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Fluids and electrolytes2015



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Fluids and electrolytes2015

  1. 1. Fluids & ElectrolytesFluids & Electrolytes Dr. Faiez AlhmoudDr. Faiez Alhmoud Albashir Teaching HospitalAlbashir Teaching Hospital
  2. 2. Why do we care about fluids in theWhy do we care about fluids in the body?body?
  3. 3. Fluids factsFluids facts Over 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,, andand 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
  5. 5. Body Fluid : FunctionBody Fluid : Function – Transport nutrients to the cells and carriesTransport nutrients to the cells and carries waste products away from the cells (cellwaste products away from the cells (cell functionfunction – Maintains blood volumeMaintains blood volume – Regulates body temperatureRegulates body temperature – Serves as aqueous medium for cellularServes as aqueous medium for cellular metabolismmetabolism – Assists in digestion of food through hydrolysisAssists in digestion of food through hydrolysis
  6. 6. So where are theseSo where are these fluids kept?fluids kept?
  7. 7. Compartments ofCompartments of Body FluidsBody Fluids Intercellular Intravascular Interstitial 40% 16% 4% Body Water = 60% of a patient’s body weight blood
  8. 8. Compartments…Compartments… Intracellular (ICF)Intracellular (ICF) – Fluid within the cells themselvesFluid within the cells themselves – The most stable & least susceptible to fluidThe most stable & least susceptible to fluid shiftsshifts – 2/3 of body fluid2/3 of body fluid – High in KHigh in K ,, Phosphors, Mg. & proteinPhosphors, Mg. & protein – Located primarily in skeletal muscle massLocated primarily in skeletal muscle mass – Assists in cellular metabolismAssists in cellular metabolism 99
  9. 9. ……CompartmentsCompartments Extracellular (ECF)Extracellular (ECF) – 1/3 of body fluid1/3 of body fluid – High in Na, Cl, Ca, Glucose, fatty &amino-acidsHigh in Na, Cl, Ca, Glucose, fatty &amino-acids – Comprised ofComprised of 3 major components3 major components ** Intravascular: =4% =3lit.,Intravascular: =4% =3lit.,least stable, mostleast stable, most susceptible to fluid shift (Plasma=90%H2O)susceptible to fluid shift (Plasma=90%H2O) ** Interstitial: =16%=10lit.,Interstitial: =16%=10lit., reserve fluid, replacingreserve fluid, replacing intravascular or intracellular as needed (Fluid inintravascular 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
  10. 10. 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 inPotential to increase significantly in abnormal conditionsabnormal conditions 1111
  11. 11. MOVEMENT OF BODY FLUIDS OsmosisOsmosis-- waterwater moves through semi permeablemoves through semi permeable membrane from dilutedmembrane from diluted to concentrated solutionto concentrated solution DiffusionDiffusion-- dissolved particles.dissolved particles. Eg.gut absorptionEg.gut absorption FiltrationFiltration-- water and dissolvedwater and dissolved. move through. move through membrane from solution having higher hydrostaticmembrane from solution having higher hydrostatic pressure Eg. (water and solute move out of the blood atpressure Eg. (water and solute move out of the blood at the arterial end of the capillary to the interstitial fluid bythe arterial end of the capillary to the interstitial fluid by filtrationfiltration Active transport-Active transport- ionsions move from the area ofmove from the area of lesserlesser concentration to area ofconcentration to area of greatergreater concentrationconcentration by energyby energy Eg. Enzymes ,nutritients &potassiumEg. Enzymes ,nutritients &potassium Hydrostatic pressure-Hydrostatic pressure- the pressure created by thethe pressure created by the weight of fluidweight of fluid against the wall that contains it.against the wall that contains it. Oncotic pressure-Oncotic pressure- or colloid osmotic pressure, that usuallyor colloid osmotic pressure, that usually tends to pulltends to pull waterwater into the circulatory system.into the circulatory system.
