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Fluids & Electrolytes Scott G. Sagraves, MD, FACS Assistant Professor Trauma & Surgical Critical Care.

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Presentation on theme: "Fluids & Electrolytes Scott G. Sagraves, MD, FACS Assistant Professor Trauma & Surgical Critical Care."— Presentation transcript:

1 Fluids & Electrolytes Scott G. Sagraves, MD, FACS Assistant Professor Trauma & Surgical Critical Care

2 The recognition and management of fluid, electrolyte, and related acid-base problems are common challenges on the surgical service. Lawrence, Essentials of General Surgery

3 Goals Review concept of total body fluids Review types of crystalloids Review electrolytes disturbances & their treatment strategies.

4 Body Fluids 40% 16% 4% Body Water = 60% of a patients body weight

5 Why do you give D 5 ½NS + 20 mEq/L KCl at 125 cc/hr to a patient?

6 Fluid Requirements typically 35 mL/kg/day insensible loss = 700 mL/day or 0.2 cc/kg/day for every 1° C > 37° 1-10 kg = 100 mL/kg/day {4mL/kg/hr} kg = 50 mL/kg/day {2mL/kg/hr} > 21 kg = 20 mL/kg/day {1mL/kg/hr} Trick for hourly maintenance = 40 + weight (kg)

7 Serum Values of Electrolytes Cations Concentration, mEq/L Sodium Potassium Calcium Magnesium Anions Chloride CO Phosphate

8 Daily Requirements for Electrolytes Sodium: 1-2 mEq/kg/d Potassium: mEq/kg/d Calcium: mg/d Magnesium: mg/d Phosphorus: mg/d

9 IV Solutions SolutionNa + Cl - K + Ca +2 HCO3 - Glu Plasma NS D5W G LR Serum Osmolality = [2 x Na] + [BUN/2.8] + [glucose/18]

10 Replacement Strategies Sweat: D 5 ¼NS + 5 mEq KCl/L Gastric: D 5 ½NS + 20 mEq KCl/L Biliary/pancreatic: LR Small Bowel: LR Colon: LR 3 rd space losses: LR

11 Resuscitation Crystalloids Replace blood loss at a 3:1 ratio Initial bolus 1-2 liters, usually normal saline If they have transient response, give additional fluids. Once 3-4 liters of crystalloid has been given consider blood.

12 INDICATORS OF SUCCESSFUL RESUSCITATION PULSE bpm URINARY OUTPUT –CHILDREN = 1.0 ml/kg/hr –ADULT = 0.5 ml/kg/hr Clearance of lactate Resolution of base deficit BLOOD PRESSURE POOR INDICATOR

13 Fluid Status [Na] ECV lownormal high GI loss SIADH Hypothyroid Cortisol CHF Cirrhosis NaHCO 3 3% NaCl Seawater DI Insensible GI Loss Renal loss Osmotic

14 Renal Regulatory Mechanisms Aldosterone –distal tubules –sodium exchanged for K + and H + –released by volume reduction Antidiuretic Hormone (ADH) –increased tubular water reabsorption –posterior pituitary release

15 Acid/base 7.4 BE = 0 HCO3 = 24 Respiratory Acidosis Metabolic Acidosis Metabolic Alkalosis Respiratory Alkalosis

16 ABG Rules Rule 1: An increase or decrease in PaCO 2 of 10 mm Hg, respectively, is associated with a reciprocal decrease or increase of 0.08 pH units. Rule 2: An increase or decrease in [HCO3 - ] or 10 mEq/L respectively is associated with a directly related increase or decrease of 0.15 pH units.

17 Acidosis pH < 7.2 –decreased responsiveness to catecholamines –cardiac dysfunction –arrhythmias –increased potassium serum levels

18 Case Studies

19 Found Down 45 yo WM, found down, presumed to be assaulted, well known to ED for EtOH CT head - hygromas, small ICH labs: –Na = 118 –K = 2.4 –Cl = 74 What do you think? What do you do?

