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Basic Intravenous Therapy 3: Fluids And Electrolytes, Balance and Imbalance, Common IVF's

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Lecture Presentation in Basic Intravenous Therapy Seminar, discussion on Body Fluids and Electrolytes, Normal Values and the Imbalances, the symptomatology and treatment and precautions, and, finally the different types of commonly available, utilized IVF in clinics

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Basic Intravenous Therapy 3: Fluids And Electrolytes, Balance and Imbalance, Common IVF's

  1. 1. BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FLUIDS AND ELECTROLYTES: Problems/Imbalances Common Intravenous Solutions
  2. 2. ?
  3. 4. FLUIDS AND ELECTROLYTES <ul><li>BODY FLUIDS </li></ul><ul><li>Refers to the body water in which electrolytes are dissolved </li></ul><ul><li>Described as “a sea within” </li></ul><ul><li>Water – is the largest single constituent of the body, representing 45% - 74% of the body weight, depending on age, gender and body fat </li></ul>
  4. 5. FLUIDS AND ELECTROLYTES
  5. 7. FLUIDS AND ELECTROLYTES <ul><li>In the newborn infant – almost ¾ of the body weight is water, with the greatest percentage found in extracellular compartment </li></ul><ul><li>By adulthood </li></ul><ul><ul><li>the young male’ s body water is only 60% and 2/3 of this is in the intracellular compartment </li></ul></ul><ul><ul><li>In the average young female – only approximately 50% of body weight (due to increased amount of fat in women which is essentially water-free </li></ul></ul>
  6. 8. <ul><li>All the body's fluid compartments are in osmotic equilibrium (except for transient changes) </li></ul><ul><li>The ions and small solutes that constitute the ECF are in equilibrium with similar concentrations in each sub-compartment </li></ul><ul><li>The ECF volume is proportional to the total Na content. </li></ul>Total Body Water = 60% of weight Extracellular =20% Intracellular Water = 40%     The 60-40-20 Rule: 60 % of body weight is water 40% of body weight is intracellular fluids 20% of body weight is extracellular fluid T r a n s 1 L P l a s m a 4 L 14% ISF 10 L 40% x 70 kg = 28 L water
  7. 9. FLUIDS AND ELECTROLYTES <ul><li>Functions of Body Fluids: </li></ul><ul><ul><li>Transport nutrients to the cells and carries waste products away from the cells </li></ul></ul><ul><ul><li>Maintains blood volume </li></ul></ul><ul><ul><li>Regulates body temperature </li></ul></ul><ul><ul><li>Serves as aqueous medium for cellular metabolism </li></ul></ul><ul><ul><li>Assists in digestion of food through hydrolysis </li></ul></ul><ul><ul><li>Acts as solvents in which solutes are available for cell function </li></ul></ul><ul><ul><li>Serves as medium for the excretion of waste products </li></ul></ul>
  8. 11. FLUIDS AND ELECTROLYTES <ul><li>Body Fluids are distributed in the body in 2 compartments : </li></ul><ul><ul><li>Intracellular (ICF) – within the cell, approximately 2/3 of the body fluid; located primarily in the skeletal muscle mass, provides the aqueous medium for cellular function </li></ul></ul>
  9. 12. <ul><ul><li>2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells </li></ul></ul><ul><ul><li>a. Interstitial fluid – between the cells, fills spaces between most cells and comprises 15% of BW, e.g. lymph </li></ul></ul>FLUIDS AND ELECTROLYTES
  10. 13. FLUIDS AND ELECTROLYTES <ul><ul><li>2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells </li></ul></ul><ul><ul><li>b. Intravascular fluid – in the blood vessels, the PLASMA (i.e. watery colorless fluid of lymph and blood in which RBC, WBC and platelets are suspended) comprises 5% of BW, approximately 3L of the average 6L of blood volume is made up of plasma and the remaining 3L is made up of other blood components </li></ul></ul>
  11. 14. FLUIDS AND ELECTROLYTES <ul><ul><li>2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells </li></ul></ul><ul><ul><li>c. Transcellular – 1% to 3% of BW, the smallest division of the ECF compartment and contains approximately 1 – 2 L of fluid in any given time (e.g. CSF, pericardial, synovial, intraocular, pleural fluids, sweats, and digestive secretions) </li></ul></ul>
  12. 15. FLUIDS AND ELECTROLYTES <ul><li>There is a continuous exchange of fluid between the fluid compartment , of these spaces only the plasma is directly influenced by the intake or elimination of fluid from the body </li></ul><ul><li>There is also the so called third space fluid shift or “third spacing” where there is a loss of ECF into a space that does not contribute to the equilibrium between ICF & ECF </li></ul>
  13. 16. FLUIDS AND ELECTROLYTES <ul><li>“ Third spacing” occurs in: </li></ul><ul><ul><li>Ascites </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Bowel obstruction </li></ul></ul><ul><ul><li>Massive bleeding into body cavity or joints </li></ul></ul>
  14. 17. FLUIDS AND ELECTROLYTES <ul><li>Pathophysiology: </li></ul><ul><ul><li>The decrease in urine output despite adequate fluid intake (due to fluid shifts out of the intravascular space) kidneys receive less blood and compensate by decreasing the urine output </li></ul></ul>
  15. 18. FLUIDS AND ELECTROLYTES <ul><li>Signs and Symptoms of Intravascular Fluid Volume Deficit are: </li></ul><ul><ul><li>Increased heart rate </li></ul></ul><ul><ul><li>Decreased blood pressure </li></ul></ul><ul><ul><li>Decreased CVP </li></ul></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>Decreased BW </li></ul></ul><ul><ul><li>Imbalances in fluid I & O </li></ul></ul>
  16. 19. FLUIDS AND ELECTROLYTES <ul><li>Output of Fluid – vary due to following: </li></ul><ul><ul><li>Increased temperature </li></ul></ul><ul><ul><li>Increased respiration </li></ul></ul><ul><ul><li>Draining wounds </li></ul></ul><ul><ul><li>Ostomies </li></ul></ul><ul><ul><li>Gastric suction </li></ul></ul>
  17. 20. FLUIDS AND ELECTROLYTES <ul><li>Sources of water: </li></ul><ul><ul><li>Liquids </li></ul></ul><ul><ul><li>Water-containing foods </li></ul></ul><ul><ul><li>Metabolic activities or oxidation </li></ul></ul>
  18. 21. FLUIDS AND ELECTROLYTES <ul><li>Elimination of Fluid: </li></ul><ul><ul><li>Sensible loss (measurable) </li></ul></ul><ul><ul><li>Insensible (not measurable, e.g. skin, lungs, feces) </li></ul></ul><ul><ul><li>INSENSIBLE WATER LOSS ? </li></ul></ul>
  19. 22. FLUIDS AND ELECTROLYTES <ul><li>INSENSIBLE WATER LOSS </li></ul><ul><li>The minimal insensible loss in an adult is about 600-800 ml . </li></ul><ul><li>This is equivalent to a heat loss of about 480 kcals/day which is about 25% of basal heat production. </li></ul><ul><li>On an ‘average’ day, activity will increase insensible respiratory water losses so that the overall insensible loss is more than the minimum: an estimate of 50 ml/hr has been suggested for use in unstressed hospitalized patients. </li></ul><ul><li>In clinical calculations of fluid balance, insensible losses are unmeasured are usually accounted for by an estimate such as the one above. </li></ul><ul><li>Metabolic water production ( 400 mls/day ) is also unmeasured and can be considered to replace up to 50% of the insensible losses. </li></ul>
  20. 23. FLUIDS AND ELECTROLYTES <ul><li>Water Balance I & O </li></ul><ul><li>( in adult eating 2500/day) </li></ul>Output 100 Feces 2500 Total 2500 Total 1400 Urine 300 Oxidation 500 Perspiration 1000 Food Intake 500 Breathing 1200 Liquids Amount of loss (ml) Route Amount of gain (ml) Route Intake
  21. 24. FLUIDS AND ELECTROLYTES <ul><li>Routes Gain and Losses: </li></ul><ul><li>Kidneys </li></ul><ul><ul><li>Usual daily urine volume in adult = 1 – 2 L </li></ul></ul><ul><ul><li>General Rule: 1 ml/kg/hour in all age groups </li></ul></ul>
