# Definition of Fluid Electrolytes Management - PowerPoint

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```					  Fluids &
Electrolytes
Scott G. Sagraves, MD, FACS
Assistant Professor
Trauma & Surgical Critical Care
The recognition and
management of fluid,
electrolyte, and related
acid-base problems are
common challenges on the
surgical service.

Lawrence, Essentials of General Surgery
Goals
• Review concept of total body fluids

• Review types of crystalloids

• Review electrolytes disturbances & their
treatment strategies.
Body Fluids

16%

Intercellular
Intravascular
40%         Interstitial
4%

Body Water = 60% of a patient’s body weight
Why do you give
D5½NS + 20 mEq/L KCl
at 125 cc/hr to a
patient?
Fluid Requirements
• typically 35 mL/kg/day
• insensible loss = 700 mL/day or 0.2
cc/kg/day for every 1° C > 37°
• 1-10 kg = 100 mL/kg/day {4mL/kg/hr}
• 11-20 kg = 50 mL/kg/day {2mL/kg/hr}
• > 21 kg = 20 mL/kg/day {1mL/kg/hr}

Trick for hourly maintenance = 40 + weight (kg)
Serum Values of
Electrolytes
Cations      Concentration, mEq/L
Sodium                 135 - 145
Potassium               3.5 - 4.5
Calcium                 4.0 - 5.5
Magnesium               1.5 - 2.5
Anions
Chloride                95 - 105
CO2                      24 - 30
Phosphate               2.5 - 4.5
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
IV Solutions
Solution    Na+   Cl-    K+    Ca+2 HCO3- Glu

Plasma      141   103    4-5   5     26        0

NS          154   154    0     0     0         0

D5W         0     0      0     0     0         50 G

LR          130   109    4     3     28        0

Serum Osmolality = [2 x Na] + [BUN/2.8] + [glucose/18]
Replacement Strategies

•   Sweat: D5¼NS + 5 mEq KCl/L
•   Gastric: D5½NS + 20 mEq KCl/L
•   Biliary/pancreatic: LR
•   Small Bowel: LR
•   Colon: LR
•   3rd space losses: LR
Resuscitation
• Crystalloids
• Replace blood loss at a 3:1 ratio
• Initial bolus 1-2 liters, usually normal
saline

• If they have transient response, give
additional fluids. Once 3-4 liters of
crystalloid has been given consider
blood.
INDICATORS OF SUCCESSFUL
RESUSCITATION
• PULSE 100 - 120 bpm
• URINARY OUTPUT
– CHILDREN = 1.0 ml/kg/hr
• Clearance of lactate
• Resolution of base deficit

• BLOOD PRESSURE POOR
INDICATOR
Fluid Status
Hypothyroid
120   GI loss       Cortisol
CHF
Cirrhosis

140                  140
[Na]

GI Loss                   NaHCO3
160   Renal loss        DI       3% NaCl
Osmotic      Insensible   Seawater

low         normal       high
ECV
Renal Regulatory
Mechanisms
• Aldosterone
– distal tubules
– sodium exchanged for K+ and H+
– released by volume reduction

– increased tubular water reabsorption
– posterior pituitary release
Acid/base
Respiratory         Metabolic
Acidosis           Alkalosis

BE = 0
HCO3 = 24

Metabolic           Respiratory
Acidosis             Alkalosis

7.4
ABG Rules
• Rule 1: An increase or decrease in
PaCO2 of 10 mm Hg, respectively, is
associated with a reciprocal decrease or
increase of 0.08 pH units.

• Rule 2: An increase or decrease in
[HCO3-] or 10 mEq/L respectively is
associated with a directly related
increase or decrease of 0.15 pH units.
Acidosis
• pH < 7.2
– decreased responsiveness to catecholamines
– cardiac dysfunction
– arrhythmias
– increased potassium serum levels
Case Studies
“Found Down”
• 45 yo WM, found down, presumed to be
assaulted, well known to ED for EtOH
• CT head - hygromas, small ICH
• labs:
– Na = 118
– K = 2.4
– Cl = 74

What do you think? What do you do?
Severe Hyponatremia
• Correct sodium to above 120 mEq/dl
– NaCl + 40 mEq/L KCl
– 3% Saline
– furosemide diuresis (euvolemic)
– serial electrolytes
– be prepared to handle seizures
• Replace potassium
• Cl should correct itself
Hyponatremia
• 1% of hospitalized are hyponatremic
• Neurologic conditions:
– Seizures, coma, encephalopathy
– Results from rapid  [Na]

