1. Fluid & Electrolyte Emergencies In Critically Ill
Dr.Patibandla.Sowjanya
Dept Of Accident , Emergency & Critical Care Medicine
Vinayaka Missions Kirupanandavariyar Medical College

2. Introduction Total body water (60%)
Two third is intracellular fluid (40%)
One third is extra cellular fluid (20%)
- Interstitial fluid (15%)
- Intravascular fluid (5%)

3. Fluid shifts EXTRACELLULAR INTERSTITIAL 9 LIT IV 5 LIT 15% 5%
INTRACELLULAR 30 LIT
40%
EXTRACELLULAR
INTERSTITIAL 9 LIT
15%
IV 5 LIT 5%

4. Electrolyte Components
142
Na+
150 K+
Ca2+
Mg2+
Cl-
HCO3-
HPO42-
SO42-
Organic acid
Protein

5. ICF ECF Major Cation Potassium Magnesium Sodium Major Anion Phosphate
Sulphate
Protein
Chloride
Bicarbonate

6. Osmolarity
Measurement of the total solutes in a water solution per liter.
Osmolarity = [sodiumx2 ]+urea/2.8+glucose/18
Serum osmolarity is mOsm/L
mOsmol/L- Isotonic
> 300 mOsmol/L – Hypertonic
< 280 mOsmol/L - Hypotonic

7. Three categories of fluids
Isotonic - Fluid has the same osmolarity as plasma
Eg: Normal saline
Ringers lactate

8. Hypotonic - Fluid has fewer solutes than plasma
Eg : Water, 1/2 N/S (0.45% NaCl)

9. Hypertonic - Fluid has more solutes than plasma
Eg:5% Dextrose in Normal Saline (D5 N/S) , 3% saline solution.

10. Isotonic Infusion
2 litres of
blood
30 litres
9 litres
3 litres

11. Intravascular Volume increases to 5 liters
30 litres
9 litres
5 litres

12. Hypertonic
Infusion
2 litres of
colloid
30 litres
9 litres
3 litres

13. Initially it becomes 5 L
30 litres
9 litres
5 litres

14. 8 litres 29 litres Hypertonicity of Colloid shifts I/C fluid into I/V

15. 9 litres 30 litres If 2 L of Crystalloid infused… 2 litres of
0.9% saline
30 litres
9 litres
3 litres

16. Initially I/V becomes 5L
30 litres
9 litres
5 litres

17. Isotonicity of Crystalloid shifts I/C & I/V volume into interstitial space
29 litres
10.5 litres
4.5 litres

18. Hypotonic Infusion
2 litres of 5%dextrose
30 litres
9 litres
3 litres

19. 9.7 litres 31 litres Hypotonicity Shifts the fluid into the I/C space

20. Signs of Volume depletion
Postural hypotension
Tachycardia
Absence of JVP
Dry mucosa
Decreased skin turgor
Oliguria

21. Signs of Volume overload
Hypertension
Raised JVP/gallop
Pedal edema
Pulmonary edema
Ascites
Organ failure

22. Basic principles of fluid therapy
Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock
Replace
Insensible water loss + urine
Maintain
Acid base, electrolyte imbalances
Repair

23. The rules of fluid replacement
Replace blood with blood
Replace plasma with colloid
Resuscitate with colloid / crystalloid
Replace ECF depletion with saline
Rehydrate with dextrose

24. Case Scenario
45 yr old was brought to ER with h/o loose stools & vomiting since 2 days
Drowsy and lethargic with signs of severe dehydration, BP-80/50 , PR-120
What is initial fluid of choice?

25. Why? Isotonic saline / Ringer’s lactate
No dextrose containing fluid initially
Why?

26. Disturbances
Electrolyte
Potassium
Sodium
Critically ill

27. Case Study #1
HPI:
A 55 year old man is in the Neuro ICU for acute non hemorrhagic stroke.
Hospital course:
Decreasing urine output (< 0.5 ml/kg/hr) over the last 24 hours.
What is your differential diagnosis? What diagnostic studies would you order?

