Fluids And Electrolytes
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Fluids And Electrolytes Fluids And Electrolytes Presentation Transcript

  • Celso M. Fidel, MD,FPCS,FPSGS Diplomate Philippine Board of Surgery FLUIDS AND ELECTROLYTES
  • INTRODUCTION  HOMEOSTASIS is determined by:  Individual’s Intake and output  Carefully and precisely regulated by the body during Health  One of the most critical aspects of patient’s care is management of the body composition of fluids and electrolytes
  • INTRODUCTION
    •  Situations that impose a great impact on
    • physiology of body fluid & electrolytes:
    •  Diseases
    •  Injuries
    •  Operative Trauma
    •  In disease states --- regulatory mechanisms
    • often becomes impaired & IMBALANCES
    • occur
  • INTRODUCTION  Thorough understanding of the mechanisms of fluids and electrolytes and certain metabolic responses is essential to the care of surgical patients  SURGEONS encounter these PROBLEMS:  Additional stress of SURGERY  Use of tubes that drain fluids  Patient’s inability to tolerate oral intake of fluids and nutrients
  • BODY WATER  Water constitutes between 50% to 70%TB Wt.  Average Normal Values Young Adult Male 60% of body wt. Young Adult Female 50% of body wt.  Total Body Water (% TBW) decreases steadily and significantly with age:  52% in males  47% in females
  • BODY WATER  Highest proportion of TB water :  Infants 75% to 80% of body weight  One Year Old averages 65% of BWt.  Lean individuals has greater proportion of water to TBW than the obese
  • FUNCTIONAL COMPARTMENT OF BODY FLUIDS  INTRACELLULAR  fluid w/in the body’s diverse cell population represent---- 40%  largest proportion ---- skeletal muscle  principal CATION----- K (potassium)‏  principal ANION ------ phosphates & proteins
  • FUNCTIONAL COMPARTMENT OF BODY FLUIDS  EXTRACELLULAR  Represents----- 20% of the BW  Two major subdivisions  plasma volume----- 5% of BW  Interstitial( extravascular ) 15% of BW
  • FUNCTIONAL COMPARTMENT OF BODY FLUIDS  EXTRACELLULAR  Non-functioning components----1%-2% B wt.  Connective tissue water  Cerebrospinal fluid  Joint fluids  The principal CATION----- Na+( Sodium)‏  The principal ANION------- Cl (Chloride and bicarbonates
  • FUNCTIONAL COMPARTMENT OF BODY FLUIDS  Gibbs-Donnan Equilibrium----- The product of concentration of any pair of diffusable cation and anion on one side of a semi-permeable membrane will equal the product of the same pair of ions on the other side
  • FUNCTIONAL COMPARTMENT OF BODY FLUIDS  TWO THIRDS RULE  Determination of the exact size of any one of the 3 compartments is virtually impossible  Total Body Compartment is approximately 2/3 of BODY Weight
  • FUNCTIONAL COMPARTMENT OF BODY FLUIDS  TWO THIRDS RULE  Of this 2/3; 2/3 is INTRACELLULAR & 1/3 is EXTRACELLULAR  Of the extracellular portion 2/3 is INTERSTITIAL & 1/3 intravascular
  • REPLACEMENT OF WATER  By Ingestion  By Metabolism-----combustion of foodstuff:  Each 100 calories of  FAT  CARBOHYDRATES  PROTEINS VITAL NEEDS W/C DEMANDS continuous water EXPENDITURE  Removal of Body Heat ----800cc ( SKIN AND LUNGS) 600-1000 >>>> RANGE DAILY RELEASES 14 CC OF WATER
  •  VITAL NEEDS W/C DEMANDS continuous water EXPENDITURE  Excretion of UREA, METABOLIC PRODUCTS & MINERAL SALTS  1200 mOsm of solute have to be excreted daily  A good kidney can CONCENTRATE urine up to 1400 mOsm solute
  •  VITAL NEEDS W/C DEMANDS continuous water EXPENDITURE  Average Adult excretes 900 cc H20/day  Normal H20 loss in Urine----800-1500cc/ day  Normal Na+ loss-----10-100 mEq/ liter of urine
  • Normal Daily Losses 1. GIT 100-200 ml loss in stools 2. GUT 1000- 1500 ml loss in urine 3. Insensible 600-800 ml in adults (divided equally between lungs and skin) a better term would be imperceptible loss
  • Abnormal Losses of Water 1. Fever - 10% increase insensible loss per degree above 37 C. 2. Tachypnea –doubling RR 50% increase resp. L 3. Evaporation- Sweating, ventilator, open wounds 4. GI –Fistula, Diarrhea, Tube drainage 5. Third space – Interstitium of lungs, bowel, soft tissues 6. Intraoperative losses
  • Tonicity  Body Fluids ---- composed of water and substances dissolved in it  Total number of particles in solution are constant throughout the body, although the nature of the individual solute varies in different parts of the body  Tonicity( property derived from the number of particles in solution) Normal----300 mOsm/L
  • Tonicity  In PLASMA 280 is due to ELECTROLYTES  1/2 --- 140 mOsm is coming from Na+  1/2 --- 140 mOsm from Chlorides & Bicarbonates  Crystalloids:  Sugar  Urea 10-20 mOsm  Creatinine  Protein ------ 2 mOsm
  • Electrolytes, What are They ?  Group of compounds-----DISSOCIATES in solution to form “IONS’ after the greek for “ GOING”  These ions each carry an electrical charge; example; NaCl -----dissolved in water provides Na+ ---- carries a positive charge Cl- -----carries a negative charge
  • Electrolytes, What are They ?  Those IONS carrying a (+) charge migrated to FARADAY’s (-) electrode or “CATHODE” were called ”Cations” after the Greek for “DOWN”  Those IONS carrying a (-) charge migrated to FARADAY’s (+) electrode or “ANODE” were called ”anions” after the Greek for “UP”
  • Electrolytes, What are They ?  Cations in the body; Na+, K+, Ca++, Mg++  Anions in the body include ; Cl-, HCO3-, HPO4=, SO4=; ions of inorganic acids such as:  Lactate  Pyruvate  Aceto-Acetate  Proteinates
  • Electrolytes, What are They ?  Each of the water compartments of the body contains electrolytes. However the composition and concentration of these electrolytes in the water of each compartment differ from that of the others.
