Fluids and electrolytes2015

1. Fluids & ElectrolytesFluids & Electrolytes
Dr. Faiez AlhmoudDr. Faiez Alhmoud
Albashir Teaching HospitalAlbashir Teaching Hospital

2. Why do we care about fluids in the Why do we care about fluids in the
body?body?

4. Fluids factsFluids facts
Over half of our body weight is fluid materialOver half of our body weight is fluid material
- Total body water is a function of - Total body water is a function of ageage, , body massbody mass, ,
and and body fatbody fat..
- Fluids are 60% of an adult’s body weight - Fluids are 60% of an adult’s body weight
- 70 Kg adult male has 60% X 70= 42 Liters- 70 Kg adult male has 60% X 70= 42 Liters
- Infants have more water = 75-80% of BW- Infants have more water = 75-80% of BW
- Elderly have less water = 45-50% of BW- Elderly have less water = 45-50% of BW
- More fat means ↓water (female has 50-55%)- More fat means ↓water (female has 50-55%)
- More muscle means ↑water (male has 55-60%)- More muscle means ↑water (male has 55-60%)
- Infants and elderly are more prone to fluid imbalance- Infants and elderly are more prone to fluid imbalance
- In adults, a loss of just 1/5 of body fluid weight can - In adults, a loss of just 1/5 of body fluid weight can
be fatal (Marathon runners). be fatal (Marathon runners).
44

5. VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT
AGE & GENDERAGE & GENDER

6. Body Fluid : FunctionBody Fluid : Function
–Transport nutrients to the cells and carries Transport nutrients to the cells and carries
waste products away from the cells (cell waste products away from the cells (cell
functionfunction
–Maintains blood volumeMaintains blood volume
–Regulates body temperatureRegulates body temperature
–Serves as aqueous medium for cellular Serves as aqueous medium for cellular
metabolismmetabolism
–Assists in digestion of food through hydrolysisAssists in digestion of food through hydrolysis

7. So where are these So where are these
fluids kept?fluids kept?

8. Compartments of Compartments of
Body FluidsBody Fluids
Intercellular
Intravascular
Interstitial
40%
16%
4%
Body Water = 60% of a patient’s body weight
blood

9. Compartments…Compartments…
Intracellular (ICF)Intracellular (ICF)
–Fluid within the cells themselves Fluid within the cells themselves
–The most stable & least susceptible to fluid The most stable & least susceptible to fluid
shiftsshifts
–2/3 of body fluid2/3 of body fluid
–High in KHigh in K , , Phosphors, Mg. & protein Phosphors, Mg. & protein
–Located primarily in skeletal muscle massLocated primarily in skeletal muscle mass
–Assists in cellular metabolism Assists in cellular metabolism
99

10. ……CompartmentsCompartments
Extracellular (ECF)Extracellular (ECF)
–1/3 of body fluid1/3 of body fluid
–High in Na, Cl, Ca, Glucose, fatty &amino-acids High in Na, Cl, Ca, Glucose, fatty &amino-acids
–Comprised of Comprised of 3 major components3 major components
** Intravascular: =4% =3lit., Intravascular: =4% =3lit.,least stable, most least stable, most
susceptible to fluid shift (Plasma=90%H2O)susceptible to fluid shift (Plasma=90%H2O)
** Interstitial: =16%=10lit., Interstitial: =16%=10lit., reserve fluid, replacing reserve fluid, replacing
intravascular or intracellular as needed (Fluid in intravascular or intracellular as needed (Fluid in
and around tissues)and around tissues)
**Transcellular: Transcellular: ~ 1% or up to one Lit.. ~ 1% or up to one Lit..
(Cerebrospinal, pericardial, synovial, (Cerebrospinal, pericardial, synovial,
intraocular, pleural fluids..)intraocular, pleural fluids..) 1010

11. CompartmentsCompartments
Transcellular componentTranscellular component
–1% of ECF1% of ECF
–Located in joints, connective tissue, bones, Located in joints, connective tissue, bones,
body cavities, CSF, and other tissuesbody cavities, CSF, and other tissues
–Potential to increase significantly in Potential to increase significantly in
abnormal conditions abnormal conditions
1111

12. MOVEMENT OF BODY FLUIDS
OsmosisOsmosis-- waterwater moves through semi permeable moves through semi permeable
membrane from dilutedmembrane from diluted to concentrated solutionto concentrated solution
DiffusionDiffusion-- dissolved particles.dissolved particles. Eg.gut absorption Eg.gut absorption
FiltrationFiltration- - water and dissolvedwater and dissolved. move through . move through
membrane from solution having higher hydrostatic membrane from solution having higher hydrostatic
pressure Eg. (water and solute move out of the blood at pressure Eg. (water and solute move out of the blood at
the arterial end of the capillary to the interstitial fluid by the arterial end of the capillary to the interstitial fluid by
filtration filtration
Active transport-Active transport- ionsions move from the area of move from the area of lesserlesser
concentration to area of concentration to area of greatergreater concentration concentration by energy by energy
Eg. Enzymes ,nutritients &potassiumEg. Enzymes ,nutritients &potassium
Hydrostatic pressure- Hydrostatic pressure- the pressure created by the the pressure created by the
weight of fluid weight of fluid against the wall that contains it.against the wall that contains it.
Oncotic pressure- Oncotic pressure- or colloid osmotic pressure, that usually or colloid osmotic pressure, that usually
tends to pull tends to pull waterwater into the circulatory system. into the circulatory system.