28. Case Study #1 Differential diagnosis
Oliguria
1) Pre-Renal (decreased effective renal blood flow)
Diminished intravascular volume, cardiac dysfunction, vasodilatation
2) Post-Renal
Outlet obstruction (intrinsic vs. extrinsic), foley catheter occlusion
3) Renal
Acute tubular necrosis, acute renal failure, SIADH, ...

29. Case Study #1 Laboratory studies
Serum studies Sodium 120 mEq/L BUN 4 mg/dL Chloride 98 mEq/L Creatinine 0.4 mg/dL Potassium 3.7 mEq/L Glucose 129 mg/dL Bicarbonate 25 mEq/L Osmolality 260 mosmol/kg Urine studies Specific gravity Sodium 58 mEq/L Osmolality 645 mosmol/kg What are the primary abnormalities?

30. Case Study #1 Laboratory studies
Major abnormalities 1) Hyponatremia 2) Oliguria (inappropriately concentrated urine) What is the most likely explanation for these findings?

31. In Hyponatremia…… SIADH Renal water conservation Dilutional
Cerebral salt wasting Syndrome
Natriuresis with Dehydration

32. Case Study #1 Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Variable etiology
Trauma
Infection
Psychosis
Malignancy
Medications
Diabetic ketoacidosis
CNS disorders
Positive pressure ventilation
“Stress”

33. SIADH
By definition, “inappropriate” implies having excluded normal physiologic reasons for release of ADH:
1) In response to hypertonicity.
2) In response to life threatening hypotension.
Hyponatremia
Oliguria
Concentrated urine
elevated urine specific gravity
“inappropriately” high urine osmolality in face of hyponatremia
Normal to high urine sodium excretion

34.  urine osmolality,  SG,  urine sodium excretion
Case Study #1 SIADH
Diagnosis
Critical level of suspicion.
Demonstration of inappropriately concentrated urine in face of hyponatremia
 urine osmolality,  SG,  urine sodium excretion
Be certain to exclude normal physiologic release of ADH

35. Treatment Fluid restriction Avoid hypotonic fluids
Case Study #1 SIADH
Treatment
Fluid restriction
Avoid hypotonic fluids
Hypertonic saline / oral sodium chloride
Frusemide.

36. Cerebral Salt wasting Syndrome
Development of excessive natriuresis with hyponatremic dehydration in patients with intracranial disease
Seen in Head injury, Brain tumor, Intracranial Surgery or stroke

37. CSW vs SIADH features CSW SIADH Volume status Low Normal Wt Loss
No change
Orthostatic signs
Present
Absent
Sr Na
Decreased
Hematocrit
Increased
Uric acid
Normal or inc
Resp to hydration
Improvement
Dec Na
Resp to fluid rest
Possible shock
improve
Urine Na
>100
>20

38. Case Study #1 The saga continues….
Hospital course: Four hours after beginning fluid restriction, you are called because the patient is having a generalized seizure. There is no response to two doses of IV lorazepam and a loading dose of fosphenytoin What is the most likely explanation?

39. Case Study #1 The saga continues
Seizure 1) Worsening hyponatremia 2) Intracranial event 3) Meningitis 4) Other electrolyte disturbance 5) Medication 6) Hypertension What diagnostic studies would you order?

40. Case Study #1 The saga continues
Stat labs: Sodium 110 mEq/L What would you do now?

41. Case Study #1 Hyponatremic seizure
Treatment
Hypertonic saline (3% NaCl) infusion
To correct sodium to 125 mEq/L, the deficit is equal to
0.6 X weight[kg] X (125 - measured sodium)
0.6 X 60 X ( ) = 54O mEq

42. Newer method Rate of infusion of 3%NaCl = Na Requirement x 1000
infusate sodium x time
(Desired-Actual Na) x 0.6.body wt x 1000
513 x no of hours
As patient is symptomatic, rate of correction is 1 mEq/hr,
Required rate of infusion of 3% NaCl = 1 x 0.6 x 60 x 1000
513 x 1
= 70 ml/hr
Check sodium after 4 hours and correct accordingly

