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Fluids and Electrolytes

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1 Fluids and Electrolytes

2 Objectives To discuss fluid and electrolyte changes:
How to assess fluid patterns and changes in electrolytes To focus on hypo and hypernatremia, hypo and hyperkalemia, hypo and hypercalcemia and hypophosphatemia

3 Most common fluid disorder deficits
Excessive loss / inadequate intake G.I. losses from vomiting, nasogastric suction, diarrhea, and fistula drainage Fluid sequestration Pre and postoperative deficits NPO Bowel prep Vomiting, NGT losses Ileus, obstruction Peritonitis

4 Gastrointestinal fluid daily output

5 How to assess and manage fluid status
IVFV 5%, plasma volume = 3.5L 70 kg male Plasma volume Total Blood Volume IVBV 5.6 L ECF = 14 L ICF = 28 L Is the patient in need of fluid? How much? If you know the amount of losses – replace them and deliver rapidly Example: hypotensive patient given a 2 liter bolus as initial treatment If not: replace losses as they occur Fluid given based on composition, tonicity of fluid lost Example: ileostomy losses replaced volume per volume every 4 hrs with lactated Ringer’s solution (better with sterofundin) 2 liters 8.4L = interstitial fluid Resurreccion R. PCS Committee on Critical Care. Handbook of Critical Care and Surgical Nutrition First Ed, Philippine College of Surgeons

6 How to assess and manage fluid status
Is the patient in need of fluid? How much? If you know the amount of losses – replace them and deliver rapidly Example: hypotensive patient given a 2 liter bolus as initial treatment If not: replace losses as they occur Fluid given based on composition, tonicity of fluid lost Example: ileostomy losses replaced volume per volume every 4 hrs with lactated Ringer’s solution (better with sterofundin) Total Blood Volume Plasma volume RESUSCITATION 2 liters IVBV 5.6 L REPLACEMENT ICF = 28 L IVFV 5%, plasma volume = 3.5L ECF = 14 L 8.4L = interstitial fluid Resurreccion R. PCS Committee on Critical Care. Handbook of Critical Care and Surgical Nutrition First Ed, Philippine College of Surgeons 70 kg male

7 How to assess and manage fluid status
Maintenance requirements: after resuscitation and replacement Based on normal physiologic requirements Get the accurate weight Get the 5% plasma volume (70 kg x 5% = 3.5 liters) Get 1/2 of the plasma volume = 3.5 liters divided by ½ = 1.75 liters Add the “insensible loss” of 70 kg x 0.05 ml/kg/day = liters = liters/day or 2 liters/day Similar to daily fluid requirement = kg BW x 30 cc/kg/day or 70 kg x 30 ml/kg/day = 2.1 liters/day or 2 liters/day MAINTENANCE

8 Fluid overload and mortality
Overload criteria: > 10% weight gain from pre-admission weight Weight gain and mortality: 5% weight gain -> 10% mortality 15% weight gain -> 20% mortality 32% weight gain -> 100% mortality Fluid overload criterion = >10% weight gain from pre-admission weight The information on perioperative volume delivery is important because of the following data: 5% weight gain = 10% mortality 15% weight gain = 20% mortality 32% weight gain = 100% mortality REFERENCE: Lowell JA, Schifferdecker C, Driscoll DF et al. Postoperative fluid overload: Not a benign problem. Crit Care Med 1990; 18: Lowell JA, Schifferdecker C, Driscoll DF et al. Postoperative fluid overload: Not a benign problem. Crit Care Med 1990; 18:

9 The effect of fluid overload
These data from the anesthesiologists’ study showed the impact of fluid overload on complications of morbidity and mortality. In the standard or usual management group there was significant increase of major and minor complications, tissue healing complications, cardiopulmonary complications and deaths. REFERENCE: Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multi-center trial. Annals of Surgery 2003; 238:

