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Fluids and electrolytes
- 1. FLUIDS & ELECTROLYTES PART II 24 May,2017 SPEAKER – Dr. Ankit Kaura Post Graduate Dept. of Surgery MODERATOR – Dr. Tanweer Karim Professor Dept. of Surgery
- 2. BODY FLUID COMPARTMENTS 5% P 15% IF 40% ICF 2/3 BODY WATER ECF 1/3 BODY WATER
- 3. WATER BALANCE INTAKE Water from beverages 1200ml Water from solid food 1000ml Water from oxidation 300ml OUTPUT Urine 1500ml Insensible loss from skin & lung 900ml Faeces 100ml Normal Daily Insensible fluid loss = Fluid loss – Fluid Input = (900+100) – 300 = 700ml
- 4. ELECTROLYTE ECF(mmol/L) ICF(mmol/L) Total Body (mmol) Sodium 140-155 10-18 3000-4000 Potassium 3.5-5.5 120-145 3000-4000 Calcium 2.2-2.5 25000-27000 Ionized Calcium 0.9-1.3 Magnesium 0.7-1.2 15-25 900-1200 Chloride 98-106 2-6 3000-4000 Phosphate 0.7-1.3 8-20 30000-32000 ECF ICF Major Cation Na K & Mg Major Anion Cl & HCO3 Phosphate, Sulphate & Protein ELECTROLYTE DISTRIBUTION
- 5. BASIC PHYSICS • IONS • ANION • CATION • MOLE & MILLIMOLES • EQUIVALENT &MILLIEQUIVALENT
- 6. RELATIONSHIP • mmol/L = mg/dL * 10 Atomic Weight • mEq/L = mg/dL * 10 * Valence Molecular Weight
- 7. CONVERSION FACTORS SALT mEq Cation or Anion/gm of salt Mg of salt/ mEq NaCl 17 58 KCl 13 75 NaHCO3 12 84 Calcium Gluconate 4 224 Calcium Chloride 14 73 MgSO4 8 123 Example- K+ concentration in mEq in 10ml ampoule of 15% KCl
- 8. • Plasma Osmolality = 2* Na + Glucose(mg/dL) + BUN( mg/dL) 18 2.8 • Effective Osmolality = 2*Na(mEq/L) + Glucose(mg/dL) 18
- 9. WATER & SODIUM REGULATION • Total Na = 57mmol/kg ( 3900 mmol) • ECF = 44% • ICF = 9% • Bone = 47% • Chief base of blood • Normal Na+ requirement = 1-2mmol/kg/day
- 10. SODIUM • Main extracellular fluid (ECF) cation • Helps govern normal ECF osmolality • Helps maintain acid-base balance • Activates nerve & muscle cells • Influence water distribution ( with chloride)
- 11. Water & Sodium Balance • Water provides about 90-95% of volume of body fluids • Sodium salts approximately 90-95% of solutes in extracellular compartment • Together they regulate the distribution of fluid between intracellular & extracellular compartment • All gains or losses of sodium & water occur through extracellular fluid compartment.
