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Fluid and ElectrolyteSurvey
Dr. Thomas VanderLaanDr. Melanie Walker
Huntington Memorial HospitalPasadena, California
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Anatomy of Body FluidCompartments
Total body water 50 to 70% of total body weight
Varies with age, sex and fat content
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Functional Compartments ofBody Fluids
Plasma
Interstitial
Fluid
Intracellular
volume
70 kg male
3,500 cc
10,500 cc
28,000 cc
42,000 cc
% Body weight
Total extracellular
volume 20%
plasma 5%
interstitial 15%
Total intracellular
volume 40%
Total body water 60%
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Chemical Composition of BodyFluid Compartments
154 mEq/L 154 mEq/L 153 mEq/L 153 mEq/L
200 mEq/L 200 mEq/L
Na+142
K+
4
Ca++
5
Mg++
3
Cl-
103
HCO3-27
SO4-
PO4-
3
Organic acids
5
Protein16
Na+
144
K+
4
Ca++
3
Mg++
2
Cl-
114
HCO3-30
SO4-
PO4-
3
Organic acids
5
Protein
1
cations anions cations anions
cations anions
K+
150
Mg++
40
Na+10
HPO4---
SO4
150
HCO3-
10
Protein40
PLASMA INTERSTITIAL FLUID INTRACELLULAR FLUID
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Volume Deficit
** Most common volume disorder insurgical patients
Measurable CausesMeasurable Causes NonNon--measurable Causesmeasurable CausesBlood loss Third spacing / fluid
sequestration
Gastrointestinal loss Traumatized tissues
Inflammatory processes
Intestinal obstruction
Burns
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AnuriaOliguriaRenal
Marked temp.
decrease
Temperature
decrease, mild
Metabolism
Atonic muscles
Sunken eyes
Soft small tongue
Decreased turgor
Tissue signs
Hypotension
Distant heart soundsCold extremities
Absent pulses
Tachycardia
Collapsed veinsCollapsing pulse
Orthostatic
hypotension
Cardiovascular
Nausea
Vomiting
Silent ileus
Decrease in food
consumption
Gastrointestinal
Decreased tendon
reflexes
Stupor
Coma
Sleepiness
Apathy
Slow response
Anorexia
Central nervous
system
SEVEREMODERATESYMPTOMS
VOLUME DEFICIT
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Oliguria: Definitions
Prerenal and how to tellRenal and how to tell
Oliguria vs. Anuria
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Oliguria: Things to Monitor
Urine osmolalityUrine sodium
BUN / serum creatinineUrine and plasma urea
Urine and plasma creatinine
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Oliguria: Things to Monitor
Urine osmolalityUrine sodium
BUN / serum creatinineUrine and plasma urea
Urine and plasma creatinine
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Fractional excretion of sodium
Can tell you if the kidney is functioningproperly
FENa = Urine / Plasma NaX 100
Urine / Plasma Creatinine
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Treatment of Volume Deficits
1. Estimate the deficit
Maintenance:1st 10 kg body weight 100 cc / kg /day
2nd
10 kg body weight 50 cc / kg /day
> 20 kg body weight 20 cc / kg / day
Measurable losses
Blood loss, GI loss
Insensible losses
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Treatment of Volume Deficits
2. Replace Volume IntravenouslyCrystalloid
Colloid
Blood
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Treatment of Volume Deficits
3. Assess resultsVital signs
Urine Output
Central venous pressure
Swan-Ganz measurements
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Electrolyte Content of Fluids
1680.9% Ammonium Cl
8558555% NaCl
5135133% NaCl
1,0001,0
00M Sodium lactate
167*167M/6 Sodium lactate
1541540.9% NaCl
28*1092.74130Lactated Ringers
3271030.3354142Extracellular fluid
HPO4HPO4--HCO3HCO3--ClCl--NH4+NH4+Mg++Mg++Ca++Ca++K+K+NaNa
++
ANIONSCATIONSSOLUTION
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Using different fluids
Advantages and Disadvantages of: Lactated Ringers
NS
Hypertonic Solution Hypotonic solution
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Volume excess
Most common in the elderly and patientswith heart disease
Often iatrogenic from over-resuscitation
Acute renal failure can be a cause
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Symptoms of Volume Excess
Nervous System Rarely symptoms
Gastrointestinal At operation, edema
of stomach, colon,
omentum and small
bowel mesentery
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Cardiovascular Symptoms ofVolume Excess
Moderate venous pressure
Distension of veins
cardiac output
Murmurs
pulse pressure
Severe Pulmonary edema
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Tissue Symptoms of VolumeExcess
Moderate Pitting edema
Basilar rales
Severe Anasarca
Vomiting
Diarrhea
Rales
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Symptoms of Volume Excess
Metabolic None
Renal Moderate: None
Severe: None
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Treatment of Volume Excess
Decrease fluid intakeDiuretics
Inotropic agents
Vasodilators
Hemodialysis
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Concentration Abnormalities
Serum Sodium and OsmolalityCell membrane permeability
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Sodium
Plays a major role in water balance andmuscle contraction
Draws water through permeable
membranes in the body therebydistributing fluid throughout the body
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Hyponatremia
Causes Almost always due to free water
Often iatrogenic (fluid replacement)
Oliguria Endogenous water release (cell
catabolism)
Intracellular shifts (sepsis) SIADH
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Central Nervous System Signsof Hyponatremia
Moderate Muscle twitching
tendon reflexes
intracranial pressure
Severe Convulsions
Loss of reflexes
intracranial pressure
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Signs and Symptoms ofHyponatremia
Cardiovascular Changes in blood pressure and pulse
related to ICP
Tissues Increased salivation
Diarrhea
Renal Oliguria progressing to anuria
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Treatment of Hyponatremia
Calculate sodium deficit Total body weight X (140 mEq Serum
