this is presentation which is presented in BMCH quetta Pakistan to guided resident for fluid and electrolytes management

2. FLUID AND ELECTROLYTES
• DR IBRAHIM MOHAMMAD HASSANI
• PG SU-3
• BMCH

3. OBJECTIVE
FLUID AND ELECTROLYTE MANAGEMENT ARE PARAMOUNT TO
THE CARE OF THE SURGICAL PATIENT. CHANGES IN BOTH
FLUID VOLUME AND ELECTROLYTE COMPOSITION OCCUR PRE-
OPERATIVELY, INTRA-OPERATIVELY, AND POST OPERATIVELY,
AS WELL AS IN RESPONSE TO TRAUMA AND SEPSIS.

4. INTRODUCTION
BODY WEIGHT
FLUIDS ----------60%
SOLIDS-----------40%

5. FLUIDS
Body Weight Of
Adult Male 55-60%
Female 50-55%
Newborn 75-80%
Very Little In Adipose Tissues
Loss Of 20% - Fatal
Elderly - Decreases To 45-50% Of Body
Weight
Decreased Muscle Mass, Smaller Fat
Stores, And Decrease In Body Fluids

6. BODY FLUID COMPARTMENTS:
ICF:
28L
Intravascular
plasma
5.6L
Extravascular
Interstitial
Fluid
8.4L
TBW
ECF
3/4
1/4
2/3
1/3

7. COMPARTMENTS
Intracellular (ICF)
Fluid Within The Cells Themselves
2/3 Of Body Fluid
Located Primarily In Skeletal Muscle Mass
High In K, Po4, Protein
Moderate Levels Of Mg

8. COMPARTMENTS
Extracellular (ECF)
1/3 Of Body Fluid
Comprised Of 3 Major Components
Intravascular
Plasma
Interstitial
Fluid In And Around Tissues
Transcellular
Over Or Across The Cells

9. COMPARTMENTS
Extracellular
Nutrients For Cell Functioning
Na
Ca
Cl
Glucose
Fatty Acids
Amino Acids

10. COMPARTMENTS
Intravascular Component
Plasma
Fluid Portion Of Blood
Made Of:
Water
Plasma Proteins
Small Amount Of Other Substances

11. COMPARTMENTS
Interstitial Component
Made Up Of Fluid Between Cells
Surrounds Cells
Transport Medium For Nutrients, Gases,
Waste Products And Other Substances
Between Blood And Body Cells
Back-up Fluid Reservoir

12. COMPARTMENTS
Transcellular Component
 1% Of ECF
 Located In Joints, Connective Tissue, Bones, Body Cavities,
CSF, And Other Tissues
 Potential To Increase Significantly In Abnormal Conditions
12

13. BODY FLUID COMPARTMENTS:
ICF:
28L
Intravascular
plasma
5.6L
Extravascular
Interstitial
Fluid
8.4L
TBW
ECF
3/4
1/4
• MALE 60% OF LBW IS FLUID
• FEMALE 50% OF LBW IS FLUID
• 70 KG MALE
• BW X 0.6 = TBW
• 70KG X 0.6 = 42 L
• ICF= 2/3 X 42 = 28L
• ECF= 1/3 X 42 = 14L
• ECF
• 1/4 IS INTRAVASCULAR PLASMA
• 1/4 X 14 = 5.6L
• 3/4 IS INTERSTITIAL
• 3/4 X 14 = 8.4L
2/3
1/3

14. WHO HAVE MORE BODY
FLUIDS
• Muscle And Solid Organs Have Higher Water Content Than Fat
And Bone
• Higher Proportion Of Water In:
 Young
 Lean
 Males

15. FUNCTIONS OF BODY FLUID
Medium For Transport
Needed For Cellular Metabolism
Solvent For Electrolytes And Other Constituents
Helps Maintain Body Temperature
Helps Digestion And Elimination
Acts As A Lubricant

16. SOLUTES – DISSOLVED PARTICLES
• Electrolytes – Charged Particles
• Cations – Positively Charged Ions
• Na+, K+ , Ca++, H+
• Anions – Negatively Charged Ions
• Cl-, HCO3
- , PO4
3-
• Non-electrolytes - Uncharged
• Proteins, Urea, Glucose, O2, CO2