  12. 12. osmosis
  13. 13. DiffusionDiffusion
  14. 14. Water ConflictWater Conflict
  15. 15. 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
  16. 16. 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
  17. 17. Fluid shifts / loses Intracellular 30 litres Interstitial 9 litres Intravascular 3 litres Kidneys Guts Lungs Skin Extracellular fluid - 12 litres
  18. 18. 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
  19. 19. Regulation of Fluid Balance Fluid intakeFluid intake Fluid outputFluid output Hormonal influenceHormonal influence Lymphatic influencesLymphatic influences Neurologic influencesNeurologic influences Renal influencesRenal influences
  20. 20. ↓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 HORMONEANTIDIURETIC HORMONE REGULATION MECHANISMSREGULATION MECHANISMS
  21. 21. 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- convertingconverting enzymeenzyme ALDOSTERONE Intestine, sweat glands, Salivary glands Via vasoconstriction of arterial smooth muscle ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM
  22. 22. ALDOSTERONE-RENIN-ANGIOTENSINALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMSYSTEM Renal sympathetic nerves Renin-angiotensin- aldosterone system Atrial natriuretic peptide (ANP)
  23. 23. Fluid Volume ShiftsFluid Volume Shifts Fluid normally shifts between intracellularFluid normally shifts between intracellular and extracellular compartments toand extracellular compartments to maintain equilibrium between spacesmaintain equilibrium between spaces Fluid not lost from body but not availableFluid 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
  24. 24. Third SpacingThird Spacing Accumulation and sequestration of trappedAccumulation and sequestration of trapped extracellular fluid in a body spaceextracellular fluid in a body space This fluid is a volume loss and it’sThis 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
  25. 25. EdemaEdema The excess accumulation of fluid in theThe excess accumulation of fluid in the interstitial space.interstitial space. Causes include surgery, accidents, andCauses include surgery, accidents, and trauma.trauma. Anasarca is generalized body edemaAnasarca is generalized body edema
  26. 26. Save Water, Save LifeSave Water, Save Life
  27. 27. RememberRemember Fluids and electrolytesFluids and electrolytes always want to shift fromalways want to shift from an area of higheran area of higher concentration to an area ofconcentration to an area of lower concentration tolower concentration to equilibrateequilibrate
  28. 28. FLUID IMBALANCES There are five types of fluid imbalances thatThere 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)
  29. 29. EXTRACELULLAR FLUID VOLUME DEFICIT An ECFVD, commonly called asAn 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 lossAn ECFVD can result in cellular fluid loss if it is sudden or severeif it is sudden or severe
  30. 30. THREE TYPES OF ECFVDTHREE TYPES OF ECFVD Hyperosmolar fluid volume deficit-Hyperosmolar fluid volume deficit- water loss is greater than the electrolytewater loss is greater than the electrolyte lossloss Iso-osmolar fluid volume deficitIso-osmolar fluid volume deficit – equal– equal proportion of fluid and electrolyte lossproportion 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
  31. 31. ETIOLOGY AND RISK FACTORS (EVFVD)(EVFVD) Severe vomitingSevere vomiting DiaphoresisDiaphoresis Traumatic injuriesTraumatic injuries Third space fluid shiftsThird space fluid shifts [ intestinal obst., pleural&[ intestinal obst., pleural& pertonial cavity]pertonial cavity] FeverFever Gatrointestinal suctionGatrointestinal suction IleostomyIleostomy FistulasFistulas BurnsBurns HyperventilationHyperventilation Decresed ADH secretionsDecresed ADH secretions Diabetes insipidusDiabetes insipidus Addison’s disease orAddison’s disease or adrenal crisisadrenal crisis Diuretic phase of acuteDiuretic phase of acute renal failurerenal failure Use of diureticsUse of diuretics
  33. 33. CLINICAL MANIFESTATION(EVFVD)(EVFVD) ThirstThirst Muscle weaknessMuscle weakness Dry mucus membrane; dryDry mucus membrane; dry cracked lips or dry tonguecracked lips or dry tongue Apprehension , restlessness,Apprehension , restlessness, headache , confusion, comaheadache , confusion, coma in severe deficitin severe deficit Elevated temperatureElevated temperature Tachycardia, weak threadyTachycardia, weak thready pulsepulse Decreased number andDecreased number and moisture in stoolsmoisture in stools Weight lossWeight loss Peripheral vein fillingPeripheral vein filling> 5> 5 Narrowed pulse pressure,Narrowed pulse pressure, decreased CVP&PCWPdecreased CVP&PCWP Flattened neck veins inFlattened neck veins in supine positionsupine position Oliguria<30ml/hOliguria<30ml/h Postural systolic BP fallsPostural systolic BP falls >>25mm Hg and diastolic fall25mm Hg and diastolic fall >> 20 mm Hg , with pulse20 mm Hg , with pulse increasesincreases >> 3030 Eyeballs soft and sunkenEyeballs soft and sunken (severe deficit)(severe deficit)
  34. 34. Clinical assessment of degree ofClinical 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 (<3seconds) Normal (<3seconds) Delayed (≤3seconds) 5-Urine output Normal Slightly decreased Decreased or absent 6-Mental status Normal Slightly fussy Irritable or lethargic
  35. 35. Dehydration in ChildrenDehydration in Children
  36. 36. Degrees Of Dehydration in adults Mild=2%of total body water ~ 1-1.4lit ThirstThirst Marked=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 ~ 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 fatal AnuriaAnuria Coma leading to deathComa leading to death
  37. 37. LABORATORY FINDINGS (EVFVD)(EVFVD) Increased osmolality(Increased osmolality(>> 295 mOsm/ kg)295 mOsm/ kg) Increased or normal serum sodium levelIncreased 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)
  38. 38. MANAGEMENT (EVFVD)(EVFVD) Mild fluid volume loss can be corrected withMild 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 hoursintake to 2500 ml in 24 hours
  39. 39. MANAGEMENT (EVFVD)(EVFVD) Estimate Fluid DeficitEstimate Fluid Deficit (% :- Mild, Moderate, Severe).(% :- Mild, Moderate, Severe). Find Type of DehydrationFind 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 16Half 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).
