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Fluids and Electrolytes. Roy R. Danks, DO, FACOS. Objectives. Review commonly used intravenous fluids and their compositions Review indications for fluid adjustments Review common electrolyte derangements and how to correct them. Body Water. 50-70 % of the body is water

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Fluids and electrolytes

Fluids and Electrolytes

Roy R. Danks, DO, FACOS


Objectives
Objectives

Review commonly used intravenous fluids and their compositions

Review indications for fluid adjustments

Review common electrolyte derangements and how to correct them


Body water
Body Water

  • 50-70 % of the body is water

    • More muscle = more water

    • Males = more water

    • Decreases with age

  • About 2/3 of this water is found within the cells (intracellular)…depending on the source you read


How much does your patient need
How much does your patient need?

  • 35 mL/kg/day

  • GI “turn over”

    • 6000 – 9000 mL/day

    • 200-400 mL/day lost in stool

  • Renal

    • 1000 – 1500 mL/day

  • Insensible losses

    • 600 – 800 mL/day


Increased needs
Increased Needs

  • Fever

    • 10-15% increase needed for each 1 degree C increase in temperature

  • Tachypnea

    • 50% increase or each doubling of RR

  • Evaporation

    • Sweating, vent and open abdomen

  • GI

    • Fistula, diarrhea and T-tube

  • Operative

    • 600 – 1000 mL/hr in major abd operations



Sodium
Sodium

  • The major determinant of tonicity

  • It’s the primary extracellular cation

  • Adults need 100-150 mEq/day

  • Primary organs for regulation:

    • Kidneys

    • Pituitary (ADH [posterior pituitary])

    • Adrenals (Aldosterone [adrenal cortex])


Sodium1
Sodium

  • Assuming normal water content

    • Low plasma volume  low BP  Angiotensin II

    • Angiontensin II  Thirst + Aldosterone

    • Aldosterone  Resorption of sodium

      Salt excess?

    • Plasma osmolality increases  ADH released

    • ADH release  water retention



Potassium
Potassium

  • Critical for glucose transport, intracellular protein deposition and myoneural conduction

  • One of 2 major intracellular cations

    • The other is….?

  • Serum levels do not reflect intracellular values

    • 1 mEq/L ECF = 200 mEq/L ICF

  • Affected by: Acid base balance, Na metabolism, nutritional state, renal ftn and diuretics


Potassium1
Potassium

  • Daily requirements

    • 50 – 100 mEq/day (adult)

  • More is needed when pts are on NG suction and/or K+ losing diuretics (the loop diuretics)


Derangements of k
Derangements of K+

  • HypoK+

    • Replace based on serum value

    • Manage with constant infusion of IVF

    • Identify cause(s) of ongoing losses

      • Salivary: 20-30 mEq/L (1-2 liters/day)

      • Stomach: 0-30 mEq/L (up to 4 L/day)

      • Colon: 30 mEq/L


Derangements of k1
Derangements of K+

  • HyperK+

    • Leukocytosis, hemolysis and thrombocytosis will cause a pseudohyperkalemia

    • Acidosis, hypoinsulinism, tissue necrosis, reperfusion and dig toxicity (redistributional)

    • Renal insufficency, excessive intake, mineralocorticoid deficiency, diabetes and spironolactone use (elevated total body K+)


Treatment of hyperk
Treatment of HyperK+

  • Remove exogenous source

  • For critically high (>7.5 mEq/L or EKG changes)

    • Calcium gluconate: 1 gm over 2 min IV

    • Sodium bicarb: 1 amp IV

    • D50, 1 amp + 10 units of regular insulin

    • Emergent dialysis

  • Hydrate and force diuresis

  • Kayexalate 20-50 gm in 200 mLsorbitol PO and repeat every 4 hrs as needed


Calcium
Calcium

We store it!

It’s often low in our malnourished patients

Usually asymptomatic until <8 mEq/L

Look for neurologic signs

Use ionized Ca++ over serum Ca++ for day to day management


Hypocalcemia
Hypocalcemia

Calcium chloride or gluconate IV

Chronic low Ca++?: tums, OsCal, etc

Phosphate binding antacids improve Ca absorption

Add Vit D once phos is normal


Hypercalcemia
Hypercalcemia

Most often due to malignancy or hyperparathyroidism

Also: thiazides, mild-alkali syndrome, granulomatous dz, acute AI, hyperthyroidism, prolong immorbilization, Pagets disease

First! Check PTH

Treat: Hydrate, loop diuresis, steriods and a medicine consult


Magnesium
Magnesium

Check it just like all your electrolytes

Very often will find it to be low

Replace with 1-2 gm per day, IV

Low Mg will cause arrhythmias, so when your patient’s develop these post op….


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