17. REGULATION OF FLUIDS
Hypothalmus –Thirst Receptors (Osmoreceptors)
Continuosly Monitor Serum Osmolarity (Concentration).
If It Rises, Thirst Mechanism Is Triggered.
+Vasopressin (AKA ADH )– Increasing H20 Reabsorption
Pituitary Regulation- Posterior Pituitary Releases
ADH (Antidiuretic Hormone) In Response To
Increasing Serum Osmolarity. Causes Renal Tubules
To Retain H20.
Thirst Is A Late Sign Of Water Deficit

18. REGULATION OF FLUIDS (CONTINUED )
Renal Regulation- Nephron Receptors Sense Decreased
Pressure (Low Osmolarity) And Kidney Secretes RENIN.
Renin – Angiotensin I – Angiotensin II
Angiotensin II Causes Na And H20 Retention By Kidneys
AND…..
Stimulates Adrenal Cortex To Secrete Aldosterone Which
Causes Kidneys To Excrete K And Retain Na And H20.

19. Methods of Fluid & Electrolyte
Movement
“ Where sodium goes, water follows.”
Diffusion – movement of particles down a
concentration gradient.
Osmosis – diffusion of water across a selectively
permeable membrane
Active transport – movement of particles up a
concentration gradient ; requires energy

20. FILTRATION
Movement Of Fluid Through A
Selectively Permeable Membrane From
An Area Of Higher Hydrostatic Pressure
To An Area Of Lower Hydrostatic
Pressure
Arterial End Of Capillary Has
Hydrostatic Pressure > Than Osmotic
Pressure So Fluid & Diffusible Solutes
Move Out Of Capillary

21. • Osmole
• Measure Of Solution’s Ability To Create Osmotic
Pressure & Thus Affect Movement Of Water
• Proportional To The Number Of Osmotic Particles
Formed In Solution
• 1 Mole Of Nonionizable Substance= 1 Osmole.
• 1mole Of Glucose Forms A 1 Osmolar Solution In 1l
Water
• 1mole Of Nacl Forms A 2 Osmolar Solution In 1L Water
• 1mole Of Cacl2 Forms A 3 Osmolar Solution In 1L Water
• Osmolality
• When The Concentration Of A Solution Is
Expressed In Osmoles Per Kilogram Of Water, The
Osmolar Concentration Of A Solution Is Referred
To As Its Osmolality.
• 1 Osmoles/Kg H2o=1 Osmoles/L = 1000
Milliosmoles/L= 1000 Mosm =1000mmol/L

22. • In Normal Condition, The Osmolality Of Plasma = Interstitial Fluid
= Intracellular Fluid = 280-310 Mosm/ Kg Or 280-310 Mmol/L
• The Osmolality Is Determined Mainly By:
• In ECF: Na+ And Cl- (80%)
• In Clinical Practice, Serum Osmolality Can Be Estimated By Doubling
Serum Sodium
• In ICF: K+ (50%)
Because water can move freely
through cell membrane and blood
capillary wall, so there is no osmotic
disequilibrium among different fluid
compartment

23. hypotonic isotonic hypertonic
Particle concentration
compared with intracellular
fluid
fewer same more
Osmolality (mmol/L) <280 280-310 >310
Representative solution 0.45% NaCl 0.9% NaCl 3% NaCl
Distilled water 5% glucose 20% glucose
Response of cell placed in
solution
Swell & burst no alteration wrinkle or shrivel

24. MECHANISMS OF
FLUID GAIN AND LOSS
Gain
• Fluid Intake 1500ml
• Food Intake 1000ml
• Oxidation Of
Nutrients 300ml
(10ml Of H20 Per 100
Kcal)
LOSS
• “Sensible”
Can Be Seen.
Urine 1500ml
Sweat 100ml
• “Insensible”
Not Visible.
Skin (Evaporation)
500ml
Lungs 400ml
Feces
200ml

26. BODY FLUIDS
Water= Most Important Nutrient For Life.
Water= Primary Body Fluid.
Adult Weight Is 55-60% Water.
Loss Of 10% Body Fluid = 8% Weight Loss Serious
Loss Of 20% Body Fluid = 15% Weight Loss FATAL
Fluid Gained Each Day Should = Fluid Lost Each Day
(2 -3L/Day Average)
What Is The Minimum Output Per Hour Necessary To Maintain Renal
Function?
30ml/hr

27. Fluid Homeostasis
 Average person
o intake- 2L of water per day (75% oral, 25% from solids)
o Output- 1L of urine, 250ml of stool, 600ml of insensible
loss(skin and lungs-pure water)
 Insensible losses increased by fever, hpyermetabolism and
hyperventilation
 Sweating is an active process and is electrolytes and water
 Average salt intake- 3-5 grams

