2. NORMAL PHYSIOLOGY:
• Total body water is 60% of bodyweight in males
,50% of bodyweight in females i.e.30 lit
• Intracellular water- 20 lit
• Extracellular water -10 lit
• Plasma(1/4) - 2.5 litres
• Interstitial Fluid-7.5 litres
3.
4. WATER LOSS(Volume Loss):
• It is decrease in the whole body fluid which includes both
ECF and ICF.
• It is usually ECF loss which is more important and assessed.
It can be isotonic volume depletion with both salt and water
loss leading to hypovolemia or
• Only water loss with only minimal loss of electrolytes
leading to dehydration.
5. CAUSES & FEATURES:-
• Isotonic volume depletion occurs due to diarrhoea,vomiting
and excess diuresis.
• Here normal or decreased sodium is observed.
• Fluid loss is only ECF and so early depletion of intravascular
volume reduction occurs.
• This causes hypotension and decreased perfusion.
6. • Features are dry tongue,rapid pulse,cold clammy
extremities,sunken eyes,hypotension,
oliguria,raised blood urea,decreased urinary
sodium.
• Hypovolemia can be
Mild - <2 lit fluid loss
• Moderate - 2-3 lit fluid loss
• Severe- >3 lit fluid loss
7. MANAGEMENT:
• Evaluation is done by doing serum sodium,urinary
sodium and blood urea.
• Isotonic volume depletion is corrected by 0.9%
normal saline.
• Pure water depletion is corrected by more water
intake/ intravenous 5% dextrose.
• Monitoring fluid therapy by skin and tongue
examination, weight gain ,pulse,BP,CVP,PCWP.
8. WATER EXCESS:
• Causes:
• Excessive amount of intravenous dextrose (5%)
• In TURP surgery
• In syndrome of inappropriate ADH secretion which
is commonly associated with lobar
pnuemonia,empyema,oat cell carcinoma and head
injury.
9. CLINICAL FEATURES:
• Drowsiness,weakness
• Convulsions and coma
• Nausea ,vomiting
• Pedal edema
• Gain in body weight- most sensitive and consistent
sign
• Circulatory overload- tachycardia,pulmonary
edema,hypertension
• Raised CVP,PCWP.
10. TREATMENT:
• Water and salt restriction and observation.
• Monitoring in ICU
• Fluid and electrolyte balance.
• Administaration of diuretics and hypertonic saline
should be avoided,as it may cause rapid changes in
serum sodium and water level which will lead to
nueronal demyelination and fatal outcome.
14. •TREATMENT:
• Intravenous infusion of normal saline as a slow
and gradual correction @2mEq/L/hr in acute cases
and <1 mEq/L/hr in chronic cases
• Correction should not exceed >20mEq/L/day and
>10mEq/L/day in chronic cases.
• The cause should be treated.
15. HYPERNATRENEMIA:
• Serum sodium level >150 mEq/L.
• Excess infusion of normal saline causes overload in
circulating salt and water.
• CAUSES:
• Renal dysfunction
• Cardiac failure
• Drug induced like NSAIDS,Corticosteroid.
16. CLINICAL FEATURES:
• Pitting edema
• Puffiness of face
• Increased urination
• Often dilated jugular veins
• Features of pulmonary edema.
17. MANAGEMENT
• Restriction of saline and sodium.
• Treatment of pulmonary edema.
• Hypernatrenemia is always corrected as follows:
• Initial infusion of normal saline,then infusion of half
strength saline(0.45%) and later with 5% dextrose
i.e., gradual controlled correction is done otherwise
cerebral edema and hyperglycemia can develop.
• Oral and nasogastric administration of water/fluids.
18. HYPOKALEMIA:
Serum K+ level <3.5 mEq/L.
• Causes:
• Diarrhoea of any cause,villous tumour of the
rectum,ulcerative colitis.
• After trauma or surgery.
• Pyloric stenosis with gastric outlet obstruction.
• Duodenal fistula,ileostomy.
• Insulin therapy.
