fluid and electrolyte presntetion by lemessa

Fluid and Electrolyte

by: Lemessa Jira

Fluid and Electrolyte

http://www.uog.edu.et/




Presentation out lines

Session objectives

Introduction to body water & its Distribution

Fluid regulation and it’s factors

Electrolyte composition in human body

Factors affecting fluid & Electrolyte balance

Disorder Fluid Volume changes

Principles of fluid and electrolyte therapy

August 4, 2016 pp by Lemessa J. 2

Cont..

Evidence based practice in fluid and electrolyte

balance

References

Acknowledgement


Session objectives

Describe the normal distribution and regulation of fluid

and electrolyte in human body .

Discuses factors affecting fluid regulation .

Discuses Factors affecting fluid & Electrolyte Balance.

Describe disorder and their treatment of fluid and

electrolyte.

use evidences regarding fluid and electrolyte in surgical

patient.


Introduction

Electrolytes are chemicals dissolved molecules that serve

various functions in the body play important roles in nerve

conduction, muscle contraction ,heart rhythm and

maintenance of the body’s fluid balance.

Body fluids are in constant motion transporting nutrients ,

electrolyte and oxygen to the cells away west products in

our body .

(Bozkurt P. ,2010)


Cont.

Many diseases, injuries, treatment and even operative

trauma have a great impact on the physiology of fluids

and electrolytes balance in the body.

Especially surgical patient is at risk for several

derangements of body fluid volume and composition.

One of the most critical aspects of patient care is

management of the composition of body fluids and

electrolytes. (Benjamin J. Freda,2012)


NORMAL

DISTRIBUTION OF

BODY FLUIDS


Normal Distribution Of Body Fluids

The total body water constitutes 45 – 85% of total body

weight but it depending on gender , age , and body mass

(muscle mass). Men tend to have higher percentages of

water (about 60%) than women (about 55%) mainly

because of their increased muscle mass and lower amount

of subcutaneous fat.

( Practice N, Fluid R.,2013 107(28):12–6)

pp by Lemessa J. 8 August 4, 2016

Cont.

Fat has less water content than any other body tissue. This

also accounts for a lower than normal water percentage in

obese people.

Infants have a higher percent of water than adults do as

much as 77% but their total water content of the body

decreases most dramatically during the first 10 years.

at old age only 45% of the total body weight.

(Bozkurt P,2010.)


Cont.

Total body water is further divided into two:

1. Intracellular fluid, comprising 2/3 of total body

water

2. Extra cellular fluid, comprising 1/3 of total body

water. The extra cellular fluid is sub divided into:

Intravascular (plasma) comprising 2/3 of extra

cellular fluid .

Interstitial which comprises 1/3 of extra cellular

Trans cellular compartment: consists of those spaces in the

body where fluid does not normally collect in larger amounts.


Distribution of Water

♣ Plasma -------------5%

♣ Interstitial ---------15% Extracellular fluid

♣ Intracellular--------40%

♣ Total ----------60 % Water

♣ Remaining -Solids - 40%:fat, protein,

carbohydrates, minerals

( Practice N, Fluid R ,2013107(28):12–6)


Distribution of Water


Regulation…

Approximately 90% of the body's water intake comes via

the gastro-intestinal tract and the remaining 10% is

called metabolic water and it is produced as the result of

various chemical reactions in the cells of the body's

tissues.

In a normal, healthy human being :

WATER INPUT = WATER OUTPUT

Maintaining this ratio : is prime importance in

maintaining health.


Cont.

Normal adults are considered to have a minimal

water intake of approximately 1600 mL per day,

Ingested water – 500 mL

Water in food – 800 mL

Water from metabolism – 300 mL

The sources of output in normal adults are

Urine – 500 mL

Skin – 500 mL

Respiratory tract – 400 mL

Stool – 200 ml

(Started G, Diet P, Your Key 2015. )


Regulation…

Organs that involve in fluid regulation:

1. Hypothalamus

2. Posterior pituitary (ADH)

3. Adrenal

4. Kidney


Regulation…

Factors affect fluid regulation

primary factor: the problem is from in put and out put of

fluid it affects only one electrolyte .

Secondary factors is one resulting from an abnormality

in some other physiological function and usually affect

more than one electrolyte

( Practice N, Fluid R. 2013107(28):12–6. )


Electrolytes

Electrolytes are the chemicals dissolved molecules in the

body fluid that play a vital role in maintaining homeostasis

within the body.

