This document discusses fluid, electrolyte and acid-base balance. It covers topics like fluid intake and output, water balance, sodium, potassium, calcium and acid-base balance. Key points include: - Infants and children have higher fluid requirements due to larger surface area and immature kidneys. - Fluid intake is around 2-3 liters per day for adults, with output through lungs, skin, feces and urine of around 1500ml per day. - Electrolyte abnormalities can cause various clinical symptoms and need to be treated by correcting underlying causes and restoring electrolyte levels slowly. - Acid-base balance is maintained through respiratory and renal systems to balance pH, PCO2

1. FLUID,ELECTROLYTE AND ACIDFLUID,ELECTROLYTE AND ACIDFLUID,ELECTROLYTE AND ACIDFLUID,ELECTROLYTE AND ACID
BASE BALANCEBASE BALANCEBASE BALANCEBASE BALANCE

3. FLUID,ELECTROLYTE AND ACID
BASE BALANCE
FLUID IN TAKE :
1) EXOGENOUS – 2 to 3 Litres /24 Hours
WATER REQUIREMENTS OF INFANTS AND CHILDREN ARE RELATIVELY
GREATER THAN THOSE OF ADULTS BECAUSE OF
THE LARGER SURFACE AREA PER UNIT OF BODY WEIGHT
THE GREATER METABOLIC ACTIVITY DUE TO GROWTH
THE COMPARATIVELY POOR CONCENTRATING ABILITY OF THE IMMATURE
KIDNEY
2) ENDOGENOUS - Normally Less than 500ml/24 Hour.
IT IS RELEASED DURING THE OXIDATION OF INGESTED FOOD.
HOWEVER DURING STARVATION,THIS AMOUNT IS SUPLEMENTED BY
WATER RELEASED FROM THE BREAKDOWN OF BODY TISSUES.

4. FLUID OUT PUT :
LUNGS – 400ml / 24 Hours
SKIN – 600ml to 1000ml / 24Hrs
FAECES – 60 to 150ml / 24 Hrs
URINE – Approx.1500ml 24Hrs
OLIGURIA – >300 ml / 24 Hours
ANURIA – Complete absence of Urine

5. WATER DEPLETION :
DIMINSHED INTAKE
PURE WATER DEPLETION
CLINICAL FEATURES :
WEAKNESS,INTENSE THIRST, SUNKEN EYES, DRY MUCUS
MEMBRANES,DECREASED URINE OUTPUT, LOW PULSE
PRESSURE, LOW B.P., CONFUSION.
CVP – Normal 3-8 cm H2O.
TREATMENT : USING NS OR 5%D SOLUTIONS OR
APPROPRIATE WATER REPLACEMENT FORMULAS.

6. WATER INTOXICATION
TURP SYNDROME
SIADH : SYNDROME OF INAPPROPIATE ANTIDIURETIC
HORMONE SECRETION
COLORECTAL WASH OUTS WITH PLAIN WATER INSTEAD OF
SALINE
CLINICAL FEATURES : DROWSINESS, WEAKNESS,
CONVULSIONS AND COMA.
NAUSEA AND VOMITING OF CLEAR FLUID, PASSING LARGE
AMOUNT OF DILUTE URINE.
TREATMENT : STOP INTAKE OF WATER.TRANSFER TO ICU.
TREAT WITH DIURETICS OR HYPERTONIC SALINE.
RAPID CHANGES IN SERUM SODIUM CONCENTRATION –
NEURONAL DEMYELINATION.

7. WATER BALANCE OF A HEALTHY
ADULT(70kg)
INTAKE:
WATER FROM BEVERAGE=1200ml
WATER FROM SOLID FOOD=1000ml
WATER FROM OXIDATION=300ml
OUTPUT:
URINE – 1500ml
SKIN – 500ml
INSENSIBLE LOSS
LUNGS – 400ml
FAECES – 100ml

8. NORMAL VALUES OF SERUM ELECTROLYES
Na+ - 133 to 144mmol/L
K+ - 3.5 to 5.3mmol/L
Cl- - 90 to 110mmol/L
HCO3
- -25mmol/L
Ca+ 8 to 10mg/dl.

9. SODIUM BALANCE
SODIUM – PRINCIPAL CATION OF ECF.
NORMAL VALUE (SERUM) 133-144 mmol/L
DAILY INTAKE – AVERAGE 1mmol/kg Nacl or
500ml ISOTONIC 0.9% SALINE SOLUTION.
CONTROL BY ADRENAL GLANDS.

10. HYPONATREMIA
SERUM SODIUM < 120mmol/L
CAUSES :
BOWEL OBSTRUCTION
FISTULAE
VOMITING
DIARRHOEA.
CLINICAL FEATURES :
CONFUSION, LETHARGY, DISORIENTATION
SEVERE(<120 mmol/L)-SEIZURES, COMA.

