Fluid & Electrolytes

Dewi Kartikawati N.

FLUIDS
50-60% of the human body is water (decreases with age) Body fluids are classified according to their location with most of the body’s fluids found within the cell
– –

Intracellular Extracellular (mainly responsible for transport of nutrients and wastes)

Fluid compartments are separated by selectively permeable membranes that control movement of water and solutes The process of homeostasis involves delivery of oxygen and nutrients to the cells and removal of waste

Body Fluid Compartments:
2/3

ICF: 55%~75%

X 50~70% lean body weight

TBW

3/4

Male (60%) > female (50%) Most concentrated in skeletal muscle TBW=0.6xBW ICF=0.4xBW ECF=0.2xBW

1/3

ECF
1/4

Extravascular Interstitial fluid Intravascular plasma

Body Fluid Compartments Cont’d……..
2/3 (65%) of TBW is intracellular (ICF) 1/3 extracellular water
  

25 % interstitial fluid (ISF) 5- 8 % in plasma (IVF intravascular fluid) 1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)
5

requires energy and pump. Diffusion is the movement of a substance from area of higher concentration to one of lower concentration. Sodium/potassium pump . Active Transport is the movement of substance across permeable membrane and gradient. Ex.Regulation of Body Fluid Compartments Osmosis is the diffusion of water caused by fluid gradient.

Regulation of Body Fluid Compartments Cont’d………… Filtration is the movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure Osmolality reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis Osmotic pressure is the amount of hydrostatic pressure needed to stop the flow of water by osmosis .

. water pulled out of fluid to equalize. equal.Osmolarity Isotonic – same solute concentration. water pulled into fluid to equalize. no movement across membrance Hypertonic/hyper-osmotic – greater osmotic pressure (concentration). Hypotonic/hypo-osmotic – lesser osmotic pressure (concentration).

9 .

Cell in a hypertonic solution 10 .

Cell in a hypotonic solution 11 .

Regulation of Fluids: Renal sympathetic nerves Renin-angiotensinaldosterone system Atrial natriuretic peptide (ANP) .

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Regulation of Fluid Volume Kidneys – – – Capillary pressure forces fluid through the walls and into the tubule At this point H2O or electrolytes are then either retained or excreted The urine becomes more dilute or more concentrated based on the needs of the body .

Regulation of Fluid Volume. and some meds . pain. cont. Antidiuretic hormone (ADH) – – – – – – Produced by the hypothalamus Stored in the pituitary gland Restores blood volume by increasing or decreasing excretion of water Increased osmolality or decreased blood volume stimulates the release of ADH Then the kidneys reabsorb water Also may be released by stress. surgery.

Regulation of Fluid Volume. Renin-angiotensin-aldosterone system – Renin secreted in kidney  Amount of renin produced depends on blood flow and amount of Na in the blood – – – Produces angiotensin II (vasoconstrictor) Angiotensin causes peripheral vasoconstriction Angiotensin II stimulates the production of aldosterone . cont.

Aldosterone – – – – – – Secreted by the adrenal gland response to angiotensin II The adrenal gland may also be stimulated by the amount of Na and K + in the blood Causes the kidneys to retain Na and H2O Leads to increases in fluid volume and Na levels Decreases the reabsorption of K+ Maintains B/P and fluid balance .Regulation of Fluid Volume. cont.

Regulation of Fluid Volume. cont Atrial natriuretic peptide or factor (ANP) (ANF) – – – – – – – – Cardiac hormone Released in response to increased pressure in the atria (increased blood volume) Opposes the renin-angiotensin-aldosterone system Stimulates excretion of Na and H2O Suppresses renin level Decreases the release of aldosterone Decreases ADH release Reduces vascular resistance by causing vasodilation .

cont Atrial natriuretic peptide or factor (ANP) (ANF) – – – – – – – – Cardiac hormone Released in response to increased pressure in the atria (increased blood volume) Opposes the renin-angiotensin-aldosterone system Stimulates excretion of Na and H2O Suppresses renin level Decreases the release of aldosterone Decreases ADH release Reduces vascular resistance by causing vasodilation .Regulation of Fluid Volume.

Fluid shifting 1st space shifting.excess accumulation of interstitial fluid (edema) 3rd space shifting.normal distribution of fluid in both the ECF compartment and ICF compartment.fluid accumulation in areas that are normally have no or little amounts of fluids (ascites) . 2nd space shifting.

Balance Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output 21 .

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23 .

