Post on 26-May-2015
Celso M. Fidel,Celso M. Fidel,
MD,FPCS,FPSGSMD,FPCS,FPSGS
Diplomate Philippine Board Diplomate Philippine Board of Surgeryof Surgery
FLUIDS AND FLUIDS AND ELECTROLYTESELECTROLYTES
INTRODUCTIONINTRODUCTION
HOMEOSTASIS HOMEOSTASIS is determined by:is determined by: Individual’s Intake and outputIndividual’s Intake and output Carefully and precisely regulated by the Carefully and precisely regulated by the body during Healthbody during Health
One of the most critical aspects of One of the most critical aspects of patient’s care is management of the patient’s care is management of the body composition of fluids and body composition of fluids and electrolyteselectrolytes
INTRODUCTIONINTRODUCTION Situations that impose a great impact on Situations that impose a great impact on physiology of body fluid & electrolytes:physiology of body fluid & electrolytes: DiseasesDiseases InjuriesInjuries Operative TraumaOperative Trauma In disease states ---In disease states ---regulatory regulatory
mechanisms mechanisms often becomes impaired & often becomes impaired &
IMBALANCES IMBALANCES occuroccur
•
INTRODUCTIONINTRODUCTION Thorough understanding of the Thorough understanding of the mechanisms of fluids and electrolytes mechanisms of fluids and electrolytes and certain metabolic responses is and certain metabolic responses is essential to the care of surgical essential to the care of surgical patientspatients SURGEONS encounter these PROBLEMS:SURGEONS encounter these PROBLEMS: Additional stress of SURGERYAdditional stress of SURGERY Use of tubes that drain fluidsUse of tubes that drain fluids Patient’s inability to tolerate oral Patient’s inability to tolerate oral intake of fluids and nutrientsintake of fluids and nutrients
BODY WATERBODY WATER
Water constitutes between 50% to Water constitutes between 50% to 70%TB Wt.70%TB Wt. Average Normal ValuesAverage Normal Values Young Adult Male 60% of body Young Adult Male 60% of body wt.wt. Young Young Adult FemaleAdult Female 50% of body 50% of body wt.wt. Total Body Water (% TBW) decreasesTotal Body Water (% TBW) decreases steadily and significantly with age:steadily and significantly with age: 52% in males52% in males 47% in females47% in females
BODY WATERBODY WATER
Highest proportion of TB water : Highest proportion of TB water :
Infants 75% to 80% of body weightInfants 75% to 80% of body weight
One Year Old averages 65% of BWt.One Year Old averages 65% of BWt.
Lean individuals Lean individuals has greaterhas greater proportion proportion of water to TBW than the obeseof water to TBW than the obese
FUNCTIONAL COMPARTMENT OF BODY FLUIDSFUNCTIONAL COMPARTMENT OF BODY FLUIDS
INTRACELLULARINTRACELLULAR
fluid w/in the body’s diverse cell fluid w/in the body’s diverse cell populationpopulation
represent---- 40%represent---- 40%
largest proportion ---- skeletal musclelargest proportion ---- skeletal muscle
principal principal CATION-----CATION-----K (potassium)K (potassium)
principal principal ANION ------ANION ------phosphates & phosphates & proteinsproteins
FUNCTIONAL COMPARTMENT OF BODY FLUIDSFUNCTIONAL COMPARTMENT OF BODY FLUIDS
EXTRACELLULAREXTRACELLULAR
Represents----- 20% of the BWRepresents----- 20% of the BW
Two major subdivisionsTwo major subdivisions
plasma volume----- 5% of BWplasma volume----- 5% of BW
Interstitial( extravascular ) 15% of Interstitial( extravascular ) 15% of BWBW
FUNCTIONAL COMPARTMENT OF BODY FLUIDSFUNCTIONAL COMPARTMENT OF BODY FLUIDS
EXTRACELLULAREXTRACELLULAR
Non-functioning components----1%-2% Non-functioning components----1%-2% B wt.B wt.
Connective tissue waterConnective tissue water
Cerebrospinal fluidCerebrospinal fluid
Joint fluidsJoint fluids
The principal The principal CATION-----CATION-----Na+( Sodium)Na+( Sodium)
The principal The principal ANION-------ANION-------Cl (Chloride Cl (Chloride andand
bicarbonatesbicarbonates
FUNCTIONAL COMPARTMENT OF BODY FLUIDSFUNCTIONAL COMPARTMENT OF BODY FLUIDS
Gibbs-Donnan Equilibrium-----Gibbs-Donnan Equilibrium-----The The
product of concentration of any pair of product of concentration of any pair of
diffusable diffusable cation cation and and anionanion on one side on one side
of a semi-permeable membrane will of a semi-permeable membrane will
equal the product of the same pair of equal the product of the same pair of
ions on the other sideions on the other side
FUNCTIONAL COMPARTMENT OF BODY FLUIDSFUNCTIONAL COMPARTMENT OF BODY FLUIDS
TWO THIRDS RULETWO THIRDS RULE
Determination of the exact size of Determination of the exact size of
any one of the 3 compartments is any one of the 3 compartments is
virtually impossiblevirtually impossible
Total Body Compartment is Total Body Compartment is
approximately 2/3 of BODY Weightapproximately 2/3 of BODY Weight
FUNCTIONAL COMPARTMENT OF BODY FUNCTIONAL COMPARTMENT OF BODY FLUIDSFLUIDS
TWO THIRDS RULETWO THIRDS RULE
Of this 2/3; 2/3 is INTRACELLULAR Of this 2/3; 2/3 is INTRACELLULAR
& 1/3 is & 1/3 is EXTRACELLULAREXTRACELLULAR
Of the extracellular portion Of the extracellular portion
2/3 is INTERSTITIAL &2/3 is INTERSTITIAL &
1/3 intravascular1/3 intravascular
REPLACEMENT OF WATERREPLACEMENT OF WATER By IngestionBy Ingestion
By Metabolism-----combustion of foodstuff:By Metabolism-----combustion of foodstuff:
Each 100 calories ofEach 100 calories of
FATFAT
CARBOHYDRATESCARBOHYDRATES
PROTEINSPROTEINS
VITAL NEEDS W/C DEMANDS continuous VITAL NEEDS W/C DEMANDS continuous
water EXPENDITUREwater EXPENDITURE Removal of Body Heat ----800cc Removal of Body Heat ----800cc ((SKIN AND SKIN AND
LUNGS) 600-1000 >>>> RANGE DAILYLUNGS) 600-1000 >>>> RANGE DAILY
RELEASES 14 CC OF WATER
VITAL NEEDS W/C DEMANDS continuous VITAL NEEDS W/C DEMANDS continuous
water EXPENDITUREwater EXPENDITURE
Excretion of UREA, METABOLIC Excretion of UREA, METABOLIC PRODUCTSPRODUCTS
& MINERAL SALTS& MINERAL SALTS
1200 mOsm of solute have to be 1200 mOsm of solute have to be excreted excreted
daily daily
A good kidney can CONCENTRATE A good kidney can CONCENTRATE urine up urine up
to 1400 mOsm soluteto 1400 mOsm solute
VITAL NEEDS W/C DEMANDS continuous VITAL NEEDS W/C DEMANDS continuous
water EXPENDITUREwater EXPENDITURE
Average Adult excretes 900 cc Average Adult excretes 900 cc H20/dayH20/day
Normal H20 loss in Urine----800-Normal H20 loss in Urine----800-1500cc/ day1500cc/ day
Normal Na+ loss-----10-100 mEq/ liter Normal Na+ loss-----10-100 mEq/ liter of of
urineurine
Normal Daily LossesNormal Daily Losses
1. GIT 100-200 ml loss in stools1. GIT 100-200 ml loss in stools
2. GUT 1000- 1500 ml loss in urine2. GUT 1000- 1500 ml loss in urine
3. Insensible 600-800 ml in adults (divided equally3. Insensible 600-800 ml in adults (divided equally between lungs and skin) a better term wouldbetween lungs and skin) a better term would be imperceptible lossbe imperceptible loss
Abnormal Losses of WaterAbnormal Losses of Water
1. Fever - 10% increase insensible loss per 1. Fever - 10% increase insensible loss per degree above 37 C.degree above 37 C. 2. Tachypnea –doubling RR 50% increase resp. L2. Tachypnea –doubling RR 50% increase resp. L 3. Evaporation- Sweating, ventilator, open wounds3. Evaporation- Sweating, ventilator, open wounds 4. GI –Fistula, Diarrhea, Tube drainage4. GI –Fistula, Diarrhea, Tube drainage 5. Third space – Interstitium of lungs, bowel, soft5. Third space – Interstitium of lungs, bowel, soft tissuestissues 6. Intraoperative losses6. Intraoperative losses
TonicityTonicity Body Fluids ---- composed of water and Body Fluids ---- composed of water and
substances dissolved in itsubstances dissolved in it
Total number of particles in solution areTotal number of particles in solution are
constant throughout the body, constant throughout the body, although the although the
nature of the individual solute varies nature of the individual solute varies inin
different parts of the bodydifferent parts of the body
Tonicity( property derived from the Tonicity( property derived from the number ofnumber of
particles in solution) Normal----300 particles in solution) Normal----300 mOsm/L mOsm/L
TonicityTonicity In PLASMA 280 is due to ELECTROLYTESIn PLASMA 280 is due to ELECTROLYTES
1/2 --- 140 mOsm is coming from Na+1/2 --- 140 mOsm is coming from Na+
1/2 --- 140 mOsm from Chlorides & 1/2 --- 140 mOsm from Chlorides &
BicarbonatesBicarbonates
Crystalloids:Crystalloids:
SugarSugar
Urea 10-20 mOsmUrea 10-20 mOsm
CreatinineCreatinine
Protein ------ 2 mOsmProtein ------ 2 mOsm
Electrolytes, What are TheyElectrolytes, What are They??
Group of compounds-----DISSOCIATES in Group of compounds-----DISSOCIATES in solution to form solution to form “IONS’“IONS’ after the greek after the greek
for for “ “ GOING”GOING” These ions each carry an electrical These ions each carry an electrical
charge; charge; example; NaCl -----dissolved in water example; NaCl -----dissolved in water providesprovides Na+ ---- carries a positive chargeNa+ ---- carries a positive charge Cl- -----carries a negative chargeCl- -----carries a negative charge
Electrolytes, What are TheyElectrolytes, What are They?? Those IONS carrying a (+) charge Those IONS carrying a (+) charge
migrated to migrated to FARADAY’s (-)FARADAY’s (-) electrode electrode
or “CATHODE” were called or “CATHODE” were called ”Cations””Cations”
after the Greek for after the Greek for “DOWN”“DOWN”
Those IONS carrying a (-) charge Those IONS carrying a (-) charge
migrated to migrated to FARADAY’s (+)FARADAY’s (+) electrode electrode
or “ANODE” were called or “ANODE” were called ”anions””anions” after after
the Greek for “UP”the Greek for “UP”
Electrolytes, What are TheyElectrolytes, What are They?? Cations in the body; Na+, K+, Ca++, Cations in the body; Na+, K+, Ca++,
Mg++Mg++
Anions in the body include ; Cl-, HCO3-, Anions in the body include ; Cl-, HCO3-,
HPO4=, SO4=; ions of inorganic acids HPO4=, SO4=; ions of inorganic acids such such
as:as:
LactateLactate
PyruvatePyruvate
Aceto-AcetateAceto-Acetate
ProteinatesProteinates
Electrolytes, What are TheyElectrolytes, What are They??
