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By Request Basic Fluids and Electrolytes

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Title: ALL NEW FOR 2005(6)! Fluids and Electrolytes Made Simple Last modified by: Douglas Slakey Created Date: 10/19/2010 1:26:31 AM Document presentation format – PowerPoint PPT presentation

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Title: By Request Basic Fluids and Electrolytes


1
By RequestBasic Fluids and Electrolytes
  • Douglas P. Slakey

2
Why ?
  • Essential for surgeons (and ALL physicians)
  • Based upon physiology
  • Disturbances understood as pathophysiology
  • To Encourage Thought Not Mechanical Reaction
  • Most abnormalities are relatively simple, and
    many iatrogenic

3
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4
It's better to keep your mouth shut and let
people THINK you're a fool than to open it and
remove all doubt.
  • Mark Twain

5
Patient Safety
  • Lets add all sorts of layers of complexity and
    make healthcare safer!

6
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7
Its All About Balance
  • Gains and Losses
  • Losses
  • Sensible and Insensible
  • Typical adult, typical day
  • Skin 600 ml
  • Lungs 400 ml
  • Kidneys 1500 ml
  • Feces 100 ml
  • Balance can be dramatically impacted by illness
    and medical care

8
Fluid Compartments
  • Total Body Water
  • Relatively constant
  • Depends upon fat content and varies with age
  • Men 60 (neonate 80, 70 year old 45)
  • Women 50

9
TOTAL BODY WATER 60 BODY WEIGHT
ECF 1/3
ICF 2/3
H2O
Predominant solute K
Predominant solute Na
10
I Love Salt Water!
11
Electrolytes
  • (mEq/L) Plasma Intracellular
  • Na 140 12
  • K 4 150
  • Ca 5 0.0000001
  • Mg 2 7
  • Cl 103 3
  • HCO3 24 10
  • Protein 16 40

12
Fluid Movement
  • Is a continuous process
  • Diffusion
  • Solutes move from high to low concentration
  • Osmosis
  • Fluid moves from low to high solute
    concentration.
  • Active Transport
  • Solutes kept in high concentration compartment
  • Requires ATP

13
Movement of Water
  • Osmotic activity
  • Most important factor
  • Determined by concentration of solutes
  • Plasma (mOsm/L)
  • 2 X Na Glc BUN
  • 18 2.8

14
Third Space
  • Abnormal shifts of fluid into tissues
  • Not readily exchangeable
  • Etiologies
  • Tissue trauma
  • Burns
  • Sepsis

15
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16
Fluid Status
  • Blood pressure
  • Check for orthostatic changes
  • Physical exam
  • Invasive monitoring
  • Arterial line
  • CVP
  • PA catheter
  • Foley

17
Remember JVD?
18
Dx of Fluid Imbalances
  • Must assess organ function
  • Renal failure
  • Heart failure
  • Respiratory failure
  • Excessive GI fluid losses
  • Burns
  • Labs electrolytes, osmolality, fractional
    excretion of Na, pH,

19
Disorders to be able to diagnoseAND Treat
  • Volume deficit
  • Volume excess
  • Hyper/hypo natremia
  • Hyper/hypo kalemia
  • Hyper/hypo -calcemia

20
Volume Deficit
  • Most common surgical disorder
  • Signs and symptoms
  • CNS sleepiness, apathy, reflexes, coma
  • GI anorexia, N/V, ileus
  • CV orthostatic hypotension, tachycardia with
    peripheral pulses
  • Skin turgor
  • Metabolic temperature

21
  • Dehydration
  • Chronic Volume Depletion
  • Affects all fluid components
  • Solutes become concentrated
  • Increased osmolarity
  • Hct can increase 6-8 pts for 1 L deficit
  • Patients at risk
  • Cannot respond to thirst stimuli
  • Diabetes insipidus
  • Treatment typically low Na fluids

22
HypovolemiaAcute Volume Depletion
  • Isotonic fluid loss, from extracellular
    compartment
  • Determine etiology
  • Hemorrhage, NG, fistulas, aggressive diuretic
    therapy
  • Third space shifting, burns, crush injuries,
    ascites
  • Replace with blood/isotonic fluid
  • Appropriate monitoring
  • Physical Exam
  • Foley (u/o gt 0.5 ml/kg/min)
  • Hemodynamic monitoring

23
Fluid ReplacementGulf of Honduras
24
Fluid Replacement
  • Isotonic/physiologic
  • NS (154 meq, 9 grams NaCl/L)
  • LR (130 Na, 109 Cl, 28 lactate, 4 K, 3 Ca)
  • Less concentrated
  • 0.45NS, 0.2NS
  • Maintenance
  • Hypertonic Na

25
Fluid Replacement
  • Plasma Expanders
  • For special situations
  • Will increase oncotic pressure
  • If abnormal microvasculature, will extravasate
    into third space
  • Then may take a long time to return to
    circulation

26
Fluid Replacement
  • Maintenance
  • 4,2,1 rule
  • Other losses (fistulas, NG, etc)
  • Can measure volume and composition!!!
  • Should be thoughtfully assessed and prescribed
    separately if pathologic
  • (i.e. gastric H, Na, Cl)

