Fluid and electrolyte 29 jun
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Transcript of Fluid and electrolyte 29 jun
Presented by: Dr. Mohd Anuar Bin Awang
Dr. Ainin Tasneem Bt Abdul Rafa
Supervised by:Dr. Norhafiza Bt Ab Rahman
1st July 2014
CONTENT
• Introduction• Fluid compartments & distribution• Principle of fluid therapy• Common electrolytes imbalance, causes &
management• Take home messages• References
INTRODUCTION
• Water & electrolyte balance is crucial for body hemostasis & is one of the most protected physiological mechanism in body• A critical role of kidney is to maintain circulating
volume, plasma osmolality & electrolyte hemostasis within relatively narrow limit• Changes in both fluid volume & electrolyte
composition occur preoperatively, intraoperatively & postoperatively, as well response to trauma or sepsis
MOHD ANUAR
FLUID
TOTAL BODY WATER
• Varies with age, gender and body habitus
FLUID COMPARTMENTS
Total body water (TBW)(70kg man )
42L
ECF1/3 of TBW
14 L
ICF2/3 of TBW
28L
Interstitial fluid¾ of ECF
11 L
Plasma¼ of ECF
3L
TBW =0.6X Body Weight
BODY FLUID COMPOSITION
FLUID EXCHANGE
Volume Composition
Disturbance in Fluid Balance
HypovolumiaHypervolumia
SodiumPotassiumCalcium
MagnesiumPhosphate
FLUID THERAPY
PRINCIPLE OF FLUID THERAPY
1. Correction of existing fluid abnormalities • Fluid resuscitation
• Sepsis (sepsis bundle) – 30 ml/kg• Burn = TBSA(%) x 4 x body weight (kg) – Parkland’s
formula
2. Maintenance of daily requirement• Normal ongoing loss – Sensible & insensible3. Replacement of ongoing abnormal losses4. Reassess the patient ( clinical and laboratory
parameter eg. blood pressure, urine output, central venous pressure )
FLUID MAINTENANCE
100/50/10 rule
•100ml/kg for first 10kg•50ml/kg for next 10kg
•20ml/kg for every kg (divided by 24 for hourly rate)
4/2/1 rule
• 4 ml/kg/H for the first 10kg
• 2 ml/kg/H for next 10kg• 1 ml/kg/H every kg
(total is according to/H)
Average: 30-40 ml/kg/day
CASE ILLUSTRATION
• Mr X is a 50 year old man with weight of 70 kg. He has no known comorbids. He was electively admitted for inguinal repair for reducible right inguinal hernia. He was planned to be kept NBM by 12 midnight.
1) HOW TO CALCULATE FOR FLUID MAINTENANCE FOR HIM?
Using 100/50/20 formula:
•100 x 10kg =1000 ml•50 x 10 kg = 500 ml•20 x 50 kg = 1000 ml
Total = 2500 ml
Using 4/2/1 formula:•4 x 10kg =40 ml/H•2 x 10 kg = 20 ml/H•1 x 50 kg = 50 ml/H
Total 110 ml/H x 24 H = 2640 ml
Using average 35 ml/kg/day: 2450 ml
≈ 5 pints
What type of fluid to give?
To be continued……………….
