2.  Solvent
 Volume
 Dielectric constant
 Surface tension
 Some more

3. Seizures in pyogenic meningitis………
Had seizure on 2nd day . On Dilantin.
10 months female with meningitis.
Second L.P.( 3rd day ) showed improvement
Refractory seizure on 6th day
S.I.A.D.H.

4. Hyponatremia………………………………..
K/C of Thalassemia
Admitted for G / E improved
Was found to be Hyponatremic on
admission ( 112 )
Correction done twice but Hypon. Cont.
Asymptomatic all throughout.
PSEUDO HYPONATREMIA…..

5. Respiratory failure………………………………..
5 months male with R.A.D. was doing well
On extensive nebulization and supportive therapy.
Deteriorated on 4 the day , lethargic, look exhausted .
Respiratory rate is less now.
ABG day 2..pH 7.34.,pO2 80 on FiO2 of 50. CO2 30
ABG day 4..pH 7.23.,pO2 85 on FiO2 of 30. CO2 67
Electrolytes gave the answer…

6. Seizures in falciparum malaria
Status on 4 th day
On mannitol
Blood sugar 377 mg %
Serum sodium 151. BUN 38
Osmolality (mOsm/kg) = 2 [mEq/L Na+] +
(mg/dL glucose) / 18 + (mg / dL BUN) /2.8
= 336

7. 14 months male with RTA
Hypo tonic no h/o seizures
 ECG : suggestive of Hypokalemia with extra systoles
 Plasma sodium = 140
 Plasma potassium = 1.3
 Chloride = 117
 Bicarbonate = 10
 Ca = 6.3
 Arterial pH = 7.26
 PCO 2 = 23
 What effect would correction of acidosis
have on plasma K + ?
 Would correction of Ca be part of
initial management . ?

8.  What effect would correction of acidosis
have on plasma K + ?
 Would correction of Ca be part of
initial management ?
 Correction of acidosis will drive k + into the cells
Further worsening hypokalemia.Acidosis is not sever
and can wait. Hypokalemia first.
 Hypocalcaemia protects against hypokalemia
Thus treatment of hypokalemia should precede
Hypocalcaemia.
Correction of hypokalemia may precipitate
Tetany , this is a less serious than hypokalemia.

9. 1. Anions - Negatively charged ions, such as chloride .
2. Cations - Positively charged ions as sodium .
3. Colloid/Colloid solution - Liquid containing
suspended substances that do not settle out of the
liquid/solution
4. Crystalloid - a substance that in solution can pass
through a semi permeable membrane and be
crystallized.
5. Electrolytes - cations or anions which have the ability
to conduct electrical current in solutions.

10. TBW as % of ECF as % of ICF as % body
Age
body weight body weight weight
Premature 75-80
Newborn 70-75 50 35
1 Year Old 65 25 40-45
Adolescent
60 20 40-45
Male
Adolescent
55 18 40
Female

11. MAINTENANCE REQUIRMENT……
Up to 10 Kg 100 ml/Kg
10 to 20 Kg 1000 ml + 50 ml / Kg above 10.
20 Kg onwards 1500 ml + 25 ml / Kg above 20.
3 mEq Na and K per 100 ml of water

12. Maintenance requirements
Usually estimated from body weight
insensible water loss averages 50 ml per 100
kcal consumed. Provision of 50 ml of water
per 100 kcal consumed allows the excretion
of isotonic urine. Thus, 100 ml of water is
required for each 100 kcal consumed.
Empirically, 1-3 mEq Na+ and K+ are
required for each 100 kcal . Five percent
dextrose is necessary to prevent protein and
lipid catabolism. Maintenance requirements
are best replaced with [5% dextrose, 0.2%
NaCl + 20 mEq KCl/liter].