20 Severe Hyponatremia Correct sodium to above 120 mEq/dl –NaCl + 40 mEq/L KCl –3% Saline –furosemide diuresis (euvolemic) –serial electrolytes –be prepared to handle seizures Replace potassium Cl should correct itself

21 Hyponatremia 1% of hospitalized are hyponatremic Neurologic conditions: –Seizures, coma, encephalopathy –Results from rapid [Na] Peripheral symptoms: –Cramping, twitches, fasciculations –Results from ion conduction aberrations

22 Hints… Na + deficit (mEq) = (140 – Na serum ) x 0.6 x Kg Glucose increase 100 mg/dL or a BUN increase of 30 mg/dL decrease of 1.5 – 2 mEq/L Sodium

23 Central Pontine Myelinosis Results from overcorrection of sodium Correction of > 25 mEq per hrs Concurrent hypoxia Presence of liver disease Acute correction limit 25 mEq /day Chronic correction limit 10 mEq/day

24 Treatment Strategies Hypovolemic Hyponatremia –expand intravascular volume 0.9% NS or 3% Hypertonic Saline Hypervolemic Hyponatremia –water restriction –treat medical condition –hemodialysis Euvolemic Hyponatremia –SIADH restrict fluid: 7-10 ml/kg/d demeclocycline antagonizes vasopressin

25 HDU Code A Code Blue is called in the HDU. 65 yo male with ESRD has arrested awaiting his dialysis treatment. CPR and BVM resuscitation are in progress and an IV has been established. What do you think? What do you do?

26 Pre-Arrest Rhythm Strip

27 Arrest Strip

28 Diagnosis? HYPERKALEMIA Treatment CaCl 2 10% - 1 ampule Sodium Bicarbonate - 1 ampule D 50 & Insulin 10 U 2 - agonist nebulizer- cellular K Kayexalate ®

29 Causes of Hyperkalemia Renal dysfunction Acidemia Hypoaldosteronism Drugs Excessive intake WBC > 100,000 Platelets > 600,000 Cell Death –Rhabdomyolysis –Tumor lysis –Burns –Hemolysis

30 Potassium Metabolism Normal daily intake 100 mEq Renal filters & reabsorbs prox. Tubule Potassium 1/[aldosterone] Acidosis [potassium] with H + out Alkalosis [potassium] with H + in

31 Post op patient 42 year old female admitted to the ICU post op after undergoing a thyroidectomy for thyroid cancer. She is complaining of peri-oral numbness and tingling. Her DTRs are hyperactive and her ECG has a prolonged QT interval. What do you think? What do you do?

32 HYPOCALCEMIA Chvosteks sign - facial muscle spasm Trousseaus sign - carpal spasm Treatment –monitor ECG –IV calcium –follow up labs –oral calcium supplements normal is 1 gram/day

33 Blunt Trauma 23 year old male, s/p MVC with blunt abdominal and orthopedic trauma HD#3 develops fever, N/V, abdominal pain, refractory hypotension, with oliguria. Na + 130, K - 5.5, Glu 65, pH 7.29 What do you think? What do you do?

34 ACUTE ADRENAL INSUFFICIENCY Treatment –fluid and vasopressor support –treat precipitating conditions –draw baseline cortisol level –administer dexamethasone –ACTH stimulation test –hydrocortisone 100 mg IV q 8

35 Hydrocortisone Stimulation Test Baseline cortisol –> 20 - no further therapy – test –< 15 empiric therapy Administer Cortrosyn 250 g IV Obtain levels 30 & 60 minutes post injection

36 You are called to the Bedside… What Do You Think? What Do You Do? 55 yo male, s/p fall with isolated, repaired fractured femur. Pts LOC decreased and patient began to seize. EKG showed…

37 Hypomagnesemia Mg plays role in energy metabolism, protein synthesis, cell division, & calcium regulation in muscle. Definition < 1.6 mg/dL Causes: poor diet, diuretics, gut losses, & massive diarrhea, resuscitation.

38 Mg Rx Replacement Magnesium Sulfate –1 gram = 8 mEq –Infuse at rate of 2 gram/hour –Emergency: 2 grams over 5 minutes

39 Closed Head Injury 32 year old female, MVC, GCS -7, intubated, with CT scan showing SAH, cerebral edema. ICP monitor shows a pressure of 27. CPP 55. Over the next several days, Na + > 150. What do you think? What do you do?