28. FLUID VOLUME DEFICIT
• MILD – 2% OF BODY WEIGHT LOSS
• MODERATE – 5% OF BODY WEIGHT LOSS
• SEVERE – 8% OR MORE OF BODY
WEIGHT LOSS

29. TYPES OF FLUIDES
• Isotonic
• Hypotonic
• Hypertonic

30. 30
ISOTONIC SOLUTIONS
•0.9% Sodium
Chloride Solution
•Ringer’s Solution
•Lactated Ringer’s
Solution

31. 31
HYPOTONIC SOLUTIONS
•5% Dextrose &
Water
•0.45% Sodium
Chloride
•0.33% Sodium
Chloride

32. HYPERTONIC SOLUTIONS
•3% Sodium Chloride
•5% Sodium Chloride
•Whole Blood
•Albumin
•Total Parenteral Nutrition
•Tube Feedings
•Concentrated Dextrose (>10%)

35. DAILY FLUID REQUIREMENTS
AVERAGE ADULT NEEDS:
1. H2O ~ 30-35ml/Kg/Hr (2-3
Liters/Day)
2. Na+ ~ 1 ml/kg/hr
3. K+ ~ 1 ml/kg/hr
4. Cl- ~ 1.5 ml/kg/hr

36. COMPOSITION OF GI
SECRETIONS
Source
Volume
(ml/24h)
Na+* K+ Cl- HCO3
-
Salivary 1500 (500~2000) 10 (2~10) 26 (20~30) 10 (8~18) 30
Stomach 1500 (100~4000) 60 (9~116) 10 (0~32) 130 (8~154) 0
Duodenum 100~2000 140 5 80 0
Ileum 3000 140 (80~150) 5 (2~8) 104 (43~137) 30
Colon 100-9000 60 30 40 0
Pancreas 100-800 140 (113~185) 5 (3~7) 75 (54~95) 115
Bile 50-800 145 (131~164) 5 (3~12) 100 (89~180) 35
* Average concentration: mmol/L

37. FLUID VOLUME DEFICIT
(HYPOVOLEMIA, ISOTONIC DEHYDRATION)
Common Causes
 Hemorrhage
 Vomiting
 Diarrhea
 Burns
 Diuretic Therapy
 Fever
 Impaired Thirst

38. CLINICAL MANIFESTATIONS
• Signs/Symptoms
 Weight Loss
 Thirst
 Orthostatic Changes In Pulse Rate And BP
 Weak, Rapid Pulse, Heart Rate
 Decreased Urine Output
 Dry Mucous Membranes
 Poor Skin Turgor
 Concentrated Urine
 Flattened Neck Veins
 Increased Temperature
 Decreased Central Venous Pressure

39. DIAGNOSIS
Insufficient Intake, Vomiting, Diarrhea,
Hemorrage
 Dry Mucous Membranes, Low BP, HR 112-
122, BUN 28, Na 152, Urine Dark Amber;
Intake 200ml/Output 450ml Over 24 Hours
Goal:
Patient Should Have Adequate Fluid
Volume
Within 24 Hours .
Moist Tongue, Mucous Membranes, BP WNL,
HR WNL, BUN Between 8-20, Na 135-
145, Urine Clear Yellow, Balanced I/O

40. BODY FLUID
COMPARTMENTS:
ICF:
28L
Intravascular
plasma
5.6L
Extravascular
Interstitial
Fluid
8.4L
TBW
ECF
3/4
1/4
2/3
1/3
If 1 liter of NS is given, only 250 ml will
stay in intravascular.
1000ml x 1/4 = 250 ml (Intravascular)
1000ml x 3/4 = 750 ml (Interstitial)
If 1 liter of D5W is given, only
about 100 ml will stay in
intravascular.
1000ml x 2/3 = 667ml (ICF)
1000ml x 1/3 = 333 ml (ECF)
333 ml x 1/4 = 83 ml (IV)
333 ml x 3/4 = 250 ml (IT)

41. CRYSTALLOIDS:
• Isotonic Crystalloids
- Lactated Ringer’s, 0.9% Nacl
- Only 25% Remain Intravascularly
• Hypotonic Solutions
- D5w
- Less Than 10% Remain Intra-
Vascularly, Inadequate For Fluid
Resuscitation

42. COLLOID SOLUTIONS:
• Contain High Molecular Weight
Substances Too Large To Cross Capillary Walls
• Preparations
I. - Albumin: 5%, 25%
II. - Dextran
III. - Hetastrach

