Title: Fluids and Electrolytes

Lecturer: Dr. Quebral

Date: November 3, 2009

LEGEND Normal Calibri 9 - lecture ppts, audio transcription, old trans infos Underlined - info from the book Schwartz Bold - emphasized words from any source Sample cases in Bold are from old trans also. REFERENCES 2011A Trans, Dr. Quebrals ppt, audio recording, surgery book of Schwarts, surgery book of Norton There are a lot of factors that can affect the fluid and electrolyte status of a surgical patient and these status may occur before the operation (preoperatively), during the operation (intraoperatively) and after the operation postoperatively. Factors that affect the fluid and electrolyte status Preoperatively Underlying disease/condition o External e.g a Villous adenoma, there are multiple polyps in the colon manifest by severe diarrhea up to 4L/day. Blood loss in wound patients. Burn patients. o Internal Fluid sequestration Diagnostic workup e.g patients who need to undergo blood tests such as fasting for FBS, OGTT, endoscopy Preop preparation e.g Patients undergoing major surgery on the regional and general anesthesia have to be on NPO (nothing per orem) for at least 6 hours. Intraoperatively Blood loss Aside from the actual blood loss, one other mechanism is evaporation. Amount of dissection large dissection = evaporation & edema Duration of operation Longer duration = exposure to light, evaporation etc Postoperatively After the operation normal physiologic actions of the body may be temporarily disrupted due to injury. Fluid sequestration Ileus (disruption of gastric motility) after GIT operation during this time fluid is in the wrong places. Fluid is in the bowel wall not in the lumen of the intestine where they are supposed to be, fluid is in the peritoneal cavity not in the vascular system. Drains & stomas Draining fluid from the body e.g colostomy etc Fistulae abnormal connection or passageway Complications bleeding, infection (inflammation, edema), Acute Renal Failure (ARF) When we talk about fluid and electrolytes we talk about the vascular volume, so when you have fluid in the subcutaneous or bowel wall, peritoneal cavity these are fluids which are nonfunctional

Total Body Water (TBW) We are basically made up of water, about 50-70% on the average 60%. Adipose tissue holds less water. TBW refers to the water content of the body and all the dissolved substances within it. Water constitutes about 50 (female)-60 (male) % of TBW on the average. Lean tissues such as muscle and solid organs have higher water content than fat and bone. (e.g. male > female, thin> obese, young>elderly). Newborns have the highest percentage of TBW (approx. 80%). By 1 year, it decreases to about 65%, and remains fairly constant throughout The relationship between total body weight and total body water (TBW) is relatively constant for an individual and is primarily a reflection of body fat. Distribution of body Water

Figure 1. Functional body fluid compartments. TBW = total body water.

Figure 2. Allotment in different body compartments. Sixty percent of body weight is composed of total body water compartment with its subdivisions

***body water is found in different compartments, some of which are in the circulatory system, your plasma water which is about 3.5L. ***We have fluid outside of the vasculature but still extracellular this is your interstitial fluid (where edema sets in) about 10.5L. The total extracellular volume is about 14L. The rest is intracellular 28L of the total 42L TBW.

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar

Total blood volume is 7-8% of total body weight = 5 litres. RBC volume: 2-3% of TBW TBW (50-60% body weight)

ICF - 2/3 of TBW - 40% of body weight

ECF - 1/3 of TBW - 20% of body weight

Plasma - 5% of body weight

Interstitial Fluid - 15% of body weight

Figure 4. Chemical composition of body fluid compartments.

Figure 3: Functional body fluid compartments. (ICF intracellular fluid; ECF extracellular fluid; ICF has the largest proportion in the skeletal muscle mass.)

