Success is never permanent. Failure is never final.

So, always do not stop effort until your victory makes a history. GOOD LUCK!

FLUID AND ELECTROLYTES

Done by : GROUP B Supervisor : DR MUHAMAD YASIN

Surah AL- MURSALAT (Those Sent Forth)

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Have We not created You from a fluid (Held) despicable? Holy Quran

INTRODUCTION
To maintain good health, a balance of fluids and electrolytes, acids and bases must be normally regulated for metabolic processes to be in working state.

A cell, together with its environment in any part of the body, is primarily composed of FLUID.

BODY FLUIDS
A. Function 1.Transporter of nutrients , wastes, hormones, proteins and etc. 2.Medium or milieu for metabolic processes 3.Body temperature regulation 4.Lubricant of musculoskeletal joints 5.Insulator and shock absorber

BASIC PHYSIOLOGY :
Total body water : Total body water content is about 60% of body weight in an young adult male and about 50% in an young adult female. Since fat contains less water, an obese person will have proportionately less body water as compared to lean person. Infants = more water Elderly = less water More fat = water More muscle = water Infants and elderly - prone to fluid imbalance

Percentage of Body Water

(depending on age & gender)
75% 60%

55%
45%

Total Body Fluid by Compartment

Total Body Water

Body Fluid Transport

DIFFUSION Higher to lower concentration OSMOSIS Lower to higher concentration Semi permeable membrane FILTRATION Particles ACTIVE TRANSPORT Na-K Pump Requires ATP

Diffusion
Figure 3.

Fluid

Solutes

High Solute Concentration

Low Solute Concentration

Osmosis
Figure 2.

Fluid High Solution Concentration, Low Fluid Concentration Low Solute Concentration, High Fluid Concentration

EXTRACELLULAR Active transport FLUID Na + Na + Na + Na + Na + Na + Na + ATP Na + Na + Na + Na + Na + Na + Na + Na + Na + Na + Na + Na + ATP Na +

K+ K+

K+
K+

K+
K+ K+

K+ K+ K+

ATP
K+

K+

K+

K+ K+

ATP

K+

K+
.

INTRACELLULAR FLUID

Third Spacing
Occurs when the fluid is trapped in the interstitial spaces. Fluids shifts from the vascular space into an area where it is not readily accessible as extracellular fluid. This fluid is remains in the body but is essentially unavailable for use, causing an isotonic fluid volume deficit. Pt. may not manifest fluid loss or weight loss.

Causes can occur in liver failure, liver of Fluid Shifts Albumin losses
dysfunction, and malnutrition

Albumin losses can lead to fluid shifting into the peritoneum, causing ascites Destruction of endothelial cells, such as in bowel surgery, can cause fluid to move and be trapped in the interstitial spaces Fluid trapped in the lungs can lead to pulmonary edema

Regulation of Body Fluid

1. The Kidney Regulates primarily fluid output by urine formation 1.5L Releases RENIN Regulates sodium and water balance

2. Endocrine regulation thirst mechanism thirst center in hypothalamus ADH increase water reabsorption on collecting duct Aldosterone increases Sodium and water retention retention in the distal nephron

3. Gastro-intestinal regulation - GIT digests food and absorbs water - Only about 200 ml of water is excreted in the fecal material per day

4. Heart and Blood Vessel Functions - pumping action of heart circulates blood through kidneys

5. Lungs insensible water loss through respiration

FLUID BALANCE
BODY INPUT Fluids 1500mL Food 500mL Digestion 500mL Total >2500mL
BODY OUTPUT Urine 1500mL Feces 200-400mL Respiration200-400mL Skin 200-400mL Total >2500mL

INTRAVENOUS FLUIDS
ISOTONIC: Equal in concentration 0.9% Na Cl D5 Water, Lactated Ringers HYPOTONIC: Salt or solute Cellular swelling 0.45% NaCl, Distilled water HYPERTONIC: Solute Cellular shrinkage D5 NSS, D10 Water D5 0.45 % NaCl, D5 LRS

The rules of fluid replacement:

Replace blood with blood Replace plasma with colloid

Resuscitate with colloid

Replace ECF depletion with saline Rehydrate with dextrose

WATER LOSS

CAUSES OF WATER LOSS

Poor intake, Vomiting, diarrhea, GI suctioning, sweating
Diabetes Insipidus

Adrenal insufficiency
Osmotic diuresis Hemorrhage 3rd space fluid shift

CLINICAL FEATURES Drop in ECF is balanced by Drop in ICF so clinically Patient is not dehydrated even though there is water loss. Thirst ,confusion and hypothermia are the clinical features.
INVESTIGATION: Raise in plasma sodium and urea TREATMENT: Oral water or IV isotonic fluid .5% Destrose

WATER INTOXICATION
CAUSES: -Excessive amount of intravenous dextrose 5% -During colorectal bowel wash for preparation of large bowel for Surgery, if water is used instead of saline especially in children -in TURP when excess irrigating fluid water or Glycine is used (commonly used) -in SIAHD which is commonly associated with lobar pneumonia ,empyema and head injury