43. BODY FLUID COMPARTMENTS:
ICF:
28L
Intravascular
plasma
5.6L
Extravascular
Interstitial
Fluid
8.4L
TBW
ECF
3/4
1/4
2/3
1/3
If 1 liter of 5% albumin is given, all will
stay in intravascular because of its large
molecule that will not cross cell
membrance.
1000ml x 1 = 1000 ml
If 100 ml of 25% albumin is given,
it will draw 5 times of its volume in
to intravascular compartment.
100ml x 5 = 500 ml

44. THE INFLUENCE OF COLLOID & CRYSTALLOID ON
BLOOD VOLUME:
1000cc
500cc
500cc
100cc
200 600 1000
NS or Lactated Ringers
5% Albumin
6% Hetastarch
25% Albumin
Blood volume
Infusion
volume

45. FLUID RESUSCITATION
• Calculate The Fluid Deficit Base On Serum
Sodium Level (Assume Patient Na Is 120 mmole/l
And Patient Weight Is 70 Kg)
Fluid Deficit = Bw X 0.5 ( Avg Na – Pt Na )
Na Avg
= 70 X 0.5 ( 140 – 120)
140
= 5 L

46. FLUID RESUSCITATION
• Calculate The Fluid Deficit Base On Patient Actual Weight
If You Know The Patient Weight Before The Dehydration Then
Simply Subtract Patient Current Weight From Patient Previous
Weight
Pt Wt Before Dehydration – Pt Current Wt
Exp If Pt Weight Was 70 Kg Before And Now Pt Weight 65 Kg
Then
70 Kg – 65 Kg = 5 Kg Equal To 5 L Of Water Loss (S.G For Water
Is 1)

47. FLUID RESUSCITATION
Use Crystalloids (NS Or Lactate Ranger)
Colloids Is Not Superior To Crystalloids
Administer 500-1000 ml/hr Bolus(30-60 Mins) And Then 250-500
ml/hr For 6 To 8 Hours And Rest Of The Fluid Within 24 Hours
Maintain IV Fluid (D5 ½ NS) Until Vital Signs Are Normalized
And Patient Is Able To Take Adequate Oral Fluid

48. CALCULATION OF MAINTENANCE FLUIDS
For A 24 Hr Period, Use 100/50/20
Rule
100ml/Kg For First 10kg
50ml/Kg For Next 10kg
20ml/Kg For Every Kg Over 20
For Hourly Maintenance Rate, Use
4/2/1 Rule
4ml/Kg For First 10kg
2ml/Kg For Next 10kg
1ml/Kg For Every Kg Over 20

49. FLUID VOLUME DISTURBANCES
•FLUID VOLUME EXCESS
(HYPERVOLEMIA)

50. FLUID VOLUME EXCESS
 COMMON CAUSES:
 Congestive Heart Failure
 Renal Failure
 Cirrhosis
 SIADH
 IV Therapy
 Excessive Sodium Ingestion
 Corticosteroid

51. CLINICAL MANIFESTATIONS
SIGNS/SYMPTOMS
 Increased BP
 Bounding Pulse
 Venous Distention
 Pulmonary Edema
 Dyspnea
 Orthopnea (Diff. Breathing When Supine)
 Crackles

52. DIAGNOSIS AND GOAL
Fluid Volume Excess Cause CHF, Excess
Sodium Intake, Renal Failure :
Weight Gain Of 6 Lb. In 24 Hours; Lungs
With Crackles In Bases Bilaterally; 2+ Edema
In Ankles Bilaterally
Goal:
Patient Should Have Normal Fluid
Volume Within 48 Hours :
Decreased Weight Of 1 Lb. Per Day, Lung
Sounds Clear In All Fields, Ankles Without
Edema

53. MANAGEMENT
DRUG THERAPY
Diuretics may be ordered if renal failure is not the cause.
Restriction Of Sodium And Saline Intake
I/O
WEIGHT

54. Electrolyt
es

55. ELECTROLYTES
o Substance when dissolved in solution separates into ions
& is able to carry an electrical current
o CATION - positively charged electrolyte
o ANION - negatively charged electrolyte
o Commonly measured in milliequivalents / liter (meq/l)

56. ELECTROLYTES IN
BODY FLUID COMPARTMENTS
INTRACELLULAR EXTRACELLULAR
POTASSIUM SODIUM
MAGNESIUM CHLORIDE
PHOSPHOROUS BICARBONATE
Electrolytes
ICF:
28L
Intravascular
plasma
5.6L
Extravascular
Interstitial
Fluid
8.4L
TBW
ECF
3/4
1/4
2/3
1/3

