Inventory ledger.ppt

1. Dr Mathias Negussie, MD
Consultant Anesthesiologist
2021

2. At the end of this session participants are expected to:
 Describe different types of fluids and their components,
advantages &disadvantages
 Develop skills on fluid requirement, their calculation
and fluid balance monitoring
 understand sodium disorder and its management
 know potasium disorder and its management

3.  A 35 years old man admitted to ICU after he presented
with Acute abdomen sec. to peritonitis. Laparotomy
was done under GA. On arrival to the ICU he is sleepy,
VS BP 80/50, P120/min, RR 30/min, SO2 83% , has
cold extremities, capillary refill >2sec
 Discussion points
 Assess the fluid requirement
 Discus on the choice of the fluid &Calculate the fluid
requirement
 which electrolyte abnormality do you expect for this pt.

4. Body fluid composition
 Total body water ≈ 60% of body weight in average male,
and ≈ 50%in average female.
 A 70kg lean adult man has a total body water of 42liters,
which is 60%of total body weight.
 The distribution is 66% intracellular, 34%extracellular
compartment.
 The extracellular is further subdivided into intravascular
25% (3.5L), and an interstitial 75 %( 10.5L)

6.  Crystalloid- normal saline 0.18-0.9 , Ringers lactate…
 Colloids
1. Natural – blood and blood products
2. Synthetic – Dextran, Albumin, …

7. Plasma 0.9%
NaCl
Lactated
Ringer's
Plasma-
Lyte 148a
Albumin
5%
Sodium,
mmol/1
140 154 131 140 130–160
Potassium
, mmol/l
5 – 5.4 5 ≤2
Chloride,
mmol/l
100 154 111 98 –
Calcium,
mmol/l
2.2 – 2 – –
Magnesiu
m, mmol/l
1 – 1 1.5 –

8. Solution Nature Amount
of volume
expansion
Allergic
reaction
Molecul
ar
weight
Remark
Hetastarch Synthetic
starch
1to 1 Rare
Dextran 40 Polysacharid
e,
1to2 1% 40,000 Interference with
subsequent cross
matching , when
>1.5gm/kg/d/ is
given
bleeding may occur
Dextran 70 70,000

9.  Euvolemia
 Hypovolemia
 Hypervolemia

10.  use of high chloride, may be associated with major complications
following surgery and increased mortality in critically ill patients with
sepsis.
 The relative risk of in‐hospital mortality was progressively lower
among patients who received a greater proportion of balanced fluid,
than 0.9 normal saline
 higher serum chloride levels, found reduce renal artery blood velocity
and reduced renal cortical tissue perfusion
 metabolic acidosis produced by infusion of 0.9% saline significantly
impaired gastro pyloric motility by reducing pyloric contraction
amplitude, which results in delayed gastric emptying or gastro paresis.
 Therefore while resuscitating patients balanced fluid or using other
crystalloids alternatively is advised.

11.  5R principles
1. Resuscitation- shock, deficit
2. Routine maintenance – 24hrs requirement(for whom)
3. Replacement- ongoing loss
4. Redistribution – 3rd space lose, sepsis
5. Reassessment- monitoring, adjustment of the order
Other considerations
 Type of fluid
 Rate and volume of administration

12. Types of
loss
Blood loss Vomiting ,
NGD
Diarrhea
/colostomy
Biliary,
pancreatic
Insensible
(fever,
respiration,
perspiratio
n )
Loss content RBC,
Plasma
Coagulation
factors
Water +
Na 30-
60mml/l
K 14mml/l
Cl-140mml/l
H -60-
80mmol/l
Water +
Na -30-140
K 30-70
HCO-20-80
Water +
Na -125-145
K -5-8
Cl -56-105
HCO -30-85
Pure water
Type of
fluid
required
Balanced
solution
&colloids
Balanced
solution
Balanced
solution
Balanced
solution
Pure water

13.  BP (systolic)
 Pb/m
 Capillary refill
 Mucus membrane
 Extremities temperature
 RR
 Urine out put (UOP)
 Mentation
 Passive Leg Raise (PLR

14. Signs of fluid deficit – shock
 SBP<100mmHg,
 P>90/min,
 Capillary refill >2sec,
 periphery cold on touch,
 PLR +ve
 UOP- <0.5ML/hr

15. Resuscitation Maintenance Replacement &
redistribution
SBP<100mmHg, P>90/min, Capillary refill
>2sec, periphery cold on touch, PLR+ve
No sign of fluid deficit
or no ongoing loss
Estimate the
loss; GI, high T,
3rd space loss,
fistula
Give o2, secure large bore IV access, give
500ml crystalloid/15min, reassess if still no
change on the symptoms give ≈2000cc,
determine the cause, catheterize pt. see the
amount &color of the urine = balanced
solutions and colloids
4:2:1/kg/hr
1mmol/Kg Na, K, Cl.
50-100g/d, Glucose
Plus insensible loss 500-
800cc/d= DNS
Maintenance
plus amount of
estimated deficit
or ongoing loss
= balanced
solutions and
glucose
Frequent monitoring Reassess &monitor Reassess
&monitor

