fluid therapy and electrolite

8/11/2019 Fluid Therapy and Electrolite

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Fluid therapyand electrolite


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TBW = 60% BB


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Fluid composition differs between

compartments


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Starlings equation

Qf= Kf [(Pc-Pi) d(c-i)]


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Microvascular fluid exchange


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Hydrostatic and oncotic pressure


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Resuscitation Maintenance

NutritionCristalloid

Replace acute losses(hemorrhage,

GI loss, 3 rdspace)

1. Normal requirement(IWL + urine + feses)

2. Nutritional support

Fluid therapy

Colloid Elektrolite

Repair


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Crystalloids


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Colloid

High molecular weight substance that

largely remain in the intravascular

compartment, thereby generating anoncotic pressure. To have a greater

intravascular persistence when

compare to cristalloids


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Colloid


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Advantages


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Disadvantages


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Sodium

The main determinant of ECF osmolality

The body fluid osmolality is 285 295

mOsm/kgCalculated ECF osmolality is

2 x Na + glucose / 18


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Hypernatremia

Na > 145 mmol / L

Hypertonicity and absolute or relative

water deficitNeurologic effect ( altered mental status,

coma and seizure )


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Caused

Hypovolemic hypernatremia

Loss of hypotonic fluids

Euvolemic hypernatremiaNet loss of free water

Hypervolemic hypernatremia

Gain of hypertonic fluid


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Treatment

In hypovolemic replace volume deficit

with isotonic saline then correct hyper

Na with hypotonic fluids ( 0,45 % NaCl or

D5W ) In hypervolemic, enhance removal of

excess Na with loop diuretic

Correction < 0.5 mmol/hr for chronic and

< 1 mmol/hr for acute, and no more than10 mmol for 24 hrs


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Current TBW x current Na = normal TBW x normal Na

Current TBW = normal TBW x ( 140 / current Na )

TBW deficit = normal TBW current TBW

= 0.6 BB current TBW

= ( 0.6 BB ) ( 1 140 / current Na )

Treat underlying disease


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Hyponatremia

Na < 135 mmol / L

Pseudo hyponatremia : normal or

increase plasma osmolality True hyponatremia : increase free water

relative to sodium


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Treatment

1. Low ECFAsymptomatic : isotonic saline

Symptomatic : Hypertonic saline

2. Normal ECF

Asymptomatic : furosemide + isotonicsaline

Symptomatic : furosemide + hypertonicsaline

3. High ECF

Asymptomatic : furosemide

Symptomatic : furosemide + hypertonic

saline


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Na deficit = TBW x ( desired Na current Na )= ( 0.6 BB ) ( 130 current Na )

3% NaCl = 513 mmol Na0.9% NaCl = 154 mmol Na


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Potassium

Predominant intracellular

< 2% potassium in the ECF fluid


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Hypokalemia

T inverted, U wave, atrial and ventricular

arrhythmias

Muscle weakness, ileus and paralysis

Nefrogenic DI


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Treatment

Potassium replacement are hyperosmolar

and should preferable through CVC

Replacement rate 10 30 mEq/hr diluted in

100 200 ml NS/D5%


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Hyperkalemia

Tall peaked T wave, prolonged PR

interval, flattened P wave, Widened QRS

complex, VT, VF and cardiac arrestNeuromuscular weakness, areflexia,

paralysis and paresthesia


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Treatment

IV Ca gluconate or CaCl2 10 20 ml in 5

minutes

IV Dextrose 50% 50 ml + IV 5 10 U

regular insulin in 10 minutes

IV NaHCO350 100 meq in 10 minutes

Hemodialysis / CRRT


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Calcium

In extracellular, calcium is free or bound

to albumin

The ionized ( free ) is biologically active

Acidosis decreases bindingAlkalosis increases binding


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Hypercalcemia

Mental manifestation vary from stupor to

coma

Neurologic effects ( redices muscle tone

and reflexes ) Vomiting, polyuria, polydipsia and

constipation

Arrhythmias


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Treatment

Hydration to achieve urine 3 5 L / day

Furosemide

Calcitonin

Biphosphonates


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Hypocalcemia

Neurologic manifestations include

hyperreflexia and tetany


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Treatment

Ca gluconate or Ca chloride 10 ml in 50

ml Dx 5% over 10 min

Infusion of 1 2 mg calcium / kg / hour

until ionized calcium is 4.5 mg / dL ortotal calcium is 7 mg / dL

Vitamin D


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Magnesium

Free form 70%, 30% bound to albumin

Magnesium level depend on intestinal

absorption and renal excretion


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Hypermagnesemia

Decreased reflexes, flaccid paralysis,

stupor and coma

Most common caused is renal failure

and aggravated use of magnesium


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Treatment

Dialysis when renal function is impaired

Diuretic to increased urine production

Ca gluconate 10 ml in 50 ml Dx 5% over

10 minutes


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Hypomagnesemia

Secondary effect of hypocalcemia. Lowmagnesium impairs PTH secretion which

result in hypocalcemia


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Treatment

1 2 gr MgSO4 over 5 10 minutes

Can be followed by infusion 1 5 gr over

4 6 hours.


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fluid therapy and electrolite

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