57. ELECTROLYTES
• Na+: most abundant electrolyte in the body
• K+: essential for normal membrane excitability for
nerve impulse
• Cl-: regulates osmotic pressure and assists in
regulating acid-base balance
• Ca2+: usually combined with phosphorus to form the
mineral salts of bones and teeth, promotes nerve
impulse and muscle contraction/relaxation
• Mg2+: plays role in carbohydrate and protein
metabolism as well as storage and use of
intracellular energy and neural transmission.
Important in the functioning of the heart, nerves,
and muscles

58. MAJOR ELECTROLYTE IMBALANCES
 Hyponatremia (Sodium Deficit < 130meq/L)
 Hypernatremia (Sodium Excess
>145meq/L)
 Hypokalemia (Potassium Deficit
<3.5meq/L)
 Hyperkalemia (Potassium Excess
>5.1meq/L)
 Chloride Imbalance (<98meq/L Or

59. Sodium
oNormal person consumes 3-5g of NaCl = 130-217 mmol Na daily
oSodium balanced maintained primarly by the kidney
oNormal conc. bw 135-145mmolL or 310-333mg/dl
oThe Na conc. Largely determines the plasma osmolality which is
bw 290-310 mOsm/L
oCalculation of plasma osmolality
• P.OSM=2[NA+K] + GLUCOSE/18 + BUN/2.8

60. Diagnostic approach to hyponatremia
oIsotonic hyponatremia
I. Pseudohyponatrem
ia
a) Hyperlipidemia
b) hyperproteinemi
a
II. Isotonic infusions
III. TURP
Lab investigation
Measure serum osmolality
Blood glucose
Lipid and protein

61. CONT-
oHypertonic
hyponatremia
1. Hyperglycemia
2. Hypertonic infusions
3. TURP
Lab investigation
Measure serum Osmolality
Blood glucose

62. Hypotonic hyponatremia
Hypovolemia
 Extra-renal Sodium Loss (UNa<10)
1) Sweat, Diarrhea, Vomiting
2) 3rd Spacing: Trauma,
Burns, Pancreatitis
3) Through Respiration
 Renal Sodium Loss (UNa >20)
1) Diuretics
2) Cerebral Salt Wasting
3) Proximal Type II RTA
Euvolemia (UNa>20)
1) SIADH
2) Hypothryoidism
3) Drugs
4) Water intoxication
5) K loss
Una= urinary
sodium
Hypervolemia (UNa<20)
1) Acute Or Chronic
Renal Failure
Una>20
2) Congestive Heart
Failure
3) Cirrhosis/Hepatic
Failure
4) Nephrotic Syndrome
5) TURP
Clinically
asses ECF
Measure
urinary na
p.Osm

63. Clinical manifestation
oLethargy
oNausea
oVomiting
oConfusion
oSeizures
oComa

64. MANAGEMENT
• Correct rapidly with 3% NS for severely symptomatic
patients
• 4ml/kg 3%NS will increase [na] by 5meq/l
• Normalize sodium at A rate of 8-12 meq/l over 24 hours
with 0.45% or 0.9% NS
• Try to avoid repid correction may it will cause Central
pontine myelinolysis
• May be irreversible
• Dysarthria, dysphagia, spastic paresis, coma

65. SIADH
Causes
Intracranial pathology, mechanical ventilation,
post-operative, malignancy, neck surgery,
pulmonary pathology
Diagnosis
Patient should be euvolemic
Labs: serum osm, urine osm, Una
Urine will be inappropriately concentrated for A
patient who is hypoosmolar
Urine Na will be elevated and urine output will be
low
Treatment
3% Ns
Fluid restriction to 30-50%
Avoid excess free water-

66. HYPERNATREMIA: CAUSES
Hypovolemic hypernatremia (loss of
H2O & Na)
Post obstructive diuresis
Acute and chronic renal disease
Sweating, fistula, burns, diarrhea,
vomiting
Partial Urinary tract obstruction
Respiratory loss
Hypervolemic hypernatremia (Sodium
gain)
Hypertonic saline or sodium
bicarbonate
TPN
Hyperaldosteronism
Isovolemic hypernatremia (free
loss of H2O)
1. Skin and respiratory loss
2. Urinary free water loss
3. Iatrogenic
4. Diabetic insipidis
o Central & Nephorgenic

