This patient presented with acute ischemic stroke and was found to be dehydrated based on laboratory findings. Specifically, the BUN/creatinine ratio was greater than 20 and the serum osmolarity was elevated above the threshold for hyperosmolarity. The patient also had mild hypokalemia and was experiencing respiratory acidosis. Administration of mannitol is not recommended for respiratory acidosis as it could cause intracellular acidosis. The hyperglycemia should be regulated with insulin to maintain blood sugar between 150-180 mg/dL. Intravenous fluids like aminofluids can be given with insulin to prevent further hyperglycemia.

1. dr Iyan Darmawan

2. Patient was admitted 24 hours ago with
loss of consciousness and hemiparesis of
face and upper extremity several hours
before admission. D/ Acute ischemic
stroke.
PE : stupor, BP 180/110, 37oC, HR 112, RR 12 shallow
breathing
Electrolyte/metabolic panel
ABG : PCO2 48 , PO2 90, pH 7.2
145 87
3 32
22
0.8
240
1. Is this patient dehydrated?
2. Any electrolyte disorder?
3. What acid-base disorder in this patient? Can we administer Meylon?
4. How should neurologist handle the hyperglycemia?
5. Can Aminofluid be given at this stage?

3. 1. Yes. The patient was dehydrated. How do I know? First, ratio of BUN /
creatinine> 20 indicated dehydration. Second, serum osmolarity in this
patients was as high as 2 x [Na +] + glu / 18 = 2 x 145 + 240/18 = 290 +
13.33 = 303.33. Hiperosmolarity is defined as osmolarity > 296 mosm / L.
It is an indicator of dehydration
2. Patients experienced mild hypokalemia. Hypokalemia is common in stroke
patients
3. The patient experienced respiratory acidosis (PCO2 48 Torr. Normal 40)
with a compensatory increase in bicarbonate 32 (Normal 22-26 mmol / L).
Meylon not be given to patients with respiratory acidosis, because it can
be harmful and cause intracellular acidosis.
4. Hyperglycemia in patients with stroke after passing 24 hours should be
regulated by insulin. GDP> 140 mg / dl or random> 180 mg / dl should be
corrected until stabilized at 150 mg / dl. Parenteral glucose can be given
after a blood sugar of 150 mg / dl but need the addition of insulin, 1 U per
10 g of glucose. If 1 L Aminofluid is administered (75 g glucose) it is
necessary to increase insulin regular (drip) by 7.5 units, preferably
separately by a syringe pump.
5. How to know whether hyperglycemia here is due to reactive hyperglycemia
or diabetes exist before a stroke? Check HbA1c. If> 7% means no DM
and patients require insulin dose fixed, ie, basal + prandial. The dose of
insulin on DM 0.3-0.5 U / kg / day. TDDI basal dose 40% (total daily dose
of insulin)
145 87
3 32
22
0.8
240

4. Dehydration in Stroke
• Of 2591 patients registered, 1606 (62%) were
dehydrated at some point during their admission.
• Independent risk factors for dehydration included older
age, female gender, total anterior circulation syndrome,
and prescribed diuretics (all P<0.001).
• Patients with dehydration were significantly more likely
be dead or dependent at hospital discharge than those
without (χ2=170.5; degrees of freedom=2; P<0.0001).
Dehydration in Hospital-Admitted Stroke Patients: Detection, Frequency, and
Association Stroke (2012) 43(3): 857-859

5. • Hemodynamic status?
• Cardiovascular and renal function?
• Degree of dehydration?
• Electrolyte status?
• Acid-base?
• Comorbidity?
Physiological
Fluid Choice
Most patients get empiric fluid therapy
(Isotonic solution for replacement and maintenance solution
for hemodynamically stable patients)
Ideally Fluid therapy should be tailor-made

6. Hemodynamic Disturbance
(Shock)?
MAP < 65 mmHg
Tachycardia
Cold extremities
CRT > 2 seconds
Yes No
RESUSCITATION Electrolyte/Metabolic Disturbance?
ASERING
Lactated Ringer’s Yes No
Normal Saline
Colloid Malnourished?
Corrected
NaCl 3%
KAEN4A Yes No
KCl 7.46%
Meylon PPN Maintenance
MgCl 20% Amiparen Aminofluid
Insulin Aminovel KAEN3B/3A
Glukosa 40% KAENMG3 KAEN 4A/4B
Lipid

7. Insulin
Catecholamine
ADH(AVP)
Aldosterone
Renal
function
IV
Fluid &
Electrolyte
status
Drugs
Trauma
Infection
sepsis
Intake &
excretion

8. Conditions of Acute Stroke
• Dehydration
• Hyperglycemia
• Inadequate oral intake, dysphagia
• Electrolyte disorders: HypoK+, HypoNa+