Electrolytes Major cations for extracellular fluid – Sodium Major cations for intracellular Potassium Cations  Calcium. magnesium .phosphorus.

Function of sodium:    Controlling and regulating water balance. Maintaining blood volume Transmitted nerve impulses. .Sodium (Na): Is the most abundant cation in the extracelluar fluid and major contributor to serum osmolality.

Sodium is found in many foods. table salt . Hyponatremia: sodium deficit in the blood. Hypernatremia: sodium excess in the blood.    Normal level is 135 – 145 mg/dl. such as processed cheese.

Potassium: Is the major cation in intracellular fluid. Function of potassium:      Maintain ICF osmolality. Skeletal and smooth muscle function. Regulate cardiac impulses. Regulate acid base balance . Transmitting nerve impulses.

. milk. Hyperkalemia: potassium excess in the blood. Normal level of potassium is 3.    Potassium is found in many fruits and vegetables. meat. fish.3meq/l.5 – 5. Hypokalemia: potassium deficit in the blood.

O2. glucose. CO2 Non-electrolytes . HCO3.Solutes – dissolved particles Electrolytes – charged particles   Cations – positively charged ions  Na+. K+ . PO43 Proteins. Ca++.Uncharged 29 . urea. H+ Anions – negatively charged ions  Cl-..

Environment: excess heat stimulates the sympathetic nervous system and cause person to sweat. .Factor effecting fluid and electrolyte balance: Age: infant have greater water need and greater loss due to greater metabolic rate.

Diet: in nutritional deficiency. the body preserved the protein by breaking down the fat and glycogen. Stress: water retention and increase the production antiduritic hormone. renal disorder . Illness: burn.

Client with special drainage.Client at risk for fluid and electrolyte imbalance: Post operative client. Client who receiving diuretic . Client with chronic disease as congestive heart failure. Client with sever trauma or burn. Client with intravenous infusion.

Hypovolemia Hypervolemia .FLUIDS IMBALANCES…….

Signs of Hypovolemia: Diminished skin turgor Dry oral mucus membrane Oliguria .5~1ml/kg/h Tachycardia Hypotension Hypoperfusioncyanosis Altered mental status .normal: 0.<500ml/day .

GI bleeding…etc BUN : Creatinine > 20 : 1 . glucocorticoid therapy. UGI bleeding Increased specific gravity Increased hematocrit Electrolytes imbalance Acid-base disorder .BUN↑: hyperalimentation.Clinical Diagnosis of Hypovolemia: Thorough history taking: poor intake.

correction of electrolyte abnormality .useful for volume expansion (mainly interstitial space) .Parenteral Fluid Therapy: Crystalloids: .contain Na as the main osmotically active particle .for maintenance infusion .

Crystalloids: Isotonic crystalloids . inadequate for fluid resuscitation .45% NaCl .3% NaCl Hypotonic solutions .Lactated Ringer’s.less than 10% remain intravascularly.9% NaCl .D5W.only 25% remain intravascularly Hypertonic saline solutions . 0. 0.

Haes-steril 10% . 25% .Dextran .Colloid Solutions: Contain high molecular weight substancesdo not readily migrate across capillary walls Preparations .Gelifundol .Albumin: 5%.

45% NaCl D5W D5/0.500 20.5 <2.45% NaCl 3% NaCl 6% Hetastarch 5% Albumin 25% Albumin 500 250.9% NaCl 0.5 77 513 154 130160 130160 50 406 1026 310 330 330 Volumes Na+ 142 130 154 77 K+ 4 4 Ca2+ 5 3 Mg2+ Cl103 109 154 77 HCO327 28 Dextrose mOsm/L 280-310 273 308 154 .50.100 77 513 154 130160 130160 <2.Common parenteral fluid therapy Solutions ECF Lactated Ringer’s 0.

The Influence of Colloid & Crystalloid on Blood Volume: Blood volume Infusion volume 1000cc 200 600 1000 Lactated Ringers 500cc 5% Albumin 500cc 6% Hetastarch 500cc Whole blood .

Signs of Hypervolemia: Hypertension Polyuria Peripheral edema Especially when hypo-albuminemia Wet lung Jugular vein engorgement .

Pitted edema Fluid overload .

Pitting odema .

Management of Hypervolemia: Prevention is the best way Guide fluid therapy with CVP level or pulmonary wedge pressure Diuretics Increase oncotic pressure: FFP or albumin infusion (may followed by diuretics) Dialysis .

heart failure and renal insufficiency patient .Fluid Management: Goal: .K+: 0.5~1.0mg/kg/h Electrolytes require: .0mmol/kg/day Avoid fluid overload.to maintain urine output of 0.5~1. especially in malnutrition.Na+: 1-2mmol/kg/day .