16.  Fluid balance is a term used to describe the balance of
the input and output of fluids in the body to allow
metabolic processes to function correctly
 The core principle of fluid balance is that the amount of
fluid lost from the body must equal the amount of fluid
taken in;

17.  The output urination, defecation, and insensible (via
respiration, perspiration, and expectoration) must equal
the input (via eating and drinking, or by parenteral
intake).
 Euvolemia is the state of normal body fluid volume,
including blood volume, interstitial fluid volume, and
intracellular fluid volume;
 hypovolemia and hypervolemia are imbalances.

18.  Normal urine output is in a range of 0.5-2ml/kg per
hour &the urine should be a light yellow colour.
 Insensible losses account for 500 to 800 ml/day
 In children insensible fluid loss is calculated 400 ml/m2
body surface area.
 Fluid loss through feces 100 ml/day
 For females, an additional 50 ml/day is lost through
vaginal secretions.

20.  The requirement to provide accurate, correct fluid balance
monitoring and recording as part of the patient‟s vital sign
data should be established as a fundamental standard
 24 hour chart divided every 6hrs or when necessary hrly
measurements of fluid inputs and outputs,
 Hemodynamic parameters of hypovolemia (e.g.
hypotension, tachycardia, poor capillary refill, Tachypnea
and altered mental status) and
 Filling pressure (jugular vein felling, central venous
pressure) should addressed

21.  The body's homeostatic control mechanisms, which maintain a
constant internal environment, ensure that a balance between fluid
gain and fluid loss is maintained.
 The anti-diuretic hormones vasopressin (ADH) and aldosterone play
a major role in this.
 If the body is becoming fluid-deficient, there will be an increase in
the secretion of these hormones, causing fluid to be retained by the
kidneys and urine output to be reduced.
 Conversely, if fluid levels are excessive, secretion of these hormones
is suppressed, resulting in less retention of fluid by the kidneys and
a subsequent increase in the volume of urine produced.

23.  Substance when dissolved in solution dissociates into
ions
 These ions are able to carry an electrical current
 Which develops an electrical charge when dissolved
in water
 Salts like NaCl and KCl in aqueous solutions gets
dissociated to
 Charged ions Na+ and Cl- called as Electrolytes.
 The concentration of these Electrolytes is expressed
as mEq/L.

24. 24
INTRACELLULAR
Electrolytes
EXTRACELLULAR
Electrolytes
POTASSIUM SODIUM
MAGNESIUM CHLORIDE
PHOSPHOROUS BICARBONATE

