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Fluids & Electrolytes

Janeen Jordan, MD TACS Fellow

In General
60% of total body weight is water
40% (2/3) is intracellular (ICF) 20% (1/3) is extracellular (ECF)
5% in intravascular 15% is interstitial

Blood Volume (rbcs + plasma) = 7% TBW ECF vs ICF cations


Na+: 142 mEq/L vs 10 mEq/L K+: 4 vs 150 Ca++: 5 Mg++: 3 vs 40

ECF anions
Cl-: 103 HCO3: 27

ICF anions
Phosphates 107 Proteins 40 Sulfates 43

In General
Starling forces control net fluid flux Q = Kf(Pc-Pi) (c-i)
Q net fluid flux (mL/min) (Pc Pi) hydrostatic pressure difference between the capillary and interstium (c-i) oncotic pressure difference Kf filtration coefficient for membrane

the permeability factor

the permeability factor In shock states is increased Colloids cannot maintain oncotic pressure Replaced with isotonic fluid (3:1)
Hypotonic will distribute to all compartments Isotonic solutions: 9%NS and LR

Surrogate measures of adequate volume


Blood pressure, heart rate, uop, cardiac/cerebral perfusion

Hyponatremia
Defined as <135 mEq/L Renal defense (can excrete massive load 15L/d) FW intake with impaired FW excretion
Pathologic release of ADH (stress, pain, n/v, narcotics, hypovolemia) Thiazide diuretics anticonvulsants

Hyponatremia
When is aggressive tx indicated? What are the sxs? What causes these sxs? What group of patients are at risk? Na <120meq/L & low plasma osm Nausea, malaise, lethargy, seizures, MS changes, coma Cerebral edema Women w/ postop low Na
Pt w/ psychogenic polydipsia Elderly women on thiazide or loop diuretics Postop pts who are over resuscitated (premenopausal)

What is the appropriate emergent tx? What risk is associated with tx? Whick patients are at risk for CPM? What is the most common cause of postop hyponatremia?

Lasix in conjunction with NS or hypertonic saline to increase Na 1meq/hr, then fluid restriction If tx too rapid, CPM or osmotic cerebral demyelinating syndrome Pt with preexisting alcoholism or malnutrition Pts with a rate of correction >2.5meq/l/hr or >20meq/day Fluid overload

Assessment of Hyponatremia
Normal (280-285mOsm) Isoosmotic hyponatremia Pseudohyponatremia hyperlipidemia hyperprotenemia Isotonic infusions glucose, mannitol, glycine, ethanol. glycerol Hypovolemic, hyposmotic Hyponatremia >20 <10

Serum Osmolality
Low (<280mOsm) Assess clinical extracellular fluid volume Elevated (>285mOsm) Hyperosmotic hyponatremia Hyperglycemia Hypertonic infusions glucose, mannitol, glycine, ethanol, glycerol Hypervolemic hypoosmotic Hyponatremia

Isovolemic, hypoosmotic Hyponatremia

Urine Na (meq/L)

Urine Na (meq/L)

<10
Water Intoxication

>20
Renal failure SIADH Hypothyroidism Pain Emotion Drugs Adrenal Insuff

<10
Nephrosis Cirrhosis CHF

>20
Acute/chronic renal failure

Renal Losses Extrarenal Losses GI loss Diuretic Renal injury Obstruction Adrenal Insuff Skin loss RTA Lung loss Salt wasting Nephritis vomiting diarrhea pancreatitis

Isotonic Saline

Water Restrict

Water Restrict

Calulate the Na deficit = 0.6(kg)x(140-Na)+(140xVol deficit in L)

Corrected Na = 0.016(measured glucose 100)+measured Na

Hyponatremia summary.
High-risk groups for poor outcome
Menstruant females Children Hypoxic patient

Asymptomatic hyponatremia
Fluid restriction unless hypovolemia is suspected Demeclocycline Vasopressin V2 receptor antagonist (Vaptans)

Hyponatremic encephalopathy (seizures, AMS, HA, n/v)


Infuse 3% NaCl at a rate of 1mL/kg/h. ICU setting using an infusion pump. Check serum Na every 2hrs until sxs free Stop HTS when asymptomatic OR Na has increased by 15-20meq in initial 48hrs

Hyponatremic encephalopathy with evidence of severe cerebral edema (active seizures, respiratory arrest)
Bolus 100mL of 3% NaCl over 10min Can repeat bolus 1-2times with the goal of increasing Na 2-4meq/L or until clinical improvement Begin infusion as for hyponatremic encephalopathy
Ayus, JC, et al. N Engl J Med. 1987; 317(19): 1190-95.

Hypernatremia
What sxs are present when Na >160meq/L? What sxs are present when Na >180meq/L? What is the appropriate tx? Irritability, ataxia, anorexia and cramping Confusion, stupor, seizure, coma Correction of volume deficit, if present
Replacement of water deficit with D5W Tx of underlying cause

What is the rate of correction?