  • Electrolytes, What are They ?  Physiologic and Chemical Activity of electrolytes are proportional to:  Number of particles present per unit volume ( MOLES or MILLIMOLES)‏  No. of electrical charges per unit volume ( Equivalents or Milliequivalents per liter)‏
  • Electrolytes, What are They ?  mEq/L=mgs./L X val. divided by the atomic Wt. = mgs/ 1000cc X Valence Atomic Weight  OSMOLARITY >>>expression of concentration of ions and proteins in solution in body water.  Water moves freely in the body to prevent the development of any compartmentalized osmolar concentration difference.
  • Electrolytes, What are They ?  Electrolyte Concentration in Serum Na+ -------- 135-145 mEq/ liter K+ -------- 3.5-5.5 mEq/liter Cl- ----- 85-115 mEq/liter HCO3- ---- 22-29 mEq/liter Mg++ ---- 1.5-2.5 mEq/liter Ca++ ---- 4-5.5 mEq/liter
  •  
  • ELECTROLYTE COMPOSITION OF BODY FLUIDS Na+ K+ H+ Cl- HCO3 Proteins PO4 SO4- Plasma 142 4.5 100 25 16 2 1 Gastric Low Acid 45 30 70 120 25 High Acid 100 45 0.015 115 30 Intestinal Juice 120 20 30 Bile 140 5 40 Pancreatic Juice 130 15 80 Intracellular 10 150 5 10 60 100 20
  • NORMAL DAILY FLUID& ELECTROLYTE LOSSES AND REQUIREMENTS  LOSSES/ 24 hours  Substances Urine Skin Lungs Feces Total  WATER 1200-1500 200-400 500-700 100-200 2300-2600  SODIUM 100 mEq 40 mEq/liter 80-100 mEq  POTASSIUM 100 mEq 80-100mEq  CHLORIDES 150 mEq 40 mEq/ liter 100-150 mEq  REQUIREMENTS  WATER 35 ml/ kg. body weight PEDIATRICS 100 ml/kg first 10 kg. body weight 50 ml/kg next 10 kg. “ “ 20 ml/kg for each additional body weight  SODIUM 1 mEq/kg body weight  POTASSIUM “ “ “ “  CHLORIDE 1.5 mEq/ kg. body weight  HCO3 0.5 “ “ “ “
  • THE IONS  SODIUM  Principal Cation of extracellular fluid  Normal requirement is met by the average diet  Average intake----- 100 mgs daily  Sweat conc. -----27mEq/ L is to 100mEq /L  Total secretion---Alimentary Tract 1000-1200 mEq  ADH of Pituitary promotes Na+ excretion from the kidney to some extent & to markedly favor water resorption from the distal tubules.
  • THE IONS  POTASSIUM (cation)‏  Major exchangeable portion lies within the cell  Daily turnover of K+ requirement represents 1.5 to 5% of the total K+ content of the body.  Normal 70 kg. man----- 3,200 mEq  Average woman--------- 2,300mEq  Normal requirement met by average diet  Gastric Juice Content----15-40mEq/liter  Healthy cell maintains high K+ & low Na+ conc.  Patient under stress of disease or in the postop. period>> Normal Kidney excretes 80-90 mEq/day
  • THE IONS  POTASSIUM (cation)‏  At 7 mEq/L in Serum----- elevation of T waves on Electro Cardio Gram  At 8-10 mEq/L ------Arrhythmia & Heart Block  CHLORIDE (ANION)‏  Na+ to Cl- ratio is 3:2 in serum & extracellular compartment  It follows changes in Na+ concentration EXCEPT in GASTRIC OBSTRUCTION;  Chloride is low  Na+ is normal  Alkalosis is severe
  • DIAGNOSIS OF IMBALANCES  It is the center of any scheme of FLUID and ELECTROLYTE Balance  Nature of imbalances and approximate magnitude are based on:  History  Clinical Signs and Symptoms  Certain Laboratory Studies  Past Clinical Experience
  • DIAGNOSIS OF IMBALANCES  CLUES FROM THE HISTORY  In Gastric Outlet Obstruction present in  Duodenal Ulcer will produce  Pyloric Stenosis alkalosis (loss of Chloride & K+; Hypokalemia; loss of H20 & Na+)‏  Vomiting secondary to a cause other than gastric Outlet Obstruction:  Loss of H2O If there is a shift in ACID  Loss of Na+ BASE balance, it is towards  Loss of K+ METABOLIC ACIDOSIS vomiting
  • DIAGNOSIS OF IMBALANCES  CLUES FROM THE HISTORY  Diarrhea secondary to:  Cholera Loss of  Ulcerative Colitis H20, K+, ACIDOSIS  Ileostomy dysfunction Na+  Burns produces acute loss of PLASMA & Extra- cellular fluid (Water, Proteins, and Na+)‏  Sweating if excessive causes appreciable loss of both Na+ & H20------ Shrinkage of Extracellular Fluid Volume -------VASCULAR COLLAPSE
  • DIAGNOSIS OF IMBALANCES  P.E. should give attention to:  BODY WEIGHT  Weight gain >>>H20 retention  Weight loss 300-500 gms./day expected in postoperative Patients.>>>> In excess of 300- 500 gms/ day indicates H20 loss.  Tissue Turgor >>Decrease in T T in volume of the Interstitial Fluid compartment of ECF ( Na+ dependent)‏  Skin Turgor>> useful indicator of diminished interstitial fluid volume
  • DIAGNOSIS OF IMBALANCES  P.E. should give attention to:  Tissue turgor  Tongue>> most reliable indicator forT.T  Normally it has a single “Median Furrow”  Additional furrows parallel to the median furrow appears with decrease interstitial volume and a need for Na+  Moisture of the axilla and groin . Dry but other- wise normal axilla----H20 deficit, at least 150cc  Jugular Veins ------Normally it fills to the anterior border of the sternocleidomastoid muscle when the patient is supine.
