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Fluid

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Fluid & Electrolyte balance Dr M A Maleque Molla; ... Is the major chemical base buffer required for acid base balance Is found in ECF and ICF Regulated by kidneys ... – PowerPoint PPT presentation

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Title: Fluid


1
Fluid Electrolyte balance
Dr M A Maleque Molla FRCP(ED), FRCPCH
  • October 22, 2014

2
Pre review test
  • What percentage of body wt of an infant is
    water?
  • A. 25
  • B. 30
  • C. 60
  • D. 65
  • Answer D

3
  • 2. Major cation in the ECF is
  • Potassium
  • Calcium
  • Sodium
  • Magnesium

Answer C
4
  • 3. Homeostasis of body water and electrolytes
    are made by all the hormone except
  • ADH
  • Aldosterone
  • Atrial natriuretic peptide
  • Cortisol
  • Answer D

5
Body Composition
  • Fluid 60
  • Solid 40
  • Fat
  • Protein
  • Carbohydrate
  • Minerals

6
Distribution of body fluids (by wt)
  • Fluid 60 of BW
  • Itracellular
  • Extracellular
  • Intrstitial
  • Intra vascular(plasma)

There is continuous ongoing equilibrium between
the intracellular and extracellular spaces.
7
Fluid content according to age
  • Total body water (TBW) vary with age
  • Preterm 80-85
  • Term 75
  • Infant 65
  • Older children adult male 60
  • Adult female50
  • TBW ? to 60 by 1st yr of life
  • Female has less fluid content because of more fat
    cells

8
Effective circulating volume (ECV)
  • Def Portion of the ECF that take part in tissue
  • perfusion.
  • Only 5 of TBW (intra vascular fluid) are ECV
  • Adequate ECF must be maintained all the times

9
Composition of body fluid
  • Water
  • Electrolytes Inorganic salts, Sodium(Na),
    Potassium(K), Calcium (Ca), Chloride(Cl),
    Phosphate(Po4), Bicarbonate(HCO3, Sulphate(SO4)
  • Nonelectrolytes Minerals -iron and zinc,
    Glucose, Lipids, Creatinine, Urea

10
Electrolytes of body fluid
  • Electrolytes are measured in mEq or mmol
  • Circulating electrolytes electrically charged
  • When positively charge called cation Na, K,
    Ca
  • When negatively charge called anions Cl-
    ,HCO3-, SO4-

11
Electrolytes composition of body fluids
  • Normal Values(serum)
  • Cation
  • Sodium (Na) 135 145 mEq/L
  • Potassium (K) 3.5 5.50 mEq/L
  • Calcium (Ca) 8.5 10.5 mg/dL
  • Ionized Calcium 4.5 5.5 mg/dL
  • Magnesium (Mg) 1.5 2.5 mEq/L
  • Anion
  • Bicarbonate (HCO-3) 24 30 mEq/L
  • Chloride (Cl--) 95 105 mEq/L
  • Phosphate (PO4---) 2.8 4.5 mg/dL

12
Na 140
K 140
Cl- 140
Phos- 107
INTRA CELLULAR FLUID
EXTRA CELLULAR FLUID
  • Distribution of Cation and Anion in ECF ICF
    (mEq/l)

13
Fluid Electrolyte balance?

OUT PUT
INTAKE
14
Daily physiological fluid balance
  • INTAKE
  • Ingested liquid 1500 ml
  • Ingested food 800 ml
  • Metabolism 200 ml
  • Total 2500 ml/day
  • OUTPUT
  • Kidney 1500 ml
  • Skin loss 600 ml
  • GI 100 ml
  • Lung 300 ml
  • Total 2500 ml

Daily fluid balance of an adult
15
Movement of fluid electrolytes
  • A. Passive transport (no energy required)
  • Osmosis Fluid move from higher concentration to
    lower concentration
  • Diffusion Molecules move from higher
    concentration to lower (Concentration gradient)
  • Filtration Fluid and diffusible substances
    move together across a membrane moving from ?
    pressure to ? pressure
  • Hydrostatic pressure Fluids moves from an area
    of higher pressure to area of lower pressure
  • B. Active transport( energy required)
  • Sodium-Potassium Pump

