 Solvent
 Volume
 Dielectric constant
 Surface tension
 Some more

Seizures in pyogenic meningitis………
Had seizure on 2nd
day . On Dilantin.
10 months female with meningitis.
Second L.P.( 3rd
day ) showed improvement
Refractory seizure on 6th
day
S.I.A.D.H.

Hyponatremia………………………………..
K/C of Thalassemia
Admitted for G / E improved
Was found to be Hyponatremic on
admission ( 112 )
Correction done twice but Hypon. Cont.
Asymptomatic all throughout.
PSEUDO HYPONATREMIA…..

Respiratory failure………………………………..
5 months male with R.A.D. was doing well
On extensive nebulization and supportive therapy.
Deteriorated on 4 the day , lethargic, look exhausted .
Respiratory rate is less now.
ABG day 2..pH 7.34.,pO2 80 on FiO2 of 50. CO2 30
ABG day 4..pH 7.23.,pO2 85 on FiO2 of 30. CO2 67
Electrolytes gave the answer…

Status on 4 th day
On mannitol
Blood sugar 377 mg %
Serum sodium 151. BUN 38
= 336
Seizures in falciparum malaria
Osmolality (mOsm/kg) = 2 [mEq/L Na+
] +
(mg/dL glucose) / 18 + (mg / dL BUN) /2.8

14 months male with RTA
Hypo tonic no h/o seizures
 ECG : suggestive of Hypokalemia with extra systoles
 Plasma sodium = 140
 Plasma potassium = 1.3
 Chloride = 117
 Bicarbonate = 10
 Ca = 6.3
 Arterial pH = 7.26
 PCO 2
= 23
 What effect would correction of acidosis
have on plasma K +
?
 Would correction of Ca be part of
initial management . ?

 Correction of acidosis will drive k +
into the cells
Further worsening hypokalemia.Acidosis is not sever
and can wait. Hypokalemia first.
 Hypocalcaemia protects against hypokalemia
Thus treatment of hypokalemia should precede
Hypocalcaemia.
Correction of hypokalemia may precipitate
Tetany , this is a less serious than hypokalemia.
 What effect would correction of acidosis
have on plasma K +
?
 Would correction of Ca be part of
initial management ?

1. Anions - Negatively charged ions, such as chloride .
2. Cations - Positively charged ions as sodium .
3. Colloid/Colloid solution - Liquid containing
suspended substances that do not settle out of the
liquid/solution
4. Crystalloid - a substance that in solution can pass
through a semi permeable membrane and be
crystallized.
5. Electrolytes - cations or anions which have the ability
to conduct electrical current in solutions.

Age
TBW as % of
body weight
ECF as % of
body weight
ICF as % body
weight
Premature 75-80
Newborn 70-75 50 35
1 Year Old 65 25 40-45
Adolescent
Male
60 20 40-45
Adolescent
Female
55 18 40

MAINTENANCE REQUIRMENT……
Up to 10 Kg 100 ml/Kg
10 to 20 Kg 1000 ml + 50 ml / Kg above 10.
20 Kg onwards 1500 ml + 25 ml / Kg above 20.
3 mEq Na and K per 100 ml of water

Usually estimated from body weight
insensible water loss averages 50 ml per 100
kcal consumed. Provision of 50 ml of water
per 100 kcal consumed allows the excretion
of isotonic urine. Thus, 100 ml of water is
required for each 100 kcal consumed.
Empirically, 1-3 mEq Na+ and K+ are
required for each 100 kcal . Five percent
dextrose is necessary to prevent protein and
lipid catabolism. Maintenance requirements
are best replaced with [5% dextrose, 0.2%
NaCl + 20 mEq KCl/liter].
Maintenance requirements

RESUSCITATION MAINTENANCE
Crystalloid
Replace acute loss
1. Replace normal loss
(IWL + urine+ faecal)
2. Nutrition support
ELECTROLYTES
FLUID THERAPY
Colloid NUTRITION

Percent
Dehydration
Infa
nt
Chil
d
Clinical Signs and Symptoms
Mild 5%
3-
4%
Increased thirst, tears present, mucous membranes moist, ext.
jugular visible when supine, capillary refill > 2 seconds centrally,
urine specific gravity > 1.020
Moderate 10%
6-
8%
Tacky to dry mucous membranes, decreased tears, pulse rate may
be elevated somewhat, fontanels may be sunken,oliguria, capillary
refill time between 2 and 4 seconds, decreased skin turgor
Severe 15% 10%
Tears absent, mucous membranes dry, eyes sunken, tachycardia,
slow capillary refill, poor skin turgor, cool extremities, orthostatic
to shocky, apathy, somnolence
Shock
>15
%
>10
%
Physiologic decompensation: insufficient perfusion to meet end-
organ demand, poor oxygen delivery, decreased blood pressure.

