Fluids and electrolytes september 10 2008
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Fluids and Electrolytes September 10, 2008. Karen Koo, PGY5 Chief Critical Care Medicine Fellow Division of Critical Care Medicine McMaster University, Hamilton ON. Objectives. Major Body Fluid Compartments Review of physiology of volume regulation Parenteral Fluid Therapy

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Fluids and electrolytes september 10 2008

Fluids and ElectrolytesSeptember 10, 2008

Karen Koo, PGY5

Chief Critical Care Medicine Fellow

Division of Critical Care Medicine

McMaster University, Hamilton ON


Objectives

Objectives

  • Major Body Fluid Compartments

  • Review of physiology of volume regulation

  • Parenteral Fluid Therapy

  • Cases of Electrolyte imbalances


Relationship between the volumes of major fluid compartments

Relationship between the volumes of major fluid compartments


Composition body fluid compartments

Composition body fluid compartments


Daily fluid requirements

Daily Fluid Requirements

  • Average Adult needs:

    H2O~ 30-35ml/kg/hr (2-3 liters/day)

    Na+~ 1 ml/kg/hr

    K+~ 1 ml/kg/hr

    Cl-~ 1.5 ml/kg/hr


Sources of daily water loss

Sources of daily water loss

  • Urine 1200-1500 ml/d (30ml/hr)

  • Sweat200-400 ml/d

  • Lungs 500ml/d

  • Feces100-200 ml/d


Composition of gi secretions

Composition of GI Secretions

* Average concentration: mmol/L


Daily electrolyte loss

Daily Electrolyte loss

Na+100 mEq

K+ 100 mEq

Cl- 150 mEq


Quiz 1

Quiz #1:

  • True or False statements

    Concerning body fluid compartments:

    a) Water constitutes 70% of the total body weight b) Plasma constitutes a quarter of the ECF volume d) Interstitial fluid volume for a 70 kg man is approximately 9 litres e) The ECF/ICF volume ratio is smaller in infants and children than it is in adults


Regulation of fluids

Regulation ofFluids


Regulation of fluids1

Regulation of Fluids

  • Renal sympathetic nerves

  • Renin-angiotensin-

  • aldosterone system

  • Atrial natriuretic peptide (ANP)


Parenteral fluid therapy

Parenteral Fluid Therapy

Crystalloids

  • Na+  main osmotically

    active particle

  • useful for volume expansion (mainly

    interstitial space)

  • for maintenance infusion

  • correction of electrolyte abnormality


Crystalloids

Crystalloids

  • Isotonic crystalloids

    - Lactated Ringer’s, 0.9% NaCl

    - 25% remain intravascularly

  • Hypertonic saline solutions

    - 3% NaCl

  • Hypotonic solutions

    - D5W, 0.45% NaCl

    - < 10% remain intra-

    vascularly, inadequate for fluid

    resuscitation


Colloid solutions

Colloid Solutions

  • Contain high molecular weight

    substancesdo not readily migrate across

    capillary walls

  • Preparations

    - Albumin: 5%, 25%

    - Hydoxyethyl starches

    ie pentaspan

    - Red cell concentrates

    - platelets, plasma


Distribution of parenteral fluids

Distribution of Parenteral Fluids


Fluids and electrolytes september 10 2008

Composition of Parenteral Fluids


Quiz 2

Quiz #2:

  • 70F has small-bowel fistula with output of 1.5L/d. Replacement of daily losses should be handled using the fluid solution that has the following composition:

    NaKClHCO3

    a) 130410928

    b)154015440

    c)770770

    e)51305130


Quiz 3

Quiz #3:

  • 68M admitted with diagnosis of partial SBO with Hx of Chrons Disease vomits bilious coloured emesis. His is lethargic.