43. Hyponatremia

44. Case Study # 2
60 year old retired engineer presented to ER with history of inability to speak and move all 4 limbs since today morning. Detailed history revealed that he has been on naturopathy diet since 6 months and had developed GTCS 2 days back. He was treated outside for GTCS and following the treatment he is unable to communicate or use his limbs

45. His previous lab reports showed Na is 117 mEq/L and rest of the parameters are within normal Limits
Repeat Sodium in our hospital showed 145 mEq/L
What could be the possibility?

46. Central Pontine Myelinolysis
Develops with
Aggressive treatment of Chronic hyponatremia
Raising Sr.Na >25mEq/L in first 48 hours
Raising Sr.Na to Normal or Above normal in 48 hours

47. CPM Focal demyelination in the Pons & extrapontine areas.
Causes  Mutism / dysarthria
Spastic Quadriplegia
Pseudobulbar palsy
Seizures
Altered Mental Status
Coma & Death
CPM is irreversible

48. Principles of Hyponatremia Management
Asymptomatic Hyponatremia Use 0.9%NaCl
Symptomatic Hyponatremia Use 3% NaCl
Correct only 12mEq/L defecit only perday
Chronic Hypernatremia with severe symptoms should receive hypertonic saline only to arrest the symptoms and followed by slow 0.5 mEq/L

49. Hyponatremia Management is Double Edged Sword
Knowledge
Wisdom

50. Case Study #3
HPI: A 5 month-old girl presents with a one day history of irritability and fever. Mother reports three days of “bad” vomiting and diarrhea. Home meds: Paracetamol and ibuprofen for fever PE: BP 70/40, HR 200, R 60, T38.3 C. Irritable, sunken eyes and fontanelle.

51. Case Study #3
No one can obtain IV access after 15 minutes, what would you do now?

52. Case Study #3 Place intraosseous line Serum studies
Bolus 40 ml/kg of isotonic saline
Reassessment (HR 170, RR 40, BP 75/40)
Serum studies
Sodium 164 mEq/L BUN 75 mg/dL
Chloride 139 mEq/L Creatinine 3.1 mg/dL
Potassium 5.5 mEq/L Glucose 101 mg/dL
Bicarbonate 12 mEq/L
pH pCO2 11
pO HCO3 8

53. Case Study #3
What is the most likely explanation of this patient’s Condition?

54. Case Study #2 Treatment of Hypernatremia
To stop ongoing fluid loss
To correct water deficit
= plasma Na – 140 x 0.6 x body wt. in kg
140
Water deficit can be replaced with water by mouth or IV 5% dextrose or 0.45% NaCl

55. Rate Of Correction
Acute Hypernatremia ½ body water defecit in 24 hours
Chronic Hypernatremia ½ body water defecit in 48 hours
Rapid correction  cerebral edema & Neurological deterioration

56. Case Study #4
HPI:
A 50 year old man was involved in a motor vehicle accident two days ago. He sustained an isolated head injury with intraventricular hemorrhage and multiple large cerebral contusions. Three hours ago, he had an episode of severe intracranial hypertension (ICP 90mm Hg, MAP 50mm Hg, requiring volume plus epinephrine infusion for hypotension. Over the last two hours, his urine output has increased to ml/hour

57. What is your differential diagnosis? What test would you order?

58. Case Study #4 Differential diagnosis
Polyuria 1) Central diabetes insipidus Deficient ADH secretion (idiopathic, trauma, pituitary surgery, hypoxic ischemic encephalopathy) 2) Nephrogenic diabetes insipidus Renal resistance to ADH (X-linked hereditary, chronic lithium, hypercalcemia, ...) 3) Primary polydipsia (psychogenic) Primary increase in water intake (psychiatric), occasionally hypothalamic lesion affecting thirst center 4) Solute diuresis Diuretics (lasix, mannitol,..), glucosuria, high protein diets, post-obstructive uropathy, resolving ATN, ….