  • DIAGNOSIS OF IMBALANCES  P.E. should give attention to:  Blood Pressure and Pulse  Tachypnea>> earliest sign of decrease BVolume  Postural Hypotension Need for Blood & Na  Hypotension when Supine containing fluid  Edema and Rales  Pitting Edema>>> Na+ increase >> 400 mEq  Rales>> Acute increase in Volume by at least 1500cc
  • DIAGNOSIS OF IMBALANCES  LABORATORY TESTS & Other PARAMETERS  Hematocrit  Urine Specific Gravity  Na+ levels in serum and urine  CVP monitoring  Pulmonary Wedge Pressure
  • DIAGNOSIS OF IMBALANCES  LABORATORY TESTS & Other PARAMETERS  Hematocrit  Urine Specific Gravity  Na+ levels in serum and urine  CVP monitoring  Pulmonary Wedge Pressure  Determining the Amount of the Deficit  A Vol(H2O) deficit---- Estimate from patient’s Body Wt.& appearance or from the serum Sodium level. The hematocrit gives also useful information.
  • DIAGNOSIS OF IMBALANCES  CLINICAL ESTIMATES  MILD Dehydration----- Patient losses 3% of the Body Weight ----- THIRSTY  MODERATE Dehydration ------ Patient losses 6% of the Body Wt. Clinical signs of dehydration are Evident:  Marked Thirst and Dry Mouth  No groin and axillary Sweat  Loss of Skin Turgor .
  •  
  • DIAGNOSIS OF IMBALANCES  CLINICAL ESTIMATES  SEVERE Dehydration------Patient losses 10% of Body Weight:  Clinical signs of Dehydration are marked.  Hypotension may be present  Patient may be confused & delirious.  BODY WATER CALCULATIONS  Body H20 = Normal Serum Na+ X normal B H20 Measured Na+ value
  • DIAGNOSIS OF IMBALANCES  Electrolyte deficits. They are calculated after the lab results for Na+. K, Cl, and NaHC03 are in.  NaCl & HCO3 deficit are calculated using foll: DEFICIT= NORMAL VOLUME –OBSERVED BODY VOLUME x ELECTROLYTE DISTRIBUTION IN BODY COMP% x BODY WT(KG) WHERE: NA DISTRIBUTION = 60 % CL “ 20 % HCO3 “ 5O%
  • DIAGNOSIS OF IMBALANCES  Electrolyte deficits.  The K+ deficit is figured differently w/normal Blood pH:  For every 1.0 mEq/L decrease in concentration at or above 3.0 mEq----consider the total body deficit as 100-200 mEq.  For every1.0 mEq/L decrease in the K+ conc. below 3.0 mEq/L -----consider the total body deficit as another 300-400 mEq.