10 In the resuscitation phase what to do?
BLS and ATLS protocols Not ABC, but CAB (=establish perfusion first to reach the microcirculation then oxygenation and the rest follows) Ventilation: bag > mask > intubate Establish intravenous line when possible (large bore needle) > central line is ideal if possible Crystalloids: first line > give as much as 2-3 liters fast (500 ml bolus every minutes) Colloids: given as blood volume deficits Medications: inotropes Blood: Hb? Hct? what level? To provide correct and adequate resuscitation one needs both basic and advanced life support training. These are some of the updates: Circulation needs to be established first hence the CAB steps. (Circulation, Airway, Breathing) Next ventilation is priority and if there is a need to intubate it has to be done. A venous line should be established with colloids as the first fluids of choice Reference: Aquino ML, Resurreccion R. PCS Committee on Critical Care. Handbook of Critical Care and Surgical Nutrition First Ed, Philippine College of Surgeons Aquino ML, Resurreccion R. PCS Committee on Critical Care. Handbook of Critical Care and Surgical Nutrition First Ed, Philippine College of Surgeons

11 Plasma and crystalloids given
* Balanced electrolyte solution Ringer’s Lactate Sterofundin The closest crystalloid to the composition of plasma is “Sterofundin”. It is called a balanced electrolyte solution and except for its “zero” calcium is the most ideal for fluid replacement and maintenance. It has no dextrose which will make the solution isotonic. When you add dextrose to all of the above > HYPO-OSMOLAR

12 What happens when you increase blood volume by 1 liter?
IVFV ECFV ICFV 20% 40% 9.4L D5W 6L 14.4L 36L 5L 0.9% NaCl 16L 1L 6% HES Capillary membrane Cell membrane Zander R. Fluid management.2nd ed., Mainz, Germany. Intracerebral edema

13 Specific electrolyte management

14 Hyponatremia <135 Determine volume status Hypovolemia
Principles of Surgery 10th ed; G. Tom Shires III Hypovolemia Give 0.9 NaCl solution Causes: GI losses Renal losses Primary renal disease Euvolemia Correct using hypertonic 3% NaCl (513 mEq/L) Normovolemia Water restriction (0.5 – 1.5 liter per day) (evidence of peripheral edema, ascites, pleural effusion Avoid diuretics to lessen urinary Na+ losses Correct hyperglycemia Monitor and decrease increased plasma lipids or proteins SIDH Calculate for total sodium deficit in mEq = (135 – serum Na) x 0.6 x kg body weight Ex: ( ) x 0.6 x 70kg = 5 x 0.6 x 70 = 210 mEq to add Rate of correction should follow the following: Risk of demyelinating encephalopathy with rapid correction of hyponatremia Maximum rate of correction is 0.5 mEq/L/hr Resurreccion R. PCS Committee on Critical Care. Handbook of Critical Care and Surgical Nutrition First Ed, Philippine College of Surgeons

15 Hypernatremia > 140 Determine volume status Hypovolemia
Principles of Surgery 10th ed; G. Tom Shires III Hypovolemia Non-renal water losses Skin and GI losses Renal water losses as in renal tubule disease Osmotic diuresis Diabetes insipidus Adrenal failure Euvolemia Non-renal water losses Skin and GI losses Renal water losses as in renal tubule disease Osmotic diuresis Diabetes insipidus Adrenal failure Hypervolemia Iatrogenic sodium administration Mineralocorticoid excess Aldosteronism Cushing’s disease Congenital adrenal hyperplasia Treatment for hypernatremia, regardless of its cause, is free water replacement. For a 70 kg man with hypernatremia of 10, needs 3 liters of free water replacement

16 Hypernatremia correction
How to give free water replacement H2O deficit (liters) = 0.60 x weight (kg) x (serum Na – 140) ÷ 140 Water deficit (L) = [0.6 x 70 kg x ( )] / 140 = 3 liters One half of the water deficit should be given over the first 24 hours, with the remainder given over the next 24 to 48 hours 3 liters – 24 hrs = 1.5 liters in 24 hours The rest in the next 24 to 48 hours (e.g. 1.5 liters in 48 hours or 31 ml/hr for 48 hours) If diabetes insipidus: give DDAVP (Desmopressin), an ADH analogue Minirin 100 mcg tablet every 12 hrs DDAVP nasal spray 1μg/spray, 2-4 μg BID Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

17 Hypokalemia < 3 Serum potassium less than 3 mEq/L
Common problem in the surgical patient Caveats Measured extracellular potassium represents only a small proportion of total body potassium Small changes in serum concentrations correspond to significant alterations in total body potassium No reliable equation to compute for K deficit Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