RESTORATION
OF CIRCULATING
VOLUME IS THE
TOP PRIORITY
FLUID IS ……..
NORMAL SALINE

I .C .F B
L
O
O
D
K = 140
Osm = 280
Na = 140
Osm = 280
I .C .F In.
S
F
K = 140
Osm = 280
Na = 140
Osm = 280
B
L
O
O
D
In.
S
F
E.C.F. E.C.F.I.C.F. I.C.F.
DEHYDRATION

I S O HYPERHYPO
120 140 160
240 280 320
W W
ICF ICF
ICF

Isonatremic dehydration….
Correction over 24 hours…
20 Kg child
10 % Dehy.
Na = 140
Maintenance Replacement Total
½ N.S.X X
2000 ml
10 % of 20 Kg
1500 ml 3500 ml
5 % dext.
H20
Na
3 mEq / 100 ml.
15 3 = 45
10 20 = 200 mEq
245 mEq / 3.5 Lt.Loss =
10mEq / Kg

Hyponatremic dehydration….
Slow correction , over 48 hours…
Not more than 10 mEq in 24 hours
20Kg child
10 % Dehy.
Na = 110
Maintenance Replacement Total
( As 5 % dextrose )
1 / 2 N.S.
XNa
3 mEq / 100 ml.
30 3 = 90
140-110 ½ wt.X
300 mEq
390 / 5 Lit.
2000 ml
10 % of 20 Kg1500 2
3000ml
5000 mlXH2O

HYPONATRMIC
EMERGENCIES
 3% hyper tonic saline
 5 ml/kg over 1 hour with the goal
sodium level of 125meq/ L , then correct
sodium further by calculating deficit

Maintenance Replacement Total
1/4 N.S.
Hypertonic dehydration….
Slow correction , over 48 hours
Not more than 10 mEq in 24 hours
20 Kg child
10 % Dehy.
Na = 165
400 m.l. of N.S.
= 61 mEq
Free water deficit = ( 4 X wt inKg ) X ( Serum Na – 145)
1500 2
3000ml
3 mEq / 100 ml.
30 3 = 90X
X Deficit = 2000
F.W.D. = 1600
Reminder as N.S.
5000 ml
151 mEq / 5 lit.
H20
Na

HYPER
160
320
W
ICF
HYPER
CHRONIC
160
320
W
ICF
RAPID
TREAT.
130
290
W
ICF

Seizure while treating
hypernatremia

D 5 % with ½ Normal Saline = 77 mEq Na /
Lit.
Add 150ml of 3 % Normal Saline to a Liter of 5
% Dextrose
D 5 % with ¼ Normal Saline = 34 mEq Na /
Lit.
Add 70 ml of 3 % Normal Saline to a Liter of 5
% Dextrose

Isonatremic dehydration is best replaced with
5% dextrose, ½ NaCl + 20 mEq KCl/L over
24 hours. ( Deduct bolus therapy )
Hyponatremic dehydration is best replaced
with 5% dextrose ½ NaCl + 20 mEq KCl/L
over 48 hours. ( Deduct bolus therapy )
Hypernatremic dehydration is best replaced
with 5% dextrose with ¼ NaCl + 20 mEq
KCl/L over 48 hours. ( Deduct bolus therapy )

Fallacies of body fluid calculations
 Lean body mass calculations
 Variation in body secretion
 Variation in renal handling
 Effect of body temperature
 Isohydric effect
 Variation in surface area