11. TREATMENT
HYPOVOLEMIC HYPONATREMIA :
1) GI FLUID OR BLOOD LOSS - REPLACE VOLUME USING
A CRYSTALLOID(0.9%NaCl or RL) OR A COLLOID.
HYPERVOLEMIC HYPONATREMIA :
1) CHF, CIRROHSIS,NEPHROTIC SYNDROME
2) TREAT THE DISORDER
3) Na RESTRICTION
4) DIURETUICS+WATER RESTRICTION

12. EUVOLEMIC HYPONATREMIA
1) SIADH
2) WATER RESTRICTION TO <1L/day.
RULE OF THUMB :
1. LIMIT THE CHANGE 1mmol/L OF SODIUM TO HALF OF THE
TOTAL DIFFERENCE IN THE FIRST 24 HRS.
2. RELATIVELY SLOW CORRECTION 0.5mmol/L PER Hour.
RAPID CORRECTION – PONTINE DEMYELINATION.

13. HYPERNATREMIA
CAUSES :
EUVOLEMIC HYPERNATREMIA
(PURE WATER LOSS)
SWEATING,FEVER,TACHYPNOEA, DIABETES INSIPIDUS.
HYPOVOLEMIC HYPERNATREMIA
(WATER DEFECIET IN EXCESS OF SODIUM DEFECIET)
BURNS, FISTULAS
HYPERVOLEMIC HYPERNATREMIA
(SODIUM GAIN IN EXCESS OF WATER GAIN)
EXCESSIVE 0.9% SALINE ADMINISTRATION,ADRENAL HYPER
FUNCTION.

14. CLINICAL FEATURES
SIGNS:
PUFFINES OF THE FACE. PITTING OEDEMA –
SACRAL REGION, 4.5 Litres OF EXCESS FLUID.
TREATMENT :
HYPOVOLEMIC HYPERNATREMIA
RESTORE ECF VOLUME BY 5%D OR 0.45%NS
HYPERVOLEMIC HYPERNATREMIA
DIURETICS
DIALYSIS IN PRESENCE OF RENAL FAILURE
EUVOLEMIC HYPERNATREMIA
WATER REPLACEMENT WITH 5%D

15. POTASSIUM BALANCE
POTASSIUM :
NORMAL RANGE 3.5 – 5.3 mmol /L POTASSIUM IS ALMOST
ENTIRLY INTRACELLULAR(98%) NORMAL ADULT GETS 1.0
mmol/kg of K+.
FRUIT,MILK AND HONEY ARE RICH SOURCES.
POTASSIUM DEPLETION :
THE AUGMENTED POTASSIUM EXCRETION OF TRAUMA -
DEGREE OF TISSUE DAMAGE IS DIRECTLY PROPORTIONAL
TO LOSS, IS GREATEST DURING THE FIRST 24 HRS AND
LASTS FOR 3 OR 4 DAYS.
HYPOKALEMIA REVEALS AFTER 48 HRS.

16. HYPOKALEMIA
SUDDEN HYPOKALEMIA :
DIABETIC COMA, TREATED BY INSULIN AND
PROLONGED INFUSION OF SALINE.
GRADUAL HYPOKALEMIA :
DIURETICS
DIARRHOEA
IBD
VILLOUS TUMOURS
EXTERNAL FISTULAE(GI)

17. CLINICAL FEATURES
CLINICAL FEATURES :
LISTLESSNESS,SLURRED SPEECH,MUSCULAR
HYPOTONIA,DEPRESSED REFLEXES,ABDOMINAL
DISTENTION(PARALYTIC ILEUS) RAPID SHALLOW
RESPIRATION.
DIAGNOSIS BY ECG :
PROLONGED QT INTERVAL,DEPRESSION OF ST
SEGMENT,FLATTENGING OR INVERSION OF T WAVE

18. TREATMENT
TREATMENT :
ORAL – MILK,MEAT,FRUIT JUICES,HONEY
POTASSIUM CHLORIDE 2G ORALLY 6TH HOURLY.
INTRAVENOUS :
RAPID CORRECTION-DYSRHYTHMIAS AND CARDIAC
ARREST.
40mmol Kcl to EACH 1 LITRE OF 5% D OR DNS OR
0.9% SALINE - 6 TO 8 HOURLY.

19. HYPERKALEMIA
HYPERKALEMIA :
BRADYCARDIC CARDIAC ARREST
MAJOR CAUSES :
RENAL TUBULAR ACIDOSIS
ADDISON’S DISEASE, CONGESTIVE HEART FAILURE.
DRUGS :
DIGOXIN, AMILORIDE, SPIRINOLACTONE,
TRIMETHOPRIM, NSAIDS, CYCLOSPORINE.