WATER INTOXICATION

CLINICAL FEATURES - Drowsiness ,weakness -convulsion and coma - Nausea and vomiting -passage of dilute urine INVESTIGATION: -Haematocrit and sodium level -low potassium and low blood urea TREATMENT: -Water restriction and observation - Monitoring on ICU - Management of fluid and electrolyte balance - Infusion of hypotonic sodium chloride

 ECF LOSSES
Here only ECF loss is present with normal ICF It is seen in vomiting, diarrhoea and intestinal obstruction TTT: Is infusion of normal saline

ECF EXCESS
Only ECF excess without an ICF excess Excessive infusion of saline with impaired excretion Raised JVP(earliest and best clinical sign),Cardiac failure and peripheral oedema TTT: Is fluid restriction and diuretics like Frusemide

ELECTROLYTES
Electrolytes are charged ions capable of conducting electricity and are solutes found in all body compartments.

1. Sources of electrolytes Foods and ingested fluids, medications; IVF and TPN solutions

FUNCTIONS OF ELECTROLYTES
Electrolytes serve four general functions in the body. 1-Because they are more numerous than nonelectrolytes, electrolytes control the osmosis of water between body compartments. 2-Maintain the acid-base balance required for normal cellular activities. 3-Carry electrical current, which allows production of action potentials and graded potentials and controls secretion of some hormones and neurotransmitters. Electrical currents are also important during development. 4-Cofactors needed for optimal activity of enzymes.

Concentration expressed in mEq/liter or milliequivalents per liter for plasma, interstitial fluid and intracellular fluid

Fluids & Electrolytes Ions = Charged particles

Cation: Positively Charged particles. Sodium ( Na +) Potassium ( K+) Calcium (Ca++) Magnesium (Mg++) Anion: Negatively charged particles. Chloride (Cl-) Bicarbonate (HCO3-) Phosphate (HPO4 -)

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Ion CATIONS

ECF(mmol/l)

ICF(mmoll/l)

Na K
Ca ionised Ca total Mg ANIONS Bicarbonate Cl phosphate Organic anions Protein

135-145 3.5-5
1.0-1.25 2.12-2.65 1.0

4-10 150
0.001 ---40

25 95-105 1.1 3.0 1.1

10 15 100 0 8

Sodium
Most abundant extracellular cation. Regulates body water distribution. Aids nerve impulse transmission. Aids transfer of calcium into cells. Recommended adult intake 50-140mmol in food and drinks,12mmol/kg IV Na levels are controlled by the kidneys; 80% reabsorbed in the proximal convoluted tubule Aldesterone( mechanism involves renin angiotensin system) ADH mechanism- retention of Na leads to retension of H2O. 5/4/2012 Increased Na [ ] stimulates ADH section and vise versa.

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Disturbances of Na Balance
Hyponatraemia-[Na] <130mmol/l May be due to;-water retention -Na depletion separately or -in combination

Clinical features of Hyponatraemia

With salt and water depletion are due to EC dehydration;-sunken eyes -cold clammy skin -hypontension -rapid thready pulse -nausea,vomiting and muscle cramps o -scanty urine,dark in colour and o of high specific gravity o Plasma changes;-reduced plasma volume evidenced by raised levels of proteins PCV and Hb

Treatment of hyponatremia
Hyponatremia due Na loss;-0.9% normal saline

Hyponatremia due to water intoxication;-stop all fluids and prevent excess water intake

Hypernatremia [Na]>145mmol/l
Causes insufficient water intake Renal water loss(osmotic duresis due to renal failure or DKA) sweating hyperventilation voluntally over ingestion by a mentally deranged person excessive IV infusion of 0.9% normal saline post operatively.

Clinical features of hypernatremia

Puffiness of the face is the early sign In infants, increased tension of anterior fontanelle Sacral edema( 4.5 l of fluids must have accumulated in tissue space) Increased body weight Pulmonary edema may kill the patient.

Treatment of hypernatremia
If due to water depletion, give 5%dextose solution If due to Na excess, restrict Na intake Not more than a half the water deficit should be replaced in the first 12 -24 hrs( cns detoriation)

Potassium
Most abundant intracellular cation.(150mmol/l) Necessary for transmission and conduction of nerve impulses. Maintenance of normal cardiac rhythm. Necessary for smooth and skeletal muscle contraction. Intracellullar K

Hypokalemia- serum K >3.5mmol/l

Causes Inadequate intake K free IV fluids -reduced oral intake Excessive loses; GIT -vomiting or diarrhoea -fistula loss e.g deodnal fistula -villous adenoma of rectum RENAL-osmotic duresis -primary hyperaldesteronism(co nns syndrome -cushing syndrome, exogenous steroids

Clinical features of hypokalemia

Muscular weakness Cardiac arrythmias ECG changes; -flattened T-waves with STsegment depression and prolonged QT-interval impaired concentrating ability of kidneys leading to polyuria and polydypsia

Diagnosis of hypokalemia
ECG findings Hypertension; suggests hyperaldosteronism or glucocorticoid excess Renal K excretion ;- urinary excretion of >2025mmol/l or per day