16
Concentration of Body fluid
  • Units of solute concentration are osmolarity and
    osmolality
  • Osmolarity Number of osmoles of solute per liter
    (L) of solution. It is expressed as osmol/L
  • e.g 1 mol/L NaCl solution has an osmolarity of
    2 osmol/L
  • Osmolality Number of osmoles of solute per
    kilogram(kg) of solvent. It is expressed as
    osmol/kg
  • Normal serum osmolality280-298 mosmol/kg

17
Clinical relevance of osmolality
  • Calculation
  • Serum osmolality (mosmol/kg)
  • Effective osmolality Osmotic force that is
    mediating the shift of water between the ECF and
    the ICF
  • The osmotic gap (osmolal gap) is the difference
    between the actual osmolality (measured by the
    laboratory) and the calculated osmolality
  • A normal osmolal gap is lt 10 mOsm/kg

2(Na K) mmol/l Urea (mmol/l) Glucose
(mmol/l)
2 x Na (mmol/l ) Glucose (mmol/l)
18
Regulation of Body Fluids
  • Body fluid Homeostasis is maintained through
  • Fluid intake
  • Hormonal regulation
  • Antidiuretic hormone(ADH)
  • Renin-Angeotensin-Aldosterone Mechanism
  • Natriuretic Peptides
  • Fluid output

19
A. Fluid intake
  • Intake is control by hypothalamic thirst center
  • ? plasma osmolality
  • of 12
  • ? plasma volume
  • 1015
  • Baroreceptor input,
  • angiotensin II, and
  • other stimuli

-Ve
  • Moistening of the mucosa of the mouth and throat
  • Activation of stomach and intestinal stretch
    receptors

20
1. Antidiuretic hormone(ADH)
B. Hormonal regulation
  • ADH Secreted by the hypothalamus, and stored in
    the posterior pituitary gland
  • ADH is released by, thrust, ? fluid volume, High
    serum osmolality
  • Acton
  • reabsorb water from collecting duct of kidney
  • inhibit sweat glands to ? perspiration to
    conserve water
  • acts on arterioles, causes constriction thus ?
    BP
  • ADH is Inhibited by
  • Excessive of fluid volume
  • Low osmolality of serum

21
2. Renin- Angiotensin-Aldosterone Mechanism

22
3. Natriuretic Peptides
  • Natriuretic Peptides
  • Atrial Natriuretic Peptide(ANP ) from atria
  • Brain Natriuretic Peptide(BNP) from ventricle
  • Action
  • Acts like a diuretic that causes sodium loss and
    inhibits the thirst mechanism
  • Inhibit rennin release
  • Inhibit the secretion of ADH and aldosterone
  • Vasodilatation

23
C. Regulation by fluid output
  • Daily fluid losses 2500 ml for an adult
  • Kidney(Urine) 55
  • Skin 30
  • Lung 10
  • GI (Stool) 2-5

24
Renal handling of Fluid Electrolytes
Substance Filtered Excreted Net reabsorption
Water 180 L 1.5 L 98-99
Na 26,000 mmol 100-250 mmol gt99
Cl- 21,000 mmol 100-250 gt99
K 800 mmol 40-120 mmol gt85-95
HCO3_ 4,800 mmol 0 mmol 100
Urea 54 gm 27-32 g 40-50
25
  • Regulation of Electrolytes

26
Regulation of Sodium Water
  • Major cation in the ECF (N135 - 145 mEq/L)
  • Combines with chloride and bicarbonate to help
    regulate acid-base balance
  • Recommended daily in take 2.5gm/day
  • Kidney regulates sodium balance and is the
    principal site of sodium excretion
  • Aldosterone helps in sodium and water
    conservation

27
Potassium regulation
  • Major electrolyte and principle cation in the ICF
  • Regulates metabolic activities
  • Required for glycogen deposits in the liver and
    skeletal muscle
  • Required for transmission of nerve impulses,
    normal cardiac conduction and normal smooth and
    skeletal muscle contraction
  • Daily intake 1-2 mEq/kg
  • Regulated by dietary intake and renal excretion
  • Intestine absorbs about 90 of ingested
    potassium
  • Regulate by renin-angiotensin-aldosterone
    mechanism

