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Fluid and electrolyte imbalance

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by

Amjad M

on 18 June 2014

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Transcript of Fluid and electrolyte imbalance

Fluids & Electrolyte imbalance
Done by:
Amjad AlTurki

IV fluids come in four different forms:

•Colloids.
•Crystalloids.
•Blood products.
•Oxygen-carrying solutions.

Body fluid compartment :
50-70% of the average human body is comprised of body fluid
- Male
-skeletal muscle
- Age
1/3 Extracellular
Interstitial fluid
Plasma
Na+, Cl-, HCO3-
2/3 Intracellular
ECF
15 %
ICF
40 %
Plasma (5%)
TBW at 12 wks of gestation 94%
TBW at 32 wks of gestation 80%
In the 1st few days TBW decrease by 10%
By 1½ years of age reaching the adult level 60%
Colloid solutions are IV fluids that contain solutes in the form of large proteins or other similarly sized molecules.



The proteins and molecules are so large that they cannot pass through the walls of the capillaries and onto the cells.
very expensive

Crystalloids contain electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids.
Commonly used colloid solutions include:
Dextran
Albumin
Hetastarch
Crystalloids
vs
Colloids
Objective :
1-Basic theoretical concepts
2-Regulation of Fluid & Electrolyte Balance
3- Fluid therapy
4- Common electrolytes disturbance in pediatrics

Colloid solutions
Crystalloids come in many preparations and are classified according to their “tonicity.”:
Isotonic (e.g Normal saline, lactated Ringer's solution )
Hypotonic
Hypertonic ( e.g dextrose 5% in NS soulution )
Crystalloids
Sodium (Na + )

defined as serum sodium (Na) concentration of less than
135
mmol/L.

considered the most common electrolyte disorder encountered in hospitalized patients.

50% of presenting children develop symptoms when serum Na levels
fall below 120

mEq/L



Treatment of hypo Na :

Correct serum Na increased by no more than
12 mmol/L
in 24 hours of treatment
Check serum Na
q4hr
Use
3%
saline in severe hyponatremia
Goal is serum Na
130
Avoid too rapid correction:
Central pontine demyelination


Presentation:
it might be asymptomatic

CNS: Headache, Decreased conscious state , Hallucinations, Obtundation

GI: Nausea, vomiting

Musculoskeletal findings:Weakness,Muscular cramps

The daily water loss in an adult is about 1500 ml. in urine and 250 ml. in stool.

Water requirements
increase
with: fever, sweating, burns, tachypnea, surgical drains.

For example, it increase by 100 to 150 mL/day for each centigrade elevation of body temperature .

Normal fluid and electrolyte requirements:
Fluid management is divided into 3 phases:

Maintenance fluid:

Fluid and electrolyte needs from basal metabolism, it is amount of fluid lost normally (sensible and insensible losses)
.

Ongoing loss:

it is loss from sources other than evaporative and urinary losses from NGT, stoma, fistula,


Deficit fluid:

means the fluid lost through abnormal ways ..

K+, Mg+, and Phosphate -
Estimation of the severity of dehydration:

mild
dehydration
(
5% of body volume
)
eg:vomiting, diarrhea, with minimal physical findings




A guide for maintenance fluid therapy for children is as follows:

0-10 kg - 100 mL/kg/d (
4 mL/kg/h
)

10-20 kg - 1000 mL/d + 50 mL/kg/d (
40 mL/h + 2 mL/kg/h
)

Greater than 20 kg - 1500 mL/d + 25 mL/kg/d (
60 mL/h + 1 mL/kg/h
)

Common electrolytes disturbances
hypernatermia
- serum sodium concentration of more than
145 mmol/L
.

- It is characterized by a deficit of total body water
(TBW)
relative to total body sodium levels due to either loss of
free water
, or infrequently, the administration of
hypertonic sodium solutions
.

- In healthy individual, the body's 2 main defense mechanisms against hypernatremia are
thirst and the stimulation of vasopressin release


Mainly neurological symptoms
Thirst
Lethargy
Irritability
Seizures
Fever
Oliguria


Predominant extracellular cation
Daily Sodium requirements is
2 - 3 mEq/day

Normal Na+ concentration is 135 to 145 mmol/L
Pairs with Cl- , HCO3- to neutralize charge
Most important ion in water balance
Important in nerve and muscle function
Reabsorption in renal tubule regulated by: Aldosterone and Renin/angiotensin
hyponatremia
hypertonicity
Hyperglycemia
isotonicity
Hyperlipidemic
Hyperproteinemic
hypotonicity
ECV
ICV
Na+ con
volume
Hypovolemic hypotonic hyponatremia
Extrarenal losses :
caused by vomiting, diarrhea, sweat ..
Renal losses :
caused by diuretic excess, salt-wasting nephropathy, adrenal insufficiency, proximal renal tubular acidosis, metabolic alkalosis ..