Each of the water compartments of Each of the water compartments of the the
body contains electrolytes. body contains electrolytes. However However
the composition and concentration the composition and concentration of of
these electrolytes in the water of these electrolytes in the water of each each
compartment differ from that of compartment differ from that of the the
others.others.
Electrolytes, What are TheyElectrolytes, What are They??
Physiologic and Chemical Activity of Physiologic and Chemical Activity of electrolytes are proportional to:electrolytes are proportional to: Number of particles present per unit Number of particles present per unit
volumevolume ( MOLES or MILLIMOLES)( MOLES or MILLIMOLES)
No. of electrical charges per unit No. of electrical charges per unit volumevolume
( Equivalents or Milliequivalents per ( Equivalents or Milliequivalents per liter)liter)
Electrolytes, What are TheyElectrolytes, What are They?? mEq/L=mgs./L X val. divided by the atomic mEq/L=mgs./L X val. divided by the atomic
Wt.Wt. ==mgs/ 1000cc X Valencemgs/ 1000cc X Valence Atomic WeightAtomic Weight OSMOLARITY OSMOLARITY >>>expression of concentration >>>expression of concentration of ions and proteins in solution in body water.of ions and proteins in solution in body water.
Water moves freely in the body to prevent Water moves freely in the body to prevent the development of any compartmentalizedthe development of any compartmentalized osmolar concentration difference.osmolar concentration difference.
Electrolytes, What are TheyElectrolytes, What are They?? Electrolyte Concentration in SerumElectrolyte Concentration in Serum
Na+ -------- 135-145 mEq/ literNa+ -------- 135-145 mEq/ liter
K+ -------- 3.5-5.5 mEq/literK+ -------- 3.5-5.5 mEq/liter
Cl- ----- 85-115 mEq/literCl- ----- 85-115 mEq/liter
HCO3- ---- 22-29 mEq/literHCO3- ---- 22-29 mEq/liter
Mg++ ---- 1.5-2.5 mEq/literMg++ ---- 1.5-2.5 mEq/liter
Ca++ ---- 4-5.5 mEq/literCa++ ---- 4-5.5 mEq/liter
ELECTROLYTE COMPOSITION OF BODY FLUIDSELECTROLYTE COMPOSITION OF BODY FLUIDS
Na+ K+ H+ Cl- HCO3 Proteins PO4 SO4- Na+ K+ H+ Cl- HCO3 Proteins PO4 SO4- Plasma 142 4.5 Plasma 142 4.5 100 25 16 2 1 100 25 16 2 1
GastricGastric
Low Acid Low Acid 45 45 30 70 120 25 30 70 120 25
High Acid High Acid 100 45 0.015 115 30100 45 0.015 115 30
Intestinal Juice 120 20 30Intestinal Juice 120 20 30
Bile 140 5 40Bile 140 5 40
Pancreatic Juice 130 15 80Pancreatic Juice 130 15 80
Intracellular 10 150 5 10 60 100 20Intracellular 10 150 5 10 60 100 20
NORMAL DAILY FLUID& ELECTROLYTE LOSSES NORMAL DAILY FLUID& ELECTROLYTE LOSSES AND REQUIREMENTS AND REQUIREMENTS
LOSSES/ 24 hoursLOSSES/ 24 hours SubstancesSubstances Urine Urine SkinSkin LungsLungs Feces Feces TotalTotal WATER WATER 1200-1500 200-400 500-700 100-200 2300-26001200-1500 200-400 500-700 100-200 2300-2600
SODIUM SODIUM 100 mEq 40 mEq/liter 80-100 mEq100 mEq 40 mEq/liter 80-100 mEq
POTASSIUM POTASSIUM 100 mEq100 mEq 80- 80-100mEq100mEq
CHLORIDES CHLORIDES 150 mEq 40 mEq/ liter150 mEq 40 mEq/ liter 100-150 100-150 mEq mEq
REQUIREMENTSREQUIREMENTS WATER 35 ml/ kg. body weightWATER 35 ml/ kg. body weight
PEDIATRICS 100 ml/kg first 10 kg. body weightPEDIATRICS 100 ml/kg first 10 kg. body weight 50 ml/kg next 10 kg. “ “50 ml/kg next 10 kg. “ “
20 ml/kg for each additional body weight20 ml/kg for each additional body weight
SODIUM 1 mEq/kg body weight SODIUM 1 mEq/kg body weight
POTASSIUM “ “ “ “POTASSIUM “ “ “ “
CHLORIDE 1.5 mEq/ kg. body weightCHLORIDE 1.5 mEq/ kg. body weight
HCO3 0.5 “ “ “ “HCO3 0.5 “ “ “ “
THE IONSTHE IONS
SODIUMSODIUM
Principal Principal CationCation of extracellular fluid of extracellular fluid
Normal requirement is met by the average dietNormal requirement is met by the average diet
Average intake----- 100 mgs dailyAverage intake----- 100 mgs daily
Sweat conc. -----27mEq/ L isSweat conc. -----27mEq/ L is to 100mEq /L to 100mEq /L Total secretion---Alimentary Tract Total secretion---Alimentary Tract 1000-12001000-1200mEqmEq
ADH of Pituitary promotes Na+ excretion from ADH of Pituitary promotes Na+ excretion from
the kidney to some extent & to markedly the kidney to some extent & to markedly
favor water resorption from the distal favor water resorption from the distal tubules. tubules.
THE IONSTHE IONS
POTASSIUM (cation)POTASSIUM (cation)
Major exchangeable portion lies within the cellMajor exchangeable portion lies within the cell
Daily turnover of K+ requirement represents Daily turnover of K+ requirement represents
1.5 to 5% of the total K+ content of the body.1.5 to 5% of the total K+ content of the body.
Normal 70 kg. man----- 3,200 mEqNormal 70 kg. man----- 3,200 mEq
Average woman--------- 2,300mEqAverage woman--------- 2,300mEq
Normal requirement met by average dietNormal requirement met by average diet
Gastric Juice Content----15-40mEq/literGastric Juice Content----15-40mEq/liter
Healthy cell maintains high K+ & low Na+ conc.Healthy cell maintains high K+ & low Na+ conc.
Patient under stress of disease or in the postop.Patient under stress of disease or in the postop. period>> Normal Kidney excretes 80-90 period>> Normal Kidney excretes 80-90 mEq/daymEq/day
THE IONSTHE IONS
POTASSIUM (cation)POTASSIUM (cation) At 7 mEq/L in Serum----- elevation of T waves onAt 7 mEq/L in Serum----- elevation of T waves on Electro Cardio GramElectro Cardio Gram At 8-10 mEq/L ------Arrhythmia & Heart BlockAt 8-10 mEq/L ------Arrhythmia & Heart Block
CHLORIDE (ANION)CHLORIDE (ANION) Na+ to Cl- ratio is 3:2 in serum & extracellularNa+ to Cl- ratio is 3:2 in serum & extracellular compartmentcompartment
It follows changes in Na+ concentration EXCEPTIt follows changes in Na+ concentration EXCEPT in GASTRIC OBSTRUCTION;in GASTRIC OBSTRUCTION; Chloride is lowChloride is low Na+ is normalNa+ is normal Alkalosis is severe Alkalosis is severe
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
It is the center of any scheme of FLUID It is the center of any scheme of FLUID
and ELECTROLYTE Balanceand ELECTROLYTE Balance
Nature of imbalances and approximate Nature of imbalances and approximate
magnitude are based on:magnitude are based on:
HistoryHistory
Clinical Signs and SymptomsClinical Signs and Symptoms
Certain Laboratory StudiesCertain Laboratory Studies
Past Clinical ExperiencePast Clinical Experience
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
CLUES FROM THE HISTORYCLUES FROM THE HISTORY
In Gastric Outlet Obstruction present inIn Gastric Outlet Obstruction present in
Duodenal Ulcer will produce Duodenal Ulcer will produce
Pyloric Stenosis alkalosis (loss ofPyloric Stenosis alkalosis (loss of
Chloride & K+; Hypokalemia; loss of H20 & Chloride & K+; Hypokalemia; loss of H20 & Na+)Na+)
Vomiting secondary to a cause other than Vomiting secondary to a cause other than gastric gastric
Outlet Obstruction:Outlet Obstruction:
Loss of H2O If there is a shift in ACIDLoss of H2O If there is a shift in ACID
Loss of Na+ BASE balance, it is Loss of Na+ BASE balance, it is towardstowards
Loss of K+ METABOLIC ACIDOSISLoss of K+ METABOLIC ACIDOSIS
vomiting
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
CLUES FROM THE HISTORYCLUES FROM THE HISTORY
Diarrhea secondary to:Diarrhea secondary to:
Cholera Loss of Cholera Loss of
Ulcerative Colitis H20, K+, Ulcerative Colitis H20, K+, ACIDOSISACIDOSIS
Ileostomy dysfunction Na+Ileostomy dysfunction Na+
Burns produces acute loss of PLASMA & Burns produces acute loss of PLASMA & Extra-Extra-
cellular fluid (Water, Proteins, and Na+)cellular fluid (Water, Proteins, and Na+)
Sweating if excessive causes appreciable Sweating if excessive causes appreciable loss ofloss of
both Na+ & H20------ Shrinkage of both Na+ & H20------ Shrinkage of ExtracellularExtracellular
Fluid Volume -------VASCULAR COLLAPSEFluid Volume -------VASCULAR COLLAPSE
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
P.E. should give attention to: P.E. should give attention to:
BODY WEIGHTBODY WEIGHT
Weight gain >>>H20 retentionWeight gain >>>H20 retention
Weight loss 300-500 gms./day expected in Weight loss 300-500 gms./day expected in
postoperative Patients.>>>> In excess of postoperative Patients.>>>> In excess of 300- 300-
500 gms/ day indicates H20 loss.500 gms/ day indicates H20 loss.