They help to regulate heart, neurological function, fluid

balance, oxygen delivery, acid-base balance and much

more. Sodium and chloride is found mostly in extra-

cellular fluid, while potassium and phosphate are the main

ions in the intracellular fluid. August 4, 2016 pp by Lemessa J. 17

https://en.wikipedia.org/wiki/Homeostasis

https://en.wikipedia.org/wiki/Fluid_balance



Electrolyte composition in human body


ELECTROLYTE DISTRIBUTION Positive ions -meq/liter


Extra cellular Intracellular Function

Sodium 152 10 fluid balance, osmotic

pressure

Potassium 5 157 Neuromuscular excitability acid- base balance

Calcium 5 - bones, blood clotting

Magnesium 2 26 enzymes

Electrolyte Distribution Negative ions -meq/liter


Extra cellular Intra

cellular

function

Chloride 113 2 Fluid balance , osmotic

pressure

Bicarbonate 24 8 Acid-base balance

proteins 16 55 Osmotic pressure

phosphate 2 153 Energy storage

sulfate 1 20 Protein metabolism

Factors affecting fluid & Electrolyte Balance

Kidney Disease :-it is the most organ which is

involved in maintaining of fluid and electrolyte in

our body.

Medicines:-Certain medicines can affect

electrolyte levels. Diuretics, used to control high

blood pressure, work by increasing the excretion

of sodium and water in the urine.

Dehydration :-Dehydration can affect

electrolyte levels. Sodium level in particularly can be adversely affected.


Factors affecting cont…

Adrenal Problems :-The adrenals is a pair of triangle-

shaped glands located atop each kidney secrete hormones

involved in the body’s stress response, sexual

development and fluid balance. The main adrenal

hormone involved in electrolyte balance is aldosterone.

Operative trauma

(Pandey CK. ,2003;47(October):380–7. )


DISTURBANCES OF FLUID AND ELECTROLYTES

Fluid volume excess

Fluid volume deficit

Electrolyte excess

Electrolyte deficit


1,FLUID VOLUME – EXCESS/OVERHYDRATION

When more fluid is consumed than can be excreted

The blood vessels overfill, and fluid moves from the blood

vessels into the Interstitial Space causing edema.

(Benjamin J. Freda,2010)


causes

Cardiac failure :heart cannot pump blood adequately.

Kidney disorders : kidney can not excrete enough H2O

Antidiuretic hormone : (Forces kidneys to retain more

water). Overproduction of ADH caused by ; pneumonia ,

stroke and by drugs such as carbamazepine

Drugs: especially steroids .

Foods :that are high in sodium fluids ration /over

hydration Intravenous fluids.


Clinical Features / Diagnosis

Edema -Swelling in the legs.

Dyspnea/Shortness of breath because

fluid backs up in the lungs it is worse when a

person lies down.

Puffiness of face

Swelling and enlargement of organs-cardio/ hepatomegaly

The engorgement of veins in the neck- JVP


Diagnosis

Blood tests –urea/ electrolytes

Organ function test

A chest x-ray –hiler shadows fluid in the lungs.

Cardiac size


Treatment

Restrict the fluids

Help the body excrete the excess water.

Diuretics - kidneys to excrete the excess

can be taken by mouth or I/V.

Thiazides- often used first- mild and tend

to have few side effects.

Frurosemide more potent.


Treatment…

Consume less salt also helps. If edema is due to poor circulation

rather than over hydration.

Increase physical activity . Usually, the blood vessel disorder that

is causing poor circulation is treated.

Correct the cause of over hydration .

Give I/v fluids with caution

Treat Heart failure and kidney disorders.

Discontinue drugs if cause or limit its use- steroids - arthritis

Overproduction of ant diuretics hormone –restrict fluid intake


2 ,Fluid volume - deficit / Dehydration/ Extra cellular fluid (ECF) volume deficit is the most

common fluid volume disorder in the surgical

patient.(Gwinnutt M, Thorburn J,2010;(JUNE):1–8. (2)(3))

The lost fluid is not water alone, but water and

electrolytes in approximately the same proportion as they

exist in normal extra cellular fluid.


Causes Losses of gastro-intestinal fluids: e.g. vomiting, gastric

tube, diarrhea .

loss of fluid during soft tissue injuries , infections and

burns.

Intra-abdominal and retroperitoneal inflammatory

processes such as peritonitis, intestinal obstruction, etc.


Cont….

Hot weather, fever and to much exercise .

Diabetes - the body produces more urine.

Kidney disorders- kidneys unable to concentrate

urine as needed.

Diuretics- increase the water and salt excretion.


Cont.…

Clinical features- General

Dry skin

Fast pulse

low blood pressure

Low urine out put- The kidneys try to conserve

Cold extremity


Clinical Picture of Dehydration

Signs &

Symptoms

Mild [10-20%] Moderate [ 20-30%] Severe [ 40% or

above]

General Thirsty, restless,

alert Confusion,

Tachycardia

Drowsy, limp cold,

Peripheral

pulses Normal Rapid and weak Rapid and thready

Breathing Normal Deep ,rapid Deep , rapid

Fontanels and eye Normal Sunken Very sunken

Capillary Refill < 2 Seconds Prolonged 3-4

sec

Very prolonged >

4 sec

Skin and the

membranes Moist but nose and

eyes become dry.