  40. 40. If haemorrhage is the cause for ECFVD Packed red cells followed by hypotonic IVPacked red cells followed by hypotonic IV fluids is administeredfluids is administered In situations where the blood loss is lessIn situations where the blood loss is less than 1 L Normal Saline or Ringer lactatethan 1 L Normal Saline or Ringer lactate may be usedmay be used Patients with severe ECFVD accompaniedPatients with severe ECFVD accompanied by severe heart , liver, or kidney diseaseby severe heart , liver, or kidney disease cannot tolerate large volumes of fluid andcannot tolerate large volumes of fluid and sodium & need monitoring (sodium & need monitoring (CVP)CVP)
  41. 41. EXTRACELLULAR FLUID VOLUME EXCESS ECFVE isECFVE is increased fluidincreased fluid retention in theretention in the intravasular andintravasular and interstitial spacesinterstitial spaces
  42. 42. ETIOLOGY AND RISK FACTORS(EVFVE) Heart failureHeart failure Renal failureRenal failure Cirrhosis of liverCirrhosis of liver Increased ingestion of high sodium foodsIncreased ingestion of high sodium foods Excessive amount of IV fluids containingExcessive amount of IV fluids containing sodiumsodium Electrolyte free IV fluidsElectrolyte free IV fluids SepsisSepsis Decreased colloid osmotic pressureDecreased colloid osmotic pressure Lymphatic and venous obstructionLymphatic and venous obstruction Cushing’s syndrome & glucocorticoidsCushing’s syndrome & glucocorticoids
  43. 43. CLINICAL MANIFESTATION (EVFVE)(EVFVE) Constant irritating coughConstant irritating cough Dyspnoea & crackles in lungsDyspnoea & crackles in lungs Cyanosis, pleural effusionCyanosis, pleural effusion Neck vein distentionNeck vein distention Bounding pulse &elevated BPBounding pulse &elevated BP S3 gallopS3 gallop Pitting & anasacra edemaPitting & anasacra edema Weight gainWeight gain Increased CVP& PCWPIncreased CVP& PCWP Change in level of consciousnessChange in level of consciousness
  44. 44. 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]
  45. 45. MANAGEMENT (EVFVE)(EVFVE) Diuretics [combination of potassiumDiuretics [combination of potassium sparing and potassium depletingsparing and potassium depleting diuretics]diuretics] In people with CHF: ACE inhibitors andIn people with CHF: ACE inhibitors and low dose of beta blockers are usedlow dose of beta blockers are used A low sodium dietA low sodium diet
  46. 46. EXTRACELLULAR FLUID VOLUME SHIFT: THIRD SPACING(shift) Fluid that shifts into nonfunctioningFluid that shifts into nonfunctioning spaces and remain there is called asspaces and remain there is called as third space fluidthird space fluid Common sites are abdomen , pleuralCommon sites are abdomen , pleural cavity, peritoneal cavity and GI lumencavity, peritoneal cavity and GI lumen
  47. 47. RISK FACTORS(shift) Crushing injuries, major tissue traumaCrushing injuries, major tissue trauma Major surgeryMajor surgery Extensive burnsExtensive burns PancreatitisPancreatitis Perforated peptic ulcers - peritonitisPerforated peptic ulcers - peritonitis Intestinal obstructionIntestinal obstruction Lymphatic obstructionLymphatic obstruction HypoalbumenemiaHypoalbumenemia
  48. 48. CLINICAL MANIFESTATION(shift) skin pallorskin pallor Cold extremitiesCold extremities Weak and rapid pulseWeak and rapid pulse HypotensionHypotension OliguriaOliguria Decreased levels of consiousnessDecreased levels of consiousness LAB INVESTIGATION Elevated hematocrit & BUN levelElevated hematocrit & BUN level As in the iso-osmolarAs in the iso-osmolar
  49. 49. MANAGEMENT(shift) Treat the cause • For burns and tissue injuries large volumeFor 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 majorIV fluid intake is maintained after major surgery to maintain kidney perfusionsurgery to maintain kidney perfusion • Paracentesis or tapping for ascitis orParacentesis or tapping for ascitis or pleural effusionpleural effusion
  50. 50. INTRACELLULAR FLUID VOULME EXCESS:WATER INTOXICATION ICFVE is increase in amount of waterICFVE is increase in amount of water inside the cellsinside the cells
