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  • Fluid normally shifts between the ICF and ECF compartment each and every day, to help keep our bodies in homeostasis. The principles involved in this shifting are osmosis, diffusion, and filtration.Osmosis is movement of water from low solute concentration to high solute concentration. Passive process.Diffusion – high to lowOsmosisLow to highWater potentialDiffusionHigh to lowMovement of particlesBoth can occur at the same timeHydrostatic Pressure (capillary bed pressure)is the mechanical force of water pushing against a membrane. In the intravascular space, it is the pumping action of the heart that generates this force. at the arterial end of the capillary, hydrostatic pressure forces water, sodium and glucose across the membrane into the interstitial space
  • NUP released due to cardiac distension caused by increase BP or increase in blood volume.Effects : reduce thirst, block ADH release, inhibit RAA system.
  • When conservative Mx fail/irreversible.persistenthyperK, hemodialysis or peritoneal dialysis is required
  • Transcript

    • 1. Fluid and electrolytes
    • 2. Body Fluids
      16%
      40%
      4%
      Body Water (~40L) = 60% of body weight
    • 3. Body fluid compartments
      Interstitial
      fluid
      s
      Intracellular fluid
      Intravascular
      fluid
    • 4. Intracellular Fluid (ICF)
      Fluid within the cells
      Located primarily in skeletal muscle mass
      Provide nutrients for metabolism:
      High in potassium, phosphate, & protein
      Moderate levels of Mg, SO4
      Assists in cellular metabolism
    • 5. Extracellular fluid (ECF)
      Intravascular
      - plasma (half of total blood volume)
      Interstitial
      - surround all cells (eg. lymph)
      * Some interstitial fluid is TRANSCELLULARor under the influence of metabolic activity
      - respiratory fluid - pericardial fluid
      - GI digestive fluid - peritoneal fluid
      - CSF - intraocular fluid
      - pleural fluid - synovial fluid
      - gland secretions (sweat, enzymes)
    • 6. Extracellular fluid (ECF)
      Surrounds cells
      Transport medium for nutrients, gases, waste products and other substances between blood and body cells
      Back-up fluid reservoir
      Nutrients for cell functioning
      Na
      Ca
      Cl
      Glucose
      Fatty acids
      Amino Acids
    • 7. Fluid Movement
      Fluid movement is constant and is influenced by:
      1. membrane permeability
      Active : require energy to transport eg. Na/K pump
      Passive : osmosis, diffusion, hydrostatic force
      2. colloid osmotic pressure (plasma proteins)
      3. hydrostatic pressure (cap. bed pressure)
      Mechanical force of water pushing against membrane
      Forces H2O, Na, glucose to go across membrane to interstitial fluid
    • 8. Renal Regulation
      Kidneys are the most important regulators of volume and composition of body fluids
      Hormonal Control
      Antidiuretic hormone (ADH)
      Renin-angiotensin-aldosterone system(RAA)
      Natriuretic peptides (NUP)
    • 9. ADH regulatory mechanism
    • 10. NUP regulatory mechanism
    • 11. RAA regulatory mechanism
    • 12. Daily Intake & Output
      Intake 2,500 – 3,000 ml
      Liquids 1,500 – 2,000 ml
      Water in food 700 ml
      Water of oxidation 250 ml
      Output 1,400-2,300 ml
      Respiration & Perspiration (insensible) 600-900 ml
      Urine 800-1500 ml
      Stool 250 ml
    • 13. Water loss
    • 14. Serum Osmolarity (Concentration)
      Normal value = 275 -295
      >295 = concentrated (dehydrated)
      <275 = dilute (fluid overloaded)
      Serum Osmo = 2(Na) + glucose/18 +BUN/2.8
      Serum Osmo = Sodium x 2 (quick reference)
    • 15. Serum Laboratory Findings (Normal)
      Serum sodium : 135-145 mEq/L
      Serum potassium : 3.5 – 5 mEq/L
      Serum chloride : 95 – 105 mEq/L
      Serum osmolarity : 275-295 mOsm/L
      Urea : 15 – 40 mg/dL
      Creatinine : 0.6 – 1.5 mg/dL
      BUN: creatinine : 10:1 ratio
      Hematocrit (males 40-52% , females 37-46%)
      Total protein : 6.5 - 8.0 g/dL
    • 16. Fluid volume deficit
      Output > Intake -> Water extracted from ECF
      ECF hypertonic (water moves out of cell -> cell dehydration) + osmotic pressure increased (stimulates thirst receptor in hypothalamus)
      ICF hypotonic with decreased osmotic pressure -> posterior pituitary secretes more ADH
      Decreased ECF volume -> adrenal glands secrete Aldosterone
      Lab
      Increased HCT
      Increased BUN out of proportion to Cr
      High serum osmolarity
      Increased urine osmolarity
      Increased specific gravity
      Decreased urine volume, dark color
    • 17. Signs and symptoms
      Acute weight loss
      Decreased skin turgor
      Oliguria
      Concentrated urine