- 12. SODIUM DEFICIT Na+ Deficit Hypovolemia Stimulates Angiotensin II Aldosterone Increased Renal Na+ & fluid reabsorption Body priority to reclaim= Na+>H+>K+
- 13. Sodium Excess Na+ Excess Increased ECF Volume Angiotensin II Aldosterone ANP Decreased Renal Na+ & fluid Natriuresis & reabsorption Diuresis Decreased Increased
- 14. HYPONATREMIA • Na+ less than 135mEq/L • Etiology-(based on Osmolality) - Pseudohyponatremia 1.Normal Osmolality: Hyperlipidemia, Hyperproteinemia 2. High Osmolality: Hyperglycemia , Mannitol - True Hyponatremia Low osmolality
- 15. Evaluation of Hyponatremia Measure Serum Osmolality Measure Lipid, Protein Measure Blood GlucoseHypotonic (<280mOsm) Isotonic (280-290mOsm) Hypertonic (>290mOsm) Clinically asess ECF volume ISOTONIC HYPONATREMIA HYPERTONIC HYPONATREMIA HYPOTONIC HYPONATREMIA Pseudohyponatremia -Hyperlipidemia -Hyperproteinemia 1.Hyperglycemia 2.Hypertonic infusion -Glucose -Mannitol - Glycine Hypovolemic Hypervolemic Isovolemic
- 16. • CLINICAL FEATURES - No thirst initially, loss of tissue turgor - Sunken eyes, collapsed veins, pale, hypotensive, oliguria - Convulsions at <110mmol/L • CLASSIFICATION – MILD 130-138 mEq/L MODERATE 120-130 mEq/L SEVERE <120 mEq/L
- 17. ASSESSMENT • Volume Status – -Hypovolemic Hyponatremia : Dry mucus membrane, Tachycardia , Diminished skin turgor , Orthostasis. -Hypervolemic Hyponatremia- Rales,S3,Edema,Ascites -No sign of hypo/hypervolemia: Adrenal insufficiency, SIADH • Neurological Signs-(Severity) -Level of alertness -Cognitive impairment -Seizures -Signs of brain herniation
- 18. Treatment of Hyponatremia Volume Status Low Salt & water Supplementation IV isotonic Saline Normal Water restriction High No salt Water restriction Loop Diuretics
- 19. TREATMENT OF HYPONATREMIA Chronic asymptomatic Hyponatremia • Max rate of 0.25mEq/L/hr • Rate of increase in serum Na+ should not exceed 8 mEq/kg/day. Central Pontine Myelinosis Na+ <110mEq/L & Neurogenic Symptoms • Treated emergently to raise [Na+] above 120mEq/L -3%NaCl(513mEq/L) -Rate- 1.5-2mEq/L/hr for first 3-4hr -Water restriction – no role • If seizures + - [Na+] increase by 4-5mEq/L in 1st hour • S.Electrolytes- every 2hr
- 20. How much? • Conventional Method- Na requirement = (Desired Na-Actual Na)*Total body weight*0.6 • Newer Method- Change in S.[Na+] = Infusate Na/L-Serum Na Total Body water(L) + 1
- 21. HYPERNATREMIA • Serum Na+ >148mEq/L • Serum Osmolality > 295mOsm/kg • Urine Specific Gravity >1.030 • Hypernatremia is usually due to water deficit & not sodium overload.
- 22. Etiology • Excess Water loss -Insensible loss 1.Dermal- heat exposure, severe burn, severe exercise 2.Respiratory- Mechanical ventilator -Renal Loss: Diabetes Insipidus, Excess Diuretic -GI losses: Osmotic Diarrhoea • Water deficit due to impaired thirst • Sodium Retention- Excess iv hypertonic NaCl & NaHCO3
- 23. Evaluation of Hypernatremia ECF Volume HYPOVOLEMIC HYPERNATREMIA HYPERVOLEMIC HYPERNATREMIA ISOVOLEMIC HYPERNATREMIA Loss of water & Na Loss of water Gain of water Diuretics Mineralocorticoids Glycosuria Urea Diuresis Acute/Chronic Renal Failure Partial Obstruction GI loss(diarrhea) Respiratory loss Skin loss(burns) Adrenal Insufficiency Diabetes Insipidus Skin losses-sweating Iatrogenic Excess
- 24. Treatment of Hypernatremia Volume Status LOW IV Isotonic Saline Initially Then 5%D or 0.45% saline NORMAL Water (5%D) HIGH No Salt Loop Diuretrics With water
- 25. POTASSIUM(K+) • Dominant cation in ICF • Regulates cell excitability • Permeates cell membrane, thereby affecting cell’s electrical status • Help’s control ICF osmolality & ICF Osmotic Pressure • Normal Requirement:50-80mEq/day • Normal Serum level : 3.5-5.5mEq/L
- 26. Potassium Regulation • Renal excretion by secretion • Controlled by – -Aldosterone -Distal fluid & Na delivery -Serum K ion -Serum H ion
- 27. Important Points • Renal K absorption is never complete : 20mEeq lost everyday • Hyperkalemia = increased total body K • Level of Hypokalemia underestimate K deficit • Increased plasma osmomlality(hyperglycemia) raises plasma K d/t shift of K out of cells • Metabolic acidosis promotes K exit from cells in exchange for H+ as the cell attempt to buffer ECF pH.