9. Electrolyte Composition
mEq/L
Na+
K+
Ca2+
Mg2+
Cl-
HCO3-
HPO42-
SO42-
Organic Acid
Protein
Total
Total
Extracellular Fluid Intracellular
Fluid
Plasma Interstisial
4
5
3
154
144
4
2.5
1.5
152
15
150
2
27
194
27
2
1
5
16
154
114
30
2
1
5
0
152
1
10
100
20
63
194
103
142
CationAnion
K+ Mg2+
HPO4
2-
Na+
Cl-
Predominant ions in
ICF
Predominant ions in
ECF
Capillary Membrane Cellular membrane
-

10. Terminology
• %
• mmol
• mEq
• mOsm
= g/dl
= mg/BM
MW = molecular weight
= mmol x valency
= Σ mmol solutes
e.g NaCl 0.9% = 0.9 g/dl = 9 g/L
5% dextrose = 5 g/dl = 50 g/L
e.g. NaCl 9 g/L = 9 x 1000
23 + 35.5
= 154 mmol/L
e.g. 1.75 mmol Ca++ = 3,5 mEq

11. Plasma Osmolarity
• Effective Osmolality (Osmotic pressure)=
2 x [Na+] + [Glu]/18
• 285 + 5 mOsm/L
Osmolalirity= 2 x [Na+] + [glucose mg/dl] + [BUN mg/dl]
18 2,8

12. Replace acute/
abnormal
loss
Isotonic infusion
800 ml 200 ml
• ASERING
• Lactated Ringer’s
• Normal saline
1 L of
increases ECF
ICF ISF Plasma

13. Na+ 130 Cl- 109 K+ 4 Ca++ 3 lactate- 28
Na+ 154Cl- 154
Na+ 130 Cl- 109 K+ 4 Ca++ 3 acetate- 28
Shock + acidosis
Shock + alkalosis
Hyponatremia

14. increases ICF > ECF
ICF ISF Plasma
Replace Normal
loss (IWL + urine)
Hypotonic infusion
5% dextrose/ Maintenance sol
85 ml255 ml660 ml
1 L of

15. increases intravascular
ICF ISF Plasma
Hemorrhagic shock
Burn
Reserved for patients
in whom ISF expanded
but intravascular and
albumin is severely
depleted
Albumin infusion
Albumin 25%
300-600 ml over 30-60 min
100 ml L of
Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 221

16. increases intravascular
ICF ISF Plasma
Hemorrhagic shock
DSS
Loading reg anes
Plasma Expander infusion
Dextran
Gelatin
HES
500 m L of
750 ml at 1 hour; 1050 ml at 2 hr
Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 225

17. Electrolyte Disorders
• More common in SAH, head injury than
in ischemic stroke
• Hyponatremia (CSWS ; SIADH)
• Hypokalemia

18. Hyponatremia
SIADH CSWS
Volume replacement
with saline
Fluid restriction
Vasopressin antagonist,
eg tolvaptan
•more common in SAH & head injury
•mortality rate 15%

19. SIADH vs CSWS
SIADH
• Hematocrit N or low
• Well hydrated
• Avg day of
appearance 8th day
• Heart rate slow/N
• Urea or creatinine
N/low
• GFR increased
CSWS
• N or high
• Dehydrated
• 4-5th day
• Tachycardia or N
• Urea or creatinine N
or high
• GFR decreased
•James Springate. Cerebral Salt-Wasting Syndrome eMedicine Journal, November 1 2001, Volume 2,
Number 11 Neurosurg Clin N Am 21 (2010) 339–352

20. Hypernatremia
•Fluid restriction, osmotic challenge
•mortality rate 42%
Diabetes insipidus Iatrogenic
urine output > 300 ml/hr
Spec gravity < 1.003
Urine osmolarity < 250
5-10 units Pitressin IV or IM
Desmopressin acetate
Appropriate fluid
management

21. Hypokalemia (serum K+ < 3.4 mEq/L)
• Observational study of 421 stroke patients
• More prevalent than myocardial infarction (84
[20%] vs 15[10%] ) or hypertension(84 (20%) vs
13(10%), even after patients receiving diuretics
had been excluded.
• Higher risk of death
• Hypokalemia in post stroke patients are common
and associated with poor outcome
Garibella SE, Robinson TG, Fotherby MD. Hypokalemia and potasssium
excretion in stroke patients.J Am Geriatr Soc 1997 Dec;45(12):1454-58

22. Dehydration and VET after Stroke
• Serum Osmolarity >297 mOsm/kg,
• Urea >7.5 mmol/l and
• Urea:creatinine ratio (mmol:mmol) >80
several days post stroke was associated with
odds ratios for VTE, 4.7, 2.8 dan 3.4 (p = 0.02,
0.05, 0.02) respectively using multivariable
analysis
Kelly J.at al. Dehydration and VET after acute stroke. QJM, (2004) 97 (5): 293-296.

