Dr Krunal Karade

1)The human body consists of about 50-70% liquids & 30-50% solids by weight. The liquid portion varies with age , sex & fat content (as fat contain very little water) . 2)In adult male TBW: 60% In adult female: 50% In neonates: 80% In TBW Thin > than obese individuals.

Body wt%
Total intracellular extracellular a) Plasma b) Interstitial 60 40 20 5 15

Total body water%

100 67(2/3) 33(1/3) 8 25

Oral (or IV)fluid intake & urine output are important measurable parameters of body fluid balance. To determine daily fluid requirement of body we should know insensible fluid input & loss:

 PASSIVE

ACTIVE

TRANSPORT SYSTEMS
Diffusion Filtration Osmosis

TRANSPORT SYSTEM
Pumping Requires

energy expenditure

 Isotonic
Hypotonic Hypertonic

 No

fluid shift because solutions are equally concentrated

saline (NS)solution (0.9% NaCl)

Normal

 Lower
Fluid

solute concentration

shifts from hypotonic solution into the more concentrated solution to create a balance (cells swell) saline solution (0.45% NaCl)

Half-normal

 Higher
Fluid

solute concentration

is drawn into the hypertonic solution to

create a balance (cells shrink)

5%

dextrose in normal saline (DNS)

 Baroreceptor
Volume

reflex
mechanism

receptors hormone (ADH)

Renin-angiotensin-aldosterone Antidiuretic

 Respond

to a fall in arterial blood pressure Located in the atrial walls, vena cava, aortic arch and carotid sinus Constricts afferent arterioles of the kidney resulting in retention of fluid

 Respond

to fluid excess in the atria and great

vessels Stimulation of these receptors creates a strong renal response that increases urine output

Renin
Enzyme

secreted by kidneys when arterial pressure or volume drops Interacts with angiotensinogen to form angiotensin I (vasoconstrictor)

 Angiotensin

Angiotensin

I is converted in lungs to angiotensin II using ACE (angiotensin converting enzyme) Produces vasoconstriction to elevate blood pressure Stimulates adrenal cortex to secrete aldosterone

 Aldosterone

Mineralocorticoid Increases

that controls Na+ and K+ blood levels Cl- and HCO3concentrations and fluid volume

 When

ECF & Na+ levels drop secretion of ACTH by the anterior pituitary release of aldosterone by the adrenal cortex fluid and Na+ retention

 Also

called vasopressin

Released Release Fluid Fluid

by posterior pituitary when there is a need to restore intravascular fluid volume

is triggered by osmoreceptors in the thirst center of the hypothalamus

volume excess decreased ADH

volume deficit increased ADH

 Dehydration
Hypovolemia Hypervolemia

of body fluids increased concentration of solutes in the blood and a rise in serum Na+ levels Fluid shifts out of cells into the blood to restore balance Cells shrink from fluid loss and can no longer function properly
Loss

 Confused
Comatose Bedridden Infants Elderly Enterally

fed

 Irritability

Fever

Confusion
Dizziness Weakness

Dry

Extreme

thirst urine output

skin/mucous membranes Sunken eyes Poor skin turgor Tachycardia

 Fluid

Replacement - oral or IV over 48 hrs.

symptoms and vital signs I&O

Monitor

Maintain

Maintain
Daily Skin

IV access

weights

and mouth care

 Isotonic

fluid loss from the extracellular space Can progress to hypovolemic shock

Caused

by: Excessive fluid loss (hemorrhage) Decreased fluid intake Third space fluid shifting

 Mental

status deterioration Thirst Tachycardia Delayed capillary refill

postural

hypotension Urine output < 30 ml/hr Cool, pale extremities Weight loss

 Fluid

replacement Albumin replacement Blood transfusions for hemorrhage

Dopamine

to maintain BP MAST trousers for severe shock Assess for fluid overload with treatment

 Excess

fluid in the extracellular compartment as a result of fluid or sodium retention, excessive intake, or renal failure Occurs when compensatory mechanisms fail to restore fluid balance Leads to CHF and pulmonary edema

 Tachypnea

Increased

Dyspnea
Crackles Rapid,

bounding

pulse Hypertension

CVP, pulmonary artery pressure and pulmonary artery wedge pressure Increased JVP Acute weight gain Edema

 Fluid

is forced into tissues by the hydrostatic pressure First seen in dependent areas Anasarca - severe generalized edema Pitting edema Pulmonary edema

 Fluid

and Na+ restriction Diuretics Monitor vital signs Hourly I&O Breath sounds

Monitor

ABGs and

labs Maintain IV access Skin & mouth care Daily weights

 Hyponatremia/
Hypokalemia/

hypernatremia
Hypercalcemia

Hyperkalemia

Hypocalcemia/

Hypophosphatemia/
Hypochloremia/

Hyperphosphatemia

Hyperchloremia

 Major

extracellular cation
fluid and helps preserve fluid with chloride and bicarbonate to