    37C, 88/50 mmHg, HR 110, RR 25, SpO2 99 on 2Lnp

    JVP flat, chest clear with normal heart sounds

    Abd distended & mild epigastric tenderness

    Na 130, Cl 108, K 5.1, Cr 110, BUN 10.2

    Hg 100, WBC 9.9, Plts 400, INR 1.5, APTT 30


Quiz 31

Quiz #3:

  • Your staff asks you to see this patient. What is the most appropriate resusitation fluid:

    a) 1 unit of packed RBC

    b) 500 ml of Ringers Lactate solution

    c) 500ml 5% albumin

    d) 500ml Pentaspan

    e) 500ml 0.9% normal saline


Safe study nemj 2004 350 safe investigators

SAFE Study (NEMJ 2004:350 Safe Investigators)

  • RCT: 4% albumin vs normal saline for intravascular-fluid resuscitation

  • Primary outcome: 28 day all cause mortality

  • N = 6997 patients

  • No significant differences

    • 726 deaths albumin group vs 729 deaths saline group

      (RR 0.99; 95% CI 0.91 to 1.09; P=0.87

    • numbers of days spent in the ICU or in the hospital

    • days of mechanical ventilation

    • days of renal-replacement therapy


Fluids and electrolytes september 10 2008

28% day Kaplan–Meier Estimates Probability of Survival: normal saline vs 4% albumin(NEMJ 2004:350 Safe Investigators)


Rr of death among the patients in the six predefined subgroups nemj 2004 350 safe investigators

RR of Death among the Patients in the Six Predefined Subgroups(NEMJ 2004:350 Safe Investigators)


Colloid solutions for fluid resuscitation cochrane database syst rev 2008

Colloid solutions for fluid resuscitation(Cochrane Database Syst Rev. 2008)

  • Seventy RCTs comparing colloid solutions in critically ill and surgical patients thought to need volume replacement,

  • N = 4375 participants

  • Albumin versus hydroxyethyl starch pooled RR 1.14 (95% CI 0.91 to 1.43) for mortality

  • albumin versus dextran (RR= 3.75 95% CI 0.42 to 33.09).

  • no evidence that one colloid solution is more effective or safe than any other


Calculation of maintenance fluids

Calculation of Maintenance Fluids

  • For a 24 hr period, use 100/50/20 Rule

    100ml/kg for first 10kg

    50ml/kg for next 10kg

    20ml/kg for every kg over 20

  • For hourly maintenance rate, use 4/2/1 Rule

    4ml/kg for first 10kg

    2ml/kg for next 10kg

    1ml/kg for every kg over 20


Quiz 4

Quiz #4

  • 55M has been admitted for an elective resection of a pelvic mass. He is NPO for the next 12 hours. He weighs 70kg and has normal renal function. What is the most appropriate iv maintenance rate?

  • 0.9% NS at 200ml/hr

  • 0.45% NS/D5W at 100ml/hr

  • D5W at 100ml/hr

  • Ringer’s Lactate at 50ml/hr


Clinical cases electrolyte imbalances

Clinical Cases: Electrolyte Imbalances


Case 1

Case 1

  • 39M POD2 following ventral hernia repair.

  • Background: HTN, DM nephropathy

  • Meds: Ramipril 10mg daily, morphine prn

  • Patient is weak, c/o paraethesia

  • Post-op EKG: Sinus bradycardia 40bpm, peaked T waves, depressed ST with prolonged PR, wide QRS

  • O/E DTR depressed


Case 11

Case 1

  • What is electrolyte disturbance?

     Hyperkalemia

  • What are the most likely surgical causes?

     RF, Drugs, Acidosis, Tissue injury

    blood transfusions

  • What is the acute management strategy?

     Cardioprotection, shifting, elimination


Case 2

Case 2

  • 70F one week of constipation and vomitting.

  • Background: DM, Dilated cardiomyopathy, Intestinal fistula

  • Meds: Insulin, Lasix 80mg bid

  • Patient c/o weakness, nausea/vomitting and abdominal tenderness

  • O/E 36.4C 100/60 HR 110, RR12, SpO2 99% r/a

    JVP flat, chest clear, normal heart sounds, Abdominal distension, no bowel sounds

  • EKG: Sinus tachycardia with occasional PVCs, diffuse flattening of T waves, U waves


Case 21

Case 2

  • What is electrolyte disturbance?