13. osmosis

14. DiffusionDiffusion

15. Water ConflictWater Conflict

16. Sources of Body WaterSources of Body Water
-1250cc from drinking-1250cc from drinking
-1000 cc-1000 cc from solids (eating) from solids (eating)
-250 cc from oxidation -250 cc from oxidation
OrOr
-Enteral & parenteral support -Enteral & parenteral support

EnteralParenteral
eating
drinking

17. What are the expected losses ?What are the expected losses ?
Measurable:Measurable:
–urine =1-2lit.urine =1-2lit.
–GI =100-200ccGI =100-200cc
( stool, stoma )( stool, stoma )
Insensible or:Insensible or:
UnmeasurableUnmeasurable
--sweat=up to 1litsweat=up to 1lit
-exhalation=400cc-exhalation=400cc

18. Fluid shifts / loses
Intracellular
30 litres
Interstitial
9 litres
Intravascular
3 litres
Kidneys Guts Lungs Skin
Extracellular fluid - 12 litres

19. Regulation of Fluid Balance
Renal regulationRenal regulation
Hypothalamic regulationHypothalamic regulation
Pituitary regulationPituitary regulation
Adrenal cortical regulationAdrenal cortical regulation
Cardiac regulationCardiac regulation
Gastrointestinal regulationGastrointestinal regulation
Insensible water lossInsensible water loss
oror

20. Regulation of Fluid Balance
Fluid intakeFluid intake
Fluid outputFluid output
Hormonal influenceHormonal influence
Lymphatic influencesLymphatic influences
Neurologic influencesNeurologic influences
Renal influencesRenal influences

21. ↓Blood
volume
or ↓BP
Volume receptor
Atria and great veins
Hypothalamus
↓
Posterior
pituitary gland
Osmoreceptors in
hypothalamus
↑Osmolarity
↑ADH
Kidney
tubules
↑H2O
reabsorption
↑vascular
volume and
↓osmolarity
Narcotics, Stress,
Anesthetic agents, Heat,
Nicotine, Antineoplastic
agents, Surgery
ANTIDIURETIC HORMONE ANTIDIURETIC HORMONE
REGULATION MECHANISMSREGULATION MECHANISMS

22. Juxtaglomerular
cells-kidney
↓Serum Sodium
↓Blood volume
Angiotensin I
Kidney tubules
Angiotensin II
Adrenal Cortex
↑Sodium
resorption
(H2O resorbed
with sodium); ↑
Blood volume
Angiotensinogen in
plasma
RENIN
Angiotensin-Angiotensin-
converting converting
enzymeenzyme
ALDOSTERONE
Intestine, sweat
glands, Salivary
glands
Via vasoconstriction of arterial smooth muscle
ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM

23. ALDOSTERONE-RENIN-ANGIOTENSIN ALDOSTERONE-RENIN-ANGIOTENSIN
SYSTEMSYSTEM
Renal sympathetic nerves
Renin-angiotensin-
aldosterone system
Atrial natriuretic peptide
(ANP)

24. Fluid Volume ShiftsFluid Volume Shifts
Fluid normally shifts between intracellular Fluid normally shifts between intracellular
and extracellular compartments to and extracellular compartments to
maintain equilibrium between spacesmaintain equilibrium between spaces
Fluid not lost from body but not available Fluid not lost from body but not available
for use in either compartment – for use in either compartment –
considered third-space fluid shift (“third-considered third-space fluid shift (“third-
spacing”)spacing”)
Enters serous cavities (transcellular)Enters serous cavities (transcellular)
2424

25. Third SpacingThird Spacing
Accumulation and sequestration of trapped Accumulation and sequestration of trapped
extracellular fluid in a body spaceextracellular fluid in a body space
This fluid is a volume loss and it’s This fluid is a volume loss and it’s
unavailable for normal physiologic functionunavailable for normal physiologic function
Fluid may be trapped in pericardial, pleural, Fluid may be trapped in pericardial, pleural,
peritoneal cavities, soft tissue or joints.peritoneal cavities, soft tissue or joints.
e.g.e.g.
AscitesAscites
EffusionEffusion

26. EdemaEdema
The excess accumulation of fluid in the The excess accumulation of fluid in the
interstitial space.interstitial space.
Causes include surgery, accidents, and Causes include surgery, accidents, and
trauma.trauma.
Anasarca is generalized body edemaAnasarca is generalized body edema