Attracts

volume
Combines

help regulate acid-base balance

Normal

range of serum sodium 135 - 145

mEq/L

 If

sodium intake suddenly increases, extracellular fluid concentration also rises Increased serum Na+ increases thirst and the release of ADH, which triggers kidneys to retain water Aldosterone also has a function in water and sodium conservation when serum Na+ levels are low

 Sodium

(abundant outside cells) tries to get into cells Potassium (abundant inside cells) tries to get out of cells Sodium-potassium pump maintains normal concentrations

Pump

uses ATP, magnesium and an enzyme to maintain sodium-potassium concentrations Pump prevents cell swelling and creates an electrical charge allowing neuromuscular impulse transmission

 Serum

Na+ level < 135 mEq/L Several types

Dilutional Depletional Hypovolemic Hypervolemic Isovolemic

 Dilutional

- results from Na+ loss, water gain Depletional - insufficient Na+ intake Hypovolemic - Na+ loss is greater than water loss; can be renal (diuretic use) or non-renal (vomiting) Hypervolemic - water gain is greater than Na+ gain; edema occurs Isovolumic - normal Na+ level, too much fluid

 Primarily

neurologic symptoms

Headache,

N/V, muscle twitching, altered mental status, stupor, seizures, coma

Hypovolemia

- poor skin turgor, tachycardia, decreased BP, orthostatic hypotension Hypervolemia - edema, hypertension, weight gain, bounding tachycardia

 MILD

CASE

SEVERE

CASE

Restrict fluid intake for hyper/isovolemic hyponatremia

IV fluids and/or increased po Na+ intake for hypovolemic hyponatremia

Infuse hypertonic NaCl solution (3% or 5% NaCl)

Furosemide to remove excess fluid Monitor client in ICU

 Excess

Na+ relative to body water Occurs less often than hyponatremia Thirst is the bodys main defense When hypernatremia occurs, fluid shifts outside the cells May be caused by water deficit or overingestion of Na+ Also may result from diabetes insipidus

Think S-A-L-T

Skin flushed Agitation Low grade fever Thirst

Signs of hypovolemia

 Correct

underlying disorder Gradual fluid replacement Monitor for cerebral edema (headache, loss of coordination , weakness, and decreasing levels of consciousness including disorientation, loss of memory, hallucinations, psychotic behavior, and coma) Monitor serum Na+ level

 Major

intracellular cation

Untreated

changes in K+ levels can lead to serious neuromuscular and cardiac problems

Normal

K+ levels = 3.5 - 5 mEq/L

 Most

K+ ingested is excreted by the kidneys Three other influential factors in K+ balance :

Na+/K+ pump Renal regulation pH level

 Uses

ATP to pump potassium into cells Pumps sodium out of cells Creates a balance

 Increased

urine Aldosterone secretion causes Na+ reabsorption and K+ excretion pH: Potassium ions and hydrogen ions exchange freely across cell membranes In Acidosis hyperkalemia (K+ moves out of cells) In Alkalosis hypokalemia (K+ moves into cells)

K+ levels increased K+ loss in

 Serum
Can

K+ < 3.5 mEq/L

be caused by GI losses, diarrhea, insufficient intake, non-K+ sparing diuretics (thiazide, furosemide)

 Think

S-U-C-T-I-O-N

Skeletal muscle weakness U wave (ECG changes) Constipation, ileus Toxicity of digitalis glycosides Irregular, weak pulse Orthostatic hypotension Numbness (paresthesias)

 Increase
Oral IV

dietary K+

KCl supplements

K+ replacement

Change
Monitor

to K+-sparing diuretic
ECG changes

 Mix

well when adding to an IV solution bag Concentrations should not exceed 40-60 mEq/L Rates usually 10-20 mEq/hr NEVER GIVE IV PUSH POTASSIUM

 Serum
Less

K+ > 5 mEq/L

common than hypokalemia

Caused

by altered kidney function, increased intake (salt substitutes), blood transfusions, meds (K+-sparing diuretics), cell death (trauma)

 Irritability
Paresthesia Muscle

weakness (especially legs) pulse

ECG

changes

Irregular

Hypotension

Nausea,

abdominal cramps, diarrhea

 MildWhat

Do We Do?

Loop diuretics (Lasix) Dietary restriction Kayexalate

Moderate

Emergency

10% calcium gluconate for cardiac effects

Sodium bicarbonate for acidosis

 99%

in bones, 1% in serum and soft tissue (measured by serum Ca++) Works with phosphorus to form bones and teeth Role in cell membrane permeability Affects cardiac muscle contraction Participates in blood clotting

 Affected

by body stores of Ca++ and by dietary intake & Vitamin D intake Parathyroid hormone draws Ca++ from bones increasing low serum levels (Parathyroid pulls) With high Ca++ levels, calcitonin is released by the thyroid to inhibit calcium loss from bone (Calcitonin keeps)

 Serum

calcium < 8.9 mg/dl Ionized calcium level < 4.5 mg/Dl Caused by inadequate intake, malabsorption, pancreatitis, thyroid or parathyroid surgery, loop diuretics, low magnesium levels