Table 1. Volume and Composition of GI Fluids

Source

Intracellular and Extracellular Body Solutes Principal Ions Cations Anions ICF Potassium (K) Magnesium (Mg) Phosphate (PO4 ) Sulfate ECF Sodium (Na)

Chloride (Cl) Bicarbonate (HCO3 ) Albumin Mnemonic for major ions: PISO (potassium - in, sodium out) Our body fluids are not just water but also contain cellular elements, osmotically active substances and electrolytes. The concentration gradient between compartments is maintained by ATP-driven sodium-potassium pumps located within the cell membranes. The composition of the plasma and interstitial fluid differs only slightly in ionic composition, with the primary difference being the slightly higher protein composition in plasma. (looking at figure 4, protein is 16 in plasma while only 1 in interstitial fluid..pero ayon kay Schwartz slightly higher concn lang daw iyon..) Proteins in plasma specifically albumin is responsible for plasma oncotic pressure and contribute to the balance of forces that determine fluid balance across the capillary endothelium. Water is freely diffusible. It is distributed evenly throughout all fluid compartments of the body so that a given volume of water increases the volume of any one compartment relatively little. However, in the case of sodium, because of its osmotic and electrical properties, it remains associated with water. Recall that sodium is confined to the extracellular fluid compartment. Thus, when sodium-containing fluids are administered, it will be distributed throughout the extracellular fluid and add to the volume of both the intravascular and interstitial spaces. It also expands the interstitial space by approximately three times as much as the plasma. Take note of the difference between the intracellular and the extracellular compartments

Volu Na Cl K HCO3 H me (mEq/ (mEq/ (mEq/ (mEq/ (mEq/ (ml) L) L) L) L) L) Stomach 1000 20 - 130 10 30 120 15 100 4200 Duodenum 100 110 115 15 10 2000 Ileum 1000 80 60 - 10 30 150 110 50 3000 Colon 500 120 90 25 45 1700 Bile 500 140 100 5 25 1000 Pancreas 500 - 140 30 5 115 1000 There are other body fluids but the lecture concentrated on GI fluids because they are the most active. Fluid and electrolyte disturbances occur in the loss of these fluids. Take note that different parts of the GIT have different electrolyte composition; this is important in fluid replacement in the GIT. We are not expected to memorize this daw. How do we gain and lose water? The body produces water to a certain extent from certain oxidative processes (oxidation from metabolism produces water as one of its by-products, recall Krebs Cycle). but only in insignificant amounts. Average Intake and Losses Intake Oral 2000-2500 ml/day Oxidation* 250 ml/day

800 1500 ml/day Stool 250 ml/day Insensible 600 900 losses** ml/day Water loss depends on water intake, ambient temperature and activity, and intake of diuretics such as coffee. Regulation: Arginine Vasopressin (AVP) **insensible losses 75% through skin, 25% respiration, and is by definition, pure water. Insensible losses can be increased by such factors as fever, hypermetabolism, and hyperventilation. For every o degree rise above 37 C, there is additional 10% insensible loss. So a o febrile patient with a temp of 40 C will have a 30% additional insensible loss.

Losses Urine

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar

Sweating, on the other hand, is an active process and involves loss of (hypotonic) electrolytes and water. To clear the products of metabolism, the kidneys must excrete a minimum of 500 to 800 mL of urine per day, regardless of the amount of oral intake. The normal person also consumes about 3 to 5 g of salt per day, with the balance maintained by the kidneys. With hyponatremia, sodium excretion can be reduced to as little as 1 mEq/d or maximized up to 5000 mEq/d to achieve balance in lieu of salt-wasting kidneys. Maintenance of Water Requirement How to correct water volume? *This is correcting for the water volume only regardless of the electrolytes it contains Weight st 1 10 kg nd 2 10 kg Each kg > 20 kg Adult ml/kg/day Pediatric ml/kg/hr If you have a 60Kg adult needs WATER VOLUME ONLY correction. First 10Kg = 10kg X 100 ml/kg/day = 1000ml/day Second 10Kg = 10Kg X 50 ml/kg/day = 500ml/day Remaining 40Kg = 40Kg X 20 ml/kg/day = 800ml/day Total: 2300ml/day So a 60Kg adult needs 2300ml or 2.3L or water a day to correct water volume w/o consideration of electrolytes. This is just maintenance, you also have to consider deficit and ongoing losses (pero hindi niya tinuro yun sa lecture). Maintenance of Electrolyte Requirements Na: K: 1 2 mEq/kg/day 0.5 1 mEq/kg/day ml/kg/hr 4 2 1 ml/kg/day 100 50 20