25.  Extracellular fluid volume is directly proportional to
total body sodium (Na + ) content.
 Renal Na + excretion ultimately controls extracellular
fluid volume and total body Na + content.
 HYPONATREMIA
 Defined as serum Na + <135mmol/l.
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26.  To identify causes of abnormalities of sodium
homeostasis it is important to assess plasma and urinary
Na + levels along with the patient’s state of hydration
(hypo-/eu-/hypervolemia)
 Continued solute-free water intake with a decreased
renal capacity for solute-free water excretion
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27.  Presentation
 Important to differentiate between acute and chronic hyponatremia.
 Speed of onset is much more important for manifestation of symptoms than
the absolute Na + level.
 Rare to get clinical signs if Na + >125mmol/l.
• Na + 125–130mmol/l causes mostly GI symptoms, i.e. nausea/vomiting.
• Na + <125mmol/l nausea/vomiting, muscular weakness, headache, lethargy,
psychosis‚ raised ICP, seizures, coma, and respiratory depression.
 Mortality high if untreated.
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28. • Step 1. Measure Serum Osmolality
• Hypo osmolality rules out pseudo (factitious)- and hypertonic
hyponatremia. Hypotonic hyponatremia is called true
hyponatremia.
Step 2. Estimate volume status
 History
• Assess fluid loss (diarrhea, vomiting)
• Review medications such as oral hypoglycemic,
antihypertensive
• Review medical conditions such as, cardiovascular, thyroid,
renal, and liver, including adrenal disease
• Check IV fluids for maintenance.
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29.  Physical Examination
• Vital signs with orthostatic changes (very important and mandatory)
• Exam of neck, lungs, heart, and lower extremities for fluid status
• Evaluation of mental status is extremely important
• Based on volume status, classify hypotonic hyponatremia into
1. Hypovolemic hyponatremia (relatively more Na+ than water loss)
2. Hypervolemic hyponatremia (relatively more water than Na+ gain)
3. Normovolemic hyponatremia (relatively more water relative to Na+)
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31. Step 3. Obtain Pertinent Laboratory Tests
• Serum chemistry and lipid panel
• Complete blood count
• Serum and osmolality and urine Na+ plus K+
• Fractional excretion of Na+, uric acid, and phosphate
is needed occasionally
• Check liver, thyroid, and adrenal tests.
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32.  Treatment of Hyponatremia
 Hyponatremia is classically defined as acute (< 48 h
duration) or chronic (> 48 h duration), and further
characterized as asymptomatic or symptomatic.
depends on four factors:
1. Severity of hyponatremia,
2. Duration of hyponatremia,
3. Signs and symptoms of hyponatremia, and
4. Volume status
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33.  Hypovolemic hyponatremia: Symptoms are unusual
because osmotic shifts in the brain are limited by the
loss of both Na+ and water.
 ECF volume should be restored with isotonic saline,
which will also reduce ongoing ADH release.
• Hypervolemic hyponatremia: Free water restriction,
optimization of the underlying disease state, such as
improving cardiac output with ACEI to reduce the
neurohormonal response.
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34. • Chronic, asymptomatic hyponatremia: underlying
cause should be treated. Fluid restriction,ADH
antagonists (lithium, demeclocycline), and loop
diuretics may be used.
• Acute Symptomatic hyponatremia: Acute
symptomatic hyponatremia (seizures, respiratory
distress, etc.) is a medical emergency.
 3 % NaCl is the fluid of choice, because it has high
osmolality than most of the patients’ urine
osmolality.
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35.  In patients with moderate symptoms (confusion,
lethargy, nausea, and vomiting)
 Hypertonic 3% saline may be used.
 Initial rate of 1 mL/kg/h with the goal of increasing
[Na+] by 0.5 -1 mEq/L/h for 3 to 4 hours,
 Then electrolytes should be rechecked.
 The infusion rate should be modified to ensure that
[Na+] is increased by no more than 10 mEq/L in the
first 24hrs of rx.
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36.  Severely symptomatic hyponatremia (coma, seizures, often with [Na+] <120 mEq/L)
is typically of acute onset and the risks of undertreating
are more than those of osmotic demyelination.
 A bolus of 100 mL of 3% saline should initially be given with
the aim of acutely increasing [Na+] by 2 to 3 mEq/L.
 If no improvement in neurologic status occurs, this approach may be repeated once
or twice at 10-minute intervals.
 After this, treatment should continue as for moderately symptomatic patients.
 Increasing [Na+] by no more than 10 mEq/L in the first 24 hours.
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37.  Assuming no urine excretion of Na+, a bolus of 100 ml
raises serum [Na+] by 1 mEq.
 To avoid overcorrection, calculate Na required to
achieve….
 Amount of Na+needed = Total body water ×(desired
Na − actual Na).
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38. 1.Cerebral Edema
 Most of the signs and symptoms of hyponatremia are
neurologic due to cerebral Edema.
2.Osmotic Demyelination Syndrome.
 Clinical Manifestations
 1. Paraparesis or quadriparesis
 2. dysarthria or dysphagia
 3. Locked-in syndrome
 4. Movement or behavioral disorders
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39.  Hypernatremia ([Na] > 145 mEq/L) is less common
than hyponatremia, but may affect up to 10% of
critically ill patients.
 If severe ([Na] > 160 mEq/L),a 75% mortality may
occur depending on the severity of the underlying
disease process.
 The major mechanisms are excessive water loss with
inadequate compensatory intake, lack of ADH, or
administration of exogenous Na.
 Diabetes insipidus(DI)
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40.  Central DI is seen after pituitary surgery, subarachnoid
hemorrhage, traumatic brain injury (particularly skull base
fractures).
 Nephrogenic DI may be due to renal disease, electrolyte
disorders, or drugs (lithium, foscarnet, amphotericin B,
demeclocycline).
 Clinical features of hypernatremia include altered mental
status, lethargy, irritability, seizures, hyperreflexia, and
spasticity.
 Diagnosis is based on assessment of intravascular volume
status and urinary osmolality and Na+ concentration.
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41.  In patients with persistent urine output of more than 100
mL/hr and hypernatremia, DI should be Considered.
 Diagnostic criteria include an inappropriately dilute urine
(<300 mOsm/kg) in combination with hypernatremia and high
serum osmolality (>305 mOsm/kg).
 Urine specific gravity (SG) may provide a rapid guide to urine
osmolality where urgent treatment is being considered; urine
SG less than 1.005 in the context of hypernatremia and a
potential underlying cause is consistent with DI.
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42.  Treatment of hypernatremia depends on 6 factors:
1. Correction of the underlying cause
2. Calculation of water deficit
3. Selection and route of fluid administration
4. Volume status
5. Onset of hypernatremia (acute or chronic)
6. Rate of correction
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43.  Treatment is tailored to the intravascular volume status,
but as with hyponatremia, correction of the Na+
concentration should be no more rapid than 10
mEq/L/day unless the onset has been very acute.
 Hypovolemic hypernatremia: Correction of the
intravascular volume deficit with isotonic saline and
correction of the underlying cause (e.g., insulin to
reduce hyperglycemia), then correction of the water
deficit with 0.45% saline, 5% dextrose or enteral water
to cover the deficit and ongoing losses.
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44.  Euvolemic hypernatremia: Use of 0.45% saline, 5% dextrose, or
enteral water to replace the deficit and ongoing loss.
 In central DI, in which urine output is greater than 250 mL/hr
and risk exists for hypovolemia, use ADH
analogue(Desmopressin acetate).
• Hypervolemic hypernatremia: Stop administration of exogenous
Na+, give furosemide with 5% dextrose or enteral water. Dialysis
may be indicated in the presence of renal failure.
@Water deficit= TBW*Actual Na/Desired Na-1
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45.  Defined as plasma potassium <3.5mmol/l.
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 Moderate-to-severe hypokalemia (2 to 2.5 mEq/L)
leads to muscle weakness,ECG abnormalities (ST
segment depression, T wave depression, U wave
elevation),and arrhythmias (atrial fibrillation).
 Such treatment is of prime importance when acute
arrhythmias exist, and K+ should be maintained at
greater than 4 to 4.5 mEq/l.