18 Hypokalemia correction
Estimate of K+ deficit: If serum K+: 3.0 to 4.0 mEq/L → total deficit: 100 to 200 mEq If serum K+: 2.0 to 3.0 mEq/L → total deficit: 200 to 400 mEq Management: Intravenous: Maximum rate of KCl infusion 10 mEq/hr (in the floors) to 20 mEq/hour (ICU under cardiac monitor) Use central vein for KCl incorporation >40 mEq/L Oral: Kalium durule 0.75 mg (10mEq), 3 durules q 4 hrs NGT: do not crush Kalium! Use oral KCl solution (1mEq/cc) Total max dose: 3 mEq/kg/day If persistently low K+ despite correction, check Mg levels for concurrent hypomagnesemia Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

19 Hyperkalemia > 5.5 Serum K+ greater than 5.5 mEq/L Management:
Cardiac monitoring indicated Renal excretion can be enhanced by the administration of loop diuretics K+ binding resins: ex. Kalimate 5g/sachet 3 sachets in 1/2 glass of water BID Hemodialysis in renal failure Immediate treatment required if: K+ > 6.0 mmol/L with ECG changes or K+ > 6.5 mmol/L with or without ECG changes Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

20 Hyperkalemia correction
Management Calcium gluconate 10% soln, 10mL IV over 2 to 5 minutes: to decrease myocardial excitability. Does not decrease K levels NaHCO3 44 to 132 mEq (1 to 3 amps of 7.5%) IV over 5 min, given after calcium in a separate line, repeat in 10 to 15 minutes, ff by infusion of 2 to 3 amps in D5W titrated over 2 to 4 hours Insulin 10 to 20 U regular in D10W 500 mL over 1 hour, or 10 U IV push with 1 amp 50% glucose (25 gm) over 5 mins. Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

21 Hypocalcemia < 2.2 Serum Ca < 2.2 mmol/L
Artifact of hypoalbuminemia: serum calcium predominantly bound to albumin. For every 1 g /L decrease in albumin, serum Ca decreases by mmol/L. Symptoms: Chvostek’s sign, Trousseau’s sign Management: Calcium gluconate 10% soln, 10 – 20 mL IV bolus over 10 to 15 minutes. Followed by mL ampoules of 10% calcium gluconate in 1L D5W Maintenance: Calcium carbonate 1-2g P.O. TID with Vitamin D3 (Calcitriol; brand name: Rolcaltrol) 0.25 mcg capsule/day Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

22 Hypercalcemia > 3 Serum Ca > 3.0 mmol/L Causes: Management:
Hyperparathyroidism Bone metastases (breast, lung, thyroid, colon, multiple myeloma) Vitamin D intoxication Management: Hydration with normal saline Diuretics (except thiazide diuretics) Chronic therapy for: Bone metastases: biphosphonate therapy Paresthesias Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

23 Hypophosphatemia < 2.5
Serum phosphate < 2.5mg/dl Normal levels: mg/dl or mmol/L Classified as Moderate: 0.32 – 0.65 mmol/L Severe: < 0.32 mmol/L Causes Transcellular shift (Refeeding syndrome; Phil incidence = 9%) Diminished intake (long-term TPN, alcoholism) Renal replacement therapy (deficiency of trace elements) Stanga R. Refeeding syndrome in ESPEN basic clinical nutrition manual. Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS. Mustofa N. Refeeding syndrome. PhilsPEN online j paren ent nutr. POJ_0097.html

24 Hypophosphatemia Manifestations:
Muscle dysfunction: respiratory failure, myocardial dysfunction, skeletal muscle weakness, rhabdomyolysis Altered mental status, seizures, encephalopathy Arrhythmia: ventricular tachycardia, supraventricular tachycardia Hemolysis Jeejeebhoy. Malnutrition,, starvation and Refeeding Syndrome. Stanga R. Refeeding syndrome in ESPEN basic clinical nutrition manual. Resurreccion R. Fluids, electrolytes and acid base management in Handbook of Surgical Critical Care and Surgical Nutrition 1st ed. PCS.

25 Thank You


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