  22. 26. FLUIDS AND ELECTROLYTES <ul><li>Three processes occurring in successive portions of the nephron accomplish the function of urine formation : </li></ul><ul><li>Filtration of water and dissolved substances out of the blood in the glomeruli and into Bowman's capsule; </li></ul><ul><li>Reabsorption of water and dissolved substances out of the kidney tubules back into the blood (note that this process prevents substances needed by the body from being lost in the urine); </li></ul><ul><li>Secretion of hydrogen ions (H+), potassium ions (K+), ammonia (NH3), and certain drugs out of the blood and into the kidney tubules, where they are eventually eliminated in the urine. </li></ul>
  23. 27. FLUIDS AND ELECTROLYTES <ul><li>Routes of Gain & Losses: </li></ul><ul><li>Skin </li></ul><ul><ul><li>Sensible perspiration or sweating </li></ul></ul><ul><ul><li>Chief solutes are Na, Cl, & K </li></ul></ul><ul><ul><li>Actual sweat losses vary from 0 – 1000ml or more every hour depending on environmental temperature </li></ul></ul><ul><ul><li>Conditions: </li></ul></ul><ul><ul><ul><li>fever – increased water loss through skin and lungs </li></ul></ul></ul><ul><ul><ul><li>burns – natural skin barrier is destroyed </li></ul></ul></ul>
  24. 28. FLUIDS AND ELECTROLYTES <ul><li>Routes of Gain & Losses: </li></ul><ul><li>Lungs </li></ul><ul><ul><li>Normally eliminate water vapor (insensible loss) </li></ul></ul><ul><ul><li>Rate is at 300 – 400ml/day </li></ul></ul><ul><ul><li>Loss is greater with increased respiratory rate or depth </li></ul></ul>
  25. 29. FLUIDS AND ELECTROLYTES <ul><li>Routes of Gain & Losses: </li></ul><ul><li>Gastrointestinal Tract </li></ul><ul><ul><li>Loss is at 100 – 200ml /day </li></ul></ul><ul><ul><li>Because the bulk of fluid is reabsorbed in the small intestine </li></ul></ul><ul><ul><ul><li>diarrhea and fistulae are associated with large losses </li></ul></ul></ul>
  26. 30. FLUIDS AND ELECTROLYTES <ul><li>Evaluating Fluid Status: </li></ul><ul><li>Osmolality </li></ul><ul><ul><li>Reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis </li></ul></ul><ul><ul><li>Measures the solute concentration per kilogram in blood and urine </li></ul></ul><ul><ul><li>Also measures the ability of a solution to create osmotic pressure and affects movement of water </li></ul></ul><ul><ul><li>Most reliable in measuring urine concentration </li></ul></ul><ul><ul><li>Reported as milliosmoles per kilogram of water (mOsm/kg) </li></ul></ul><ul><ul><li>Normal serum osmolality = 280 – 300 mOsm/kg </li></ul></ul><ul><ul><li>Normal urine osmolality = 50 – 1400 mOsm/kg </li></ul></ul>
  27. 31. FLUIDS AND ELECTROLYTES <ul><li>Laboratory Tests for Evaluating Fluid Status: </li></ul><ul><li>Osmolarity </li></ul><ul><ul><li>Reflects the concentration of the solutions </li></ul></ul><ul><ul><li>Measured in milliosmoles per liter (mOsm/L) </li></ul></ul>Solution is a homogeneous mixture composed of two or more substances. In such a mixture, a solute is dissolved in another substance, known as a solvent
  28. 32. FLUIDS AND ELECTROLYTES <ul><li>Comparison of Serum & Urine Osmolality: </li></ul>Fluid volume excess Diabetes insipidus Fluid volume deficit SIADH Urine SIADH Renal Failure Diuretic use Adrenal insufficiency Free water loss Diabetes insipidus Sodium overload Hyperglycemia Uremia Serum Factors decreasing Factors increasing Fluid
  29. 33. FLUIDS AND ELECTROLYTES <ul><li>ELECTROLYTES </li></ul><ul><ul><li>Chemical compounds in solution that have the ability to conduct an electrical current </li></ul></ul><ul><ul><li>Distributed in different concentrations in the intracellular, intravascular, & interstitial </li></ul></ul><ul><ul><li>They break into ions: </li></ul></ul><ul><ul><ul><li>Cations – positively charge (Na, K, Ca, Mg, H ions) </li></ul></ul></ul><ul><ul><ul><li>Anions – negatively charge (Cl, bicarbonate, phosphate, sulfate, proteinate ions) </li></ul></ul></ul>
  30. 34. FLUIDS AND ELECTROLYTES <ul><li>Electrolytes are minerals found naturally in the body, such as </li></ul><ul><ul><li>Potassium </li></ul></ul><ul><ul><li>Calcium </li></ul></ul><ul><ul><li>Sodium </li></ul></ul><ul><ul><li>magnesium </li></ul></ul><ul><li>Electrolytes are needed to keep the body's balance of fluids at the proper level and to maintain normal functions, such as </li></ul><ul><ul><li>heart rhythm </li></ul></ul><ul><ul><li>muscle contraction </li></ul></ul><ul><ul><li>brain function </li></ul></ul>
  31. 35. <ul><li>If the body's electrolytes are not in proper balance, a person may have </li></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>an irregular heartbeat </li></ul></ul><ul><ul><li>muscle weakness </li></ul></ul><ul><ul><li>other problems </li></ul></ul><ul><li>Electrolyte imbalances can be caused by a variety of health conditions, such as </li></ul><ul><ul><li>chronic heart or kidney disease </li></ul></ul><ul><ul><li>endocrine diseases (such as problems with the adrenal, pituitary, thyroid, or parathyroid glands) </li></ul></ul><ul><ul><li>eating disorders </li></ul></ul><ul><ul><li>or bone disorders </li></ul></ul><ul><ul><li>Any condition that causes the body to lose too much water (such as diarrhea, vomiting, fever, or taking medications called diuretics) can also lead to an electrolyte imbalance </li></ul></ul>FLUIDS AND ELECTROLYTES
  32. 37.                                                                           The role of salt in body fluids
  33. 38. FLUIDS AND ELECTROLYTES <ul><li>General Functions of Electrolytes </li></ul><ul><ul><li>Promote neuromuscular irritability </li></ul></ul><ul><ul><li>Maintain body fluid volume and osmolality </li></ul></ul><ul><ul><li>Distribute body water between compartments </li></ul></ul><ul><ul><li>Regulate acid-base balance </li></ul></ul>
  34. 39. <ul><li>Approximate Major Electrolyte Content in Body Fluid </li></ul>* main electrolyte Cations: Cations: 17 Proteinate 5 Organic Acids 1 Sulfate (SO 4 -- ) 40 Proteinate 2 Phosphate (HPO 4 -- ) 10 Bicarbonate (HCO 3 - ) 26 Bicarbonate (HCO 3 - ) 150 Phosphates & Sulfates 103 Chloride (Cl - ) Anions: Anions: 2 Magnesium (Mg ++ ) 10 Sodium (Na + ) 5 Calcium (Ca ++ ) 40 Magnesium (Mg ++ ) 5 Potassium (K + ) 150 * Potassium (K + ) 142 * Sodium (Na + ) mEq/L Electrolytes mEq/L Electrolytes Intracellular Fluid (ICF) Extracellular Fluid (ECF) Plasma
  35. 40. FLUIDS AND ELECTROLYTES <ul><li>The Electrolytes: </li></ul><ul><ul><li>Cations: </li></ul></ul><ul><ul><ul><li>Sodium </li></ul></ul></ul><ul><ul><ul><li>Potassium </li></ul></ul></ul><ul><ul><ul><li>Calcium </li></ul></ul></ul><ul><ul><ul><li>Magnesium </li></ul></ul></ul><ul><ul><li>Anions: </li></ul></ul><ul><ul><ul><li>Chloride </li></ul></ul></ul><ul><ul><ul><li>Bicarbonate </li></ul></ul></ul><ul><ul><ul><li>Phosphate </li></ul></ul></ul>
  36. 41. FLUIDS AND ELECTROLYTES <ul><li>Sodium (Na + ) </li></ul><ul><ul><li>Normal concentration = 138 – 145 mEq/L </li></ul></ul><ul><ul><li>Most prevalent cation in the extracellular </li></ul></ul><ul><ul><li>Controls the osmotic pressure of the ECF compartment </li></ul></ul><ul><ul><li>Importance: </li></ul></ul><ul><ul><ul><li>essential for neuromuscular functioning </li></ul></ul></ul><ul><ul><ul><li>helps in the maintenance of acid-base balance </li></ul></ul></ul>
  37. 42. FLUIDS AND ELECTROLYTES <ul><li>Potassium (K + ) </li></ul><ul><ul><li>Normal concentration = 3.5 – 5.0 mEq/L </li></ul></ul><ul><ul><li>Major cation of the cell intracellularly </li></ul></ul><ul><ul><li>K enters the cell during anabolism (tissue formation) or glycogenesis </li></ul></ul><ul><ul><li>K goes out the cell during catabolism (tissue breakdown) – trauma, dehydration, starvation </li></ul></ul><ul><ul><li>Mostly located in intracellular compartment </li></ul></ul><ul><ul><li>Importance: </li></ul></ul><ul><ul><ul><li>has a direct effect on the excitability of nerves and muscles </li></ul></ul></ul><ul><ul><ul><li>contributes most to the intracellular osmotic pressure </li></ul></ul></ul><ul><ul><ul><li>helps maintain acid-base balance and kidney function </li></ul></ul></ul>
