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FLUID & ELECTROLYTE BALANCE
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FLUID & ELECTROLYTE BALANCE

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  1. FLUID & ELECTROLYTE BALANCE Prof. M. H. Mumtaz

  2. BALANCE • Water Balance • Elecrolyte Balance • Acidbase Balance • Nutritional Balance

  3. FLUID & ELECTROLYTE BALANCE • Intke & loss routes. • Distribution of water and electrolytes. • Physiological control of water and sodium. • Assessment of balance. • Physiological response to pathological conditions. • Practical approach to therapy.

  4. INTAKE Food Drink Metabolic OUTPUT Urine Stool Sweat Respiration NORMAL ROUTES

  5. Intravenous Nasogastric aspiration Enterostomy Colostomy PATHOLOGICAL ROUTES

  6. RENAL LOSS FILTERATION REABSORPTION

  7. WATER 180L/24h 125mls/min 7.5/hr 4xBW =15xECF =60xPV SODIUM 30000mmol/24hr 18125Ueq/min FILTERATION

  8. WATER 75%PT 5%L 15%DT 4-4.86%CT Urine 1ml/kg/hr SODIUM CI 14585Ueq HCO3 3375Ueq PO4 NH3 50Ueq K+ 50Ueq Total – 18060Ueq REABSORPTION

  9. 24-HRS RENAL DEALING

  10. SECRETION IN GUT • SALIVARY • Quantitiy 1500/24 hrs. • GASTRIC • Quantitiy 3000/24 hrs. • BILIARY • Quantitiy 500/24 hrs. • PANCREATIC • Quantitiy 2000/24 hrs. • TOTAL • Quantitiy 7000mls.

  11. FEACAL LOSS • Na+ & H2O secretion • Na+ & H2O absorption • Epithelial cells • Duration of contact • H2O secreted > 7000ml • Loss = 100-150mls • Na+ secreted. • 1500mmols/24hrs • Loss 15mmol/24hrs

  12. LOSS IN SWEAT & EXPIRED AIR • 900mls water • 30mmols Na • Sweat loss. • Temp. • ADH. • Aldosterone • Respiratory loss. • Respiratory rate. • Hamidification.

  13. DISTRIBUTION OF WATER & ELECTROLYTEwater distribution • Total body water 60% of body wt in male • Total body water 52% of body wt in female 2/3rd IC 1/3rd EC 66% extravascular 33% intravascular

  14. ELECTROLYTE DISTRIBUTION mmol/L

  15. PHYSIOLOGIC CONTROL OF SODIUM • Aldosterone (2nd factor) • Non aldosterone (factors) • GFR (1st factor) • Renal blood flow. • Oncotic pressure in tubular blood. • Third factor

  16. LIVER 2 GLOBULIN RENIN FROM KIDNEY & ELSEWHERE ANGIOTENSINOGEN ANGIOTENSIN I ANGIOTENSIN II ANGIOTENSIN III DECAPEPTIDE CONVERTING ENZYME IN LUNG OCTAPEPTIDE INACTIVE METABOLITES INACTIVE METABOLITES AMINOPEPTIDE HEPTAPEPTIDE

  17. RENIN ANGIOTENSIN SYSTEM • Indomethacin • B. Blocker • Peptostatin • Captopril • Saralasin

  18. PHYSIOLOGIC CONTROL OF WATER • Intake. • Thirst. • Loss. • ADH • Non ADH factors. • Mannitol. • Urea. • Glucose.

  19. ADH Water A Renal Blood flow Hypothalmic Cellular arosmolality Renin B Angiotensin Na+ Concentration (Osmolality) Aldosterone

  20. CONTROL OF WATER IN COMPARTMENTS INTRAVASCULAR/INTERSTITIAL • Proteins – colloid osmotic pressure. • Hydrostatic pressure. INTERSITITAL/INTRACELULAR • Osmolality – predominantly – Na+