*Take note of different electrolyte contents

Solution D5W D5LR D5NSS D5NM

Na (mEq/L) 0 130 154 40

K (mEq/L) 0 4 0 13

Cl (mEq/L) 0 109 154 40

Lactate 0 28 0 13

Glucose (g/L) 50 50 50 50

Table 4. Available IV Fluid solutions locally (from Schwartz)

Solution ECF

Electrolyte Composition (mEq/L) Na Cl K HCO3 Ca 142 103 4 27 5

Mg 3

Lactated 130 109 4 28 3 Ringers 0.9% 154 154 308 Sodium Chloride D5 0.45% 77 77 407 Sodium Chloride D5W 253 3% 513 513 1026 Sodium Chloride * D5LR and D5NSS belong to crystalloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid Types of Parenteral Solutions *not in the lecture, but in the 2011 trans so malay mo diba. Maikli lang naman to basahin nyo na. I. Crystalloids A. Isotonic Solutions - have an osmolarity about equal to that of serum - stays in intravascular space and expands intravascular compartments - CAUTION: can expand vascular compartments B. Hypertonic Solutions -draws fluid into the intravascular compartment Used to replace electrolytes C. Hypotonic Solutions - shifts fluids out of the intravascular space - hydrates cells and interstitial compartments - CAUTION: it lowers Na levels. Take into consideration hypotensive patients because this depletes the circulatory system. Examples: Lactated Ringers Solution (LRS) - slightly hypotonic in that it contains 130 mEq of sodium, which is balanced by 109 mEq of chloride and 28 mEq of lactate (pero considered as isotonic pa rin sya sabi ni Schwartz) - replacing gastrointestinal losses and extracellular volume deficits -often used for fluid resuscitation after a blood loss due to trauma, surgery, or burn. - also used to induce urination in patients with renal failure - used to counteract acidosis - not suited for maintenance due to high Na and low K content - lactate is used rather than bicarbonate because it is more stable for storage purposes. It is converted into bicarbonate in the liver following infusion, even in the face of hemorrhagic shock 0.9% NaCl (aka Plain NSS or PNSS) -mildly hypertonic, containing 154 mEq of sodium that is balanced by 154 mEq of chloride. (like LRS, considered isotonic pa din sya, nonetheless)

mOsm 280310 273

Ex. 60Kg man named Delo boy needs 60-120 mEq/day sodium, 30-60 mEq/day potassium as maintenance. This does not include losses from NGT, vomiting, fistula etc. Equivalence = atomic weight (g) / valence For univalent ions such as sodium (Na ), 1 mEq is the same as 1 2+ mmol. For divalent ions such as magnesium (Mg ), 1 mmol equals 2 mEq.
+

Sample Case 1: A 26 y/o man weighing 70 kg is for elective herniorrhaphy at 8:00 am. Preoperative preparation requires putting him on NPO after midnight. What are his fluid & electrolyte requirements? Using ml/kg/day 10 kg x 100 10 kg x 50 50 kg x 20 Using ml/kg/hr 10 kg x 4 10 kg x 2 50 kg x 1

1000 500 1000 2,500 ml/day or 2.5 L

40 20 50 110 ml/kg/hr X 24 hrs 2640 ml/day Na: 70 - 140 mEq/kg/day K: 35 - 70 mEq/kg/day