Na)
Replace slowly < 12 mEq / L / 24 hours
Dangers of central pontine myelinosis
Isotonic vs. Hypertonic solutions
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Causes of Hypernatremia
Excessive extrarenal water loss Fever
Tracheostomy
Burns
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Causes of Hypernatremia
Renal water loss High output renal failure
Diabetes insipidus
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Causes of Hypernatremia
Solute loading protein intake
Osmotic diuretics
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CNS Signs of Hypernatremia
Moderate Restlessness
weakness
Severe Delirium
Maniacal behavior
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Signs of Hypernatremia
Cardiovascular Tachycardia
Hypotension
Renal Oliguria
Fever
Tissue Decreased saliva
and tears
Dry mucous
membranes Swollen tongue
Flushed skin
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Treatment of Hypernatremia
Calculate free water deficit0.6 X Total body weight -- 140 X (0.6 X TBW)
Na
Replace free water Balanced salt solution to prevent CNS
symptoms
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Potassium
Normal dietary intake = 50 -100 mEq /day
Most is excreted in urine
Important for cardiac and neuromuscularfunction
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Hyperkalemia
Causes:
Usually acute renal
failure
Stress
Catabolism Acidosis
Symptoms
GI:
Nausea / vomiting
Diarrhea
CV: Rhythm
abnormalities
Heart block
Cardiac arrest
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Hyperkalemia: Treatment
Withhold exogenous potassium
Calcium gluconate
Can suppress myocardial effects
Sodium bicarbonate, insulin and D10W
Helps transfer K intracellularDialysis
Cation exchange resins
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Hypokalemia: Causes
More common in surgical patients Prolonged use of IV solutions with K+
Alkalosis
Sodium loading
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Hypokalemia: Symptoms andSigns
Failure of muscle contractility Cardiac, skeletal and smooth muscle
Weakness
tendon reflexes Ileus
EKG changes
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Hypokalemia: Treatment
Prevention Replace renal and GI losses of K+ in IV
solution
Avoid cardiac toxicities 40 mEq KCl / liter IV fluid
< 20 mEq KCl / hour replacement
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Calcium
Critical for:
normal cell function neural transmission, cell membrane
stability
bone structure blood coagulation
Daily losses in feces, urine and through
skinDaily exchange in bones, GI tract,
kidneys
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Hypocalcemia: Causes
Chronic renal failureMultiple transfusions
Pancreatitis
Nutritional deficiency (esp. Vitamin D)Magnesium depletion
Drugs
Thyroidectomy / Parathyroidectomy
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Management of Hypocalcemia
SEVERE SYMPTOMS: tetany
20 ml IV 10% Calcium gluconate over 20 minutes
then 15 mg/kg Calcium gluconate every six hours
reassure patient to minimize respiratory alkalosis
from hyperventilation
Calcium < 8.0-8.5 mg/dlSYMPTOMATIC
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Management of Hypocalcemia
MILD SYMPTOMS: paresthesias Oral Calcium treatment
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Management of Hypocalcemia
SEEK CAUSE consider magnesium deficiency
exclude hypoalbuminemia
measure serum phosphate (see next slide) could be excess hydration
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Phosphate and Hypocalcemia
High serum phosphate Suspect
hypoparathyroidism
Low or normal serumphosphate
Suspect bone
disease
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Hypercalcemia: Symptoms
bone defects cardiac changes
shock
renal hypertension and failure
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Hypercalcemia: Causes
1 hyperparathyroidism
Malignancy
With or without bone
metastasis
Drugs Some diuretics
Vitamins A or D
Calcium carbonate
Metabolic disorders
Osteoporosis
Thyrotoxicosis
Renal tubular
acidosis Pheochromocytoma
(rare)
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Management of Hypercalcemia
Rehydrate with normal saline
Check serum phosphate
Give furosemide 40 mg intially then 40-80 mg q. 2 hr
Monitor serum electrolytes
If patient remains unstable
Calcitonin 4 IU/kg subcutaneous or IM q12
Dialysis might be necessary
UNSTABLE PATIENT> 14 mg/dl
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Management of Hypercalcemia
Low serum phosphate
Usually 1
hyperparathyroidism, can
give oral phosphate
Normal or high
serum phosphate
Suspect malignancy
STABLE PATIENT
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Magnesium
Essential for function of most enzymesystems
Half of total magnesium is stored in bone
Kidneys can conserve and excrete
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Magnesium Deficiency:Causes
Starvation
Malabsorption
GI loss
PancreatitisAlcoholism
Diabetic ketoacidosis
1 aldosteronism
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Magnesium Deficiency: Signs andSymptoms
Weakness
Vertigo
DysphagiaSeizures
Tetany
Delerium
deep tendon reflexes
Similar to hypocalcemia
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Treatment ofHypomagnesemia
Correct over-hydration
Ifsevere and symptomatic:
Give 4-8 ml of a 50% MgSO4 solution in
100-200 ml of D5W IV over 15 minutes
Look for causes
Oral supplements for stable patients
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Magnesium Excess
Rare
Associated with:
Acute renal failure
Antacids Massive trauma
Burns
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Magnesium Excess: Signs andSymptoms
Lethargy
Weakness
deep tendon reflexes
EKG abnormalities
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Treatment ofHypermagnesemia
Withhold exogenous magnesium
Correct acidosis
Dialysis may be necessary
For the symptomatic patient Calcium Gluconate 10% 1-10 ml IV
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