28
Calcium regulation
  • 99 of calcium is in the bones and teeth
  • 1 is in ECF
  • 50 of calcium in the ECF is bound to protein
    (albumin)
  • 40 is free in ionized form-Ionized calcium
  • Ca is needed for
  • Bone and teeth formation
  • Blood clotting
  • Hormone secretion
  • Cell membrane integrity
  • Cardiac conduction
  • Transmission of nerve impulses
  • Muscle contraction

29
Anions
  • Chloride (Cl-)
  • Major anion in ECF
  • Follows sodium
  • Bicarbonate (HCO3-)
  • Is the major chemical base buffer required for
    acid base balance
  • Is found in ECF and ICF
  • Regulated by kidneys

30
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31
Maintenance replacement therapy
  1. Maintenance therapy Replacement of daily
    physiologic losses of water and electrolytes
    under normal condition
  2. Replacement therapy Replacement of abnormal loss

32
Maintenance fluid requirement
  • Water requirements are directly related to
    caloric energy expenditures
  • Daily caloric expenditure water requirement
    depends on weight of the children
  • For first 10 kg of wt spend 100 kcal/kg needs
    100 ml/kg of water
  • Second 10 kg of wt spend 50 kcal/kg needs
    50ml/kg of water
  • gt20 kg up to 80 kg, spends 20 kcal/kg needs 20
    ml/kg of water

33
Calculation of daily maintenance fluid
  • Daily Basis
  • Wt 1-10 kg 100 ml/kg
  • Wt 11 to 20 kg 50 ml/kg
  • Wt gt20 kg up to 80 kg20 ml/kg
  • Maximum 2400 ml/day.

Holliday-Segar Method
34
Maintenance fluid requirement
  • Daily losses in normal condition 100ml/100kcal
  • Sensible losses 60
  • Urine 55- 55 ml/100kcal
  • Stool 5- 5 ml/100 kcal
  • Insensible losses 40
  • Skin 30 -30ml/100 kcal
  • Lung 10 -10 ml/100 kcal
  • Insensible loss increase Fever-by 10-12 per 1
    0C above 37.8 0C, tachypnea by 10-30

35
Daily maintenance electrolyte requirement
  • Sodium 2 - 3 mmol/100ml H2O /day
  • Potassium 1 - 2 mmol/100ml H2O /day
  • Chloride 2 - 3 mmol/100ml H2O /day

36
Maintenance therapy
Example A child is comatosed, not dehydrated.
Vital signs stable. wt 25 kg. outline his fluid
management plan.
  • Fluid requirement
  • First 10 kg 10 x 100 1000 ml
  • Second 10 kg 10 x 50 ml 500 ml
  • Rest 5 kg 5 x 20 ml/kg100 ml
  • Total 1600 ml/day.
  • Electrolytes requirements
  • Sodium 16 x 3 48 mmol/day
  • Potassium 16 x 2 32 mmol/day
  • Chloride 16 x 2 32 mmol/day

37
What types of IV fluid ?
  • Types of IVF used
  • Normal saline (0.9 NaCl/L) 154 mEq Na/L
  • One-half NS (0.45 NaCl/L) 77 mEq Na/L
  • One-third NS (0.33 NaCl/L) 57 mEq Na/L
  • One-quarter NS (0.25 NaCl/L) 38 mEq Na/L
  • One fifth NS(0.18 Nacl) 30 mmol/l
  • Ringers lactate Na 130 mmol/l, K 4 mmol/l,
    Cl- 109 mmol/l, bicarb 28 mmol/l , and Ca 3
    mg/dl )
  • Q. What type of fluid to be used for the child of
    25 kg for
  • maintenance?
  • Maintenance fluid for the child wt 25 kg-D5 ¼ th
    NS with 20 meq potassium/liter will be adequate

38
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39
Fluid Imbalance
  • Fluid deficit -Dehydration
  • Fluid excess- Hypervolemia