  21. CONTRIBUTION OF PLASMA CONSTITUENTS TO PLASMA OSMOLARITY

  22. HP THE KINETICS OF PVE INTRACELLULAR INTERSTITIAL VASCULAR CAPILLARY EG CELL OSMILALITY Na+ COP

  23. BLOOD VOLUME RENIN ALDOSTE Na+ Na+ ADH Osmolality H2O

  24. ASSESSMENT OF BALANCEassessment of state of hydration • History. Helping Tools • Clinical state. 1,CVP • Blood pressure. 2,T.E.D. S,D,M, 3,LIDCO/any? • Heart rate. • Temperature. • Skin texture.

  25. ASSESSMENT OF BALANCEassessment of state of hydration • Lab evidence. • Haemoconcentration. • Proteins. • Hb. • Haematocrit. • Hemodilution. • Protein. • Hb. • HCT

  26. ASSESSMENT OF IMBALANCE • Hypo-osmolality (hyponatraemia) • Cellular overhydration. • Headache. • Confusion. • Fits. • Coma. • Hyper-osmolality (hypernatraemia) • Cellular dehydration. • Thirst. • Confusion. • Coma. • No fits.

  27. HYPOVOLEMIA (ISOMOLOL) • Hypotension. • Collapse. • Haemoconcentration . • Low GFR uremia. HYPERVOLEMIA (ISOMOLOL) • Blood pressure. • Oedema. • Cardiac failure. • Haemodilution. • Urea.

  28. CLINICAL PRESENTATIONS

  29. I Predominant H2O depletion. With homeostasis Without homeostatis II Predominant Na+ depletion. With homeostasis Without homeostatis DISTURBANCE OF Na+ & H2O METABOLISMH2O & Na+ Deficiency

  30. III Predominant H2O excess. With homeostasis Without homeostatis IV Predominant Na+ excess. Without homeostatis DISTURBANCE OF Na+ & H2O METABOLISMH2O & Na+ Excess

  31. WITH HOMEOSTASIS Excess fluid loss. Sweat. Gastric juice. Stool. On respirator. Extensive burns. Deficient intake. Inadequate water supply Mechanical obstruction to intake. WITHOUT HOMEOSTASIS Comatosed patient response to thirst. Diabetes inspidus. Osmotic diresis. Nephrogenic diabetes inspidus. PREDOMINANT H2O DEPLETION

  32. HOMEOSTASIS? Clinical signs. Hypernatraemia. Dehydration. Oligurea. Lab. Findings Hypernatremia & haemacrit. Mild uraemia Urine. volume osmolality. SG Urea increase CLINICAL FINDINGS Polyrea. Urine of low osmolality. Low SG. Low urea concentration. PREDOMINANT H2O DEPLETION

  33. UNCONSCIOUS PATIENT water depletion Na+ CAUSES • Over breathing. • Pneumonia. • Acidosis. • Brain stem injury. • Inadequate humidification. • Hypertonic infusions. • Diabetes inspidus. • No response to thirst. • Infants with gastroenteritis. • Infats with bronchopneumonia.

  34. ADH Water A? Renal Blood flow Hypothalmic Cellular arosmolality Renin B Angiotensin Na+ Concentration (Osmolality) Aldosterone

  35. WITH HOMEOSTASIS Vomiting Diarrhoea. Fistula Sweating Replacement low Na+ homeostasis? WITHOUT HOMEOSTASIS Addison disease. Psaudo-addison disease. Renal tubular failure. PREDOMINANT Na+ DEPLETION

  36. WITH HOMEOSTASIS Clinical signs. Hypernatraemia. Lab. Findings Hypernatremia  vol. of urine Haemodilution plasone urea. Urinary Na+ excretion. WITHOUT HOMEOSTASIS Clinical signs. Fluid depletion Hypo-osmolality. Lab. Finding Haemo-concentration Renal circulatory insufficiency uraemia. PREDOMINANT Na+ DEPLETION