27
Maintenance Fluid
  • Daily Na requirement 1 to 2 mEq/kg/day
  • Daily K requirement 0.5 to 1 mEq/kg/day
  • AHA Recommended Na intake 4 to 6 grams per day
  • To Replace Ongoing Losses, NOT Pre-existing
    Deficits

28
Maintenance Fluids D5 0.45NS 20 mEq KCl/L at
125 ml/H
29
How much Sodium is Enough???
  • NS
  • 0.9 9 grams Na per liter
  • 0.45 NS 4.5 grams per liter
  • 125 ml/hour 3000 ml in 24 hours
  • 3 liters X 4.5 grams Na 13.5 GRAMS Na!
  • (If 0.2 NS 3 liters X 2 grams Na 6 grams Na)

30
Assessment of Disorders of Volume and Electrolytes
  • Effects are variable and complex
  • Simplified treatment algorithms cannot address
    the variable and complex nature of these
    disorders
  • Acid - Base balance is integral with these
    disorders

31
BTW Dr Slakey, the sodium is 120Hyponatremia
  • Na loss
  • True loss of Na
  • Dilutional (water excess)
  • Inadequate Na intake
  • Classified by extracellular volume
  • Hyovolemic (hyponatremia)
  • Diuretics, renal, NG, burns
  • Isotonic (hyponatremia)
  • Liver failure, heart failure, excessive hypotonic
    IVF
  • Hypervolemic (hyponatremia)
  • Glucocorticoid deficiency, hypothyroidism

32
Na
Volume
Check Ur Na
lt 10 mmol/L
gt 20 mmol/L
Adrenal Insufficiency Diuretics Salt-Wasting
Syndrome SIADH
Vomiting Diarrhea 3rd space Hepatorenal
33
FeNa
  • Na urine x Cr serum
  • --------------------------------------------
  • Na serum x Cr urine

34
SIADH
  • Causes
  • Surgical stress (physiologic)
  • Cancers (pancreas, oat cell)
  • CNS (trauma, stroke)
  • Pulmonary (tumors, asthma, COPD)
  • Medications
  • Anticonvulsants, antineoplastics, antipsychotics,
    sedatives (morphine)

35
SIADH
  • Too much ADH
  • Affects renal tubule permeability
  • Increases water retention (ECF volume)
  • Increased plasma volume, dilutional
    hyponatremia, decreases aldosterone
  • Increased Na excretion (Ur Na gt40mEq/L)
  • Fluid shifts into cells
  • Symptoms thirst, dyspnea, vomiting, abdominal
    cramps, confusion, lethargy

36
SIADH Treatment
  • Fluid restriction
  • Will not responded to fluid challenge!
  • i.e. a Bolus will not work
  • (distinguishes from pre-renal cause)
  • Possibly diuretics

37
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38
Hypovolemia and Metabolic Abnormality
  • Acidosis
  • May result from decreased perfusion
  • Alkalosis
  • Complex physiologic response to more chronic
    volume depletion
  • i.e. vomiting, NG suction, pyloric stenosis,
    diuretics

39
Paradoxical Aciduria
Hypochloremic Hypovolemia
Na
Na
H
Cl
K
Loop of Henle
40
Do you want more?
41
Hypernatremia
  • Relatively too little H2O
  • Free water loss (burns, fever)
  • Diabetes insipidus (head trauma, surgery,
    infections, neoplasm)
  • Dilute urine (Opposite of SIADH)
  • Nephrogenic DI
  • Kidney cannot respond to ADH

42
Aldosterone
  • Reduced (Addisons) Increased (Conns)
  • Mineralocorticoid
  • Increases Na and water reabsorption and K
    excretion

43
Hypernatremia
  • Hypovolemic
  • GI loss, osmotic diuresis
  • Increased Na load (usually iatrogenic)

Free water deficit
0.6 X wt (kg) X Serum Na/140 - 1
44
Hypernatremia Volume Replacement
  • Example
  • Na 153, 75 kg person
  • (0.6 X 75) X (153/140) - 1
  • 45 X 1.093 -1
  • 45 X 0.093 4.2 Liters

45
Potassium and Ph
  • Normally 98 intracellular
  • Acidosis
  • Extracellular H increases, H moves
    intracellular, forcing K extracellular
  • Alkalosis
  • Intracellular H decreases, K moves into cells
    (to keep intracellular fluid neutral)

46
Hyperkalemia
  • Associated medications
  • Too much K!, ACE inhibitors, beta-blockers,
    antibiotics, chemotherapy, NSAIDS, spironolactone
  • Treatment
  • Mild dietary restriction, assess medications
  • Moderate Kayexalate
  • Do NOT use sorbitol enema in renal failure
    patients
  • Severe dialysis

47
Hyperkalemia
  • Emergency (gt 6 mEq/l)
  • Treatment
  • Monitor ECG, VS
  • Calcium gluconate IV (arrhythmias)
  • Insulin and glucose IV
  • Kayexalate, Lasix IVF, dialysis

48
The new boat Makani ui
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