40
Dehydration
  • Abnormal fluid loss causes fluid deficit called
    dehydration
  • Conditions can leads to dehydration
  • Skin Fever, under heater, heat exhaustion, burn
  • GI Gastroenteritis, fistula, intestinal
    obstruction
  • Lung Tachypnea
  • Kidney Polyuria e.g. diabetes
  • Miscellaneous Surgical drain, third spacing

41
Severity of dehydration
  • According to severity
  • Mild dehydration -3-5 loss of BW
  • Moderate dehydration-6-9 loss of BW
  • Severe dehydration- 10 loss of BW

42
Clinical features of dehydration
From Lissauer Graham 2002
43
Signs Symptoms MILD MODERATE SEVERE
Wt Loss 3-5 6-9 gt10
General condition Well, alert Irritable Lethargic/floppy
Thirst Thirsty Drinks eagerly Unable to drink
Oral mucous Slightly dry Dry Parched
Ant fontanel Normal Depressed Depressed
Eyes Normal Sunken Sunken
Skin turgor Skin pinch retracts Normal Normally Depress in gt2 sec Tenting Takesgt3 sec
Urine output Normal Decrease No urine
Pulse Normal Rapid Rapid weak
Respiration Normal Deep Deep Rapid
BP Normal Normal Decrease
Capillary refill time Normal 2 Sec gt 3 sec

Clinical assessment of severity of dehydration
44

Types of dehydration
  • According to serum Sodium (Na) concentration
  • Isonatremic (Isotonic)S. Na 135-150 mmol/l
  • Hyponatremic (Hypotonic) S. Na lt135 mmol/l
  • Hypernatremic (Hypertonic) S. Nagt150 mmol/l

45
Management of dehydration
  • Fluid therapy
  • Enteral
  • Oral rehydration therapy
  • By NGT
  • Parenteral
  • Intravenous

46
Management of dehydrationOral rehydration
therapy (ORT)
  • Indication
  • Mild moderate dehydration due to
    gastroenteritis
  • Relative Contra indication
  • Shock
  • Altered mental status
  • Severe dehydration
  • Parental limitations
  • Excessive vomiting
  • Abdominal distention or absent bowel sounds

47
Composition of different types of ORS other
solution
Solution Glucose Mmol/l Na Mmol/l Cl Mmol/l K Mmol/l HCO3 Mmol/l Osmolality
WHO 1975 111 90 80 20 30 310
WHO 2002 75 75 65 20 30 245
Pedialyte 140 45 35 20 30 250
Rehydrate 140 75 65 20 30 310
Cola 700 2 2 0 13 750
Apple juice 690 3 32 0 730
48
Management of dehydrationFluid calculation
  • Water deficit Wt X of dehydration
  • In mild dehydration deficit 50 ml/kg
  • (1kg1000gm1000 ml 5 50ml/kg)
  • In moderate dehydration deficit 60-90 ml/kg
  • In severe dehydration deficit gt 100 ml/kg

49
Oral rehydration therapy (ORT)
  • ORT is divided into 2 phases
  • A. Rehydration phase aims to restore the
    existing deficit fluid
  • B. Maintenance phase compensate for continued
    fluid loss
  • Golden rule
  • Give them as much as they will drink

50
Oral rehydration therapy
  • A. Rehydration phase Replacement of existing
    deficit
  • Deficit is calculated according to severity of
    dehydration
  • Mild dehydration 50 ml/kg
  • Moderate dehydration 70 ml/kg.
  • Calculated deficit should be given over 4-6 hour
    by small and frequent feed

51

Oral rehydration therapy (cont..)
  • B. Maintenance phase Replacement of fluid for
    continued loss until diarrhea stops
  • 1 mL of ORS should be replace for each gram of
    diarrheal stool
  • Mild diarrhea ( 1 stool every 2 hours) ORS
    100 ml/kg/day until diarrhea stops
  • Severe diarrhea (gt 1 stool every 2 hours) Need
    hospital supervision.
    Replace as follows
  • If stool can not be measure- 10 ml/kg/motion
  • in severe diarrhea- 10 ml/kg/hour
  • If vomiting 2 mL/kg for each episode of vomiting

52
Management of dehydration Parenteral therapy
  • Indications
  • Severe dehydration
  • Persistent vomiting
  • Unable to take orally
  • Intestinal surgery
  • Paralytic Ileus