Treatment of hypokalemia
Increase dietary intake e.g milk, fruit juices, honey or supplementation with K salts like effervescent tabs of Kcl 2g by mouth 6hourly IV Kcl -20mmol/l hourly

Hyperkalemia
Plasma level above 7.5mmol/l produces clinical symptoms Causes EXCESSIVE INTAKE; Rapid infusion of K containing IV fluids in conditions of hypokalemia Massive blood transfusion INADEQUATE EXCRETION; Patients with acute renal failure,rare in chronic renal failure Addisons disese. K spairing duretics SHIFT OF K from TISSUES into PLASMA Tissue damage Haemolysis Metabolic acidosis,hypoxia and shock Na-K ATPase pump is impaired Insulin defficiency

Clinical features of hyperkalemia

Confussion Apathy Paresthesia There may be severe muscle weakness

Diagnosis of Hyperkalemia
Serum K estimation and

ECG;- Peaked T-waves, loss of p-waves, abnormal QRS intervals

Treatment of hyperkalemia
Recognition and control of hyperkalemia is a medical emergency Stop all forms of K administration Maintain a good urine output; give IV fluids and if required frusemide

In severe hyperkalemia,[K]>8mmol/l -50-100ml of 50%dextrose with 10-20Units of insulin given IV every 2hrs
Correct acidosis with IV, 1-2mmol/kg NaHCO3 in 1L of 5% dextose Hemo and peritoneal dialysis

Calcium
Main regulators of ionised plasma Ca are PTH,Vit D and Calcitonin. Normal serum Ca level is 8.5-10.5mg/dl(2.2-2.6mmol/l) Total Ca in body is abt 1200gms with 99% in bones and 1% in body fluids and soft tissues Normal daily intake;- 1-3gms most of is excreted by GIT and about 200mg in urine per day Plays role in nerve impulse transmission. Increases force of muscle contractions. Functions as an enzyme co-factor in blood clotting. Necessary for structure of bone and teeth. Decreased ionised Ca in blood leads to tetany

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Calcim disturbances,

Hypocalcemia, <8mg/dl or <2mmoll/l

Causes Hypoparathyrodism Vit D defficiency Chronic renal failure( increased plasma PO4 levels,decreased vitD3 synthesis Acute pancreatitis(dystrophic calcification) Excessive transfussion of citrated blood

Clinical features of hypocalcemia

Hypersensitivity of nerves and muscles(latent tetany) -chevosks sign -trousseau sign(carpal spasm) Carpal pedal spasm(long standing hypocalcemia) Sponteneous laryngospasm(laryngismus) Convulsions Epileptic fits Muscle cramps and weakness

Treatment of Hypocalcemia
IV calcium gluconate for acute symptoms

Calcium lactate per oral for those requiring prolonged replacement

Hypercalcemia
Causes Malignancy;- osteolytic mets e.g breast cancer,multiple myeloma or hodgikins disease Hyperparathyrodism Hypervitaminosis D Immobised patient Compulsive milk drinking

Clinical features of Hypercalcemia

Renal stones Tiredness Mental confusion Comma

Treatment of Hypercalcemia
Correct depleted ECF volume with IV Fluids which lowers Ca levels by dilution

Metastatic cancer;- treatment is prophylactic with patient place on low Ca diet and adequate hydration.

Magnesium
predominantly Intracellular cation.(20mmol/l) Mostly excreted in feaces and the rest in urine Activates (ATP-ase) the primary energy source for the sodium potassium pump. Plays important role in the relaxation of smooth muscle. Stabilizes cardiac muscle cells - decreases fibrillation threshold. Mg ion is essential for proper functioning of most enzyme systems

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Magnesium Defficiency
Causes Starvation Prolonged IV administration of Mg free fluids Excess GIT fluid loss like GI fistulae,ulcerative colitis Acute pancreatitis DKA Late stages of major burns

Clinical features of Mg deficiency

Neuro-mascular and CNS hyperactivity Muscle tremors and tetany progressing to delirium and convulsions in severe cases

Diagnosis of Mg deficiency
A surgical patient who exhibits disturbed neuromascular or cerebral activity in the post operative period, put Mg deficiency in mind.

Treatment of Mg defficiency
Parenteral MgSO4 or Cl, dose is 40mmol of MgSO4 dissolved in 5% Dextrose or isotonic saline per day

Magnesium excess causes/etiology Massive trauma Most common cause is severe renal failure Acidosis also shifts Mg out of cells

Clinical features of magnesium excess

Drowsiness at plasma levels of 4mmol/l and comma at levels of 7mmol/l Peripheral vasodilation, hypotension and mascular flacidity Death is due to cardiac arrest

Treatment of Mg excess
Contol acute symptoms by slow IV infussion of CaCl or gluconate 5-10mEq Presistent elavated levels treated by peritoneal or haemodialysis

Chloride Balances cations Plays role in fluid balance and renal function.

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Phosphate Plays an important role in ATP storage. Chief intracellular buffer acts to maintain intracellular pH.

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Thank you