ROUTE OF ADMINISTRATION
• Enteral• Parenteral
• Crystalloids• Colloids• Blood products
CRYSTALLOID COLLOID
DEFINITION Balanced salt solution, administered intravenously
Plasma expander containing larger insoluble molecules
ADVANTAGES • Cheaper • Easily available• More shelf life• Not disturb coagulation
• Less risk of APO• Ratio of replacement 1:1
DISADVANTAGES • Ratio replacement 1:3• More risk of APO
• Expensive• Disturb coagulopathy
CRYSTALLOID
1) Hypotonic• HS , 1/5 NSD5, 2) Isotonic• NS, HM, D5%3)Hypertonic• D10%, mannitol, 3% NS, NSD5
SODIUM CHLORIDE 0.9%(NORMAL SALINE)
• Isotonic solution (150mmol Na + 150 mmol Cl per litre)• Useful for resuscitation• Potential risk of
hyperchloraemic metabolic acidosis & hypernatraemia where large volume are administered
HARTMANN’S SOLUTION
• Contains Na, K, Ca, Cl & lactate• Most physiological
especially when large volume are required• Useful in resuscitation of
burn patient• However contains
excessive Na, lower level of Cl & can cause metabolic acidosis if being use as the sole fluid
DEXTROSE 5%
• Isotonic solution - No electrolytes• 50 g/L of glucose• Provide modest calories
(1L - 200kcal)• Rapidly metabolized &
distribute evenly throughout the all compartments
COLLOID
• Gelatin based• E.g Gelafundin
• Starch based• E.g. Voluven
AININ TASNEEM
ELECTROLYTES
SODIUM
SODIUM
•Normal requirements: 1 - 2 mmol/kg/day•Normal level: 135 – 145 mmol/L• The major cation of the ECF & therefore the osmotic pressure is governed by sodium concentration
HYPONATREMIA
• Vomiting, diarrhea,• burn• bowel obstruction • third space loss • diuretics• dilutional
related to brain cell swelling •Mild Asymptomatic •Moderate Restlessness, confusion,altered mental state
•Severe Seizure,coma
CAUSESCLINICAL
FEATURES
• Rapid correction of Na may cause central pontine myelinolysis; < 10 mmol/24H for chronic
• Correct Na fast (3mmol/L for first 3 hour) for acute
• Modality of treatment 3% NaCl = 513 mmol/L
0.9 % NaCl = 154 mmol/L
• Change in Se Na=‘Infusate Na – Serum Na
(TBW+1)
• Bolus of 100 ml of 3% hypertonic saline which generally raise serum sodium level by 2-3 mmol/L
MANAGEMENT OF HYPONATREMIA
HYPERNATREMIA
CAUSES
Inadequate water intake, Vomiting,
diarhea, Excessive sweating, diuretics,
salt ingestion,
CLINICAL FEATURES
related with cerebral dehydration; Tremor , irritability, dizziness, weakness , mental confusion, coma
MANAGEMENT
Target fall in serum Na concentration of 10
mmol/L/day Modality of treatment: D5% = 0 mmol/L of
sodium 0.45 % NaCl =77 mmol/L of sodium
POTASSIUM
POTASSIUM
• Requirements : 0.5 – 1 mmol/kg/day•Normal level : 3.5 – 5 mmol/L• Potassium is the main cation within the cell• Its high concentration in cell is being maintained by the Na-K ATPase pump
HYPOKALEMIA
• vomiting,• diarhea • Ileostomy • Sweating• Burn• insulin
treatment• beta agonist• Alkalosis• leucocytosis
K < 2.5 mmol/L
Neuromuscular - weakness - cramps, - paraesthesia - paralysis Gastrointestinal - Constipation- ileusCVS – Arrythmias; AF, VT, VF, Heart block
CAUSESCLINICAL
FEATURES
Oral therapy (K > 2.5 mmol/L):- Mist KCl 15 ml TDS - T. Slow K (1 tablet = 600mg = 8 mmol/L) IV therapy (K < 2.5 mmol/L), ECG changes, symptomatic, unable to take orally:IV KCl, rate: <20 mmol/hr
Fast correction1g KCL in 100cc NS over 1 H
1 g K = 13.3 mmol
K deficit:(Desired value – Patient’s value) x body wt (in kg) x 0.4
13.3K maintainance:
Body weight (in kg) 13.3
Done under cardiac monitoring
MANAGEMENT OF
HYPOKALEMIA
HYPERKALEMIA
• Acidosis• insulin
deficiency• Intravascular
haemolysis• tumour lysis
syndrome• crush injury
Usually occur when K > 6.5 mmol/L
Neuromuscular: Weakness, paraesthesia, areflexia, ascending paralysis
Cardiac: Bradycardia, prolongation of AV conduction, complete heart block, wide complex tachycardia, ventricular fibrillation, assystole
CAUSESCLINICAL
FEATURES
Severe lytic coctail-10 mls 10% IV calcium gluconate- 50 mls IVD50% (30 – 60mins)- 10U rapid acting insulin-Then, maintain with D5%
IV salbutamol 0.5 mgSodium Bicarbonate infusionDialysis
MANAGEMENT OF
HYPERKALEMIA
CASE ILLUSTRATION
• Remember Mr X? Overnight, he started to complaint of pain over affected site with persistent vomiting. His blood investigations were repeated & he was reassessed again.