27. Save Water, Save LifeSave Water, Save Life

28. RememberRemember
Fluids and electrolytes Fluids and electrolytes
always want to shift from always want to shift from
an area of higher an area of higher
concentration to an area of concentration to an area of
lower concentration to lower concentration to
equilibrateequilibrate

29. FLUID IMBALANCES
There are five types of fluid imbalances that There are five types of fluid imbalances that
may occur are:may occur are:
Extracellular fluid volume deficitExtracellular fluid volume deficit (EVFVD) (EVFVD)
Extracellular fluid volume excessExtracellular fluid volume excess (ECFVE) (ECFVE)
Extracellular fluid volume shiftExtracellular fluid volume shift
Intracellular fluid vloume excessIntracellular fluid vloume excess (ICFVE) (ICFVE)
Intracellular fluid volume deficitIntracellular fluid volume deficit (ICFVD) (ICFVD)

30. EXTRACELULLAR FLUID
VOLUME DEFICIT
An ECFVD, commonly called as An ECFVD, commonly called as
dehydrationdehydration , is a decrease in , is a decrease in
intravascular and interstitial fluidsintravascular and interstitial fluids
An ECFVD can result in cellular fluid loss An ECFVD can result in cellular fluid loss
if it is sudden or severe if it is sudden or severe

31. THREE TYPES OF ECFVDTHREE TYPES OF ECFVD
Hyperosmolar fluid volume deficit-Hyperosmolar fluid volume deficit-
water loss is greater than the electrolyte water loss is greater than the electrolyte
lossloss
Iso-osmolar fluid volume deficitIso-osmolar fluid volume deficit – equal – equal
proportion of fluid and electrolyte loss proportion of fluid and electrolyte loss
Hypotonic fluid volume deficitHypotonic fluid volume deficit – –
electrolyte loss is greater than fluid losselectrolyte loss is greater than fluid loss

32. ETIOLOGY AND RISK FACTORS
(EVFVD)(EVFVD)
Severe vomiting Severe vomiting
DiaphoresisDiaphoresis
Traumatic injuriesTraumatic injuries
Third space fluid shifts Third space fluid shifts
[ intestinal obst., pleural& [ intestinal obst., pleural&
pertonial cavity] pertonial cavity]
FeverFever
Gatrointestinal suctionGatrointestinal suction
IleostomyIleostomy
FistulasFistulas
BurnsBurns
HyperventilationHyperventilation
Decresed ADH secretionsDecresed ADH secretions
Diabetes insipidusDiabetes insipidus
Addison’s disease or Addison’s disease or
adrenal crisisadrenal crisis
Diuretic phase of acute Diuretic phase of acute
renal failurerenal failure
Use of diureticsUse of diuretics

33. ELDERLY AND CHILDREN AREELDERLY AND CHILDREN ARE
AT HIGH RISK OF ECFVDAT HIGH RISK OF ECFVD

34. CLINICAL MANIFESTATION (EVFVD)(EVFVD)
Thirst Thirst
Muscle weaknessMuscle weakness
Dry mucus membrane; dry Dry mucus membrane; dry
cracked lips or dry tongue cracked lips or dry tongue
Apprehension , restlessness, Apprehension , restlessness,
headache , confusion, coma headache , confusion, coma
in severe deficit in severe deficit
Elevated temperature Elevated temperature
Tachycardia, weak thready Tachycardia, weak thready
pulsepulse
Decreased number and Decreased number and
moisture in stoolsmoisture in stools
Weight lossWeight loss

Peripheral vein fillingPeripheral vein filling> 5 > 5
Narrowed pulse pressure, Narrowed pulse pressure,
decreased CVP&PCWPdecreased CVP&PCWP
Flattened neck veins in Flattened neck veins in
supine positionsupine position
Oliguria<30ml/hOliguria<30ml/h
Postural systolic BP falls Postural systolic BP falls
>>25mm Hg and diastolic fall 25mm Hg and diastolic fall
>> 20 mm Hg , with pulse 20 mm Hg , with pulse
increases increases >> 30 30
Eyeballs soft and sunken Eyeballs soft and sunken
(severe deficit)(severe deficit)

35. Clinical assessment of degree of Clinical assessment of degree of
dehydration(Children)- dehydration(Children)- ((EVFVDEVFVD))
Degree Mild
(5-7% ofBW)
Moderate
(7-10% ofBW
Severe
(>10% ofBW)
1- FontanellaSlightly sunkenVery sunken Very sunken
2- Mucous
membranes
Slightly sticky dry Very dry
3- Skin turgor Normal Slightly
decreased
Markedly
decreased
4- Capillary
refill time
Normal
(<3 seconds)
Normal
(<3 seconds)
Delayed
(≤ 3 seconds)
5- Urine output Normal Slightly
decreased
Decreased or
absent
6-Mental status Normal Slightly fussyIrritable or
lethargic