      Weak, rapid pulse
      CRT >2s
      Decreased BP
      Increased pulse
      Sensations of thirst, weakness,
      dizziness, muscle cramps
      Sunken eyeballs
      Depressed fontanels
    • 18. Management
      Major goal : correction and prevention of ARF
      Encourage oral fluids
      IV fluids
      Isotonic solutions (0.9% NS or Hartmann) until BP back to normal, then hypotonic (0.45% NS)
      Monitor I & O, urine specific gravity, daily weights
      Monitor skin turgor
      Monitor VS and mental status
      Evaluation
      Normal skin turgor, increased UOP with normal specific gravity, normal VS, alert and conscious, good oral intake of fluids
    • 19. Fluid volume excess
      Hypervolemia
      Isotonic expansion of ECF caused by abnormal retention of water and sodium
      Fluid moves out of ECF into cells and cells swell
      Causes
      Cardiovascular – Heart failure
      Urinary – Renal failure
      Hepatic – Liver failure, cirrhosis
      Other – Cancer, thrombus, PVD, drug therapy (i.e., corticosteriods), high sodium intake, protein malnutrition
    • 20. Signs and symptoms
      Physical assessment
      Weight gain
      Distended neck veins
      Periorbital edema, pitting edema
      Lungs crepitation
      Dyspnea
      Mental status changes
      Generalized or dependent edema
      VS
      High CVP/PAWP
      ↑ cardiac output
      Lab data
      ↓ Hct (dilutional)
      ↓ BUN (dilutional)
      Low serum osmolality
      Low specific gravity
    • 21. Signs and symptoms
      Radiography
      Pulmonary vascular
      congestion
      Pleural effusion
      Pericardial effusion
      Ascites
    • 22. Management
      Sodium restriction (foods/water high in sodium)
      Fluid restriction, if necessary
      Closely monitor IVF
      If dyspnea or orthopnea > Semi-Fowler’s
      Strict I & O, lung sounds, daily weight, degree of edema, reposition q 2 hr
      Promote rest and diuresis
    • 23. IV fluids
    • 24. Crystalloids
    • 25. Content of crystalloids
    • 26. Electrolytes
      Major intracellular electrolytes
      Potassium (cation)
      Phosphorus (anion)
      Major extracellularelectrolytes
      Sodium (cation)
      Chloride (anion)
      * Sodium is the determinant of osmolality (tonicity) since it is the major ECF cation
    • 27. Sodium
      Normal 135-145 mEq/L
      Major cation in ECF
      Regulates voltage of action potential; transmission of impulses in nerve and muscle fibers, one of main factors in determining ECF volume
      Elderly at risk
      Helps maintain acid-base balance
    • 28. Hypernatremia
      Causes
      Symptoms
      - extreme thirst - tachycardia
      - dry mucous membranes - low grade fever
      - irritability - weakness/lethargy
      - spasticity - oliguria/polyuria
      Lab
      Increased serum Na
      Increased serum osmolality
      Increased urine specific gravity
    • 29. Management
      Water depletion
      Oral hydration if tolerated
      IV infusion D5% or 0.45% NaCl
      Give maintenance fluid requirement (40ml/kg/day)
      Salt gain
      Remove sodium using potent diuretic (eg. IV furosemide) with D5% infused
      In severe cases dialysis may be necessary
      *Assessment
      1) Normal level of serum Na
      2) Resolution of signs and symptoms
    • 30. Hyponatremia
      Decrease in measured serum Na concentration below 135 mEq/L
      Mild 125-134mEq/L
      Moderate 110-124mEq/L
      Severe 100-109mEq/L
      Evaluate serum osmolarity
      If osmolarity is hypotonic, evaluate volume status:
      Hypervolemia
      Euvolemia
      Hypovolemia
    • 31. Causes
      Results from excess Na loss or water gain
      GI losses, diuretic therapy, severe renal dysfunction, severe diaphoresis, DKA, unregulated production of ADH associated with cerebral trauma, narcotic use, lung cancer, some drugs (eg. Thiazides, carbamazepine, desmopressin, oxytocin)
      Clinical manifestations
      ↓ BP, confusion, headache, lethargy, seizures,
      decreased muscle tone, muscle twitching and tremors, vomiting, diarrhea, and cramps
    • 32. Lab & Management
      Lab investigation
      Increased HCT, K
      Decreased Na, Cl, Bicarbonate, UOP with low Na and Cl concentration
      Urine specific gravity ↓ 1.010
      Management
      Mild
      Water restriction if water retention problem
      Increase Na in foods if loss of Na
      Moderate
      IV 0.9% NS, 0.45% NS, Hartmann
      Severe
      3% NS – short-term therapy in ICU setting
    • 33. Potassium
      Normal 3.5-5.5 mEq/L
      Major ICF cation
      Vital in maintaining normal cardiac and neuromuscular function, influences nerve impulse conduction, important in carbohydrate(CHO) metabolism, helps maintain acid-base balance, control fluid movement in and out of cells by osmosis
    • 34. Hypokalemia