20. TREATMENT
1. CALCIUM GLUCONATE 10 ml OF 10% SOLUTION OVER 2-3
MIN WHEN K+>6.5
2. INSULIN+GLUCOSE 10 units REGULAR IV+50% DEXTROSE
3. NAHCo3 : 90 mmol(2 ampules IV PUSH OVER 5 MIN)
4. KAYEXALATE+SORBITOL
ORAL 30G WITH 20% SORBITOL RECTAL
50G IN 200ml 20% SORBITAL ENEMA RETAIN 45 MIN
5. FUROSEMIDE : 20-40mg 1V PUSH
6. DIALYSIS

21. CALCIUM BALANCE
CALCIUM :
EXTRA CELLULAR CATION
PLASMA CONCENTRATION OF 2.2-2.5mmol/L(8 to 10mg/dl)
IT EXIST IN THREE FORMS
1. BOUND TO PROTIEN
2. FREE NON IONISED
3. FREE IONISED
LAST FORM :
NECESSARY COMPONENT FOR BLOOD
COAGULATION AND FOR AFFECTING THE NEURO
MUSCULAR EXCITABILITY

22. HYPERCALCEMIA
HYPERCALCEMIA :
Ca LEVELS>2.9mmol/L(>11.5mg/dl)
CLINICAL FEATURES :
FATIGUE, DEPRESSION, CONFUSION, ANOREXIA, NAUSEA,
CONSTIPATION, POLYURIA, ARRHYTHMIAS
SEVERE HYPERCALCEMIA – 3.7 mmol/L(>15mg/dl)
MEDICAL EMERGENCY – COMA AND CARDIAC ARREST
CAUSES :
PARATHYROID ADENOMAS, MEN SYNDROMES, MULTIPLE MYELOMAS,
METASTASES(BREAST Ca), LUNG AND KIDNEY MALIGNANCIES, VITAMIN
D INTOXICATION.

23. BONES, STONES, ABDOMIAL GROANS
AND PSYCHIC MOANS
TREATMENT :
1. HYDRATION WITH SALINE(6L/day)
2. FORCED DIURESIS-FUROSEMIDE 4-12hourly ALONG WITH
AGGRESSIVE HYDRATION
3. BISPHOSPHONATES-PAMIDRONATE 30-90 mg IV OVER 4
HOURS
4. CALCITONIN-2-8 U/kg IV/IM 6-12 hrs
5. GLUCOCORTICOIDS - PREDINSONE 10-25mg qid
6. MITHRAMYCIN
7. DIALYSIS

24. HYPOCALCEMIA
CLINICAL FEATURES :
PERIPHERAL AND PERIORAL PARESTHESIA, MUSCLE
SPASMS, CARPOPEDAL SPASMS, LARYNGEAL SPASM,
SEIZURES, RESPIRATORY ARREST. TETANY. TROUSSEAU’S
SIGN, CHEVOSTEK’S SIGN
CAUSES :
BURNS, SEPSIS, ACUTE RENAL FAILURE, MASSIVE BLOOD
TRANSFUSIONS.
TREATEMENT :
1. 10ml OF 10% Ca gluconate given over 10 min
2. CALCIUM GLUCONATE IV 20 – 50ml OVER 8 HRS
HYPOPARATHYROIDISM :
Ca+VITAMIN D OR CALCITRIOL

25. MAGNESIUM
INTRA CELLULAR CATION
NORMAL LEVELS – 0.7 – 0.9mmol/L.
20mmol MAGNESIUM SULPHATE ADDED
TO 5% D OR NS SOLUTIONS TO TREAT
HYPOMAGNESEMIA.

26. ACID BASE BALANCE
PH NORMAL RANGE – 7.35 - 7.45
PH LOW ACIDOSIS
PH HIGH ALKALOSIS
PO2 :-NORMAL VALUE - 80-110 mmHg
PCO2 :-NORMAL VALUE - 35-45 mmHg
HCO3 :-NORMAL VALUE - 25 mmol/L

27. PH PCO2 HCO3
RESPIRATORY
ACIDOSIS
METABOLIC
ACIDOSIS
RESPIRATORY
ALKALOSIS
METABOLIC
ALKALOSIS

28. NORMAL RANGE OF PH 7.35-7.45
PCO2 :
PARTIAL PRESSURE OF CO2 IN THE BLOOD NORMAL VALUE
35-45mmHg or 4.1-5.6 K Pa
PO2 :
PARTIAL PRESSURE OF OXYGEN IN THE BLOOD NORMAL
VALUE - 80-110mmHg or 10.5 – 14.5 KPa
STANDARD BICARBONATE :
IS THE CONCENTRATION OF THE SERUM BICARBONATE
AFTER FULLY OXGENATED BLOOD HAS BEEN
EQUILIBRATED WITH CO2 at 40mmHg at 380C
NORMAL LEVELS :
22-25mmol/Litre