2) He was put on NBM. What fluid regime to start?
• Fluid maintenance =(100 x 10) + (50 x 10) + (20 x 50) = 2500 ml
• Na maintenance = 1-2 mmol/kg = 70-140 mmol/day
• K maintenance = 0.5-1 mmol/kg = 35-70 mmol/day• Therefore =
• 2 pints NS (0.9% NaCl) = 150 mmol Na + 1 L water
• 3 pints D5% = 1.5 L water + 150 g glucose• 70 mmol KCl = 5.26 g
3) After persistent vomiting, he was noted to be confused. His Na level came back as 111 mmol/L. How to correct his Na level?
• Total body water = 70 x 0.6 = 42 L• He is severely symptomatic Correct Na fast• Correct 3 mmol/L in 3 hour with 3% NaCl• Change in serum Na = Infusate Na – Serum Na
Total body water + 1 = 513 – 111
42 + 1 = 9.35 mmol/L
• To aim for 3 mmol/L elevation = 3 ÷ 9.35 = 0.32 L of 3% NaCl
= 320 ml 3% NaCl over 3 hour
4) His K level came back as 3.0 mmol/L. How to correct his K level?
•K deficit = (4.0 – 3.0) X 70 X 0.4
13.3= 2.1 g•Solution = Fast correction 2 g KCl in 200 ml NS over 2 hours
CALCIUM
CALCIUM
• Requirements : 0.1 mmol/kg/day• Normal level: 8.5 – 10.6 mg/dL; 2.1-2.65 mmol/L• Functions:• Bone density• Muscle contraction• Second messenger for hormones & neurotransmitters• Blood coagulation pathway (intrinsic pathway)
HYPOCALCEMIA
• Hypoparathyroidism• post thyroidectomy• vitamin D deficiency• severe sepsis• Burn• phosphate therapy
• Paraesthesia• circumoral numbness• cramp• Tetany• Dystonia• Convulsion• psychosis
SIGN• Chvostek’s sign• Trousseau’s sign• Dry skin(long standing)
CAUSESCLINICAL
FEATURES
Acute:•10-20ml of IV Ca gluconate 10% dilute in 100 ml NS over 10 min•±IVI at 0.5-2mg/kg/hour (10-50ml of Cal gluconate in 500ml D5% over 4-8 hours)
Long term:•1-2 elemental Cal (Cal lactate/Ca carbonate) TDS•Calcitriol 0.25mcg daily
MANAGEMENT OF HYPOCALCEMIA
HYPERCALCEMIA
CAUSESHyperparathyroidism, . Humoral hypercalcemia of malignancy (Breast ca, SCC, RCC, ovarian
ca),
CLINICAL FEATURES “Stones, bones, abdominal moans, psychic groans”
MANAGEMENT Rehydration & saline diuresis 0.45-0.9% saline, about (3-4 L) for 2-3 daysIV frusemide
Biphosphonates - Pamidronate 30 mg stat dose
Dialysis
• Water constitute 50-60% of body weight• The principal extracellular cation is Na and
principal anion are Cl and HCO3.
• In contrast principal intracellular cation is K and Mg and principal anion is PO4
• In normal individual, fluid balance is achieved through water intake and loss.• Water loss can be divided to insensible and
sensible loss• Extracellular volume deficit is most common fluid
disorder in surgical patient
TAKE HOME MESSAGES
• Most acute surgical illness are accompanied by some degree volume loss or redistribution, thus isotonic fluid administration is most common initial IV fluid given.
• The most important type of hyponatraemia in surgical patients is due to hypovolumia thus management is directed towards replacement of water volume & Na level.
• Symptoms of hypernatraemia are related to hyperosmolarity effect of Na which results in cellular dehydration
• Hypokalaemia is one of the important cause of ileus
REFERENCES
• Schwartz’s Principle of Surgery (9th edition), G. Tom Shires 111, 2010• The Washington Manual of Surgery (6th edition),
Klingensmith et al, 2012• Maintainance and replacement fluid therapy in
adult, H Stern, Uptodate.com, 2014• Sarawak Handbook of Medical Emergencies, 3rd
edition, Soo et al, 2011• Surgicall Recall, 6th edition, Blackbourne, 2012