• Peripheral symptoms:
– Cramping, twitches, fasciculations
– Results from ion conduction aberrations
Hints…
• Na+ deficit (mEq) =
(140 – Naserum) x 0.6 x Kg

• Glucose increase 100 mg/dL or a BUN
increase of 30 mg/dL  decrease of 1.5
– 2 mEq/L Sodium
Central Pontine
Myelinosis
• Results from overcorrection of
sodium
• Correction of > 25 mEq per 24-48 hrs
• Concurrent hypoxia
• Presence of liver disease
• Acute correction limit 25 mEq /day
• Chronic correction limit 10 mEq/day
Treatment Strategies
• Hypovolemic Hyponatremia
– expand intravascular volume
• 0.9% NS or 3% Hypertonic Saline
• Hypervolemic Hyponatremia
– water restriction
– treat medical condition
– hemodialysis
• Euvolemic Hyponatremia
• restrict fluid: 7-10 ml/kg/d
• demeclocycline antagonizes vasopressin
HDU Code

A Code Blue is called in the HDU.

65 yo male with ESRD has “arrested”
awaiting his dialysis treatment. CPR and
BVM resuscitation are in progress and an
IV has been established.

What do you think? What do you do?
Pre-Arrest Rhythm Strip
“Arrest” Strip
Diagnosis?
HYPERKALEMIA
Treatment
 CaCl2 10% - 1 ampule
 Sodium Bicarbonate - 1 ampule
 D50 & Insulin 10 U
 2 - agonist nebulizer- cellular K 
 Kayexalate®
Causes of
Hyperkalemia
•   Renal dysfunction     • Cell Death
•   Acidemia                –   Rhabdomyolysis
•   Hypoaldosteronism       –   Tumor lysis
–   Burns
•   Drugs
–   Hemolysis
•   Excessive intake
•   WBC > 100,000
•   Platelets > 600,000
Potassium Metabolism
•   Normal daily intake 100 mEq
•   Renal filters & reabsorbs prox. Tubule
•   Potassium  1/[aldosterone]
•   Acidosis  [potassium] with H+ out
•   Alkalosis  [potassium] with H+ in
Post op patient
• 42 year old female admitted to the ICU
post op after undergoing a
thyroidectomy for thyroid cancer.

• She is complaining of peri-oral
numbness and tingling. Her DTRs are
hyperactive and her ECG has a
prolonged QT interval.

What do you think? What do you do?
HYPOCALCEMIA
• Chvostek’s sign - facial muscle spasm
• Trousseau’s sign - carpal spasm
• Treatment
– monitor ECG
– IV calcium
– oral calcium supplements
• normal is 1 gram/day
Blunt Trauma
• 23 year old male, s/p MVC with blunt
abdominal and orthopedic trauma

• HD#3 develops fever, N/V, abdominal
pain, refractory hypotension, with
oliguria.

• Na+ 130, K- 5.5, Glu 65, pH 7.29

What do you think? What do you do?
INSUFFICIENCY
• Treatment
– fluid and vasopressor support
– treat precipitating conditions
– draw baseline cortisol level
– ACTH stimulation test
– hydrocortisone 100 mg IV q 8
Hydrocortisone Stimulation
Test
• Baseline cortisol
– > 20 - no further therapy
– 15 - 20 - test
– < 15 empiric therapy

• Administer Cortrosyn 250 g IV
• Obtain levels 30 & 60 minutes post
injection
You are called to the
Bedside…
• 55 yo male, s/p fall with isolated,
repaired fractured femur.

• Pt’s LOC decreased and patient began
to seize.

• EKG showed…
What Do You Think? What Do You Do?
Hypomagnesemia
• Mg plays role in energy metabolism,
protein synthesis, cell division, &
calcium regulation in muscle.

• Definition < 1.6 mg/dL

• Causes: poor diet, diuretics, gut losses,
& massive diarrhea, resuscitation.
Mg Rx
• Replacement Magnesium Sulfate
– 1 gram = 8 mEq
– Infuse at rate of 2 gram/hour
– Emergency: 2 grams over 5
minutes
• 32 year old female, MVC, GCS -7,
intubated, with CT scan showing SAH,
cerebral edema. ICP monitor shows a
pressure of 27. CPP 55.

• Over the next several days, Na+ > 150.