  • DIAGNOSIS OF IMBALANCES  ABNORMAL PATTERNS in Fluids & Electrolytes  Disorders of composition & concentration  Disorders of Volume  Disorders of Acid-Base Balance CLINICAL STATES  HYPONATREMIA  HYPERCLOREMIA  HYPERNATREMIA  ACID BASE BALANCE  ISOTONIC DEHYDRATION  HYPOKALEMIA  HYPERKALEMIA
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  Pathophysiology  Hypovolemic or Isovolemic  Mechanism:  Loss of Na+ containing fluid and replacement with salt free fluid( isovolemic)‏  Salt free fluid and administration in excess in the absence of salt loss ( dilutional Hyponatremia)‏
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  Causes  Loss of fluid with high Na+ content:  Fistula  Ngt Drainage  Vomiting  Diarrhea  Excessive URINE Na+ wastage  Diuretics  Chronic Nephritis  Adrenal Cortical Insufficiency as in Addison’s disease  Over infusion of salt free fluid ( dilutional Hyponatremia)‏
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  Causes cont’d  Loss of Extracellular Fluid:  Externally:  Burns  Marked Sweating  Internally as in Third Space loss:  Peritonitis  Ascites  Ileus  Pancreatitis
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  Clinical Presentation  Accumulation of intracellular fluid could cause CNS symptoms:  Serum Na+ below 130 mEq/Liter ( Mild)‏  “ “ “ 113 “ “ (Severe)‏  CNS depression, Confusion, Somnolence  Signs of Increase Intracranial pressure  OLIGURIC Renal Failure in Severe Hyponatremia
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  Management  Repeated Na+ determination; other Electrolytes  H20 deprivation, Use diuretics  Administer Na+ containing Fluids  Sodium must be Titrated slowly back to Normal
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  “ Sample CASE” A muscular 50 year old man with polycystic kidney disease presents w/ hypotension, confusion, oliguria, and no axillary sweat. Past medical record reveals that he has polyuria has been eating a low salt diet because of mild hypertension. BUN has been stable at 40mgs/dL;Blood CO2 is 15mmol/L (Metabolic Acidosis) and Na+ level of 120mEq/L.Body Weight is 90kgs; Urine output- 170ml/day GIVEN: Na+ deficit =140mEq – 120mEq = 20mEq/L Total Body H20 = 90kgs X 60 = 54 L Fluid Loss = 10% (Clinical Findings)‏ First Step: COMPUTE for Hypotonic Na+ deficit Hypotonic Na+ deficit = Na+ deficit X TBW = 20mEq X 54 L =1080(Hypotonic Na+ def.)‏
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  “ Sample CASE” 2 nd Step : COMPUTE for the isotonic Na+ deficit Find out the Isotonic Fluid loss or How much fluid is necessary to revert to ISOTONIC STATE . Formula ISOTONIC FLUID LOSS =Weight X % of FLUID LOSS 90 Kgs. X 10% (9 Liters)‏ Then compute for isotonic Na+ deficit Formula: Isotonic Na+ Loss X NORMAL Na+ level 9 Liters X 140mEq = 1260mEq Total Na+ REQUIREMENT: Hypotonic Na+ Deficit + Isotonic Na+ deficit + Daily requirement 1080mEq + 1260mEq + 75mEq = 2415mEq Initially only ½ is given so divide it by 2 =1207.5 mEq
  • DIAGNOSIS OF IMBALANCES  HYPONATREMIA  “ Sample CASE” 3 rd Step: COMPUTE for the 24 hours H20 requirement The daily H20 requirement in an OLIGURIC patient is reduced: FORMULA 0.2 ml/kg body wt. + preceeding 24 hour Urine Output +10% for every rise of 1 degree in body temp. =(0.2ml X 90 X 24) + 170 =602 ml/day 24 HOUR H20 requirement = Isotonic Fluid loss(9 L) + 600 = 4.8 Liters 2 4 th Step: Compute for Bicarbonate. The ideal replacement solution should contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.
  • DIAGNOSIS OF IMBALANCES  HYP0NATREMIA  “ Sample CASE” 4 th Step: Compute for Bicarbonate. The ideal replacement solution should contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC. Sub- Step: Compute for Chloride Requirement 1.4 = 1245 X= 1245 =890 mEq as NaCl 1 X(mEq) 1.4  The Bicarbonate requirement is thus: 1245- 890 =355 mEq of HCO3  PATIENT’S FLUID & ELECTROLYTE REQUIREMENT  4.8 liters of 5% Dextrose in 0.9 % NaCl Add 8 vials of Na2CO3 (44 mEq/50 cc)‏ Plus 200 cc of 5% NaCl injection
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  Pathophysiology ECF Hyperosmolarity= shift of H20 from cell----  --  ECF-  More Fluid ---  DEHYDRATION Increased Intracellular Osmolality --  CNS effects:  Fever  Hallucination  Delirium
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  Causes  Prolonged Fever  Large surface Burns --  3-5 Liters loss/day  Tachypnea – Do Tube Tracheostomy  Renal Damage  Loss of Solute  Urine High Output Failure  Desert Exposure  Drinking Salt H2O
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  Management  Gradual Reduction of Serum Na+  Rehydrate patient with salt Free H20  Formula: 70 kg patient with Na+ of 160mEq Total Body Water 60% X 70kgs = 42 Liters= Current Body Water 140 =0.87 or 0.9 16 0.9 X 42 =37.8 Liters current Body Water 42L- 37.8= 4.2 Liters ( water Needed)‏
