficit Find out the Isotonic Fluid loss or How much fluid is necessary Find out the Isotonic Fluid loss or How much fluid is necessary

toto revert to revert to ISOTONIC STATEISOTONIC STATE.. Formula ISOTONIC FLUID LOSS =Weight X % of FLUID LOSSFormula ISOTONIC FLUID LOSS =Weight X % of FLUID LOSS 90 Kgs. X 10% (9 Liters)90 Kgs. X 10% (9 Liters) Then compute for Then compute for isotonic Na+ deficitisotonic Na+ deficit Formula:Formula: Isotonic Na+ Loss X NORMALIsotonic Na+ Loss X NORMAL Na+ levelNa+ level 9 Liters X 140mEq =9 Liters X 140mEq = 1260mEq1260mEq

Total Na+ REQUIREMENT:Total Na+ REQUIREMENT: Hypotonic Na+ Deficit + Isotonic Na+ deficit + Daily Hypotonic Na+ Deficit + Isotonic Na+ deficit + Daily

requirementrequirement 1080mEq + 1260mEq + 75mEq = 1080mEq + 1260mEq + 75mEq =

2415mEq2415mEq

Initially only ½ is given so divide it by 2 =1207.5 mEqInitially only ½ is given so divide it by 2 =1207.5 mEq


HYPONATREMIAHYPONATREMIA “ “ Sample CASE”Sample CASE” 33rdrd Step: Step: COMPUTE for the 24 hours H20 requirementCOMPUTE for the 24 hours H20 requirement The daily H20 requirement in an OLIGURIC patient is reduced:The daily H20 requirement in an OLIGURIC patient is reduced: FORMULAFORMULA 0.2 ml/kg body wt. +0.2 ml/kg body wt. + preceeding 24 hour Urine Output +10% forpreceeding 24 hour Urine Output +10% for every rise of 1 degree in body temp.every rise of 1 degree in body temp. =(0.2ml X 90 X 24) + 170 =602 ml/day=(0.2ml X 90 X 24) + 170 =602 ml/day

24 HOUR H20 requirement =24 HOUR H20 requirement =Isotonic Fluid loss(9 L) + 600 Isotonic Fluid loss(9 L) + 600 = 4.8 = 4.8 LitersLiters

22

44thth Step: Compute for Bicarbonate. The ideal replacement solution Step: Compute for Bicarbonate. The ideal replacement solution shouldshould

contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.


HYP0NATREMIAHYP0NATREMIA “ “ Sample CASE”Sample CASE” 44thth Step: Step: Compute for Bicarbonate. The ideal replacement solution Compute for Bicarbonate. The ideal replacement solution

shouldshould contain a NaCl ratio of 1.4:1 particularly if the patient is contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.ACIDOTIC.

Sub- Step:Sub- Step: Compute for Chloride Requirement Compute for Chloride Requirement 1.4 1.4 = = 1245 1245 X= X= 12451245 =890 mEq as NaCl =890 mEq as NaCl 1 X(mEq) 1.41 X(mEq) 1.4 The Bicarbonate requirement is thus:The Bicarbonate requirement is thus: 1245- 890 =355 mEq of HCO31245- 890 =355 mEq of HCO3

PATIENT’S FLUID & ELECTROLYTE REQUIREMENTPATIENT’S FLUID & ELECTROLYTE REQUIREMENT

4.8 liters of 5% Dextrose in 0.9 % NaCl4.8 liters of 5% Dextrose in 0.9 % NaCl

Add 8 vials of Na2CO3 (44 mEq/50 cc)Add 8 vials of Na2CO3 (44 mEq/50 cc)

Plus 200 cc of 5% NaCl injectionPlus 200 cc of 5% NaCl injection


HYPERNATREMIAHYPERNATREMIA PathophysiologyPathophysiology

ECF Hyperosmolarity= shift of H20 from cell----ECF Hyperosmolarity= shift of H20 from cell----

----ECF-ECF-More Fluid ---More Fluid ---DEHYDRATIONDEHYDRATION

Increased Intracellular Osmolality --Increased Intracellular Osmolality --CNS CNS effects:effects:

FeverFever

Hallucination Hallucination

DeliriumDelirium


HYPERNATREMIAHYPERNATREMIA

CausesCauses

Prolonged FeverProlonged Fever

Large surface Burns --Large surface Burns --3-5 Liters loss/day3-5 Liters loss/day

Tachypnea – Do Tube TracheostomyTachypnea – Do Tube Tracheostomy

Renal Damage Renal Damage Loss of Solute Loss of Solute

Urine High Output FailureUrine High Output Failure

Desert ExposureDesert Exposure

Drinking Salt H2ODrinking Salt H2O


HYPERNATREMIAHYPERNATREMIA ManagementManagement Gradual Reduction of Serum Na+Gradual Reduction of Serum Na+ Rehydrate patient with salt Free H20Rehydrate patient with salt Free H20 Formula: Formula: 70 kg patient with Na+ of 160mEq70 kg patient with Na+ of 160mEq Total Body Water 60% X 70kgs = 42 Liters=Total Body Water 60% X 70kgs = 42 Liters= Current Body Water Current Body Water 140140 =0.87 or 0.9 =0.87 or 0.9 1616

0.9 X 42 =37.8 Liters current Body Water0.9 X 42 =37.8 Liters current Body Water 42L- 37.8= 4.2 Liters ( water Needed)42L- 37.8= 4.2 Liters ( water Needed)



“ “ Sample CASE”Sample CASE” A moderately lean woman with A moderately lean woman with esophageal stricture has a serum Na+ level of 160mEq /L esophageal stricture has a serum Na+ level of 160mEq /L (normal is 140mEq). Her(normal is 140mEq). Her

present weight is 70kgs.present weight is 70kgs.