 Neuromuscular

Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany

Fractures Diarrhea ECG

changes

 Oral

or IV calcium replacement
gluconate for postop thyroid or monitoring

Calcium

parathyroid client
Cardiac

 Serum

calcium > 10.1 mg/dl

calcium > 5.1 mg/dl

Ionized Two

major causes

Cancer
Hyperparathyroidism

 Fatigue,

confusion, lethargy, coma Muscle weakness, hyporeflexia Bradycardia cardiac arrest Anorexia, nausea/vomiting, decreased bowel sounds, constipation Polyuria, renal calculi, renal failure

 If

asymptomatic, treat underlying cause

the patient to encourage diuresis diuretics

Hydrate Loop

Corticosteroids

 Advantage:
1)Accurate

,controlled & predictable way of administration. 2)Immediate response due to direct infusion in intravascular compartment. 3)Prompt correction of serious fluid & electrolyte disturbances.

1)
2) 3)

4)
5)

6) 7)

Conditions when oral intake is not possible e.g. coma , anesthesia ,surgery. Severe vomiting & diarrhoea. Moderate to severe dehydration & shock Hypoglycemia where 25% dextrose is life saving. As a vehicle for various I.V. medication e.g. antibiotics , chemotherapeutic agents , insulin, vasopressor agents. Total parenteral nutrition. Treatment of critical problems: shock ,anaphylaxis ,cardiac arrest & forced diuresis in drug overdose ,poisoning.

1)
2)

I.V. fluid should be avoided if patient is able to take oral fluid. Preferable to avoid I.V. fluid in patient with congestive heart failure or volume overload.

 1)Local-

Heamatoma , infiltration & infusion phlebitis. 2)Systemic- circulation overload with cardiac problem , rigors ,air embolism & septicaemia. 3)Others- fluid contamination, fungus in I.V. fluids, mixing of incompatible drugs ,improper technique of infusion , iv set or iv catheter related problems.

1)Maintenance fluids: Its replaces fluid lost from lungs ,skin ,urine & faeces. These losses are poor in salt so this maintenance fluid should be hypotonic to plasma .e.g. 5% dextrose ,dextrose with 0.45%NaCL solution. 2)Replacement Fluids: formulated to correct body fluid deficit caused by losses such as gastric drainage, vomiting ,diarrhoea ,fistula drains , intestinal oedema, oozing from trauma, infection, burns,ect. E.g. Rigers lactate, Isotonic saline, DNS , isolyte-M,P &G. 3)Special fluids: Special fluids are used for the special indications such as hypoglycemia , hypokalemia & metabolic acidosis.e.g 25% dextrose , inj dextrose ,inj potassium chloride & inj sodium bicarbonates.

 Indication:1)

correction of salt depletion & hypovolemia with supply of energy. 2)Correction of vomiting or nasogastric aspiration induced alkalosis & hypochloremia along with supply of calories. 3)fluid compatible with blood transfusion. Contraindications: 1)Anasarca 2) Hypovolemic shock.

Indication: 1) correction of severe hypovolemia rapidly. 2)for replacing fluid in postoperative patients, burns ,fractures ,peritoneal irrigation ect. 3)Diarrhoea induced hypovolemia. 4) In diabetic ketoacidosis 5)For maintaining normal ECF fluid & electrolyte balance during & after surgery. Contraindication: in liver disease ,in severe CHF ,Rl & blood product in one IV line is contraindicated , calium In RL binds with certain drugs (amphotericin ,ampicillin).

 Indication:1)water

& salt depletion as in diarrhoea , vomitting ,excessive diuresis. 2)Treatment of hypovolemic shock. 3)Irrigation of washing of body fluids. 4)As a vehicle for certain drugs & can be given safely with blood. Contraindications:Avoid in hypertensive or preeclampsia ,CHF ,renal disease & cirrhosis. Dehydration with severe hypokalemia.

Indication:1)Fluid to provide adequate calories to body. 2)For pre & post operative fluid replacement. 3)For I.V. administration of various drugs 4) For treatment of ketosis in starvation ,diarrhoea ,vomiting & high grade fever. Contraindication: Cerebral oedema , Neurosurgical procedures, stroke.

 Indication:

1)Used as maintenance fluid in infants & children to provide daily water & electrolytes. 2)Excessive water loss or inability to concentrate urine.(DI) Contraindication: Renal failure, Hypovolemic shock.

Patients awaiting surgery need to be kept fasting for a few hours prior to & after the surgery hence fluid loss during this period needs to be replaced. Replacement as follows: 1)Fluid requirement during starvation- 2ml/kg/h of fasting ,replaced over 2-3 hrs. 2)Maintenance requirement- 2ml/kg/hr of surgery. 3)Third space lossesa)minimal dissection-4ml/kg/hr b) Moderate dissection-6ml/kg/hr c) Large amount of dissection- 8ml/kg/hr of surgery

 Starvation

losses: replaced by an infusion of 5% dextrose. Maintenance & 3rd space losses : By RL.