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  “ Sample CASE” A moderately lean woman with esophageal stricture has a serum Na+ level of 160mEq /L (normal is 140mEq). Her present weight is 70kgs.  HER REQUIREMENTS WOULD BE CALCULATED AS FOLLOWS:  Current Body Water 140mEq =7/8 =87.5 % of normal 160mEq  WATER Loss>>> 100%- 87.5% =12.5% of water  PATIENT’S NORMAL total BODY WATER 70 X 60% = 42 Liters  H20 DEFICIT 42 L X 12.5% = 5.3 Liters
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  “ Sample CASE ” A moderately lean woman with esophageal stricture has a serum Na+ level of 160mEq /L (normal is 140mEq). Her present weight is 70kgs.  HER Fluid REQUIREMENT 2.7 + 2.4 = 5.1 L of fluid needed in the next 24 hours containing 70mEq of Na+ FORMULA USED: ½ H20 Deficit + normal daily fluid requirement ½ H2O Deficit + ( 35cc X70 kgs.) 2.4 Liters
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  Example If the same patient has diarrhea as well as esophageal stricture and has persisted with weakness, confusion; hypotension  CALCULATIONS WOULD BE AS FOLLOWS  Present Body Water 140 =7/8 = 87% of NORMAL 160  Water Loss 100-87.5 =12.5%  Patient’s Normal Body Water =70kgs X 60% = 42 Liters  H20 Deficit: 42 L X 12.5% =5.3 Liters  CLINICAL Findings shows 10% dehydration CALCULATIONS should be changed
  • DIAGNOSIS OF IMBALANCES  HYPERNATREMIA  Example If the same patient has diarrhea as well as esophageal stricture and has persisted with weakness, confusion; hypotension  CLINICAL Findings shows 10% dehydration CALCULATIONS should be changed  FLUID LOSS 10% of 70kgs = 7 liters  ISOTONIC Fluid loss = 7 – 5.3 =1.7 Liters  Na+ loss in Isotonic Fluid = 1.7 L X 140mEq = 238mEq  24 Hour Fluid Requirement= ½ H20 deficit + Normal Body Fluid = ½ of 7( 7/2) +2.4 = 5.9 L  24 Hour Na+ Requirement = ½ Na+ deficit + 70 =189mEq  This can be given as: 4 liters of 5% Dextrose in Water plus 1200 cc of NORMAL Saline Solution
  • DIAGNOSIS OF IMBALANCES  ISOTONIC DEHYDRATION  The Serum Na+ Concentration is Normal  “ EXAMPLE” A short obese alcoholic patient presents with  Vomiting due to gastritis  102 F fever due to pneumonitis  Complaining of thirst  Has dry mouth  No groin or Axillary Sweat  Alert and Normotensive  Weight of 100kgs.  Serum Na+ is 140mEq/L  Serum K+ 3mEq/L
  • DIAGNOSIS OF IMBALANCES  ISOTONIC DEHYDRATION  FLUID and ELECTROLYTE Requirement  Fluid Loss = 6% (based on Clinical Findings)‏  Isotonic Fluid loss 100kgs X 6% = 6 Liters  Na+ loss (in isotonic fluid) 140mEq X 6=840mEq  24 hours Na+ Requirement 840 + 100mEq = 520mEq 2  24 hour Fluid Requirement 6 + 4.9 L =7.9 L 2
  • DIAGNOSIS OF IMBALANCES  ISOTONIC DEHYDRATION  FLUID and ELECTROLYTE Requirement  EXPLANATIONS:  The daily requirement is 4.9 instead of 3.5 because of the patient’s fever. Each 1 degree rise in temperature increase by at least 10%  Fluid and Na+ replacement can be given as:  3 Liters of 5% dextrose in Normal Saline  2 Liters of 5% dextrose in water  200cc of Normal saline  KCl should be added as indicated at ½ of the DEFICIT plus the the daily requirement (100mEq) provided urine flow is adequate.  KCl should be divided among the solutions
  • DIAGNOSIS OF IMBALANCES  HYPOKALEMIA  CAUSES.  Chronic Pyloric Obstruction  Ulcerative Colitis  Prolonged Vomiting  Fistula  Diarrhea  Diuretic Therapy  Nephritis  Adrenal Hyperactivity( Stress; Cushing’s Syndrome)‏  PATHOPHYSIOLOGY  Loss of GASTRIC JUICE --  minimal loss of K+ --  Loss of Cl.---  insufficient Cl. For renal Tubular reabsorption of Na+ Loss of Na+ ions>>>Adrenal and Renal mechanisms will conserve Na+>>>and add in exchange K+ and H+ are excreted>>>>>>HYPOKALEMIA
  • DIAGNOSIS OF IMBALANCES  HYPOKALEMIA  CLINICAL FEATURES  Less than 3.5mEq/L in serum  Associated with:  Diuretics  Metabolic Alkalosis  Aldosterone Secretion  GIT losses
  • DIAGNOSIS OF IMBALANCES  HYPOKALEMIA  CLINICAL FEATURES  Prolonged Ileus, Hyporeflexia, Paralysis  Increased sensitivity to digitalis  Favors ALKALOSIS (because of Acid loss) and alkalosis DECREASE K+  ECG shows Prolonged QT; Depressed ST; T Wave inversion  Early Signs of K+ Depletion:  Malaise and Weakness  Paralytic Ileus and Distention  Muscular Paresis
  • DIAGNOSIS OF IMBALANCES
    •  HYPOKALEMIA
    • MANAGEMENT
    •  Add KCl to IV Solution but not to exceed 20mEq/hour
    •  Usual Daily Requirement is 40mEq/day
    •  CONTRAINDICATIONS TO K+ THERAPY
    •  UNTREATED Adrenal Insufficiency
    •  UNTREATED Renal Failure
    •  TEMPORARY Renal Shutdown
  • DIAGNOSIS OF IMBALANCES
    •  HYPERKALEMIA
    • CLINICAL FEATURES
    •  Serum K+ 6mEq/L or over
  • DIAGNOSIS OF IMBALANCES
    •  HYPERKALEMIA
    • CLINICAL FEATURES
    •  Seen in:
    •  Renal Failure
    •  Massive injury like Burns
    •  Acidosis and Low Flow States
    •  Massive GI Hemorrhage
    •  Administration of K+
  • DIAGNOSIS OF IMBALANCES
    •  HYPERKALEMIA
    • CLINICAL FEATURES
    •  Manifested as :
    • 1. Nausea
    • 2. Vomiting
    • 3. Diarrhea
    • 4. Heart BLOCK
    • 5. Loss of Digitalis Effect
    • 6. CARDIAC ARREST
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  • DIAGNOSIS OF IMBALANCES
    •  HYPERKALEMIA
    • PATHOPHYSIOLOGY
    •  In Renal Failure K+ cannot be Excreted, there will
    • be >>accumulation in PLASMA.