  38. 43. FLUIDS AND ELECTROLYTES <ul><li>Calcium (Ca ++ ) </li></ul><ul><ul><li>Normal concentration = 4.5 – 5.8 mEq/L </li></ul></ul><ul><ul><li>Has 2 forms: </li></ul></ul><ul><ul><ul><li>Ionized (free) calcium – physiologically active </li></ul></ul></ul><ul><ul><ul><li>Ca bound to plasma proteins </li></ul></ul></ul>
  39. 44. FLUIDS AND ELECTROLYTES <ul><li>Calcium (Ca ++ ) </li></ul><ul><ul><li>Free ionized Ca is needed for: </li></ul></ul><ul><ul><ul><li>Blood coagulation </li></ul></ul></ul><ul><ul><ul><li>Muscle function (smooth, skeletal, cardiac) </li></ul></ul></ul><ul><ul><ul><li>Nerve function </li></ul></ul></ul><ul><ul><ul><li>Bone and teeth formation </li></ul></ul></ul><ul><ul><li>Calcium level depends on 3 hormones : </li></ul></ul><ul><ul><ul><li>Parathormone – decreased Ca & increase P </li></ul></ul></ul><ul><ul><ul><li>Vitamin D – from sunlight, for Ca absorption </li></ul></ul></ul><ul><ul><ul><li>Calcitonin – decreases Ca levels preventing bone resorption, opposes effects of PTH and Vit D on bones </li></ul></ul></ul>
  40. 45. FLUIDS AND ELECTROLYTES <ul><li>Magnesium (Mg ++ ) </li></ul><ul><ul><li>Normal concentration = 1.5 – 2.5 mEq/L </li></ul></ul><ul><ul><li>About 50% is located in bones, 5% in ECF, and 45% in the ICF compartment </li></ul></ul><ul><ul><li>Vital for enzyme activation reactions, especially in carbohydrate metabolism </li></ul></ul><ul><ul><li>Has a sedative effect on CNS </li></ul></ul>
  41. 46. Laboratory Values Used in Evaluating Fluid and Electrolyte Status 3.5-5.5 g/dL 3.5-5.5 g/dL Serum Albumin 3.9-6.1 mmol/L 70-110 mg/dL Serum Glucose Volume fraction: 0.39-0.47 Female: 39-47 % Volume fraction: 0.44-0.52 Male: 44-52 % Hematocrit 10:1 BUN/Creatinine ratio 62-133 mmol/L 0.7-1.5 mg/dL Serum creatinine 3.5-7 mmol/L of urea 10-20 mg/dL BUN 280-295 mmol/L 280-300 mOsm/kg Serum osmolality 24-30 24-30 Carbon Dioxide content 96-106 96-106 Serum Chloride 0.80-1.5 2.5-4.5 Serum Phosphorus 0.80-1.2 1.5-2.5 mEq/L Serum Mg 2.1-2.6 8.5-10.5 mg/dL Total serum Ca 3.5-5.5 3.5-5.5 mEq/L Serum K 135-145 mmol/L 135-145 mEq/L Serum Na SI Units Usual Reference Guide Test
  42. 47. Laboratory Values Used in Evaluating Fluid and Electrolyte Status < 6.6 < 6.6 typical urine 4.5-8.0 4.5-8.0 Urinary pH 500-800 500-800 mOsm/L typical urine 40-1400 mmol/kg 50-1400 mOsm/L extreme range Urine Osmolality Physiologic range after fluid restriction: 1.010-1.020 random specimen with normal intake 1.025-1.035 1.025-1.035 Urinary Specific Gravity 110-250 110-250 mEq/day Urinary Cl 40-80 40-80 mEq/day Urinary K 50-220 mmol/day 50-220 mEq/day Urinary Na SI Units Usual Reference Guide Test
  43. 48. FLUIDS AND ELECTROLYTES <ul><li>Regulation of Body Fluid Compartments </li></ul><ul><ul><li>Movement of particles through the cell membrane occurs via the following transport mechanisms: </li></ul></ul><ul><ul><ul><li>Passive transport : </li></ul></ul></ul><ul><ul><ul><ul><li>Osmosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diffusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Filtration </li></ul></ul></ul></ul><ul><ul><ul><li>Active transport </li></ul></ul></ul><ul><ul><ul><ul><li>Na-K pump </li></ul></ul></ul></ul>
  44. 49. <ul><li>Osmosis – movement of fluid to area of high concentration and gradual equalization of solute concentration </li></ul><ul><li>Diffusion – movement of fluid and solutes and equalization of solute concentration </li></ul>A B
  45. 50. FLUIDS AND ELECTROLYTES <ul><li>OSMOSIS </li></ul><ul><ul><li>The movement of water through a semipermeable membrane from a solution that has a low concentration of particles towards a solution that has a high concentration of particles </li></ul></ul><ul><ul><li>Normal serum osmolality = 280-300 mOsm/kg </li></ul></ul><ul><ul><li>Osmolality of ECF and ICF is always equal </li></ul></ul>
  46. 51. FLUIDS AND ELECTROLYTES <ul><li>DIFFUSION </li></ul><ul><ul><li>Is the natural tendency of substance to move from an area of higher concentration to one of lower concentration </li></ul></ul><ul><ul><li>Occurs through the random movement of ions and molecules </li></ul></ul><ul><ul><li>Particles will distribute themselves evenly </li></ul></ul><ul><ul><li>Example: exchange of O 2 and CO 2 between pulmonary capillaries and alveoli </li></ul></ul>
  47. 52. FLUIDS AND ELECTROLYTES <ul><li>FILTRATION </li></ul><ul><ul><li>The process by which water and diffusible substances move together in response to fluid pressure </li></ul></ul><ul><ul><li>This process is active in capillary beds </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>Passage of water and electrolytes from the arterial capillary bed to the interstitial fluid </li></ul></ul></ul>
  48. 54. FLUIDS AND ELECTROLYTES <ul><li>ACTIVE TRANSPORT </li></ul><ul><ul><li>The movement of substances across the cell membrane by chemical activity or energy expenditure, that allows cells to admit larger molecules </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>sodium-potassium pump – Na is pumped out of the cell, K is pumped in against pressure gradient </li></ul></ul></ul>
  49. 55. FLUIDS AND ELECTROLYTES
  50. 57. FLUIDS AND ELECTROLYTES <ul><li>Regulation of Body Fluids </li></ul><ul><ul><li>Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are: </li></ul></ul><ul><ul><ul><li>Kidneys </li></ul></ul></ul><ul><ul><ul><li>Heart and Blood vessels </li></ul></ul></ul><ul><ul><ul><li>Lungs </li></ul></ul></ul><ul><ul><ul><li>Glands </li></ul></ul></ul><ul><ul><ul><li>Other Mechanisms </li></ul></ul></ul>
  51. 58. The Renal Tubules
  52. 59. FLUIDS AND ELECTROLYTES <ul><li>Regulation of Body Fluids </li></ul><ul><ul><ul><li>Other mechanisms: </li></ul></ul></ul><ul><ul><ul><ul><li>Baroreceptors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Renin-Angiotensin-Aldosterone System </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ADH and thirst </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Osmoreceptors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Release of Atrial Natriuretic Peptide </li></ul></ul></ul></ul>
  53. 60. Types of Fluid Balance And Imbalance
  54. 61. FLUIDS AND ELECTROLYTES <ul><li>Types of Fluid Balance and Imbalance: </li></ul><ul><li>Saline </li></ul><ul><ul><li>ECF, reflects the volume of water and salt </li></ul></ul><ul><li>Water </li></ul><ul><ul><li>Osmolar proportion of water and salt (concentration) </li></ul></ul>
  55. 62. FLUIDS AND ELECTROLYTES <ul><li>Saline Balance </li></ul><ul><ul><li>Refers to maintaining the proper volume of ECF and the three mechanisms involved in regulating saline balance </li></ul></ul><ul><ul><li>Aldosterone – a major regulator of saline balance (ECF volume) </li></ul></ul>
  56. 63. FLUIDS AND ELECTROLYTES <ul><li>Saline Imbalance </li></ul><ul><ul><li>Changes in the volume of extracellular fluid compartment </li></ul></ul><ul><ul><li>Mechanisms in Regulating Saline Balance (ECF Volume): </li></ul></ul><ul><ul><ul><li>Pituitary Gland – Aldosterone * </li></ul></ul></ul><ul><ul><ul><li>Atrial Natriuretic Peptide </li></ul></ul></ul><ul><ul><ul><li>Neural Mechanism </li></ul></ul></ul>* Adrenocorticotropic hormone – potent regulator of Na + K + metabolism
  57. 66. FLUIDS AND ELECTROLYTES <ul><li>Mechanisms in Saline Balance Regulation </li></ul><ul><li>(ECF Volume) </li></ul><ul><li>Pituitary Gland: </li></ul><ul><li>Ineffective blood volume (decrease blood circulation/ decrease ECF volume) </li></ul><ul><li>Stimulates adrenal cortex </li></ul><ul><li>Secrete aldosterone </li></ul><ul><li>Increase Na + reabsorption in distal tubule, collecting ducts </li></ul><ul><li>Increase saline retention </li></ul><ul><li>Increase in volume of water </li></ul><ul><li>Relieving saline imbalance </li></ul>