Tissue TurgorTissue Turgor >>Decrease in T T in volume >>Decrease in T T in volume of of
the Interstitial Fluid compartment of ECFthe Interstitial Fluid compartment of ECF
( Na+ dependent)( Na+ dependent)
Skin Turgor>> useful indicator of diminishedSkin Turgor>> useful indicator of diminished
interstitial fluid volumeinterstitial fluid volume
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
P.E. should give attention to: P.E. should give attention to:
Tissue turgorTissue turgor
Tongue>> most reliable indicator forT.TTongue>> most reliable indicator forT.T Normally it has a single “Median Furrow”Normally it has a single “Median Furrow”
Additional furrows parallel to the median furrowAdditional furrows parallel to the median furrow
appears with decrease interstitial volume and appears with decrease interstitial volume and aa
need for Na+need for Na+
Moisture of the axilla and groinMoisture of the axilla and groin. Dry but . Dry but other-other-
wise normal axilla----H20 deficit, at least wise normal axilla----H20 deficit, at least 150cc150cc
Jugular VeinsJugular Veins ------Normally it fills to the ------Normally it fills to the anterioranterior
border of the sternocleidomastoid muscle border of the sternocleidomastoid muscle whenwhen
the patient is supine.the patient is supine.
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
P.E. should give attention to: P.E. should give attention to: Blood Pressure and PulseBlood Pressure and Pulse
Tachypnea>> earliest sign of decrease Tachypnea>> earliest sign of decrease BVolume BVolume
Postural Hypotension Need for Blood & Postural Hypotension Need for Blood & NaNa
Hypotension when Supine containing fluidHypotension when Supine containing fluid
Edema and RalesEdema and Rales
Pitting Edema>>> Na+ increase >> 400 Pitting Edema>>> Na+ increase >> 400 mEqmEq
Rales>> Acute increase in Volume by at Rales>> Acute increase in Volume by at least least
1500cc 1500cc
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
LABORATORY TESTS & Other LABORATORY TESTS & Other PARAMETERS PARAMETERS
HematocritHematocrit
Urine Specific GravityUrine Specific Gravity
Na+ levels in serum and urineNa+ levels in serum and urine
CVP monitoringCVP monitoring
Pulmonary Wedge PressurePulmonary Wedge Pressure
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
LABORATORY TESTS & Other PARAMETERSLABORATORY TESTS & Other PARAMETERS
HematocritHematocrit
Urine Specific GravityUrine Specific Gravity
Na+ levels in serum and urineNa+ levels in serum and urine
CVP monitoringCVP monitoring
Pulmonary Wedge PressurePulmonary Wedge Pressure
Determining the Amount of the DeficitDetermining the Amount of the Deficit
A Vol(H2O) deficit---- Estimate from patient’s A Vol(H2O) deficit---- Estimate from patient’s Body Body
Wt.& appearance or from the serum Sodium Wt.& appearance or from the serum Sodium level.level.
The hematocrit gives also useful information.The hematocrit gives also useful information.
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
CLINICAL ESTIMATES CLINICAL ESTIMATES
MILD Dehydration----- Patient losses 3% of MILD Dehydration----- Patient losses 3% of the the
Body Weight ----- Body Weight ----- THIRSTYTHIRSTY
MODERATE Dehydration ------ Patient losses MODERATE Dehydration ------ Patient losses 6%6%
of the Body Wt. Clinical signs of of the Body Wt. Clinical signs of dehydrationdehydration
are Evident:are Evident:
Marked Thirst and Dry MouthMarked Thirst and Dry Mouth
No groin and axillary SweatNo groin and axillary Sweat
Loss of Skin TurgorLoss of Skin Turgor
..
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
CLINICAL ESTIMATESCLINICAL ESTIMATES
SEVERE Dehydration------Patient losses 10% SEVERE Dehydration------Patient losses 10% ofof
Body Weight:Body Weight:
Clinical signs of Dehydration are marked.Clinical signs of Dehydration are marked.
Hypotension may be presentHypotension may be present
Patient may be confused & delirious.Patient may be confused & delirious.
BODY WATER CALCULATIONSBODY WATER CALCULATIONS
Body H20 = Body H20 = Normal Serum Na+Normal Serum Na+ X normal B X normal B H20H20
Measured Na+ valueMeasured Na+ value
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
Electrolyte deficits.Electrolyte deficits. They are They are calculatedcalculated
after the lab results for Na+. K, Cl, and after the lab results for Na+. K, Cl, and NaHC03 are in.NaHC03 are in.
NaCl & HCO3 deficit are calculated NaCl & HCO3 deficit are calculated using foll:using foll:
DEFICIT= DEFICIT= NORMAL VOLUME –OBSERVED BODY VOLUME x ELECTROLYTE NORMAL VOLUME –OBSERVED BODY VOLUME x ELECTROLYTE
DISTRIBUTIONDISTRIBUTION IN BODY COMP% x BODY WT(KG)IN BODY COMP% x BODY WT(KG) WHERE: NA DISTRIBUTION = 60 %WHERE: NA DISTRIBUTION = 60 % CL “ 20 %CL “ 20 % HCO3 “ 5O%HCO3 “ 5O%
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
Electrolyte deficits.Electrolyte deficits.
The K+ deficit is figured differently w/normalThe K+ deficit is figured differently w/normal
Blood pH:Blood pH:
For every 1.0 mEq/L decrease in For every 1.0 mEq/L decrease in concentrationconcentration
at or above 3.0 mEq----consider the total at or above 3.0 mEq----consider the total bodybody
deficit as 100-200 mEq.deficit as 100-200 mEq.
For every1.0 mEq/L decrease in the K+ For every1.0 mEq/L decrease in the K+ conc. conc.
below 3.0 mEq/L -----consider the total below 3.0 mEq/L -----consider the total bodybody
deficit as another 300-400 mEq.deficit as another 300-400 mEq.
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
ABNORMAL PATTERNS in Fluids & ElectrolytesABNORMAL PATTERNS in Fluids & Electrolytes
Disorders of composition & concentrationDisorders of composition & concentration
Disorders of VolumeDisorders of Volume
Disorders of Acid-Base BalanceDisorders of Acid-Base Balance
CLINICAL STATESCLINICAL STATES
HYPONATREMIA HYPONATREMIA HYPERCLOREMIA HYPERCLOREMIA
HYPERNATREMIA HYPERNATREMIA ACID BASE BALANCE ACID BASE BALANCE
ISOTONIC DEHYDRATIONISOTONIC DEHYDRATION
HYPOKALEMIAHYPOKALEMIA
HYPERKALEMIAHYPERKALEMIA
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA
PathophysiologyPathophysiology
Hypovolemic or IsovolemicHypovolemic or Isovolemic
Mechanism:Mechanism:
Loss of Na+ containing fluid and Loss of Na+ containing fluid and replacementreplacement
with salt free fluid( isovolemic)with salt free fluid( isovolemic)
Salt free fluid and administration in excess Salt free fluid and administration in excess inin
the absence of salt loss the absence of salt loss ((dilutional Hyponatremia)dilutional Hyponatremia)
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA
CausesCauses
Loss of fluid with high Na+ content:Loss of fluid with high Na+ content:
Fistula Fistula Ngt Drainage Ngt Drainage
Vomiting Vomiting Diarrhea Diarrhea
Excessive URINE Na+ wastageExcessive URINE Na+ wastage
Diuretics Diuretics Chronic Nephritis Chronic Nephritis
Adrenal Cortical Insufficiency as in Adrenal Cortical Insufficiency as in Addison’sAddison’s
diseasedisease Over infusion of salt free fluid (Over infusion of salt free fluid (dilutional dilutional
Hyponatremia)Hyponatremia)
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA
Causes cont’dCauses cont’d
Loss of Extracellular Fluid:Loss of Extracellular Fluid:
Externally:Externally:
Burns Burns Marked Sweating Marked Sweating
Internally as in Third Space loss:Internally as in Third Space loss:
Peritonitis Peritonitis Ascites Ascites
Ileus Ileus Pancreatitis Pancreatitis
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA
Clinical PresentationClinical Presentation
Accumulation of intracellular fluid could causeAccumulation of intracellular fluid could cause
CNS symptoms:CNS symptoms:
Serum Na+ below 130 mEq/Liter ( Mild)Serum Na+ below 130 mEq/Liter ( Mild)
“ “ “ “ “ “ 113 “ “ (Severe)113 “ “ (Severe)
CNS depression, Confusion, Somnolence CNS depression, Confusion, Somnolence
Signs of Increase Intracranial pressureSigns of Increase Intracranial pressure
OLIGURIC Renal Failure in Severe OLIGURIC Renal Failure in Severe HyponatremiaHyponatremia
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA
ManagementManagement
Repeated Na+ determination; other Repeated Na+ determination; other ElectrolytesElectrolytes
H20 deprivation, Use diureticsH20 deprivation, Use diuretics
Administer Na+ containing FluidsAdminister Na+ containing Fluids
Sodium must be Titrated slowly back to Sodium must be Titrated slowly back to
NormalNormal
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA “ “ Sample CASE”Sample CASE” A muscular 50 year old man with A muscular 50 year old man with
polycysticpolycystic kidney disease presents w/ hypotension, confusion, oliguria, and kidney disease presents w/ hypotension, confusion, oliguria, and
no axillary sweat. Past medical record reveals that he has no axillary sweat. Past medical record reveals that he has polyuria has been eating a low salt diet because of mild polyuria has been eating a low salt diet because of mild hypertension. BUN has beenhypertension. BUN has been
stable at 40mgs/dL;Blood CO2 is 15mmol/L (Metabolic Acidosis) stable at 40mgs/dL;Blood CO2 is 15mmol/L (Metabolic Acidosis) andand
Na+ level of 120mEq/L.Body Weight is 90kgs; Urine output- Na+ level of 120mEq/L.Body Weight is 90kgs; Urine output- 170ml/day170ml/day
GIVEN:GIVEN: Na+ deficit =140mEq – 120mEq = 20mEq/L Na+ deficit =140mEq – 120mEq = 20mEq/L Total Body H20 = 90kgs X 60 = 54 LTotal Body H20 = 90kgs X 60 = 54 L Fluid Loss = 10% (Clinical Findings)Fluid Loss = 10% (Clinical Findings)
First Step:First Step: COMPUTE for Hypotonic Na+ deficitCOMPUTE for Hypotonic Na+ deficit Hypotonic Na+ deficit = Na+ deficit X TBWHypotonic Na+ deficit = Na+ deficit X TBW = 20mEq X 54 L =1080(Hypotonic Na+ = 20mEq X 54 L =1080(Hypotonic Na+
def.)def.)