    •  In Renal Failure >>>>The Failure to excrete H+ will
    • shift H+ into Cell to maintain pH>>>>K+ will
    • leave cell>>>PLASMA Hyperkalemia.
    •  ECG will show peaked T Waves ,Wide QRS
  • DIAGNOSIS OF IMBALANCES
    •  HYPERKALEMIA
    • MANAGEMENT The principle is to shift back K+ into the cell.
    • 1. Na2C03 given to combat Acidosis>>K+ ion to back into
    • the cell in exchange of H+
    • 2. IV glucose with insulin>> K+ taken up into the cell w/
    • each molecule of glucose that enters the cell.
    • 3. Dialysis
    • 4. Exchange Resin
    • 5. Diminished uptake of K+
  • DIAGNOSIS OF IMBALANCES
    •  HYPOCHLOREMIA
    • CLINICAL FEATURES
    •  Sodium Chloride is below 85mEq/Liter
    •  Seen in Upper GI Obstruction w/ vomiting. One
    • may loss as much as 120-130mEq/day
    •  Hypochloremia in itself does not produce
    • striking Clinical Changes.
  • DIAGNOSIS OF IMBALANCES
    •  HYPOCHLOREMIA
    • PATHOPHYSIOLOGY
    •  Diuretics >> cause increase loss of Chloride thru
    • Kidney>> Urinary Concentration of Chlorides
    • higher than Sodium Concentration.
    •  MANAGEMENT
    •  Treat with KCl solution
    •  May use NH4Cl or 0.1 N HCl (ideal for hypochlo-
    • remia due to metabolic Alkalosis )‏
  • DIAGNOSIS OF IMBALANCES
    •  HYPERCHLOREMIA
    • CLINICAL FEATURES
    •  Chloride above 105mEq/L
    •  Seen in Hypernatremia
    •  Seen in Uretero Intestinal Anastomosis
    •  Seen in Obstructive Uropathy
    •  Excessive intake of NH4Cl
  • DIAGNOSIS OF IMBALANCES
    •  HYPERCHLOREMIA
    • PATHOPHYSIOLOGY
    •  Uretero Intestinal Anastomosis>>>Reabsorption
    • by bowel>>>Accumulation of Cl in excess of Na+
    • ion ( potentiated by Renal Insufficiency)‏
    •  Associated w/ Metabolic Acidosis
    •  MANAGEMENT
    •  Correct Associated Abnormalities
    •  Remove Salt ( Ammonium)‏
    •  Allow Kidneys to Compensate
  • PRINCIPLES OF ACID BASE BALANCE  Normal H+ ion concentration in Extracellular fluid is maintained at pH 7.36-7.42  Daily Metabolic products are H+ and CO2  To keep the pH constant, Acids are neutralized by two mechanisms:  Buffer System of Body Fluids  Regulatory functions of the LUNGS & KIDNEY  Most important Buffer System is the Bicarbonate Carbonic Acid System H2CO3 HCO3 + H+
  • PRINCIPLES OF ACID BASE BALANCE
    • pH is determined by ratio of base bicarbonate
    • to carbonic Acid:
    • HCO3
    • pH = Pk LOG H2CO3
    • ( HENDERSON HASSELBACH’S EQUATION)‏
    •  Carbonic Acid (H2CO3) is a function of the dissolved
    • CO2. This is determined by the pCO2 of Blood &
    • is regulated rapidly and accurately by the LUNGS
    • Bicarbonate(HCO3) of blood is controlled by the
    • rate of its renal secretion .
