1. Fluid & electrolytes for 4th year studies; revision. Paddy Gibson Renal unit, RIE

2. What to do …. This presentation is based on a fluid and electrolytes lecture for 4th year students; in the absence of a speaker, it now has speakers notes ( click on view ), which should help you. If confused, reach for a textbook. Good luck.

3. Objectives: zRevision of fluid compartments zOsmotic/oncotic pressure / osmolality zFluid shifts in disease zPrescribing fluids

4. We are approximately two- thirds water

5. Fluid shifts / intakes Intracellular 30 litres Interstitial 9 litres IV 3 litres Kidneys Guts Lungs Skin Extracellular fluid - 12 litres

6. Osmotic / oncotic pressure Na + PP IntracellularInterstitialIntravascular

7. Calculation of osmolality zDifficult: measure & add all active osmoles zEasy = [ sodium x 2 ] + urea + glucose zNormal = 280 - 290 mosm / kg

8. The role of ADH: zADH = urinary concentration zADH = secreted in response to osmo; = secreted in response to vol; zADH acts on DCT / CD to reabsorb water zActs via V2 receptors & aquaporin 2 zActs only on WATER

9. Fluid shifts in disease zFluid loss: yGI: diarrhoea, vomiting, etc. yrenal: diuresis yvascular: haemorrhage yskin: burns zFluid gain: yIatrogenic: yHeart / liver / kidney failure:

10. Prescribing fluids: zCrystalloids: y0.9% saline - not normal ! y5% dextrose y0.18% saline + 0.45% dextrose yOthers zColloids: yblood yplasma / albumin ysynthetics

11. The rules of fluid replacement: zReplace blood with blood zReplace plasma with colloid zResuscitate with colloid zReplace ECF depletion with saline zRehydrate with dextrose

12. Crystalloids & colloids 30 litres 9 litres3 litres 2 litres of blood

13. Crystalloids & colloids 30 litres 9 litres5 litres

14. Crystalloids & colloids 30 litres 9 litres3 litres 2 litres of colloid

15. Crystalloids & colloids 30 litres 9 litres5 litres

16. Crystalloids & colloids 29 litres 8 litres7 litres

17. Crystalloids & colloids 30 litres 9 litres3 litres 2 litres of 0.9% saline

18. Crystalloids & colloids 30 litres 9 litres5 litres

19. Crystalloids & colloids 29 litres 10.5 litres4.5 litres

20. Crystalloids & colloids 30 litres 9 litres3 litres 2 litres of 5% dextrose

21. Crystalloids & colloids 31 litres 9.7 litres3.3 litres

22. How much fluid to give ? zWhat is your starting point ? yEuvolaemia ?( normal ) yHypovolaemia ?( dry ) yHypervolaemia ? ( wet ) zWhat are the expected losses ? zWhat are the expected gains ?

23. Signs of hypo / hypervolaemia: Signs of … Volume depletion Volume overload Postural hypotension Hypertension Tachycardia Absence of JVP @ 45 o Raised JVP / gallop rhythm Decreased skin turgor Oedema Dry mucosae Pleural effusions Supine hypotension Pulmonary oedema Oliguria Ascites Organ failure

24. What are the expected losses ? zMeasurable: yurine ( measure hourly if necessary ) yGI ( stool, stoma, drains, tubes ) zInsensible: ysweat yexhaled

25. What are the potential gains ? zOral intake: yfluids ynutritional supplements ybowel preparations zIV intake: ycolloids & crystalloids yfeeds ydrugs

26. Examples: zWhat follows is a series of simple - and some more complex fluid-balance problems for you zAnswers are in the speakers notes.

27. Case 1: zA 62 year old man is 2 days post-colectomy. He is euvolaemic, and is allowed to drink 500ml. His urine output is 63 ml/hour: 1. How much IV fluid does he need today ? 2. What type of IV fluid does he need ?

28. Case 2: z3 days after her admission, a 43 year old woman with diabetic ketoacidosis has a blood pressure of 88/46 mmHg & pulse of 110 bpm. Her charts show that her urine output over the last 3 days was 26.5 litres, whilst her total intake was 18 litres: 1. How much fluid does she need to regain a normal BP ? 2. What fluids would you use ?

29. Case 3: zAn 85 year old man receives IV fluids for 3 days following a stroke; he is not allowed to eat. He has ankle oedema and a JVP of +5 cms; his charts reveal a total input of 9 l and a urine output of 6 litres over these 3 days. 1. How much excess fluid does he carry ? 2. What would you do with his IV fluids ?

30. Case 4: z5 days after a liver transplant, a 48 year old man has a pyrexia of 40.8 o C. His charts for the last 24 hours reveal: zurine output:2.7 litres zdrain output:525 ml znasogastric output:1.475 litres zblood transfusion:2 units (350 ml each) zIV crystalloid:2.5 litres zoral fluids:500 ml

31. Case 4 cont: zOn examination he is tachycardic; his supine BP is OK, but you cant sit him up to check his erect BP. His serum [ Na+ ] is 140 mmol/l. zHow much IV fluid does he need ? zWhat fluid would you use ?