HER REQUIREMENTS WOULD BE CALCULATED AS FOLLOWS:HER REQUIREMENTS WOULD BE CALCULATED AS FOLLOWS: Current Body WaterCurrent Body Water 140mEq140mEq =7/8 =87.5 % of normal =7/8 =87.5 % of normal 160mEq160mEq

WATER Loss>>> 100%- 87.5% =12.5% of waterWATER Loss>>> 100%- 87.5% =12.5% of water PATIENT’S NORMAL total BODY WATERPATIENT’S NORMAL total BODY WATER 70 X 60% = 42 Liters70 X 60% = 42 Liters H20 DEFICITH20 DEFICIT 42 L X 12.5% = 5.3 Liters42 L X 12.5% = 5.3 Liters



“ “ Sample CASESample CASE”” A moderately lean A moderately lean woman with esophageal stricture has a serum woman with esophageal stricture has a serum Na+ level of 160mEq /L (normal is 140mEq). Na+ level of 160mEq /L (normal is 140mEq). HerHer

present weight is 70kgs.present weight is 70kgs. HER Fluid REQUIREMENTHER Fluid REQUIREMENT 2.7 + 2.4 = 5.1 L of fluid needed in the 2.7 + 2.4 = 5.1 L of fluid needed in the

next 24 hours next 24 hours containing 70mEq of Na+containing 70mEq of Na+ FORMULA USED:FORMULA USED: ½ H20 Deficit + normal daily fluid ½ H20 Deficit + normal daily fluid

requirementrequirement ½ H2O Deficit + ( 35cc X70 kgs.) 2.4 ½ H2O Deficit + ( 35cc X70 kgs.) 2.4

LitersLiters


HYPERNATREMIAHYPERNATREMIAExampleExample If the same patient has diarrhea as well If the same patient has diarrhea as well

as esophagealas esophageal stricture and has persisted with weakness, confusion; stricture and has persisted with weakness, confusion;

hypotensionhypotension CALCULATIONS WOULD BE AS FOLLOWSCALCULATIONS WOULD BE AS FOLLOWS Present Body WaterPresent Body Water 140 140 =7/8 = 87% of NORMAL =7/8 = 87% of NORMAL 160160 Water Loss 100-87.5 =12.5%Water Loss 100-87.5 =12.5% Patient’s Normal Body Water =70kgs X 60% = 42 Patient’s Normal Body Water =70kgs X 60% = 42

LitersLiters H20 Deficit: 42 L X 12.5% =5.3 LitersH20 Deficit: 42 L X 12.5% =5.3 Liters CLINICAL Findings shows 10% dehydrationCLINICAL Findings shows 10% dehydration CALCULATIONS should be changed CALCULATIONS should be changed



ExampleExample If the same patient has diarrhea as well as If the same patient has diarrhea as well as esophagealesophageal

stricture and has persisted with weakness, confusion; hypotensionstricture and has persisted with weakness, confusion; hypotension

CLINICAL Findings shows 10% dehydrationCLINICAL Findings shows 10% dehydration

CALCULATIONS should be changed CALCULATIONS should be changed

FLUID LOSS 10% of 70kgs = 7 litersFLUID LOSS 10% of 70kgs = 7 liters

ISOTONIC Fluid loss = 7 – 5.3 =1.7 LitersISOTONIC Fluid loss = 7 – 5.3 =1.7 Liters

Na+ loss in Isotonic Fluid = 1.7 L X 140mEq = 238mEqNa+ loss in Isotonic Fluid = 1.7 L X 140mEq = 238mEq

24 Hour Fluid Requirement= ½ H20 deficit + Normal Body Fluid24 Hour Fluid Requirement= ½ H20 deficit + Normal Body Fluid

= ½ of 7( 7/2) +2.4 = 5.9 L= ½ of 7( 7/2) +2.4 = 5.9 L

24 Hour Na+ Requirement = ½ Na+ deficit + 70 =189mEq24 Hour Na+ Requirement = ½ Na+ deficit + 70 =189mEq

This can be given as: 4 liters of 5% Dextrose in Water plusThis can be given as: 4 liters of 5% Dextrose in Water plus

1200 cc of NORMAL Saline Solution 1200 cc of NORMAL Saline Solution


ISOTONIC DEHYDRATIONISOTONIC DEHYDRATION The Serum Na+ Concentration is NormalThe Serum Na+ Concentration is Normal “ “EXAMPLE” A short obese alcoholic patient presents EXAMPLE” A short obese alcoholic patient presents

withwith Vomiting due to gastritisVomiting due to gastritis 102 F fever due to pneumonitis102 F fever due to pneumonitis Complaining of thirstComplaining of thirst Has dry mouthHas dry mouth No groin or Axillary SweatNo groin or Axillary Sweat Alert and NormotensiveAlert and Normotensive Weight of 100kgs.Weight of 100kgs. Serum Na+ is 140mEq/LSerum Na+ is 140mEq/L