Table 3. Available IV Fluid solutions locally

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar

- its high chloride concentration imposes a significant chloride load upon the kidneys and may lead to a hyperchloremic metabolic acidosis. - ideal solution for correcting volume deficits associated with hyponatremia, hypochloremia, and metabolic alkalosis D5 0.45% NaCl - 5% of dextrose and 0.45% of NaCl - good for maintenance in post operations - dextrose: for keeping osmolality and prevention of RBC cell lysis 3% NaCl - ideal solution for correcting hyponatremia, hypochloremia, and metabolic alkalosis as is indicated by the high Na content. - CAUTION: high chloride concentration imposes a significant chloride load upon the kidneys and may lead to a hyperchloremic metabolic acidosis. D5W (5% Dextrose in Water) D5NSS (dextrose 5% in normal saline solution) D5LR (Dextrose in Lactated Ringers) D5NM (Normosol-M in 5% Dextrose) hypertonic solution of balanced electrolytes and 5% dextrose in water D5 NSS D5 NSS D10 (10% Dextrose) II. Alternatives (Colloids) Colloids - gives more efficient plasma volume expansion - comprise preparations of plasma or high-molecular weight synthetic substances - they are initially contained in the intravascular space - CAUTION: take into the consideration severe hemorrhagic shock patients where in the capillaries have increased permeability Albumin - heat sterilized from a pooled human plasma source - watch out for allergic reactions Dextran - glucose polymers produced by Leuconostoc mesentroides and Streptococcus mutans, lactic acid bacteria grown in sucrose - primarily used to lower blood viscosity rather than as volume expanders Hydroxyethyl Starch - a non-ionic starch derivative - produced by the hydrolysis of insoluble amylopectin, followed by a varying number of substitutions of hydroxyl groups for carbon groups on glucose molecules - has a limited role in massive resuscitation because of its associated coagulopathy and hyperchloremic acidosis (due to its high chloride content) Gelatins - from bovine collagen Distribution Volume Different IV fluids, while these are infused intravenously, will not stay in the circulatory system because of the similarities or dissimilarities of these fluids with certain body compartments. An area or volume where the IV fluids will stay or not stay is called distribution volume. - the volume in which the administered solution will equilibrate over the short term. e.g. TBW distribution vol. of Na-free water ECV dist. vol. of crystalloid solution PV dist. vol. of most colloid solutions Important formulae are as follows:

Expected Plasma Volume increment = Volume infused x normal PV distribution volume Volume infused = Expected PV increment x distribution volume Normal PV Ex. A Px with a stab wound in the chest where you were able to drain 1L of blood. Now the patient is missing 1L of blood, you are to replace the lost blood with blood also. Blood stays in the circulatory system so replace 1L of blood with 1L of blood. Using blood to replace the blood deficit Vol inf. = 1L (obviously, because you want to replace 1L of lost blood w/ 1Liter of blood). This can be shown thru the formula mentioned earlier. Expected PV increment 1L (1L blood loss) Normal PV = 3.5 distribution volume(blood) = 3.5L (since blood will stay in the circulatory system, you use plasma water volume which is 3.5L)

maintenance So the equation is 1L X 3.5L/3.5L = 1L volume infused If using plain water w/o electrolytes (D5W) to replace 1L of lost blood. Using the same equation volume infused: Expected Plasma Volume increment = 1L because you want to replace 1L of loss blood Distribution volume(water)= 42L or the TBW. Why? Because your using water, and unlike blood, water does not stay in the circulatory system but is distributed in the entire body Normal PV = 3.5L So the equation is 1L x 42L / 3.5L = 12L volume infused (too much daw ito sabi sa lec baka malunod na px mo. If lactated ringers (D5LR) Using the same equation volume infused: Expected PV increment = 1L (because you want to replace 1L of blood lost) Distribution volume(EC fluid) = 14L. (Why? Because your lactated ringers has a composition very similar to plasma and interstitial fluid so it will be distributed to both plasma and interstitial fluid. plasma water volume is 3.5, interstitial fluid is 10.5, add them you get 14, this is equivalent to extracellular volume) Normal PV = 3.5L So the equation is 1L x 14L / 3.5L = 4L volume infused Sample Case 2: th A 23 y/o man weighing 70 kg, sustains a stab wound at the 4 ICS RMCL. He is brought to the ER & a chest tube is inserted. The initial drainage is 1L of blood. What would happen if D5W were used for resuscitation? If Lactated Ringers? If colloid? 10 kg x 100 10 kg x 50 50 kg x 20 1000 500 1000 2,500 ml/day or 2.5 L

2.5L + 1L (blood loss) = 3.5 L fluid needed to be replaced D5W = (1L x 42L)/3.5L = 12 liters need to replace 1 liter blood loss (D5W is Na-free TBW 42L) LRS = (1L x 14L)/3.5L = 4 liters to replace 1 liter blood loss (crystalloids ECV 14L). 250 ml per 1 liter of LRS will stay in intravascular compartment