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48.  Step 1 History and physical examination is essential. BP
important, as high or low BP gives clues to the etiology of
hypokalemia.
 Step 2 Rule out pseudo hypokalemia. Patients with
leukemia with leukocyte count > 100,000/μl can present
with hypokalemia because of K+ uptake by these
leukocytes.
 Step 3 In true hypokalemia, total body K+ is depleted.
 Determination of 24-h urine Na+ and K+ concentration is
important.
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. Hypokalemic ECG changes

50.  Management
• Check Ses
 Hypokalemia resistant to treatment may be due to
concurrent hypomagnesaemia.
• Exclude Cushing’s and Conn’s syndromes.
• Oral replacement is safest, up to 200mmol/d, e.g. potassium
chloride
two tablets 4 times a day = 96mmol K + .
• IV replacement—essential for patients with cardiac
manifestations,
skeletal muscle weakness, or where oral replacement not
appropriate.
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51. • Aim to increase K + to 4.0mmol/l if treating cardiac
manifestations.
• Maximum concentration for peripheral administration is
40mmol/l
(greater concentrations than this can lead to venous
necrosis).
 40mmol KCl can be given in 100ml 0.9% sodium
chloride over 1hr but only via an infusion device, with
ECG monitoring, in HDU/ICU/theatre environment,
and via a central vein.
 Plasma K + should be measured at least hourly during
rapid replacement.
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 The features of hyperkalemia include muscle
weakness,paralysis, and altered cardiac conduction
(increased automaticity and enhanced repolarization)
with consequent ECG changes as K+ levels increase.
• 5.5 to 6.5 mEq/L: Tall, peaked T waves
• 6.5 to 7.5 mEq/L: Prolonged PR interval
• Greater than 7.5 mEq/L: Widened QRS
• Greater than 9.0 mEq/L: Sine wave pattern,
bradycardia,ventricular tachycardia, increased risk for
cardiac arrest.

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56.  Acute hyperkalemia sufficient to induce
electrocardiographic changes is a medical emergency
that requires rapid treatment.
 Hyperkalemia greater than 6.5 mEq/L, in the context of
anuric renal failure, is an indication for acute renal
replacement therapy.
11/10/2023 56

57.  99% is found in the skeletal system (bone and teeth)
 1% skeletal calcium exchange with blood calcium
 calcium plays a major role in transmitting nerve
impulses and helps to regulate muscle contraction and
relaxation, including cardiac muscles.

58.  ionized [Ca2+] < 4 mg/dL or <1 mmol/L
 any condition that cause a decrease in the production of
PTH may result in hypocalcemia
 Causes
◦ multiple blood tranfusion
◦ chronic renal failure
◦ elevated phosphurus
◦ chronic alcoholism
◦ alkalosis
 signs - chvostek’s
- trousseau’s

59.  IV administrations of calcium like
◦ calcium gluconate
◦ calcium chloride
 Vit. D therapy initiated to increase calcium absorption
from GI
 increase the dietary intake of calcium

60.  ionized [Ca2+] > 1.5 mmol/L or total serum calcium >
10.5 mg/dL
 dangerous inbalance when severe(total serum calcium
> 13 mg/dL)
 high mortality if untreated (50%)
 Causes;
◦ multiple myeloma
◦ vit. D overdose
◦ prolonged immobilization
◦ thiazide diuretics

61.  administer fluid (0.9% NS)
 promote excretion with furosemide
 give calcitonin

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