36. Dehydration in ChildrenDehydration in Children

37. Degrees Of Dehydration in adults
Mild=2%of total body water ~ 1-1.4lit
ThirstThirst
Marked=5% of total body water ~ 3-3.5lit.
Marked thirst,oliguria,Ht.,pulse,R.R, BP, Dry mucous & Marked thirst,oliguria,Ht.,pulse,R.R, BP, Dry mucous &
Low grade fever.Low grade fever.
Severe= 8%Severe= 8% ofof total body water ~ 5-5.5lit.total body water ~ 5-5.5lit.
Symptoms of marked dehydration plus:Symptoms of marked dehydration plus:
Systolic blood pressure drop (60 mm Hg or below)Systolic blood pressure drop (60 mm Hg or below)
Behavioral changes (restlessness, irritability, deliriumBehavioral changes (restlessness, irritability, delirium
& disorientation,)& disorientation,)
Fatal 22–30% of total body water loss~ 15lit. or more
Can prove fatalCan prove fatal
AnuriaAnuria
Coma leading to deathComa leading to death

38. LABORATORY FINDINGS
(EVFVD)(EVFVD)
Increased osmolality(Increased osmolality(>> 295 mOsm/ kg) 295 mOsm/ kg)
Increased or normal serum sodium level Increased or normal serum sodium level
((>> 145mEq/ L ) 145mEq/ L )
Increase BUN (Increase BUN (>>25 mg / L )25 mg / L )
Hyperglycemia ( Hyperglycemia ( >>120 mg /dl )120 mg /dl )
Elevated hematocrit (Elevated hematocrit (>> 55%) 55%)
Increased urine specific gravity ( Increased urine specific gravity ( >> 1.030) 1.030)

39. MANAGEMENT (EVFVD)(EVFVD)
Mild fluid volume loss can be corrected with Mild fluid volume loss can be corrected with
oral fluid replacementoral fluid replacement
-if patient tolerates solid foods advice to take -if patient tolerates solid foods advice to take
1200 ml to 1500ml of oral fluids1200 ml to 1500ml of oral fluids
-if patient takes only fluids, increase the total -if patient takes only fluids, increase the total
intake to 2500 ml in 24 hours intake to 2500 ml in 24 hours

40. MANAGEMENT (EVFVD)(EVFVD)
Estimate Fluid Deficit Estimate Fluid Deficit
(% :- Mild, Moderate, Severe).(% :- Mild, Moderate, Severe).
Find Type of Dehydration Find Type of Dehydration
(Isonatremic, Hyponatremic, Hypernatremic).(Isonatremic, Hyponatremic, Hypernatremic).
Give daily Maintenance.Give daily Maintenance.
Give Deficit as follows: Give Deficit as follows:
Half volume over 8 hours, half volume over 16 Half volume over 8 hours, half volume over 16
hourshours
(Exception: in Hypernatremic Dehydration, (Exception: in Hypernatremic Dehydration,
replace deficit over 48 hours).replace deficit over 48 hours).

41. If haemorrhage is the cause
for ECFVD
Packed red cells followed by hypotonic IV Packed red cells followed by hypotonic IV
fluids is administeredfluids is administered
In situations where the blood loss is less In situations where the blood loss is less
than 1 L Normal Saline or Ringer lactate than 1 L Normal Saline or Ringer lactate
may be usedmay be used
Patients with severe ECFVD accompanied Patients with severe ECFVD accompanied
by severe heart , liver, or kidney disease by severe heart , liver, or kidney disease
cannot tolerate large volumes of fluid and cannot tolerate large volumes of fluid and
sodium & need monitoring (sodium & need monitoring (CVP)CVP)

43. EXTRACELLULAR FLUID
VOLUME EXCESS
ECFVE is ECFVE is
increased fluid increased fluid
retention in the retention in the
intravasular and intravasular and
interstitial spacesinterstitial spaces

44. ETIOLOGY AND RISK
FACTORS(EVFVE)
Heart failureHeart failure
Renal failureRenal failure
Cirrhosis of liverCirrhosis of liver
Increased ingestion of high sodium foodsIncreased ingestion of high sodium foods
Excessive amount of IV fluids containing Excessive amount of IV fluids containing
sodiumsodium
Electrolyte free IV fluidsElectrolyte free IV fluids
SepsisSepsis
Decreased colloid osmotic pressureDecreased colloid osmotic pressure
Lymphatic and venous obstruction Lymphatic and venous obstruction
Cushing’s syndrome & glucocorticoids Cushing’s syndrome & glucocorticoids

45. CLINICAL MANIFESTATION
(EVFVE)(EVFVE)
Constant irritating coughConstant irritating cough
Dyspnoea & crackles in lungsDyspnoea & crackles in lungs
Cyanosis, pleural effusionCyanosis, pleural effusion
Neck vein distention Neck vein distention
Bounding pulse &elevated BPBounding pulse &elevated BP
S3 gallopS3 gallop
Pitting & anasacra edemaPitting & anasacra edema
Weight gainWeight gain
Increased CVP& PCWPIncreased CVP& PCWP
Change in level of consciousnessChange in level of consciousness