Serum K+ 3mEq/LSerum K+ 3mEq/L



FLUID and ELECTROLYTE RequirementFLUID and ELECTROLYTE Requirement Fluid Loss = 6% (based on Clinical Findings)Fluid Loss = 6% (based on Clinical Findings) Isotonic Fluid loss 100kgs X 6% = 6 LitersIsotonic Fluid loss 100kgs X 6% = 6 Liters Na+ loss (in isotonic fluid) 140mEq X Na+ loss (in isotonic fluid) 140mEq X

6=840mEq6=840mEq 24 hours Na+ Requirement24 hours Na+ Requirement 840840 + 100mEq = 520mEq + 100mEq = 520mEq 2 2 24 hour Fluid Requirement24 hour Fluid Requirement 6 6 + 4.9 L =7.9 L + 4.9 L =7.9 L 22



FLUID and ELECTROLYTE RequirementFLUID and ELECTROLYTE Requirement EXPLANATIONS:EXPLANATIONS: The daily requirement is 4.9 instead of 3.5 because of the patient’sThe daily requirement is 4.9 instead of 3.5 because of the patient’s fever. Each 1 degree rise in temperature increase by at least fever. Each 1 degree rise in temperature increase by at least

10%10% Fluid and Na+ replacement can be given as:Fluid and Na+ replacement can be given as:

3 Liters of 5% dextrose in Normal Saline3 Liters of 5% dextrose in Normal Saline 2 Liters of 5% dextrose in water2 Liters of 5% dextrose in water 200cc of Normal saline200cc of Normal saline

KCl should be added as indicated at ½ of the DEFICIT plus theKCl should be added as indicated at ½ of the DEFICIT plus the the daily requirement (100mEq) provided urine flow is the daily requirement (100mEq) provided urine flow is

adequate.adequate. KCl should be divided among the solutions KCl should be divided among the solutions


HYPOKALEMIAHYPOKALEMIA

CAUSES.CAUSES. Chronic Pyloric Obstruction Chronic Pyloric Obstruction Ulcerative Colitis Ulcerative Colitis Prolonged Vomiting Prolonged Vomiting Fistula Fistula Diarrhea Diarrhea Diuretic Therapy Diuretic Therapy

NephritisNephritis Adrenal Hyperactivity( Stress; Cushing’s Syndrome)Adrenal Hyperactivity( Stress; Cushing’s Syndrome)

PATHOPHYSIOLOGYPATHOPHYSIOLOGY Loss of GASTRIC JUICE --Loss of GASTRIC JUICE -- minimal loss of K+ -- minimal loss of K+ --Loss of Cl.---Loss of Cl.--- insufficient Cl. For renal Tubular reabsorption of Na+ Loss of Na+ insufficient Cl. For renal Tubular reabsorption of Na+ Loss of Na+

ions>>>Adrenal and Renal mechanisms will conserve ions>>>Adrenal and Renal mechanisms will conserve Na+>>>and add inNa+>>>and add in

exchange K+ and H+ are excreted>>>>>>HYPOKALEMIAexchange K+ and H+ are excreted>>>>>>HYPOKALEMIA


HYPOKALEMIAHYPOKALEMIA CLINICAL FEATURESCLINICAL FEATURES Less than 3.5mEq/L in serumLess than 3.5mEq/L in serum Associated with:Associated with:

Diuretics Diuretics Metabolic AlkalosisMetabolic Alkalosis Aldosterone Secretion Aldosterone Secretion GIT lossesGIT losses


HYPOKALEMIAHYPOKALEMIA CLINICAL FEATURESCLINICAL FEATURES Prolonged Ileus, Hyporeflexia, ParalysisProlonged Ileus, Hyporeflexia, Paralysis Increased sensitivity to digitalisIncreased sensitivity to digitalis Favors ALKALOSIS (because of Acid loss) and alkalosis Favors ALKALOSIS (because of Acid loss) and alkalosis DECREASE K+DECREASE K+ ECG shows Prolonged QT; Depressed ST; T Wave ECG shows Prolonged QT; Depressed ST; T Wave

inversioninversion Early Signs of K+ Depletion:Early Signs of K+ Depletion: Malaise and WeaknessMalaise and Weakness Paralytic Ileus and DistentionParalytic Ileus and Distention Muscular ParesisMuscular Paresis


HYPOKALEMIAHYPOKALEMIAMANAGEMENTMANAGEMENT Add KCl to IV Solution but not to exceed Add KCl to IV Solution but not to exceed

20mEq/hour20mEq/hour

Usual Daily Requirement is 40mEq/dayUsual Daily Requirement is 40mEq/day

CONTRAINDICATIONS TO K+ THERAPYCONTRAINDICATIONS TO K+ THERAPY

UNTREATED Adrenal InsufficiencyUNTREATED Adrenal Insufficiency

UNTREATED Renal FailureUNTREATED Renal Failure

TEMPORARY Renal ShutdownTEMPORARY Renal Shutdown


HYPERKALEMIAHYPERKALEMIA CLINICAL FEATURESCLINICAL FEATURES

Serum K+ 6mEq/L or Serum K+ 6mEq/L or overover


HYPERKALEMIAHYPERKALEMIA CLINICAL FEATURESCLINICAL FEATURES Seen in: Seen in:

Renal Failure Renal Failure

Massive injury like BurnsMassive injury like Burns Acidosis and Low Flow Acidosis and Low Flow

States States Massive GI HemorrhageMassive GI Hemorrhage Administration of K+Administration of K+


HYPERKALEMIAHYPERKALEMIA CLINICAL FEATURESCLINICAL FEATURES

Manifested as :Manifested as : 1. Nausea 1. Nausea 2. Vomiting2. Vomiting 3. Diarrhea3. Diarrhea 4. Heart BLOCK 4. Heart BLOCK 5. Loss of Digitalis Effect 5. Loss of Digitalis Effect 6. CARDIAC ARREST6. CARDIAC ARREST


HYPERKALEMIAHYPERKALEMIA• PATHOPHYSIOLOGYPATHOPHYSIOLOGY

In Renal Failure K+ cannot be Excreted, there In Renal Failure K+ cannot be Excreted, there will will

be >>accumulation in PLASMA.be >>accumulation in PLASMA.