  51. 51. ETIOLOGY (ICFVE) Administration of excessive amount ofAdministration of excessive amount of hyposmolar IV fluids[0.45%saline orhyposmolar IV fluids[0.45%saline or 5%dextrose in water]5%dextrose in water] Consumption of excessive amount of tapConsumption 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 ADHSIADH results from innapropriate ADH secretion resulting in innapropriatesecretion resulting in innapropriate retention of ingested/infused waterretention of ingested/infused water
  52. 52. CLINICAL MANIFESTATIONS (ICFVE) HeadachesHeadaches Behavioral changesBehavioral changes ApprehensionApprehension Irritability, disorientation and confusionIrritability, disorientation and confusion Increased ICP – pupillary changes andIncreased ICP – pupillary changes and decreased motor and sensory functiondecreased motor and sensory function Bradycardia, elevated BP, widened pulseBradycardia, elevated BP, widened pulse pressure & altered respiratory patterns,pressure & altered respiratory patterns, Babinski’s response flaccidity, projectileBabinski’s response flaccidity, projectile vomiting, papilledema, delirium, convulsionsvomiting, papilledema, delirium, convulsions &coma&coma
  53. 53. LABORATORY FINDINGS (ICFVE) Low serum sodium level- 125 mEq/LLow serum sodium level- 125 mEq/L decreased hamatocritdecreased hamatocrit
  54. 54. MANAGEMENT (ICFVE) Early administration of IV fluids containingEarly administration of IV fluids containing sodium chloride can prevent SIADHsodium chloride can prevent SIADH oral fluids such as juices or soft drinks can beoral fluids such as juices or soft drinks can be given orally every hourgiven orally every hour Perform neurologic checks every hour to see ifPerform neurologic checks every hour to see if cranial changes are presentcranial changes are present Monitor fluid intake , IV fluids and fluid outputMonitor fluid intake , IV fluids and fluid output hourly and weight dailyhourly and weight daily Administer antiemetics for food and fluidAdminister antiemetics for food and fluid retentionretention
  55. 55. INTRACELLULAR FLUID VOLUME DEFICIT Severe hypernatremia and dehydrationSevere hypernatremia and dehydration can cause ICFVDcan cause ICFVD Relatively rare in healthy adultsRelatively rare in healthy adults Common in elderly people and in thoseCommon in elderly people and in those conditions that result in acute water lossconditions that result in acute water loss Symptoms include confusion, coma, andSymptoms include confusion, coma, and cerebral hemorrhagecerebral hemorrhage
  56. 56. Assessment of fluid andAssessment of fluid and Electrolytes Imbalance;Electrolytes Imbalance; Observation of general condition of the patient,Observation of general condition of the patient, includingincluding vital signsvital signs,, neck veinsneck veins,, skinskin, and, and mucous membranesmucous membranes,, weightweight,, presence ofpresence of edemaedema andand appetite.appetite. Type of fluid lost.Type of fluid lost. Character and volume of urine & specific gravityCharacter 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.
  57. 57. 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. needsHyponatremic pt. needs NSS or hypertonic salineNSS or hypertonic saline Hypernatremic pt. needsHypernatremic pt. needs – D5W or hypotonic salineD5W or hypotonic saline
  58. 58. Hypo versus HyperHypo versus Hyper
  60. 60. 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 ?
  61. 61. MAINTENANCE THERAPY.. Maintenance therapy is usually undertakenMaintenance therapy is usually undertaken when the individual is not expected to eat orwhen 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 8-12Big picture: Most people are “NPO” for 8-12 hours each day.hours each day. Patients who won’t eat for > one to two weeksPatients who won’t eat for > one to two weeks should be considered for parenteral or enteralshould be considered for parenteral or enteral nutrition.nutrition.