67. Clinical manifestations
o Lethargy
o Weakness
o Irritablity
o fasciculations
o Seizures
o Coma
o Irreversible neurological damage
o Hyperactive Deep Tendon Reflexes

68. MANAGEMENT
oRisk of seizures and cerebral edema if corrected
too rapidly
oCorrect hypovolemia with NS
oCorrect Na with 0.45% NS
oCheck na frequently and adjust fluid therapy for
A goal of 0.5-1meq/L decrease qhour

69. DIABETES INSIPIDUS (CENTRAL)
Causes
Surgical Resection, Trauma, Tumor Infiltration and
Genetic
Diagnosis
Rising Na And Serum Osmolality
 Low Uosm And Low Urine SG
Increased UOP
Treatment
Urine Replacement With 1/2 Or 1/4 NS
Vasopressin Infusion: Titrate To UOP 3-4ml/Kg/H
Na Checks Every Hour

70. POTASSIUM
o Potassium is the most abundant cation in the
body cells
o 97% is found in the intracellular fluid
o Also plentiful in the GI tract
o Normal extracellular K+ is 3.5-5.3
o A serum K+ level below 2.5 or above 7.0 can
cause cardiac arrest
o 80-90% is excreted through the kidneys
o Functions
• Promotes conduction and transmission of nerve
impulses
• Contraction of muscle
• Promotes enzyme action
• Assist in the maintenance of acid-base
o Daily intake of k is necessary because it is
poorly conserved by the body
o 50 to 100 mmol (195 to 390mgdl) ingested
and absorbed daily

71. HYPOKALEMIA: CAUSE
oCutaneous lose
 burn
oRenal loss
 Primary hyperaldosteronism, genetic syndromes
(i.E. Liddle’s), type I and II RTA, drugs (i.E.
Amphotericin, foscarnet, diuretic )
oGI loss
 Vomiting, diarrhea ,vipoma, enteric fistula,
malabsorption, jejunoileal bypass and NG
suctioning
oRefeeding syndrom
oAcute intracellular uptake
 Alkalosis, beta agonists, caffeine, insulin,
thryrotoxicosis, MI, delirium tremors,
hypothermia, theophylline toxicity

72. CLINICAL MANIFESTATIONS
oGeneralized muscle weakness
oParalytic ileus
oCardiac arrhythmias
o Atrial tachycardia
o AV dissociation
oAscending paralysis and impaired
respiratory function (K<2)

74. MANAGEMENT
Determine The Cause
Calculate K deficit={(4-Pt k)0.4xpt Bwt}+ pt.Bwt
Administered with
 0.5-1 meq/kg Over 1 Hour
 Should not exceed 40mmol/l
 The rate should not exceed 20mmol/l
Use.
 In mild case KCl PO
 In sever case K-Phos ,K-acetate, KCl IV
Monitor ECG
Hypomagnesaemia accompanies hypokalemia must be
corrected

75. ECG CHANGES
oEcg changes
o Flat/inverted T waves
o ST segment
depression
o U waves

76. HYPERKALEMIA: CAUSES
1. Impaired excretion
 Renal failure, mineralocorticoid deficiency,
drugs(succinylcholine), type IV RTA,
2. Pseudo hyperkalemia release from leukocytes and platelets
coagulation
3. Insulin deficiency
4. Hemolysis or phlebotomy from strangulated arm
5. Transcellular shift
 Acidosis, beta blockers, digitalis intoxication, somatostatin
6. Other
 Tumor lysis (after chemotherapy)
 Rhabdomyolysis
 Reperfusion of ischemic limb

77. CLINICAL MANIFESTATIONS
o Apathy
o Confusion
o Numbness/Paresthesia Of Extremities
o Abdominal Cramps
o Nausea
o Flaccid Muscles
o Diarrhea
o Oliguria
o Bradycardia
o Cardiac Arrest

79. SEVERE HYPERKALEMIA
Definition: K>6 Meq/L
ECG Changes:
 Tall Peaked T Waves, Prolonged PR
Interval, Widened QRS, V-fib, Flat P-wave

80. MANAGEMENT
• Mild hyperkalemia
• Reduce K intake
• Loop diuretic (furosemide)
• Stop medication causing impair K hemostasis
1. Beta agonist
2. ACE-inhibitors
3. K-sparing diuretic
4. NSAID