  • PRINCIPLES OF ACID BASE BALANCE  At pH 7.4 ratio of Carbonate to Carbonic Acid is 20:1  In METABOLIC ACID BASE Shifts, effects on buffer system is on LEVEL of BICARBONATE INCREASED: Increased Bicarbonate = ALKALOSIS Decreased “ = ACIDOSIS
  • PRINCIPLES OF ACID BASE BALANCE  In METABOLIC ACID BASE shifts = LUNGS compensates:  Metabolic Acidosis>> Increased Ventilation >> more CO2 released less H2CO3  Metabolic Alkalosis>> Decreased Ventilation > more CO2 retained >> Increased H2CO3  IN RESPIRATORY ACID BASE shifts the effect on the buffer system is a GAIN or LOSS of CARBONIC ACID  Compensatory Mechanism is via the KIDNEYS by retaining or Excreting BICARBONATES
  • PRINCIPLES OF ACID BASE BALANCE  Respiratory Acidosis = Increased H2CO3 Compensated by RENAL RETENTION OF BICARBONATE  Respiratory Alkalosis = Decreased H2CO3 is Compensated by RENAL EXCRETION of BICARBONATE  Serum HCO3 20 pH = Kidney Serum H2CO3 1 Lungs
  • PRINCIPLES OF ACID BASE BALANCE   To Follow Acid Base Changes KNOW:  Signs and Symptoms  Pathophysiology  Plasma pH  Arterial pCO2  Total Extractable CO2 measured as venous CO2 content corrected to pCO2 of 40mm Hg
  • PRINCIPLES OF ACID BASE BALANCE   METABOLIC ACIDOSIS  Clinical Aspects  Excess H+ in plasma>>Fall in pH >>Diminished>> Plasma Bicarbonates seen in:  Loss of fluid rich in Na2CO3  Adrenal Insufficiency>> Renal loss of Na2C03  Low flow state >>>Lactic Acid  Diabetes Mellitus
  • PRINCIPLES OF ACID BASE BALANCE   METABOLIC ACIDOSIS  Pathophysiology  Increased rate & depth of breathing> Decrease plasma pC02>>>Decrease H2CO3 with return of pH to normal  Laboratory Findings  pH below 7.38  HCO3 less than 24mEq/minute  Arterial pCO2 40mmHg  Acidic Urine w/ low Na+ content
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  • PRINCIPLES OF ACID BASE BALANCE   METABOLIC ACIDOSIS  Management  Treat Cause  Adjustment to respirator (if patient is attached to one). Increased RATE decrease arterial pCO2.  METABOLIC ALKALOSIS  Clinical Aspects  HCl loss due to vomiting, gastric drainage  Loss of K+ and Cl- in urine
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Clinical Aspects cont’d  Diuretics  Adrenal Steroids  Administration of Na2CO3 or Sodium Citrate (in blood transfusion)‏  Pathophysiology  Due to uncompensated loss of Acids or retention of Bases
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Pathophysiology  In Metabolic Alkalosis Increase urinary K+ loss>>H+ and Na+ ion enter the cell>> Decrease of Extracellular H+ ion concentration>> further >>increase in Alkalosis.
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Pathophysiology  LUNG Compensation: Hypoventilation>>> CO2 accumulation>> Increased Carbonic Acid.
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Pathophysiology RENAL Compensation: Increased Excretion of Bicarbonat e in ALKALINE Urine
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Condition is usually seen in:  Multiple Transfusion  Hyperventilation  Volume Reduction  Increased Aldosterone Secretion  Administration of Large volume of Ringer’s Lactate
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Laboratory Findings: 1. Blood pH Higher than 7.44 2. HCO3= Higher than 28mEq/L 3. Arterial PCO2= 40 in the presence of Respiratory Compensation
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Management  Replace lost Na+, Cl, and K+ ions  Lower pH by using of 0.1 N HCl  In moderately severe Alkalosis where there is Increased Renal K+ excretion, permit the tubule to retain H+ (treat) w/ IV KCl  Severe METABOLIC ALKALOSIS is the only good indication for the administration of NH4CL
  • PRINCIPLES OF ACID BASE BALANCE  METABOLIC ALKALOSIS  Severe METABOLIC ALKALOSIS is the only good indication for the administration of NH4CL
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ACIDOSIS  Clinical Aspects  It is caused by Pulmonary Insufficiency 1. Failure to excrete CO2 via the Lungs with normal efficiency as in: a. Pneumonia b. Emphysema c. Fibrosis
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ACIDOSIS  Clinical Aspects  It is caused by Pulmonary Insufficiency 2. Hypoventilation caused by a. Pulmonary Edema b. Injury c. Post op. Atelectasis d. Drugs e. Poor Ventilation( Respirator)‏
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ACIDOSIS  Clinical Aspects  Manifested by: 1. Somnolence 2. Confusion 3. Coma due to CO2 Narcosis
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ACIDOSIS  Pathophysiology  Compensatory Mechanism: 1. Increase Tubular reabsorption of Na+ and bicarbonate by Kidneys 2. Increase excretion of H+ ions
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ACIDOSIS  Laboratory Findings 1. Blood pH below 7.38 2. Arterial pCO2 over 50mm Hg 3. Acute Respiratory Acidosis= Plasma H2CO3 not increased 4. In Chronic state it’s elevated to 20mEq/L
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ACIDOSIS  Management  Control ventilation to increase inspired 02>>> Return of Arterial Blood Gas to Normal  Careful and slow correction of pH and pCO2 so as not to produce rapid changes with associated Cardiac instability
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ALKALOSIS  Clinical Features  Due to Hyperventilation seen in: 1. Pulmonary Infection 2. Hysteria 3. CNS Injury 4. Occasionally during Anesthesia 5. Fever 6. Pain 7. Apprehension 8. Salicylate Poisoning
  • PRINCIPLES OF ACID BASE BALANCE
    •  RESPIRATORY ALKALOSIS
    • Pathophysiology
    •  Hyperventilation leads to Decrease in Alveolar
    • CO2 concentration>>> Decrease in serum
    • H2CO3
    •  Compensatory Mechanism: RENAL increase
    • tubular excretion of Na2CO3
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ALKALOSIS  Laboratory Findings : 1. Blood pH more than 7.46 2. Arterial pCO2 is lower than 36mm Hg. 3. With renal compensation Bicarbonate level will fall 4. Urinary Na+ concentration is high
  • PRINCIPLES OF ACID BASE BALANCE  RESPIRATORY ALKALOSIS  Management  Directed at its initiating Causes  Note:  Mild respiratory alkalosis is common postoperative problem  Associated muscle irritability or frank tetany especially if serum calcium++ level is low  Corrected by administration of calcium salts Calcium Chloride, Calcium Gluconate
  • PRINCIPLES OF ACID BASE BALANCE  FORMULA FOR Acid Base Imbalance Serum HCO3 = 20 Serum H2CO3 1  in the numerator 20/1 to 10/1 >Met. ACIDOSIS  in the numerator 20/1 to 30/1 >Met. ALKALOSIS  in the denominator 20/1 to 20/2>>Resp Acidosis  in the denominator 20/1 to 20/.5 > R. Alkalosis
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  PRIORITIES 1. Correct SHOCK and restore Blood Volume>>Normal 2. Restore Colloid Osmotic Pressure 3. Correct Acid Base Imbalance 4. Restore Blood Osmolality 5. Correct K+ deficit 6. Correct Total Body Electrolytes disturbance (static debt) and establish daily maintenance
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  DEFICIT CORRECTION  Fluid and Electrolyte Therapy to Correct existing Deficit. Examples :  Blood volume deficit in Acute or Chronic Blood loss.  Extracellular or Intracellular deficit in dehydration  Deficit correction is added to maintenance and replacement therapy in order to restore H20, salt balance  Deficit correction is also Top priority in Fluid and Electrolyte therapy
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  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY Necessary to Replace Abnormal (continuing) losses from or within the body. Example via drainage tubes.