  62. 62. ..MAINTENANCE THERAPY water requirements increase with:water requirements increase with: fever, sweating, burns, tachypnea, surgicalfever, sweating, burns, tachypnea, surgical drains, polyuria, or ongoing significantdrains, polyuria, or ongoing significant gastrointestinal lossesgastrointestinal losses.. For example, water requirementsFor example, water requirements increase byincrease by 100 to 150 mL/day100 to 150 mL/day for each C degree of bodyfor each C degree of body temperature elevation.temperature elevation.
  63. 63. ..MAINTENANCE THERAPY 4/2/1 rule4/2/1 rule 4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24h4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24h then 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/24h then 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 kg then 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 IVWeight 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
  64. 64. Electrolytes
  66. 66. Serum Values of Electrolytes Cations (+)Cations (+) ConcentrationConcentration SodiumSodium 135 – 145 mEq/L135 – 145 mEq/L PotassiumPotassium 3.5 - 4.5 mEq/L3.5 - 4.5 mEq/L CalciumCalcium 9-10.5 mg/dL9-10.5 mg/dL MagnesiumMagnesium 1.5 - 2.5 mEq/L1.5 - 2.5 mEq/L Anions (-)Anions (-) ChlorideChloride 95 – 107 mEq/L95 – 107 mEq/L CO2CO2 24 – 30 mEq/L24 – 30 mEq/L PhosphatePhosphate 2.5 - 4.5 mEq/L2.5 - 4.5 mEq/L HCOHCO33 22 – 26 mEq/LmEq/L
  67. 67. Location of Ions Intracellular Ions Mg++ K+ Ph- Cl- Na+ Ca++ Extracellular Ions
  68. 68. 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
  69. 69. Sodium imbalance s Definiti on Risk factors/ etiology Clinical manifestation Laboratory findings management Hyponat raemia     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
  70. 70. CLINICAL MANIFESTATIONS OF HYPONATREMIACLINICAL MANIFESTATIONS OF HYPONATREMIA Muscle Weakness Apathy Postural hypotension Nausea and Abdominal Cramps Weight Loss In severe hyponatremia: mental confusion, delirium, shock and coma
  71. 71. Sodium imbalan -ce Definiti on causes Clinical manifestation Lab findings management Hypernat -remia It is define d as plasm a sodiu m level greate r than 145m E q/L *Ingestion of large amount of concentrated salts *Iatrogenic administratio n of hypertonic saline IV *Excess alderosteron e 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 osmolality295 mO 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
  72. 72. CLINICAL MANIFESTATIONS of HYPERNATREMIA Thirst Dry & sticky mucous membranesThirst Dry & sticky mucous membranes Firm, rubberyFirm, rubbery tissue turgortissue turgor Manic excitementManic excitement TachycardiaTachycardia DEATHDEATH
  73. 73. Potassium imbalances Definitio n Causes Clinical manifestation Lab findings Management Hypokale mia It is defined as plasma potassiu m 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]
  74. 74. Definition Causes Clinical manifestation Lab findings Management Hyperk alemia It is defined as the elevation of potassiu m 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 activity[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 myocardium 2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake 3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema
  75. 75. Calcium imbalan ces Definitio n Causes Clinical manifestation Lab finding s Management hypoc alcemi a It is a plasma calcium level below 8.5 mg/dl •Rapid administration of blood containing citrate, •hypoalbuminemi a, •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 calciu m less than 4.3 mEq/L and ECG change s 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
  77. 77. Calcium imbalance Definition Causes Clinical manifestation Lab findings Management Hyperc alcemia It is calcium plasma level over 5.5 mEq/l or 11mg/dl •Hyperparathy roidism,   •Metastatic bone tumors,   •paget’s disease, •osteoporosis , •prolonged immobalisatio n •Decreased muscle tone, •anorexia,   •nausea, vomiting, •weakness , lethargy,   •low back pain from kidney stones, •decreased level of consciousnes s & cardiac arrest •High serum calcium level 5.5mEq/L, • x- ray showing generalized osteoporosis, •widened bone cavitation, •urinary stones, •elevated BUN 25mg/100ml, •elevated creatinine1.5 mg/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
  79. 79. Thank Thank ouou

Notas del editor

  • So why do we care about fluids in the body, anyway? Over half of our body weight is fluid material, greater than ¾ in an infant is fluid. In adults, a loss of just 1/5 of your body fluid weight can be fatal. That is how marathon runners who are not adequately hydrated die in mile 21. Excellent shape, indeed, but the loss of fluids and electrolytes through perspiration on a very hot, humid day did them in.