Dray Dray

Blood Pressure Normal Postural

hypotension

Hypotension and

Shock


Treatment

Mild dehydration: - 2 to 3 liters of water to drink

over a period of a few hours.

Moderate dehydration: - Add some salt (sodium)

and other electrolytes.

Severe Dehydration: -Intravenous Replacement.


Commonly available replacement fluids Ions

(millimol per liter)

Carbohydrate

(gram per liter)

Used for

replacement of

Fluid Na+ Cl Ka+

Normal saline 154 154 0 0 Replacing GI and

extra cellular fluid

loss

Ringer’s lactate 131 112 5 0 Blood, intracellular

fluid loss

5% glucose in water

(D/W)

0 0 0 50 Maintenance and

for medication

DNS 77 77 0 0 For GI and

extracellular loss


Cont..

Normal daily maintenance fluid replacement

1. 100 ml/kg of body weight for the first 10 kg

2. 50 ml/kg of body weight for the second 10 kg

3. 20 ml/kg of body weight for the remaining


Disorders of Electrolyte Balance

The most serious electrolyte disturbances involve

abnormalities in the levels of sodium, potassium

and calcium but Other electrolyte imbalances are

less common.

Electrolyte levels Often change when water levels

in the body change.

(Vanholder R, Ball S. 2014;320–31.) August 4, 2016) pp by Lemessa J. 38

Disorders Of Sodium Balance

Hyponatremia: is serum sodium level less than

135mEq/L

Result from

Not consuming enough sodium in the diet,

Excreting too much salt (in sweat or urine)

Over hydration when large amounts of fluids that do

not contain enough sodium are given intravenously

resulting in a low sodium level.

Diuretics



Hyponatremia… Symptoms

confusion, drowsiness, muscle weakness, and seizures.

NB: A rapid fall in the sodium level often causes more

severe symptoms than a slow fall (Benjamin J. Freda,2010)

Treatment

A low sodium level restored to a normal by:

gradually and steadily giving sodium and water

Orally/intravenously.



Hypernatremia

Hypernatremia: is serum sodium level greater than

145mEq/L

caused by ;

Dehydration

Excessive loss of fluid without loss of salt

Addition of excessive salt without proportionate fluid

volume

symptoms

Typically--- thirst is the first symptom.

weakness and sluggishness.

A very high sodium level can cause confusion

paralysis, coma, and seizures.


Hypernatremia con…

Treatment

Oral plain fluids - If the sodium level is slightly

high.

Intravenous fluids – giving iv fluid which is free

from Na like D5W.

NB :-For elective surgery Na level must be greater

than135meq/L<150meq/L

(BozkurtP. ,2010;47(October):380–7. )


Disorders Of potassium Balance

Hypokalemia: Is serum Potacium level less than 3.5mEq/L

causes

Diarrhea or vomiting for a long time.

Diuretics.

Poor consumption of potassium reach foods.

Symptoms

1. Mild decrease -- no symptoms.

2. Moderate -- fatigue, confusion, muscle weakness and cramps .

3. Severe -- paralysis and arrhythmia.


cont.. Treatment

Potassium supplements by mouth as a tablet or

liquid or eating foods rich in potassium like

Banana , potato , Carrots and meat .

Potassium-sparing diuretic –In People on diuretics

reduces the amount of potassium excreted .

IV-supplement in surgical cases


Hyperkalemia: It is serum Potassium level greater than

5.0mEq/L

A high potassium level (hyperkalemia) is much

more dangerous than a low potassium level.

Most common causes :

increasing intake

Renal failure

severe injury and surgery.

Potassium-sparing diuretics

(Pandey CK,2003;47(October):380–7.)


cont..

Treatment

Stop eating potassium-rich foods and stop taking

potassium supplements.

Avoid intravenous solutions containing K

Then diuretics Frusemide prevents potassium

from being re-absorbed are given to reduce the

amount of potassium in the body.


Disorders Of Calcium Balance

Hypocalcaemia: Is serum calcium level less

than 8.4 mg/dL

It is the result of

Massive soft tissue infection .

Hypoparathyroidism- if the parathyroid

glands are removed or damaged during

neck surgery.

Deficiency of vitamin D. (Vitamin D helps

the body absorb calcium .)


Cont…

Certain drugs: such as the anticonvulsants

phonation and Phenobarbital can interfere with

the processing of vitamin D, resulting in a

deficiency of vitamin D.

( Hoorn EJ, 2012 revision. 2012;153–65)


Hypocalcaemia…

Clinical Features

weakness , numbness in the hands and feet.

confusion or seizures

Muscle twitching / tetany /

Treatment

IV Calcium gluconate (10ml of 10% solution over

10 minute) or calcium chloride.

