fluid therapy
TRANSCRIPT
Under the guidance of: DR. B.SHASHIDHARAN. Professor and Chief Unit-III
By, Dr. Henley Punnen Andrews
Water is the most abundant constituent in the body comprising about 50% of the body weight in women and 60% in men
1. INTRACELLULAR COMPARTMENT :
◦ Largest compartment,55 to 75% is the intracellular compartment
◦ ICF– primarily a solution of potassium and organic anions, proteins
2. EXTRACELLULAR COMPARTMENT :
◦ Fluid that is not contained inside a cell comprises the
extracellular compartment ◦ 25 to 45 % of the total body water ◦ ECF – primarily a NaCl and NaHCO3 solution
ECF
Circulating Compartment
Intravascular
(Blood Plasma)
Extravascular
(Interstitial Lymph)
Transcellular Fluid Made of CSF, Digestive Juices,
mucus etc
Considered in terms of : 1. Internal balance 2. External balance
Internal balance [flux]: ◦ This is the movement of water across the capillaries of
the body and movement of water between interstitial and intracellular fluids.
Some examples: ◦ Diffusional turnover of water in the body’s capillaries is
about 80,000 liters a day. ◦ Lymph flow is about 1 to 25 L/day. ◦ GFR is 180 L/day and majority of this is reabsorbed in
the renal tubules. ◦ Turnover of fluids in the bowel is about 8 to 9 L/day.
Name given to the interstitial fluid which enters the lymphatic vessels
Lymphatic capillaries are present in all the tissues except the CNS and bone
FUNCTIONS OF THE LYMPHATIC SYSTEM ◦ Return of protein and fluid from the interstitial space to
the circulation to maintain oncotic pressure gradient across the capillary membrane. Edema will occur if interstitial oncotic pressure is not kept low.
◦ Role in absorption and transport of fat from small intestine.
◦ Immunological role – lymph glands and circulation of immune cells.
There are about one million glomeruli in each kidney.
Glomerulus consists of a tightly coiled network of capillaries surrounded by podocytes.
Blood passes through each glomerulus filtering water and metabolic waste through capillary walls by the surrounding podocytes. The net excess in the glomerular capillaries is 180 litres per day and is known as GFR.
Fluid in the bowel is considered as part of transcellular compartment.
Around 9 – 10 liters of fluid enters the gut each day.
98% of this fluid is reabsorbed resulting in a fecal water loss of only 200 ml per day.
Reabsorbtion predominantly occurs in the jejunum and ileum with over a liter per day absorbed in the colon.
2. EXTERNAL BALANCE ◦ External balance refers to the comparison between
the water input from and the water output to the external environment. ◦ Over any period of time, input equals output and
the organism is in water balance
The afferent or sensor mechanisms which sense abnormalities in ECF volume homeostasis include the following
1. Low pressure baroreceptors i. Carotid atria ii. Great veins iii. Cardiac ventricles iv. Pulmonary capillaries
2. High pressure baroreceptors i. Carotid sinus ii. Aortic arch iii. Intrarenal(juxtaglomerular apparatus)
3. CNS osmoreceptors. 4. Intrahepatic receptors.
Exactly what is sensed by these receptors is not
completely defined.
The term ‘effective circulatory volume’ describes the factors which are sensed by these receptors. Cardiac output Arterial resistance Mean arterial pressure Blood volume Venous capacitance
OSMORECEPTORS
◦ Osmoreceptors are specialized cells in the hypothalamus.
◦ Responds to changes in extracellular tonicity.
BARORECEPTORS ◦ Regulation of arterial blood pressure is accomplished by
negative feed back system incorporated in baroreceptors.
◦ Arterial baroreceptors are located in the carotid sinus at
the bifurcation of external and internal carotids and also in the aortic arch.
◦ Carotid sinus is innervated by the sinus nerve, branch of
the glossopharyngeal nerve(9th nerve) which synapses in the brain stem.
Aortic arch baroreceptors are innervated by the aortic nerve, combines with vagus nerve and travels to the brain stem.
Aortic arch receptors are more sensitive in detecting hypovolemia while carotid sinus receptors are more sensitive in detecting hypotension.
Hence the carotid sinus receptors are the dominant arterial baroreceptors.
