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Fluids and Electrolytes September 10, 2008 Karen Koo, PGY5 Chief Critical Care Medicine Fellow Division of Critical Care Medicine McMaster University,

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Presentation on theme: "Fluids and Electrolytes September 10, 2008 Karen Koo, PGY5 Chief Critical Care Medicine Fellow Division of Critical Care Medicine McMaster University,"— Presentation transcript:

1 Fluids and Electrolytes September 10, 2008 Karen Koo, PGY5 Chief Critical Care Medicine Fellow Division of Critical Care Medicine McMaster University, Hamilton ON

2 Objectives Major Body Fluid Compartments Major Body Fluid Compartments Review of physiology of volume regulation Review of physiology of volume regulation Parenteral Fluid Therapy Parenteral Fluid Therapy Cases of Electrolyte imbalances Cases of Electrolyte imbalances

3 Relationship between the volumes of major fluid compartments

4 Composition body fluid compartments Ion Plasma (mmol/L) ICF (mmol/L) Na K Ca2+1,3<0,8 Mg Cl HCO HPO ,4 74 Sulphate-0,419 Protein - 1,14 64

5 Daily Fluid Requirements Average Adult needs: Average Adult needs: H 2 O~ 30-35ml/kg/hr (2-3 liters/day) Na1 ml/kg/hr Na +~ 1 ml/kg/hr K1 ml/kg/hr K +~ 1 ml/kg/hr Cl -~ 1.5 ml/kg/hr

6 Sources of daily water loss Urine ml/d (30ml/hr) Urine ml/d (30ml/hr) Sweat ml/d Sweat ml/d Lungs 500ml/d Lungs 500ml/d Feces ml/d Feces ml/d

7 Composition of GI Secretions Source Volume (ml/24h) Na +* K+K+K+K+ Cl - HCO 3 - Salivary 1500 (500~2000) 10 (2~10) 26 (20~30) 10 (8~18) 30 Stomach 1500 (100~4000) 60 (9~116) 10 (0~32) 130 (8~154) 0 Duodenum100~ Ileum (80~150) 5 (2~8) 104 (43~137) 30 Colon Pancreas (113~185) 5 (3~7) 75 (54~95) 115 Bile (131~164) 5 (3~12) 100 (89~180) 35 * Average concentration: mmol/L

8 Daily Electrolyte loss Na100 mEq Na+100 mEq K100 mEq K+ 100 mEq Cl- 150 mEq

9 Quiz #1: True or False statements True or False statements Concerning body fluid compartments: a) Water constitutes 70% of the total body weight b) Plasma constitutes a quarter of the ECF volume d) Interstitial fluid volume for a 70 kg man is approximately 9 litres e) The ECF/ICF volume ratio is smaller in infants and children than it is in adults

10 Regulation of Fluids

11 Renal sympathetic nerves Renin-angiotensin- aldosterone system Atrial natriuretic peptide (ANP)

12 Parenteral Fluid Therapy Crystalloids Na+  main osmotically Na+  main osmotically active particle active particle useful for volume expansion (mainly useful for volume expansion (mainly interstitial space) interstitial space) for maintenance infusion for maintenance infusion correction of electrolyte abnormality correction of electrolyte abnormality

13 Crystalloids Isotonic crystalloids Isotonic crystalloids - Lactated Ringer’s, 0.9% NaCl - Lactated Ringer’s, 0.9% NaCl - 25% remain intravascularly - 25% remain intravascularly Hypertonic saline solutions Hypertonic saline solutions - 3% NaCl - 3% NaCl Hypotonic solutions Hypotonic solutions - D5W, 0.45% NaCl - D5W, 0.45% NaCl - < 10% remain intra- - < 10% remain intra- vascularly, inadequate for fluid vascularly, inadequate for fluid resuscitation resuscitation

14 Colloid Solutions Contain high molecular weight Contain high molecular weight substances  do not readily migrate across substances  do not readily migrate across capillary walls capillary walls Preparations Preparations - Albumin: 5%, 25% - Albumin: 5%, 25% - Hydoxyethyl starches - Hydoxyethyl starches ie pentaspan ie pentaspan - Red cell concentrates - Red cell concentrates - platelets, plasma - platelets, plasma

