Fluid & Electrolytes

Dr. Faiez Alhmoud

Albashir Teaching Hospital

Why do we care about fluids in the

body?

Fluids facts
Over half of our body weight is fluid material
- Fluids are 60% of an adults body weight
- 70 Kg adult male has 60% X 70= 42 Liters
- Infants have more water = 75-80% of BW
- Elderly have less water = 45-50% of BW
- More fat means water (female has 50-55%)
- More muscle means water (male has 55-60%)
- Infants and elderly are more prone to fluid imbalance
- In adults, a loss of just 1/5 of body fluid weight can
be fatal (Marathon runners).
3

VARIATIONS IN FLUID CONTENT

AGE & GENDER

Body Fluid : Function

Transport nutrients to the cells and carries
waste products away from the cells (cell
function
Maintains blood volume
Regulates body temperature
Serves as aqueous medium for cellular
metabolism
Assists in digestion of food through hydrolysis

So where are these fluids kept?

Compartments of
Body Fluids
16%

4%

blood

40%

Body Water = 60% of a patients body weight

Compartments
Intracellular (ICF)
Fluid within the cells themselves
The most stable & least susceptible to fluid
shifts
2/3 of body fluid
High in K , Phosphors, Mg. & protein
Located primarily in skeletal muscle mass
Assists in cellular metabolism

Compartments
Extracellular (ECF)
1/3 of body fluid
High in Na, Cl, Ca, Glucose, fatty &amino-acids
Comprised of 3 major components
* Intravascular: =4% =3lit.,least stable, most
susceptible to fluid shift (Plasma=90%H2O)
* Interstitial: =16%=10lit., reserve fluid, replacing
intravascular or intracellular as needed (Fluid in
and around tissues)
*Transcellular: ~ 1% or up to one Lit..
(Cerebrospinal, pericardial, synovial,
intraocular, pleural fluids..)
9

Compartments
Transcellular component
1% of ECF
Located in joints, connective tissue, bones,
body cavities, CSF, and other tissues
Potential to increase significantly in
abnormal conditions

10

MOVEMENT OF BODY FLUIDS

Osmosis- water moves through semi permeable
membrane from diluted to concentrated solution
Diffusion- dissolved particles. Eg.gut absorption
Filtration- water and dissolved. move through
membrane from solution having higher hydrostatic
pressure Eg. (water and solute move out of the blood at
the arterial end of the capillary to the interstitial fluid by
filtration
Active transport- ions move from the area of lesser
concentration to area of greater concentration by energy
Eg. Enzymes ,nutritients &potassium
Hydrostatic pressure- the pressure created by the
weight of fluid against the wall that contains it.

Oncotic pressure- or colloid osmotic pressure,

tends to pull water into the circulatory system.

that usually

osmosis

Diffusion

Sources of Water
1000 cc

1250cc

Parenteral

Enteral

250cc
From
Oxidation

What are the expected losses ?

Measurable:
urine =1-2lit.
GI =100-200cc
( stool, stoma )

Insensible or:
Unmeasurable
-sweat=up to 1lit
-exhalation=400cc

Fluid shifts / loses

Kidneys

Guts

Lungs

Skin

Intracellular
30 litres
Interstitial
9 litres

Intravascular
3 litres

Extracellular fluid - 12 litres

REGULATION OF BODY
FLUIDS
Fluid intake
Fluid output
Hormonal influence
Lymphatic influences
Neurologic influences
Renal influences

ANTIDIURETIC HORMONE
REGULATION MECHANISMS
Osmolarity

Blood
volume
or BP

Volume receptor
Atria and great veins

Narcotics, Stress,
Anesthetic agents, Heat,
Nicotine, Antineoplastic
agents, Surgery

Osmoreceptors in
hypothalamus
Hypothalamus

Posterior
pituitary gland

ADH

Kidney
tubules
H2O
reabsorption
vascular
volume and
osmolarity

ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM
Serum Sodium
Blood volume

Juxtaglomerular
cells-kidney

RENIN

Angiotensinogen in
plasma
Angiotensin I

Sodium
resorption
(H2O resorbed
with sodium);
Blood volume

Via vasoconstriction of arterial smooth muscle

Angiotensinconverting
enzyme

Angiotensin II
Kidney tubules

Intestine, sweat
glands, Salivary
glands

ALDOSTERONE

Adrenal Cortex

ALDOSTERONE-RENIN-ANGIOTENSIN
SYSTEM
Renal sympathetic nerves
Renin-angiotensinaldosterone system
Atrial natriuretic peptide
(ANP)