81. CONT-
• Severe hyperkalemia
Temporizing measures causing shift
from ECF to ICF
1. Calcium Gluconate 10%
• 100mg/Kg IV Peripheral Or
Central
• Or 5-10ml IV over 2min
2. Insulin/Glucose
• Insulin 0.1units/Kg IV
• Glucose 2ml/Kg D10 Or D25
• The Most Effective Way To Quickly
Lower K!!!
3. Inhaled beta agonist
• Albuterol sulfate 2-4ml of 0.5%
solution(10-20mg) via nebulizer
4. Sodium Bicarbonate
• 1-2meq/Kg or 1-2 ampules IV over
 Therapeutic measure
• Hemodialysis
• Hydration
• 0.9 NS with diuretic
• Kayexalate
1. 1gram/Kg Po Or
PR

82. CALCIUM
 Regulated By The Parathyroid Gland and vitamin D
 Normal range 8.9-10.3mg/dl
 Serum ca exists in three form
1. Ionized 45%
2. Protein bound 40%
3. Free 15%
 Vitamin D
 Increase ca and phosphate absorption from intestine
 Parathyroid Hormone
 Helps With Calcium Retention And Phosphate Excretion
Through The Kidneys
 Promotes Calcium Absorption In The Intestines
 Helps Mobilize Calcium From The Bone

83. CALCIUM HOMEOSTASIS
Hormone Calcium Phosphate
PTH Increase Kidney
reabsoption
of Ca
decreased Decreased
absorption
in kidney
Vitamin D Increase Increased
absorption
in kidney
and
intestine
increased Increased
absorption
in kidney
and
intestine
Calcitonin Decrease Decreased
bone
resorption/
decreased
kidney
reabsorptio
n
No effect

84. HYPOCALCAEMIA: CAUSES
1. Hypoparathyroidism
 Irradiation, Surgery, Hypomagnesaemia
2. Transient decrease ca
 Total thyroidectomy
 Vascular compromise of parathyroid gland
3. Vitamin D Deficiency
 Malnutrition, Malabsorption, Hepatobiliary Disease, Low Sun
Exposure
4. Calcium Chelation/Precipitation
 Tumor Lysis, Rhabdomyolysis, Citrate, Foscarnet
5. Multifactorial
• Sepsis, Pancreatitis, Burns , Hyperphosphatemia , Renal
Failure, hypoalbuminemia and acute alkalosis due to
hyperventilation or fast IV bicarbonate

85. CLINICAL MANIFESTATIONS
Symptoms Include:
 Tetany
 Paresthesias Of Hands/Feet
 perioral Numbness
 Laryngospasm Or Bronchospasm
 Alter mantal status
 Hypotension
 Rickets
DIAGNOSIS
 PTH Level
 Vitamin D Levels (25OHD3 And
1,25OHD3)
 24 Hour Urine Calcium
 Diagnosis should be made on
ionized ca rather then on total
 Serum Ca++levels < 8.5 mg/dl
 Prolonged PT And PTT

86. ECG CHANGE
Prolonged QT or ST interval

87. POSITIVE TROUSSEAU’S SIGN

88. POSITIVE CHVOSTEK’S SIGN

89. MANAGEMENT
• Oral
• Ca-gluconate or ca-carbonate should be supplement with vitamin D
• IV
• Ca-gluconate 10% 10-20ml bolus over 10min
• Ca-gluconate maintenance infusion of 1-2mg/kg
• Check Mg, Phos and K level and replete as necessary
• Administered cautiously to pt. who received digitalis preparation because digitalis
toxicity
• Avoid Treating Hypocalcaemia?
Tumor Lysis Syndrome (Unless Patient Is Symptomatic)

90. HYPERCALCEMIA: CAUSE
o Excessive Intake
o Excessive Use Of Antacids With Phosphate-binding
o Prolonged Immobility
o Vitamin D Intoxication
o Thiazide Diuretics
o Malignancy
o Hyperparathyroidism
o Hyperthyroidism
o Long term TPN
o Granulomatous disease

91. CLINICAL MANIFESTATIONS
May be associated with parathyroid bone disease or
nephrolithiasis
Muscle Weakness
Personality Changes
Nausea And Vomiting
Extreme Thirst
Constipation
Adynamic ileus
Calcifications In The Skin And Cornea
Cardiac Arrest

92. DIAGNOSTIC FINDINGS
Serum Ca++ > 10.5 mg/dl
Bone Changes On X-ray
ECG Changes
QT Interval Is Short
In Severe Hypercalcaemia, Osborn Waves (J Waves) May Be Seen

