Fluid and Electrolytes - Dr. Satish Deopujari

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Fluid and Electrolytes - Dr. Satish Deopujari

  1. 1.  Solvent  Volume  Dielectric constant  Surface tension  Some more
  2. 2. 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.
  3. 3. 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…..
  4. 4. 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…
  5. 5. Status on 4 th day On mannitol Blood sugar 377 mg % Serum sodium 151. BUN 38 = 336 Seizures in falciparum malaria Osmolality (mOsm/kg) = 2 [mEq/L Na+ ] + (mg/dL glucose) / 18 + (mg / dL BUN) /2.8
  6. 6. 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 . ?
  7. 7.  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.  What effect would correction of acidosis have on plasma K + ?  Would correction of Ca be part of initial management ?
  8. 8. 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.
  9. 9. Age TBW as % of body weight ECF as % of body weight ICF as % body weight Premature 75-80 Newborn 70-75 50 35 1 Year Old 65 25 40-45 Adolescent Male 60 20 40-45 Adolescent Female 55 18 40
  10. 10. 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
  11. 11. 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]. Maintenance requirements
  12. 12. RESUSCITATION MAINTENANCE Crystalloid Replace acute loss 1. Replace normal loss (IWL + urine+ faecal) 2. Nutrition support ELECTROLYTES FLUID THERAPY Colloid NUTRITION
  13. 13. Percent Dehydration Infa nt Chil d Clinical Signs and Symptoms Mild 5% 3- 4% Increased thirst, tears present, mucous membranes moist, ext. jugular visible when supine, capillary refill > 2 seconds centrally, urine specific gravity > 1.020 Moderate 10% 6- 8% Tacky to dry mucous membranes, decreased tears, pulse rate may be elevated somewhat, fontanels may be sunken,oliguria, capillary refill time between 2 and 4 seconds, decreased skin turgor Severe 15% 10% Tears absent, mucous membranes dry, eyes sunken, tachycardia, slow capillary refill, poor skin turgor, cool extremities, orthostatic to shocky, apathy, somnolence Shock >15 % >10 % Physiologic decompensation: insufficient perfusion to meet end- organ demand, poor oxygen delivery, decreased blood pressure.
  14. 14. RESTORATION OF CIRCULATING VOLUME IS THE TOP PRIORITY FLUID IS …….. NORMAL SALINE
  15. 15. I .C .F B L O O D K = 140 Osm = 280 Na = 140 Osm = 280 I .C .F In. S F K = 140 Osm = 280 Na = 140 Osm = 280 B L O O D In. S F E.C.F. E.C.F.I.C.F. I.C.F. DEHYDRATION
  16. 16. I S O HYPERHYPO 120 140 160 240 280 320 W W ICF ICF ICF
  17. 17. Isonatremic dehydration…. Correction over 24 hours… 20 Kg child 10 % Dehy. Na = 140 Maintenance Replacement Total ½ N.S.X X 2000 ml 10 % of 20 Kg 1500 ml 3500 ml 5 % dext. H20 Na 3 mEq / 100 ml. 15 3 = 45 10 20 = 200 mEq 245 mEq / 3.5 Lt.Loss = 10mEq / Kg
  18. 18. Hyponatremic dehydration…. Slow correction , over 48 hours… Not more than 10 mEq in 24 hours 20Kg child 10 % Dehy. Na = 110 Maintenance Replacement Total ( As 5 % dextrose ) 1 / 2 N.S. XNa 3 mEq / 100 ml. 30 3 = 90 140-110 ½ wt.X 300 mEq 390 / 5 Lit. 2000 ml 10 % of 20 Kg1500 2 3000ml 5000 mlXH2O
  19. 19. 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
  20. 20. Maintenance Replacement Total 1/4 N.S. Hypertonic dehydration…. Slow correction , over 48 hours Not more than 10 mEq in 24 hours 20 Kg child 10 % Dehy. Na = 165 400 m.l. of N.S. = 61 mEq Free water deficit = ( 4 X wt inKg ) X ( Serum Na – 145) 1500 2 3000ml 3 mEq / 100 ml. 30 3 = 90X X Deficit = 2000 F.W.D. = 1600 Reminder as N.S. 5000 ml 151 mEq / 5 lit. H20 Na
  21. 21. HYPER 160 320 W ICF HYPER CHRONIC 160 320 W ICF RAPID TREAT. 130 290 W ICF
  22. 22. Seizure while treating hypernatremia
  23. 23. 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
  24. 24. 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 )
  25. 25. 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
  26. 26. HYPERNATREMIA IN ICU Urine output Low High Urine osmolality Urine osmolality Low HighHigh Hypo tonic fluid loss  Insensible loss  G I Loss  Diuretics D. Insipidus Osmotic diuresis  Central  Nephrogenic
  27. 27. Common IV Solutions Solution Glucose (g/L) Na+ K+ Ca+2 Cl- Lactate PO4 -3 Mg+2 5% Dextrose (D5 W) 50 0 0 0 0 0 0 0 10% Dextrose (D10 W) 100 0 0 0 0 0 0 0 Normal Saline (NS) 0 154 0 0 154 0 0 0 D5 NS 50 154 0 0 154 0 0 0 D5 ½NS 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 D5 LR 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.
  28. 28. 98 % 2 %
  29. 29. 98 % 2 % Hyperkalemia K +
  30. 30. H I O N S K ACIDOSIS CAUSES HYPERKALEMIA ALKALOSIS ……… LOW K +
  31. 31. True Hyperkalemia Excess K+ intake Redistribution Decreased excretion Renal failure Oliguria Hypoaldo. Nsaids Ace inhibitors Acidosis Insulin Def. Adrenal Ins. Periodic P.
  32. 32. 98 % 2 % K + + + +
  33. 33.  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 Hyperkalemia
  34. 34. Hypokalemia…
  35. 35. Hypokalemia true Distribution Increased loss Urinary K + Decreased Hypertension Normal B.P. Acidosis Alkalosis Renin G.I.loss Biliary ETC.
  36. 36. 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.
  37. 37. Potassium should be administered slowly, preferably Orally, at a dosage of 4 to 6 mEq/kg per day.
  38. 38. ADH excess Water retention E.C.Fluid ++ Serum Na low Urinary sodium increased
  39. 39. Hypotonic Hyponatremia (Na < 135 meq. /L) Hypovolemia Euvolemia Hypervolemia Urinary sodium  More than 20 Urinary loss  Less than 20 G I Loss Diuretics  SIADH  Adrenal  Drugs  HypoTH  More than 20 C.C.F. Hepatic F.  Less than 20 Renal disease Urinary sodium
  40. 40. SIADH……………… Definition: AVP excess associated with hyponatremia without edema or hypovolemia. The AVP excess is inappropriate in the face of hypoosmolality. Clinical manifestations are those of water intoxication and depend on rate more than magnitude of development of hyponatremia. Commonest cause of euvolemic hyponatremia
  41. 41. 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. SIADH………………
  42. 42. Management Restrict fluid Diuretics Emergency management and the other drugs…… SIADH………………
  43. 43. The right solution for correct fluid ………..
  44. 44. Thanks Dr Deopujari

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