Indra Wijaya

Department of Internal Medicine

Faculty of Medicine, UPH
Siloam Lippo Village Hospital
FLUID
FLUID / WATER BALANCE
Normal plasma osmolality 275-290 mosmol/kg

ETIOLOGY
I. ECF volume contracted
A. Extrarenal Na
+
loss
B. Renal Na
+
and water loss
C. Renal water loss

II. ECF volume normal or expanded
A. Decreased cardiac output
B. Redistribution
C. Increased venous capacitance


Sign and Symptoms
General weakness - fatigue
Delirium
Hangover
Thirsty
Hypotension
Dry mouth
Skin turgor
Decreased urin volume

TREATMENT
I.V line Hidration 1 - 2 liters!

Normonatremic and most hyponatremia:
normal saline (NaCl 0.9%)

Hypernatremia:
half-normal saline (NaCl 0.45%)/
D5% infusion.

Hemorrhage, anemia, or intravascular volume
depletion:
blood transfusion / colloid
ETIOLOGY
Excessive sodium and fluid intake:
IV therapy containing sodium
Transfusion reaction to a rapid blood transfusion.
High intake of sodium
Sodium and water retention:
Heart failure
Liver cirrhosis
Nephrotic syndrome
Corticosteroid therapy
Hyperaldosteronism
Low protein intake
Fluid shift into the intravascular space:
Fluid remobilization after burn treatment
Administration of hypertonic fluids
Administration of plasma proteins, such as albumin
Sign and Symptoms
Shortness of breathing

Paroxysmal nocturnal dyspneu

High JVP

Ascites

Edema

TREATMENT
Treat etiology / underlying cause

Loop Diuretics monitor BP

Dialysis
SODIUM
Na < 135 mmol/L
CLINICAL FEATURES
Maybe asymptomatic

Nausea and malaise

Headache, lethargy, confusion, and
obtundation

Stupor, seizures, and coma:
Na < 120 mmol/L
TREATMENT
Asymptomatic hyponatremia associated with
ECF volume contraction isotonic saline

Hyponatremia associated with edematous states
restriction of Na
+
and water intake

Euvolemic and hypervolemic hyponatremia
nonpeptide vasopressin antagonists
0.51.0 mmol/L per h
or
1012 mmol/L over the first 24 h
ODS
Na+ > 145 mmol/L
ETIOLOGY
Primary hypodipsia

Renal

Extra renal
Skin
Respiratory tract
GI tract
CDI
NDI
CLINICAL FEATURES
Polyuria or thirst
Altered mental status
Weakness
Neuromuscular irritability
Focal neurologic deficits
Coma or seizures
TREATMENT
correct the water deficit
5% dextrose / half-isotonic saline

treating the underlying cause:
stop ongoing water loss
CDI desmopressin intranasally
NDI amiloride
Low-salt diet in combination with low-dose
thiazide diuretic therapy NDI+CDI

Plasma [Na
+
] should be lowered by 0.5 mmol/L per h and
< 12 mmol/L over the first 24 h
POTASSIUM
K+ < 3.5 mmol/L
ETIOLOGY
I. Decreased intake

II. Redistribution into cells
A. Acid-base
B. Hormonal
C. Anabolic state
D. Other

III. Increased loss
A. Renal
B. Non Renal
CLINICAL FEATURES
Fatigue

Myalgia

Weakness of lower extremities

Diaphragm paralysis

ECG?

TREATMENT



Potassium chloride: p.o / i.v

Potassium bicarbonate and citrate
hypokalemia associated with
chronic diarrhea/RTA
The maximum concentration of administered K
+

should be no more than 40 mmol/L via peripheral vein
60 mmol/L via central vein
K+ > 5 mmol/L
ETIOLOGY
I. Renal Failure

II. Decreased distal flow

III. Decreased K
+
secretion
A. Impaired Na
+
reabsorption
B. Enhanced Cl
-
reabsorption
(chloride shunt)
CLINICAL FEATURES

Weakness

Flaccid paralysis

Hypoventilation

Cardiac toxicity

ECG?
TREATMENT

Calcium gluconate

10 units of regular insulin and
50 gram of glucose

Diuretics

Cation-exchange resin

Dialysis