46. LAB INVESTIGATION
(EVFVE)
serum osmolality <275mOsm/ kgserum osmolality <275mOsm/ kg
Low , normal or high sodiumLow , normal or high sodium
Decreased hematocrit [ < 45%]Decreased hematocrit [ < 45%]
Urine specific gravity below 1.010Urine specific gravity below 1.010
Decreased BUN [< 8mg/ dl] Decreased BUN [< 8mg/ dl]

47. MANAGEMENT
(EVFVE)(EVFVE)
Diuretics [combination of potassium Diuretics [combination of potassium
sparing and potassium depleting sparing and potassium depleting
diuretics]diuretics]
In people with CHF: ACE inhibitors and In people with CHF: ACE inhibitors and
low dose of beta blockers are used low dose of beta blockers are used
A low sodium diet A low sodium diet

48. EXTRACELLULAR FLUID
VOLUME SHIFT: THIRD
SPACING(shift)
Fluid that shifts into nonfunctioning Fluid that shifts into nonfunctioning
spaces and remain there is called as spaces and remain there is called as
third space fluid third space fluid
Common sites are abdomen , pleural Common sites are abdomen , pleural
cavity, peritoneal cavity and GI lumen cavity, peritoneal cavity and GI lumen

49. RISK FACTORS(shift)
Crushing injuries, major tissue traumaCrushing injuries, major tissue trauma
Major surgeryMajor surgery
Extensive burnsExtensive burns
PancreatitisPancreatitis
Perforated peptic ulcers - peritonitisPerforated peptic ulcers - peritonitis
Intestinal obstructionIntestinal obstruction
Lymphatic obstruction Lymphatic obstruction
HypoalbumenemiaHypoalbumenemia

50. CLINICAL
MANIFESTATION(shift)
skin pallorskin pallor
Cold extremitiesCold extremities
Weak and rapid pulseWeak and rapid pulse
Hypotension Hypotension
OliguriaOliguria
Decreased levels of consiousness Decreased levels of consiousness
LAB INVESTIGATION
Elevated hematocrit & BUN levelElevated hematocrit & BUN level
As in the iso-osmolarAs in the iso-osmolar

51. MANAGEMENT(shift)
Treat the cause
•For burns and tissue injuries large volume For burns and tissue injuries large volume
of isosmolar IV fluid is administeredof isosmolar IV fluid is administered
•Albumin is administered for protein deficitAlbumin is administered for protein deficit
•IV fluid intake is maintained after major IV fluid intake is maintained after major
surgery to maintain kidney perfusion surgery to maintain kidney perfusion
•Paracentesis or tapping for ascitis or Paracentesis or tapping for ascitis or
pleural effusion pleural effusion

52. INTRACELLULAR FLUID
VOULME EXCESS:WATER
INTOXICATION
ICFVE is increase in amount of water ICFVE is increase in amount of water
inside the cellsinside the cells

53. ETIOLOGY (ICFVE)
Administration of excessive amount of Administration of excessive amount of
hyposmolar IV fluids[0.45%saline or hyposmolar IV fluids[0.45%saline or
5%dextrose in water]5%dextrose in water]
Consumption of excessive amount of tap Consumption of excessive amount of tap
water without adequate nutritional intakewater without adequate nutritional intake
(Schizophrenia[compulsive water (Schizophrenia[compulsive water
consumption])consumption])
SIADH results from innapropriate ADH SIADH results from innapropriate ADH
secretion resulting in innapropriate secretion resulting in innapropriate
retention of ingested/infused water retention of ingested/infused water

54. CLINICAL MANIFESTATIONS
(ICFVE)
HeadachesHeadaches
Behavioral changes Behavioral changes
ApprehensionApprehension
Irritability, disorientation and confusionIrritability, disorientation and confusion
Increased ICP – pupillary changes and Increased ICP – pupillary changes and
decreased motor and sensory functiondecreased motor and sensory function
Bradycardia, elevated BP, widened pulse Bradycardia, elevated BP, widened pulse
pressure & altered respiratory patterns, pressure & altered respiratory patterns,
Babinski’s response flaccidity, projectile Babinski’s response flaccidity, projectile
vomiting, papilledema, delirium, convulsions vomiting, papilledema, delirium, convulsions
&coma&coma

55. LABORATORY FINDINGS
(ICFVE)
Low serum sodium level- 125 mEq/L Low serum sodium level- 125 mEq/L
decreased hamatocritdecreased hamatocrit

56. MANAGEMENT (ICFVE)
Early administration of IV fluids containing Early administration of IV fluids containing
sodium chloride can prevent SIADHsodium chloride can prevent SIADH
oral fluids such as juices or soft drinks can be oral fluids such as juices or soft drinks can be
given orally every hourgiven orally every hour
Perform neurologic checks every hour to see if Perform neurologic checks every hour to see if
cranial changes are presentcranial changes are present
Monitor fluid intake , IV fluids and fluid output Monitor fluid intake , IV fluids and fluid output
hourly and weight dailyhourly and weight daily
Administer antiemetics for food and fluid Administer antiemetics for food and fluid
retention retention