    Our elderly patients are even more at risk. Why do you think that is? Certainly, they have less muscle mass. This also means that a smaller amount of fluid loss can and will be detrimental.
  • So where are these fluids kept?
    As you may remember from your anatomy and physiology classes, body fluids are divided between the intracellular and extracellular department.
    As you can see from the slide here, most of your body fluid is found in the intracellular department. ICF assists in cellular metabolism, and is high in potassium, phosphors, and protein.
  • The extracellular component of body fluids is about 33% of the total body fluid mass.
    ECF is divided into three major components:
    Intravascular – the fluid within the blood vessels. Plasma accounts for about half of the total blood volume of the body,
    Interstitial – the fluid that surrounds the cells – an example of interstitial fluid is lymph,
    And finally,
    Transcellular fluid – which is fluid found in the cerebrospinal column, pericardial envelope, synovial joints, or intraocular space
    Plasma: 93% water (&amp; 7% ‘plasma solids’)
    Fat: 10-15% water
    Bone: 20% water
  • Finally, there is the transcellular component, which accounts for less than 1 liter in an adult.
    Who remembers where transcellular fluid comes from?
    Cerebrospinal, pericardial, synovial, intraocular, pleural fluids, sweat, digestive secretions
    Even though this is a very small amount of fluid, imagine what would happen if the pericardial sack was punctured and all the fluid leaked out. Would your heart contract appropriately?
  • Fluid losses in disease and in health are those that can be seen and measured, and those that cannot; the latter are insensible losses.
    Any fluid lost from the body is potentially in need of replacement, be it urine, stool, or fluid from drains, or other tubes. If possible, measuring these losses is a great help.
    Insensible losses make up about 500 ml a day in health. In febrile illnesses, insensible losses increase by 100 ml / day / degree centigrade.
  • The majority of our total body water is locked within our cells; this is the intracellular compartment. Bathing our cells, and occupying extracellular spaces such as the pleural cavity, joint spaces etc., is a smaller amount of interstitial water. Our intravascular compartment holds the smallest amount of water at around 3 litres ( a further 2 litres of red cells makes up our total blood volume ). The interstitial and intravascular compartments make up our extracellular space.
    Water moves freely between these compartments, but in our day to day use, fluids can only be given into, or taken from the vascular space.
    Fluid losses occur mainly from the vascular compartment as well. We lose water through our renal and gastrointestinal tracts, and this can be seen and measured. The water we lose from our skin and respiratory tract can not be measured with ease, and makes up our insensible losses. These amount to 500 ml a day in health ( on average ), and increase in sickness, particularly when febrile.
  • If you see a decrease in urine output without a decrease with the client’s input, and the urine is becoming more concentrated (therefore, you have an increase in urine mOsm and urine specific gravity) – you might begin to suspect that your client is third spacing.
    This fluid is not available for use, so therefore the kidneys are not receiving as much blood as usual. They attempt to compensate by concentrating urine.
  • What IV fluid to give, in what situation is dealt with in the next series of slides. There are some basic rules though:
    1. Someone with serious intravascular volume depletion, hypotension and reduced cardiac output is shocked, be it from blood loss ( eg. haemorrhage ), plasma loss ( eg. major burns ), or water loss. The aim here is to restore intravascular volume with a fluid that remains in the vascular compartment, and may even draw water from the intracellular space, into the blood system. A fluid with a high oncotic pressure would do this job. Blood remains the fluid of choice to treat someone with blood loss. Colloid is the fluid of choice in resuscitation when blood loss is not pronounced, or whilst waiting for blood.
    2. Any crystalloid will enter the vascular space, then distribute around the other compartments. By containing sodium, the main extracellular cation, saline will expand the interstitial and intravascular compartments more than will dextrose, most of which will enter the intracellular space.
    Several examples follow.
  • The aim of fluid administration is the maintenance of organ perfusion by keeping total body water at 55 - 60% - this is the euvolaemic state.
    Hypovolaemia, when total body water is deficient is not compatable with normal organ perfusion; hypervolaemia, when body water is in excess, is occasionally necessary for organ perfusion, but is usually deleterious.
    In order to assess how much fluid to give to someone, we need to know what their level of hydration is, what losses they may expect, and what gains they may receive.
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