guidance for use of fluids electrolytes and energy in routine clinical practice

1. Managing Fluid, Electrolytes and
Energy for Holistic Recovery
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2. This presentation will cover
Natural History of illness
Disease management: Approach
Need to look for underlying fluid and electrolyte deficit
Case scenarios
Q&A
1
2
3
4
5
2
All cases are for representation purpose

3. Clinical scenario
A 56-year-old woman presents to the clinic complaining of abdominal pain.
Twenty-four hours previously she developed a continuous pain in the upper
abdomen which has become progressively more severe. The pain radiates into the
back. She feels nauseated and complains of vomiting.
Her past medical history is notable for a duodenal ulcer which was successfully
treated with Helicobacter eradication therapy 5 years earlier.
What do you think are the key stages in her illness journey?
What will be your next steps?
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams

4. Natural History of Disease
Source: Centers for Disease Control and Prevention. Principles of epidemiology, 2nd ed. Atlanta: U.S. Department of Health and Human Services;1992.
Stage of
Susceptibility
Stage of Subclinical
Disease
Stage of Clinical
Disease
Stage of Recovery,
Disability or Death
Exposure
Pathologic
changes
Onset of
symptoms
Usual time of
diagnosis

5. Disease management
intervention
/ systematic
approach
diagnose
treat
prevent
Int J Integr Care. 2009 Jan-Mar; 9: e06
Employing multiple
treatment modalities

6. What will you ask / look for in this patient?
Ask for relevant history
General status
Signs of dehydration
Conduct general and
systemic examinations

7. Look for underlying fluid deficit
Patient has
- nausea
- Vomiting
- Abdominal
pain
So patient may not be
eating / drinking
adequate amount of
food or fluids
Dehydration
+ general
weakness
• The patient looks unwell and dehydrated. She weighs 65 kg. She is afebrile,
her pulse is 88/min and blood pressure 124/76 mmHg.
• Cardiovascular and respiratory system examination is normal.
• Tenderness in the right upper quadrant and epigastrium, with guarding and
rebound tenderness.
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams

8. What if the patient had fever?
• Fever may lead to increased loss of fluids from body and aggravate
dehydration
• Worsen the general condition of the patient
• Line of management will differ based on the diagnosis
1. https://mrmjournal.biomedcentral.com/articles/10.1186/s40248-019-0200-9
2. https://indianapublicmedia.org/amomentofscience/dehydrated-sick.php

9. What next?
Acute cholecystitis
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams
Investigations
Normal
Haemoglobin 14.7 g/dL 11.7–15.7 g/dL
White cell count 19.8 x 109/L 3.5–11.0 x 109/L
Platelets 239 x 109/L 150–440 x 109/L
Sodium 137 mmol/L 135–145 mmol/L
Potassium 4.8 mmol/L 3.5–5.0 mmol/L
Urea 8.6 mmol/L 2.5–6.7 mmol/L
Creatinine 116 µmol 70–120 µmol/
Bilirubin 19 µmol/L 3–17 µmol/L
Alkaline phosphatase 58 IU/L 30–300 IU/L
Alkaline aminotransferase (AAT) 67 IU/L 5–35 IU/L
Gamma-glutamyl transpeptidase 72 IU/L 11–51 IU/L
C-reactive protein (CRP) 256 mg/L < 5 mg/L

10. What is Recovery?
“Recovery is ‘Return to a normal state of
health, mind, or strength”

11. Aiding holistic recovery during illness
Indian Medical Association Restoration Guidelines 2017.
Nutrition?
Rest?
Fluid and Electrolytes?
Exercise and lifestyle changes?
What do you generally advice along with the core
treatment in your patients?

12. Hydration does not always receive the attention it
deserves
• Water is essential for life and performs crucial functions in the human body
• Nutrient transport through the circulatory system
• Tissue and joint lubrication
• Maintenance of a stable body temperature
• As the medium that allows the chemical reactions of the organism to take
place
Nutrients. 2019 Mar; 11(3): 669.