Receptors are sensitive to Steady or mean arterial pressure. Rate of pressure change: Decreasing the pulse
pressure decreases the baroreceptor firing rate.
Control of water input – Thirst which is mechanism for adjusting water input via the GIT.
Control of water output – ADH which provides a mechanism for adjusting water output via the kidney.
1. Molarity – it is the number of moles of solute per 1 liter of solution.
2. Molality – it is the number of moles of solute in 1000gm solvent.
m = moles solute / 1000gm solvent.
1. Normality – it is the gram equivalent of solute in 1 liter of solution.
2. Osmolarity of a solution – is the number of moles of solute per liter of solution.
3. Osmolality of a solution - is the number of osmoles of solute per kg of solvent.
PLASMA OSAMOLALITY = GLUCOSE IN MG% BLOOD UREA IN MG% 2 x PLASMA Na+ + + . (275 – 290mOSM/kg) 18 5.9
IV fluids supply two things - ◦ fluid volume ◦ electrolytes
Need for IV fluids: ◦ To expand intravascular volume acutely and produce
enough urine volume to excrete solutes. ◦ To correct an underlying imbalance in fluids or electrolytes
lost from urine, skin and gut. ◦ To supply necessary vitamins and minerals. ◦ To satisfy the calorie needs there by decreasing tissue
catabolism.
Several methods proposed to relate maintenance needs to body weight, these include: ◦ Basal calorie method based on metabolic rate. ◦ Surface area method ◦ Holliday-Segar System based on weight.
The basal calorie method requires a table and
involves most calculations.
The Surface area method also requires a table to determine surface area and ideal knowledge of patients height and weight.
The Holliday-Segar System is used most frequently because of the ease with which the formulae can be remembered.
Requirement of fluid of a 10year old boy weighing 32kg using the Holliday-Segar method (10×100) + (10×50) + (12×20)=1740 mL (10×4) + (10×2) + (12×1)=72 mL/hr
CRYSTALLOIDS-Clear solutions –fluids- made up of water & electrolyte solutions & small molecules.
◦ ADVANTAGES: Inexpensive. Easy to store with long shelf life. Readily available. Very low incidence of adverse reaction. Effective for use as replacement fluids or maintenance fluids.
◦ DISADVANTAGE: It takes approximately 2-3 x volume of a crystalloid to cause
the same intravascular expansion as a single volume of colloid.
Causes peripheral edema. Dilute plasma proteins.
CLASSIFICATION: 1) Replacement solutions 2) Maintenance solutions 3) Special Solutions
Replacement solutions: ◦ Used to replace ECF. ◦ Isotonic Solution. ◦ Solutions have Na+ similar to that of ECF. ◦ It is used to replace blood loss; 3 to 4 times the
volume lost must be administered as only 1/3 to ¼ remains intravascular after 1 hour.
◦ Solutions used are Normal Saline and lactated Ringers Solution.
◦ Ringers Lactate : Has small amounts of K+ and Lactate. Lactate is metabolized in the liver to bicarbonates and
helps if acidosis is present.
Maintenance Solutions: ◦ Used to provide maintenance fluids. ◦ They are isosmotic when administered and do not
cause haemolysis. ◦ Dextrose 5% has no Na+ so it is distributed
throughout the total body water with each compartment getting fluid in proportion to its contribution to the Total Body Water.
Special Solutions: ◦ Crystalloid solutions used for special purposes are
grouped together: Hypertonic 3% saline. Half normal saline. 8.4% bicarbonate solution. Potassium Chloride. Mannitol 20%. 25% Dextrose.
5% DEXTROSE SOLUTION ◦ Maintenance solution. ◦ Dextrose used is dextrose monohydrate. ◦ pH range is 3.6 – 6.5.
◦ Indications As a caloric nutrition to provide the patient with
carbohydrate calories. As a water supply in hypertonic dehydration cases. Correction of hypernatraemia. To increase blood sugar in cases of hypoglycemia. Hepato-protective. As an emergency fluid to prevent the risk of shock which
occurs due to sudden decrease of blood or plasma volume.
As a carrier solution for infusion of drugs- Amphotericin B, Noradrenalin, Sodium Nitroprusside, Amiodarone, Propofol.