Fluid Volume Shifts

Fluid normally shifts between intracellular
and extracellular compartments to
maintain equilibrium between spaces
Fluid not lost from body but not available
for use in either compartment
considered third-space fluid shift (thirdspacing)
Enters serous cavities (transcellular)
21

Third Spacing
Accumulation and sequestration of trapped
extracellular fluid in a body space
This fluid is a volume loss and its
unavailable for normal physiologic function
Fluid may be trapped in pericardial, pleural,
peritoneal cavities, soft tissue or joints.
Eg.
Ascites
Effusion

Edema
The excess accumulation of fluid in the
interstitial space.
Causes include surgery, accidents, and
trauma.
Anasarca is generalized body edema

Remember

Fluids and electrolytes always

want to shift from an area of
higher concentration to an area
of lower concentration to
equilibrate

FLUID IMBALANCES
There are five types of fluid imbalances that
may occur are:
Extracellular fluid volume deficit (EVFVD)
Extracellular fluid volume excess (ECFVE)
Extracellular fluid volume shift
Intracellular fluid vloume excess (ICFVE)
Intracellular fluid volume deficit (ICFVD)

EXTRACELULLAR FLUID
VOLUME DEFICIT
An ECFVD, commonly called as
dehydration , is a decrease in
intravascular and interstitial fluids
An ECFVD can result in cellular fluid loss
if it is sudden or severe

THREE TYPES OF ECFVD

Hyperosmolar fluid volume deficitwater loss is greater than the electrolyte
loss
Iso-osmolar fluid volume deficit equal
proportion of fluid and electrolyte loss
Hypotonic fluid volume deficit
electrolyte loss is greater than fluid loss

ETIOLOGY AND RISK FACTORS

(EVFVD)
Severe vomiting
Diaphoresis
Traumatic injuries
Third space fluid shifts
[ intestinal obst., pleural&
pertonial cavity]
Fever
Gatrointestinal suction
Ileostomy
Fistulas
Burns

Hyperventilation
Decresed ADH secretions
Diabetes insipidus
Addisons disease or
adrenal crisis
Diuretic phase of acute
renal failure
Use of diuretics

ELDERLY AND CHILDREN ARE

AT HIGH RISK OF ECFVD

CLINICAL MANIFESTATION(EVFVD)
Thirst
Muscle weakness
Dry mucus membrane; dry
cracked lips or dry tongue
Apprehension , restlessness,
headache , confusion, coma
in severe deficit
Elevated temperature
Tachycardia, weak thready
pulse
Decreased number and
moisture in stools
Weight loss

Peripheral vein filling> 5

Narrowed pulse pressure,
decreased CVP&PCWP
Flattened neck veins in
supine position
Oliguria<30ml/h
Postural systolic BP falls
>25mm Hg and diastolic fall
> 20 mm Hg , with pulse
increases > 30
Eyeballs soft and sunken
(severe deficit)

Clinical assessment of degree of

dehydration(Children)- (EVFVD)
Degree

Mild
Moderate
Severe
(5-7% ofBW) (7-10% ofBW (>10% ofBW)

1- Fontanella

Slightly sunken

Very sunken

Very sunken

Mucous - 2
membranes

Slightly sticky

dry

Very dry

Normal

Slightly
decreased

Markedly
decreased

Normal
)seconds 3(<

Normal
)seconds 3(<

Delayed
)seconds 3(

Urine output- 5

Normal

Slightly
decreased

Decreased or
absent

Mental status-6

Normal

Slightly fussy

Irritable or
lethargic

Skin turgor- 3
Capillary- 4
refill time

Dehydration in Children

Degrees Of Dehydration in adults

Mild=2%of total body water ~ 1-1.4lit
Thirst
Marked=5% of total body water ~ 3-3.5lit.
Marked thirst,oliguria,Ht.,pulse,R.R, BP, Dry mucous &
Low grade fever.
Severe= 8% of total body water ~ 5-5.5lit.
Symptoms of marked dehydration plus:
Systolic blood pressure drop (60 mm Hg or below)
Behavioral changes (restlessness, irritability, delirium
& disorientation,)
Fatal 2230% of total body water loss~ 15lit. or more
Can prove fatal
Anuria
Coma leading to death