  58. 67. FLUIDS AND ELECTROLYTES <ul><li>Mechanisms in Saline Balance Regulation </li></ul><ul><li>(ECF Volume) </li></ul><ul><li>Atrial Natriuretic Peptide: </li></ul><ul><li>Atrial distention (increase ECF) </li></ul><ul><li>Release Peptides </li></ul><ul><li>Acts on kidney </li></ul><ul><li>Increase renal excretion of Na + & water </li></ul><ul><li>Relieving distention </li></ul>
  59. 68. FLUIDS AND ELECTROLYTES <ul><li>Mechanisms in Saline Balance Regulation </li></ul><ul><li>(ECF Volume) </li></ul><ul><li>Neural mechanism: </li></ul><ul><li>Decrease ECF volume </li></ul><ul><li>Stimulate renal sympathetic nerves </li></ul><ul><li>Release of Renin and stimulate the kidneys </li></ul><ul><li>Decrease renal secretion of saline </li></ul><ul><li>Increase ECF volume </li></ul><ul><li>Atrial distention </li></ul><ul><li>Mechano-receptors in the wall of left atrium </li></ul><ul><li>Decrease activity of sympathetic nerve </li></ul><ul><li>Increase excretion of saline by the kidney </li></ul>
  60. 69. FLUIDS AND ELECTROLYTES <ul><li>Saline Imbalance: Saline Deficit </li></ul><ul><ul><li>ECF volume deficit </li></ul></ul><ul><ul><li>Isotonic contraction </li></ul></ul><ul><ul><li>Isosmotic dehydration </li></ul></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Extracellular volume depletion </li></ul></ul><ul><ul><li>- DEHYDRATION - decrease volume ! </li></ul></ul>
  61. 70. FLUIDS AND ELECTROLYTES <ul><li>Saline balance: Saline Deficit </li></ul><ul><ul><li>Clinical Manifestations: - dehydration </li></ul></ul><ul><ul><ul><li>Weight loss </li></ul></ul></ul><ul><ul><ul><li>Postural BP drop </li></ul></ul></ul><ul><ul><ul><li>Increased small vein filling time </li></ul></ul></ul><ul><ul><ul><li>Neck vein flat or collapsing with inspiration </li></ul></ul></ul><ul><ul><ul><li>Dizziness, syncope </li></ul></ul></ul><ul><ul><ul><li>Oliguria or anuria </li></ul></ul></ul><ul><ul><ul><li>Decreased CVP </li></ul></ul></ul><ul><ul><ul><li>Decreased skin turgor </li></ul></ul></ul><ul><ul><ul><li>Longitudinal furrow in the tongue </li></ul></ul></ul><ul><ul><ul><li>Dry mucous membrane </li></ul></ul></ul><ul><ul><ul><li>Hard, dry stools </li></ul></ul></ul><ul><ul><ul><li>Decreased tears and sweat </li></ul></ul></ul><ul><ul><ul><li>Sunken eyeballs </li></ul></ul></ul><ul><ul><ul><li>Hypovolemic shock </li></ul></ul></ul>
  62. 71. FLUIDS AND ELECTROLYTES <ul><li>Saline balance: Saline Deficit </li></ul><ul><ul><li>Laboratory Values: </li></ul></ul><ul><ul><ul><li>Urinalysis – increased Cl </li></ul></ul></ul><ul><ul><ul><li>Blood studies – increased BUN, increased Hct, increased plasma protein, increased Na </li></ul></ul></ul><ul><ul><li>Medical Therapy: </li></ul></ul><ul><ul><ul><li>Saline replacement through IV related to complication of medical therapy </li></ul></ul></ul><ul><ul><ul><li>Dx – potential for injury related to complication </li></ul></ul></ul>
  63. 72. FLUIDS AND ELECTROLYTES <ul><li>Saline Imbalance: Saline Excess </li></ul><ul><ul><li>ECF volume excess </li></ul></ul><ul><ul><li>Isotonic expansion </li></ul></ul><ul><ul><li>Hypervolemia </li></ul></ul><ul><ul><li>Circulatory overload </li></ul></ul>
  64. 73. FLUIDS AND ELECTROLYTES <ul><li>Saline balance: Saline Excess </li></ul><ul><ul><li>Clinical Manifestations: </li></ul></ul><ul><ul><ul><li>Weight gain (0.5kg/day) – sign of volume expansion </li></ul></ul></ul><ul><ul><ul><li>Edema </li></ul></ul></ul><ul><ul><ul><li>Vascular expansion </li></ul></ul></ul><ul><ul><ul><li>Crackles or rales in lungs – fluid accumulation </li></ul></ul></ul><ul><ul><ul><li>Dyspnea, orthopnea due to volume overload </li></ul></ul></ul><ul><ul><ul><li>Increased CVP (5 – 10 cmH 2 0) – right atrium </li></ul></ul></ul>
  65. 75. FLUIDS AND ELECTROLYTES <ul><li>Water Balance and Imbalance </li></ul><ul><li>Refers to the maintenance of the proportion of salt to water in the blood </li></ul><ul><li>Important Facts: </li></ul><ul><ul><li>Serum Na concentration is a useful measure of water balance (normal serum Na = 135 – 145 mEq/L in adults of all ages) </li></ul></ul><ul><ul><ul><li>If the serum Na is decreased: </li></ul></ul></ul><ul><ul><ul><ul><li>The osmolality of blood is decreased </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood is less concentrated than normal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood has excess water relative to the amount of salt </li></ul></ul></ul></ul><ul><ul><ul><li>If the serum Na is increased: </li></ul></ul></ul><ul><ul><ul><ul><li>Osmolality of blood has increased </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood is more concentrated </li></ul></ul></ul></ul><ul><ul><ul><ul><li>The blood has a deficit of water relative to the amount of salt </li></ul></ul></ul></ul>
  66. 76. FLUIDS AND ELECTROLYTES <ul><li>Normal and Abnormal Routes of Water Entry and Exit </li></ul>- Parenteral - Rectal 300 ml Metabolic water 1,200 ml Water in food 1,200 ml Drink Oral Gastrointestinal Average Volume (per 24 hours) Route of Entry
  67. 77. FLUIDS AND ELECTROLYTES <ul><li>Normal and Abnormal Routes of Water Entry and Exit </li></ul>- Hemorrhage - Paracentesis procedures Others: - Drainage from lesions 600 ml Insensible perspiration Skin - Fistula - Emesis 100 ml Fecal Gastrointestinal 400 ml Respiratory 1,500 ml Renal Average Volume (per 24 hours) Route of Exit
  68. 78. FLUIDS AND ELECTROLYTES <ul><li>Water Balance and Imbalance </li></ul><ul><li>The major regulators of oral water intake are: </li></ul><ul><ul><ul><li>Thirst </li></ul></ul></ul><ul><ul><ul><li>Habit patterns </li></ul></ul></ul><ul><ul><ul><li>Social influence </li></ul></ul></ul><ul><li>Three major mechanism of thirst: </li></ul><ul><ul><ul><li>Cellular dehydration thirst </li></ul></ul></ul><ul><ul><ul><li>Baroreceptor – mediated thirst </li></ul></ul></ul><ul><ul><ul><li>Angiotensin – mediated thirst </li></ul></ul></ul>
  69. 79. FLUIDS AND ELECTROLYTES <ul><li>Water Balance and Imbalance </li></ul><ul><li>Cycle of Urine Excretion : </li></ul><ul><li>Increase in osmolality of blood </li></ul><ul><li>Hypothalamus </li></ul><ul><li>Pituitary Gland </li></ul><ul><li>Release of ADH </li></ul><ul><li>Collecting ducts of kidneys </li></ul><ul><li>Reabsorption of water back to the blood stream </li></ul><ul><li>Dilute the blood </li></ul><ul><li>Restore osmolalilty </li></ul><ul><li>Note: The excretion of urine (of water) is controlled by ADH. </li></ul>
  70. 80. FLUIDS AND ELECTROLYTES <ul><li>TYPES OF WATER IMBALANCE </li></ul><ul><li>WATER DEFICIT: </li></ul><ul><ul><li>Hypernatremia </li></ul></ul><ul><ul><li>Water depletion </li></ul></ul><ul><ul><li>Hypertonicity </li></ul></ul><ul><ul><li>Hyperosmolar balance </li></ul></ul>
  71. 81. FLUIDS AND ELECTROLYTES <ul><li>WATER DEFICIT </li></ul><ul><li>Causes: </li></ul><ul><li>1. Loss of water relative to salt </li></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><ul><li>Dibetes insipidus (salt gain due to polyuria) </li></ul></ul></ul><ul><ul><ul><li>Osmotic diuresis (polyuria) </li></ul></ul></ul><ul><ul><ul><li>Renal concentrating disorder </li></ul></ul></ul><ul><ul><ul><li>Renal failure </li></ul></ul></ul><ul><ul><li>Other sources: </li></ul></ul><ul><ul><ul><li>Prolonged diarrhea without water replacement </li></ul></ul></ul><ul><ul><ul><li>Excessive sweating without water replacement </li></ul></ul></ul><ul><ul><ul><li>Dysfunctional humidifier of mechanical ventilators (dry air inhalation) </li></ul></ul></ul>