      Serum potassium level below 3.5 mEq/L
      Causes
      Loss of GI secretions (diarrhea, vomiting, villous adenoma, ileostomy or uterosigmoidostomy, fistula)
      Excessive renal excretion of potassium (diuretics, increased aldosterone secretion, renal tubular damage etc)
      Movement of K into the cells (insulin therapy)
      Prolonged fluid administration without K supplementation
      Diuretics (thiazide, loop, mannitol)
    • 35. Signs and symptoms
      Skeletal muscle weakness, ↓ smooth muscle function, ↓ DTR’s
      ↓ BP, heart block, AF, VT, VF
      ECG changes (small/inverted T, prominent U, ST depression, prolonged PR intervals)
      Constipation, ileus
      Metabolic alkalosis
      Mental depression and confusion
    • 36. Management
      Mild – moderate (K > 2.5)
      Oral KCl 2-4 hourly until return of serum K to at least 3.5
      Monitor K level to prevent hyperK
      Potassium-sparing diuretics (amiloride, triamterene, spironolactone) can be given of hypoK is secondary to renal losses
      Severe (< 2.5) and/or with ECG changes
      Fast correction 2g KCl in 200ml NS to infuse in 2 hours (<3g KCl/L)
      With ECG monitoring
      When ECG and cardiac rhythm normalize, IV infusion gradually tapered down and discontinue. Oral KCl is initiated.
    • 37. Hyperkalemia
      Serum potassium level above 5.3 mEq/L
      Causes
      Excessive K intake (IV or PO) especially in renal failure
      Tissue trauma
      Acidosis
      Catabolic state
      Signs and symptoms
      ECG changes – tachycardia to bradycardia to possible cardiac arrest
      Tall, tented T waves
      Cardiac arrhythmias
      Muscle weakness, paralysis, paresthesia of tongue, face, hands, and feet, N/V, cramping, diarrhea, metabolic acidosis
    • 38. Management
      Stop K supplements and avoid K in foods, fluids, salt substitutes
      Lytic IV cocktail
      Calcium gluconate 10% 10ml in 10 minutes
      Insulin 10U in D50 50ml in 30-60min, then maintain on D5
      Sodium bicarbonate 100-200mmol/L over 30min
      Kalimate 5-10g tds/Resonium A 15-30 tds/qid PO or PR (cation exchange solution)
      Beta agonist therapy
      IV salbutamol 0.5mg in 15min or 10mg nebulization
    • 39. Calcium
      Normal 4.5-5.5 mEq/L
      99% of Ca in bones, other 1% in ECF and soft tissues
      Total Calcium – bound to protein – levels influenced by nutritional state
      Ionized Calcium – used in physiologic activities – crucial for neuromuscular activity
    • 40. Required for blood coagulation, neuromuscular contraction, enzymatic activity, and strength and durability of bones and teeth
      Nerve cell membranes less excitable with enough calcium
      Ca absorption and concentration influenced by Vit D, calcitriol (active form of Vitamin D), PTH, calcitonin, serum concentration of Ca and Phos
    • 41. Hypocalcemia
      Most common – depressed function or surgical removal of the parathyroid gland
      Hypomagnesemia
      Hyperphosphatemia
      Administration of large quantities of stored blood (preserved with citrate)
      Renal insufficiency
      ↓ absorption of Vitamin D from intestines
    • 42. Signs and symptoms
      Abdominal and/or extremity cramping
      Tingling and numbness (circumoral)
      Positive Chvostek sign (tapping over facial nerve
      -> twitching)
      PositiveTrousseau sign (inflate cuff for 5 min over diastolic P -> carpopaedal spasm)
      Tetany; hyperactive reflexes
      Irritability, reduced cognitive ability, psychosis, seizures
      Prolonged QT on ECG, hypotension, decreased myocardial contractility
      Abnormal clotting
    • 43. Management
      High calcium diet or oral calcium salts (mild) - √ formulas for calcium content
      IV calcium as 10% calcium chloride or 10% calcium gluconate in D5W– give with caution
      Close monitoring of serum Ca and digitalis levels
      ↓ Phosphorus levels with calcium carbonate
      ↑ Magnesium levels
      Vitamin D therapy
      D2 (ergocalciferol) 25,000-150,000 IU/day
      D3 (cholecalciferol) 50,000-100,000 IU PO daily
    • 44. Hypercalcemia
      Causes
      Mobilization of Ca from bone
      Malignancy
      Hyperparathyroidism
      Immobilization – causes bone loss
      Thiazide diuretics
      Thyrotoxicosis
      Excessive ingestion of Ca or Vit D (milk alkali syndrome)
    • 45. Signs and symptoms
      Anorexia, constipation, nausea, vomiting
      Generalized muscle weakness, lethargy, loss of muscle tone, ataxia
      Depression, fatigue, confusion, coma
      Soft tissue and corneal calcification (band keratopathy)
      Dysrhythmias and heart block
      ECG : shortened QT intervals
      Deep bone pain and demineralization
      Polyuria & predisposes to renal calculi
      Pathologic bone fractures
      Osteitisfibrosa in hyperparathyroidism
    • 46.