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar

Colloid = (1L x 3.5L)/3.5L = 1 L (1:1 replacement) (colloid PV 3.5L), eg, 5% albumin, D5W is not used in resuscitation because of the very high volume needed, since resuscitation of intravascular volume is of primary importance. Generally, colloids are not used either. Sample Case 3: A 66 y/o man weighing 65 kg, is admitted for vomiting, abdominal distention and non-passage of stool and flatus. 30 years ago he had an operation for a perforated appendix. Upon admission, an NGT is inserted & drains 700 ml bilious material in 24 hrs. How will you compute for his fluid & electrolyte requirements? What is the appropriate IVF for replacing the NGT losses? 10 kg x 100 1000 10 kg x 50 500 45 kg x 20 900 2,400 ml/ day or 2.4 L 2,400 ml + 700 ml (bilious material) = 3,100 ml **Recall Volume and Composition of GI Fluids above. Electrolyte requirements: Na (65kg x 2meq) + (140meq x 0.7L) = 228 meq

Table 5: Schwartz)

Signs

and

Symptoms

of

Volume

Disturbances.

(from

Treatment Fluid resuscitation Maintenance + deficit + ongoing losses Appropriate fluid crystalloids, colloids, blood Add electrolytes edema fluid give colloids so you can mobilize edema fluids, put them into circulation and let the kidneys expel it. Hard to excrete if the fluid is in the edema. x 8hrs, remainder in 16hrs* constantly asses and reassess the Px. What you computed now may not be applicable 8hrs later Monitoring Intake & output charting Vital signs, UO, CVP Electrolytes, ABGs, BUN, creatinine

*140 meq is the normal level of Na

K (65kg x 1meq) + (5meq x 0.7L) = 68.5 meq *5 meq is the normal value of K IVF orders: DLRS 1L + KCl 20meq x 8hr D5W 1L x 8hr D5LRS 1L + KCl 20meq x 8hr or give LRS for ml per ml replacement for NGT losses as side drip to maintenance IVF Fluid and Electrolyte Balance Abnormalities Disorders of volume Disorders of concentration Disorders of composition Fluid Volume & Concentration Disorders Causes Decreased volume-normal electrolytes -> burns, fractures, duodenal fistula, perforated viscus, pancreatitis, intestinal infarct, distal SBO Decreased volume-decreased electrolytes -> proximal GI obstruction, ileal fistula + water intake, diarrhea + water intake, diuretics, salt-losing nephropathy Normal/increased water-decreased electrolytes -> inappropriate ADH, chronic renal failure, hepatic failure, cardiac failure, cirrhosis

Electrolyte Composition Disorders ***See figure 4 in page 2 for normal meq of ions. I. Disorders of Sodium Homeostasis - Na balance determines volume status; water balance determines tonicity (Na conc) Volume overload = increased total body Na (regardless of serum Na conc) Euvolemia = normal total body Na (regardless of serum Na conc) Volume depletion = decreased total body Na (regardless of serum Na conc) A. Hyponatremia (relative water excess) - Primary vs secondary vs factitious -100mg/dl rise in glucose = 1.3mEq fall in Na* - Glucose attracts waterwill cause a relative decrease in Na (sodium becomes diluted by water) - Causes Na losses (plasma, GI, skin, renal), increased ECF volume, reduced ECF volume, normal ECF volume - Na < 125 mEq/l causes cerebral edema - Correct deficit at 0.5mEq/hr - Na deficit = 0.60 x LBW(kg) x (120 plasma Na) - ex. Dilutional hyponatremia with hyperglycemia - Water restriction for increased ECF volume (CHF, hypoproteinemia) - For slow Na loss, patient may remain asymptomatic until Na < 110mEq/l - Too rapid correction may lead to pontine myelinosis resulting in irreversible brainstem injury - most cases, can be treated by free water restriction, and if sever, the administration of sodium - Posm = 2Na + glucose/20 + BUN/3 - ADH regulator of plasma osmolarity ***When you have a hypovolemic hyponatremia, you have two problems, the relative excess of water (compared to sodium) but