Hypervolemic hypotonic hyponatremia
congestive heart failure
cirrhosis
nephrotic syndrome
acute or chronic renal failure
Isovolemic hypotonic hyponatremia
SIADH
water intoxication
glucocorticoid deficiency
hypothyroidism
Rx: Volume resuscitation with NS

urine sodium concentration is greater than 20 mEq/L

Rx: Fluid restriction 1,000 mL/day
Correct endocrine abnormality

Rx: Correct underlying state

Presentation:
Treatment of Hypernatremia
Calculate the free water deficit:
0.6 x wt (kg) x (patient’s sodium/140  - 1)
only one half of the water deficit should be corrected over the first
24 hours
remainder being corrected over the following
2 to 3
days
Check serum Na q4hr
Use isotonic salt-free IV fluid

Major intracellular cation
normal serum concentration is
3.3 to 4.9
mmol/L
Daily Potassium requirements is
1 - 2
mEq /day
Regulates resting membrane potential
Regulates fluid, ion balance inside cell
Regulation : Aldosterone in the kidney and by Insulin

Potassium
Hypokalemia
Serum K+ <3 mmol/L
Beware if diabetic

Causes of Hypokalemia
renal losses e.g. diuretics, fluid mobilization
GI losses e.g. Severe vomiting/diarrhea, nasogastric suctioning
cutaneous losses e.g., burns
insulin excess, metabolic alkalosis
Increased aldosterone
Decreased intake of K+
Clinical manifestations
of Hypokalemia :
Neuromuscular disorders Weakness, respiratory arrest, constipation

Dysrhythmias, Early (ECG) manifestations
T-wave
depression, and prominent
U waves
Postural hypotension
Treatment
treatment of hypokalemia in the patient with intact renal function is 40 to 100 mmol KCl
orally
in single or divided doses
Hyperkalemia
Mild
hyperkalemia K+
> 5 to 6
mmol/L
Sever
hyperkalemia K+
>6.5
mmol/L
elevation in K+ may result from commonly by phlebotomy from a
strangulated arm
Insulin deficiency
Addison’s disease
Rhabdomyolysis

Clinical manifestations
Mild hyperkalemia :
asymptomatic

sever hyperkalemia
: hyperactive muscles paresthesia
Late :
muscle weakness, flaccid paralysis

Most notably
ECG abnormalities
: symmetric peaking
of T waves and widening of the
QRS complex
Management
1- Mild hyperkalemia
[K+ = 5 to 6 mmol/L]
can be treated
conservatively
by the reduction in daily K+ intake and, if needed, the addition of a
loop diuretic
2- Severe hyperkalemia
[K+ >6.5 mmol/L]
-

NaHCO3
[
1 mmol/kg
] can be infused intravenously over a 3 to 5 minute period.if ECG abnormalities persist repeat after 10 to 15 minutes.
-

Dextrose
(
0.5 g/kg
body weight) infused with
insulin
(0.3 unit of regular
insulin/g of dextrose)
-Calcium gluconate
(
5
to
10
mL intravenously over 2 minutes)
should be administered to patients with profound ECG changes
- Inhaled B-agonists
e.g. albuterol sulfate 2 to 4 mL via nebulizer
Therapeutic measures

:

definitively decrease total body potassium by increasing potassium excretion
Fluid physiology
The body tries to maintain homeostasis of fluids and electrolytes by regulating:

Volumes
Solute charge and osmotic load

Homeostasis

Maintained by:
Ion transport
Water movement
Kidney function

These functions act to keep body fluids:
Electrically neutral
Osmotically stable (specified number of particles per volume of fluid)


severe
dehydration

(15% of body volume)

have cardiovascular instability (e.g. skin mottling, tachycardia, hypotension) and neurologic involvement (e.g., irritability, coma).
moderate
dehydration
(
10% of body volume
)
with

apparent physical findings (e.g., tenting of the skin, weight loss, sunken eyes and fontanel, slight lethargy, and dry mucous membranes.
Hyponatremia :
osmolality
=
[ sodium x 2 ] + urea + glucose
Normal =
280 - 290 mosm / kg

1- Sodium polystyrene sulfonate

: can be administered orally (20 to 50 g) or rectally ( 50 g )
A decrease in serum K + level typically occurs
2 to 4
hours after administration.

2- Hydration

with 0.9% NaCl in combination with a loop diuretic ( 20 to 100 mg intravenously) in patients with adequate renal function to promote renal K+ excretion.
3- Dialysis :
is definitive therapy in severe or life-threatening hyperkalemia.
Fluid compartments are separated by membranes that are freely permeable to water but impermeable to solutes
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