  72. 82. FLUIDS AND ELECTROLYTES <ul><li>WATER DEFICIT </li></ul><ul><li>Causes: </li></ul><ul><li>2. Gain of salt relative to water </li></ul><ul><ul><li>Decrease water intake </li></ul></ul><ul><ul><ul><li>No access to water </li></ul></ul></ul><ul><ul><ul><li>Prolonged nausea </li></ul></ul></ul><ul><ul><ul><li>Difficulty swallowing fluid (Parkinson’s disease) </li></ul></ul></ul><ul><ul><ul><li>Inability to respond to thirst </li></ul></ul></ul><ul><ul><li>Increase salt intake </li></ul></ul><ul><ul><ul><li>By means of tube feeding </li></ul></ul></ul><ul><ul><ul><li>Half and half for ulcer diet </li></ul></ul></ul><ul><ul><ul><li>Excess hypertonic NaCl or NaHCO 3 </li></ul></ul></ul>
  73. 83. FLUIDS AND ELECTROLYTES <ul><li>WATER DEFICIT </li></ul><ul><li>Clinical Manifestations: </li></ul><ul><ul><li>Serum Na is above normal (blood is concentrated) </li></ul></ul><ul><ul><li>Thirst (due to lack of water) </li></ul></ul><ul><ul><li>Oliguria </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Mild muscle weakness </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Coma (varies in severity) </li></ul></ul>
  74. 84. FLUIDS AND ELECTROLYTES <ul><li>WATER DEFICIT </li></ul><ul><li>Clinical Manifestations: </li></ul><ul><li>Pathophysiology: </li></ul><ul><li>Decrease Water </li></ul><ul><li>Increase Osmolality </li></ul><ul><li>Osmosis </li></ul><ul><li>ICF </li></ul><ul><li>ECF </li></ul><ul><li>Attempt to restore osmolality </li></ul><ul><li>Cells shrivels </li></ul><ul><li>Cell dysfunction </li></ul>
  75. 85. FLUIDS AND ELECTROLYTES <ul><li>WATER DEFICIT </li></ul><ul><li>Medical Therapy: </li></ul><ul><li>Replacement of fluid loss by IVF or oral route </li></ul><ul><ul><li>Institute or encourage oral fluid intake </li></ul></ul><ul><ul><li>Administer in small amount </li></ul></ul><ul><ul><li>Help patient in taking his I & O measurement </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Cerebral edema (therapy too rapid) </li></ul></ul><ul><ul><li>Rebound fluid excess (therapy excessive) </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Infiltration </li></ul></ul>Because of IV therapy
  76. 86. FLUIDS AND ELECTROLYTES <ul><li>TYPES OF WATER IMBALANCE </li></ul><ul><li>WATER EXCESS: </li></ul><ul><ul><li>Hyponatremia (decrease serum Na - < 135mEq/L) </li></ul></ul><ul><ul><li>Water intoxication </li></ul></ul><ul><ul><li>Hypotonicity </li></ul></ul>
  77. 87. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Causes: </li></ul><ul><li>I. General etiology: Gain or water relative to salt </li></ul><ul><ul><li>A. Endocrine: </li></ul></ul><ul><ul><ul><li>Stimulation of ADH </li></ul></ul></ul><ul><ul><ul><ul><li>Stressors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Post-surgical state </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nausea </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain </li></ul></ul></ul></ul><ul><ul><ul><li>Ectopic production of ADH </li></ul></ul></ul>
  78. 88. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Causes: </li></ul><ul><li>I.General etiology: Gain or water relative to salt </li></ul><ul><ul><li>B. Iatrogenic – caused by medical therapy </li></ul></ul><ul><ul><ul><li>Excessive tap water enema </li></ul></ul></ul><ul><ul><ul><li>Excessive infusion of D5W </li></ul></ul></ul><ul><ul><ul><li>Excessive use of ultrasonic nebulizer </li></ul></ul></ul><ul><ul><ul><li>Hypotonic irrigating solution (by process of osmosis) </li></ul></ul></ul><ul><ul><ul><li>Excessive water ingestion after poisoning </li></ul></ul></ul><ul><ul><ul><li>Excessive water ingestion before an UTZ examination </li></ul></ul></ul>
  79. 89. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Causes: </li></ul><ul><li>I. General etiology: Gain or water relative to salt </li></ul><ul><ul><li>A. Others </li></ul></ul><ul><ul><ul><li>Psychogenic polydipsia – excessive thrist </li></ul></ul></ul><ul><ul><ul><li>Excessive beer drinking </li></ul></ul></ul><ul><ul><ul><li>Near drowning in fresh water </li></ul></ul></ul><ul><ul><ul><li>Overdose of Barbiturates </li></ul></ul></ul>
  80. 90. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Causes: </li></ul><ul><li>II. General Etiology: Lost of salt relative to water </li></ul><ul><ul><li>A. Renal </li></ul></ul><ul><ul><ul><li>Salt wasting renal disease </li></ul></ul></ul><ul><ul><ul><li>Use of many types of diuretics (Thiazides) </li></ul></ul></ul>
  81. 91. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Causes: </li></ul><ul><li>II. General Etiology: Lost of salt relative to water </li></ul><ul><ul><li>B. Gastrointestinal – due to water replacement not by salt </li></ul></ul><ul><ul><ul><li>Nasogastric suction </li></ul></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><ul><ul><li>Diarrhea </li></ul></ul></ul><ul><ul><ul><li>Hypotonic irrigation solutions </li></ul></ul></ul>
  82. 92. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Causes: </li></ul><ul><li>II. General Etiology: Lost of salt relative to water </li></ul><ul><ul><li>C. Others </li></ul></ul><ul><ul><ul><li>Burns </li></ul></ul></ul><ul><ul><ul><li>Excessive sweating </li></ul></ul></ul>
  83. 93. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Clinical Manifestations: </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Increased Water </li></ul><ul><li>Decrease Osmolality </li></ul><ul><li>Osmosis </li></ul><ul><li>ECF </li></ul><ul><li>ICF </li></ul><ul><li>Attempt to restore Osmolality </li></ul><ul><li>Cell swollen </li></ul><ul><li>Cell dysfunction </li></ul>
  84. 94. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Clinical Manifestations: </li></ul><ul><ul><li>Decrease serum Na </li></ul></ul><ul><ul><li>Malaise </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Coma </li></ul></ul>
  85. 95. FLUIDS AND ELECTROLYTES <ul><li>WATER EXCESS </li></ul><ul><li>Medical Therapy/ Management: </li></ul><ul><li>Restrict water intake below the daily insensible losses (1,000 ml) </li></ul><ul><li>The kidney will excrete the excess water </li></ul><ul><li>Administration of diuretic ( Furosemide ) </li></ul><ul><li>Administration of ADH-blocking agent Demeclocycline or LiCO 3 ) </li></ul>
  86. 97. FLUIDS AND ELECTROLYTES <ul><li>EDEMA </li></ul><ul><li>Fluid accumulation at the interstitial space </li></ul><ul><li>Maybe a sign of saline excess </li></ul><ul><li>Governed by the net result of the ff: </li></ul><ul><ul><li>Blood hydrostatic pressure </li></ul></ul><ul><ul><li>Interstitial fluid hydrostatic pressure </li></ul></ul><ul><ul><li>Blood colloid osmotic and oncotic pressure </li></ul></ul><ul><ul><li>Interstitial fluid osmotic pressure </li></ul></ul>
  87. 100. FLUIDS AND ELECTROLYTES <ul><li>EDEMA </li></ul><ul><li>Capillary Mechanism for Edema Formation </li></ul><ul><li>1. Increase blood hydrostatic pressure </li></ul><ul><li>A. Increase capillary flow </li></ul><ul><ul><ul><ul><li>Local infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inflammation </li></ul></ul></ul></ul><ul><li>B. Venous congestion </li></ul><ul><ul><ul><ul><li>External pressure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Venous thrombosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Right heart failure </li></ul></ul></ul></ul>
  88. 101. FLUIDS AND ELECTROLYTES <ul><li>EDEMA </li></ul><ul><li>Capillary Mechanism for Edema Formation </li></ul><ul><li>2. Decrease blood osmotic pressure </li></ul><ul><li>A. Decrease serum Albumin </li></ul><ul><ul><ul><ul><li>Loss of albumin </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nephrotic Syndrome </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Protein-losing enteropathies </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Liver disease (Cirrhosis) </li></ul></ul></ul></ul>