13. FLUID THERAPY
RESUSCITATION MAINTENANCE
Crystalloid Colloid ELECTROLYTES NUTRITION
1. Replace normal loss
Replace acute loss (IWL + urine+ faecal)
2. Nutrition support

16. Percent Infa Chil
Clinical Signs and Symptoms
Dehydration nt d
Increased thirst, tears present, mucous membranes moist, ext.
3-
Mild 5% jugular visible when supine, capillary refill > 2 seconds centrally,
4%
urine specific gravity > 1.020
Tacky to dry mucous membranes, decreased tears, pulse rate may
6-
Moderate 10% be elevated somewhat, fontanels may be sunken,oliguria, capillary
8%
refill time between 2 and 4 seconds, decreased skin turgor
Tears absent, mucous membranes dry, eyes sunken, tachycardia,
Severe 15% 10% slow capillary refill, poor skin turgor, cool extremities, orthostatic
to shocky, apathy, somnolence
>15 >10 Physiologic decompensation: insufficient perfusion to meet end-
Shock
% % organ demand, poor oxygen delivery, decreased blood pressure.

17. RESTORATION
OF CIRCULATING
VOLUME IS THE
TOP PRIORITY
FLUID IS ……..
NORMAL SALINE

18. DEHYDRATION
In. B
I .C .F B I .C .F In.
S L L
S
F O O
F O
O
D D
K = 140 Na = 140 K = 140 Na = 140
Osm = 280 Osm = 280 Osm = 280 Osm = 280
I.C.F. E.C.F. I.C.F. E.C.F.

19. 120 140 160
240 280 320
ICF ICF
ICF
W W
HYPO ISO HYPER

20. 20 Kg child
Isonatremic dehydration…. 10 % Dehy.
Correction over 24 hours… Na = 140
Maintenance Replacement Total
10 % of 20 Kg
H20 1500 ml 3500 ml
2000 ml 5 % dext.
Loss = 245 mEq / 3.5 Lt.
3 mEq / 100 ml. 10mEq / Kg
Na 15 X 3 = 45
½ N.S.
10 X 20 = 200 mEq

21. Hyponatremic dehydration…. 20Kg child
Slow correction , over 48 hours…
10 % Dehy.
Na = 110
Not more than 10 mEq in 24 hours
Maintenance Replacement Total
H2O 1500 X 2 10 % of 20 Kg 5000 ml
3000ml 2000 ml ( As 5 % dextrose )
140-110 X ½
3 mEq / 100 ml. wt. 390 / 5 Lit.
Na 30 X 3 = 90
300 mEq 1 / 2 N.S.

22. HYPONATRMIC
EMERGENCIES
 3% hyper tonic saline
5 ml/kg over 1 hour with the goal
sodium level of 125meq/ L , then correct
sodium further by calculating deficit

23. Hypertonic dehydration…. 20 Kg child
Slow correction , over 48 hours 10 % Dehy.
Not more than 10 mEq in 24 hours Na = 165
Maintenance Replacement Total
H20 1500 X 2 Deficit = 2000
5000 ml
F.W.D. = 1600
3000ml Reminder as N.S.
3 mEq / 100 ml. 151 mEq / 5 lit.
Na 400 m.l. of N.S.
30 X 3 = 90 = 61 mEq 1/4 N.S.
Free water deficit = ( 4 X wt inKg ) X ( Serum Na – 145)

24. 160 160 130
320 320 290
ICF ICF ICF
W W W
HYPER HYPER RAPID
CHRONIC TREAT.

25. Seizure while treating
hypernatremia

26. D 5 % with ½ Normal Saline = 77 mEq Na /
Lit.
Add 150ml of 3 % Normal Saline to a Liter of 5
% Dextrose
D 5 % with ¼ Normal Saline = 34 mEq Na /
Lit.
Add 70 ml of 3 % Normal Saline to a Liter of 5
% Dextrose

27. Isonatremic dehydration is best replaced with
5% dextrose, ½ NaCl + 20 mEq KCl/L over
24 hours. ( Deduct bolus therapy )
Hyponatremic dehydration is best replaced
with 5% dextrose ½ NaCl + 20 mEq KCl/L
over 48 hours. ( Deduct bolus therapy )
Hypernatremic dehydration is best replaced
with 5% dextrose with ¼ NaCl + 20 mEq
KCl/L over 48 hours. ( Deduct bolus therapy )

28. Fallacies of body fluid calculations
 Lean body mass calculations
 Variation in body secretion
 Variation in renal handling
 Effect of body temperature
 Isohydric effect
 Variation in surface area