◦ Contraindications Cerebral edema- Causes reduction of Na+ in plasma and water passes into
the brain where Na+ concentration is higher causing raised ICT.
Ischemic Brain Injury- Elevated blood sugar levels worsens ischemic brain
damage. Glucose is metabolized to lactic acid around the ischemic
area lowering the pH and exacerbating the ischemic injury.
Hyponatraemia- Provides electrolyte free water which worsens the
situation.
NORMAL SALINE (0.9% SALINE SOLUTION) ◦ Contains 9g of NaCl per liter of water. ◦ pH is 5.0 ◦ The osmolality is 308mOsm/L.
◦ Potential problems with the use of large amounts of
normal saline are: Hyperchloraemic metabolic acidosis. Development of oedema.
◦ Indications: As replacement fluids in dehydration. Useful for maintaining the daily requirement of salt
and water.
Hypovolemia. Diabetic ketoacidosis. Vehicle for most drugs. Treatment of Hypercalcaemia. Others- Bowel wash, Peritoneal lavage, to maintain
tissue hydration during bowel exposure, flushing solution for eye surgery.
HYPERTONIC SALINE SOLUTIONS ◦ Includes 1.8%, 3%, 5%, 7.5% and 10% NaCl Solutions. ◦ Hypertonic saline 3% has an osmolality of 900
mOsm/L. ◦ Fluid shifts and osmolar changes that occur are: Fluids pass from the cells into the extravascular
compartment. The ECF volume is expanded by approx 2.5L after
administering 1 liter of 3% saline. Since Na+ and Cl- cannot freely cross cell membranes,
the ECF becomes slightly hyperosmolar. Decrease in ICF volume may have effects on brain
causing confusion and mental obtundation due to cerebral cellular dehydration and hypertonicity.
Indications- ◦ In critical care- Hyponatraemic states and diuretic overuse, Excessive
losses of GI secretions, renal disease. ◦ Brain injury- Hypertonic saline resuscitation of patients with
traumatic and non traumatic brain injury may increase survival but neurological outcomes is unknown.
◦ In scleotherapy direct injection is put into a vein. ◦ Intra-amniotic use in midtrimester abortion. ◦ Volume resuscitation in hemorrhagic shock, septic
shock and major burns.
◦ Advantages; Rapid increase in intravascular volume. Relatively small intravenous fluid volumes. Decreased intracranial pressures. Small volume resuscitation prevents inflammation and
the resulting organ dysfunction.
◦ Hypertonic saline with dextran: Tested in certain studies in trauma population. Approved for use in 14 European countries. More rapid improvement of blood pressure. Improved blood flow to the brain. Decreasing pressure in the injured brain. Decreases the risk of infection and ARDS.
HARTMANN’S SOLUTION (SODIUM LACTATE) ◦ Invented by Sydney Ringer, British physiologist. ◦ pH of 6.5 ◦ Contains- Na+ -130-131 mmol/L Cl- -109-111mmol/L HCO3
- -29mmol/L K+ -5mmol/L Ca2+ -2mmol/L ◦ The Bicarbonate ions are present in solution as
lactate and later converted in the liver to bicarbonate.
Indications: ◦ Fluid resuscitation after a blood loss- Trauma, surgery or a burn injury. ◦ Used to induce urination in patients with renal
failure. ◦ Ideal maintenance fluid during and after surgery. ◦ Used in treatment of lower GI tract losses like
diarrhea induced hypovolaemia. ◦ In metabolic acidosis, it provides a glucose free
solution and used in correcting acidosis. ◦ In DKA it has the added advantage of supplying
potassium.
Contraindication: ◦ Not suitable for maintenance therapy because the
Na+ content is too high and potassium content too low, in view of electrolyte daily requirement. ◦ In hepatic insufficiency, lactated ringers solution
can precipitate lactic acidosis. ◦ In chronic heart failure, there is an associated lactic
acidosis more in myocardial tissues. ◦ In upper GI losses there is metabolic alkalosis and
lactated ringers solution provides bicarbonate which worsens the condition.