In Renal Failure >>>>The Failure to excrete In Renal Failure >>>>The Failure to excrete H+ will H+ will

shift H+ into Cell to maintain pH>>>>K+ shift H+ into Cell to maintain pH>>>>K+ will will

leave cell>>>PLASMA Hyperkalemia.leave cell>>>PLASMA Hyperkalemia.

ECG will show peaked T Waves ,Wide QRS ECG will show peaked T Waves ,Wide QRS


HYPERKALEMIAHYPERKALEMIA• MANAGEMENTMANAGEMENT The principle is to shift back K+ into The principle is to shift back K+ into

the cell.the cell. 1. Na2C03 given to combat Acidosis>>K+ ion to back 1. Na2C03 given to combat Acidosis>>K+ ion to back

into into the cell in exchange of H+the cell in exchange of H+

2. IV glucose with insulin>> K+ taken up into the cell w/ 2. IV glucose with insulin>> K+ taken up into the cell w/ each molecule of glucose that enters the cell.each molecule of glucose that enters the cell.

3. Dialysis3. Dialysis 4. Exchange Resin4. Exchange Resin 5. Diminished uptake of K+5. Diminished uptake of K+


HYPOCHLOREMIAHYPOCHLOREMIA CLINICAL FEATURESCLINICAL FEATURES

Sodium Chloride is below 85mEq/LiterSodium Chloride is below 85mEq/Liter

Seen in Upper GI Obstruction w/ vomiting. Seen in Upper GI Obstruction w/ vomiting. OneOne

may loss as much as 120-130mEq/daymay loss as much as 120-130mEq/day

Hypochloremia in itself does not produce Hypochloremia in itself does not produce

striking Clinical Changes. striking Clinical Changes.


HYPOCHLOREMIAHYPOCHLOREMIA

• PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Diuretics >> cause increase loss of Chloride Diuretics >> cause increase loss of Chloride thru thru

Kidney>> Urinary Concentration of Kidney>> Urinary Concentration of Chlorides Chlorides

higher than Sodium Concentration.higher than Sodium Concentration.

MANAGEMENTMANAGEMENT

Treat with KCl solutionTreat with KCl solution

May use NH4Cl or 0.1 N HCl (ideal for May use NH4Cl or 0.1 N HCl (ideal for hypochlo-hypochlo-

remia due to metabolic Alkalosis )remia due to metabolic Alkalosis )


HYPERCHLOREMIAHYPERCHLOREMIA

• CLINICAL FEATURESCLINICAL FEATURES

Chloride above 105mEq/LChloride above 105mEq/L

Seen in Hypernatremia Seen in Hypernatremia

Seen in Uretero Intestinal AnastomosisSeen in Uretero Intestinal Anastomosis

Seen in Obstructive UropathySeen in Obstructive Uropathy

Excessive intake of NH4ClExcessive intake of NH4Cl


HYPERCHLOREMIAHYPERCHLOREMIA

• PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Uretero Intestinal Uretero Intestinal Anastomosis>>>ReabsorptionAnastomosis>>>Reabsorption

by bowel>>>Accumulation of Cl in excess by bowel>>>Accumulation of Cl in excess of Na+of Na+

ion ( potentiated by Renal Insufficiency)ion ( potentiated by Renal Insufficiency)

Associated w/ Metabolic AcidosisAssociated w/ Metabolic Acidosis

MANAGEMENTMANAGEMENT

Correct Associated Abnormalities Correct Associated Abnormalities

Remove Salt ( Ammonium)Remove Salt ( Ammonium)

Allow Kidneys to CompensateAllow Kidneys to Compensate

PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE

Normal H+ ion concentration in Extracellular Normal H+ ion concentration in Extracellular fluidfluid

is maintained at pH is maintained at pH 7.36-7.427.36-7.42

Daily Metabolic products are Daily Metabolic products are H+ and CO2H+ and CO2

To keep the pH constant, Acids are neutralized To keep the pH constant, Acids are neutralized

by by two mechanisms:two mechanisms:

Buffer System of Body FluidsBuffer System of Body Fluids

Regulatory functions of the Regulatory functions of the LUNGSLUNGS & & KIDNEYKIDNEY

Most important Buffer System is the Most important Buffer System is the

Bicarbonate Carbonic Acid SystemBicarbonate Carbonic Acid System

H2CO3 HCO3 + H+H2CO3 HCO3 + H+


pH is determined by ratio of base bicarbonatepH is determined by ratio of base bicarbonate to carbonic Acid:to carbonic Acid: HCO3HCO3 pH = Pk LOG H2CO3pH = Pk LOG H2CO3 ( HENDERSON HASSELBACH’S EQUATION)( HENDERSON HASSELBACH’S EQUATION) Carbonic Acid (H2CO3) is a function of the Carbonic Acid (H2CO3) is a function of the

dissolveddissolved

CO2.CO2. This is This is determined by thedetermined by the pCO2 of Blood pCO2 of Blood &&

is is regulated rapidly and accuratelyregulated rapidly and accurately by the by the LUNGSLUNGSBicarbonate(HCO3)Bicarbonate(HCO3) of blood is of blood is controlled bycontrolled by the the

rate of its renal secretionrate of its renal secretion. .