What do you think? What do you do?
DIABETES INSIPIDUS
• Signs
– [Na+]  150
– Urine specific gravity 1.007
– polyuria, clear urine
– dDAVP 1g sq raises urine osmolality in 2 hours
• Treatment
– free water deficit = (0.6) x (Kg) x ([Naserum/140] -1)
– dDAVP 2g sq every 12 hours
– for every L water deficit [Na+] will rise 3 mEq
above 140
The transfer
• 50 year old obese female, transferred for
critical care management after a bowel
resection. Presents with obtundation,
hypotension, tachypnea, and emesis.

• C/O abdominal pain and has fruity breath

• amylase, lipase are elevated, Na+ 127

What do you think? What do you do?
Work up?
•   ABG
•   Electrolyte panel
•   urine analysis
•   CBC
•   Serum Ketones
Hyperglycemia
Characteristic         DKA                NKHC
Glucose                400-800            > 1000
Acidosis               Severe             min.
Ketones                High               low
Dehydration            Mod.               High

Na  1.6 for every 100  glucose above 200
Treatment
– narrowing of anion gap
– crystalloids: LR, NS, ½ NS

• Insulin
– bolus 0.1 - 0.5 units/kg
– infusion 0.1 units/kg/hour
– goal reduce plasma glucose 75-100 mg/dL/hr

• Electrolytes
– K replacement 10-20 mEq/hour after UOP OK
– Mg, PO4 replacement
The drunk
• 37 year old male, h/o EtOH abuse fell from a
deer hunting tree stand. C5 fracture without
cord involvement.

• HD #2 develops delirium tremors moved from
SIU to ICU. Librium started.

• HD#4, dobhoff placed and tube feeds started.
That night, the patient’s respiratory status
worsens and he is intubated.

What do you think? What do you do?
HYPOPHOSPHATEMIA
• “Refeeding Syndrome”
– malnutrition
– alcoholism

• Hypophosphatemia
– immunocompromise
– muscle weakness  failure to wean
Treatment
• IV supplementation in emergent cases
– sodium or potassium phosphorous

• PO supplementation routinely

• Keep (phosphorous x calcium) ratio <
60

• Magnesium should be replenished
simultaneously
The burn patient
25 year male, caught fire after his
lawnmower exploded as he was filling it
with gasoline while smoking a cigarette.

The patient sustained second and third
degree burns estimated at 40 % total
body surface area.
Parkland Formula
4 cc x WEIGHT (kg) x (% TBSA)
Parkland Example
• 25 year old male
• weight = 220 pounds
• 40% TBSA 2° - 3° burns

• How much fluid do you need to give?
– During the first 8 hours?
– During the next 16 hours?
Parkland Example
4 cc x weight x %TBSA

4 x 100 x 40 = 16,000 cc/24 hours

first 8 hours = 16,000/2 =8,000/8 = 1,000cc/hr

next 16 hours = 8,000/16 = 500cc/hr
Diarrhea Dysrhythmia
• 68 yo female on digoxin for chronic
CHF, presents to the SIU for colitis as
evidenced by copious diarrhea.

• The patient is weak and lethargic and
ectopic beats are noted on her ECG.

What do you think? What do you do?
Hypokalemia
• Deficits
– Serum K =
• 3-4 is a 100-200 mEq deficit
• 2-3 is a 200-400 mEq deficit
• Treatment
– replacement 10 mEq/hr via peripheral IV
– 10 mEq  0.1 mEq/L increase in serum K
– Remember to check the Mg level too
• A rule:  0.1 pH   0.4 - 0.5 mEq [K+]

• pathophysiology
– loss of K, severe alkalosis, [Na+] load
– hydrogen exchanged for K
– independent of alkalosis remaining

• requires emergent replacement
Cancer
• 72 yo female with stage 4, metastatic
breast cancer.
• Patient is confused, cachetic, and
nauseated
• Na+= 147, Ca+2 = 14mg/dl

What do you think? What do you do?
HYPERCALCEMIA
• Cancers associated    • Treatment
with hypercalcemia      – hydration
– bone                  – diuretics-lasix
– breast                – mithramycin
– kidney                – corticosteroids
– colon                 – calcitonin-
– thyroid                 osteoclast
– multiple melanoma       resorption
– phosphate
Labor and Delivery

32 year old P3G3 being treated by OB
for eclampsia. You are called for a
somnolent patient in second-degree
heart block and paralysis.

What do you think? What do you do?
Hypermagnesemia
• Signs
– Prolonged PR interval
– Hypotension, hyporeflexia, paralysis

• Treatment
– Calcium gluconate
– Normal saline
– Loop diuretics
– dialysis
Questions?

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