LABORATORY FINDINGS
(EVFVD)
Increased osmolality(> 295 mOsm/ kg)
Increased or normal serum sodium level
(> 145mEq/ L )
Increase BUN (>25 mg / L )
Hyperglycemia ( >120 mg /dl )
Elevated hematocrit (> 55%)
Increased urine specific gravity ( > 1.030)

MANAGEMENT (EVFVD)
Mild fluid volume loss can be corrected with
oral fluid replacement
-if patient tolerates solid foods advice to take
1200 ml to 1500ml of oral fluids
-if patient takes only fluids, increase the total
intake to 2500 ml in 24 hours

MANAGEMENT (EVFVD)
Estimate Fluid Deficit
(% :- Mild, Moderate, Severe).
Find Type of Dehydration
(Isonatremic, Hyponatremic, Hypernatremic).
Give daily Maintenance.
Give Deficit as follows:
Half volume over 8 hours, half volume over 16
hours
(Exception: in Hypernatremic Dehydration,
replace deficit over 48 hours).

If haemorrhage is the cause

for ECFVD
Packed red cells followed by hypotonic IV
fluids is administered
In situations where the blood loss is less
than 1 L Normal Saline or Ringer lactate
may be used
Patients with severe ECFVD accompanied
by severe heart , liver, or kidney disease
cannot tolerate large volumes of fluid and
sodium & need monitoring (CVP)

EXTRACELLULAR FLUID
VOLUME EXCESS
ECFVE is increased fluid retention in the
intravasular and interstitial spaces

ETIOLOGY AND RISK

FACTORS(EVFVE)
Heart failure
Renal failure
Cirrhosis of liver
Increased ingestion of high sodium foods
Excessive amount of IV fluids containing sodium
Electrolyte free IV fluids
Sepsis
Decreased colloid osmotic pressure
Lymphatic and venous obstruction
Cushings syndrome & glucocorticoids

CLINICAL MANIFESTATION
(EVFVE)
Constant irritating cough
Dyspnoea & crackles in lungs
Cyanosis, pleural effusion
Neck vein distention
Bounding pulse &elevated BP
S3 gallop
Pitting & anasacra edema
Weight gain
Increased CVP& PCWP
Change in level of consciousness

LAB INVESTIGATION
(EVFVE)
serum osmolality <275mOsm/ kg
Low , normal or high sodium
Decreased hematocrit [ < 45%]
Urine specific gravity below 1.010
Decreased BUN [< 8mg/ dl]

MANAGEMENT
(EVFVE)
Diuretics [combination of potassium
sparing and potassium depleting
diuretics]
In people with CHF: ACE inhibitors and
low dose of beta blockers are used
A low sodium diet

EXTRACELLULAR FLUID
VOLUME SHIFT: THIRD
SPACING(shift)
Fluid that shifts into nonfunctioning
spaces and remain there is called as
third space fluid
Common sites are abdomen , pleural
cavity, peritoneal cavity and GI lumen

RISK FACTORS(shift)
Crushing injuries, major tissue trauma
Major surgery
Extensive burns
Pancreatitis
Perforated peptic ulcers - peritonitis
Intestinal obstruction
Lymphatic obstruction
Hypoalbumenemia

CLINICAL
MANIFESTATION(shift)
skin pallor
Cold extremities
Weak and rapid pulse
Hypotension
Oliguria
Decreased levels of consiousness

LAB INVESTIGATION
Elevated hematocrit & BUN level
As in the iso-osmolar

MANAGEMENT(shift)
Treat the cause

For burns and tissue injuries large volume

of isosmolar IV fluid is administered
Albumin is administered for protein deficit
IV fluid intake is maintained after major
surgery to maintain kidney perfusion
Paracentesis or tapping for ascitis or
pleural effusion