DEXTROSE SALINE SOLUTION ◦ Contains 0.9% normal saline and 5% dextrose. ◦ Normal saline rapidly corrects any ECF deficit of
both sodium and chloride while dextrose element provides energy. ◦ Distributed mainly in the extracellular compartment
and so does not correct intracellular dehydration. ◦ Since it is distributed in the extracellular
compartment, can be considered for the treatment of hypovolaemic shock.
SODIUM BICARBONATE SOLUTION ◦ 8.4% NaHCO3 solution has an osmolality of
2000mOsm/L. (7 times the plasma osmolality) ◦ Properties: Hypertonic- draws water out of cells until the ECF and
ICF tonicities are equal.
Alkalinizing load will increase the ECF HCO3 and cause metabolic alkalosis which in turn causes intracellular movement of K+ and ECF K+ will decrease. Hence used in the emergency treatment of Hyperkalemia.
Recommended for emergency treatment of acute hyponatraemia.
HYPERTONIC MANNITOL SOLUTIONS ◦ Mannitol is a six carbon sugar alcohol prepared by the
reduction of dextrose. ◦ Occurs naturally in fruits and vegetables. ◦ Odorless, sweet tasting, white, crystalline powder with a
melting range of 165° - 168°C.
◦ Actions: Intracellular dehydration. Expansion of ECF volume (except brain ECF) Haemodilution. Decreased blood viscosity with improved tissue blood flow. Cardiovascular effects secondary to expanded intravascular
volume( increased cardiac output, hypertension, heart failure, pulmonary edema)
Cerebral effects: ◦ Mannitol does not cross the blood brain barrier and is
effective in removing fluid from the brain. This is called mannitol osmotherapy.
◦ Mannitol infusions are used to rapidly decrease elevated ICP due to an intracranial SOL.
◦ The affect is rapid in onset but only temporary (as mannitol is excreted) but buys time for urgent definitive therapy.
◦ Repeated doses of mannitol have less effect. Prolonged use decreases the osmotic effect as mannitol molecule eventually crosses into the cerebral interstitium. Rebound intracranial hypertension is a risk.
Contraindications ◦ Anuria secondary to renal disease. ◦ Severe dehydration. ◦ Severe pulmonary congestion or pulmonary
oedema.
Mannitol therapy to be stopped if following develop during mannitol therapy: ◦ Progressive Heart failure ◦ Pulmonary congestion ◦ Progressive renal failure or damage.
Adverse Effects: ◦ Fluid and electrolyte imbalances. Adequate
monitoring and support is required. ◦ GI-nausea and vomiting. ◦ Cardiovascular-Pulmonary Edema, Congestive Heart
failure. ◦ CNS Effects- dizziness, headache, etc.
Colloids are large molecular weight solutions (nominally MW > 30,000 daltons).
These solutes are macormolecular substances made of gelatinous solutions which have particles suspended in solution and do NOT readily cross semi-permeable membranes or form sediments.
Because of their high osmolarities, these are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries.
These work well in reducing edema because they draw fluid from the interstitial and intracellular compartments into the vascular compartments.
Initially these fluids stay almost entirely in the intravascular space for a prolonged period of time compared to crystalloids.
Advantages of Colloids: ◦ ↑ plasma volume. ◦ Less peripheral edema. ◦ Smaller volumes for resuscitation. ◦ Intravascular half-life 3-6 hrs .
General ◦ Distributed to intravascular compartment only. ◦ Readily available. ◦ Long shelf life. ◦ Inexpensive. ◦ No special storage or infusion requirements. ◦ No special limitations on volume that can be infused. ◦ No interference with blood grouping or cross matching.
Physical Properties ◦ Iso-oncotic with plasma ◦ Isotonic ◦ Low viscosity ◦ Contamination easy to detect.
Pharmacokinetic properties ◦ Half life should be 6 to 12 hrs. ◦ Should be metabolized or excreted and not stored
in the body. Toxicity and other adverse effects on body
systems. ◦ No interference with organ function even with
repeated administration. ◦ Non-pyrogenic, non-allerginic and non-antigenic. ◦ Should not cause agglutination or damage blood
cells. ◦ Should not cause acid base disorders or promote
infection.
Types: ◦ Natural colloid- Human serum albumin (5%, 25%) ◦ Synthetic colloids- Dextrans Gelatins Starches Hydroxyethyl starch (HES) Pentastarch
Used for many years as 1st line colloid for volume expansion.