Calcium lactate may be given orally with or without

Vitamin D. Treat the underling Cause.


Hypercalcemia:

It is serum calcium level greater than10.2mg/dL.

Causes :

Excessive intake : like milk

Excessive brake down of bone and release of

calcium into the bloodstream.

Calcium may be released when cancer spreads to

the bone

Hyperparathyroidism: it increase the release of

calcium from the brake down of the bone.


Cont..

Symptoms:

A very high level can result in dehydration because it

causes the kidneys to excrete more water.

A very high level can also cause loss of appetite, nausea,

vomiting, and confusion. A person may even go into a

coma and die.

(Schwartz’s Principles of Surgery, 9th Edition. )


Hypercalcemia…

Treatment

♥ High calcium level rapid treatment is needed.

- fluids intravenously

- Steroids

♥ calcitonin and bisphosphonates are given

intravenously for short periods of time to decrease

the amount of bone being broken down and

decrease calcium released into the bloodstream.

♥ Treat the cause of the high calcium level.


What evidence says:

Fluid management is an important part of overall

surgical therapy and Proper administration of fluids is

critical, especially in patients who undergo major

surgeries such as emergency laparotomies, bowel

Resections and hepatectomy procedures.

(Bozkurt P. Fluid and Electrolyte Balance2010)


Evidence

American Society of Anesthesiologists were published

(2005):

if we maintain fluid and electrolyte during pre and intra

operative time, we reduces the number of patients who

experience complications and shortens the time to

recovery of gastrointestinal function and to hospital stay

by 2.7 times.


Evidence

Journal of the American Association of Nurse Anesthetists

in 2008 published that As a result of surgery a number of

changes occur in the distribution of body fluids. Most of

the gains and losses of body fluids occur from the

extracellular fluid compartment.


Evidences…

(Vanholder R, Ball S. Clinical practice guideline on diagnosis and

treatment of hyponatraemia. 2014;320–31.) published

Hyponatraemia is the most common disorder of body fluid and

electrolyte balance encountered in clinical practice and it is

present in 15–20 % of emergency admissions to hospital and

occurs in up to 20 % of critically ill patients.


(CentralHospitalofHuzhouTeachersCollege,Huzhou,ZheJiangProvince,China

in 2013 published that )

The prevention and control system of hypokalemia

with the starting point being before admission was

more effective and allows early prevention

detection ,correction, surgery, and recovery of

patients undergoing open abdominal surgeries and

also could be used in other specialized nursing

fields.


Evidences…

A study conducted in Yonsei University,

Korea(February 09, 2015): Reducing dehydration

during preoperative fasting can prevent

occurrence of postoperative nausea and vomiting.

For surgical patients, appropriate selection and

administration of fluids can mitigate against

organ failure(Piper GL & Kaplan LJ)


Evidences…

A study conducted in Nottingham, UK has highlighted

significant Proper management of fluid and electrolytes

facilitates crucial homeostasis that allows cardiovascular

perfusion, organ system function, and cellular

mechanisms to respond to surgical illness.


Nursing diagnosis

Fluid volume defecate related to nausea

,vomiting ,burn and diarrhea as evidenced by

deceased urine out put , weakness ,

,decreased skin turgor , dry mucous

membranes , increased plus rate and

decreased blood pressure .

Role of nurse

Administer iv therapy as prescribed

Give fluids as appropriate

Monitor vital sign as appropriate

Monitor accurate input and out put


Reference • J. Roger Maltby Preoperative fasting guidelines Canadian journal of surgery Can J

Surg. 2006 Apr; 49(2): 138–139.

• Lockwood JS, Randall HT. THE PLACE OF ELECTROLYTE STUDIES IN SURGICAL

PATIENTS *. 1998;

• Piper GL and Kaplan LJ Fluid and electrolyte management for the surgical patient

• Rando JT. Fluid and electrolyte management of the adult surgical patient.

2008;49–54.

• Lu G, Yan Q, Huang Y, Zhong Y, Shi P. Prevention and Control System of

Hypokalemia in Fast Recovery After Abdominal Surgery $. Curr Ther Res

[Internet].Elsevier;2013;74:68–73.Availablefrom:

http://dx.doi.org/10.1016/j.curtheres.2013.02.004

• Schwartz’s Principles of Surgery, 9th Edition.

• Vanholder R, Ball S. Clinical practice guideline on diagnosis and treatment of hyponatraemia. 2014;320–31.

Practice N, Fluid R. Measuring and managing fluid balance. 107(28):12–6.

Pandey CK. Fluid and electrolyte disorders. 2003;47(October):380–7.


MAKE WATER YOUR FIRST

CHOICE OF FLUIDS !!!!!!!


fluid and electrolyte presntetion by lemessa

Health & Medicine

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