INTRACELLULAR FLUID
VOULME EXCESS:WATER
INTOXICATION
ICFVE is increase in amount of water
inside the cells

ETIOLOGY (ICFVE)
Administration of excessive amount of
hyposmolar IV fluids[0.45%saline or
5%dextrose in water]
Consumption of excessive amount of tap
water without adequate nutritional intake
(Schizophrenia[compulsive water
consumption])
SIADH results from innapropriate ADH
secretion resulting in innapropriate retention
of ingested/infused water

CLINICAL MANIFESTATIONS
(ICFVE)
Headaches
Behavioral changes
Apprehension
Irritability, disorientation and confusion
Increased ICP pupillary changes and
decreased motor and sensory function
Bradycardia, elevated BP, widened pulse
pressure & altered respiratory patterns,
Babinskis response flaccidity, projectile vomiting,
papilledema, delirium, convulsions &coma

LABORATORY FINDINGS
(ICFVE)
Low serum sodium level- 125 mEq/L
decreased hamatocrit

MANAGEMENT (ICFVE)
Early administration of IV fluids containing
sodium chloride can prevent SIADH
oral fluids such as juices or soft drinks can be
given orally every hour
Perform neurologic checks every hour to see if
cranial changes are present
Monitor fluid intake , IV fluids and fluid output
hourly and weight daily
Administer antiemetics for food and fluid
retention

INTRACELLULAR FLUID
VOLUME DEFICIT
Severe hypernatremia and dehydration
can cause ICFVD
Relatively rare in healthy adults
Common in elderly people and in those
conditions that result in acute water loss
Symptoms include confusion, coma, and
cerebral hemorrhage

Assessment of fluid and

Electrolytes Imbalance;
Observation of general condition of the patient,
including vital signs, neck veins, skin, and
mucous membranes, weight, presence of
edema and appetite.
Type of fluid lost.
Character and volume of urine & specific gravity
Assessment of blood electrolytes level.
Blood urea nitrogen and creatinine level.
Frequency and character of stool.
Measuring and recording intake and output.

The rules of fluid replacement:

Replace blood with blood
Replace plasma with colloid or LR
Resuscitate with colloid or LR
Replace ECF depletion with saline
Rehydrate with dextrose
Hyponatremic pt. needs NSS or hypertonic saline
Hypernatremic pt. needs
D5W or hypotonic saline

Hypo versus Hyper

INDICATORS OF SUCCESSFUL
RESUSCITATION
URINARY OUTPUT
CHILDREN = 1.0 ml/kg/hr
ADULT = 0.5 ml/kg/hr

BLOOD PRESSURE
POOR INDICATOR

How much fluid to give ?

What is your starting point ?
Euvolemia ? ( normal )
Hypovolemia ? ( dry )
Hypervolemia ? ( wet )

What are the expected losses ?

What are the expected gains ?

MAINTENANCE THERAPY..
Maintenance therapy is usually undertaken
when the individual is not expected to eat or
drink normally for a longer time (eg,
perioperatively or on a ventilator).
Big picture: Most people are NPO for 8-12
hours each day.
Patients who wont eat for > one to two weeks
should be considered for parenteral or enteral
nutrition.

..MAINTENANCE THERAPY
water requirements increase with:
fever, sweating, burns, tachypnea, surgical
drains, polyuria, or ongoing significant
gastrointestinal losses.
For example, water requirements increase by
100 to 150 mL/day for each C degree of body
temperature elevation.

..MAINTENANCE THERAPY
4/2/1 rule
4 ml/kg/hr for first 10 kg (=40ml/hr)=100ml/kg/24h
then 2 ml/kg/hr for next 10 kg (=20ml/hr)=50ml/kg/24h
then 1 ml/kg/hr for any kgs over that=20ml/kg/24h
This always gives 60ml/hr for first 20 kg
then you add 1 ml/kg/hr for each kg over 20 kg

This boils down to: Weight in kg + 40 = Maintenance IV

rate/hour.
For any person weighting >20kg &<100kg.
Daily fluid maintenance in pediatrics:
0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc

Electrolytes

WHAT DO ELECTROLYTES DO?