     Hypokalemia

  • What are the most likely surgical causes?

     Drugs (diuretics, steroids, Insulin etc), diarrhea, vomitting, intestinal fistula, NG aspiration, insufficient supplementation

  • What is the acute management strategy?

     potassium supplementationiv/po


Case 3

Case 3

  • 67M unexplained 30lb wt loss over 6months and hemoptysis presents a GTC seizure

  • Background: HTN, smoker

  • Meds: HCTZ 25mg daily

  • O/E 37C 110/70 HR 88, RR14, SpO2 98%/ra

  • Lethargic & confused, No focal neuro deficits

  • JVP 4cmASA, PPP chest clear, normal heart sounds

  • Abd distended with faint bowel sounds

  • CXR: speculated LLL nodule


Case 31

Case 3

  • What is electrolyte disturbance?

     Hyponatremia

  • What are the most likely surgical causes?

     Access clinical fluid status


Case 3 hyponatremia management

Case 3 – Hyponatremia Management

What is the acute management strategy?

  • Depends on etiology & chronicity

  • Be careful! Rate of correction should be <0.5mEq/h, <10mEq/24hr, <18Eq in first 48h

  • Check lytes frequently during correction

  • Use 3% NaCl ONLY if severe hyponatremia (Na+ <115) or if dramatically symptomatic with acute onset


Case 4

Case 4

  • 89F admitted with acute pancreatitis on ward for 2 weeks. Progressive confusion in last few days with new tremors

  • Otherwise healthy, no meds. On TPN.

  • Net fluid balance 24hrs –4L, u/o 200ml/hr

  • O/E 36C 110/50 HR 110, RR 10, SpO2 98%r/a

    stupourous & clinically hypovolemic

    ++peripheral edema


Case 41

Case 4

  • What is electrolyte disturbance?

     Hypernatremia

  • What are the most likely surgical causes?

     Inadequate hydration, diabetes insipitus, diuresis, vomitting/diarrhea, iatrogenic (TPN)

  • What is the acute management strategy?

     Depends on etiology & chronicity

    (D5W or 0.45% normal saline)


Case 5

Case 5

  • 26F with newly diagnosed primary hyperparathyroidism is referred for surgical assessment.

  • She has had polydipsia, polyuria and constipation and abdominal discomfort.

  • O/E 37C, 100/80, HR99, RR 14, SpO2100%

    Confused, JVP 1cm ASA weak pulses

    ABD unremarkable

  • EKG: short QT, prolonged PR interval


Case 51

Case 5

  • What is electrolyte disturbance?

     Hypercalcemia

  • What are the most likely causes?

     Hyperparathyroidism, immobility, Pagets, Addisons, Neoplasms, xs Vitamin D, A, Sarcoidosis, Calcium supplementation, thiazides

  • What is the acute management strategy?

     Volume expansion with NS

     +/- lasix, bisphosphonates, calcitonin, steroids


Case 6

Case 6

  • 45M presents with profound weakness in setting of chronic diarrhea.

  • Background Alcohol Abuse

  • P/E is unremarkable

  • EKG: Prolonged QTc interval


Case 61

Case 6

  • What are the possible electrolyte disturbances?

     Hypokalemia, hypomagnesiumia, hypophosphtemia, hypernatremia

    What is the acute management strategy?

     replace with supplemental magnesium

    and potassium phosphate

     fluid therapy


Things you don t want to hear during surgery

Things you don't want to hear during surgery:

  • 5. Damn, there go the lights again...

  • 4. "You know, there's big money in kidneys. Heck, the guy's got two of them."

  • 3. Everybody stand back! I lost my contact lens!

  • 2. This patient has already had some kids, am I correct?

  • 1. Nurse, did this patient sign the organ donor card?


Fluids and electrolytes september 10 2008

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