Properties ◦ It is a single polypeptide consisting of 585 amino
acids. ◦ MW is 66,248 D. ◦ Albumin is an intravascular protein and stays within
the intravascular space unless the capillary permeability is abnormal. ◦ Expands volume 5 times its own volume in
30minutes. ◦ Synthesis is increased by thyroxine, insulin or
cortisol.
Side effects: ◦ Volume overload. ◦ Fever due to pyrogens in albumin. ◦ Rise in colloid oncotic pressure impairs renal salt
and water excretion. Indications: ◦ Emergency treatment of shock. ◦ Acute management of burns. ◦ Hypoproteinemia.
Dextrans are highly branched polysaccharide molecules available for use as artificial colloids.
Synthesised using bacterial enzyme dextran sucrase from the bacterium Leuconostoc mesenteroides grown in a sucrose medium.
Formulations available are- Dextran 40 and Dextran 70.
Properties: ◦ Available as a 10% solution in NS or D5%. ◦ pH-4.5-5.7. ◦ Excretion is through urine, faeces and RE system. ◦ Dextran 40 is the commonly used dextrans and induce a
marked increase in plasma volume.
Side effects: ◦ Clotting deficits. Defects in platlet interaction. Dilution of fibrinogen. ◦ Interference with cross matching so the lab must be
informed that dextrans have been used. ◦ Dextrans cause more severe anaphylactic reactions
than the gelatins or the starches. ◦ Renal failure: in patients with pre-existing kidney
disease.
Gelatine is the name give to large MW
polydisperse proteins formed from the hydrolysis of collagen.
Obtained from boiling the connective tissues of animals.
Currently used gelatine solutions: ◦ Succinylated fluid gelatins(e.g., Gelofusine) ◦ Modified fluid gelatins(e.g.,Plasmagel) ◦ Urea-cross linked gelatins(e.g.,Haemaccel, Polygeline) ◦ Oxy-poly-gelatins.
Indications: ◦ Replacement of intravascular volume.
Advantages ◦ Lower infusion volume as compared to crystalloids. ◦ Cheaper and more readily available than plasma
proteins solutions. ◦ Readily excreted by renal mechanisms. ◦ Long shelf-life, no refrigeration. ◦ No interference with blood cross-matching.
Disadvantages ◦ Higher cost than crystalloids. ◦ Anaphylactoid reactions can occur.
These polydisperse colloid solutions are produced from amylopectin(obtained from maize) which is stabilized by hydroxyl-ethylation to prevent rapid hydrolysis by amylase.
Contraindications ◦ Known hypersensitivity to hydroxyethylstarch ◦ Bleeding disorders. ◦ Congestive Heart Failure. ◦ Renal disease with oliguria or anuria.
Side-effects: ◦ Hypersensitivity.
◦ Anaphylactic reactions.
◦ Pentastarch has been shown to be embryocidal in
rabbits and mice. ◦ Headache, Diarrhoea, nausea, weakness, temporary
weight gain, insomnia, fatigue, fever, oedema, acne, malaise, dizziness, chestpain, chills, nasal congestion and increased heart rate have also been reported in clinical studies involving pentastarch.
Crystalloids need to be administered in volume 3times greater than colloids due to propensity of leakage into the extra vascular space.
Colloids offer the advantage of enhancing oxygen consumption to a greater extent than crystalloids.
Crystalloids are first line fluids for haemodynamically stable patient but colloids are preferred in haemodynamically compromised patients.
Hypovolaemic patients with normal pulmonary function, the use of colloids maintain colloid osmotic pressure and limit the development of pulmonary oedema under elevated hydrostatic pressure.
Infection: ◦ Any break in the skin carries a risk of infection. Although
IV insertion is a sterile procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter.
Phlebitis: ◦ Phlebitis is irritation of a vein that is not caused by
infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given.
Infiltration: ◦ Infiltration occurs when an IV fluid accidentally enters
the surronding tissue rather than the vein. It is characterized by coolness and pallor to the skin as well as local edema.
Fluid overload: ◦ This occurs when fluids are given at a higher rate or in a
larger volume than the system can absorb or excrete.
