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Fluid and Electrolyt.. Fluid and Electrolyt.. Presentation Transcript

  • Fluid and Electrolyte Physiology Dr. Raymon Grogan 11/6/06
  • Total Body Fluid by Compartment Total Body Water
  • Electrolyte Composition of Body Fluid Compartments
  • Composition of Parenteral Fluids (mEq/L) 7.4 145 5% Albumin 4.5 855 855 5% NaCl 4.5 513 513 3% NaCl 4.5 30 30 .2% NaCl 4.5 77 77 .45% NaCl 4.5 154 154 .9% NaCl 6.5 28 109 2.7 4 130 LR 7.4 27 103 5 4 142 ECF pH HCO3- Cl- Ca2+ K+ Na+ Fluid
  • Composition of GI Fluids (mEq/L) 0 40-60 5-10 20-70 200-1000 Sweat 0 30 30 75 200-1500 LB 25-50 100 20 140 2000-5000 SB 40 100 5-10 140 1000 Bile 40-100 60-90 5-10 140 1000 Panc 0 100 15 60-80 1000-2000 Gastric 30 70 20 30-80 1000 Saliva HCO3- Cl- K+ Na+ Daily Loss Source
  • Hyponatremia
    • Defined as serum [Na+] less than 136 mEq/L
    • Water shifts into cells causing cerebral edema
    • 125 mEq/L – nausea and malaise
    • 120 mEq/L – headache, lethargy, obtundation
    • 115 mEq/L – seizure and coma
  • Hyponatremia
    • 1. Assess plasma osmolality
    • 2. Assess volume status of patient
      • Hypervolemic, Euvolemic, Hypovolemic
    • 3. Assess Urine Sodium Concentration
      • Needed for definitive diagnosis, not needed for treatment purposes
    • 4. Calculate Na+ Deficit
      • 0.6 x weight (kg) x (130 – plasma [Na+])
    • 5. Correct at no more than 0.5mEq/L per hour or 12 mEq/L per 24 hours
  • Isosmotic and Hyperosmotic Hyponatremia
      • Iso and Hyperosmotic hyponatremia are due to excessive solutes in plasma.
      • Isosmotic
        • Pseudohyponatremia – No treatment necessary
          • Hyperlipidemia
          • Hyperproteinemia
        • Isotonic Infusions
          • Glycine
          • Mannitol
      • Hyperosmotic – Treat underlying cause
        • Hyperglycemia
          • Each 100 mg/dl of glucose reduces [Na+] by 1.6 mEq/l
        • Hypertonic Infusions
          • Glycerol
          • Mannitol
          • Glycine
  • Hyposmotic Hyponatremia
    • 1. Assess volume status
      • Hypervolemic – cirrhosis, heart failure, nephrotic syndrome
      • Euvolemic – polydipsia, SIADH
      • Hypovolemic – most common cause
        • Excessive renal (diuretic) or GI (emesis, diarrhea) losses
  • Treatment of Hyponatremia
    • Iso or Hyperosmotic
      • Correct underlying disorder
    • Hyposmotic
      • Iso or hypervolemic – fluid restriction
      • Hypovolemic
        • Asymptomatic – fluid resuscitate with isotonic saline
        • Symptomatic or plasma [Na+] less than 110 mEq/L
          • Calculate Na+ deficit
          • Correct at a rate no greater than 0.5 mEq/L/hour or 12 mEq/L/day
  • Correction of Sodium Deficit
    • Example: A 60 kg woman with a plasma sodium concentration of 120mEq/L:
    • Sodium deficit = TBW x (130 – [Na+]p)
    • Sodium deficit = 0.5 x 60 x (130-120) = 300mEq
    • 3% NaCl contains 513 mEq sodium/L
    • Volume of 3% NaCl needed = 300/513 = 585 mL
    • At 0.5 mEq/L/hr a correction of 10 mEq should be done over 20 hours
    • So, 585 mL/20 hours = 29 mL/hour of 3% NaCl
  • Hypernatremia
    • Defined as serum [Na+] greater than 146 mEq/L
    • Lethargy, weakness, and irritability that progress to seizure, coma, and death
    • Usually occurs in adults with altered mental status or no access to water
  • Hypernatremia
    • 1. Assess volume status
    • 2. Measure urine [Na+]
    • 3. Calculate water deficit
      • 0.6 x weight (kg) x ([Na+]/140 -1)
    • 4. Correct with free water no faster than 0.5 mEq/L/hour or 12 mEq/L/day
  • Hypernatremia
    • Hypovolemic – loss of hypotonic fluids
      • Diuresis, vomiting, diarrhea
    • Isovolemic – loss of free water
      • Diabetes insipidus, hypodipsia
    • Hypervolemic – gain of hypertonic fluids
      • Hypertonic saline administration
  • Treatment of Hypernatremia
    • Hypovolemic
      • Replace the free water deficit
    • Hypervolemic
      • Diuretics (lasix) to excrete sodium in urine combined with hypotonic saline for partial volume replacement
  • Treatment of Hypernatremia
    • Isovolemic
      • Diabetes Insipidus
      • Loss of hypotonic urine secondary to lack of ADH production (central) or lack of response to ADH by kidney (nephrogenic)
      • Hallmark is hypotonic urine (200-500 mOsm/L) with hypertonic plasma
      • Treat by correcting free water deficit
      • In central DI must also administer 5 – 10 units of DDAVP Q6H to prevent ongoing free water loss
  • Hyperkalemia
    • Defined as a serum [K+] greater than 4.6 mEq/L
    • Changes in cellular transmembrane potentials can lead to lethal cardiac arrhythmias
    • Most often associated with renal impairment coupled with exogenous K+ administration or drugs that increase K+
    • Transcellular shifts – acidosis, succinylcholine, insulin deficiency, massive tissue destruction
    • Massive blood transfusions
    • Pseudohyperkalemia - Thrombocytosis, hemolysis, leukocytosis
    • Urine K+ excretion rate can be used to determine exact cause of hyperkalemia
  • Hyperkalemia
    • Drugs causing hyperkalemia – K+ sparing diruetics, ACEI, NSAIDs, Heparin, Cyclosporin, Tacrolimus, Bactrim
    • EKG Changes
      • 5.5 – 6.5 mEq/L – peaked T-waves
      • 6.5 – 7.5 mEq/L – loss of P-waves
      • > 8.0 mEq/L – widened QRS
  • Treatment of Hyperkalemia
    • 1. If EKG changes administer 10 mL of 10% Calcium Gluconate
    • 2. 1 amp D50 with 10 units IV insulin (onset 10-20 minutes, duration 2-3 hours)
    • 3. Albuterol 10 -20 mg (onset 4-5 hours, duration 2-3 hours)
    • 4. Kayexalate 15-30 g (oral onset 4-5 hours, enema onset 1 hour)
    • Dialysis
  • Hypokalemia
    • Defined as serum [K+] less than 3.6 mEq/L
    • Occurs in up to 20% of hospitalized patients
    • 2.5 mEq/L – muscular weakness, myalgia
    • <2.5 mEq/L – cramps, parasthesias, ileus, tetany, rhabdomyolisis, PVCs, A-V block, V-tach, V-fib
  • Hypokalemia
    • Inadequate intake
    • Increased excretion – diarrhea, diuretics, alkalosis, glucocorticoids, RTA
    • Transcellular shifts – beta-agonists, theophylline, insulin, hyperthyroidism, barium
    • Replace no faster than 20 mEq/H peripherally and 100 mEq/H centrally