Serum Values of Electrolytes

Cations (+)
Sodium
Potassium
Calcium
Magnesium

Concentration
135 145 mEq/L
3.5 - 4.5 mEq/L
9-10.5 mg/dL
1.5 - 2.5 mEq/L

Anions (-)
Chloride
CO2
Phosphate
HCO3

95 107 mEq/L
24 30 mEq/L
2.5 - 4.5 mEq/L
22 26 mEq/L

Location of Ions
Extracellular Ions
Intracellular Ions
Cl-

Mg++

K+

Na+

Ph-

Ca++

Daily Requirements for

Electrolytes
Sodium: 1-2 mEq/kg/d
Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/d

Sodium
imbalanc
es

Hypona
traemi
a

Definit
ion

Risk factors/
etiology

Clinical
manifestation

Laboratory
findings

management

It is
define
d as a
plasm
a
sodiu
m
level
below
135
mEq/ L

Kidney diseases

Weak rapid
pulse
Hypotension
Dizziness
Apprehension
and anxiety
Abdominal
cramps
Nausea and
vomiting
Diarrhea
Coma and
convulsion
Cold clammy
skin
Finger print
impression on
the sternum
after palpation

Serum
sodium less
than
135mEq/ L

Identify the
cause and treat

Adrenal
insufficiency
Gastrointestinal
losses
Use of diuretics
(especially with
along with low
sodium diet)
Metabolic
acidosis

Personality
change

serum
osmolality
less than
280mOsm/kg
urine
specific
gravity less
than 1.010

Administration
of sodium
orally, by NG
tube or
parenterally
For patients
who are able to
eat & drink,
sodium is easily
accomplished
through normal
diet
For those
unable to
eat,Ringers
lactate solution
or isotonic
saline
[0.9%Nacl]is
given
For very low
sodium 3%Nacl
may be
indicated

CLINICAL MANIFESTATIONS OF HYPONATREMIA

Muscle
Weakness

Postural
hypotension

Nausea and

Apathy

Abdominal
Cramps

Weight Loss

In severe hyponatremia: mental confusion, delirium, shock and coma

Sodium
imbalan
-ce

Defini
tion

causes

Clinical
manifestation

Hypernat
-remia

It is
defin
ed as
plasm
a
sodiu
m
level
great
er
than
145m
E
q/L

*Ingestion
of large
amount of
concentrate
d salts
*Iatrogenic
administrati
on of
hypertonic
saline IV
*Excess
alderostero
ne
secretion

* Low grade
fever
Postural
hypertension
*Dry tongue &
mucous
membranes
* Agitation
* Convulsions
*Restlessness
*Excitability

*Oliguria or
anuria

*Thirst
*Dry &flushed
skin

Lab findings

*high serum
sodium
145mEq/L

*high serum
osmolality29
5mO sm/kg

*high urine
specificity
1.030

management

*Administration of
hypotonic sodium
solution [0.3 or
0.45%]
*Rapid lowering of
sodium can cause
cerebral edema
*Slow administration
of IV fluids with the
goal of reducing
sodium not more
than 2 mEq/L for the
first 48 hrs decreases
this risk
*Diuretics are given
in case of sodium
excess
*In case of Diabetes
insipidus
desmopressin
acetate nasal spray
is used

CLINICAL MANIFESTATIONS of
HYPERNATREMIA

Thirst

Dry & sticky mucous membranes

Firm, rubbery
tissue turgor

Tachycardia
DEATH
Manic excitement

Potassium
imbalance
s

Definiti
on

Causes

Clinical
manifestatio
n

Lab findings

Management

Hypokale
mia

It is
defined
as
plasma
potassi
um
level of
less
than
3.0
mEq/L

*Use of
potassium
wasting
diuretic

*weak
irregular
pulse

* K less
than
3mEq/L
results in
ST
depression ,
flat T wave,
taller U
wave

Mild
hypokalemia[3.3to
3.5] can be managed
by oral potassium
replacement

*diarrhea,
vomiting or
other GI
losses
*Alkalosis
*Cushings
syndrome
*Polyuria
*Extreme
sweating
*excessive
use of
potassium
free Ivs

*shallow
respiration
*hypotesion
*weakness,
decreased
bowel
sounds,
heart
blocks ,
paresthesia,
fatigue,
decreased
muscle tone
intestinal
obstruction

