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A&E(VINAYAKA) Fluid & Electrolyte Emergencies In Critically Ill Dr.Patibandla.Sowjanya Dept Of Accident, Emergency & Critical Care Medicine Vinayaka Missions.

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Presentation on theme: "A&E(VINAYAKA) Fluid & Electrolyte Emergencies In Critically Ill Dr.Patibandla.Sowjanya Dept Of Accident, Emergency & Critical Care Medicine Vinayaka Missions."— Presentation transcript:

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

2 A&E(VINAYAKA) 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 A&E(VINAYAKA) Fluid shifts INTRACELLULAR 30 LIT 40% INTERSTITIAL 9 LIT 15% IV 5 LIT 5% EXTRACELLULAR

4 A&E(VINAYAKA) Electrolyte Components 150 Na + K+K+ Ca 2+ Mg 2+ Cl - HCO 3 - HPO 4 2- SO 4 2- Organic acid Protein 142

5 A&E(VINAYAKA) ICFECF Major CationPotassium Magnesium Sodium Major AnionPhosphate Sulphate Protein Chloride Bicarbonate

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

7 A&E(VINAYAKA) Three categories of fluids Isotonic - Fluid has the same osmolarity as plasma Eg: Normal saline Ringers lactate

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

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

10 A&E(VINAYAKA) 2 litres of blood 3 litres 9 litres 30 litres Isotonic Infusion

11 A&E(VINAYAKA) 30 litres 9 litres 5 litres Intravascular Volume increases to 5 liters

12 A&E(VINAYAKA) 2 litres of colloid 30 litres 9 litres 3 litres Hypertonic Infusion

13 A&E(VINAYAKA) 30 litres 9 litres 5 litres Initially it becomes 5 L

14 A&E(VINAYAKA) 29 litres 8 litres 7 litres Hypertonicity of Colloid shifts I/C fluid into I/V

15 A&E(VINAYAKA) 30 litres 9 litres 3 litres 2 litres of 0.9% saline If 2 L of Crystalloid infused…

16 A&E(VINAYAKA) 30 litres 9 litres 5 litres Initially I/V becomes 5L

17 A&E(VINAYAKA) 29 litres10.5 litres 4.5 litres Isotonicity of Crystalloid shifts I/C & I/V volume into interstitial space

18 A&E(VINAYAKA) 30 litres 9 litres 3 litres 2 litres of 5%dextrose Hypotonic Infusion

19 A&E(VINAYAKA) 31 litres 9.7 litres 3.3 litres Hypotonicity Shifts the fluid into the I/C space

20 A&E(VINAYAKA) Signs of Volume depletion Postural hypotension Tachycardia Absence of JVP Dry mucosa Decreased skin turgor Oliguria

21 A&E(VINAYAKA) Signs of Volume overload Hypertension Raised JVP/gallop Pedal edema Pulmonary edema Ascites Organ failure

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

23 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) Isotonic saline / Ringers lactate No dextrose containing fluid initially Why?

26 A&E(VINAYAKA) Critically ill

27 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 1.025Sodium 58 mEq/L Osmolality 645 mosmol/kg What are the primary abnormalities?

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

31 A&E(VINAYAKA) In Hyponatremia……

32 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) Case Study #1 SIADH Treatment –Fluid restriction –Avoid hypotonic fluids –Hypertonic saline / oral sodium chloride –Frusemide.

36 A&E(VINAYAKA) 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 A&E(VINAYAKA) CSW vs SIADH featuresCSWSIADH Volume status LowNormal WtLoss No change Orthostatic signs PresentAbsent Sr Na DecreasedDecreased HematocritIncreasedNormal Uric acid Normal or inc Decreased Resp to hydration Improvement Dec Na Resp to fluid rest Possible shock improve Urine Na >100>20

38 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) Case Study #1 The saga continues Stat labs: Sodium 110 mEq/L What would you do now?

41 A&E(VINAYAKA) 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 (125-110) = 54O mEq

42 A&E(VINAYAKA) 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 A&E(VINAYAKA) Hyponatremia

44 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) Central Pontine Myelinolysis Develops with 1.Aggressive treatment of Chronic hyponatremia 2.Raising Sr.Na >25mEq/L in first 48 hours 3.Raising Sr.Na to Normal or Above normal in 48 hours

47 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 correction @ 0.5 mEq/L

49 A&E(VINAYAKA) Knowledge Wisdom Hyponatremia Management is Double Edged Sword

50 A&E(VINAYAKA) 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 A&E(VINAYAKA) Case Study #3 No one can obtain IV access after 15 minutes, what would you do now?

52 A&E(VINAYAKA) Case Study #3 Place intraosseous line Bolus 40 ml/kg of isotonic saline Reassessment (HR 170, RR 40, BP 75/40) Serum studies Sodium 164 mEq/LBUN 75 mg/dL Chloride 139 mEq/LCreatinine 3.1 mg/dL Potassium 5.5 mEq/LGlucose 101 mg/dL Bicarbonate 12 mEq/L pH 7.07 pCO 2 11 pO 2 121 HCO 3 8

53 A&E(VINAYAKA) Case Study #3 What is the most likely explanation of this patients Condition?

54 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 150 - 200 ml/hour

57 A&E(VINAYAKA) What is your differential diagnosis? What test would you order?

58 A&E(VINAYAKA) 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 A&E(VINAYAKA) Laboratory studies Serum studies Sodium 155 mEq/LBUN 13 mg/dL Chloride 114 mEq/LCreatinine 0.6 mg/dL Potassium 4.2 mEq/LGlucose 86 mg/dL Bicarbonate 22 mEq/LSerum osmolality: 320 mosmol/kg Other Urine specific gravity 1.005, no glucose. Urine osmolality: 160 mosmol/kg What are the main abnormalities?

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

61 A&E(VINAYAKA) 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 A&E(VINAYAKA) Case Study #4 Diabetes Insipidus Treatment –ADH preparations - dDAVP nasal spray 2-4 μg/dl –Potentiate ADH effect – chlorpropamide, carbamazepine, NSAIDs. –Increase ADH release – Clofibrate Warning –Closely monitor for development of hyponatremia

63 A&E(VINAYAKA) Hypernatremia

64 A&E(VINAYAKA) 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 A&E(VINAYAKA) 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 A&E(VINAYAKA) ECG What is this rhythm? What is your immediate treatment?

67 A&E(VINAYAKA) Case Study #5 Hyperkalemia Control effects Antagonism of membrane actions of potassium 10% Calcium gluconate 10-20 ml over 5 - 10 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 A&E(VINAYAKA) –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

69 A&E(VINAYAKA)

70 Hyperkalemia R x

71 A&E(VINAYAKA) 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 A&E(VINAYAKA) What is your differential diagnosis? What tests would you order?

73 A&E(VINAYAKA) Case Study #6 Laboratory studies Serum studies Sodium 134 mEq/LBUN 11 mg/dL Chloride 98 mEq/LCreatinine 0.4 mg/dL Potassium 2.4 mEq/LCalcium 9.2 mg/dL Bicarbonate 27 mEq/LPhosphorus 3.2 mg/dL Other ECG: Unifocal PVCs What is the main abnormality?

74 A&E(VINAYAKA) Case Study #6 Laboratory studies Major abnormality 1) Hypokalemia What would you do now?

75 A&E(VINAYAKA) 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. - never give inj.Kcl directly intravenously. Replace magnesium also if low (25-50 mg/kg MgSO 4 )

76 A&E(VINAYAKA)

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 A&E(VINAYAKA)


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