Large borne IV line .Fluid Management: For acute blood loss .Crystalloid + 5% albumin in a ratio of 4:1 .Blood transfusion .Begin with 2-3L isotonic crystalloid to restore blood pressure and peripheral perfusion .Early use of colloid .

Electrolyte Imbalances       Hypo and Hypernatremia (Na+) Hypo and Hyperkalemia (K+) Hypo and Hypercalcemia (Ca+) Hypo and Hypermagnesemia (Mg+) Hypo and Hyperphosphatemia (Phos+) Hypo and Hyperchloremia (Cl-) .

CAIRAN NON ELEKTROLIT 2. Dextran. PZ. CAIRAN ELEKTROLIT 3. Darah . Gelatin. Asering dll.MACAM CAIRAN : 1. RL. HES. KAEN. CAIRAN KOLOID GLUKOSA 5% / DEKTROSE 5% NaCl (NS). Albumin dll 48 .

KEBUTUHAN 49 .Na+ ---------.50cc / KgBB / 24 jam. > 20cc/ KgBB / 24 jam. .TETESAN / MENIT .3 – 5 mg / KgBB / 24 jam.PEMBERIAN CAIRAN MAINTENANCE .JUMLAH CAIRAN : DEWASA ANAK 50Kg / KgBB/ 24 jam 10Kg I -----.MACAM CAIRAN --------------------.100cc / KgBB / 24 jam 10Kg II ------.

CONTOH : Laki-laki. 50 .Macam Cairan ----.Terumo : 2500 x 20 24 x 60 = 2500 24 x 3 = 33-35 tts / mnt.Tetesan / menit – otsuka --.1cc = 15 tts terumo – 1cc = 20 tts. .Susunan Cairan RL 3 fles + D5% 2 fles. kekurangan cairan 1000 cc -----. 25 th. .Macam Cairan RL 3 fles --.Jumlah Cairan -------. . .Otsuka : 2500 x 15 24 x 60 = 2500 24 x 4 = 25 -30 tts / mnt . . jumlah 1500 cc.1 fles = 65 meq PZ – Na+ 154 meq/L -----.Na+ 195 meq .1 fles = 77 meq.D5% = 2 fles.50 x50 / 24Jam = 2500 cc / 24 jam. RL – Na+ 131 meq/L-----. BB 50 Kg.kebutuhan Na+ = 150 -250 mg/ 24 jam. .

500 cc -D 5% 140 cc -Tetesan : Otsuka : 1640 X 15 = 24 X 60 24 X 60 Jumlah 1.7 x 20 cc = 140 cc jumlah = 1640 cc -Macam Cairan Kebutuhan Na+ = 81 – 135 meq/ 24 jam.45% in D5% -- C2  Na+38 meq/fles -NaCl 0. 11 th .Anak.225% in D5%  C4  Na+19 meq/fles -NaCl 0. BB 27 kg. .9% - C I - Na+ 77 meq/fles -NaCl 0.10 x 100cc = 1000 cc 10Kg II ------. -NS / PZ NaCl 0.18 tts/m 96 96 51 1.10 x 50 cc = 500 cc > 7Kg -----.Jumlah Cairan 10 Kg I ----.640 cc 140 cc -Terumo : 1640 X 20 = 1640 = 22 – 24 tts/m .18 % in D5%  C5  Na+ 10 meq/fles -Macam cairan -C2 3 fles  Na+ 114 meq  jumlah Total 1640 = 16 .

25 % EBV/F hilang  syok. 1.Perdarahan …………. 15 % EBV/F hilang  hypoxia (+)  nadi meningkat 3. 52 .. VOLUME DARAH EFEKTIF (Effective blood volume/flow)  ♂ 70 – 75 cc/kgBB  ♀ 60 – 65 cc/kgBB  Anak2 90 – 100 cc/kgBB 2.

RL = 4 X 525 cc  ± 2..500 cc Darah yang hilang 15 % = 15/100 X 3.Case…….500 = 525 cc Cairan yang dimasukkan.100 cc 53 . Pasien laki2 BB 50 kg di IRD karena KLL dan perdarahan Waktu masuk: N 100 x/m T 120/80 RR 24 x/m Perhitungan : N 100 x/m  pasien perdarahan Hypoxia (+)  kira2 15 % dari EBV/F BB 50 kg  EBV 70 X 50 cc = 3.

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