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1.

FLUIDS AND ELECTROLYTES (Jaaf PSaid)


2. PARENTRAL FLUIDS
First, let me define some terms.
Infusion: Administration of > 100 ml fluid by
parentral route
Tonicity: Osmotic pressure of fluid in relation to
plasma
Parentral fluids can be into isotonic, hyper and
hypo.
Isotonic: osmotic pressure of the fluid =
OP of the plasma = 290 mOsmol/L
Hypertonic: OP > 50 i.e. >340
Hypotonic: OP < 50 i.e. <240
3. PHYSIOLOGY OF BODY WATER BALANACE
Body water is divided to 3 compartments:
The Intracellular: Interstitial: Vascular:
The Extra-cellular fluid ECF is composed of
interstitial +vascular
Actual amount of body water differs according to
Age: Newborn 70% 0f WT water
1-year-old 60% of WT water
Sex : Male (60%) > female (50%) due to
greater muscle mass
Body composition : Most concentrated in
skeletal muscle
Obese: less water because fat cells have
minimal ICF
Elderly: less water due to less muscle
mass
4. The vol in each compartment
remains constant under normal conditions
Regulated by hydrostatic and oncotic pressure
Hydrostatic: determined by cardiac
output and arterial tone which determine BP ;
= 17 mmHg and pushes water to
interstitial space
Oncotic pressure: proteins in the
vascular space pull water
5. PHYSIOLOGY OF BODY SOLUTE BALANCE
Osmotic pressure
keeps the vol of three compartments
constant
The concentration of electrolyte in each
compartment creates osmotic pressure that holds
the water in each space
6. Body Water Disturbances
Evaluated as total volume and individual
compartments
Dehydration: Fluid volume is low in all three
compartments
Hypovolemia: Low vascular fluid
Total body water overload :TBW > 60%
Edema : Collection of fluid in interstitial space
due to low oncotic pressure in the vascular
compartment. E.g low albumin levels
7. DISTRIBUTION OF IONS IN EACH
COMPARTMENT
Osmolarity
Normal 280-300 mOsmol/L
ECF: Na and Cl
ICF: K and Po4

Concentration of other ions is too low to


contribute to osmotic gradient
Other osmotically active substances:
glucose , urea, and lipids.
Osmolarity is determined by all the above
Non-Electrolyte contribution is little
8. Effective Osmolarity: Twice the Na
concentration in the ECF
Calculation of osmolarity(mmol/Kg)
2 X Na ( mEq/L) + glucose ( mg/L)/18 + urea
( mg/L)/2.5
9. THE KIDNEY AND OSMOLARITY
the kidney attempt to maintain
osmolarity by increasing excretion of glucose
and urea when their concentrations rise
if not possible or sufficient it will
increase excretion of Na
when concentration of solutes in any
compartment changes water moves to
reestablish osmotic pressure
10. Maintenance of Fluid and Electrolyte
Requirements
Maintained by equilibrium between oral
intake and evaporation from skin and lungs and
renal excretion.
The kidney or output by the action
of ADH and aldosterone
11. ADH:
osmolarity ADH water
reabsorption
osmolarity water reabsorption
Aldosterone
Na reabsorption
12. PRINCIPLES OF FLUID AND ELECTROLYTE
THERAPY
Maintenance intravenous fluids are used in a
child who cannot be fed enterally.
Replacement fluids if they have continued
excessive losses such as may occur with drainage
from a nasogastric (NG) tube
Rehydration/ Deficit therapy designed to
replace abnormal losses of fluids & electrolytes
which are reflected in the body composition by an
acute loss in body weight (acute dehydration)
13. REHYDRATION PHASE
Determine/Decide for dehydration status.
Ask about:
Diarrhea
Vomiting
Thirst***
Urine
Look at:
Condition***
Tears
Eyes
Mouth and Tongue***
Breathing

4
None or small amount
Normal
N

4-10
Some
Greater than
A small amo

Well, alert

Unwell, slee

Present
Normal
Wet
Normal

Absent
Sunken
Dry
Faster than

Feel:
Skin***
Pulse***
Fontanelle (in infants)
Take temperature
Weigh if possible (gram
lost/kg BW)