Diagnosis -History body weight changes, frequency & volume of vomiting & diarrhea, quantity of fistula losses, increase in abdominal girth (ascites), blood loss, diuretic therapy, extensive soft tissue injuries, febrile state, hypermetabolic state, burns, drug intake (diuretics) -Symptoms - Lassitude, weakness & fatigue, Anorexia, thirst, dizziness/syncope/altered level of consciousness, skin turgor, sunken eyeballs, dry mucosa, frequency of voiding, urine character (colorless diluted, orange rifampicin intake, brown liver problem, deep yellow concentrated, bright yellow vitamin C or iron supplement intake) -Physical exam orthostatic hypotension, hypotension, tachycardia, hypothermia, prolonged capillary filling time, flat jugular veins, dry mucosa, decreased CVP, poor skin turgor, oliguria, sunken fontanelles, tachycardic, tachypneic -Laboratory Tests - Hct (increased hemoconcentration possible dehydration), BUN:creatinine >20:1, urine specific gravity

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar

body water is low. The body compensates by giving priority to the more impt. function, that is to maintain circulating volume ADH secretion B. Hypernatremia (relative water deficit) - Na > 160mEq/l confusion, coma, intracranial hemorrhage - Excessive insensible loss, burns, perspiration, severe diarrhea, osmotic diuresis - H2O deficit = TBW x (plasma Na/desired Na 1) - Treatment of hypernatremia usually consists of treatment of the associated water deficit. In hypovolemic patients, volume should be restored with normal saline. Once adequate volume status has been achieved, the water deficit is replaced using a hypotonic fluid such as 5% dextrose, 5% dextrose in 1/4 normal saline, or enteral water. - to compute for water deficit Water deficit (L) =[ (serum sodium -140)/140 ] x TBW Signs and Symptoms Hyponatremia Hypernatremia Headache Lethargy Lethargy Irritability Confusion Thirst Weakness Hyperreflexia Seizure Seizures Coma Coma Death Death ***the two conditions have very similar S/Sx, the only way to know is to get the serum Na levels Normal Values Sodium Potassium Chloride Osmolality Protein Albumin Glucose 135-145mEq/l 3.5-4.5mEq/l 96-106mEq/l 285-295mOsm/kg 6.0-8.0g/dl 3.5-5.0g/dl 70-120mg/dl

- Treatment Ca gluconate, glucose-insulin-NaHCO3, Kbinding resins, dialysis - The goal of therapy is to reduce the total body potassium, shift potassium from extracellular to intracellular, and to protect the cells from the effects of increased potassium - Treatment started once K > 5.5meq/L - Ca gluconate (direct antagonist/immediate) 10-20ml IV x 2-5min - Na bicarbonate (redistribution/minutes) 50ml x 2-5min - Glucose-insulin (redistribution/minutes) 23glu/U reg insulin, 50ml D50W + insulin 10U - Kayexalate (incr elimination/2-12hr) 15-60gm PO/rectal Signs and Symptoms Hypokalemia Nausea Vomiting Weakness Constipation Ileus Paralysis Respiratory insufficiency Tachydysrhythmias III. Calcium Abnormalities Calcium - majority of the body's calcium is contained within the bone matrix with only less than 1% found in the extracellular fluid. - Serum calcium is distributed among three forms: protein-bound (40%), complexed to phosphate and other anions (10%), and ionized (50%). - It is the ionized fraction that is responsible for neuromuscular stability and can be measured directly. - adjust total serum calcium down by 0.8 %mg/dl for every 1 g/dl decrease in albumin - changes in pH will affect the ionized calcium concentration. Acidosis decreases protein binding, thereby increasing the ionized fraction of calcium. A. Hypocalcemia - defined as a serum calcium level below the normal range of 8.5 to 10.5 mEq/L, or a decrease in the ionized calcium level below the range of 4.2 to 4.8 mg/dL. - etiology: pancreatitis, massive soft tissue infections such as necrotizing fasciitis, renal failure, pancreatic and small bowel fistulas, hypoparathyroidism, toxic shock syndrome, abnormalities in magnesium, and tumor lysis syndrome. - transient hypocalcemia commonly occurs following removal of a parathyroid adenoma, Hungry bone syndrome in postoperative secondary or tertiary hyperparathyroidism, malignancies associated with increased osteoclastic activity such as breast and prostate cancer - rarely results from decreased intake, as bone reabsorption can maintain normal levels for prolonged periods of time. -asymptomatic hypocalcemia may occur with hypoproteinemia (normal ionized calcium), but symptoms can develop with alkalosis (decreased ionized calcium). - Symptoms usually do not occur until the ionized fraction falls below 2.5 mg/dL, and are neuromuscular and cardiac in origin. - ECG changes - prolonged QT interval, T-wave inversion, heart blocks, ventricular fibrillation