- 28. HYPERKALEMIA • K+ >5.5MEq/L • Dangerous due to potential for fatal dysarrythmia, cardiac arrest
- 29. Etiology • Increased intake • Tissue breakdown • Shift of K out of cell -Tissue Damage -Metabolic Acidosis -Uncontrolled Diabetes • Impaired excretion -ARF or CRF -K sparing diuretics • Pseudohyperkalemia -Traumatic hemolysis during blood drawing
- 30. Symtoms • Weakness & myocardial irritability • Nausea, vomiting, intestinal colic • Hyporeflexia, gradual paralysis • Arrest in systole.
- 31. ECG Findings Serum K ECG Findings 6-7mEq/L High Peak T wave 7-8mEq/L Loss of P waves Widening of QRS complex 8-9mEq/L QRS merges with T wave forming sine wave >9mEq/L Ventricular fibrillation
- 32. TREATMENT A) ECG EVIDENCE OF PENDING ARREST: -Loss of P wave -Broad slurring of QRS Immediate effective therapy indicated. 1.IV infusion of Calcium salts i)10ml of 10% CaCl2 over 10min ii)10ml of 10% Calcium gluconate over 3-5min 2.IV infusion of NaHCO3- 50-100mEq over 10-20min FIRST : STOP ALL INFUSION OF POTASSIUM
- 33. B) ECG EVIDENCE OF POTASSIUM EFFECT- -Peaked T wave Prompt therapy needed 1.Glucose & Insulin infusion- IV infused 50ml of D50 & 10units regular Insulin 2. Immediate hemodialysis
- 34. C) BIOCHEMICAL EVIDENCE OF HYPERKALEMIA NO ECG CHANGES Effective therapy needed within hours 1.Potassium- binding resins into GI tract with 20% sorbitol 2. Loop Diuretic
- 35. ACUTE TREATMENT OF SERIOUS HYPERKALEMIA A) Stabalize excitable tissue ( cardiac & neuromuscular) -Calcium Gluconate(10%) 10-20ml iv bolus -CaCl2 (10%) 5ml iv bolus Each may be repeated every 5min S.Potassium > 7.5mEQ/L Absent P wave QRS widening or ventricular arrythmia on ECG Profound weakness
- 36. B) Shift Potassium into cells: -Insulin & Glucose Regular Insulin (10-20 Units) + 50%D (50ml) iv bolus f/b 10%D @50ml/min -Beta-2 agonist (Salbutamol) Albuterol (5mg/L),10-20mg, nebulized over 10min
- 37. C) Remove Potassium from Body: -Loop or thiazide diuretics - Cation exchange resin Sodium Polystyrene sulfonate(15-30g) + Sorbitol(15-30ml)[oral] -Acute hemodialysis ( low potassium dialysate)
- 38. HYPOKALEMIA • K+ <3.5mEq/L • Most common type of electrolyte imbalance • Major cause is increase renal loss, most often associated with Diuretics
- 39. ETIOLOGY • Poor intake • Non Renal loss (Urine K <20mEq/day) -Vomiting -Diarrhea -Excessive sweating -Large NG aspiration • Renal Loss (Urine K >30mEq/day) -Diuretics -Osmotic Diuresis -Salt wasting Nephropathies -Mineralocorticoid excess • Redistribution(Shift of K into cells) -Metabolic Alkalosis -Insulin -Beta-2 agonist
- 40. CLINICAL FEATURES • Symptoms: -Drowsiness,confusion,decreased tendon reflex - Paralytic Ileus • ECG Changes: EARLY- Flattening or inversion of T-wave Prominent U wave Depressed ST segment SEVERE POTASSIUM DEPLETION- Prolonged PR interval Decreased Voltage Ventricular Arrythmia
- 41. TREATMENT GUIDELINES SERUM K TREATMENT 3.5-4mEq/L No potassium supplement Increased oral intake of potassium rich food Add potassium sparing diuretics or decrease dose of diuretic 3-3.5mEq/L Treatment in selected high risk patients- CHF, Digitalis therapy, h/o IHD <3mEq/L Definitive treatment
- 42. TREATMENT • Correct the cause • Oral or IV administration of K • Salt substitutes containing K • IV potassium -Don’t give >10-20mEq/h -Don’t give >40mEq/L -Don’t give >240mEq/day