Goes back slowly


physiological activities
Faster than POTASSSIUM
normal
Sunken

<25g

25-100 gmsbody

14. Evaluate dehydration status. It can be: mild, moderate,


or severe
15. Oral rehydration is underused in developed
countries, but it should be attempted for most
patients with mild to moderate diarrheal
dehydration when adequate supervision is
available.
16. Intravenous therapy may be required for
patients with severe dehydration; those with
uncontrollable vomiting; those unable to drink
because of extreme fatigue, stupor, or coma; or
those with gastric or intestinal distention.
17. The initial resuscitation and rehydration
phase is complete when the child has an
adequate intravascular volume. Typically, the
child shows clinical improvement, including a
lower heart rate, normalization of blood pressure,
improved perfusion, better urine output, and a
more alert affect.
When rehydration is Complete, maintenance
therapy should be started.

concentration in the serum controls

Pinch goes back quickly


Normal
normal

18-19. CONDITIONS THAT ALTER


MAINTENANCE FLUID
Read some!
20. Example: 34.5 kg crying child who came in
with LBM. PE findings: poor skin turgor, sunken
EB, dry lips w/ unstable vital signs. Temperature
= 39.5 C
Compute the deficit and maintenance therapy.
21. DEFICIT = First hour: 8.6 cc/
min. or 129 gtts/min.
Next 5-6 hours: 5 cc/min. or 75 gtts/min
MAINTENANCE = 23
gtts/min
22. Types of Replacement Fluids
1-Crytalloid: Contain electrolyte; Isotonic with
ECF; contain Na as the main osmotically active
particle; useful for volume expansion (mainly
interstitial space);
2-Colloid : Contain plasma protein or other
colloidal molecule do not readily migrate across
capillary walls
23. MAJOR ELECTROLYTES
Na, Cl, K, bicarbonate, ca, Mg, Po4
the main reservoir is ICF and bone
serum levels fall slowly when intake is low
numerous hormonal and homeostatic
mechanism exist to keep serum levels with
normal range
serum levels is low in relation to
intracellular concentration

Amount in vascular space = 0.4% of total

NL = 3.5-5 mmol/L (Serum levels are


usually indicative of amount in body)
Route of excretion;
Elimination by the kidney
Can be increase when intake is high
Kidney cannot conserve K
Changes in acid-base balance alter location of K
Acidosis;
K exchanges for H as an attempt to hide
and buffer protons in ICF
Alkalosis
The opposite occurs
Serum K will rise or fall by 0.6 mmol/L for very 0.1
change in PH from 7.4
CHLORIDE
Major anion in ECF
Has no physiological function
Goes up and down with TBNa
Changes cause acid-base disturbances;
because electrical neutrality must be maintained
and so serum HCO3 will change
In acidosis or alkalosis changes in CL
should not be corrected by giving or restricting Cl
Until the cause of acid-base disorder is
corrected
CL levels may normalize naturally
CALCIUM
Stored in the bone
Only 1% of body Ca is in fluid spaces
Nl = 2.2-2.6 mmol/L
50% is bound to albumin and other protein
the other 50% is the free active form
serum levels do not change with daily
intake and excretion
serum levels are controlled by parathyroid
hormone, vit D and calcitonin
through regulation of GI absorption, renal
excretion, skeletal deposition or resorption.
there is an inverse relationship with Po4
Relation to albumin
low serum albumin will result in low Ca lab
values
does not mean low ionized Ca
each 10-gm/L change in albumin will
change Ca by 0.2 mmol/l in the same direction
Relation to acid-base imbalances
acidosis more H are bound to albumin
as an attempt to buffer displacement of Ca ions
from binding sites increase free calcium
the opposite is true for alkalosis
for each 0.1 change in PH ionized Ca
changes by 0.42 mmol/L in the opposite direction
MAGNESIUM
The body contains 1000 mmol mg
99% is in bone and ICF

1% in vascular space 25 % is bound to


proteins
75% free and active
Nl = 0.8-1.2 mmol/l
Abnormal levels rarely appear isolated
usually occur with other solute abnormalities
PHOSPHORUS

99.99% contained in bone and ICF


NL= 0.8-1.6 mmol/L
Function:
Form high-energy phosphate bonds of ADP
and ATP in glycolysis and Krebs cycle
Facilitate the release of Oxygen from Hg
24. NORMAL LABORATORY VALUES