57. INTRACELLULAR FLUID
VOLUME DEFICIT
Severe hypernatremia and dehydration Severe hypernatremia and dehydration
can cause ICFVDcan cause ICFVD
Relatively rare in healthy adultsRelatively rare in healthy adults
Common in elderly people and in those Common in elderly people and in those
conditions that result in acute water lossconditions that result in acute water loss
Symptoms include confusion, coma, and Symptoms include confusion, coma, and
cerebral hemorrhagecerebral hemorrhage

58. Assessment of fluid and Assessment of fluid and
Electrolytes Imbalance;Electrolytes Imbalance;
Observation of general condition of the patient, Observation of general condition of the patient,
including including vital signsvital signs, , neck veinsneck veins, , skinskin, and , and
mucous membranesmucous membranes, , weightweight, , presence of presence of
edemaedema and and appetite.appetite.
Type of fluid lost.Type of fluid lost.
Character and volume of urine & specific gravity Character and volume of urine & specific gravity
Assessment of blood electrolytes level.Assessment of blood electrolytes level.
Blood urea nitrogen and creatinine level.Blood urea nitrogen and creatinine level.
Frequency and character of stool.Frequency and character of stool.
Measuring and recording intake and output.Measuring and recording intake and output.

59. The rules of fluid replacement:The rules of fluid replacement:
Replace blood with bloodReplace blood with blood
Replace plasma with colloid or LRReplace plasma with colloid or LR
Resuscitate with colloid or LRResuscitate with colloid or LR
Replace ECF depletion with salineReplace ECF depletion with saline
Rehydrate with dextroseRehydrate with dextrose
Hyponatremic pt. needs Hyponatremic pt. needs NSS or hypertonic salineNSS or hypertonic saline
Hypernatremic pt. needsHypernatremic pt. needs
–D5W or hypotonic salineD5W or hypotonic saline

60. Hypo versus HyperHypo versus Hyper

61. INDICATORS OF SUCCESSFUL
RESUSCITATION
URINARY OUTPUTURINARY OUTPUT
–CHILDREN = 1.0 ml/kg/hrCHILDREN = 1.0 ml/kg/hr
–ADULT = 0.5 ml/kg/hrADULT = 0.5 ml/kg/hr
BLOOD PRESSURE BLOOD PRESSURE
POORPOOR INDICATOR INDICATOR

62. How much fluid to give ?How much fluid to give ?
What is your starting point ?What is your starting point ?
–Euvolemia ?Euvolemia ?( normal )( normal )
–Hypovolemia ? ( dry )Hypovolemia ? ( dry )
–Hypervolemia ? ( wet )Hypervolemia ? ( wet )
What are the expected losses ?What are the expected losses ?
What are the expected gains ?What are the expected gains ?

63. MAINTENANCE THERAPY..
Maintenance therapy is usually undertaken Maintenance therapy is usually undertaken
when the individual is not expected to eat or when the individual is not expected to eat or
drink normally for a longer time (eg, drink normally for a longer time (eg,
perioperatively or on a ventilator).perioperatively or on a ventilator).
Big picture: Most people are “NPO” for 8-12 Big picture: Most people are “NPO” for 8-12
hours each day.hours each day.
Patients who won’t eat for > one to two weeks Patients who won’t eat for > one to two weeks
should be considered for parenteral or enteralshould be considered for parenteral or enteral
nutrition.nutrition.

64. ..MAINTENANCE THERAPY
water requirements increase with:water requirements increase with:
fever, sweating, burns, tachypnea, surgical fever, sweating, burns, tachypnea, surgical
drains, polyuria, or ongoing significant drains, polyuria, or ongoing significant
gastrointestinal lossesgastrointestinal losses..
For example, water requirements For example, water requirements increase by increase by
100 to 150 mL/day100 to 150 mL/day for each C degree of body for each C degree of body
temperature elevation.temperature elevation.

65. ..MAINTENANCE THERAPY
4/2/1 rule4/2/1 rule
4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24h4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24h
then 2 ml/kg/hr for next 10 kg (=20ml/hr)=50ml/kg/24hthen 2 ml/kg/hr for next 10 kg (=20ml/hr)=50ml/kg/24h
then 1 ml/kg/hr for any kgs over that=20ml/kg/24hthen 1 ml/kg/hr for any kgs over that=20ml/kg/24h
This always gives 60ml/hr for first 20 kgThis always gives 60ml/hr for first 20 kg
then you add 1 ml/kg/hr for each kg over 20 kgthen you add 1 ml/kg/hr for each kg over 20 kg
This boils down to: This boils down to: Weight in kg + 40 = Maintenance IV Weight in kg + 40 = Maintenance IV
rate/hourrate/hour..
For any person weighting >20kg &<100kg.For any person weighting >20kg &<100kg.
Daily fluid maintenance in pediatrics:Daily fluid maintenance in pediatrics:
0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc

66. Electrolytes

67. WHAT DO ELECTROLYTES DO?WHAT DO ELECTROLYTES DO?

68. Serum Values of Electrolytes
Cations (+)Cations (+) ConcentrationConcentration
SodiumSodium 135 – 145 mEq/L135 – 145 mEq/L
PotassiumPotassium 3.5 - 4.5 mEq/L 3.5 - 4.5 mEq/L
CalciumCalcium 9-10.5 mg/dL 9-10.5 mg/dL
MagnesiumMagnesium 1.5 - 2.5 mEq/L 1.5 - 2.5 mEq/L
Anions (-)Anions (-)
ChlorideChloride 95 – 107 mEq/L 95 – 107 mEq/L
CO2CO2 24 – 30 mEq/L 24 – 30 mEq/L
PhosphatePhosphate 2.5 - 4.5 mEq/L 2.5 - 4.5 mEq/L
HCOHCO
33
22 – 26 mEq/LmEq/L

69. Location of Ions
Intracellular Ions
Mg++ K+ Ph-
Cl-
Na+
Ca++
Extracellular Ions

70. Daily Requirements for
Electrolytes
Sodium: 1-2 mEq/kg/dSodium: 1-2 mEq/kg/d
Potassium: 0.5-1 mEq/kg/dPotassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/dCalcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/dMagnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/dPhosphorus: 800 - 1200 mg/d

71. Sodium
imbalance
s
Definiti
on
Risk factors/
etiology
Clinical
manifestation
Laboratory
findings
management

Hyponat
raemia
 
 
It is
defined
as a
plasma
sodium
level
below
135
mEq/ L
•Kidney diseases
• Adrenal
insufficiency
• Gastrointestinal
losses
• Use of diuretics
(especially with
along with low
sodium diet)
• Metabolic
acidosis
•Weak rapid
pulse
•Hypotension
•Dizziness
•Apprehension
and anxiety
•Abdominal
cramps
•Nausea and
vomiting
•Diarrhea
•Coma and
convulsion
•Cold clammy
skin
•Finger print
impression on
the sternum
after palpation
•Personality
change
•Serum sodium
less than
135mEq/ L
• serum
osmolality less
than
280mOsm/kg
•urine specific
gravity less
than 1.010
•Identify the
cause and treat
•Administration of
sodium orally, by
NG tube or
parenterally
•For patients who
are able to eat &
drink, sodium is
easily
accomplished
through normal
diet
•For those unable
to eat,Ringer’s
lactate solution or
isotonic saline
[0.9%Nacl]is
given
•For very low
sodium 3%Nacl
may be indicated
•water restriction
in case of
hypervolaemia

72. CLINICAL MANIFESTATIONS OF HYPONATREMIACLINICAL MANIFESTATIONS OF HYPONATREMIA
Muscle
Weakness
Apathy
Postural
hypotension
Nausea and
Abdominal
Cramps
Weight Loss
In severe hyponatremia: mental confusion, delirium, shock and coma

73. Sodium
imbalan
-ce
Definiti
on

causes Clinical
manifestation

Lab findings

management
Hypernat
-remia
It is
define
d as
plasm
a
sodiu
m
level
greate
r than
145m
E
q/L
*Ingestion of
large amount
of
concentrated
salts
*Iatrogenic
administratio
n of
hypertonic
saline IV
*Excess
alderosteron
e secretion
* Low grade fever
Postural
hypertension
*Dry tongue &
mucous
membranes
* Agitation
* Convulsions
*Restlessness
 *Excitability
·
*Oliguria or
anuria
·
*Thirst
*Dry &flushed
skin
*high serum
sodium
145mEq/L
 
*high serum
osmolality295
mO sm/kg
 
*high urine
specificity
1.030
*Administration of
hypotonic sodium
solution [0.3 or 0.45%] 
*Rapid lowering of
sodium can cause
cerebral edema
*Slow administration of
IV fluids with the goal of
reducing sodium not
more than 2 mEq/L for
the first 48 hrs
decreases this risk
*Diuretics are given in
case of sodium excess
*In case of Diabetes
insipidus desmopressin
acetate nasal spray is
used 
*Dietary restriction of
sodium in high risk
clients

74. CLINICAL MANIFESTATIONS of
HYPERNATREMIA
Thirst Dry & sticky mucous membranesThirst Dry & sticky mucous membranes Firm, rubbery Firm, rubbery
tissue turgortissue turgor
Manic excitementManic excitement
TachycardiaTachycardia
DEATHDEATH