  89. 102. FLUIDS AND ELECTROLYTES <ul><li>EDEMA </li></ul><ul><li>Capillary Mechanism for Edema Formation </li></ul><ul><li>3. Increase fluid osmotic pressure </li></ul><ul><li>A. Increase capillary permeability </li></ul><ul><ul><ul><ul><li>Burns </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inflammation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypersensitivity reactions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Toxins </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Trauma </li></ul></ul></ul></ul>
  90. 103. FLUIDS AND ELECTROLYTES <ul><li>EDEMA </li></ul><ul><li>Capillary Mechanism for Edema Formation </li></ul><ul><li>4. Impaired lymphatic drainage </li></ul><ul><ul><ul><li>a. obstruction of the lymph node by tumors </li></ul></ul></ul><ul><ul><ul><li>b. Surgical removal of lymph nodes </li></ul></ul></ul><ul><ul><ul><li>c. Obstruction of lymph nodes by parasites </li></ul></ul></ul>
  91. 104. FLUIDS AND ELECTROLYTES <ul><li>EDEMA </li></ul><ul><li>Medical Therapy and Interventions: </li></ul><ul><ul><li>Use of elastic stockings to enhance venous return </li></ul></ul><ul><ul><li>Administration of diuretics or a Na-restricted diet (< 500 mg/day), and if with hyponatremia ( reduced water intake < 1500 ml/day) </li></ul></ul>
  92. 106. <ul><li>Diuretics: </li></ul><ul><ul><li>Loop </li></ul></ul><ul><ul><ul><li>Furosemide </li></ul></ul></ul><ul><ul><ul><li>Bumetanide </li></ul></ul></ul><ul><ul><ul><li>Ethacrynic acid </li></ul></ul></ul><ul><ul><li>Distal – K losing </li></ul></ul><ul><ul><ul><li>HCTZ </li></ul></ul></ul><ul><ul><ul><li>Chlorthalidone </li></ul></ul></ul><ul><ul><ul><li>Metazolone </li></ul></ul></ul><ul><ul><li>Distal- K sparing </li></ul></ul><ul><ul><ul><li>Spironolactone </li></ul></ul></ul><ul><ul><ul><li>Amiloride </li></ul></ul></ul><ul><ul><ul><li>Triamterene </li></ul></ul></ul>
  93. 107. <ul><li>ELECTROLYTE BALANCE </li></ul><ul><li>AND </li></ul><ul><li>ELECTROLYTE IMBALANCES </li></ul>
  94. 108. FLUIDS AND ELECTROLYTES <ul><li>ELECTROLYTE BALANCE AND IMBALANCES </li></ul><ul><li>Electrolytes: </li></ul><ul><ul><li>Salts found in every body fluids </li></ul></ul><ul><ul><li>Na + , K + , Ca ++ , PO 3 - , Mg + (major electrolytes) </li></ul></ul><ul><ul><li>Enter the body primarily in the diet then enter the ECF and distributed to some other body electrolyte pool (bones/ inside cells) </li></ul></ul>
  95. 109. FLUIDS AND ELECTROLYTES <ul><li>Electrolytes: </li></ul><ul><li>Normal Routes of Exit: </li></ul><ul><ul><li>Urine </li></ul></ul><ul><ul><li>Feces </li></ul></ul><ul><ul><li>Sweat </li></ul></ul><ul><li>Abnormal Route: </li></ul><ul><ul><li>Fistula drainage </li></ul></ul><ul><ul><li>Emesis </li></ul></ul><ul><ul><li>Gastric or intestinal suction </li></ul></ul><ul><ul><li>Paracentesis </li></ul></ul><ul><ul><li>Exudates </li></ul></ul>
  96. 110. FLUIDS AND ELECTROLYTES <ul><li>The level of any electrolyte in the blood can become too high or too low </li></ul><ul><li>The main electrolytes in the blood are sodium, potassium, calcium, magnesium, chloride, phosphate, and carbonate </li></ul><ul><li>Most commonly, problems occur when the level of sodium, potassium, or calcium is abnormal </li></ul><ul><li>Electrolyte levels change when water levels in the body change . </li></ul>
  97. 111. FLUIDS AND ELECTROLYTES <ul><li>Doctors refer to a low electrolyte level with the prefix &quot;hypo-&quot; and to a high level with the prefix &quot;hyper-” </li></ul><ul><li>The prefix is combined with the scientific name of the electrolyte </li></ul><ul><li>For example, a low level of potassium is called hypokalemia, and a high level of sodium is called hypernatremia </li></ul><ul><li>Electrolyte abnormalities can be diagnosed by measuring electrolyte levels in a sample of blood or urine. Other tests may be needed to determine the cause of the abnormalities. </li></ul>
  98. 112. FLUIDS AND ELECTROLYTES <ul><li>SODIUM BALANCE AND IMBALANCE: </li></ul><ul><li>HYPONATREMIA </li></ul><ul><ul><li>not consuming enough sodium in the diet, excreting too much (in sweat or urine), or being overhydrated </li></ul></ul><ul><ul><li>drinks a lot of water without consuming enough salt (sodium chloride), typically during hot weather when a person also sweats more </li></ul></ul><ul><ul><li>large amounts of fluids that do not contain enough sodium are given intravenously </li></ul></ul>
  99. 113. FLUIDS AND ELECTROLYTES <ul><ul><li>diuretics may cause the kidneys to excrete more sodium than water, resulting in a low sodium level. </li></ul></ul><ul><ul><li>A low sodium level (and overhydration) can result when the body produces too much antidiuretic hormone , which signals the kidneys to retain water. Overproduction of this hormone can be caused by disorders such as pneumonia and stroke and by drugs, including anticonvulsants (such as carbamazepine) and a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs—such as sertraline). Other disorders that can cause a low sodium level include poorly controlled diabetes, heart failure, liver failure, and kidney disorders. </li></ul></ul>
  100. 114. FLUIDS AND ELECTROLYTES <ul><li>HYPONATREMIA </li></ul><ul><ul><li>Having a low sodium level can cause confusion, drowsiness, muscle weakness, and seizures. </li></ul></ul><ul><ul><li>A rapid fall in the sodium level often causes more severe symptoms than a slow fall. </li></ul></ul><ul><ul><li>A low sodium level is restored to a normal level by gradually and steadily giving sodium and water intravenously . </li></ul></ul>
  101. 115. FLUIDS AND ELECTROLYTES <ul><li>HYPERNATREMIA </li></ul><ul><ul><li>caused by dehydration or use of diuretics. (Diuretics may also cause the kidneys to excrete more water than sodium.) </li></ul></ul><ul><ul><li>Typically, thirst is the first symptom, may become weak and feel sluggish. A very high sodium level can cause confusion, paralysis, coma, and seizures. </li></ul></ul><ul><ul><li>If the sodium level is slightly high, it can be lowered by drinking fluids. </li></ul></ul><ul><ul><li>If the sodium level is very high, fluids are given intravenously. Once the body's fluids are replaced, the high level of sodium returns to a normal level. </li></ul></ul>
  102. 116. FLUIDS AND ELECTROLYTES <ul><li>POTASSIUM BALANCE AND IMBALANCES </li></ul><ul><li>Normal range = 3.5 – 5.0 mEq/L </li></ul><ul><li>“ Kalium” – Latin word for potassium </li></ul><ul><li>Potassium Homeostasis: </li></ul><ul><ul><li>Enters the cells through an active transport mechanism </li></ul></ul><ul><ul><li>Both insulin and epinephrine cause K to enter cells </li></ul></ul><ul><ul><li>Exercise causes K to exit cells initially </li></ul></ul><ul><ul><li>pH of ECF also affect the distribution </li></ul></ul>
  103. 117. FLUIDS AND ELECTROLYTES <ul><li>POTASSIUM BALANCE AND IMBALANCES </li></ul><ul><li>Normal range = 3.5 – 5.0 mEq/L </li></ul><ul><li>“ Kalium” – Latin word for potassium </li></ul><ul><li>Factors that causes K shift </li></ul><ul><li>A. Accumulation of carbonic acid </li></ul><ul><ul><ul><li>May cause a mild ECF shift </li></ul></ul></ul><ul><li>B. Accumulation of mineral acids </li></ul><ul><ul><ul><li>Causes significant extracellular K shift </li></ul></ul></ul><ul><li>C. Accumulation of organic acids </li></ul><ul><ul><ul><li>Does not in itself cause a K shift </li></ul></ul></ul>
  104. 118. FLUIDS AND ELECTROLYTES <ul><li>CALCIUM BALANCE & IMBALANCES </li></ul><ul><li>Facts: </li></ul><ul><li>Calcium ions in the body are mostly located in the bones and teeth </li></ul><ul><li>Small amount in cells of soft tissue </li></ul><ul><li>Normal concentration = 4.5 – 5.5 mEq/L </li></ul><ul><li>Calcium Homeostasis: </li></ul><ul><li>Major source of calcium intake: </li></ul><ul><ul><li>Milk </li></ul></ul><ul><ul><li>Dairy products (cheese, cream, yogurt, ice cream) </li></ul></ul><ul><ul><li>Sea foods (clams) </li></ul></ul><ul><li>Calcium is absorbed from the GIT by active transport mechanism requiring Vitamin D </li></ul><ul><li>Parathyroid hormone (PTH) increases activation of Vitamin D </li></ul>