53
Parenteral therapy Shock therapy
  • To be given in severe dehydration.
  • Goal is to expand the intravascular fluid volume
    rapidly to save the vital organs.
  • Isotonic solutions are used e.g. N. saline,
    ringer lactate, albumin, plasma
  • Normal Saline 20 ml/kg IV bolus rapidly over
    20-30 minute
  • Repeat bolus until patient is hemodynamically
    stable.
  • This phase of therapy is same for all types of
    dehydration

54
Parenteral therapy (cont..)Subsequent therapy
  • Depends upon types of dehydration
  • Isotonic hypotonic dehydration
  • Calculated deficit should be replaced over 24
    hours
  • Fluid given in initial phase is to be deducted
    from the calculated deficit
  • Calculate maintenance requirement for 24 hour
  • Calculate Na K deficit choose appropriate
    fluid
  • Half of the deficit maintenance requirement
    should be given over 8 hours
  • Remaining half to be infused over 16 hours

55
Fluid electrolyte calculation
  • Water deficit Wt X of dehydration
  • In mild dehydration deficit 50 ml/kg
  • (1kg1000gm1000 ml 5
    50ml/kg)
  • In moderate dehydration deficit 60-90 ml/kg
  • In severe dehydration deficit gt 100 ml/kg
  • Electrolyte deficit
  • Na Cl deficitwater deficit X 8 mmol/100ml
  • K deficit water deficit X 3 mmol/100 ml

56
Example Child wt 10 kg arrived in ER with
severe dehydration.
  • Shock therapy
  • 10 20200 ml of normal saline should be given
    over 20- 30 min as shock therapy
  • Serum sodium was 138 mmol/l
  • Subsequent therapy
  • Deficit fluid101001000 ml
  • Fluid given during shock therapy200 ml
  • Remaining fluid deficit 1000-200800 ml
  • Maintenance fluid for 24 hour101001000 ml
  • Total fluid for 24 hour 800 ml1000ml 1800 ml
  • One half of total fluid 900ml to be given over 8
    hour
  • Other half 900ml to be infused over 16 hour

57

Parenteral therapy(cont..)
  • Choice of fluid
  • Na requirement
  • Deficit0.8 800 64 mmol
  • Maintenance requirement 10 220 mmol
  • Total 642084 mmol/day
  • Potassium 301040 mmol/day
  • One half NS in D5W 20 mmol of KCL/l will be
    appropriate solution

58
Parenteral therapy(cont..)
  • Subsequent therapy
  • Hypernatremic dehydration S Na gt 160mmol/l
  • Initial phase of shock therapy is same
  • Deficit therapy should be spread over 36-84 hours
    according to the result of serum Na
  • Serum Na 155-170 mmol/l- over 48 hr
  • Serum Na 170-183 mmol/l over 72 hr
  • Serum Na 184-196 mmol/l over 84 hr
  • Goal is to decrease serum sodium 10 mmol/24hr

59

Parenteral therapy(cont..)Example
  • One yr. old wt 10 kg with severe dehydration in
    shock
  • Shock therapy 20 10200 ml N S to be given
    over 30 min
  • U Es result shows S. Na 170 mmol/l.
  • Subsequent therapy
  • Deficit10 1001000 ml
  • Fluid given during initial phase 200 ml
  • Remaining deficit 1000-200800 ml
  • Maintenance requirement for 48 hr(10 100)
    22000 ml
  • Total fluid 20008002800ml to be given over 48
    hr
  • NS or ½ NS D5W KCL should be use

60
Management of dehydrationReplacement of ongoing
losses
  • Can be given parenterally or orally
  • Any abnormal losses should be replace ml for ml
  • Losses from the previous hours should be
    calculated and should be replaced over next same
    duration
  • If stool quantity cannot be measure 10 ml/kg/
    per motion in previous 8 hours should be replaced
    over next 8 hours.
  • Losses should be replaced every 1-6 hours
    depending on the rate of loss
  • NG losses should be replaced 1-4 hourly,
  • In diarrhea fluid should be adjusted 6-8 hourly.
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