  37. ADH Water A Renal Blood flow Hypothalmic Cellular arosmolality Renin B? Angiotensin Na+ Concentration (Osmolality) Aldosterone

  38. WITH HOMEOSTASIS Fluid with low Na+ Homeostasis? Clinical signs. Hypo-osmolality. Lab. Findings. Haemodilution. Hyponatraemia. FAILURE OF HOMEOSTASIS Renal failure. Anappropriate ADH secretion. Oxytocin drip in 5% glucose. PREDOMINANT H2O EXCESScommonly associated with failure of homeostasis

  39. Clinical signs. Hypernatraemia. Lab. Findings Hypernatremia  vol. of urine Haemodilution plasone urea. Urinary Na+ excretion. Clinical signs. Fluid depletion Hypo-osmolality. Lab. Finding Haemo-concentration Renal circulatory insufficiency uraemia. PREDOMINANT H2O DEPLETION

  40. ADH Water A? Renal Blood flow Hypothalmic Cellular arosmolality Renin B Angiotensin Na+ Concentration (Osmolality) Aldosterone

  41. PREDOMINANT Na+ EXCESSALWAYS FAILURE OF HOMEOSTASIS • Primary aldosteronism (conn’s syndrome). • Cushings syndrome. • Secondary aldosteronism. • Clinical finding (conn’s syndrome) • Volume excess. • Hypertension rarely oedema. • Those of hypokalaemia.

  42. PREDOMINANT Na+ EXCESSALWAYS FAILURE OF HOMEOSTASIS • Lab. Findings. • Hypokaelemia. • HCO3. • Na+. • Urinary Na+ (Hypokalaemia alkalosis + BP  • Aldo + Renin.

  43. PREDOMINANT Na+ EXCESSALWAYS FAILURE OF HOMEOSTASIS • 2ndary aldosteronism. • Clinical finding (conn’s syndrome) • As in primary. • Lab. Findings. • Normal Na+ • Urinary Na+. • Findings of primary abnormality. • Hypokalaemia • Uraemia.

  44. THERAPY Water Neonate – 1 month 1st wk 110mls/kg/24hrs. 2nd 3rd wk 120-130mls/kg/24hrs. 1month – 1yr 100mls/kg/24hrs 1yr – 3yrs 90mls/kg/24hrs 3yrs – 7yrs 80mls/kg/24hrs 7yrs – 13yrs 70mls/kg/24hrs 13yrs onwards like adulsts 40-60mls/kg/24hrs Calculate/hour then/min then drops/min

  45. ELECTROLYTE • Na+ 1.5 - 2mmol/kg/24hrs • K+ 1 - 1.52mmol/kg/24hrs • Ca++ as requried • Mg 0.5mmol/GN2 loss • PO4 0.5mmol/kg/24hrs • Na+ 1.5 - 2mmol/kg/24hrs DAILY CALCULATIONS 1st day – Per kg wt Subsequent days = weighting = previous Out P+500mls

  46. THERAPY DURING OPERATION • Daily fluid requirement. • Hb correction. • Blood loss. • Newborn >10% of blood volume. • Adults >15% of blood volume. • HB correction Normal Hb of that age – Hb of patient x blood volume. • Blood volume • Premature 85-90mls/kg. • Newborn 80-85mls/kg. • Adults 75-80mls/kg.

  47. THERAPY DURING OPERATION CONTROVERSIAL? Benefit  No renal failure. Drawback Blood coaguability

  48. TO Stress – Surgery Stress – Anaesthesia PHYSIOLOGICAL RESPONSE

  49. MANAGEMENT GUIDELINES • Intr-operative • Hartmann’s solution or Ringolact solution • Blood to maintain Hb>10g/dl • Exceptions • Septicaemia. • Lung trauma. • PAWP 15ml/kg/hr