  105. 119. FLUIDS AND ELECTROLYTES <ul><li>PHOSPHATE BALANCE & IMBALANCES </li></ul><ul><li>An anion </li></ul><ul><li>Integral part of bones and are abundant inside cells </li></ul><ul><li>Normal serum concentration = 2.5 – 4.5 mg/dL </li></ul><ul><li>Serum PO 4 tends to decrease with age in both men and women </li></ul><ul><li>Phosphate Homeostasis: </li></ul><ul><ul><li>Phosphate absorption occurs in small intestine </li></ul></ul><ul><ul><li>Maybe affected by Vitamin D </li></ul></ul><ul><ul><li>Magnesium, aluminum ions diarrhea decrease the absorption of PO 4 from GIT </li></ul></ul><ul><ul><li>PO 4 distribution between the ECF and bones is under the influence of PTH which promotes bone resorption </li></ul></ul><ul><ul><li>PO 4 excretion occurs primarily in urine and feces </li></ul></ul><ul><ul><li>PTH increases renal excretion of PO 4 </li></ul></ul>
  106. 120. FLUIDS AND ELECTROLYTES <ul><li>MAGNESIUM BALANCE & IMBALANCES </li></ul><ul><li>Most of Mg ions in the body are located in the bones </li></ul><ul><li>Rest of Mg is intracellular especially in the liver and skeletal muscles </li></ul><ul><li>Small amount of Mg in the blood </li></ul><ul><li>Normal Concentration = 1.5 – 2.5 mEq/L </li></ul><ul><li>Foods high in Mg content: whole grain cereals, dark green vegetables, dried beans and peas, soy products, nuts (except cashew and almonds), peanut butter, cocoa, chocolate, bananas, egg yolk, sea salt </li></ul>
  107. 121. <ul><li>ACID – BASE BALANCE </li></ul>
  108. 122. FLUIDS AND ELECTROLYTES <ul><li>ACID – BASE IMBALANCE </li></ul><ul><li>Hydrogen ions are vital to life and health </li></ul><ul><li>The concentration of hydrogen ions in the body is less than that of other ions </li></ul><ul><li>Acid-base status of patient is obtained from sample of arterial blood (ABG) </li></ul><ul><ul><ul><li>Normal blood pH = 7.35 – 7.45 (* Henderson-Hasselbach equation ) </li></ul></ul></ul><ul><ul><ul><li>pCO 2 = 36 – 44 mmHg </li></ul></ul></ul><ul><ul><ul><li>HCO 3 = 22 – 26 mEq/L </li></ul></ul></ul><ul><li>pH < 7.35 is acidosis </li></ul><ul><li>pH > 7.45 is alkalosis </li></ul><ul><li>pH limit compatible to life 7.0 – 7.8 </li></ul><ul><ul><ul><li>*HH equa – pH is a ratio of HCO3 to pCO2 </li></ul></ul></ul>
  109. 123. FLUIDS AND ELECTROLYTES <ul><li>ACID – BASE IMBALANCE </li></ul><ul><li>Mechanisms regulating Acid-Base Balance: </li></ul><ul><li>A. Chemical buffers in cells and ECF * </li></ul><ul><ul><li>Instantaneous action </li></ul></ul><ul><ul><li>Combine acids or bases added to the system to prevent marked changes in pH </li></ul></ul><ul><li>B. Respiratory system </li></ul><ul><ul><li>Minutes to hours in action </li></ul></ul><ul><ul><li>Controls CO 2 concentration in ECF by changes in rate and depth of respiration </li></ul></ul><ul><li>C. Kidneys </li></ul><ul><ul><li>Hours to days in action </li></ul></ul><ul><ul><li>Increases or decreases quantity of NaHCO 3 in ECF </li></ul></ul><ul><ul><li>Combines HCO 3 or H with other substances and excreted in urine </li></ul></ul>* fast-acting mechanism
  110. 124. FLUIDS AND ELECTROLYTES <ul><li>ACID – BASE PNEMONIC: R – O – M – E </li></ul><ul><li>R – Respiratory </li></ul><ul><li>O – Opposite </li></ul><ul><li>pH increase pCO 2 decrease – alkalosis </li></ul><ul><li>pH decrease pCO 2 increase – acidosis </li></ul><ul><li>M – Metabolic </li></ul><ul><li>E – Equal </li></ul><ul><li>pH increase HCO 3 increase – alkalosis </li></ul><ul><li>pH decrease HCO 3 decrease – acidosis </li></ul>
  111. 125. FLUIDS AND ELECTROLYTES Elevate pH with IV NaHCO 3 Oral bicarbonate or citrate in chronic metabolic acidosis Improvement of ventilation through bronchodilators or mechanical support For severe type, infusion of NaHCO 3 to raise the pH toward normal THERAPY Decreased HCO 3 ion concentration, hyperventilation (compensatory mechanism), headache, abdominal pain, confusion, drowsiness, lethargy, stupor, coma, arrhythmias Increased pCO 2 , headache, blurred vision, disorientation, tachycardia, cardiac arrhythmias, lethargy, somnolence MANIFESTATIONS Acid accumulation by ingestion, by increased metabolic acid production, by utilization of abnormal or incomplete metabolic pathways, by impaired acid excretion, and primary decrease of HCO 3 Decreased gaseous exchange Impaired neuromuscular function Suppressed ventilatory mechanism on brain stem (medulla) CAUSE METABOLIC (Noncarbonic acid excess) RESPIRATORY (Carbonic acid excess) ACIDOSIS
  112. 126. FLUIDS AND ELECTROLYTES Directed toward treating the original cause and enhance the renal excretion of bicarbonate to correct imbalance Dialysis may be instituted if profound Correct the underlying disorder Monitor for its effectiveness and potential complications THERAPY Initial disorder, nausea, emesis, paresthesias, tetany, seizures, profound disorder, confusion, lethargy, coma Decreased pCO 2 , diaphoresis, lightheadedness, paresthesias (fingers, toes, circumoral), muscle cramps, Chvostek ’s and Trosseau ’s sign, carpopedal spasm, tetany, syncope, arrhythmias MANIFESTATIONS Decreased of acid Increased of base (bicarbonate ions) Hyperventilation CAUSE METABOLIC (Noncarbonic acid deficit) RESPIRATORY (Carbonic acid deficit) ALKALOSIS
  113. 127. <ul><li>INTRAVENOUS FLUIDS </li></ul>
  114. 128. FLUIDS AND ELECTROLYTES <ul><li>Types of Intravenous Fluids (IVF) </li></ul><ul><ul><li>Crystalloids </li></ul></ul><ul><ul><ul><li>True solutions </li></ul></ul></ul><ul><ul><ul><li>Capable of passing through a semipermeable membrane </li></ul></ul></ul><ul><ul><ul><ul><li>Isotonic solutions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypotonic solutions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypertonic solutions </li></ul></ul></ul></ul><ul><ul><li>Colloids </li></ul></ul><ul><ul><ul><li>Solutions that do not dissolved </li></ul></ul></ul><ul><ul><ul><li>Not true solutions </li></ul></ul></ul><ul><ul><ul><li>Increase intravascular colloid osmotic pressure </li></ul></ul></ul>
  115. 129. FLUIDS AND ELECTROLYTES <ul><li>TYPES OF INTRAVENOUS FLUID USED? </li></ul><ul><li>There are 4 main types of intravenous fluid based on their constituents, particularly the type and amount of electrolytes, and the clinical circumstances under which they are used: </li></ul><ul><ul><li>Resuscitation fluid. </li></ul></ul><ul><ul><li>Maintenance fluid. </li></ul></ul><ul><ul><li>Replacement fluid. </li></ul></ul><ul><ul><li>Total parenteral nutrition. </li></ul></ul>
  116. 130. FLUIDS AND ELECTROLYTES <ul><li>RESUSCITATION FLUID AND WHEN IS IT USED? </li></ul><ul><li>Resuscitation fluid is used to resuscitate </li></ul><ul><ul><li>shocked due to hypoxia, septicemia or blood loss. </li></ul></ul><ul><ul><li>As the fluid is given rapidly, it must be ISOTONIC with blood (i.e. it must contain the same concentration of electrolytes as blood). </li></ul></ul><ul><ul><li>If HYPOTONIC fluid (i.e. it has a lower concentration of electrolytes than blood) is given rapidly, the water in the fluid leaves the blood stream and enters cells causing edema and brain swelling. </li></ul></ul>
  117. 131. FLUIDS AND ELECTROLYTES <ul><li>RESUSCITATION fluids: </li></ul><ul><ul><li>Normal saline (0.9%) </li></ul></ul><ul><ul><li>Blood </li></ul></ul><ul><ul><li>Stabilized human serum (SHS) </li></ul></ul><ul><ul><li>Fresh frozen plasma </li></ul></ul><ul><ul><li>Plasmalyte B </li></ul></ul><ul><ul><li>Ringer's lactate </li></ul></ul><ul><ul><li>Haemaccel </li></ul></ul>
  118. 132. FLUIDS AND ELECTROLYTES <ul><li>MAINTENANCE FLUID AND WHEN IS IT USED? </li></ul><ul><ul><li>Maintenance fluid is used to supply the daily requirements of water and electrolytes . It also supplies some, but not all, of the energy needs. Maintenance fluid is given to patients that cannot be fed by mouth or nasogastric tube. </li></ul></ul><ul><ul><li>Maintenance fluid will provide the patient with the correct amount of electrolytes if the correct volume per kg is given a day . It is dangerous to use replacement fluid or resuscitation fluid for maintenance as it will provide too much sodium </li></ul></ul>