• Poisoning
• Drugs like beta agonists
• Familial periodic paralysis.
19. CLINICAL FEATURES:
• Slurred speech
• Muscular hypotonia
• Depressed reflexes
• Paralytic ileus
• Weakness of respiratory muscles
• Cardiac arrythmias
• Inability to produce concentrated urine and so
causes nocturia and polyuria.
21. TREATMENT:
• Oral Potassium 2gm 6th hourly,15 ml potassium
chloride syrup.
• IV KCL 40mmol/l given in 5% dextrose or normal
saline slowly,often under ECG monitoring.
• Hypokaleamic alkalosis which occurs in pyloric
stenosis should be treated carefully by IV
potassium as there will be severe potassium loss.
22. HYPERKALEMIA:
• Normal range of potassium is 3.5 to 5.0 mEq/l.
• Hyperkalaemia manifests when K+ exceeds 6mEq/l.
• Causes:
• Renal failure
• Rapid infusion of potassium.
• Transfusion of stored blood
• Diabetic ketoacidosis
• Adrenal insufficiency
23. • K+ sparing diuretics,cyclosporine,beta blockers
• Metabolic acidosis
• Insulin deficiency
• Tissue destruction, burns,trauma,tumour
necrosis,crush injury
• Potassium Excess is a dangerous condition
which can cause sudden cardiac arrest.
• ECG - Peak T wave is seen in ECG.
24. TREATMENT:
• IV administration of 50 ml of 50% glucose with 10 units
of soluble insulin ,slowly.
• Infusion of 10% Calcium gluconate ,intravenously.
• Calcium chloride is given in severe cases as calcium in
this form is released immediately without hepatic
metabolism.
• Diuresis using frusemide injection.
• Continuous ECG monitoring is a must.
• IV sodium bicarbonate- shifts K+ into the cells.7.5% with
50-100 ml intravenously in 10 mins.
25. ACID BASE BALANCE:
• Normal ph is 7.36 to 7.44.
• Acidosis is when ph of blood is <7.35
• Alkalosis is when ph is >7.45
• Metabolic alkalosis - Excess HCO3
• Metabolic acidosis - Low HCO3 or excess acid
• Respiratoty alkalosis - Low PCO2
• Respiratory acidosis- High PCO2.
26. METABOLIC ALKALOSIS:
• Primary base excess i.e., HCO3. above 27 mmol/l
• Causes:
• Repeated vomiting due to any cause.Commonly seen in a
case of pyloric stenosis.Here hypokaleamic alkalosis occurs
which is an important aspect in managing patient.
• Excess alkali ingestion e.g., antacids.
• Cortisol excess either due to over administration or
Cushing's syndrome.
27. • Clinical Features:
• Cheyne Stokes breathing with period of apnoea of
5-30 Sec.
• Tetany due to Alkalosis.
• Investigations:
• Serum electrolytes, arterial blood gas analysis.
• Treatment:
• Normal saline or double strength NS IV infusion
with slow IV KCL 40mmol/L in saline slowly under
ECG monitoring.
28. RESPIRATORY ALKALOSIS:
• Causes:
• Hyperventilation during anaesthesia,due to head
injury/ severe pain
• High altitude.
• Hyperpyrexia
• Encephalitis,hypothalamic tumours,drugs like
salicylates,due to cirrhosis of liver.
29. Features & Management
• Headache ,tingling, circumoral
anaesthesia,tightness in chest, tetany, arrythmias
are seen.
• Low PaCO2 , low HCO3 , high alkaline pH are
typical.Serum HCO3 will not fall <15mEq/L.
• It can be managed by O2 therapy, treating the
cause, acetazolamide in high altitude
• Respiratory suppression due to Alkalosis is treated
by CO2.
30. METABOLIC ACIDOSIS:
• It is an excess acid or base deficit. HCO3 levels below 21
mmol/L.
• Causes:
• Increase in acid:
• Diabetic ketoacidosis
• Starvation
• Hypoxia
• Renal insufficiency
• Excessive exercise
31. • Loss of base:
• Diarrhoea
• Ulcerative colitis
• Gastrocolic fistula
• Intestinal fistula
• Uterosigmoidostomy.