13. Fluid and electrolyte therapy: Why is it critical?
• Essential component of
the care
• Needs thorough
understanding of the
changing requirements of
growing children
• Can be life-saving in
certain conditions
J Pediatr Pharmacol Ther 2009;14:204–211
75% of the total body weight
65% of the total body weight
60% of the total body weight
Next 2- 3 days
At the end of 1st year
Obligatory diuretic phase

14. Water and the human body
1. Thomas DR, et al. Dehydration Council. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc. 2008 Jun;9(5):292-301.
2. Weight Loss by Limiting Calories. http://www.webmd.com/diet/obesity/rapid-weight-loss-diets
55 to 65% of our body
mass is composed of
water1
2/3rd is present within the cells1 (mainly
in the lean tissue*) and 1/3rd is
extracellular1
Of this extracellular water, 25% is
intravascular (about 8% of the total
body water).
*lean tissue refers to muscle and organ tissue2
TOTAL
BODY
WATER
Intracellular
Water
Extracellular
Water

15. Fluid Balance
in
physiological
condition
(no disease)
What is defined as Normal fluid balanced state?
1. Thomas DR, Cote TR, Lawhorne L, et al. Dehydration Council. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc. 2008 Jun;9(5):292-301.
2. Indian Medical Association Restoration Guidelines 2017.

16. How is this state of normal fluid-electrolyte balance
maintained?
In the body, the balance between water and dissolved materials, like electrolytes, is maintained
by “osmoregulation”
Cuzzo B, Lappin SL. Vasopressin (Antidiuretic Hormone, ADH) . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
https://www.ncbi.nlm.nih.gov/books/NBK526069/ accessed on 5/02/2020; 2. Annu Rev Physiol. 1997;59:601-19.
Homeostasis
Disrupted
Increased Na+
concentration in
ECF
Osmoreceptors
stimulated
Increased ADH
release
Increased
thirst
Decreased urinary
water loss
Increased
Water gain
Additional water
dilutes ECF, volume
increased
Homeostasis
restored
Homeostasis
Need normal Na+
concentration in
ECF

17. How electrolytes play a important role..
Respiration1
Chloride - Enables
transport of Co2 and O2
in and out of RBC’s and
Lungs
Heart musclecontractions
1,2
Sodium, potassiumand
calcium- is importantto
regulatethestrength ofa
cardiacmusclecontraction
Nerveimpulses3
Sodiumandpotassium-
importantfornerve
conduction
Glucoseabsorption1
Sodium- helps
Absorptionofglucosein
thesmall intestineand
kidneys
1. Lodish H, Berk A, Zipursky SL, et al. Molecular Cell Biology: Section 15.6 Cotransport by Symporters and Antiporters. 4th ed. Available from: http://www.ncbi.nlm.nih.gov/books/NBK21687/
2. Berg JM, Tymoczko JL, Stryer L. Biochemistry: Section 13.2 A Family of Membrane Proteins Uses ATP Hydrolysis to Pump Ions Across Membranes. 5th ed. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22464/#A1791
3. Berg JM, Tymoczko JL, Stryer L. Biochemistry: Section 13.5 Specic Channels Can Rapidly Transport Ions Across Membranes . 5th edition. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22509/#A1816

18. 18
• loss of appetite, nausea, etc.
Decreased intake
• vomiting, diarrhea, increased fluid loss through
sweat or body fluids, insensible loss through
upper respiratory tract, etc.
Increased output
Fluid-electrolyte imbalance: an abnormality observed
in illness
Kear, T.M. (2017). Fluid and electrolyte management across the age continuum. Nephrology Nursing Journal, 44(6), 491-496.

