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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
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)
  • Sweat 200-400 ml/d
  • Lungs 500ml/d
  • Feces 100-200 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 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

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:

Na K Cl HCO3

a) 130 4 109 28

b) 154 0 154 40

c) 77 0 77 0

e) 513 0 513 0

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
slide21
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
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?
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