59. Laboratory studies Serum studies Other
Sodium 155 mEq/L BUN 13 mg/dL
Chloride 114 mEq/L Creatinine 0.6 mg/dL
Potassium 4.2 mEq/L Glucose 86 mg/dL
Bicarbonate 22 mEq/L Serum osmolality: 320 mosmol/kg
Other
Urine specific gravity 1.005, no glucose.
Urine osmolality: 160 mosmol/kg
What are the main abnormalities?

60. Case Study #4 Laboratory studies
Major abnormalities
1) Hypernatremia
2) Polyuria (inappropriately dilute urine)
What is the most likely explanation?

61. Case Study #4 Diabetes Insipidus
Diagnosis
Central Diabetes insipidus
1) Polyuria
2) Inappropriately dilute urine (urine osmolality < serum osmolality)
May be seen with midline defects
Frequently occurs in brain dead patients
What should you do to treat this patient?

62. Case Study #4 Diabetes Insipidus
Treatment
ADH preparations - dDAVP nasal spray 2-4 μg/dl
Potentiate ADH effect – chlorpropamide, carbamazepine, NSAID’s.
Increase ADH release – Clofibrate
Warning
Closely monitor for development of hyponatremia

63. Hypernatremia

64. Case Study #4
HPI:
An 35 year old lady with Chronic kidney disease presents with irritability. She is on nightly peritoneal dialysis at home. The lab calls a panic potassium value of 7.1 meq/L. The tech says it is not hemolyzed.
What do you do now?

65. Case Study #4 Hyperkalemia
Treatment
Immediately repeat serum potassium.
Do not wait for confirmatory labs especially if ECG changes present.
Anticipatory
Stop potassium administration including feeds

66. ECG
What is this rhythm?
What is your immediate treatment?

67. Case Study #5 Hyperkalemia
Control effects
Antagonism of membrane actions of potassium
10% Calcium gluconate ml over minutes; may repeat x2
Shift potassium intracellularly
Glucose 1 gm/kg plus 0.1 unit/kg regular insulin
Alkali therapy - Sodium bicarbonate 1 mEq/kg IV
Inhaled 2 adrenergic agonist

68. Removal of potassium from the body
Loop / thiazide diuretics
Cation exchange resin: sodium polstyrene sulfonate (Kayexelate) 1 gm/kg PO or PR (or both)
Dialysis

70. Hyperkalemia Rx

71. Case Study #5
HPI:
A three year old boy is recovering from septic shock. He received 150 ml/kg in fluid boluses in the first 24 hours and has anasarca. You begin him on a frusemide infusion for diuresis. He develops severe weakness and begins to hypoventilate. You notice unifocal premature ventricular beats on his cardiac monitor.

72. What is your differential diagnosis? What tests would you order?

73. Case Study #6 Laboratory studies
Serum studies
Sodium 134 mEq/L BUN 11 mg/dL
Chloride 98 mEq/L Creatinine 0.4 mg/dL
Potassium 2.4 mEq/L Calcium 9.2 mg/dL
Bicarbonate 27 mEq/L Phosphorus 3.2 mg/dL
Other
ECG: Unifocal PVC’s
What is the main abnormality?

74. Case Study #6 Laboratory studies
Major abnormality
1) Hypokalemia
What would you do now?

75. Case Study #6 Hypokalemia
Treatment
Oral
Safest, although solutions may cause diarrhea IV
do not exceed 40 mEq/L or 10 – 20 mEq/hr potassium.
- never give inj.Kcl directly intravenously.
Replace magnesium also if low
(25-50 mg/kg MgSO4)

77. Summary
Disorders of sodium, water, and potassium regulation are common in critically ill.
Diagnostic approach must be considered carefully for each patient
Strict attention to detail is important in providing safe and effective therapy

78. Thank you