75. Potassium
imbalances
Definitio
n
Causes Clinical
manifestation
Lab findings Management
Hypokale
mia

















It is
defined
as
plasma
potassiu
m level
of less
than 3.0
mEq/L
*Use of
potassium
wasting
diuretic
*diarrhea,
vomiting or
other GI
losses
*Alkalosis
*Cushing’s
syndrome
*Polyuria
*Extreme
sweating
*excessive
use of
potassium
free Ivs
*weak
irregular pulse
*shallow
respiration
*hypotesion
*weakness,
decreased
bowel sounds,
heart blocks ,
paresthesia,
fatigue,
decreased
muscle tone
intestinal
obstruction
* K – less
than 3mEq/L
results in ST
depression ,
flat T wave,
taller U wave
* K – less
than 2mEq/L
cause
widened
QRS,
depressed
ST, inverted
T wave
Mild
hypokalemia[3.3to
3.5] can be managed by
oral potassium
replacement
Moderate
hypokalemia
*K-3.0to 3.4mEq/L need
100to 200mEq/L of IV
potassium for the level to
rise to 1mEq/
Severe hypokalemia
K- less than 3.0mEq/L
need 200to 400 mEq/L
for the level to rise to l
mEq/L
*Dietary replacement of
potassium helps in
correcting the
problem[1875 to 5625
mg/day]

76. DefinitionCauses Clinical
manifestation
Lab findings Management

Hyperk
alemia
It is
defined
as the
elevation
of
potassiu
m level
above
5.0mEq/L
Renal failure ,
 
Hypertonic
dehydration,
 
Burns& trauma
 
Large amount of
IV
administration of
potassium,

Adrenal
insufficiency
 
Use of
potassium
retaining
diuretics &
rapid infusion of
stored blood
Irregular slow
pulse,
 
hypotension,
 
anxiety,
 
irritability,
 
paresthesia,
 
weakness
*High
serum
potassium
5.3mEq/L
results in
peaked T
wave HR
60 to 110
 
*serum
potassium
of 7mEq/L
results in
low broad
P- wave
 
*serum
potassium
levels of
8mEq/L
results in
no arterial
activity[no
p-wave]

•Dietary restriction of
potassium for potassium
less than 5.5 mEq/L
•Mild hyperkalemia can
be corrected by
improving output by
forcing fluids, giving IV
saline or potassium
wasting diuretics
• Severe
hyperkalemia is
managed by
1.infusion of calcium
gluconate to decrease
the antagonistic effect of
potassium excess on
myocardium
2.infusion of insulin and
glucose or sodium
bicarbonate to promote
potassium uptake
3.sodium polystyrene
sulfonate [Kayexalate]
given orally or rectally as
retention enema

77. Calcium
imbalan
ces
Definitio
n
Causes Clinical
manifestation
Lab
finding
s

Management
hypoc
alcemi
a
It is a
plasma
calcium
level
below
8.5
mg/dl
•Rapid
administration of
blood containing
citrate,
•hypoalbuminemi
a,
•Hypothyroidism ,
 
•Vitamin
deficiency,
•neoplastic
diseases,
•pancreatitis
•Numbness
and tingling
sensation of
fingers,
•hyperactive
reflexes,
• Positve
Trousseau’s
sign, positive
chvostek’s sign
,
•muscle
cramps,
•pathological
fractures,
•prolonged
bleeding time
Serum
calciu
m less
than
4.3
mEq/L
and
ECG
change
s
1.Asymtomatic hypocalcemia is
treated with oral calcium
chloride, calcium gluconate or
calcium lactate
 
2.Tetany from acute
hypocalcemia needs IV calcium
chloride or calcium gluconate to
avoid hypotension bradycardia
and other dysrythmias
 
3.Chronic or mild hypocalcemia
can be treated by consumption
of food high in calcium

78. TESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCYTESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCY

79. Calcium
imbalance
Definition Causes Clinical
manifestation
Lab findings Management


Hyperc
alcemia
It is
calcium
plasma
level over
5.5 mEq/l
or
11mg/dl
•Hyperparathy
roidism,
 
•Metastatic
bone tumors,
 
•paget’s
disease,
•osteoporosis
,
•prolonged
immobalisatio
n
•Decreased
muscle tone,
•anorexia,
 
•nausea,
vomiting,
•weakness ,
lethargy,
 
•low back pain
from kidney
stones,
•decreased
level of
consciousnes
s & cardiac
arrest
•High serum
calcium level
5.5mEq/L,
• x- ray
showing
generalized
osteoporosis,
•widened
bone
cavitation,
•urinary
stones,
•elevated BUN
25mg/100ml,
•elevated
creatinine1.5
mg/100ml
1.IV normal saline, given
rapidly with Lasix
promotes urinary
excretion of calcium
 
2.Plicamycin an
antitumor antibiotics
decrease the plasma
calcium level
 
3.Calcitonin decreases
serum calcium level
 
4.Corticosteroid drugs
compete with vitamin D
and decreases intestinal
absorption of calcium
 
5. If cause is excessive
use of calcium or vitamin
D supplements reduce
or avoid the same

81. W
h
y

d
o
w
e
c
a
r
h
b
W
h
y

d
o
w
e
c
a
r
h
b ANY QUESTION?
ANY QUESTION?
8181

82. Thank
Thank
You
You