What is the risk of overly rapid correction?

water deficit in the 1st 24hrs, with a rate of Na decrease not >1meq/hr; correction of the remaining deficit over the next 2448hrs Cerebral edema and resultant neurologic dysfunction (lethargy, seizures)

Assessment of Hypernatremia
Assess clinical extracellular fluid volume Hypovolemic Hypernatremia
Loss of water+ Na

Isovolemic Hypernatremia
Loss of water Normal TB Na

Hypervolemic Hypernatremia
Gain of water+ Na (>)

Low TB Na

HighTB Na

>20

<10

Urine Na (meq/L)

variable

Urine Na (meq/L)

>20
Iatrogenic hypertonic NaHCO NaCl tablets hypertonic ivf Mineralocorticoid primary aldo cushings Cong adrenal hyperplasia Hypertonic hemodialysis/peritoneal dialysis

Renal Losses Extrarenal Losses Diuretic GI loss Glycosuria Skin loss Mannitol Lung loss Urea diuresis Acute & chronic RF

Renal loss DI Central nephrogenic

Extrarenal loss skin respiratory insensible

Hypotonic Saline
Calulate water deficit = 0.6(kg)x(Na/140-1)

Water Replacement

Diuretics & water replacement

Hypernatremia summary
1. Replete intravascular volume with colloid solution, isotonic saline or plasma. 2. Estimate water deficit. Deficit should be replaced over 48-72 hrs, aiming for a correctionof 1mOsm/L/hr. In severe hypernatremia (>170), do not correct below 150meq in first 48-72 hrs. 3. Hypotonic fluid should be used. Usual replacement fluid is NS. Glucose-containing solutions should be avoided, an oral route should be used if available. 4. Monitor plasma electrolytes every 2hrs until stable

If somethings rotating go home, you need a break! *g*

Hypokalemia
What is the normal daily K+ requirement? Why is the serum K+ level important in patients taking digoxin? What are the most common causes of low K+ in the surgical pt? What acid-base disturbances cause decreased serum K+ levels? What sxs are associated with hypokalemia? What EKG changes occur with hypokalemia? What other electrolyte imbalances often occur with hypokalemia? How is potassium replaced emergently? 40-60meq/day Digoxin and K+ compete for the same receptors, pts are susceptible to digoxin toxicity when K+ is low Vomiting, diarrhea, NG suction, loop diuretics, deficient oral intake Alkalosis. H+/K+ pump. Ileus, weakness, nausea, vomiting U-waves >1mm in ht and larger than T-waves S-T depression
T-wave flattening and inversion

Hypocalcemia, hypomagnemesia Suggested maximum infusion rate is 20meq/hr via CVL, 10meq/hr peripherally

Hyperkalemia
What situations call for emergent reduction of serum K+ levels? What is the most serious complication of hyperkalemia? What EKG changes are associated with the disorder? Pt with serum K+ >7mmol/L or EKG changes Life-threatening arrhythmia Peaked T-waves Flat P-waves Increased PR-interval Widened QRS interval with eventual progression to sine wave pattern Urine output, b/c renal failure results in rapid increase in K+ Artificially elevated K+ levels caused by hemolysis or by a tourniquet left in place too long on the arm before collection Hypertonic glucose infusion and insulin Administration of kayexalate 20g QID Hemodialysis HCO3 C BIG K DDi Calcium Lasix

In addition to vital signs, which bedside parameter should immediately checked? What is pseudohyperkalemia? How is K+ emergently reduced?

Hypocalcemia
What is the most dangerous consequence of severe hypocalcemia? What are the sxs? Laryngeal spasm may occur at very low Ca++ levels Peripheral paresthesias, Chvostek sign, Trousseau sign, tetany, seizures, MS changes 0.8(Normal albuminmeasured albumin)+observed Ca++ Ionized calcium Administration of 200mg elemental Ca++ Infiltration causes skin necrosis (CaCl)

What is the formula for corrected total Ca++? What is the most accurate measure of Ca++? How is severe hypocalcemia treated? What is the most dreaded complication of peripheral IV infusion of calcium?

Hypercalcemia
What levels of serum calcium warrant emergent therapy? What are the symptoms? 13-15mmol/L or w/ sxs

What is the appropriate tx for severe (symptomatic) hypercalcemia?

Nausea, vomiting, MS changes, delirium, polyuria, polydipsia and constipation Increase IV fluids to maintain UOP 80100mL/hr. Lasix for diuresis

Scenario
32yo F with no PMHx, elective BTL 0800 D5 NS at 125mL/hr Po intolerance, ivf continues 0245 c/o HA given vicodin Am labs Na+ 129mEq Generalized seizure and respiratory failure

References
Gabrielli, A., et al. Civetta, Taylor & Kirbys Critical Care, 4th ed. 2009. Grenvik, A. et al. Textbook of Critical Care, 4th ed. 2000. Marino, PL. The ICU Book, 3rd ed. 2007 Rollings, RC., et al. Facts and Formulas. 1984. Blackbourne, LH., et al. Advanced Surgical Recall, 3rd ed. DuBose, JJ., et al. Clinical experience using 5% hypertonic saline as a safe alternative fluid for use in trauma. J Trauma. 2010 May;68(5):1172-7