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA “ “ Sample CASE”Sample CASE” 22ndnd Step Step: : COMPUTE for the isotonic Na+ deficitCOMPUTE for the isotonic Na+ deficit Find out the Isotonic Fluid loss or How much fluid is necessary Find out the Isotonic Fluid loss or How much fluid is necessary
toto revert to revert to ISOTONIC STATEISOTONIC STATE.. Formula ISOTONIC FLUID LOSS =Weight X % of FLUID LOSSFormula ISOTONIC FLUID LOSS =Weight X % of FLUID LOSS 90 Kgs. X 10% (9 Liters)90 Kgs. X 10% (9 Liters) Then compute for Then compute for isotonic Na+ deficitisotonic Na+ deficit Formula:Formula: Isotonic Na+ Loss X NORMALIsotonic Na+ Loss X NORMAL Na+ levelNa+ level 9 Liters X 140mEq =9 Liters X 140mEq = 1260mEq1260mEq
Total Na+ REQUIREMENT:Total Na+ REQUIREMENT: Hypotonic Na+ Deficit + Isotonic Na+ deficit + Daily Hypotonic Na+ Deficit + Isotonic Na+ deficit + Daily
requirementrequirement 1080mEq + 1260mEq + 75mEq = 1080mEq + 1260mEq + 75mEq =
2415mEq2415mEq
Initially only ½ is given so divide it by 2 =1207.5 mEqInitially only ½ is given so divide it by 2 =1207.5 mEq
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPONATREMIAHYPONATREMIA “ “ Sample CASE”Sample CASE” 33rdrd Step: Step: COMPUTE for the 24 hours H20 requirementCOMPUTE for the 24 hours H20 requirement The daily H20 requirement in an OLIGURIC patient is reduced:The daily H20 requirement in an OLIGURIC patient is reduced: FORMULAFORMULA 0.2 ml/kg body wt. +0.2 ml/kg body wt. + preceeding 24 hour Urine Output +10% forpreceeding 24 hour Urine Output +10% for every rise of 1 degree in body temp.every rise of 1 degree in body temp. =(0.2ml X 90 X 24) + 170 =602 ml/day=(0.2ml X 90 X 24) + 170 =602 ml/day
24 HOUR H20 requirement =24 HOUR H20 requirement =Isotonic Fluid loss(9 L) + 600 Isotonic Fluid loss(9 L) + 600 = 4.8 = 4.8 LitersLiters
22
44thth Step: Compute for Bicarbonate. The ideal replacement solution Step: Compute for Bicarbonate. The ideal replacement solution shouldshould
contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYP0NATREMIAHYP0NATREMIA “ “ Sample CASE”Sample CASE” 44thth Step: Step: Compute for Bicarbonate. The ideal replacement solution Compute for Bicarbonate. The ideal replacement solution
shouldshould contain a NaCl ratio of 1.4:1 particularly if the patient is contain a NaCl ratio of 1.4:1 particularly if the patient is ACIDOTIC.ACIDOTIC.
Sub- Step:Sub- Step: Compute for Chloride Requirement Compute for Chloride Requirement 1.4 1.4 = = 1245 1245 X= X= 12451245 =890 mEq as NaCl =890 mEq as NaCl 1 X(mEq) 1.41 X(mEq) 1.4 The Bicarbonate requirement is thus:The Bicarbonate requirement is thus: 1245- 890 =355 mEq of HCO31245- 890 =355 mEq of HCO3
PATIENT’S FLUID & ELECTROLYTE REQUIREMENTPATIENT’S FLUID & ELECTROLYTE REQUIREMENT
4.8 liters of 5% Dextrose in 0.9 % NaCl4.8 liters of 5% Dextrose in 0.9 % NaCl
Add 8 vials of Na2CO3 (44 mEq/50 cc)Add 8 vials of Na2CO3 (44 mEq/50 cc)
Plus 200 cc of 5% NaCl injectionPlus 200 cc of 5% NaCl injection
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIA PathophysiologyPathophysiology
ECF Hyperosmolarity= shift of H20 from cell----ECF Hyperosmolarity= shift of H20 from cell----
----ECF-ECF-More Fluid ---More Fluid ---DEHYDRATIONDEHYDRATION
Increased Intracellular Osmolality --Increased Intracellular Osmolality --CNS CNS effects:effects:
FeverFever
Hallucination Hallucination
DeliriumDelirium
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIA
CausesCauses
Prolonged FeverProlonged Fever
Large surface Burns --Large surface Burns --3-5 Liters loss/day3-5 Liters loss/day
Tachypnea – Do Tube TracheostomyTachypnea – Do Tube Tracheostomy
Renal Damage Renal Damage Loss of Solute Loss of Solute
Urine High Output FailureUrine High Output Failure
Desert ExposureDesert Exposure
Drinking Salt H2ODrinking Salt H2O
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIA ManagementManagement Gradual Reduction of Serum Na+Gradual Reduction of Serum Na+ Rehydrate patient with salt Free H20Rehydrate patient with salt Free H20 Formula: Formula: 70 kg patient with Na+ of 160mEq70 kg patient with Na+ of 160mEq Total Body Water 60% X 70kgs = 42 Liters=Total Body Water 60% X 70kgs = 42 Liters= Current Body Water Current Body Water 140140 =0.87 or 0.9 =0.87 or 0.9 1616
0.9 X 42 =37.8 Liters current Body Water0.9 X 42 =37.8 Liters current Body Water 42L- 37.8= 4.2 Liters ( water Needed)42L- 37.8= 4.2 Liters ( water Needed)
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIA
“ “ Sample CASE”Sample CASE” A moderately lean woman with A moderately lean woman with esophageal stricture has a serum Na+ level of 160mEq /L esophageal stricture has a serum Na+ level of 160mEq /L (normal is 140mEq). Her(normal is 140mEq). Her
present weight is 70kgs.present weight is 70kgs.
HER REQUIREMENTS WOULD BE CALCULATED AS FOLLOWS:HER REQUIREMENTS WOULD BE CALCULATED AS FOLLOWS: Current Body WaterCurrent Body Water 140mEq140mEq =7/8 =87.5 % of normal =7/8 =87.5 % of normal 160mEq160mEq
WATER Loss>>> 100%- 87.5% =12.5% of waterWATER Loss>>> 100%- 87.5% =12.5% of water PATIENT’S NORMAL total BODY WATERPATIENT’S NORMAL total BODY WATER 70 X 60% = 42 Liters70 X 60% = 42 Liters H20 DEFICITH20 DEFICIT 42 L X 12.5% = 5.3 Liters42 L X 12.5% = 5.3 Liters
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIA
“ “ Sample CASESample CASE”” A moderately lean A moderately lean woman with esophageal stricture has a serum woman with esophageal stricture has a serum Na+ level of 160mEq /L (normal is 140mEq). Na+ level of 160mEq /L (normal is 140mEq). HerHer
present weight is 70kgs.present weight is 70kgs. HER Fluid REQUIREMENTHER Fluid REQUIREMENT 2.7 + 2.4 = 5.1 L of fluid needed in the 2.7 + 2.4 = 5.1 L of fluid needed in the
next 24 hours next 24 hours containing 70mEq of Na+containing 70mEq of Na+ FORMULA USED:FORMULA USED: ½ H20 Deficit + normal daily fluid ½ H20 Deficit + normal daily fluid
requirementrequirement ½ H2O Deficit + ( 35cc X70 kgs.) 2.4 ½ H2O Deficit + ( 35cc X70 kgs.) 2.4
LitersLiters
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIAExampleExample If the same patient has diarrhea as well If the same patient has diarrhea as well
as esophagealas esophageal stricture and has persisted with weakness, confusion; stricture and has persisted with weakness, confusion;
hypotensionhypotension CALCULATIONS WOULD BE AS FOLLOWSCALCULATIONS WOULD BE AS FOLLOWS Present Body WaterPresent Body Water 140 140 =7/8 = 87% of NORMAL =7/8 = 87% of NORMAL 160160 Water Loss 100-87.5 =12.5%Water Loss 100-87.5 =12.5% Patient’s Normal Body Water =70kgs X 60% = 42 Patient’s Normal Body Water =70kgs X 60% = 42
LitersLiters H20 Deficit: 42 L X 12.5% =5.3 LitersH20 Deficit: 42 L X 12.5% =5.3 Liters CLINICAL Findings shows 10% dehydrationCLINICAL Findings shows 10% dehydration CALCULATIONS should be changed CALCULATIONS should be changed
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERNATREMIAHYPERNATREMIA
ExampleExample If the same patient has diarrhea as well as If the same patient has diarrhea as well as esophagealesophageal
stricture and has persisted with weakness, confusion; hypotensionstricture and has persisted with weakness, confusion; hypotension
CLINICAL Findings shows 10% dehydrationCLINICAL Findings shows 10% dehydration
CALCULATIONS should be changed CALCULATIONS should be changed
FLUID LOSS 10% of 70kgs = 7 litersFLUID LOSS 10% of 70kgs = 7 liters
ISOTONIC Fluid loss = 7 – 5.3 =1.7 LitersISOTONIC Fluid loss = 7 – 5.3 =1.7 Liters
Na+ loss in Isotonic Fluid = 1.7 L X 140mEq = 238mEqNa+ loss in Isotonic Fluid = 1.7 L X 140mEq = 238mEq
24 Hour Fluid Requirement= ½ H20 deficit + Normal Body Fluid24 Hour Fluid Requirement= ½ H20 deficit + Normal Body Fluid
= ½ of 7( 7/2) +2.4 = 5.9 L= ½ of 7( 7/2) +2.4 = 5.9 L
24 Hour Na+ Requirement = ½ Na+ deficit + 70 =189mEq24 Hour Na+ Requirement = ½ Na+ deficit + 70 =189mEq
This can be given as: 4 liters of 5% Dextrose in Water plusThis can be given as: 4 liters of 5% Dextrose in Water plus
1200 cc of NORMAL Saline Solution 1200 cc of NORMAL Saline Solution
SIGNS AND SYMPTOMS OF ELECTROLYTE DISORDERS
HYPONATREMIA HYPERNATREMIA1.Headache 1. Lethargy2.Lethargy 2. Irritability3.Confusion 3. Thirst4.Weakness 4. Hyperreflexia5.Seizure 5. Seizures6.Coma 6. Coma7.Death 7. Death
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
ISOTONIC DEHYDRATIONISOTONIC DEHYDRATION The Serum Na+ Concentration is NormalThe Serum Na+ Concentration is Normal “ “EXAMPLE” A short obese alcoholic patient presents EXAMPLE” A short obese alcoholic patient presents