15 Distribution of Parenteral Fluids Type of Fluid ECF=1/3 TBW ICF=2/3TBW IVF=1/4ECFISF=3/4ECF 1000ml D5W ml 2/3:1/ ml R/L or 0.9%NS mL 5%albumin mL 25% albumin mL Pentaspan unit RBC 45000

16 SolutionsVolumes Na + K+K+K+K+ Ca 2+ Mg 2+ Cl - HCO 3 - DextrosemOsm/L ECF Lactated Ringer’s % NaCl % NaCl D5W500 D5/0.45% NaCl % NaCl % Hetastarc h % Albumin < % Albumin < Composition of Parenteral Fluids

17 Quiz #2: 70F has small-bowel fistula with output of 1.5L/d. Replacement of daily losses should be handled using the fluid solution that has the following composition: 70F has small-bowel fistula with output of 1.5L/d. Replacement of daily losses should be handled using the fluid solution that has the following composition: NaKClHCO3 a) b) c) e)

18 Quiz #3: 68M admitted with diagnosis of partial SBO with Hx of Chrons Disease vomits bilious coloured emesis. His is lethargic. 68M admitted with diagnosis of partial SBO with Hx of Chrons Disease vomits bilious coloured emesis. His is lethargic. 37C, 88/50 mmHg, HR 110, RR 25, SpO2 99 on 2Lnp 37C, 88/50 mmHg, HR 110, RR 25, SpO2 99 on 2Lnp JVP flat, chest clear with normal heart sounds JVP flat, chest clear with normal heart sounds Abd distended & mild epigastric tenderness Abd distended & mild epigastric tenderness Na 130, Cl 108, K 5.1, Cr 110, BUN 10.2 Na 130, Cl 108, K 5.1, Cr 110, BUN 10.2 Hg 100, WBC 9.9, Plts 400, INR 1.5, APTT 30 Hg 100, WBC 9.9, Plts 400, INR 1.5, APTT 30

19 Quiz #3: Your staff asks you to see this patient. What is the most appropriate resusitation fluid: Your staff asks you to see this patient. What is the most appropriate resusitation fluid: a) 1 unit of packed RBC b) 500 ml of Ringers Lactate solution c) 500ml 5% albumin d) 500ml Pentaspan e) 500ml 0.9% normal saline

20 SAFE Study ( NEMJ 2004:350 Safe Investigators) RCT: 4% albumin vs normal saline for intravascular-fluid resuscitation RCT: 4% albumin vs normal saline for intravascular-fluid resuscitation Primary outcome: 28 day all cause mortality Primary outcome: 28 day all cause mortality N = 6997 patients N = 6997 patients No significant differences No significant differences  726 deaths albumin group vs 729 deaths saline group (RR 0.99; 95% CI 0.91 to 1.09; P=0.87 (RR 0.99; 95% CI 0.91 to 1.09; P=0.87  numbers of days spent in the ICU or in the hospital  days of mechanical ventilation  days of renal-replacement therapy

21 28% day Kaplan–Meier Estimates Probability of Survival: normal saline vs 4% albumin ( NEMJ 2004:350 Safe Investigators)

22 RR of Death among the Patients in the Six Predefined Subgroups ( NEMJ 2004:350 Safe Investigators)

23 Colloid solutions for fluid resuscitation (Cochrane Database Syst Rev. 2008) Seventy RCTs comparing colloid solutions in critically ill and surgical patients thought to need volume replacement, Seventy RCTs comparing colloid solutions in critically ill and surgical patients thought to need volume replacement, N = 4375 participants N = 4375 participants Albumin versus hydroxyethyl starch pooled RR 1.14 (95% CI 0.91 to 1.43) for mortality Albumin versus hydroxyethyl starch pooled RR 1.14 (95% CI 0.91 to 1.43) for mortality albumin versus dextran (RR= % CI 0.42 to 33.09). albumin versus dextran (RR= % CI 0.42 to 33.09). no evidence that one colloid solution is more effective or safe than any other no evidence that one colloid solution is more effective or safe than any other