At pH 7.4 ratio of Carbonate to Carbonic Acid At pH 7.4 ratio of Carbonate to Carbonic Acid isis

20:120:1

In METABOLIC ACID BASE Shifts, effects on In METABOLIC ACID BASE Shifts, effects on

buffer system is onbuffer system is on LEVEL of LEVEL of BICARBONATE BICARBONATE

INCREASED:INCREASED:

Increased BicarbonateIncreased Bicarbonate = ALKALOSIS= ALKALOSIS

Decreased “Decreased “ = ACIDOSIS= ACIDOSIS


In In METABOLIC ACID BASE shiftsMETABOLIC ACID BASE shifts = = LUNGS LUNGS compensates:compensates: Metabolic Acidosis>> Metabolic Acidosis>> Increased VentilationIncreased Ventilation>>>> more CO2 released less H2CO3more CO2 released less H2CO3 Metabolic Alkalosis>> Metabolic Alkalosis>> Decreased VentilationDecreased Ventilation>> more CO2 retained >> Increased H2CO3more CO2 retained >> Increased H2CO3 IN RESPIRATORY ACID BASE shifts the IN RESPIRATORY ACID BASE shifts the effect on the buffer system is aeffect on the buffer system is a GAIN or LOSSGAIN or LOSS of CARBONIC ACIDof CARBONIC ACID Compensatory Mechanism is via theCompensatory Mechanism is via the KIDNEYS by KIDNEYS by retaining or Excreting BICARBONATESretaining or Excreting BICARBONATES


Respiratory Acidosis = Respiratory Acidosis = Increased H2CO3Increased H2CO3

Compensated by Compensated by RENAL RETENTION OF RENAL RETENTION OF

BICARBONATEBICARBONATE

Respiratory Alkalosis = Respiratory Alkalosis = Decreased H2CO3Decreased H2CO3 is is

Compensated by Compensated by RENAL EXCRETION ofRENAL EXCRETION of

BICARBONATEBICARBONATE

Serum HCO3Serum HCO3 20 20 pH = pH = KidneyKidney

Serum H2CO3 1 LungsSerum H2CO3 1 Lungs


To Follow Acid Base Changes KNOW:To Follow Acid Base Changes KNOW:

Signs and SymptomsSigns and Symptoms PathophysiologyPathophysiology Plasma pHPlasma pH Arterial pCO2Arterial pCO2 Total Extractable CO2 measured Total Extractable CO2 measured as venous CO2 content as venous CO2 content correctedcorrected to pCO2 to pCO2 of 40mm Hgof 40mm Hg


METABOLIC ACIDOSISMETABOLIC ACIDOSIS

Clinical AspectsClinical Aspects

Excess H+ in plasma>>Fall in pH Excess H+ in plasma>>Fall in pH >>Diminished>>>>Diminished>>

Plasma Bicarbonates seen in:Plasma Bicarbonates seen in:

Loss of fluid rich in Na2CO3Loss of fluid rich in Na2CO3

Adrenal Insufficiency>> Renal loss of Adrenal Insufficiency>> Renal loss of Na2C03Na2C03

Low flow state >>>Lactic AcidLow flow state >>>Lactic Acid

Diabetes MellitusDiabetes Mellitus




Increased rate & depth of breathing> Increased rate & depth of breathing> DecreaseDecrease

plasma pC02>>>Decrease H2CO3 with plasma pC02>>>Decrease H2CO3 with returnreturn

of pH to normalof pH to normal

Laboratory FindingsLaboratory Findings

pH below 7.38 pH below 7.38 HCO3 less than HCO3 less than 24mEq/minute24mEq/minute

Arterial pCO2 40mmHgArterial pCO2 40mmHg

Acidic Urine w/ low Na+ contentAcidic Urine w/ low Na+ content




Treat CauseTreat Cause

Adjustment to respirator (if patient is attachedAdjustment to respirator (if patient is attached

to one). Increased RATE decrease arterialto one). Increased RATE decrease arterial

pCO2.pCO2.

METABOLIC ALKALOSISMETABOLIC ALKALOSIS


HCl loss due to vomiting, gastric drainageHCl loss due to vomiting, gastric drainage

Loss of K+ and Cl- in urineLoss of K+ and Cl- in urine



Clinical AspectsClinical Aspects cont’d cont’d

Diuretics Diuretics

Adrenal SteroidsAdrenal Steroids

Administration of Na2CO3 or Sodium Administration of Na2CO3 or Sodium CitrateCitrate

(in blood transfusion)(in blood transfusion)


Due to uncompensated loss of Acids Due to uncompensated loss of Acids or or

retention of Basesretention of Bases




In Metabolic Alkalosis Increase In Metabolic Alkalosis Increase urinary K+ loss>>H+ and Na+ urinary K+ loss>>H+ and Na+ ion enter the cell>> Decrease of ion enter the cell>> Decrease of Extracellular H+ ion Extracellular H+ ion concentration>> further concentration>> further >>increase in Alkalosis.>>increase in Alkalosis.