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY  Gastrointestinal Losses  If these are purely gastric( succus gastricus); A solution providing 0.45% NaCl mEq plus 40 mEq of KCl per liter is used for replacement.
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY  Gastrointestinal Losses  If the fluid lost contains intestinal (succus entericus) Lactated Ringer’s solution plus 10 mEq KCl per liter is used .
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY  Third Space Loss 1. The amount of loss varies with the magnitude of injury. 2. Lactated Ringer’s solution plus Albumin is used.
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY  Continuing losses require volume for volume replacement and added to maintenance requirements.  Replacement Therapy has second priority in Fluids & Electrolyte Therapy
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  MAINTENANCE THERAPY  Clinical Example: Average size 60kgs woman has an Elective Cholecystectomy. No drainage tubes.  Patient’s Normal Daily Requirements  H2O : 35ml/kgs X 60 >>> 2100 cc  Na+ : 1mEq/kgs X 60 >>> 60mEq  K+ : 1mEq/kgs X 60 >>> 60mEq  Cl- : 1.5mEq/mEq X 60 >>> 90mEq  HCO3-: 0.5mEq/mEq X 60 >>> 30mEq
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  MAINTENANCE THERAPY Methods to calculate H20 maintenance requirement 1. Utilization of body water as a guide for H20 Ex. 70 kg. x 0.5 x 24 hrs + 500ml/24 hrs = 1340ml/24hrs 2. It can be based on patient’s weight (Pediatric Patients)‏ 100 ml/kg for the first 10 kg of body weight 50 ml/kg for the next 10 kg of body weight 20 ml/kg for each additional kg of body weight
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  MAINTENANCE THERAPY Methods to calculate H20 maintenance requirement 3. A given amount of water /kg body wt. can be used. (35 ml/kg/24 hours)‏ 4. A given amount of fluid regardless of wt. (125ml/hr)‏
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  MAINTENANCE THERAPY  IV Fluids would be as follows: 1. 1000 ml of 5% Dextrose in H2O + 40mEq Kcl 2. 650 ml of 5% Dextrose in H20 + 20mEq KCl 3. 450 ml of 5% Dextrose in Lactated Ringer’s solution
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  MAINTENANCE THERAPY  This would provide:  2100 ml of Water  58.5mEq of Na+( 4.5 X 1.3mEq/dl LR  61.8mEq of K+ (60mEq from KCl+1.8mEq  109mEq of Cl( 60mEq from KCl + 49mEq  12.6mEq of HCO3( 4.5 X 2.8mEq/dl LR
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY  The same patient develops ileus. NGT was placed. Over 24 hours 1600 ml NGT bile stained fluid was collected. Normal serum electrolytes.  For replacement she would require: 1600 ml D5LR solution +10mEq of KCl
  • PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCE  REPLACEMENT THERAPY Her maintenance requirement would be the same  1000 ml of 5% Dextrose in H2O + 30mEq Kcl  1000 ml of 5% Dextrose in H20 + 30mEq KCl  2 liters of 5% Dextrose in Lactated Ringer’s solution + 10mEq KCl to each liter.  Run at 170ml/hr( 400 maintenance 600 Replacement)‏
  • OTHER COMMONLY USED FLUIDS SOLUTIONS NA+ CONTENT Cl CONTENT USES 3% NaCl INJ. 51 51 For symptomatic Na deficit 5% NACl INJ 85 85 SAME AS ABOVE 14.9% KCl INJ 20 cc ampule 40 40 Additive for K+ Correction & maintenance 7.5% NA2CO3 44.6 44.6 HCO3 Additive for GI Losses; Correct Metabolic Acidosis
  • COMMONLY USED PARENTERAL SOLUTIONS SOLNS. Na+ K+ Cl- HCO3- Ca++ Principal Uses 0.9 NaCl 154 154 Correction of Hyponatremia ECF Replacement 0.45NaCl 77 77 Na+ Maintenance; Gastric Fluid Replacement Lactated Ringer’s Solution 130 4 109 28 9 Best ECF Replacement; Correction of Isoosmolar Deficit 5% Dextrose In Water Correction of insensible water loss; Maintenance and Correction of Hyperosmolar Dehydration
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