29. ALKALOSIS
METABOLIC ALKALOSIS :
BASE EXCESS OR ACID DEFICIT
1. EXCESSIVE INGESTION OF ABSORBABLE ALKALI
2. LOSS OF ACID FROM STOMACH :VOMITING OR
ASPIRATION
3. CORTISONE EXCESS – CUSHING’S SYNDROME
COMPENSATION :
A. RETENTION OF CO2 BY LUNGS
B. EXCREATION OF BICARBONATE BASE BY THE
KIDNEYS(ALKALINE URINE)

30. CLINICAL FEATURES
ALKALOSIS DUE TO LOSS OF ACID,MOST COMMON
PYLORIC STENOSIS
SEVERE ALKALOSIS : CHEYNE STOKES BREATHING
WITH PERIODS OF APNOEA (5 TO 30seconds),
TETANY.
RENAL EPITHELIAL DAMAGE – RENAL
INSUFFICIENCY.
TREATMENT :CORRECT THE UNDERLYING CAUSE,
ENCOURAGE HIGH URINARY OUTPUT.

31. HYPOKALEMIC ALKALOSIS :VOMITING LEADS
TO LOSS OF POTASSIUM & LOW SERUM K+ . K+
LEAVES THE CELL TO ENTER THE SERUM IN
EXCHANGE FOR Na+ & H+ IONS WHICH CAUSE
INTRACELLULAR ACIDOSIS.
TREATMENT : CORRECT HYPOKALEMIA
IV FLUIDS + 40mmol/L OF KCL IF THE URINE
OUTPUT IS ADEQUATE
MORE RAPID CORRECTION WITH ECG MONITERING

32. RESPIRATORY ALKALOSIS
PCO2 IS BELOW 35 – 45 mmHg.
EXCESSIVE PULMONARY VENTILATION.
HYPER VENTILATION ON AN ANAESTHETIZED
PATIENT, HIGH ALTITUDE, HYPER PYREXIA,
HYPOTHALAMUS LESION, HYSTERIA.
COMPENSATION : RENAL EXCREATION OF
BICARBONATE.
ANAESTHESIA ALKALOSIS :PALOR, FALL IN BP,
RESPIRATORY ARREST.
TREATMENT : INSUFFLATION OF CO2.

33. ACIDOSIS
METABOLIC ACIDOSIS :
EXCESS OF ACID OR DEFECIT OF BASE
INCREASE IN FIXED ACIDS :
KETOACIDOSIS, DIABETES OR STARVATION, RENAL
INSUFFICIENCY.
IN CARDIAC ARREST, INCREASED LACTIC AND PYRUVIC
ACIDS – ANAEROBIC TISSUE METABOLISM.
ACUTE ACIDOSIS PH>7.1
LOSS OF BASES :
SUSTAINED DIARRHOEA, ULCERATIVE COLITIS,
GASTROCOLIC FISTULAE, HIGH INTENSTINAL FISTULAE.

34. CLINICAL FEATURES :
RAPID,DEEP,NOISY BREATHING. INCREASE IN PH STIMULATION OF
RESPIRATORY CENTRE HYPERPNOEA
URINE IS STRONGLY AICIDIC
TREATMENT :
1) CORRECT TISSUE HYPOXIA AND TISSUE PERFUSION FIRST.
2) TREATMENT WITH BICARBONATE SOLUTIONS WILL CORRECT
THE MEASURED ACIDOSIS BUT NOT THE PROBLEM
ACUTE ACIDOSIS IN M.I. REQUIRES INFUSION OF 50mmol of
8.4% NaHCO3 SOLUTION.

35. RESPIRATORY ACIDOSIS
PCO2 THE NORMAL RANGE.
IMPAIRED ALVEOLAR VENTILATION.
PULMONARY DISEASES LIKE CHRONIC BRONCHITIS, EMPHYSEMA ARE
EXAMPLES OF CHRONIC CAUSES
ACUTE CAUSES INCLUDE,CEREBRAL DISEASE,GUILLAINE – BARRE
SYNDROME,MYASTHENIA GRAVIS, CARDIOPULMONARY ARREST
CLINICAL FEATURES :
CONFUSION, MYOCLONUS, PAPILLOEDEMA & WARM EXTREMETIES WITH
BOUNDING PULSE.
TREATMENT : TREAT THE UNDERLYING CAUSE.
IMPROVE THE VENTILATION.
ACUTE RESPIRATORY ACIDOSIS :ENDO TRACHEAL INTUBATION
+MECHANICAL VENTILATION.

36. THANK YOU