Electrolyte imbalance: ◦ Administering a too-dilute or too-concentrated solution
can disrupt the patient's balance of sodium, potassium, magnesium, and other electrolytes.
Embolism: ◦ A blood clot or other solid mass, as well as an air
bubble, can be delivered into the circulation through an IV and end up blocking a vessel.
Extravasation: ◦ Extravasation is the accidental administration of IV
infused medicinal drugs into the surrounding tissue.
Sodium imbalances
Definition
Risk factors/ etiology
Clinical manifestation
Laboratory findings
management
Hyponatr -aemia
It is defined as a plasma sodium level below 135 mEq/ L
Kidney diseases Adrenal insufficiency Gastrointestinal losses Use of diuretics (especially with along with low sodium diet) Metabolic acidosis
•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 •Personality change
•Serum sodium less than 135mEq/ L • serum osmolality less than 280mOsm/kg
•Identify the cause and treat *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,Ringer’s lactate solution or isotonic saline [0.9%Nacl]is given *For very low sodium 0.3%Nacl may be indicated *water restriction in case of hypervolaemia
Sodium imbalan -ce
Definition
causes
Clinical manifestation
Lab findings
management
Hypernat -remia
It is defined as plasma sodium level greater than 145mE q/L
*Ingestion of large amount of concentrated salts *Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion
• Low grade fever • Postural hypertension •Dry tongue & mucous membrane •Agitation • Convulsions •Restlessness •Excitability •Oliguria or anuria •Thirst •Dry &flushed skin
*high serum sodium 135mEq/L *high serum osmolality >295mOsm/kg
*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 *Dietary restriction of sodium in high risk clients
Potassium imbalances
Definition
Causes
Clinical manifestation
Lab findings
Management
Hypokalemia
It is defined as plasma potassium level of less than 3.0 mEq/L
*Use of potassium wasting diuretic *diarrhea, vomiting or other GI losses *Alkalosis *Cushing’s syndrome *Polyuria *Extreme sweating *excessive use of potassium free Ivs
*weak irregular pulse *shallow respiration *hypotesion *weakness, decreased bowel sounds, heart blocks , paresthesia, fatigue, decreased muscle tone intestinal obstruction
* K – less than 3mEq/L results in ST depression , flat T wave, taller U wave * K – less than 2mEq/L cause widened QRS, depressed ST, inverted T wave
Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement
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]
Definition
Causes
Clinical manifestation
Lab findings
Management
Hyperkalemia
It is defined as the elevation of potassium level above 5.0mEq/L
Renal failure , Hypertonic dehydration, Burns& trauma Large amount of IV administration of potassium, Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood
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] given orally.
Calcium imbalances
Definition
Causes
Clinical manifestation
Lab findings
Management
hypocalcemia
It is a plasma calcium level below 8.5 mg/dl
•Rapid administration of blood containing citrate,
•hypoalbuminemia,
•Hypothyroidism •Vitamin deficiency,
•neoplastic diseases,
•pancreatitis
•Numbness and tingling sensation of fingers,
•hyperactive reflexes, • Positve Trousseau’s sign, positive chvostek’s sign ,
•muscle cramps,
•pathological fractures,
•prolonged bleeding time
Serum calcium less than 4.3 mEq/L and ECG changes
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
Calcium imbalance
Definition
Causes
Clinical manifestation
Lab findings
Management
Hypercalcemia
It is calcium plasma level over 5.5 mEq/l or 11mg/dl
•Metastatic bone tumors, •paget’s disease,
•osteoporosis
•prolonged immobalisation
•Decreased muscle tone,
•anorexia, •nausea, vomiting,
•weakness , lethargy, •low back pain from kidney stones,
•decreased level of consciousness & cardiac arrest
•High serum calcium level 5.5mEq/L,
• x- ray showing generalized osteoporosis,
•widened bone cavitation,
•urinary stones,
•elevated BUN 25mg/100ml
•elevated creatinine1.5mg/100ml
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
REFERENCES ◦ Fluid Therapy by, Rashmi Datta 2008. ◦ Harrisons Book of Internal Medicine, 18Edition. ◦ McGraw-Hill - CURRENT Medical Diagnosis &
Treatment 2010. 49th Edition.