withwith Vomiting due to gastritisVomiting due to gastritis 102 F fever due to pneumonitis102 F fever due to pneumonitis Complaining of thirstComplaining of thirst Has dry mouthHas dry mouth No groin or Axillary SweatNo groin or Axillary Sweat Alert and NormotensiveAlert and Normotensive Weight of 100kgs.Weight of 100kgs. Serum Na+ is 140mEq/LSerum Na+ is 140mEq/L
Serum K+ 3mEq/LSerum K+ 3mEq/L
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
ISOTONIC DEHYDRATIONISOTONIC DEHYDRATION
FLUID and ELECTROLYTE RequirementFLUID and ELECTROLYTE Requirement Fluid Loss = 6% (based on Clinical Findings)Fluid Loss = 6% (based on Clinical Findings) Isotonic Fluid loss 100kgs X 6% = 6 LitersIsotonic Fluid loss 100kgs X 6% = 6 Liters Na+ loss (in isotonic fluid) 140mEq X Na+ loss (in isotonic fluid) 140mEq X
6=840mEq6=840mEq 24 hours Na+ Requirement24 hours Na+ Requirement 840840 + 100mEq = 520mEq + 100mEq = 520mEq 2 2 24 hour Fluid Requirement24 hour Fluid Requirement 6 6 + 4.9 L =7.9 L + 4.9 L =7.9 L 22
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
ISOTONIC DEHYDRATIONISOTONIC DEHYDRATION
FLUID and ELECTROLYTE RequirementFLUID and ELECTROLYTE Requirement EXPLANATIONS:EXPLANATIONS: The daily requirement is 4.9 instead of 3.5 because of the patient’sThe daily requirement is 4.9 instead of 3.5 because of the patient’s fever. Each 1 degree rise in temperature increase by at least fever. Each 1 degree rise in temperature increase by at least
10%10% Fluid and Na+ replacement can be given as:Fluid and Na+ replacement can be given as:
3 Liters of 5% dextrose in Normal Saline3 Liters of 5% dextrose in Normal Saline 2 Liters of 5% dextrose in water2 Liters of 5% dextrose in water 200cc of Normal saline200cc of Normal saline
KCl should be added as indicated at ½ of the DEFICIT plus theKCl should be added as indicated at ½ of the DEFICIT plus the the daily requirement (100mEq) provided urine flow is the daily requirement (100mEq) provided urine flow is
adequate.adequate. KCl should be divided among the solutions KCl should be divided among the solutions
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPOKALEMIAHYPOKALEMIA
CAUSES.CAUSES. Chronic Pyloric Obstruction Chronic Pyloric Obstruction Ulcerative Colitis Ulcerative Colitis Prolonged Vomiting Prolonged Vomiting Fistula Fistula Diarrhea Diarrhea Diuretic Therapy Diuretic Therapy
NephritisNephritis Adrenal Hyperactivity( Stress; Cushing’s Syndrome)Adrenal Hyperactivity( Stress; Cushing’s Syndrome)
PATHOPHYSIOLOGYPATHOPHYSIOLOGY Loss of GASTRIC JUICE --Loss of GASTRIC JUICE -- minimal loss of K+ -- minimal loss of K+ --Loss of Cl.---Loss of Cl.--- insufficient Cl. For renal Tubular reabsorption of Na+ Loss of Na+ insufficient Cl. For renal Tubular reabsorption of Na+ Loss of Na+
ions>>>Adrenal and Renal mechanisms will conserve ions>>>Adrenal and Renal mechanisms will conserve Na+>>>and add inNa+>>>and add in
exchange K+ and H+ are excreted>>>>>>HYPOKALEMIAexchange K+ and H+ are excreted>>>>>>HYPOKALEMIA
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPOKALEMIAHYPOKALEMIA CLINICAL FEATURESCLINICAL FEATURES Less than 3.5mEq/L in serumLess than 3.5mEq/L in serum Associated with:Associated with:
Diuretics Diuretics Metabolic AlkalosisMetabolic Alkalosis Aldosterone Secretion Aldosterone Secretion GIT lossesGIT losses
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPOKALEMIAHYPOKALEMIA CLINICAL FEATURESCLINICAL FEATURES Prolonged Ileus, Hyporeflexia, ParalysisProlonged Ileus, Hyporeflexia, Paralysis Increased sensitivity to digitalisIncreased sensitivity to digitalis Favors ALKALOSIS (because of Acid loss) and alkalosis Favors ALKALOSIS (because of Acid loss) and alkalosis DECREASE K+DECREASE K+ ECG shows Prolonged QT; Depressed ST; T Wave ECG shows Prolonged QT; Depressed ST; T Wave
inversioninversion Early Signs of K+ Depletion:Early Signs of K+ Depletion: Malaise and WeaknessMalaise and Weakness Paralytic Ileus and DistentionParalytic Ileus and Distention Muscular ParesisMuscular Paresis
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPOKALEMIAHYPOKALEMIAMANAGEMENTMANAGEMENT Add KCl to IV Solution but not to exceed Add KCl to IV Solution but not to exceed
20mEq/hour20mEq/hour
Usual Daily Requirement is 40mEq/dayUsual Daily Requirement is 40mEq/day
CONTRAINDICATIONS TO K+ THERAPYCONTRAINDICATIONS TO K+ THERAPY
UNTREATED Adrenal InsufficiencyUNTREATED Adrenal Insufficiency
UNTREATED Renal FailureUNTREATED Renal Failure
TEMPORARY Renal ShutdownTEMPORARY Renal Shutdown
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERKALEMIAHYPERKALEMIA CLINICAL FEATURESCLINICAL FEATURES
Serum K+ 6mEq/L or Serum K+ 6mEq/L or overover
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERKALEMIAHYPERKALEMIA CLINICAL FEATURESCLINICAL FEATURES Seen in: Seen in:
Renal Failure Renal Failure
Massive injury like BurnsMassive injury like Burns Acidosis and Low Flow Acidosis and Low Flow
States States Massive GI HemorrhageMassive GI Hemorrhage Administration of K+Administration of K+
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERKALEMIAHYPERKALEMIA CLINICAL FEATURESCLINICAL FEATURES
Manifested as :Manifested as : 1. Nausea 1. Nausea 2. Vomiting2. Vomiting 3. Diarrhea3. Diarrhea 4. Heart BLOCK 4. Heart BLOCK 5. Loss of Digitalis Effect 5. Loss of Digitalis Effect 6. CARDIAC ARREST6. CARDIAC ARREST
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERKALEMIAHYPERKALEMIA• PATHOPHYSIOLOGYPATHOPHYSIOLOGY
In Renal Failure K+ cannot be Excreted, there In Renal Failure K+ cannot be Excreted, there will will
be >>accumulation in PLASMA.be >>accumulation in PLASMA.
In Renal Failure >>>>The Failure to excrete In Renal Failure >>>>The Failure to excrete H+ will H+ will
shift H+ into Cell to maintain pH>>>>K+ shift H+ into Cell to maintain pH>>>>K+ will will
leave cell>>>PLASMA Hyperkalemia.leave cell>>>PLASMA Hyperkalemia.
ECG will show peaked T Waves ,Wide QRS ECG will show peaked T Waves ,Wide QRS
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERKALEMIAHYPERKALEMIA• MANAGEMENTMANAGEMENT The principle is to shift back K+ into The principle is to shift back K+ into
the cell.the cell. 1. Na2C03 given to combat Acidosis>>K+ ion to back 1. Na2C03 given to combat Acidosis>>K+ ion to back
into into the cell in exchange of H+the cell in exchange of H+
2. IV glucose with insulin>> K+ taken up into the cell w/ 2. IV glucose with insulin>> K+ taken up into the cell w/ each molecule of glucose that enters the cell.each molecule of glucose that enters the cell.
3. Dialysis3. Dialysis 4. Exchange Resin4. Exchange Resin 5. Diminished uptake of K+5. Diminished uptake of K+
SIGNS AND SYMPTOMS OF POTASSIUM DISORDER
HYPOKALEMIA HYPERKALEMIA1.NAUSEA 1. CRAMPING2.VOMITING 2. PARALYSIS3.WEAKNESS 3. NAUSEA4.CONSTIPATION 4. VOMITING5.ILEUS 5. TACHYDYSRHYTHMIAS
6.PARALYSIS 6. CARDIAC ARREST7. RESPIRATORY INSUFFICIENCY8. TACHYDYSRHYTHMIAS
HYPOMAGNESEMIA HYPERMAGNESEMIA
1. Hyperreflexia 1. Nausea
2. Tetany 2. Vomiting
3. Constipation/Ileus 3. Hyporeflexia
4. Vertigo/Ataxia 4. Hypotension
5. Nystagmus 5. Respiratory Paralysis
6. Parasthesias 6. Diplopia
7. Seizures 7. Heart Block
8. Coma 8. Paralysis
9. Death 9. Cardiac Arrest
10.Cardiac Dysrhythmias
HYPOCALCEMIAHYPERCALCEMIA1. Tetany 1. Lethargy2. Seizures 2. Confusion3. Weakness 3. Obtundation4. Cramps 4. Seizures5. Confusion 5. Constipation/Ileus6. Dementia 6. Abdominal Pain7. Heart Block 7.Polyuria8. Cardiac Arrest 8. Polydipsia9. Laryngospasm 9. Cardiac Disrhythmias
HYPOPHOSPHATEMIA HYPERPHOSPHATEMIA
1. Muscle Weakness 1. Metastatic Calcification
2. Respiratory Insufficiency 2. Signs and symptoms of hypocalcemia
3. Decreased Cardiac Contractility 3. Anorexia
4. Paralysis 4. Ileus
5. Parasthesias6. Irritability7. Ataxia8. Tremor9. Seizures
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPOCHLOREMIAHYPOCHLOREMIA CLINICAL FEATURESCLINICAL FEATURES
Sodium Chloride is below 85mEq/LiterSodium Chloride is below 85mEq/Liter
Seen in Upper GI Obstruction w/ vomiting. Seen in Upper GI Obstruction w/ vomiting. OneOne
may loss as much as 120-130mEq/daymay loss as much as 120-130mEq/day
Hypochloremia in itself does not produce Hypochloremia in itself does not produce
striking Clinical Changes. striking Clinical Changes.
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPOCHLOREMIAHYPOCHLOREMIA
• PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Diuretics >> cause increase loss of Chloride Diuretics >> cause increase loss of Chloride thru thru
Kidney>> Urinary Concentration of Kidney>> Urinary Concentration of Chlorides Chlorides
higher than Sodium Concentration.higher than Sodium Concentration.