Hyperkalemia Cramping Paralysis Nausea Vomiting Tachydysrhythmias Cardiac arrest

II. Disorders of Potassium Homeostasis A. Hypokalemia - GI [vomiting (aldosterone: Na for K), diarrhea (25 mEq/l)], renal (diuretics), skin losses [massive burns (tissue destruction)] - Arrhythmias (K < 3mEq/l); weakness (K < 2.5mEq/l) - ECG T-wave flattening/inversion, ST depression, U waves, prolonged QT interval - Transcellular flux severe metabolic acidosis, insulin deficiency (DM), rhabdomyolysis, succinylcholine - Treat if symptomatic or with ECG changes - IVF replacement with KCl *Not more than 20mEq/hr *20mEq in 50ml x 1hr (10mEq in 100ml) or 40mEq in 50ml x 2hr (20mEq in 100ml) B. Hyperkalemia - Rapid administration of K, transcellular flux, renal impairment - Clinical features when K > 6.5mEq/L. the upper limit of normal is 5.5; the lower limit is 3.5 - Weakness, paresthesia, ileus, paralysis, cardiac arrest - ECG changes peaked T, flattened P, prolonged PR, widened QRS, V-fibrillation

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar

B. Hypercalcemia -Due to hyperparathyroidism or malignancy -Confusion, lethargy, coma, muscle weakness, anorexia, nausea, vomiting, pancreatitis, constipation -Treatment: Hydration/furosemide, diphosphonates, calcitonin, mithramycin - defined as a serum calcium level above the normal range of 8.5 to 10.5 mEq/L, or an increase in the ionized calcium level above 4.2 to 4.8 mg/dL. - found in primary hyperparathyroidism and malignancy (associated bony metastasis or due to secretion of parathyroid hormonerelated protein) in hospitalized patients - Symptoms vary with the degree of severity. Includes neurologic, musculoskeletal, renal, and gastrointestinal and cardiac. - ECG - shortened QT interval, prolonged PR and QRS intervals, increased QRS voltage, T-wave flattening and widening AV block (can progress to complete heart block, then cardiac arrest with severe hypercalcemia) - Treatment is required when hypercalcemia is symptomatic, which usually occurs when the serum level exceeds 12 mg/dL. The initial treatment is aimed at repleting the associated volume deficit and then inducing a brisk diuresis with normal saline. Signs and Symptoms Hypocalcemia Paresthesia muscle cramps Carpopedal spasm Stridor Tetany Seizures Hyperreflexia (positive Chvostek's sign, Trousseau's sign) Decreased cardiac contractility Heart failure