29. HYPERNATREMIA IN ICU Urine output
Low High
Urine osmolality Urine osmolality
High Low High
Hypo tonic fluid
Osmotic
loss D. Insipidus diuresis
 Insensible loss
 Central
 G I Loss
 Nephrogenic
 Diuretics

30. Common IV Solutions
Solution Glucose (g/L) Na+ K+ Ca+2 Cl- Lactate PO4-3 Mg+2
5% Dextrose (D5W) 50 0 0 0 0 0 0 0
10% Dextrose (D10W) 100 0 0 0 0 0 0 0
Normal Saline (NS) 0 154 0 0 154 0 0 0
D5NS 50 154 0 0 154 0 0 0
D5½NS 50 77 0 0 77 0 0 0
0.2% NS 0 31 0 0 31 0 0 0
3% NaCl 0 513 0 0 513 0 0 0
Ringer's Lactate (LR) 0 130 4 3 109 28 0 0
D5LR 50 130 4 3 109 28 0 0
D10 E#48 100 30 15 0 20 25 3 3
D5 E#48 50 25 20 0 22 23 3 3
D10 E#75 100 57 35 0 40 25 12 6
D6 E#75 60 40 40 0 35 20 15 0
Note: Glucose in g/L; all ions in mEq/L.

31. 98 %
2%

32. Hyperkalemia
98 % 2%
+
K

33. +
ALKA LOSIS ……… LOW K
H
I ACIDOSIS CAUSES
K O HYPERKALEMIA
N
S

34. True Hyperkalemia
Excess K+ intake
Decreased excretion
Redistribution
Renal failure
Oliguria
Acidosis Hypoaldo.
Insulin Def. Nsaids
Adrenal Ins. Ace inhibitors
Periodic P.

35. 98 % 2%
K ++++

36. Hyperkalemia
 Calcium chloride: 0.2 mL /kg/dose of 10% sol IV over 5
min; not to exceed 5 mL (stop infusion if bradycardia
develops)
Calcium gluconate: 100 mg/kg (1 mL/kg) of 10% sol IV over
5 min; not to exceed 10 mL (stop infusion if bradycardia
develops)
 Soda bi carb …
 2 ml / kg 25 % dextrose with .1 units /kg insulin .
over 30 minutes (1 U regular insulin/5 g glucose )
 Beta agonists

37. Hypokalemia…

38. Hypokalemia true Distribution
Increased loss Urinary K + Decreased
Hypertension Normal B.P. G.I.loss
Biliary ETC.
Acidosis Alkalosis
Renin

39. I . V . Kesol should be considered for
 Significant arrhythmia
 Sever muscle weakness
 Severe hypokalemia (< 2.5.0 mEq. / L).
 Digoxin toxicity
 Hepatic encephalopathy
Maximum concentrations of KCl used in
peripheral veins generally should not exceed 4
meq. /100 cc, due to the damaging effects on
the veins , at a rate of 1 mEq/kg per hour.

40. Potassium should be administered slowly,
preferably Orally, at a dosage of 4 to 6
mEq/kg per day.

41. ADH excess
Water retention E.C.Fluid ++
Serum Na Urinary sodium
low increased

42. Hypotonic Hyponatremia (Na < 135 meq. /L)
Hypovolemia Euvolemia Hypervolemia
Urinary Urinary
sodium sodium
 More than 20  More than 20
 SIADH
Urinary loss  Adrenal C.C.F.
 Less than 20  Drugs Hepatic F.
G I Loss  Less than 20
 HypoTH
Diuretics Renal disease

43. SIADH………………
Definition: AVP excess associated with hyponatremia
without edema or hypovolemia. The AVP excess is
inappropriate in the face of hypoosmolality.
Commonest cause of euvolemic hyponatremia
Clinical manifestations are those of water
intoxication and depend on rate more than
magnitude of development of hyponatremia.

44. SIADH………………
HYPONATREMIA HYPO OSMOLAR
U. OSM. HIGHER THAN SERUM
CONTINUED URINARY Na LOSS
NORMAL RENAL FUNCTION & B.P.
NO OEDEMA
NO ENDOCRINE DISORDER
RESPONSE TO WATER REST.

45. SIADH………………
Management
Restrict fluid
Diuretics
Emergency management
and the other drugs……

46. The right solution for correct fluid ………..

47. Thanks
Dr Deopujari