24 Calculation of Maintenance Fluids For a 24 hr period, use 100/50/20 Rule For a 24 hr period, use 100/50/20 Rule 100ml/kg for first 10kg 50ml/kg for next 10kg 20ml/kg for every kg over 20 For hourly maintenance rate, use 4/2/1 Rule For hourly maintenance rate, use 4/2/1 Rule 4ml/kg for first 10kg 2ml/kg for next 10kg 1ml/kg for every kg over 20

25 Quiz #4 55M has been admitted for an elective resection of a pelvic mass. He is NPO for the next 12 hours. He weighs 70kg and has normal renal function. What is the most appropriate iv maintenance rate? 55M has been admitted for an elective resection of a pelvic mass. He is NPO for the next 12 hours. He weighs 70kg and has normal renal function. What is the most appropriate iv maintenance rate? a) 0.9% NS at 200ml/hr b) 0.45% NS/D5W at 100ml/hr c) D5W at 100ml/hr d) Ringer’s Lactate at 50ml/hr

26 Clinical Cases: Electrolyte Imbalances

27 Case 1 39M POD2 following ventral hernia repair. 39M POD2 following ventral hernia repair. Background: HTN, DM nephropathy Background: HTN, DM nephropathy Meds: Ramipril 10mg daily, morphine prn Meds: Ramipril 10mg daily, morphine prn Patient is weak, c/o paraethesia Patient is weak, c/o paraethesia Post-op EKG: Sinus bradycardia 40bpm, peaked T waves, depressed ST with prolonged PR, wide QRS Post-op EKG: Sinus bradycardia 40bpm, peaked T waves, depressed ST with prolonged PR, wide QRS O/E DTR depressed O/E DTR depressed

28 Case 1 What is electrolyte disturbance? What is electrolyte disturbance?  Hyperkalemia What are the most likely surgical causes? What are the most likely surgical causes?  RF, Drugs, Acidosis, Tissue injury blood transfusions What is the acute management strategy? What is the acute management strategy?  Cardioprotection, shifting, elimination  Cardioprotection, shifting, elimination

29 Case 2 70F one week of constipation and vomitting. 70F one week of constipation and vomitting. Background: DM, Dilated cardiomyopathy, Intestinal fistula Background: DM, Dilated cardiomyopathy, Intestinal fistula Meds: Insulin, Lasix 80mg bid Meds: Insulin, Lasix 80mg bid Patient c/o weakness, nausea/vomitting and abdominal tenderness Patient c/o weakness, nausea/vomitting and abdominal tenderness O/E 36.4C 100/60 HR 110, RR12, SpO2 99% r/a O/E 36.4C 100/60 HR 110, RR12, SpO2 99% r/a JVP flat, chest clear, normal heart sounds, Abdominal distension, no bowel sounds EKG: Sinus tachycardia with occasional PVCs, diffuse flattening of T waves, U waves EKG: Sinus tachycardia with occasional PVCs, diffuse flattening of T waves, U waves

30 Case 2 What is electrolyte disturbance? What is electrolyte disturbance?  Hypokalemia What are the most likely surgical causes? What are the most likely surgical causes?  Drugs (diuretics, steroids, Insulin etc), diarrhea, vomitting, intestinal fistula, NG aspiration, insufficient supplementation What is the acute management strategy? What is the acute management strategy?  potassium supplementation iv/po  potassium supplementation iv/po

31 Case 3 67M unexplained 30lb wt loss over 6months and hemoptysis presents a GTC seizure 67M unexplained 30lb wt loss over 6months and hemoptysis presents a GTC seizure Background: HTN, smoker Background: HTN, smoker Meds: HCTZ 25mg daily Meds: HCTZ 25mg daily O/E 37C 110/70 HR 88, RR14, SpO2 98%/ra O/E 37C 110/70 HR 88, RR14, SpO2 98%/ra Lethargic & confused, No focal neuro deficits Lethargic & confused, No focal neuro deficits JVP 4cmASA, PPP chest clear, normal heart sounds JVP 4cmASA, PPP chest clear, normal heart sounds Abd distended with faint bowel sounds Abd distended with faint bowel sounds CXR: speculated LLL nodule CXR: speculated LLL nodule