19. ©2018 J&J Asia Pacific Medical Affairs | Learning Center | OTC | Digestive Health
https://www.h4hinitiative.com/hydration-science/hydration-lab/water-and-hydration-
physiological-basis-adults/body-water-balance
Causes of DEHYDRATION
Fluid balance
Conditions leading to fluid and electrolytes deficit
FEVER
 Viral illness (URTI/Common Cold/Flu)
 ‘Special Fevers’
• Dengue
• Malaria
• Typhoid
HERAT-RELATED ILLNESS
 Heat cramps
 Heat exhaustion
 Heat stroke
GI RELATED & OTHERS
 Nausea, vomiting
 Abdominal pain with
vomiting
 Diarrhea
 Menstruation
URINARY
TRACT
INFECTIONS
fluid loss
fluid intake
Fluid deficit

20. How to identify underlying dehydration during illness?
Mild -moderate dehydration
• dry mouth/tongue,
• thirst,
• headache,
• lethargy, fatigue,
• dry skin,
• muscle weakness,
• light-headedness, dizziness and a
lack of focus
Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA. Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics. BMC Public Health. 2018 Dec 5;18(1):1346
.
Severe dehydration
• sunken eyes,
• lack of tears,
• sunken fontanels
(specifically among
infants),
• hypotension, tachycardia
and,
• in the worst-case scenario,
unconsciousness
Image source- https://www.nestlepurelife.com/us/en-us/dodging-dehydration

21. Simple ways to assess Dehydration
Hooper L, Abdelhamid A, Attreed NJ, Campbell WW, Channell AM, Chassagne P et al. Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people. Cochrane Database of
Systematic Reviews 2015, Issue 4. Art. No.: CD009647. DOI: 10.1002/14651858.CD009647.pub2. ABIM Laboratory Test Reference Ranges.[cited on internet].Available
fromhttps://www.abim.org/~/media/ABIM%20Public/Files/pdf/exam/laboratory-reference-ranges.pdf
Urine Analysis using
Armstrong chart2
Fluid intake test1*
Ad lib-water intake (including water in
water, tea and coffee) or all drinks
combined
1) Very low: < 1.4L/d in men, < 1.0
L/d in women
2) Low- 1.4 to < 2.2 L/d in men, 1.0 to
<1.6 L/d in women
3) Moderate: 2.2 to < 3.0 L/d in men,
1.6 to < 2.2 L/d in women
4. High: ≥ 3.0 L/d in men, ≥ 2.2 L/d in
women
*European guidance, EFSA 2010, suggests that men
need 2.5 L/d of fluid (overall, from food and drinks)
while women need 2.0 L/d.
What to look for

22. 22
Restoration therapy is critical to regain/rebalance the lost water,
electrolytes and energy from the body
22
Indian Medical Association

23. What about general weakness in these patients…
Substrate mobilization in catabolic response to stress and injury during acute phase.
Proposed estimations for nutrition delivery
across phases of critical illness.
Wischmeyer PE. Tailoring nutrition therapy to illness and recovery. Crit Care. 2017;21(Suppl 3):316.
Targeted nutrition delivery in critical illness
Catabolic response to stress and injury

24. 24
Dwijen Das, Tirthankar Roy . A Practical Approach to Loss of Appetite Chapter 34, http://www.apiindia.org/pdf/progress_in_medicine_2017/mu_34.pdf accessed on 26/01/2020
Energy deficit in the body
Loss of appetite in acute illness (viral or bacterial infection or drug induced)
Appetite is the desire to eat food, sometimes due to hunger.
Decreased desire to eat is termed as anorexia.
A brief period of anorexia usually accompanies almost all acute
illnesses

25. Calorie requirements (by body weight)
Davenport M, Syed HS. Fluids, Electrolytes, and Dehydration. In book: Handbook of Pediatric Surgery. DOI: 10.1007/978-1-84882-132-3_2
Requirements may be influenced by state of nutrition before and during illness
Sample fluid requirements (by body weight)
Body weight Calories required
(kcal/day)
Maintenance
(mL/day)
Maintenance
(mL/h)
3 300 300 12
5 500 500 20
10 1,000 1,000 40
20 1,500 1,500 60
45 2,000 2,000 80
70 2,500 2,500 100

26. Lets go back to the case…
• Antibiotics, appropriate analgesics, and definitive follow-up care
• Antiemetics to control nausea and to prevent fluid and
electrolyte disorders
• Appropriate hydration to manage the losses
• Address calorie requirements
https://emedicine.medscape.com/article/171886-treatment#d11 accessed on 23/2/2020
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams

27. Ideal way to restore fluid, electrolyte and energy
balance?
Ideal restoration solution
Home-made or ready-to-drink
Non-caffeinated
Non-alcoholic
Non-carbonated
With natural sugar or limited added
sugar and electrolytes
Hygienically prepared
In special cases
Minerals like calcium, magnesium
and taurine for faster muscle
recovery
Prebiotics to help recovery from
dysbiosis during antibiotic therapy
Indian Medical Association Restoration Guidelines 2017

28. Strengths Weakness
• Fluids are readily available in the home
• No special recipe is needed
• Patients are encouraged to consume fluids
that are culturally acceptable
• The amount of glucose and electrolytes
in home fluids is variable
• The glucose and electrolytes may be
less than is required for optimal
rehydration, hence, these fluids do not
adequately replace potassium, sodium,
and other ions
Elliott K, Cutting W. ORT: A life saving solution. Dialogue on Diarrhoea. 1993 March-May;Issue no. 52: 1-8.
Blackmer A B. Fluids and Electrolytes [Internet]. [cited 2020 Jan 30] Available from https://www.accp.com/docs/bookstore/pedsap/ped2018b2_sample.pdf
All oral restoration fluids may not be the same
Why home based fluids may not be the ideal solution?

29. Lets look few more cases..

30. Case 2: Anorexia and Fever
• A 22-year-old man presented with malaise and anorexia for 1
week. He vomited on one occasion, with no blood.
• He has felt feverish but has not taken his temperature. For 2
weeks he has had myalgia, aching pains in the knees, elbows
and wrists without any obvious swelling of the joints.
• He has not noticed any change in his urine or bowels.
• He smokes 25 cigarettes per day and drinks 20–40 units of
alcohol per week.
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams

31. On examination…
• He has a temperature of 38.6°C
and looks unwell. He looks as if
he may be a little jaundiced.
• He is a little tender in the right
upper quadrant of the abdomen.
• There are no abnormalities to
find on examination of the joints
or in any other system.
• What is your interpretation of the findings?
• What is the likely diagnosis?
• What treatment is required?
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams
Investigations
Normal
Haemoglobin 14.1 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 85 fL 80–99 fL
White cell count 11.5 x 109/L 3.9–10.6 x 109/L
Platelets 286 x 109/L 150–440 x 109/L
Prothrombin time 17 s 10–14 s
Sodium 135 mmol/ 135–145 mmol/L
Potassium 3.5 mmol/L 3.5–5.0 mmol/L
Urea 3.2 mmol/L 2.5–6.7 mmol/L
Creatinine 64µmol/L 70–120µmol/
Bilirubin 50 mmol/L 3–17 mmol/L
Alkaline phosphatase 376 IU/L 30–300 IU/L
Alkaline aminotransferase 570 IU/L 5–35 IU/L
Fasting glucose 4.1 mmol/L 4.0–6.0 mmol/L

32. Acute viral hepatitis….
• Viral hepatitis is often associated with a prodrome of
arthralgia and flu-like symptoms
• Treatment: supportive care
• Address hydration
• Address calorie intake and nutrition
• Monitor liver enzymes
Adapted from 100 CASES in Clinical Medicine Second edition, © 2007 P John Rees, James M Pattison and Gwyn Williams

33. A 33 year-old male* presents
with fever associated with
myalgia, fatigue and muscle
weakness
Case 7: Fever with Myalgia
1. CDC. Flu Symptoms & Diagnosis. Available from: https://www.cdc.gov/u/symptoms/index.html. Accessed on: Sept 23, 2019. 2. Crum-Cianone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev. 2008;21(3):473–
494. 3. Gibson SB, Majersik JJ, Smith AG,Bromberg MB. Three cases of acute myositis in adults following inuenza-like illness during the H1N1 pandemic. J Neurosci Rural Pract. 2013;4(1):51–54.
Presentation
Fever1,2 New onset pain in the calf
that made it made it
difficult for him to walk,
climb stairs and get up
from sitting position2,3
Lethargy1,2
Rhinorrhoea1,2
Generalized muscle weakness1,2,3
Past history
No significant past medical history No routine medications
On examination
Febrile > 1020F, vitals stable, able to
tolerate oral feeds

