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Fluid and Electrolytes

Fluid and Electrolytes. Zach Gregg Zachary_Gregg@brown.edu. Total Body Water 60% body weight (50% in women) ECW- 20% body weight ICW- 40% body weight 33% TBW 67% TBW

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Fluid and Electrolytes

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  1. Fluid and Electrolytes Zach Gregg Zachary_Gregg@brown.edu

  2. Total Body Water 60% body weight (50% in women) ECW- 20% body weight ICW- 40% body weight 33% TBW 67% TBW Interstitial – 15% body weight Intravascular – 5% body weight 25% TBW 8% TBW

  3. ECW Intravascular Interstitial Water supplies the blood Equilibrated rapidly with Maintenance essential to survival intravascular compartment Increases in size after an operation, burn, trauma, or severe illness (3rd Spacing) Plasma is separated from interstitium by an endothelial cell layer and basement membrane

  4. Electrolytes ECW ICW Na+ 142 Na+ 10 K+ 4 K+ 140 Cl- 110 Cl- 3 HCO3- 24 HCO3- 10 Inorg. Phos- 12 Org. Phos- 137

  5. Na+/K+ ATPase • Actively pumps 3 Na+ out of cell and 2K+ inside cell • Energy from ATP • Regulated by • Insulin • Aldosterone

  6. Daily Requirements • Water – 30-35 cc/kg • Sodium – 1mEq/kg • Potassium – 0.5-1mEq/kg • Chloride – 1.5 mEq/kg

  7. Fluid Loss • Urine Output • Highest daily water loss • 0.5cc/kg/hr • Sufficient UO to excrete the daily solute load • 70kg pt = 35cc/hr

  8. Fluid Loss • Insensible • Skin - 300-400 ml/day • Breathing – 400 ml/day • Feces – 100-200 ml/day • Potential • Saliva – 1000 ml/day • Bile – 500-1000 ml/day • Gastric – 1000 ml/day • Pacreatic – 1000 ml/day • Small intestine – 3000 ml/day

  9. Maintenance Fluid • 100/50/20 per 24 hrs for 70kg • First 10 kg x 100cc/kg = 1000 cc • Second 10 kg x 50cc/kg = 500 cc • Remaining 50 kg x 20cc/kg = 1000 cc 2500 cc/day

  10. Maintenance Fluid • 4/2/1 per hr for 70kg • First 10 kg x 4cc/kg = 40 cc • Second 10 kg x 2cc/kg = 20 cc • Remaining 50 kg x 1cc/kg = 50 cc 110 cc/hr

  11. Fluid Components per Liter • Resuscitative Fluids • NS (0.9%) 154mEq Na+, 154mEq Cl- • LR 130mEq Na+, 110mEq Cl-, 4mEq K+, 28mEq HCO3-, 3mEq Ca • Maintenance Fluids • ½ NS (0.45%) 77mEq Na+, 77mEq Cl- • Colloid

  12. Fluid Pearls • Resuscitation – isotonic fluid (LR or NS), no dextrose, if ongoing losses consider using colloid • Post-op – LR or NS until pt euvolemic, then switch to maintenance • Bolus – Isotonic, no dextrose • Mobilization – movement of fluid from 3rd space into intravascular space

  13. Hypovolemia • Acute volume loss • Tachycardia • Hypotension • Decreased UO • Gradual volume loss • Loss of skin turgor, dry mucus membranes • Thirst • Changes in mental status • Low CVP • Hemoconcentration (Increased HCT) • BUN:Cr > 20:1 • Metabolic acidosis due to hypoperfusion

  14. Hypervolemia • Large UO • Pitting edema • JVD • Crackles on lung exam • Hypoxia • CXR – cephalization of vessels, pulm edema

  15. Hyponatremia • Serum Na+ < 130mEq/L • Sx- Nausea, emesis, weakness, MS changes, seizure • Hypovolemic • Causes – Na+ and water are lost and replaced with hypotonic solutions • Renal – salt wasting nephropathy • GI – diarrhea, vomiting, fistulas • Excessive sweating • 3rd spacing – ascites, peritonitis, pancreatitis, burns • Hypoaldosteronism • Tx – replete with NS, no faster than 0.5 mEq/L/hr to avoid central pontine myelinolysis

  16. Hyponatremia • Euvolemic • Causes – SIADH, psychogenic polydipsia • Tx – free water restrict • Hypervolemic • Causes - Renal failure, nephrosis, CHF, cirrhosis

  17. Hypernatremia • Serum Na+ > 145 • Sx – altered level of consciousness, seizure, coma, signs of dehydration • Causes – DI, hyperosmolar diuresis, EtOH suppresses Vasopressin release • Tx – Calculate free water deficit = 0.6 x wt(kg) x (measured Na+ - 140)/140 • Replace first ½ in 24hrs, then 2nd ½ in 24 hrs. No faster then 10mEq/day to avoid cerebral edema • Use D5W, ½ NS or ¼ NS

  18. Hypokalemia • K+ < 3.5 • Sx – fatigue, weakness, ileus, N/V, arrhythmia, rhabdomylosis, flaccid paralysis, resp compromise • EKG - long QT, depressed ST, low T waves, U waves • Causes – vomiting, NGT drainage, diarrhea, high output enteric/pancreatic fistula, hyperaldo, loop diuretics • Tx – replete 10 mEq KCl for every 0.1 below 4.0, if persistent hypoK+, may also need Mg 2+ replacement

  19. Hypokalemia EKG - long QT, depressed ST, low T waves, U waves

  20. Hyperkalemia • K+ > 5.0 • Sx – weakness, N/V, abdominal cramping, diarrhea, arrhythmias • EKG – peaked T waves, prolonged PR, widened QRS, V-fib, arrest • Causes – lab error, iatrogenic, renal failure, acidosis, hemolysis, crush injury, reperfusion after 4hrs ischemia • Tx – cardiac monitoring • 1 amp calcium gluconate (stabilizes myocardium) • 1 amp glucose, 10units IV insulin (shifts K+ intracellular) • Kayexalate, dialysis

  21. Hyperkalemia EKG – peaked T waves, prolonged PR, widened QRS, V-fib, arrest

  22. Hypocalcemia • Ca2+ < 8.5 • Sx – parasthesias, muscle spasms, tetany, seizures, Chvostek, Trousseau’s • EKG – prolonged QT, can progress to complete heart block or V-fib • Causes – pancreatitis, tumor lysis syndrome, blood transfusion, renal failure, thyroid or parathyroid surgery, diet deficient in Vit D or Ca, inability to absorb fat soluble viatmins • Tx – For chronic hypoCa give supplemental Ca and Vit D. For symptomatic give IV Ca

  23. Hypercalcemia • Ca2+ > 10.5 • Sx – stones, moans, groans, psychologic overtones • Causes – CHIMPANZEES • Tx – Identify cause and treat, severe/symptomatic hyperCa tx with IVF, bisphosphonates if due to release of Ca from bone

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