LUNG Compensation:LUNG Compensation:

Hypoventilation>>>Hypoventilation>>>

CO2 accumulation>> CO2 accumulation>>

Increased Carbonic Acid.Increased Carbonic Acid.




RENAL Compensation:RENAL Compensation: Increased Increased Excretion ofExcretion of

BicarbonatBicarbonate e

in in ALKALINE UrineALKALINE Urine



Condition is usually seen in:Condition is usually seen in:

Multiple Transfusion Multiple Transfusion

Hyperventilation Hyperventilation

Volume ReductionVolume Reduction

Increased Aldosterone SecretionIncreased Aldosterone Secretion

Administration of Large volume of Administration of Large volume of Ringer’sRinger’s

LactateLactate



Laboratory Findings:Laboratory Findings:

1. Blood pH Higher than 7.441. Blood pH Higher than 7.44

2. HCO3= Higher than 28mEq/L 2. HCO3= Higher than 28mEq/L

3. Arterial PCO2= 40 in the presence 3. Arterial PCO2= 40 in the presence of of

Respiratory CompensationRespiratory Compensation




Replace lost Na+, Cl, and K+ ionsReplace lost Na+, Cl, and K+ ions

Lower pH by using of 0.1 N HClLower pH by using of 0.1 N HCl

In moderately severe Alkalosis where there In moderately severe Alkalosis where there isis

Increased Renal K+ excretion, permit the Increased Renal K+ excretion, permit the

tubule to retain H+ (treat) w/ IV KCltubule to retain H+ (treat) w/ IV KCl

Severe METABOLIC ALKALOSIS is the onlySevere METABOLIC ALKALOSIS is the only

good indication for the administration of good indication for the administration of

NH4CLNH4CL



Severe METABOLIC Severe METABOLIC ALKALOSIS ALKALOSIS

is the only good indication is the only good indication forfor

the administration of the administration of NH4CLNH4CL


RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS


It is caused by Pulmonary InsufficiencyIt is caused by Pulmonary Insufficiency

1. Failure to excrete CO2 via the Lungs 1. Failure to excrete CO2 via the Lungs withwith

normal efficiency as in:normal efficiency as in:

a. Pneumonia a. Pneumonia

b. Emphysemab. Emphysema

c. Fibrosisc. Fibrosis


RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS Clinical AspectsClinical Aspects It is It is caused bycaused by Pulmonary Insufficiency Pulmonary Insufficiency 2. Hypoventilation caused by2. Hypoventilation caused by a. Pulmonary Edemaa. Pulmonary Edema b. Injury b. Injury c. Post op. Atelectasis c. Post op. Atelectasis d. Drugsd. Drugs e. Poor Ventilation( Respirator)e. Poor Ventilation( Respirator)




Manifested by:Manifested by:

1. Somnolence 1. Somnolence

2. Confusion 2. Confusion

3. Coma due to CO2 Narcosis3. Coma due to CO2 Narcosis




Compensatory Mechanism:Compensatory Mechanism:

1. Increase Tubular 1. Increase Tubular reabsorption of reabsorption of

Na+ and bicarbonate by Na+ and bicarbonate by KidneysKidneys

2. Increase excretion of H+ 2. Increase excretion of H+ ionsions



Laboratory FindingsLaboratory Findings 1. Blood pH below 7.381. Blood pH below 7.38

2. Arterial pCO2 over 50mm Hg2. Arterial pCO2 over 50mm Hg

3. Acute Respiratory Acidosis= Plasma 3. Acute Respiratory Acidosis= Plasma H2CO3 H2CO3

not increased not increased

4. In Chronic state it’s elevated to 4. In Chronic state it’s elevated to 20mEq/L20mEq/L




Control ventilationControl ventilation to increase inspired to increase inspired

02>>> Return of Arterial Blood Gas to 02>>> Return of Arterial Blood Gas to

NormalNormal

Careful and slow correctionCareful and slow correction of pH and of pH and

pCO2 so as not to produce rapid pCO2 so as not to produce rapid changes changes

with associated Cardiac instabilitywith associated Cardiac instability


RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS Clinical FeaturesClinical Features Due to Hyperventilation seen in:Due to Hyperventilation seen in: 1. Pulmonary Infection1. Pulmonary Infection 2. Hysteria2. Hysteria 3. CNS Injury3. CNS Injury 4. Occasionally during Anesthesia4. Occasionally during Anesthesia 5. Fever5. Fever 6. Pain 6. Pain 7. Apprehension7. Apprehension 8. Salicylate Poisoning8. Salicylate Poisoning


RESPIRATORY ALKALOSISRESPIRATORY ALKALOSISPathophysiologyPathophysiology

Hyperventilation leads to Decrease in Hyperventilation leads to Decrease in AlveolarAlveolar

CO2 concentration>>> Decrease in CO2 concentration>>> Decrease in serum serum

H2CO3H2CO3 Compensatory Mechanism: Compensatory Mechanism: RENAL RENAL

increase increase tubular excretion of Na2CO3tubular excretion of Na2CO3


RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS

Laboratory FindingsLaboratory Findings::

1. Blood pH more than 7.461. Blood pH more than 7.46

2. Arterial pCO2 is lower than 36mm Hg.2. Arterial pCO2 is lower than 36mm Hg.

3. With renal compensation Bicarbonate 3. With renal compensation Bicarbonate

level will falllevel will fall

4. Urinary Na+ concentration is high4. Urinary Na+ concentration is high


RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS


Directed at its initiating CausesDirected at its initiating Causes

Note:Note:

Mild respiratory alkalosis is common Mild respiratory alkalosis is common postoperativepostoperative

problemproblem

Associated muscle irritability or frank tetanyAssociated muscle irritability or frank tetany

especially if serum calcium++ level is lowespecially if serum calcium++ level is low

Corrected by administration of calcium salts Corrected by administration of calcium salts

Calcium Chloride, Calcium GluconateCalcium Chloride, Calcium Gluconate


FORMULA FOR Acid Base ImbalanceFORMULA FOR Acid Base Imbalance Serum HCO3Serum HCO3 = = 20 20

Serum H2CO3 1Serum H2CO3 1

in the numerator 20/1 to 10/1 >Met. in the numerator 20/1 to 10/1 >Met. ACIDOSISACIDOSIS

in the numerator 20/1 to 30/1 >Met. in the numerator 20/1 to 30/1 >Met. ALKALOSISALKALOSIS

in the denominator 20/1 to 20/2>>Resp in the denominator 20/1 to 20/2>>Resp AcidosisAcidosis

in the denominator 20/1 to 20/.5 > R. in the denominator 20/1 to 20/.5 > R. AlkalosisAlkalosis

PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE

PRIORITIESPRIORITIES 1. Correct SHOCK and restore Blood 1. Correct SHOCK and restore Blood

Volume>>NormalVolume>>Normal

2. Restore Colloid Osmotic Pressure2. Restore Colloid Osmotic Pressure

3. Correct Acid Base Imbalance3. Correct Acid Base Imbalance

4. Restore Blood Osmolality4. Restore Blood Osmolality

5. Correct K+ deficit5. Correct K+ deficit

6. Correct Total Body Electrolytes disturbance6. Correct Total Body Electrolytes disturbance

(static debt) and establish daily maintenance(static debt) and establish daily maintenance


DEFICIT CORRECTIONDEFICIT CORRECTION Fluid and Electrolyte TherapyFluid and Electrolyte Therapy to Correct to Correct

existingexisting Deficit. Deficit. ExamplesExamples::

Blood volume deficit in Acute or Chronic Blood Blood volume deficit in Acute or Chronic Blood loss.loss.

Extracellular or Intracellular deficit in dehydrationExtracellular or Intracellular deficit in dehydration

Deficit correctionDeficit correction is added to is added to maintenance maintenance and and

replacement therapyreplacement therapy in order to restore in order to restore H20, H20,

salt balancesalt balance Deficit correctionDeficit correction is also is also Top priority inTop priority in Fluid Fluid and Electrolyte therapyand Electrolyte therapy


REPLACEMENT THERAPYREPLACEMENT THERAPY

Necessary to Replace Abnormal Necessary to Replace Abnormal (continuing) losses from or within (continuing) losses from or within the body. Example via drainage the body. Example via drainage tubes.tubes.



Gastrointestinal LossesGastrointestinal Losses

If these are purely gastric( succus If these are purely gastric( succus gastricus); gastricus);

A solution providing 0.45% NaCl mEq plus A solution providing 0.45% NaCl mEq plus 4040

mEq of KCl per liter is used for mEq of KCl per liter is used for replacement.replacement.



Gastrointestinal LossesGastrointestinal Losses

If the fluid lost contains intestinal If the fluid lost contains intestinal (succus entericus) (succus entericus) Lactated Ringer’sLactated Ringer’s

solution plus solution plus 10 mEq KCl10 mEq KCl per liter is per liter is

usedused..



Third Space LossThird Space Loss 1. The amount of loss varies with 1. The amount of loss varies with

the the magnitude of injury.magnitude of injury. 2. Lactated Ringer’s solution plus 2. Lactated Ringer’s solution plus Albumin is used.Albumin is used.


REPLACEMENT THERAPYREPLACEMENT THERAPY Continuing losses require Continuing losses require

volume for volume for volume replacement and volume replacement and addedadded

to to maintenancemaintenance requirements. requirements.

Replacement Therapy has Replacement Therapy has second second

priority priority in Fluids & Electrolytein Fluids & Electrolyte TherapyTherapy


MAINTENANCE THERAPYMAINTENANCE THERAPY Clinical Example: Clinical Example: Average size 60kgs woman Average size 60kgs woman

hashas an Elective Cholecystectomy. No drainage an Elective Cholecystectomy. No drainage

tubes.tubes. Patient’s Normal Daily RequirementsPatient’s Normal Daily Requirements

H2O : 35ml/kgs X 60 >>> 2100 ccH2O : 35ml/kgs X 60 >>> 2100 cc Na+ : 1mEq/kgs X 60 >>> 60mEqNa+ : 1mEq/kgs X 60 >>> 60mEq K+ : 1mEq/kgs X 60 >>> 60mEqK+ : 1mEq/kgs X 60 >>> 60mEq Cl- : 1.5mEq/mEq X 60 >>> Cl- : 1.5mEq/mEq X 60 >>>

90mEq90mEq HCO3-: 0.5mEq/mEq X 60 >>> HCO3-: 0.5mEq/mEq X 60 >>>

30mEq 30mEq

PRINCIPLES OF MANAGING FLUID, ELECTROLYTEPRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE

MAINTENANCE THERAPYMAINTENANCE THERAPY

Methods to calculate H20 maintenance Methods to calculate H20 maintenance requirementrequirement