34. What may be the reason for muscle pain and weakness in
this patient?
A. Viruses may cause diffuse muscle involvement with inflammation of
a muscle characterized by pain, tenderness, swelling, and/or
weakness;
B. Flu is severe than a cold and presents with weakness and feeling
tired, fever, dry cough, a runny nose, chills, muscle aches, a bad
headache, eye pain, and a sore throat.
American Academy Of Family Physician.Colds and the Flu: Tips for Feeling Better. Am Fam Physician. 2006 Oct 1;74(7):1179-1180.
Case 7: Fever with Myalgia

35. How should this case be managed back to
normal healthy state?
• Antipyretic to reduce temperature1
• Plenty of fluids to reduce risk of dehydration related symptoms3
CDC and Indian Guidelines for seasonal influenza management
recommend plenty of fluids, at the start of flu symptoms.1,2,3
1. Ministry of Health and Family Welfare. Directorate General of Health Services (National Centre for Disease Control) Clinical
Management Protocol for Seasonal InFLuenza. Updated on 28th May, 2018. Available from: https://mohfw.gov.in/sites/default/FIles/49049173711477913766.pdf. Accessed on: Sept 23, 2019 2. CDC. The FLu, Caring for someone sick at
home. Available from: https://www.cdc.gov/-
Fu/pdf/freeresources/general/inFLuenza_FLu_homecare_guide.pdf. Accessed on: Sept 27, 2019. 3. IMA Restoration guideline. Indian Medical Association. Restoration Guidelines. 2017. New Delhi.pp1-1.

36. A 30-year-old male who had gone trekking for 2 days in hot weather
presented with complaints of dizziness, nausea, and painful leg
cramps.
• He has been drinking water during the day, but is unsure of how
much he may have consumed.
• His food intake in these 2 days has been less.
• He has been a regular trekker and other than that there is no
other significant history.
Case 8: Muscle cramps

37. 1. Santelli J, Sullivan JM, Czarnik A et al., Heat illness in the emergency department: keeping your cool. Emerg Med Pract. 2014 Aug;16(8):1-2; quiz 21-2.
2. Glazer JL. Management of heatstroke and heat exhaustion. Am Fam Physician. 2005 Jun;7(11):2133-40.
Heat related illness
Heat cramps
•Exercise-associated
muscle contractions
Secondary to loss of
electrolytes
Heat exhaustion
•Secondary to loss of
salt and water
Fatigue, rapid pulse,
profuse sweating,
vomiting, and weakness
No central
nervous system
involvement.
Heat Stroke
•Core temperature
≥40°C (104°F)
Central nervous system
dysfunction

38. • Rest in a cool environment 2
• Protect from exposure to heat2
• Stretch the affected muscles2
• IMA restoration guidelines recommend restoration fluids with
additional minerals like calcium, magnesium and taurine for faster
muscle recovery in disease condition, daily exertion and other physical
activities like exercise.
1. Wexler RK. Evaluation and treatment of heat-related illnesses. Am Fam Physician 2002 Jun;65(11):2307-14.
2. Glazer JL. Management of heatstroke and heat exhaustion. Am Fam Physician. 2005 Jun;7(11):2133-40.
3. Indian Medical Association Restoration Guidelines 2017
Heat related illness

39. To summarize…..Aim for holistic recovery
• Recovery is ‘Return to a normal state of health, mind, or strength
• Routine assessment of hydration status is critical to support
patient care
• Restoration therapy is essential for faster recovery- critical to
regain/rebalance the lost water, electrolytes and energy from the
body
• Treat the medical cause
• Replenish the water and electrolyte loss: Maintenance and
Replacement of losses
• Ensure adequate nutrition

40. Thank you