MANAGEMENTMANAGEMENT
Treat with KCl solutionTreat with KCl solution
May use NH4Cl or 0.1 N HCl (ideal for May use NH4Cl or 0.1 N HCl (ideal for hypochlo-hypochlo-
remia due to metabolic Alkalosis )remia due to metabolic Alkalosis )
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERCHLOREMIAHYPERCHLOREMIA
• CLINICAL FEATURESCLINICAL FEATURES
Chloride above 105mEq/LChloride above 105mEq/L
Seen in Hypernatremia Seen in Hypernatremia
Seen in Uretero Intestinal AnastomosisSeen in Uretero Intestinal Anastomosis
Seen in Obstructive UropathySeen in Obstructive Uropathy
Excessive intake of NH4ClExcessive intake of NH4Cl
DIAGNOSIS OF IMBALANCESDIAGNOSIS OF IMBALANCES
HYPERCHLOREMIAHYPERCHLOREMIA
• PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Uretero Intestinal Uretero Intestinal Anastomosis>>>ReabsorptionAnastomosis>>>Reabsorption
by bowel>>>Accumulation of Cl in excess by bowel>>>Accumulation of Cl in excess of Na+of Na+
ion ( potentiated by Renal Insufficiency)ion ( potentiated by Renal Insufficiency)
Associated w/ Metabolic AcidosisAssociated w/ Metabolic Acidosis
MANAGEMENTMANAGEMENT
Correct Associated Abnormalities Correct Associated Abnormalities
Remove Salt ( Ammonium)Remove Salt ( Ammonium)
Allow Kidneys to CompensateAllow Kidneys to Compensate
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
Normal H+ ion concentration in Extracellular Normal H+ ion concentration in Extracellular fluidfluid
is maintained at pH is maintained at pH 7.36-7.427.36-7.42
Daily Metabolic products are Daily Metabolic products are H+ and CO2H+ and CO2
To keep the pH constant, Acids are neutralized To keep the pH constant, Acids are neutralized
by by two mechanisms:two mechanisms:
Buffer System of Body FluidsBuffer System of Body Fluids
Regulatory functions of the Regulatory functions of the LUNGSLUNGS & & KIDNEYKIDNEY
Most important Buffer System is the Most important Buffer System is the
Bicarbonate Carbonic Acid SystemBicarbonate Carbonic Acid System
H2CO3 HCO3 + H+H2CO3 HCO3 + H+
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
pH is determined by ratio of base bicarbonatepH is determined by ratio of base bicarbonate to carbonic Acid:to carbonic Acid: HCO3HCO3 pH = Pk LOG H2CO3pH = Pk LOG H2CO3 ( HENDERSON HASSELBACH’S EQUATION)( HENDERSON HASSELBACH’S EQUATION) Carbonic Acid (H2CO3) is a function of the Carbonic Acid (H2CO3) is a function of the
dissolveddissolved
CO2.CO2. This is This is determined by thedetermined by the pCO2 of Blood pCO2 of Blood &&
is is regulated rapidly and accuratelyregulated rapidly and accurately by the by the LUNGSLUNGSBicarbonate(HCO3)Bicarbonate(HCO3) of blood is of blood is controlled bycontrolled by the the
rate of its renal secretionrate of its renal secretion. .
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
At pH 7.4 ratio of Carbonate to Carbonic Acid At pH 7.4 ratio of Carbonate to Carbonic Acid isis
20:120:1
In METABOLIC ACID BASE Shifts, effects on In METABOLIC ACID BASE Shifts, effects on
buffer system is onbuffer system is on LEVEL of LEVEL of BICARBONATE BICARBONATE
INCREASED:INCREASED:
Increased BicarbonateIncreased Bicarbonate = ALKALOSIS= ALKALOSIS
Decreased “Decreased “ = ACIDOSIS= ACIDOSIS
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
In In METABOLIC ACID BASE shiftsMETABOLIC ACID BASE shifts = = LUNGS LUNGS compensates:compensates: Metabolic Acidosis>> Metabolic Acidosis>> Increased VentilationIncreased Ventilation>>>> more CO2 released less H2CO3more CO2 released less H2CO3 Metabolic Alkalosis>> Metabolic Alkalosis>> Decreased VentilationDecreased Ventilation>> more CO2 retained >> Increased H2CO3more CO2 retained >> Increased H2CO3 IN RESPIRATORY ACID BASE shifts the IN RESPIRATORY ACID BASE shifts the effect on the buffer system is aeffect on the buffer system is a GAIN or LOSSGAIN or LOSS of CARBONIC ACIDof CARBONIC ACID Compensatory Mechanism is via theCompensatory Mechanism is via the KIDNEYS by KIDNEYS by retaining or Excreting BICARBONATESretaining or Excreting BICARBONATES
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
Respiratory Acidosis = Respiratory Acidosis = Increased H2CO3Increased H2CO3
Compensated by Compensated by RENAL RETENTION OF RENAL RETENTION OF
BICARBONATEBICARBONATE
Respiratory Alkalosis = Respiratory Alkalosis = Decreased H2CO3Decreased H2CO3 is is
Compensated by Compensated by RENAL EXCRETION ofRENAL EXCRETION of
BICARBONATEBICARBONATE
Serum HCO3Serum HCO3 20 20 pH = pH = KidneyKidney
Serum H2CO3 1 LungsSerum H2CO3 1 Lungs
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
To Follow Acid Base Changes KNOW:To Follow Acid Base Changes KNOW:
Signs and SymptomsSigns and Symptoms PathophysiologyPathophysiology Plasma pHPlasma pH Arterial pCO2Arterial pCO2 Total Extractable CO2 measured Total Extractable CO2 measured as venous CO2 content as venous CO2 content correctedcorrected to pCO2 to pCO2 of 40mm Hgof 40mm Hg
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
Clinical AspectsClinical Aspects
Excess H+ in plasma>>Fall in pH Excess H+ in plasma>>Fall in pH >>Diminished>>>>Diminished>>
Plasma Bicarbonates seen in:Plasma Bicarbonates seen in:
Loss of fluid rich in Na2CO3Loss of fluid rich in Na2CO3
Adrenal Insufficiency>> Renal loss of Adrenal Insufficiency>> Renal loss of Na2C03Na2C03
Low flow state >>>Lactic AcidLow flow state >>>Lactic Acid
Diabetes MellitusDiabetes Mellitus
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
PathophysiologyPathophysiology
Increased rate & depth of breathing> Increased rate & depth of breathing> DecreaseDecrease
plasma pC02>>>Decrease H2CO3 with plasma pC02>>>Decrease H2CO3 with returnreturn
of pH to normalof pH to normal
Laboratory FindingsLaboratory Findings
pH below 7.38 pH below 7.38 HCO3 less than HCO3 less than 24mEq/minute24mEq/minute
Arterial pCO2 40mmHgArterial pCO2 40mmHg
Acidic Urine w/ low Na+ contentAcidic Urine w/ low Na+ content
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
ManagementManagement
Treat CauseTreat Cause
Adjustment to respirator (if patient is attachedAdjustment to respirator (if patient is attached
to one). Increased RATE decrease arterialto one). Increased RATE decrease arterial
pCO2.pCO2.
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Clinical AspectsClinical Aspects
HCl loss due to vomiting, gastric drainageHCl loss due to vomiting, gastric drainage
Loss of K+ and Cl- in urineLoss of K+ and Cl- in urine
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Clinical AspectsClinical Aspects cont’d cont’d
Diuretics Diuretics
Adrenal SteroidsAdrenal Steroids
Administration of Na2CO3 or Sodium Administration of Na2CO3 or Sodium CitrateCitrate
(in blood transfusion)(in blood transfusion)
PathophysiologyPathophysiology
Due to uncompensated loss of Acids Due to uncompensated loss of Acids or or
retention of Basesretention of Bases
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
PathophysiologyPathophysiology
In Metabolic Alkalosis Increase In Metabolic Alkalosis Increase urinary K+ loss>>H+ and Na+ urinary K+ loss>>H+ and Na+ ion enter the cell>> Decrease of ion enter the cell>> Decrease of Extracellular H+ ion Extracellular H+ ion concentration>> further concentration>> further >>increase in Alkalosis.>>increase in Alkalosis.
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
PathophysiologyPathophysiology
LUNG Compensation:LUNG Compensation:
Hypoventilation>>>Hypoventilation>>>
CO2 accumulation>> CO2 accumulation>>
Increased Carbonic Acid.Increased Carbonic Acid.
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
PathophysiologyPathophysiology
RENAL Compensation:RENAL Compensation: Increased Increased Excretion ofExcretion of
BicarbonatBicarbonate e
in in ALKALINE UrineALKALINE Urine
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Condition is usually seen in:Condition is usually seen in:
Multiple Transfusion Multiple Transfusion
Hyperventilation Hyperventilation
Volume ReductionVolume Reduction
Increased Aldosterone SecretionIncreased Aldosterone Secretion
Administration of Large volume of Administration of Large volume of Ringer’sRinger’s
LactateLactate
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Laboratory Findings:Laboratory Findings:
1. Blood pH Higher than 7.441. Blood pH Higher than 7.44
2. HCO3= Higher than 28mEq/L 2. HCO3= Higher than 28mEq/L
3. Arterial PCO2= 40 in the presence 3. Arterial PCO2= 40 in the presence of of
Respiratory CompensationRespiratory Compensation
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
ManagementManagement
Replace lost Na+, Cl, and K+ ionsReplace lost Na+, Cl, and K+ ions
Lower pH by using of 0.1 N HClLower pH by using of 0.1 N HCl
In moderately severe Alkalosis where there In moderately severe Alkalosis where there isis
Increased Renal K+ excretion, permit the Increased Renal K+ excretion, permit the
tubule to retain H+ (treat) w/ IV KCltubule to retain H+ (treat) w/ IV KCl
Severe METABOLIC ALKALOSIS is the onlySevere METABOLIC ALKALOSIS is the only
good indication for the administration of good indication for the administration of
NH4CLNH4CL
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Severe METABOLIC Severe METABOLIC ALKALOSIS ALKALOSIS
is the only good indication is the only good indication forfor
the administration of the administration of NH4CLNH4CL
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
Clinical AspectsClinical Aspects
It is caused by Pulmonary InsufficiencyIt is caused by Pulmonary Insufficiency
1. Failure to excrete CO2 via the Lungs 1. Failure to excrete CO2 via the Lungs withwith
normal efficiency as in:normal efficiency as in:
a. Pneumonia a. Pneumonia
b. Emphysemab. Emphysema
c. Fibrosisc. Fibrosis
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS Clinical AspectsClinical Aspects It is It is caused bycaused by Pulmonary Insufficiency Pulmonary Insufficiency 2. Hypoventilation caused by2. Hypoventilation caused by a. Pulmonary Edemaa. Pulmonary Edema b. Injury b. Injury c. Post op. Atelectasis c. Post op. Atelectasis d. Drugsd. Drugs e. Poor Ventilation( Respirator)e. Poor Ventilation( Respirator)
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
Clinical AspectsClinical Aspects
Manifested by:Manifested by:
1. Somnolence 1. Somnolence
2. Confusion 2. Confusion
3. Coma due to CO2 Narcosis3. Coma due to CO2 Narcosis
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
PathophysiologyPathophysiology
Compensatory Mechanism:Compensatory Mechanism:
1. Increase Tubular 1. Increase Tubular reabsorption of reabsorption of
Na+ and bicarbonate by Na+ and bicarbonate by KidneysKidneys
2. Increase excretion of H+ 2. Increase excretion of H+ ionsions
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
Laboratory FindingsLaboratory Findings 1. Blood pH below 7.381. Blood pH below 7.38
2. Arterial pCO2 over 50mm Hg2. Arterial pCO2 over 50mm Hg
3. Acute Respiratory Acidosis= Plasma 3. Acute Respiratory Acidosis= Plasma H2CO3 H2CO3
not increased not increased
4. In Chronic state it’s elevated to 4. In Chronic state it’s elevated to 20mEq/L20mEq/L
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
ManagementManagement
Control ventilationControl ventilation to increase inspired to increase inspired
02>>> Return of Arterial Blood Gas to 02>>> Return of Arterial Blood Gas to
NormalNormal
Careful and slow correctionCareful and slow correction of pH and of pH and
pCO2 so as not to produce rapid pCO2 so as not to produce rapid changes changes
with associated Cardiac instabilitywith associated Cardiac instability
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS Clinical FeaturesClinical Features Due to Hyperventilation seen in:Due to Hyperventilation seen in: 1. Pulmonary Infection1. Pulmonary Infection 2. Hysteria2. Hysteria 3. CNS Injury3. CNS Injury 4. Occasionally during Anesthesia4. Occasionally during Anesthesia 5. Fever5. Fever 6. Pain 6. Pain 7. Apprehension7. Apprehension 8. Salicylate Poisoning8. Salicylate Poisoning
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSISPathophysiologyPathophysiology
Hyperventilation leads to Decrease in Hyperventilation leads to Decrease in AlveolarAlveolar
CO2 concentration>>> Decrease in CO2 concentration>>> Decrease in serum serum
H2CO3H2CO3 Compensatory Mechanism: Compensatory Mechanism: RENAL RENAL
increase increase tubular excretion of Na2CO3tubular excretion of Na2CO3
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
Laboratory FindingsLaboratory Findings::