93. MANAGEMENT
Monitor Patient At Risk; Immobile, Cancer
Drink Plenty Of Fluids, 3-5 Liters To Help Excrete
Excess Ca++
Administer IV NS 200-500/hr If Tolerated Or For
Moderate Hypercalcemia
Administer Loop Diuretics
Administer Calcitonin
Teach Pt. To Avoid Dairy Products

94. MAGNESIUM
• Normal range 1.3-2.2meq/l
• Intracellular cation
• Renal excretion and retention play the major roll regulating body stores

95. HYPOMAGNESEMIA: CAUSES
1. GI loss
Diarrhea, malabsorption, vomiting, biliary fistulas
2. Renal loss
Diuresis, primary hyperaldosternism, RTA, chronic
alcoholsim, drugs
3. Transcellular shift
MI, alcohol withdrawal, therapy with glucose containing
solution
4. Post.op
Parathyroidectomy accompanying hypokalemia,
hypocalcaemia, hypophosphatemia

96. CLINICAL MANIFESTATIONS
Cardiac Dysrhythmias;
Tetany
Hyperactive Deep
Tendon Reflexes
Alter mental status

97. DIAGNOSTIC FINDINGS
1. Serum Mg Level < 1 meq/Liter
2. Hypocalcaemia
3. Hypokalemia
4. ECG Changes
 Tall T-wave
 QRS-complex broad
 PR & QT-interval porlong
 Depressed ST segment

98. MANAGEMENT
o Monitor Patient At Risk
o Cardiac Monitoring
o Seizure Precautions
o Magnesium sulfate 25-50 mg/kg iv
o Replace potassium and calcium
o Oral supplementation e.g magnesium oxide,
magnesium chloride

99. HYPERMAGNESEMIA
CAUSES
 Renal Failure
 Excessive Use Of Mg Containing Antacids
 Untreated Diabetic Ketoacidosis

100. CLINICAL MANIFESTATIONS
 Paralysis of voluntary muscle
 Hypoactive Deep Tendon Reflexes
 Hypotension
 Bradycardia
 Cardiac Arrest

101. DIAGNOSTIC FINDINGS
 Serum Mg > 3meq/Liter
 ECG Changes
 Prolong PR interval
 Widen ORS complex
 Prolong QT interval
PROLONGED PR INTERVAL IN HYPERMAGNESEMIA
Wide QRS complex in Hypermagnesemia

102. MANAGEMENT
Monitor Patient At Risk
Ca gluconate 10% 10-20ml over 5-10min or
NS 0.9% with loop diuretics
Definitive therapy with dailysis
Cardiac Monitoring

103. PHOSPHORUS
• Normal range is 2.5-4.5mg/dl.
• Regulated by hormone that also control ca metabolism.
• Derangements of calcium also coexist.
• Predominantly excreted by kidney.

104. HYPOPHOSPHATEMIA
oCauses
Decreased intestinal absorption ( vit-D deficiency,
malaborption and use phosphate binders)
Decreased Renal Reabsorption (acidosis, alkalosis,
diuresis and hyperglycemia)
Transcellular Shift (Respiratory Alkalosis and
refeeding syndrome )

105. CLINICAL MANIFESTATIONS
Diffuse Weakness
Respiratory muscle dysfunction
Flaccid paralysis

106. MANAGEMENT
• Determine Underlying Cause (Many Times It Is Multifactorial)
• Replace :
• In severe condition use iv
• Na.phos
• K.phos 0.08-0.32 mmol/kg Over 4-6 Hours
• When level exceeds 2mg/dl
• Neutra-phos 250-500mg PO four time a day

107. HYPERPHOSPHATEMIA
• CASUE
• Impair renal excretion
• Transcellular shift from ICF to ECF
(tissue truma, tumor lysis, insulin deficiency and
acidosis)

108. CLINICAL MANIFESTATIONS
• Hypocalcaemia
• tetany

109. MANAGEMENT
• Restrict dietary intake
• Hydrate with 0.9 NS at 250-500ml/hrs with diuretics acetazolamide 500mg
6hourly PO or IV.
• Use phosphate binders (aluminum hydroxide 30-120ml PO 6hourly).
• Dialysis in extreme conditions.

110. TREATMENT:
• HYPERKALEMIA COCKTAIL
• HYPOKALEMIA POTASSIUM
REPLACEMENT
• HYPERCALCEMIA MAGNESIUM
• HYPOCALCEMIA CALCIUM REPLACEMENT
• HYPERMAGNESEMIA CALCIUM
REPLACEMENT
• HYPOMAGNESAEMIA MG REPLACEMENT