- can produce hypocalcemia and lead to persistent hypokalemia. - when hypokalemia or hypocalcemia coexist with hypomagnesemia, magnesium should be aggressively replaced to assist in restoring potassium or calcium homeostasis. B. Hypermagnesemia - rare, but can be seen with impaired renal function and excess intake in the form of total parenteral nutrition or magnesium-containing laxatives and antacids. - Symptoms may be gastrointestinal (nausea and vomiting), neuromuscular (weakness, lethargy, and decreased reflexes), or cardiovascular (hypotension and arrest). - ECG - increased PR interval, widened QRS complex elevated T waves V. Phosphate Abnormalities Phosphorus - primary intracellular divalent anion - abundant in metabolically active cells - responsible for maintaining energy production in the form of glycolysis or high-energy phosphate products such as adenosine triphosphate (ATP), and levels are tightly controlled by renal excretion. A. Hyperphosphatemia - etiology: decreased urinary excretion or increased intake or production of phosphorus, impaired renal function, hypoparathyroidism or hyperthyroidism (can decrease urinary excretion of phosphorus), rhabdomyolysis, tumor lysis syndrome, hemolysis, sepsis, severe hypothermia, or malignant hyperthermia, excessive phosphate administration (phosphorus-containing laxatives) may also lead to elevated phosphate levels. - may lead to metastatic soft tissue calcium-phosphorus complexes. B. Hypophosphatemia - etiology: decrease in phosphorus intake (malnutrition, malabsorption, use of phosphate binders), intracellular shift of phosphorus (respiratory alkalosis, insulin therapy, the refeeding syndrome, and hungry bone syndrome), or an increase in phosphorus excretion. - symptoms are related to adverse effects on the oxygen availability of tissue and to a decrease in high-energy phosphates and can be manifested as cardiac dysfunction or muscle weakness.
Shout-outs
-Surgery transcom needs more people, if your interested talk to Al Omar a.k.a gwapo. -Hello to Trish The FISH Navarro! Yeah boy! Thanks sa hardcopy ng mga surgery trans your the best fish ever, swim your way to the ocean!!! -Beware of Pepin.exe a lame virus! Hahaha. Pepin the O detector is spreading this virus around. Yung secret 50% discount ko sa jacket ha! -Armi i can still hear your cough in the recordings! My phone is Manly! Stop picking on it -Team Switzerland Virra, Jorap and James tinatanong ng res meth dept kung 1st class ticket daw ba gusto natin or private jet, ano sa tingin nyo? Hahaha -To my med precep group neil, Vince, rors, james, jorap, virra, Erica, vin, cathy, jecyll, joie and emma. Tuloy and kainan every wed sagot ni neil! Hahahaha To delo man who is hypertensive, dont eat too much dumagete style cake (cake + toyo). Gleny boy yung equation dito sa trans ganito ba na compute yung blood transfusion mo dati? hehehe Daphne-Dominique will kill us if this trans is not out-lined properly, you have been warned! Hahaha -Al Omar Salting Hi friends, Just wanted to share the concept of ecological footprint. A simple definition of thisa measure of human demand on the Earth's ecosystems There is a calculator (just search ecological footprint calculator) wherein you will know how many planet earths will be needed if all people will live like you (of course, this is a not so exact calculation, but fun to use nevertheless). In my case, if everyone will live like me, all Glenyboys will need 2.3 earths to sustain their lifestyle (sustain there would no global warming, no erratic weather patterns as we are witnessing now). but hey, if there would be a 7th nobel prize for living an ever so earth-friendly lifestyle, I thought it would be ME!! The way I eat, the way I dispose and recycle garbage, the way I accelerate and use the breaks of a car, the way I use plastics, the way I use staple wires..and in almost everything.. I thought im living good enough.. but I was wrong even this earth wouldnt last if all people will live like me. . there is still so much I have to learn..so im encouraging you to learn in every way you can regarding the state of this earth, and DO something about it.. This earths demise will happen sooner or later.. about the exact date, only God, our Creator knows.. but the time left we can utilize just to make things easier for us. Also watch An Inconvenient Truth I can give you a copy. Thank you!!

Hypercalcemia Anorexia Abdominal pain Nausea Vomiting Weakness Confusion Coma

Bone pain Hypertension Arrhythmia Polydipsia Polyuria

Note: Mg and P Abnormalities are included in Dr. Quebrals ppt but were not discussed. So following info came from 2011a trans IV. Magnesium Abnormalities Magnesium - 4th most common mineral in the body - found primarily in the intracellular compartment, as is potassium. - should be replaced until levels are in the upper limit of normal. normal dietary intake is approximately 20 mEq (240 mg) - excreted in both the feces and urine A. Hypomagnesemia - common problem in hospitalized patients, particularly in the ICU. - results from a variety of etiologies ranging from poor intake, increased renal excretion, gastrointestinal losses, malabsorption, acute pancreatitis, diabetic ketoacidosis, and primary aldosteronism. - symptoms may be neuromuscular and central nervous system, hyperactivity, and symptoms are similar to those of calcium deficiency. Severe deficiencies can lead to delirium and seizures. - ECG - prolonged QT and PR intervals, ST-segment depression, flattening or inversion of P waves, Torsades de pointes, arrhythmias

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Libranda, Gerald Cesar Pagara, Tristan Relato, Co-Neil Villanueva, Daphne-Dominique Ventanilla, Glen Salting, Al Omar