* K less
than
2mEq/L
cause
widened
QRS,
depressed
ST, inverted
T wave

Moderate
hypokalemia
*K-3.0to 3.4mEq/L
need 100to 200mEq/L
of IV potassium for the
level to rise to 1mEq/
Severe hypokalemia
K- less than 3.0mEq/L
need 200to 400 mEq/L
for the level to rise to l
mEq/L
*Dietary replacement
of potassium helps in
correcting the
problem[1875 to 5625
mg/day]

Hyper
kalemi
a

Definitio
n

Causes

Clinical
manifestati
on

Lab findings

Management

It is
defined
as the
elevatio
n of
potassiu
m level
above
5.0mEq/
L

Renal failure ,

Hypertonic
dehydration,

Burns&
trauma

Large amount
of IV
administration
of potassium,

Irregular
slow pulse,

hypotension
,

anxiety,

irritability,

paresthesia,

weakness

*High
serum
potassium
5.3mEq/L
results in
peaked T
wave HR
60 to 110

*serum
potassium
of 7mEq/L
results in
low broad
P- wave

*serum
potassium
levels of
8mEq/L
results in
no arterial
activity[no
p-wave]

Dietary restriction of
potassium for
potassium less than
5.5 mEq/L
Mild hyperkalemia
can be corrected by
improving output by
forcing fluids, giving
IV saline or potassium
wasting diuretics
Severe
hyperkalemia is
managed by
1.infusion of calcium
gluconate to decrease
the antagonistic effect
of potassium excess
on myocardium
2.infusion of insulin
and glucose or
sodium bicarbonate to
promote potassium
uptake
3.sodium polystyrene
sulfonate [Kayexalate]

Adrenal
insufficiency

Use of
potassium
retaining
diuretics &
rapid infusion
of stored
blood

Calciu
m
imbala
nces

Definiti
on

Causes

hypoc
alcemi
a

It is a
plasma
calciu
m
level
below
8.5
mg/dl

Rapid
administration
of blood
containing
citrate,
hypoalbumine
mia,
Hypothyroidis
m,

Vitamin
deficiency,
neoplastic
diseases,
pancreatitis

Clinical
manifestatio
n

Lab
findin
gs

Numbness
and tingling
sensation of
fingers,

Serum
calciu
m less
than
4.3
mEq/L
and
ECG
chang
es

hyperactive
reflexes,
Positve
Trousseaus
sign, positive
chvosteks
sign ,
muscle
cramps,
pathological
fractures,
prolonged
bleeding time

Management

1.Asymtomatic
hypocalcemia is treated
with oral calcium chloride,
calcium gluconate or
calcium lactate

2.Tetany from acute

hypocalcemia needs IV
calcium chloride or calcium
gluconate to avoid
hypotension bradycardia
and other dysrythmias

3.Chronic or mild
hypocalcemia can be
treated by consumption of
food high in calcium

TESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCY

Calcium
imbalance

Hyperc
alcemi
a

Definition

Causes

Clinical
manifestation

Lab findings

Management

It is
calcium
plasma
level
over 5.5
mEq/l or
11mg/dl

Hyperparat
hyroidism,

Metastatic
bone
tumors,

pagets
disease,

Decreased
muscle tone,

High serum
calcium
level
5.5mEq/L,

1.IV normal saline,

given rapidly with
Lasix promotes
urinary excretion of
calcium

2.Plicamycin an
antitumor antibiotics
decrease the plasma
calcium level

3.Calcitonin
decreases serum
calcium level

4.Corticosteroid drugs
compete with vitamin
D and decreases
intestinal absorption
of calcium

5. If cause is
excessive use of
calcium or vitamin D
supplements reduce
or avoid the same

osteoporosi
s,
prolonged
immobalisati
on

anorexia,

nausea,
vomiting,
weakness ,
lethargy,

low back
pain from
kidney
stones,
decreased
level of
consciousne
ss & cardiac
arrest

x- ray
showing
generalized
osteoporosis
,
widened
bone
cavitation,
urinary
stones,
elevated
BUN
25mg/100ml
,
elevated
creatinine1.
5mg/100ml

N
O
I
T
S
E
U
Q
S?

75

k
n
a
h
T
u
o
Y