40 DIABETES INSIPIDUS Signs –[Na + ] 150 –Urine specific gravity –polyuria, clear urine –dDAVP 1 g sq raises urine osmolality in 2 hours Treatment –free water deficit = (0.6) x (Kg) x ([Na serum /140] -1) –dDAVP 2 g sq every 12 hours –for every L water deficit [Na + ] will rise 3 mEq above 140

41 The transfer 50 year old obese female, transferred for critical care management after a bowel resection. Presents with obtundation, hypotension, tachypnea, and emesis. C/O abdominal pain and has fruity breath amylase, lipase are elevated, Na What do you think? What do you do?

42 Work up? ABG Electrolyte panel urine analysis CBC Serum Ketones

43 Hyperglycemia CharacteristicDKANKHC Glucose > 1000 AcidosisSeveremin. KetonesHighlow DehydrationMod.High Na 1.6 for every 100 glucose above 200

44 Treatment Adequate fluid replacement –narrowing of anion gap –crystalloids: LR, NS, ½ NS Insulin –bolus units/kg –infusion 0.1 units/kg/hour –goal reduce plasma glucose mg/dL/hr Electrolytes –K replacement mEq/hour after UOP OK –Mg, PO 4 replacement

45 The drunk 37 year old male, h/o EtOH abuse fell from a deer hunting tree stand. C5 fracture without cord involvement. HD #2 develops delirium tremors moved from SIU to ICU. Librium started. HD#4, dobhoff placed and tube feeds started. That night, the patients respiratory status worsens and he is intubated. What do you think? What do you do?

46 HYPOPHOSPHATEMIA Refeeding Syndrome –malnutrition –alcoholism Hypophosphatemia –limits oxygen unloading –immunocompromise –muscle weakness failure to wean

47 Treatment IV supplementation in emergent cases –sodium or potassium phosphorous PO supplementation routinely Keep (phosphorous x calcium) ratio < 60 Magnesium should be replenished simultaneously

48 The burn patient 25 year male, caught fire after his lawnmower exploded as he was filling it with gasoline while smoking a cigarette. The patient sustained second and third degree burns estimated at 40 % total body surface area.

49 Parkland Formula 4 cc x WEIGHT (kg) x (% TBSA)

50 Parkland Example 25 year old male weight = 220 pounds 40% TBSA 2° - 3° burns How much fluid do you need to give? –During the first 8 hours? –During the next 16 hours?

51 Parkland Example 4 cc x weight x %TBSA 4 x 100 x 40 = 16,000 cc/24 hours first 8 hours = 16,000/2 =8,000/8 = 1,000cc/hr next 16 hours = 8,000/16 = 500cc/hr

52 Diarrhea Dysrhythmia 68 yo female on digoxin for chronic CHF, presents to the SIU for colitis as evidenced by copious diarrhea. The patient is weak and lethargic and ectopic beats are noted on her ECG. What do you think? What do you do?

53 Hypokalemia Deficits –Serum K = 3-4 is a mEq deficit 2-3 is a mEq deficit Treatment –replacement 10 mEq/hr via peripheral IV –10 mEq 0.1 mEq/L increase in serum K –Remember to check the Mg level too

54 Paradoxical Aciduria A rule: 0.1 pH mEq [K + ] pathophysiology –loss of K, severe alkalosis, [Na + ] load –hydrogen exchanged for K –independent of alkalosis remaining requires emergent replacement

55 Cancer 72 yo female with stage 4, metastatic breast cancer. Patient is confused, cachetic, and nauseated Na + = 147, Ca +2 = 14mg/dl What do you think? What do you do?

56 HYPERCALCEMIA Cancers associated with hypercalcemia –bone –breast –kidney –colon –thyroid –multiple melanoma Treatment –hydration –diuretics-lasix –mithramycin –corticosteroids –calcitonin- osteoclast resorption –phosphate

57 Labor and Delivery 32 year old P 3 G 3 being treated by OB for eclampsia. You are called for a somnolent patient in second-degree heart block and paralysis. What do you think? What do you do?

58 Hypermagnesemia Signs –Prolonged PR interval –Hypotension, hyporeflexia, paralysis Treatment –Calcium gluconate –Normal saline –Loop diuretics –dialysis

59 Questions?

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