Fluid & Electrolytes Management (1)

8/6/2019 Fluid & Electrolytes Management (1)

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Fluid & ElectrolytesFluid & Electrolytes

Management: Part IManagement: Part I

Component & composition of body

fluid

Mechanisms of fluidhomeostasis

Parenteral fluid therapy



Body Fluid Compartments:Body Fluid Compartments:

ICF:ICF:

55%~75%55%~75%

IntravascularIntravascular

plasmaplasma

X 50~70%X 50~70%

lean body weightlean body weight

ExtravascularExtravascular

InterstitialInterstitial

fluidfluid

TBW TBW

ECFECF

3/4

1/4

Male (60%) > female (50%)

Most concentrated in skeletal muscle

TBW=0.6xBW

ICF=0.4xBW

ECF=0.2xBW

2/3

1/3



Composition of Body Fluids:Composition of Body Fluids:

Ca 2+

Mg 2+

K +

Na+

Cl-

PO43-

Organicanion

HCO3-

Protein

0

50

50

100

150

100

150

Cations Anions

E C F

I C F

Osmolarity = solute/(solute+solvent)Osmolarity = solute/(solute+solvent)

Osmolality = solute/solvent (290~310mOsm/L)Osmolality = solute/solvent (290~310mOsm/L)

Tonicity = effective osmolality Tonicity = effective osmolality

Plasma osmolility = 2 x (Na) + (Glucose/18) +Plasma osmolility = 2 x (Na) + (Glucose/18) +

(Urea/2.8)(Urea/2.8)Plasma tonicit = 2 x Na + Glucose 18Plasma tonicit = 2 x Na + Glucose/18



Regulation of Fluids:Regulation of Fluids:

Hydrostatic pressure v.s. Oncotic pressure Albumin is the major determining oncoticpressure



Regulation of Fluids:Regulation of Fluids:

Renal sympathetic nerves

Renin-angiotensin-

aldosterone system

Atrial natriuretic peptide(ANP)



Composition of GIComposition of GI

Secretions:Secretions:

SourceSource VolumeVolume(ml/24h)(ml/24h)

NaNa+*+* K K ++ ClCl-- HCOHCO33--

SalivarySalivary 1500(500~2000)

10 (2~10) 26(20~30)

10 (8~18) 30

StomachStomach 1500(100~4000)

60 (9~116) 10 (0~32) 130 (8~154) 0

DuodenumDuodenum 100~2000 140 5 80 0

IleumIleum 3000 140 (80~150) 5 (2~8) 104 (43~137)30

ColonColon 100-9000 60 30 40 0

PancreasPancreas 100-800 140(113~185)

5 (3~7) 75 (54~95) 115

BileBile 50-800 145(131~164)

5 (3~12) 100 (89~180)35

* Average concentration:

mmol/L



Signs of Hypovolemia:Signs of Hypovolemia:

Diminished skin turgor

Dry oral mucus membrane

Oliguria- <500ml/day

- normal: 0.5~1ml/kg/h

Tachycardia

HypotensionHypoperfusioncyanosis

Altered mental status



Clinical Diagnosis of Clinical Diagnosis of

Hypovolemia:Hypovolemia:

Thorough history taking: poor intake, GI

bleeding…etc

BUN : Creatinine > 20 : 1

- BUN↑: hyperalimentation, glucocorticoid

therapy, UGI bleeding

Increased specific gravity

Increased hematocrit

Electrolytes imbalance

Acid-base disorder



Parenteral Fluid Therapy:Parenteral Fluid Therapy:

Crystalloids:Crystalloids:

- contain Na as the main osmotically

active particle

- useful for volume expansion (mainly

interstitial space)

- for maintenance infusion

- correction of electrolyte abnormality



Crystalloids:Crystalloids:

Isotonic crystalloids

- Lactated Ringer’s, 0.9% NaCl

- only 25% remain intravascularly

Hypertonic saline solutions

- 3% NaCl

Hypotonic solutions

- D5W, 0.45% NaCl

- less than 10% remain intra-

vascularly, inadequate for fluid

resuscitation



Colloid Solutions:Colloid Solutions:

Contain high molecular weight

substancesdo not readily migrate across

capillary walls

Preparations

- Albumin: 5%, 25%

- Dextran

- Gelifundol

- Haes-steril 10%



SolutionsSolutions VolumesVolumes NaNa++ K K ++ CaCa2+2+ MgMg2+2+ ClCl-- HCOHCO33-- DextroseDextrose mOsm/LmOsm/L

ECFECF 142 4 5 103 27 280-310

LactatedLactated

Ringer’sRinger’s130 4 3 109 28 273

0.9% NaCl0.9% NaCl 154 154 308

0.45% NaCl0.45% NaCl 77 77 154

D5WD5W

D5/0.45%D5/0.45%NaClNaCl

77 77 50 406

3% NaCl3% NaCl 513 513 1026

6%6%HetastarchHetastarch 500 154 154 310

5%5%AlbuminAlbumin

250,500 130-160

<2.5 130-160

330

25%25%

AlbuminAlbumin20,50,100 130-

160<2.5 130-

160330

Common parenteral fluid therapyCommon parenteral fluid therapy



The Influence of Colloid &The Influence of Colloid &

Crystalloid on Blood Volume:Crystalloid on Blood Volume:

1000

cc

500cc

500cc

500cc

200

600

1000

Lactated

Ringers

5% Albumin

6% Hetastarch

Whole blood

Blood volume

Infusionvolume



Signs of Hypervolemia:Signs of Hypervolemia:

Hypertension

Polyuria

Peripheral edema

Wet lung

Jugular vein engorgement

Especially whenhypo-albuminemia



Management of Management of

Hypervolemia:Hypervolemia:

Prevention is the best way

Guide fluid therapy with CVP level or

pulmonary wedge pressureDiuretics

Increase oncotic pressure: FFP or

albumin infusion (may followed bydiuretics)

Dialysis



Fluid Management:Fluid Management:

Goal:Goal:

- to maintain urine output of

0.5~1.0mg/kg/h

Rule:Rule:100*10 + 50*10 +〔 (x-20)/10 〕 *20

= 1460 + 2x

Electrolytes require:Electrolytes require:

- Na+: 1-2mmol/kg/day

- K +: 0.5~1.0mmol/kg/day

Avoid fluid overload, especially in malnutrition,

heart failure and renal insufficiency patient



Fluid Management:Fluid Management:

For acute blood lossFor acute blood loss

- Begin with 2-3L isotonic crystalloid to

restore blood pressure and peripheral

perfusion

- Early use of colloid

- Crystalloid + 5% albumin in a ratio of 4:1

- Blood transfusion

- Large borne IV line



To beTo be

Continued !!!Continued !!!

Fluid & Electrolytes Management (1)

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