1. Utilization of body water as a guide for H201. Utilization of body water as a guide for H20 Ex. 70 kg. x Ex. 70 kg. x 0.5 x 240.5 x 24 hrs + hrs + 500ml/24 hrs500ml/24 hrs = =

1340ml/24hrs1340ml/24hrs

2. It can be based on 2. It can be based on patient’s weightpatient’s weight (Pediatric (Pediatric Patients)Patients)

100 ml/kg for the first 10 kg of body weight100 ml/kg for the first 10 kg of body weight 50 ml/kg for the next 10 kg of body weight50 ml/kg for the next 10 kg of body weight 20 ml/kg for each additional kg of body 20 ml/kg for each additional kg of body

weightweight

PRINCIPLES OF MANAGING FLUID, ELECTROLYTEPRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE


Methods to calculate H20 maintenance Methods to calculate H20 maintenance requirement requirement

3. A given amount of water /kg body wt. can be 3. A given amount of water /kg body wt. can be

used.used. (35 ml/kg/24 hours)(35 ml/kg/24 hours)

4. A given amount of fluid regardless of wt. 4. A given amount of fluid regardless of wt. (125ml/hr)(125ml/hr)



IV Fluids would be as follows:IV Fluids would be as follows:

1. 1000 ml of 5% Dextrose in H2O + 1. 1000 ml of 5% Dextrose in H2O + 40mEq Kcl40mEq Kcl

2. 650 ml of 5% Dextrose in H20 + 20mEq 2. 650 ml of 5% Dextrose in H20 + 20mEq KClKCl

3. 450 ml of 5% Dextrose in Lactated 3. 450 ml of 5% Dextrose in Lactated Ringer’sRinger’s

solutionsolution



This would provide:This would provide:

2100 ml of Water2100 ml of Water

58.5mEq of Na+( 4.5 X 1.3mEq/dl LR58.5mEq of Na+( 4.5 X 1.3mEq/dl LR

61.8mEq of K+ (60mEq from 61.8mEq of K+ (60mEq from KCl+1.8mEq KCl+1.8mEq

109mEq of Cl( 60mEq from KCl + 109mEq of Cl( 60mEq from KCl + 49mEq49mEq

12.6mEq of HCO3( 4.5 X 2.8mEq/dl LR 12.6mEq of HCO3( 4.5 X 2.8mEq/dl LR



The same patient develops ileus. NGT was The same patient develops ileus. NGT was placed.placed.

Over 24 hours 1600 ml NGT bile stained fluidOver 24 hours 1600 ml NGT bile stained fluid was collected. Normal serum electrolytes.was collected. Normal serum electrolytes.

For For replacementreplacement she would she would require:require:

1600 ml 1600 ml D5LR solutionD5LR solution +10mEq +10mEq of KClof KCl


REPLACEMENT THERAPYREPLACEMENT THERAPY Her Her maintenance requirementmaintenance requirement would be the would be the

same same 1000 ml of 5% Dextrose in H2O + 30mEq 1000 ml of 5% Dextrose in H2O + 30mEq

KclKcl 1000 ml of 5% Dextrose in H20 + 30mEq 1000 ml of 5% Dextrose in H20 + 30mEq

KClKCl 2 liters of 5% Dextrose in Lactated Ringer’s2 liters of 5% Dextrose in Lactated Ringer’s solution + 10mEq KCl to each liter.solution + 10mEq KCl to each liter. Run at 170ml/hr( Run at 170ml/hr( 400400 maintenancemaintenance 600600

Replacement)Replacement)

OTHER COMMONLY USED FLUIDSOTHER COMMONLY USED FLUIDS

SOLUTIONSSOLUTIONS NA+ CONTENT NA+ CONTENT Cl CONTENTCl CONTENT USESUSES

3% NaCl INJ.3% NaCl INJ. 5151 5151 For symptomatic Na For symptomatic Na deficitdeficit

5% NACl INJ5% NACl INJ 8585 8585 SAME AS ABOVESAME AS ABOVE

14.9% KCl INJ14.9% KCl INJ

20 cc ampule20 cc ampule4040 4040 Additive for K+Additive for K+

Correction & Correction & maintenancemaintenance

7.5% NA2CO37.5% NA2CO3 44.644.6 44.644.6

HCO3HCO3

Additive for GIAdditive for GI

Losses; CorrectLosses; Correct

Metabolic AcidosisMetabolic Acidosis

COMMONLY USED PARENTERAL SOLUTIONSCOMMONLY USED PARENTERAL SOLUTIONS

SOLNS.SOLNS. Na+Na+ K+K+ Cl-Cl- HCO3-HCO3- Ca++Ca++ Principal UsesPrincipal Uses

0.9 NaCl0.9 NaCl 154154 154154 Correction of HyponatremiaCorrection of Hyponatremia

ECF ReplacementECF Replacement

0.45NaCl0.45NaCl 7777 7777 Na+ Maintenance; Gastric Fluid Na+ Maintenance; Gastric Fluid ReplacementReplacement

LactatedLactated

Ringer’s Ringer’s

SolutionSolution

130130 44 109109 2828 99 Best ECF Replacement; Correction of Best ECF Replacement; Correction of IsoosmolarIsoosmolar

DeficitDeficit

5% Dextrose5% Dextrose

In WaterIn WaterCorrection of insensible water loss; Correction of insensible water loss; Maintenance andMaintenance and

Correction of Hyperosmolar Correction of Hyperosmolar

DehydrationDehydration

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