1. Blood pH more than 7.461. Blood pH more than 7.46
2. Arterial pCO2 is lower than 36mm Hg.2. Arterial pCO2 is lower than 36mm Hg.
3. With renal compensation Bicarbonate 3. With renal compensation Bicarbonate
level will falllevel will fall
4. Urinary Na+ concentration is high4. Urinary Na+ concentration is high
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
ManagementManagement
Directed at its initiating CausesDirected at its initiating Causes
Note:Note:
Mild respiratory alkalosis is common Mild respiratory alkalosis is common postoperativepostoperative
problemproblem
Associated muscle irritability or frank tetanyAssociated muscle irritability or frank tetany
especially if serum calcium++ level is lowespecially if serum calcium++ level is low
Corrected by administration of calcium salts Corrected by administration of calcium salts
Calcium Chloride, Calcium GluconateCalcium Chloride, Calcium Gluconate
PRINCIPLES OF ACID BASE BALANCEPRINCIPLES OF ACID BASE BALANCE
FORMULA FOR Acid Base ImbalanceFORMULA FOR Acid Base Imbalance Serum HCO3Serum HCO3 = = 20 20
Serum H2CO3 1Serum H2CO3 1
in the numerator 20/1 to 10/1 >Met. in the numerator 20/1 to 10/1 >Met. ACIDOSISACIDOSIS
in the numerator 20/1 to 30/1 >Met. in the numerator 20/1 to 30/1 >Met. ALKALOSISALKALOSIS
in the denominator 20/1 to 20/2>>Resp in the denominator 20/1 to 20/2>>Resp AcidosisAcidosis
in the denominator 20/1 to 20/.5 > R. in the denominator 20/1 to 20/.5 > R. AlkalosisAlkalosis
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
PRIORITIESPRIORITIES 1. Correct SHOCK and restore Blood 1. Correct SHOCK and restore Blood
Volume>>NormalVolume>>Normal
2. Restore Colloid Osmotic Pressure2. Restore Colloid Osmotic Pressure
3. Correct Acid Base Imbalance3. Correct Acid Base Imbalance
4. Restore Blood Osmolality4. Restore Blood Osmolality
5. Correct K+ deficit5. Correct K+ deficit
6. Correct Total Body Electrolytes disturbance6. Correct Total Body Electrolytes disturbance
(static debt) and establish daily maintenance(static debt) and establish daily maintenance
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
DEFICIT CORRECTIONDEFICIT CORRECTION Fluid and Electrolyte TherapyFluid and Electrolyte Therapy to Correct to Correct
existingexisting Deficit. Deficit. ExamplesExamples::
Blood volume deficit in Acute or Chronic Blood Blood volume deficit in Acute or Chronic Blood loss.loss.
Extracellular or Intracellular deficit in dehydrationExtracellular or Intracellular deficit in dehydration
Deficit correctionDeficit correction is added to is added to maintenance maintenance and and
replacement therapyreplacement therapy in order to restore in order to restore H20, H20,
salt balancesalt balance Deficit correctionDeficit correction is also is also Top priority inTop priority in Fluid Fluid and Electrolyte therapyand Electrolyte therapy
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY
Necessary to Replace Abnormal Necessary to Replace Abnormal (continuing) losses from or within (continuing) losses from or within the body. Example via drainage the body. Example via drainage tubes.tubes.
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY
Gastrointestinal LossesGastrointestinal Losses
If these are purely gastric( succus If these are purely gastric( succus gastricus); gastricus);
A solution providing 0.45% NaCl mEq plus A solution providing 0.45% NaCl mEq plus 4040
mEq of KCl per liter is used for mEq of KCl per liter is used for replacement.replacement.
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY
Gastrointestinal LossesGastrointestinal Losses
If the fluid lost contains intestinal If the fluid lost contains intestinal (succus entericus) (succus entericus) Lactated Ringer’sLactated Ringer’s
solution plus solution plus 10 mEq KCl10 mEq KCl per liter is per liter is
usedused..
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY
Third Space LossThird Space Loss 1. The amount of loss varies with 1. The amount of loss varies with
the the magnitude of injury.magnitude of injury. 2. Lactated Ringer’s solution plus 2. Lactated Ringer’s solution plus Albumin is used.Albumin is used.
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY Continuing losses require Continuing losses require
volume for volume for volume replacement and volume replacement and addedadded
to to maintenancemaintenance requirements. requirements.
Replacement Therapy has Replacement Therapy has second second
priority priority in Fluids & Electrolytein Fluids & Electrolyte TherapyTherapy
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
MAINTENANCE THERAPYMAINTENANCE THERAPY Clinical Example: Clinical Example: Average size 60kgs woman Average size 60kgs woman
hashas an Elective Cholecystectomy. No drainage an Elective Cholecystectomy. No drainage
tubes.tubes. Patient’s Normal Daily RequirementsPatient’s Normal Daily Requirements
H2O : 35ml/kgs X 60 >>> 2100 ccH2O : 35ml/kgs X 60 >>> 2100 cc Na+ : 1mEq/kgs X 60 >>> 60mEqNa+ : 1mEq/kgs X 60 >>> 60mEq K+ : 1mEq/kgs X 60 >>> 60mEqK+ : 1mEq/kgs X 60 >>> 60mEq Cl- : 1.5mEq/mEq X 60 >>> Cl- : 1.5mEq/mEq X 60 >>>
90mEq90mEq HCO3-: 0.5mEq/mEq X 60 >>> HCO3-: 0.5mEq/mEq X 60 >>>
30mEq 30mEq
PRINCIPLES OF MANAGING FLUID, ELECTROLYTEPRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
MAINTENANCE THERAPYMAINTENANCE THERAPY
Methods to calculate H20 maintenance Methods to calculate H20 maintenance requirementrequirement
1. Utilization of body water as a guide for H201. Utilization of body water as a guide for H20 Ex. 70 kg. x Ex. 70 kg. x 0.5 x 240.5 x 24 hrs + hrs + 500ml/24 hrs500ml/24 hrs = =
1340ml/24hrs1340ml/24hrs
2. It can be based on 2. It can be based on patient’s weightpatient’s weight (Pediatric (Pediatric Patients)Patients)
100 ml/kg for the first 10 kg of body weight100 ml/kg for the first 10 kg of body weight 50 ml/kg for the next 10 kg of body weight50 ml/kg for the next 10 kg of body weight 20 ml/kg for each additional kg of body 20 ml/kg for each additional kg of body
weightweight
PRINCIPLES OF MANAGING FLUID, ELECTROLYTEPRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
MAINTENANCE THERAPYMAINTENANCE THERAPY
Methods to calculate H20 maintenance Methods to calculate H20 maintenance requirement requirement
3. A given amount of water /kg body wt. can be 3. A given amount of water /kg body wt. can be
used.used. (35 ml/kg/24 hours)(35 ml/kg/24 hours)
4. A given amount of fluid regardless of wt. 4. A given amount of fluid regardless of wt. (125ml/hr)(125ml/hr)
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
MAINTENANCE THERAPYMAINTENANCE THERAPY
IV Fluids would be as follows:IV Fluids would be as follows:
1. 1000 ml of 5% Dextrose in H2O + 1. 1000 ml of 5% Dextrose in H2O + 40mEq Kcl40mEq Kcl
2. 650 ml of 5% Dextrose in H20 + 20mEq 2. 650 ml of 5% Dextrose in H20 + 20mEq KClKCl
3. 450 ml of 5% Dextrose in Lactated 3. 450 ml of 5% Dextrose in Lactated Ringer’sRinger’s
solutionsolution
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
MAINTENANCE THERAPYMAINTENANCE THERAPY
This would provide:This would provide:
2100 ml of Water2100 ml of Water
58.5mEq of Na+( 4.5 X 1.3mEq/dl LR58.5mEq of Na+( 4.5 X 1.3mEq/dl LR
61.8mEq of K+ (60mEq from 61.8mEq of K+ (60mEq from KCl+1.8mEq KCl+1.8mEq
109mEq of Cl( 60mEq from KCl + 109mEq of Cl( 60mEq from KCl + 49mEq49mEq
12.6mEq of HCO3( 4.5 X 2.8mEq/dl LR 12.6mEq of HCO3( 4.5 X 2.8mEq/dl LR
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY
The same patient develops ileus. NGT was The same patient develops ileus. NGT was placed.placed.
Over 24 hours 1600 ml NGT bile stained fluidOver 24 hours 1600 ml NGT bile stained fluid was collected. Normal serum electrolytes.was collected. Normal serum electrolytes.