23. Osmolality mortality
Bhalla A. Influence of Raised Plasma Osmolality on Clinical Outcome After Acute Stroke
Stroke 2000;31:2043-2048
• 167 Patients . Mean admission (300 mOsm/kg, SD 11.4),
maximum (308.1 mOsm/kg, SD 17.1), and AUC (298.3
mOsm/kg, SD 11.7)
• Plasma osmolality were significantly higher in those who
died compared with survivors (293.1 mOsm/kg [SD 8.2],
297.7 mOsm/kg [SD 8.7], and 291.7 mOsm/kg [SD 8.1],
respectively; P<0.0001).
• Admission plasma osmolality >296 mOsm/kg was
significantly associated with mortality (OR 2.4, 95% CI 1.0
to 5.9). In patients hydrated intravenously, there was no
significant fall in plasma osmolality compared with
patients hydrated orally (P=0.68).

24. Innovation is needed to improve quality
of care

25. Role of electrolytes (cations & anions)
Electrolytes Role Conc
Na+
Cl-
HCO3-
Protein
K+
Mg++
Ca++
P
Maintain extracellular osmolaroty and
volume
Major extracellular anion (Na+ pair)
Maintain blood pH (pH 7,4)
Maintain circulatory volume
Nerve conduction and muscle contraction
Co-enzyme
Formation of bones and teeth,
nerve conduction and muscle contraction
Formation of bone and teeth, energy source
(ATP)
135-145 mEq/L
97-106 mEq/L
22-26 mEq/L
6,7-8,3 g/dl
3,5-5.5 mEq/L
1,8-2,4 mg/dl
8,5-10,5 mg/dl
2,5-4,5 mg/dl

26. Cut-off glucose levels for
intervention
• Stroke 2004;35;363-364 :(European Stroke Initiative
[EUSI] guidelines 10 mmol/L, American Stroke
Association [ASA] guidelines 300 mg/dL)
Adams HP,et al. Guidelines for the Early Management of
Adults With Ischemic StrokeStroke. 2007;38:1655-1711
A reasonable goal would be to treat those patients’
elevated glucose concentrations (140 to 180 mg/dL).

27. Typical Infusion Solutions
• NaCl 0.9%
• Ringer’s solution
• Ringer’s acetate
• Ringer’s lactate
• 5% Dextrose

28. Solutions with Na > 130 mEq/L
Na+
(mEq/L)
K+
(mEq/L)
Cl-
(mEq/L)
Dextrose
(g/L)
mOsm/L)
NaCl 0,9% 154 - 154 - 308
Ringer 147 4 155,5 - 310
RL/ RA 130 4 109 - 273
Plasma 142 4 103 285 + 5

29. Ringer Solution
is NOT
RL minus lactate

30. Na Lactate Bicarbonate
LACTATE VS. ACETATE
Na Acetate Bicarbonate
100 mEq/hr
250-400 mEq/hr

31. Normal osmolality
• calculated: 2 x[Na+] + Glu/18 +
urea/2.8
• 285 + 5 mOsm/L
> 296 mOsm/L hyperosmolar state

32. Vol of MgSO4 added into
1L Acetated Ringer’s
Current Osmolarity of Desired
Asering (Ringer’s acetate) osmolarity
273.4 285 7.25
273.4 290 10.375
273.4 295 13.5
273.4 300 16.625
ml of 20% MgSO4
to be added to 1L
12 mEq
17 mEq
22.41 mEq
27.5 mEq
Σ Mg

33. Mannitol vs HS
Mannitol
• Freely filtered at glomerulus,
accounting for diuresis and
hyponatremia
• Reduces systemic vasc
resistance
• Mild positive inotropic
• Scavenges toxic oxygen free
radical (cytoprotection
• 0.25-1.5 g/kg iv bolus
• Max effect in 20-40 minutes
HS
• Diureric effect via ANP
• Augment intravascular volume
and cardiac performance
• 1-2 ml/kg/hr
• 300 ml/20 min  Intracranial
pressure fell immediately after
initiation of infusion with further
significant decreases observed
at 20 and 60 minutes (30.4 ±
8.5, 24.3 ± 7.4, and 23.8 ± 8.3
mm Hg, respectively; P < .01)
1. 1ilkes GE, Whitfield PC Intracranial pressure and cerebral blood flow Surgery (Oxford), Volume 25, Issue 12, December 2007, Pages 530-535
2. Wendy C. Ziai, Thomas J.K. Toung, Anish Bhardwaj Hypertonic saline: First-line therapy for cerebral edema? Journal of the Neurological Sciences,
Volume 261, Issues 1-2, 15 October 2007, Pages 157-166
3. Sheng-Jean Huang, Lin Chang, Yin-Yi Han, Yuan-Chi Lee, Yong-Kwang Tu Efficacy and safety of hypertonic saline solutions in the treatment of
severe head injury Surgical Neurology, Volume 65, Issue 6, June 2006, Pages 539-546

34. Conclusion
• Dehydration and increased osmolarity should be
managed
• Hyperglycemia(or hypoglycemia) and
electgrolyte imbalances could occur (eg
Hyponatremia, hypokalemia)
• Acute Phase: isotonic fluid (eg. Acetated
rfinger’s, normal saline); avoid glucose
• Maintenance Phase, glucose and potassium
containing solutions

35. Thank you