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Dr Mathias Negussie, MD
Consultant Anesthesiologist
2021
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
 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.
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)
Fluid and Electrolyte Imbalance.pptx
 Crystalloid- normal saline 0.18-0.9 , Ringers lactate…
 Colloids
1. Natural – blood and blood products
2. Synthetic – Dextran, Albumin, …
Ad

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Fluid and Electrolyte Imbalance.pptx

  • 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
  • 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.
  • 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. 11/10/2023 25
  • 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 11/10/2023 26
  • 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. 11/10/2023 27
  • 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. 11/10/2023 28
  • 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+) 11/10/2023 29
  • 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. 11/10/2023 31
  • 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 11/10/2023 32
  • 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. 11/10/2023 33
  • 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. 11/10/2023 34
  • 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. 11/10/2023 35
  • 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. 11/10/2023 36
  • 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). 11/10/2023 37
  • 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 11/10/2023 38
  • 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) 11/10/2023 39
  • 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. 11/10/2023 40
  • 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. 11/10/2023 41
  • 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 11/10/2023 42
  • 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. 11/10/2023 43
  • 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 11/10/2023 44
  • 45.  Defined as plasma potassium <3.5mmol/l. 11/10/2023 45
  • 46. 11/10/2023 46  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.
  • 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. 11/10/2023 48
  • 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. 11/10/2023 50
  • 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. 11/10/2023 51
  • 53. 11/10/2023 53  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.
  • 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