  119. 133. FLUIDS AND ELECTROLYTES <ul><li>Maintenance Fluids are: </li></ul><ul><li>Hypotonic solutions </li></ul><ul><ul><li>0.45% NaCl </li></ul></ul><ul><ul><li>5% Dextrose Water </li></ul></ul><ul><ul><li>0.2% NaCl </li></ul></ul><ul><li>Isotonic solutions </li></ul><ul><ul><li>Ringer’s lactate </li></ul></ul><ul><ul><li>blood components </li></ul></ul><ul><ul><li>0.9% NaCl </li></ul></ul>
  120. 134. FLUIDS AND ELECTROLYTES <ul><li>Hyponatremia is the commonest electrolyte abnormality in hospitalized patients. </li></ul><ul><ul><li>If the plasma sodium concentration (P Na) declines to ~120 mM in <48 h, brain cell swelling might result in herniation, with devastating consequences. </li></ul></ul><ul><ul><li>The volume and/or the composition of fluids used for intravenous therapy often contribute to the development of acute hyponatremia. </li></ul></ul><ul><ul><li>Our hypothesis is that the traditional calculation of the daily loss of insensible water overestimates this parameter, leading to an excessive daily recommended requirement for water. </li></ul></ul>
  121. 135. <ul><li>Hypotonic Versus Isotonic Maintenance Intravenous Fluid Therapy in Hospitalized Children: A Systematic Review </li></ul><ul><li>Carolyn E. Beck, MD, MSc, FRCPC Division of Paediatric Medicine and the Paediatric Outcomes Research Team, The Hospital for Sick Children, and the University of Toronto, Toronto, Ontario, Canada, [email_address] </li></ul><ul><li>A systematic review of studies comparing hypotonic versus isotonic intravenous maintenance fluids in hospitalized children was conducted to determine whether hypotonic solutions increase the risk of acute hyponatremia . Studies were identified from electronic databases and hand-searched reference lists. A total of 283 abstracts were reviewed, 55 full-text articles were retrieved, and 3 studies were included. All studies were observational and were overall inconclusive . All authors cautioned against the routine use of hypotonic maintenance fluids, but hypotonic fluid administration did not always explain the development of acute hyponatremia. Further evidence is required as to the appropriate maintenance solution for hospitalized children. </li></ul>
  122. 136. <ul><li>Hypotonic vs isotonic saline solutions for intravenous fluid management of acute infections </li></ul><ul><li>Duke T, Mathur A, Kukuruzovic R, McGuigan M </li></ul><ul><li>No evidence so far to support use of isotonic saline as a maintenance fluid instead of hypotonic saline </li></ul><ul><li>It is common practice to give intravenous (i.v.) fluids to patients with serious acute infections but there is no agreement as to what the sodium concentration of these fluids should be. Doctors have traditionally used intravenous fluid that contains a lower sodium concentration than is found normally in human serum; this is known as hypotonic saline. However, as patients with severe infections often have low sodium levels and adverse effects sometimes occur with the use of large amounts of hypotonic saline, it has been proposed to use intravenous fluids that have a sodium concentration similar to that of a healthy person isotonic saline. This review has been unable to find any data from randomized trials that establish which is best. </li></ul>
  123. 137. FLUIDS AND ELECTROLYTES <ul><li>REPLACEMENT FLUID AND WHEN IS IT USED? </li></ul><ul><ul><li>Replacement fluid is used to correct the fluid and electrolyte balance after excess fluid and electrolyte has been lost in the stool, urine, sweat or by vomiting. Therefore, replacement fluid is used to correct dehydration. </li></ul></ul><ul><ul><li>Replacement fluids contain 3 times more sodium than maintenance fluids. In addition, half strength Darrow's contains a lot of potassium and is, therefore, used to replace fluid losses in gastroenteritis. Half-normal saline does not contain potassium and is, therefore, used to replace fluid lost by vomiting and excessive sweating where sodium and water but not potassium are lost. </li></ul></ul>
  124. 138. FLUIDS AND ELECTROLYTES <ul><li>REPLACEMENT fluids are: </li></ul><ul><ul><li>Half-strength Darrow's. </li></ul></ul><ul><ul><li>Half-normal saline. </li></ul></ul><ul><li>Darrow's solution </li></ul><ul><li>a mixture of potassium chloride, sodium chloride and sodium lactate; used in fluid therapy to repair a potassium deficit. Also called lactated potassium saline injection . </li></ul>
  125. 139. FLUIDS AND ELECTROLYTES <ul><li>TOTAL PARENTERAL NUTRITION AND WHEN IS IT USED? </li></ul><ul><li>Total parenteral nutrition (or TPN) is used to meet all the fluid, electrolyte and nutritional requirements of a patient who cannot be fed by mouth or nasogastric tube for more than a few days. </li></ul><ul><ul><li>Total parenteral nutrition is only used in hospitals with special expertise in parenteral feeding. </li></ul></ul>
  126. 140. FLUIDS AND ELECTROLYTES B. Isotonic Fluid: Osmolality = 240 – 340 mOsm/L, treat hypotension due to hypovolemia Ringer’s lactate, blood components, 0.9% NaCl C. Hypertonic Fluid: Osmolality 340 mOsm/L or higher 5% Dextrose in 0.45% NaCl, 5% Dextrose and 0.9% NaCl, 10% or 20% or 50% Dextrose, 3% and 5% NaCl, hyperalimentation A.Hypotonic Fluid: Osmolality < 240 mOsm/L, lower serum Na 0.45% NaCl, 5% Dextrose Water, 0.2% NaCl True solutions Capable of passing through a semipermeable membrane CRYSTALLOID SOLUTIONS TYPES OF INTRAVENOUS SOLUTIONS
  127. 141. FLUIDS AND ELECTROLYTES Blood and blood products Stabilized human serum (SHS) Haemacel Human albumin Plasma protein fraction (PPF) Solutions that do not dissolved Not true solutions Increase intravascular colloid osmotic pressure COLLOID SOLUTIONS TYPES OF INTRAVENOUS SOLUTIONS
  128. 142. Osmosis. Erythrocytes undergo no change in size in Isotonic solutions (A). There is increase in size in Hypotonic solutions (B) and decrease in size [shrink/crenate] in Hypertonic solution (C).
  129. 143. <ul><li>Exerts higher osmotic pressure than that of blood plasma </li></ul><ul><li>Increases solute concentration of plasma, drawing water out of cells into ECF compartment </li></ul><ul><li>Uses: </li></ul><ul><li>Electrolyte replacement </li></ul><ul><li>Expand intravascular compartment </li></ul><ul><li>Total parenteral nutrition </li></ul><ul><li>Caution: </li></ul><ul><li>Irritating to veins </li></ul><ul><li>May cause circulatory overload </li></ul><ul><li>Exerts the same osmotic pressure as that found in plasma </li></ul><ul><li>Use to expand ECF compartments </li></ul><ul><li>Do not affect the intracellular and interstitial compartments </li></ul><ul><li>Fluid does not alter serum osmolality </li></ul><ul><li>Can be used to treat hypotension caused by hypovolemia </li></ul><ul><li>Uses: </li></ul><ul><li>Expands intravascular compartment </li></ul><ul><li>Caution: </li></ul><ul><li>Can cause circulatory overload </li></ul><ul><li>Dilutes concentration of Hgb </li></ul><ul><li>Exerts less osmotic pressure than that of blood plasma </li></ul><ul><li>Cause dilution of plasma solute concentration, cause the fluid shift out of blood vessels and interstitial spaces where osmolality is higher </li></ul><ul><li>Caution: </li></ul><ul><li>Hydrates cell while depleting circulatory system </li></ul><ul><li>Lowers serum Na </li></ul><ul><li>Not to give hypotonic solutions to hypotensive patients </li></ul>HYPERTONIC ISOTONIC HYPOTONIC
  130. 144. Thank You ! Dr. Ronald Sanchez - Magbitang

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