Fluid and Electrolyt..

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Fluid and Electrolyt..

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

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