HYPERNATREMIA IN ICU Urine output
Low High
Urine osmolality Urine osmolality
Low HighHigh
Hypo tonic fluid
loss
 Insensible loss
 G I Loss
 Diuretics
D. Insipidus
Osmotic
diuresis
 Central
 Nephrogenic

Common IV Solutions
Solution Glucose (g/L) Na+
K+
Ca+2
Cl-
Lactate PO4
-3
Mg+2
5% Dextrose (D5
W) 50 0 0 0 0 0 0 0
10% Dextrose (D10
W) 100 0 0 0 0 0 0 0
Normal Saline (NS) 0 154 0 0 154 0 0 0
D5
NS 50 154 0 0 154 0 0 0
D5
½NS 50 77 0 0 77 0 0 0
0.2% NS 0 31 0 0 31 0 0 0
3% NaCl 0 513 0 0 513 0 0 0
Ringer's Lactate (LR) 0 130 4 3 109 28 0 0
D5
LR 50 130 4 3 109 28 0 0
D10
E#48 100 30 15 0 20 25 3 3
D5
E#48 50 25 20 0 22 23 3 3
D10
E#75 100 57 35 0 40 25 12 6
D6
E#75 60 40 40 0 35 20 15 0
Note: Glucose in g/L; all ions in mEq/L.

98 %
2 %

98 % 2 %
Hyperkalemia
K
+

H
I
O
N
S
K ACIDOSIS CAUSES
HYPERKALEMIA
ALKALOSIS ……… LOW K
+

True Hyperkalemia
Excess K+ intake
Redistribution
Decreased excretion
Renal failure
Oliguria
Hypoaldo.
Nsaids
Ace inhibitors
Acidosis
Insulin Def.
Adrenal Ins.
Periodic P.

98 % 2 %
K + + + +

 Calcium chloride: 0.2 mL /kg/dose of 10% sol IV over 5
min; not to exceed 5 mL (stop infusion if bradycardia
develops)
Calcium gluconate: 100 mg/kg (1 mL/kg) of 10% sol IV over
5 min; not to exceed 10 mL (stop infusion if bradycardia
develops)
 Soda bi carb …
 2 ml / kg 25 % dextrose with .1 units /kg insulin .
over 30 minutes (1 U regular insulin/5 g glucose )
 Beta agonists
Hyperkalemia

Hypokalemia…

Hypokalemia true Distribution
Increased loss Urinary K + Decreased
Hypertension Normal B.P.
Acidosis Alkalosis
Renin
G.I.loss
Biliary ETC.

I . V . Kesol should be considered for
 Significant arrhythmia
 Sever muscle weakness
 Severe hypokalemia (< 2.5.0 mEq. / L).
 Digoxin toxicity
 Hepatic encephalopathy
Maximum concentrations of KCl used in
peripheral veins generally should not exceed 4
meq. /100 cc, due to the damaging effects on
the veins , at a rate of 1 mEq/kg per hour.

Potassium should be administered slowly,
preferably Orally, at a dosage of 4 to 6
mEq/kg per day.

ADH excess
Water retention E.C.Fluid ++
Serum Na
low
Urinary sodium
increased

Hypotonic Hyponatremia (Na < 135 meq. /L)
Hypovolemia Euvolemia Hypervolemia
Urinary
sodium
 More than 20
Urinary loss
 Less than 20
G I Loss
Diuretics
 SIADH
 Adrenal
 Drugs
 HypoTH
 More than 20
C.C.F.
Hepatic F.
 Less than 20
Renal disease
Urinary
sodium

SIADH………………
Definition: AVP excess associated with hyponatremia
without edema or hypovolemia. The AVP excess is
inappropriate in the face of hypoosmolality.
Clinical manifestations are those of water
intoxication and depend on rate more than
magnitude of development of hyponatremia.
Commonest cause of euvolemic hyponatremia

HYPONATREMIA HYPO OSMOLAR
U. OSM. HIGHER THAN SERUM
CONTINUED URINARY Na LOSS
NORMAL RENAL FUNCTION & B.P.
NO OEDEMA
NO ENDOCRINE DISORDER
RESPONSE TO WATER REST.
SIADH………………

Management
Restrict fluid
Diuretics
Emergency management
and the other drugs……
SIADH………………

The right solution for correct fluid ………..

Thanks
Dr Deopujari