For For replacementreplacement she would she would require:require:
1600 ml 1600 ml D5LR solutionD5LR solution +10mEq +10mEq of KClof KCl
PRINCIPLES OF MANAGING FLUID, ELECTROLYTE PRINCIPLES OF MANAGING FLUID, ELECTROLYTE AND ACID BASE IMBALANCEAND ACID BASE IMBALANCE
REPLACEMENT THERAPYREPLACEMENT THERAPY Her Her maintenance requirementmaintenance requirement would be the would be the
same same 1000 ml of 5% Dextrose in H2O + 30mEq 1000 ml of 5% Dextrose in H2O + 30mEq
KclKcl 1000 ml of 5% Dextrose in H20 + 30mEq 1000 ml of 5% Dextrose in H20 + 30mEq
KClKCl 2 liters of 5% Dextrose in Lactated Ringer’s2 liters of 5% Dextrose in Lactated Ringer’s solution + 10mEq KCl to each liter.solution + 10mEq KCl to each liter. Run at 170ml/hr( Run at 170ml/hr( 400400 maintenancemaintenance 600600
Replacement)Replacement)
OTHER COMMONLY USED FLUIDSOTHER COMMONLY USED FLUIDS
SOLUTIONSSOLUTIONS NA+ CONTENT NA+ CONTENT Cl CONTENTCl CONTENT USESUSES
3% NaCl INJ.3% NaCl INJ. 5151 5151 For symptomatic Na For symptomatic Na deficitdeficit
5% NACl INJ5% NACl INJ 8585 8585 SAME AS ABOVESAME AS ABOVE
14.9% KCl INJ14.9% KCl INJ
20 cc ampule20 cc ampule4040 4040 Additive for K+Additive for K+
Correction & Correction & maintenancemaintenance
7.5% NA2CO37.5% NA2CO3 44.644.6 44.644.6
HCO3HCO3
Additive for GIAdditive for GI
Losses; CorrectLosses; Correct
Metabolic AcidosisMetabolic Acidosis
COMMONLY USED PARENTERAL SOLUTIONSCOMMONLY USED PARENTERAL SOLUTIONS
SOLNS.SOLNS. Na+Na+ K+K+ Cl-Cl- HCO3-HCO3- Ca++Ca++ Principal UsesPrincipal Uses
0.9 NaCl0.9 NaCl 154154 154154 Correction of HyponatremiaCorrection of Hyponatremia
ECF ReplacementECF Replacement
0.45NaCl0.45NaCl 7777 7777 Na+ Maintenance; Gastric Fluid Na+ Maintenance; Gastric Fluid ReplacementReplacement
LactatedLactated
Ringer’s Ringer’s
SolutionSolution
130130 44 109109 2828 99 Best ECF Replacement; Correction of Best ECF Replacement; Correction of IsoosmolarIsoosmolar
DeficitDeficit
5% Dextrose5% Dextrose
In WaterIn WaterCorrection of insensible water loss; Correction of insensible water loss; Maintenance andMaintenance and
Correction of Hyperosmolar Correction of Hyperosmolar
DehydrationDehydration
ECG CHANGES IN ELECTROLYTES IN BALANCE
HYPERKALEMIAPeaked T waves (early change)
Flattened P wave
Prolonged PR interval (first degree block)
Widened QRS complex
Sine wave formation
Ventricular fibrillation
HYPOKALEMIA
U Waves
T Wave Flattening
ST – segment changes
Arrhythmias
HYPERKALEMIA
Shortened QT interval
Prolonged PR and QRS intervals
Increased QRS voltage
T-wave flattening and widening
AV block (can progress to complete heart block)
HYPOCALCEMIA
Prolonged QT interval
T-wave inversion
Heart blocks
Ventricular fibrillations
HYPERMAGNESEMIA
Increased PR interval
Widened QRS complex
Elevated T-waves
HYPOMAGNESEMIA
Prolonged QT and PR interval
ST segment depression
Flattening or inversion of P waves
Arrythmias
MECHANISM THERAPHY DOSE ONSET OF ACTION
DURATION OF ACTION
Membrane stabilization
Calcium gluconate 1-2 grams IV over 5-10 min.
1-2 min. 30 min.
Intracellular potassium shift
Sodium bicarbonate 50-100 meq IV over 2-5 min.
30 min. 2-6 hours
Insulin and glucose 5-10 units RHI IV with 50ml of 50% dextrose (25g)
15-45 min. 2-6 hours
ᵦ₂ agonists Albuterol
Depends upon drug 10-20 mg nebulized
20-30 min. 1-2 hours
Potassium removal Furosemide 20-40 mg IV. 5-15 min. 4-6 hours
Sodium polystyrene sulfonate
15-60 g PO or PR 4-6 hours 4-6 hours
Hemodialysis 2-4 hours Immediate Duration of dialysis
COMPOSITION OF INTRAVENOUS FLUIDS(mEq/L)
FLUID SODIUM
POTASSIUM
CHLORIDE
CALCIUM MAGNESSIUM
BICARBONATE
OSMOLALITY
Plasma 141 4-5 103 5 2 27 289LR 130 4 109 3 0 28 2733% Saline
513 0 513 0 0 0 1026
0.9% Saline
154 0 154 0 0 0 308
0.45% Saline
77 0 77 0 0 0 154
0.2% Saline
34 0 34 0 0 0 68
D5W 0 0 0 0 0 0 253
DISORDER PRIMARY DISTURBANCE
COMPENSATORY RESPONSE
COMPENSATION FORMULA*
Metabolic acidosis
↓HCO-₃ ↓PaCO₂ ∆ PaCO₂ = 1.2 X ∆ HCO-₃
Metabolic alkalosis
↑HCO-₃ ↑PaCO₂ ∆ PaCO₂ = 0.6 X ∆ HCO-₃
Acute respiratory acidosis
↑PaCO₂ ↑HCO-₃ ∆ HCO-₃ = 0.1 X ∆ PaCO₂
Chronic respiratory acidosis
↑PaCO₂ ↑↑HCO-₃ ∆ HCO-₃ = 0.35 X ∆ PaCO₂
Acute respiratory alkalosis
↓PaCO₂ ↓HCO-₃ ∆ HCO-₃ = 0.2 X ∆ PaCO₂
Chronic respiratory alkalosis
↓PaCO₂ ↓↓HCO-₃ ∆ HCO-₃ = 0.5 X ∆ PaCO₂
CAUSE MECHANISM TREATMENT
METEBOLIC ACIDOSIS: ANION GAP
Renal failure Accumulation of fixed acids ( proteins, sulfates, phosphates), impaired bicarbonate reabsorption /regeneration
Low-protein diet, administration of sodium bicarbonate, dialysis
Lactic acidosis Accumulation of lactic acid caused by anaerobic glycolysis
Restoration of cellular oxygen delivery
Diabetic ketoacidosis, fasting, chronic alcoholism
Increased glucagon-to-insulin ratio leads to enhanced lipolysis and metabolism through ketoacids, dehydration
Administration of insulin (for diabetic ketoacidosis): provision of carbohydrate; rehydration
Toxic ingestions: salicylates, methanol, ethylene glycol, paraldehyde, toluene
Addition of fixed acids Emhancement of excretion ( hydration, dialysis); urine alkalinization for salicylate poisoning; ethanol was used in the past for the ethylene glycol and methanol poisoning to block the conversion by alcohol dehydrogenase into toxic metabolites, but now fomepizole is used
CAUSE MECHANISM TREATMENT
METABOLIC ACIDOSIS:NONANION GAP
Diarrhea, ileus, fistula, and ureterosigmoidostomy
Gastrointestinal HCO-₃ loss
Replacement of volume and electrolytes
Proximal renal tubular acidosis, acetazolamide
Renal HCO-₃ loss Discontinuation of acetazolamide
Saline administration (large volumes administered quickly)
Renal HCO-₃ loss Avoidance
Distal renal tubular acidosis
Failure renal HCO-₃ loss production
Alkali administration
METABOLIC ALKALOSISChloride Responsive
CAUSE MECHANISM TREATMENT
Vomiting nasogastric suction
Loss of HCI, to relative excess of HCO-₃ increased renal absorption of CI- because of depletion
Provision of CI’ ( as NaCl or KCl); restoration of intravascular volume
Diuretic Therapy CI- loss in urine, volume depletion, increased renal HCO-₃, generation, hypokalemia
Provision of CI’ as NaCl or KCl; restoration of intravascular volume
Posthypercapnia Renal excretion of acid and generation of HCO-₃ during respiratory
Provision of CI’
METABOLIC ALKALOSISChloride ResistantCAUSE MECHANISM TREATMENT
Mineralocorticoid excess(Cushing’s syndrome, hyperaldosteronism
Direct stimulation of Na -H and Na -K ⁺ ⁺ ⁺ ⁺exchange in distal tubule; increased renal generation and reabsortion of HCO-₃
Correction of underlying disorder; spironolactone; K ⁺replacement
Bartter’s syndrome (renal tubular salt wasting)
Increased distal tubular Na delivery ⁺increases distal tubular Na reabsorption and ⁺exchange with K and ⁺H⁺
K replacement ⁺nonsteroidal antiinflammatory agents volume expansion
Excessive alkali administration
Usually associated with renal insufficiency; citrate (from red cell transfusions); hyperalimentation solutions; milk-alkali syndrome
Cessation of alkali administration
Severe potassium depletion
Impaired renal Cl’ reabsortion leading to increased Na -H ⁺ ⁺exchange and generation of HCO-₃
K repletion⁺
RESPIRATORY ACIDOSIS
CAUSE MECHANISM TREATMENT
Sedatives, hypnotics, narcotics, central, nervous system lesions
Suppression of respiratory drive
Discontinuation or reversal of pharmacologic suppression of respiration; mechanical ventilation
Restrictive lung disease
Increased work of breathing
Treatment of underlying disease; mechanical ventilation as needed
Pulmonary fibrosis
Pleural
Ankylosing spondylitis
Severe kyphosis
Obstructive lung disease
Increased work of breathing
Treatment of underlying disease; mechanical ventilation as needed
Upper airway obstruction
Asthma
Myopathies/neurophaties
Relative increase in work of breathing
Mechanical ventilation if severe
Paralysis
Guillain-Barre’ syndrome
Fever, seizures Increased CO₂ production in the presence of a fixed minute ventilation
Control of fever; mechanical ventilation rarely required in cases of excess CO₂ production
Large pulmonary embolus
Increased alveolar dead space in the presence of a fixed minute ventilation
Thrombolytic therapy; mechanical ventilation to further increase minute ventilation
RESPIRATORY ALKALOSIS
CAUSE MECHANISM THERAPY
Pain, fever, gram-negative sepsis, cirrhosis, central nervous system lesions, pregnancy (progesterone effect), salicylates theophylline
Increased respiratory drive
Treatment of underlying cause; discontinuation/ increased elimination of pharmacologic stimulation
Hypoxia, hypotension
Peripheral chemoreceptorstimulation
Correction of hypoxia, hypotension
Pneumonia, pulmonary edema, pulmonary embolus
Pulmonary receptor stimulation
Treatment of underlying cause