    • 47. Hypercalcemic crisis
      Emergency – level of 8-9 mEq/L
      Intractable nausea, dehydration, stupor, coma, azotemia, hypokalemia, hypomagnesemia, hypernatremia
      High mortality rate from cardiac arrest
    • 48. Treatment
      NS IV – match infusion rate to amount of UOP
      I&O hourly
      Loop diuretics
      Corticosteroids and Mithramycin in cancer clients to inhibit osteolytic bone resorption
      Biphosphonates and/or calcitonin to inhibit bone resorption and increase renal Ca excretion
      Oral phosphate 1-3g/day
      Encourage fluids
      Dialysis
    • 49. Magnesium
      Causes vasodilatation
      Decreases peripheral vascular resistance
      Balance - closely related to K and Ca balance
      Intracellular compartment electrolyte
      Hypomagnesemia - < 1.5 mEq/L
      Hypermagnesemia - > 2.5 mEq/L
    • 50. Hypomagnesemia
      Causes
      Decreased intake or decreased absorption or excessive loss through urinary or bowel elimination
      Acute pancreatitis, starvation, malabsorption syndrome, chronic alcoholism, burns, prolonged hyperalimentation without adequate Mg
      Hypoparathyroidism with hypocalcemia
      Diuretic therapy
    • 51. Signs and symptoms
      Tremors, tetany, ↑ reflexes, paresthesias of feet and legs, convulsions
      Positive Babinski, Chvostek and Trousseau signs
      Personality changes with agitation, depression or confusion, hallucinations
      ECG changes (PVC’S, V-tach and V-fib)
      Treatment
      Mild
      Diet – Best sources are unprocessed cereal grains, nuts, legumes, green leafy vegetables, dairy products, dried fruits, meat, fish
      Magnesium salts
      More severe
      MgSO4 IM
      MgSO4 IV slowly
      Monitor Mg q 12 hr
      Monitor VS, knee reflexes
      Precautions for seizures/confusion
      Check swallow reflex
    • 52. Hypermagnesemia
      Most common cause is renal failure, especially if taking large amounts of Mg-containing antacids or cathartics; DKA with severe water loss
      Signs and symptoms
      Hypotension, drowsiness, absent deep tendon reflex, respiratory depression, coma, cardiac arrest
      ECG – Bradycardia, complete HB, cardiac arrest, tall T waves
      Treatment
      Withhold Mg-containing products
      Calcium chloride or gluconate IV for acute symptoms
      IV hydration and diuretics
      Monitor VS, LOC
      Check patellar reflexes
    • 53. Phosphorus
      Normal 2.5-4.5 mg/dL
      Intracellular mineral
      Essential to tissue oxygenation, normal CNS function and movement of glucose into cells, assists in regulation of Ca and maintenance of acid-base balance
      Influenced by parathyroid hormone and has inverse relationship to Calcium
    • 54. Hypophosphotemia
      • Causes
      - Malnutrition
      - Hyperparathyroidism
      - Certain renal tubular defects
      - Metabolic acidosis (esp. DKA)
      - Disorders causing hypercalcemia
      Signs and symptoms
      Impaired cardiac function
      Poor tissue oxygenation
      Muscle fatigue and weakness
      N/V, anorexia
      Disorientation, seizures, coma
      Treatment of moderate to severe deficiency
      Oral or IV phosphate (do not exceed rate of 10 mEq/h)
      Identify patients at risk for disorder and monitor
      Prevent infections
      Monitor levels during treatment
    • 55. Hyperphosphotemia
      Causes
      Chronic renal failure (most common)
      Hyperthyroidism, hypoparathyroidism
      Severe catabolic states
      Conditions causing hypocalcemia
      Signs and symptoms
      Muscle cramping and weakness
      ↑ HR
      Diarrhea, abdominal cramping, and nausea
      Treatment
      Prevention is the goal
      Restrict phosphate-containing foods
      Administer phosphate-binding agents
      Diuretics
      Treat cause
      Treatment may need to focus on correcting calcium levels
    • 56. Thank you for your attention

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