• Features:
• Rapid, deep, noisy breathing - Kussumaul's breathing.
• Cold clammy skin, tachycardia, right heart strain,altered
level of consciousness.
32. • Cardiac arrhythmias, hypotension
• Anorexia, muscle weakness, vomiting.
• pH <7.2 is dangerous and life threatening
• Capillary stasis
• Urine is strongly acidic
• Low standard HCO3 levels
• Base deficit.
33. TREATMENT:
• Correction of hypoxia.
• 50 mmol of 8.4% NaHCO3 IV Infusion.
• Correction of electrolytes.
• Specific therapies for diabetic ketoacidosis,
alcoholic acidosis, aspirin poisoning, renal causes.
34. RESPIRATORY ACIDOSIS
• It is a feature of respiratory failure with high arterial PCO2
causing fall in pH.
• Causes:
• During and after anaesthesia.
• Chronic bronchitis
• Emphysema
• Thoracic diseases
• Upper abdominal surgeries and diseases.
• Stroke, obesity, infection, hypoventilation.
35. • Features & Management:
• Features of hypercapnia like dyspnoea, confusion,
psychosis, hallucinations, sleep disturbances, tremor,
jerks and personality changes.
• CNS manifestations are more severe in respiratory
acidosis than in metabolic acidosis as lipid soluble CO2
cross BBB easily than HCO3.
• Acute respiratory acidosis is managed by O2 therapy,
ventilator support.
• Alkali therapy also is not usually used unless acidosis is
very severe.
36. Principles of fluid therapy:
• Indications:
• For rapid destruction of fluid & electrolytes in dehydration
due to vomiting, diarrhoea, shock due to hemorrhage or
sepsis or burns.
• Total parenteral nutrition
• Anaphylaxis, cardiac arrest, hypoxia
• Post gastrointestinal surgeries.
• For maintenance, replacement of loss or as a special fluid.
37. • Advantage: Controlled, accurate and adjustable, rapid and
predictable.
• Problems:
• Needs hospitalisation, costly, needs asepsis.
• Fluid overload, pulmonary edema and cardiac failure,
infection.
• Thrombophlebitis, hematoma cellulitis in local area.
• Pyrogenic reaction, air embolism, bacteremia.
• Discomfort and poor patient acceptance
38. • Daily requirement of Na is 100 mEq; K+ is 60 mEq; Calcium is
5 mEq.
• One litre of normal isotonic saline contains 154 mEq of Na.
• RL is the most physiological fluid(crystalloid) contains
• Na - 130 mEq/L
• K+ - 4 mEq/L
• CL - 109 mEq/L
• It should be avoided in liver failure patients.
• As it does not contain glucose it can be used in diabetics.
39. • Other crystalloid fluids are - Normal saline, dextrose saline,
5% dextrose, isolyte P, isolyte G,isolyte M.
• Colloids are of large molecules which shift the fluid from
interstitial compartment to intravascular compartment and
are used as plasma expanders.
• Haemaccel, hetastarch, pentastarch, dextran 40/70 are
colloids.
• Special purpose fluids are NaHCO3 7.5% and 8.4% are used
in metabolic acidosis, forced diuresis, hyperkalaemia.
• Mannitol 10/20% as osmotic diuretic agent
• Albumin 4.5% as plasma expanders, albumin 20% in severe
hypoalbuminemia.
40. • Calculation of Drop rate of IV fluids:
• 1 ml = 16 drops in usual drip set.
• 1 ml = 60 drops in microdrip set.
• Drop rate/min = Quantity of fluid required in litre perday × 10.
2.5 lit is usually used quantity of fluid/day.So 2.5×10 = 25
drops/min.
• Fluid volume in ml to be infused in 1 hr divided by four =
Number of drops/min
• Example: 100ml /hr means 25 drops /min.
• Number of microdrip /min = Volume in ml/hr
• 50 microdrip/min = 50 ml/hr.