32 Case 3 What is electrolyte disturbance? What is electrolyte disturbance?  Hyponatremia What are the most likely surgical causes? What are the most likely surgical causes?  Access clinical fluid status

33

34 Case 3 – Hyponatremia Management What is the acute management strategy? Depends on etiology & chronicity Depends on etiology & chronicity Be careful! Rate of correction should be <0.5mEq/h, <10mEq/24hr, <18Eq in first 48h Be careful! Rate of correction should be <0.5mEq/h, <10mEq/24hr, <18Eq in first 48h Check lytes frequently during correction Check lytes frequently during correction Use 3% NaCl ONLY if severe hyponatremia (Na+ <115) or if dramatically symptomatic with acute onset Use 3% NaCl ONLY if severe hyponatremia (Na+ <115) or if dramatically symptomatic with acute onset

35 Case 4 89F admitted with acute pancreatitis on ward for 2 weeks. Progressive confusion in last few days with new tremors 89F admitted with acute pancreatitis on ward for 2 weeks. Progressive confusion in last few days with new tremors Otherwise healthy, no meds. On TPN. Otherwise healthy, no meds. On TPN. Net fluid balance 24hrs –4L, u/o 200ml/hr Net fluid balance 24hrs –4L, u/o 200ml/hr O/E 36C 110/50 HR 110, RR 10, SpO2 98%r/a O/E 36C 110/50 HR 110, RR 10, SpO2 98%r/a stupourous & clinically hypovolemic ++peripheral edema

36 Case 4 What is electrolyte disturbance? What is electrolyte disturbance?  Hypernatremia What are the most likely surgical causes? What are the most likely surgical causes?  Inadequate hydration, diabetes insipitus, diuresis, vomitting/diarrhea, iatrogenic (TPN) What is the acute management strategy? What is the acute management strategy?  Depends on etiology & chronicity (D5W or 0.45% normal saline)

37 Case 5 26F with newly diagnosed primary hyperparathyroidism is referred for surgical assessment. 26F with newly diagnosed primary hyperparathyroidism is referred for surgical assessment. She has had polydipsia, polyuria and constipation and abdominal discomfort. She has had polydipsia, polyuria and constipation and abdominal discomfort. O/E 37C, 100/80, HR99, RR 14, SpO2100% O/E 37C, 100/80, HR99, RR 14, SpO2100% Confused, JVP 1cm ASA weak pulses Confused, JVP 1cm ASA weak pulses ABD unremarkable ABD unremarkable EKG: short QT, prolonged PR interval EKG: short QT, prolonged PR interval

38 Case 5 What is electrolyte disturbance? What is electrolyte disturbance?  Hypercalcemia What are the most likely causes? What are the most likely causes?  Hyperparathyroidism, immobility, Pagets, Addisons, Neoplasms, xs Vitamin D, A, Sarcoidosis, Calcium supplementation, thiazides What is the acute management strategy? What is the acute management strategy?  Volume expansion with NS  +/- lasix, bisphosphonates, calcitonin, steroids

39 Case 6 45M presents with profound weakness in setting of chronic diarrhea. 45M presents with profound weakness in setting of chronic diarrhea. Background Alcohol Abuse Background Alcohol Abuse P/E is unremarkable P/E is unremarkable EKG: Prolonged QTc interval EKG: Prolonged QTc interval

40 Case 6 What are the possible electrolyte disturbances? What are the possible electrolyte disturbances?  Hypokalemia, hypomagnesiumia, hypophosphtemia, hypernatremia What is the acute management strategy?  replace with supplemental magnesium and potassium phosphate and potassium phosphate  fluid therapy  fluid therapy

41 Things you don't want to hear during surgery: 5. Damn, there go the lights again Damn, there go the lights again "You know, there's big money in kidneys. Heck, the guy's got two of them." 4. "You know, there's big money in kidneys. Heck, the guy's got two of them." 3. Everybody stand back! I lost my contact lens! 3. Everybody stand back! I lost my contact lens! 2. This patient has already had some kids, am I correct? 2. This patient has already had some kids, am I correct? 1. Nurse, did this patient sign the organ donor card? 1. Nurse, did this patient sign the organ donor card?

42 The End The End


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