Fluid & Electrolytes Management.ppt

7/29/2019 Fluid & Electrolytes Management.ppt

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Fluid & Electrolytes

Dewi Kartikawati N.


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FLUIDS50-60% of the human body is water (decreases withage)Body fluids are classified according to their locationwith most of the bodys fluids found within the cell

Intracellular Extracellular (mainly responsible for transport of nutrients

and wastes)

Fluid compartments are separated by selectivelypermeable membranes that control movement of

water and solutesThe process of homeostasis involves delivery ofoxygen and nutrients to the cells and removal ofwaste


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Body Fluid Compartments:

ICF:55%~75%

Intravascularplasma

X 50~70%lean body weight

ExtravascularInterstitial

fluid

TBW

ECF

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Male (60%) > female (50%)

Most concentrated in skeletal muscle

TBW=0.6xBW

ICF=0.4xBW

ECF=0.2xBW

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Body Fluid Compartments

Contd..2/3 (65%) of TBW is intracellular (ICF)

1/3 extracellular water

25 % interstitial fluid (ISF)

5- 8 % in plasma (IVF intravascular fluid)

1- 2 % in transcellular fluids CSF, intraocular

fluids, serous membranes, and in GI, respiratoryand urinary tracts (third space)


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Regulation of Body FluidCompartments

Osmosis is the diffusion of water caused by fluidgradient.Diffusion is the movement of a substance fromarea of higher concentration to one of lowerconcentration.Active Transport is the movement of substanceacross permeable membrane and gradient; requiresenergy and pump. Ex. Sodium/potassium pump


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Regulation of Body FluidCompartments Contd

Filtration is the movement of water and solutesfrom an area of high hydrostatic pressure to anarea of low hydrostatic pressure

Osmolality reflects the concentration of fluid thataffects the movement of water between fluidcompartments by osmosisOsmotic pressure is the amount of hydrostaticpressure needed to stop the flow of water by

osmosis


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Osmolarity

Isotonic same solute concentration; equal;no movement across membrance

Hypertonic/hyper-osmotic greater osmoticpressure (concentration); waterpulled intofluid to equalize.

Hypotonic/hypo-osmotic lesser osmoticpressure (concentration); waterpulled out of

fluid to equalize.


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Cell in a

hypertonicsolution


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Cell in ahypotonicsolution


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Regulation of Fluids:

Renal sympathetic nerves

Renin-angiotensin-

aldosterone system

Atrial natriuretic peptide (ANP)


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Regulation of Fluid Volume

Kidneys

Capillary pressure forces fluid through the

walls and into the tubule At this point H2O or electrolytes are then

either retained or excreted

The urine becomes more dilute or moreconcentrated based on the needs of thebody


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Regulation of Fluid Volume, cont.

Antidiuretic hormone (ADH) Produced by the hypothalamus

Stored in the pituitary gland

Restores blood volume by increasing or decreasingexcretion of water

Increased osmolality or decreased blood volumestimulates the release of ADH

Then the kidneys reabsorb water Also may be released by stress, pain, surgery, and

some meds


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Renin-angiotensin-aldosterone system

Renin secreted in kidney

Amount of renin produced depends on bloodflow and amount of Na in the blood

Produces angiotensin II (vasoconstrictor)

Angiotensin causes peripheralvasoconstriction

Angiotensin II stimulates the production ofaldosterone


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Aldosterone

Secreted by the adrenal gland response toangiotensin II

The adrenal gland may also be stimulated by theamount of Na and K + in the blood

Causes the kidneys to retain Na and H2O

Leads to increases in fluid volume and Na levels Decreases the reabsorption of K+

Maintains B/P and fluid balance


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Regulation of Fluid Volume,cont

Atrial natriuretic peptide or factor (ANP)(ANF) Cardiac hormone

Released in response to increased pressure in theatria (increased blood volume)

Opposes the renin-angiotensin-aldosterone system

Stimulates excretion of Na and H2O

Suppresses renin level Decreases the release of aldosterone

Decreases ADH release

Reduces vascular resistance by causing

vasodilation


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Regulation of Fluid Volume,cont

Atrial natriuretic peptide or factor (ANP)(ANF) Cardiac hormone

Released in response to increased pressure in theatria (increased blood volume)

Opposes the renin-angiotensin-aldosterone system

Stimulates excretion of Na and H2O

Suppresses renin level Decreases the release of aldosterone

Decreases ADH release

Reduces vascular resistance by causing

vasodilation


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Fluid shifting1st space shifting- normal distribution offluid in both the ECF compartment andICF compartment.

2nd space shifting- excess accumulation ofinterstitial fluid (edema)

3rd space shifting- fluid accumulation inareas that are normally have no or little

amounts of fluids (ascites)


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Balance

Fluid and electrolyte homeostasis ismaintained in the body

Neutral balance: input = output

Positive balance: input > output

Negative balance: input < output


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Electrolytes

Major cations for extracellular fluidSodium

Major cations for intracellular -

Potassium

Cations

Calcium,phosphorus, magnesium


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Sodium (Na):

Is the most abundant cation in theextracelluar fluid and major contributor toserum osmolality.

Function of sodium: Controlling and regulating water balance.

Maintaining blood volume

Transmitted nerve impulses.


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Normal level is 135 145 mg/dl.

Hyponatremia: sodium deficit in the blood.

Hypernatremia: sodium excess in the

blood. Sodium is found in many foods, such as

processed cheese, table salt


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Potassium:

Is the major cation in intracellular fluid.Function of potassium:

Maintain ICF osmolality.

Transmitting nerve impulses.

Regulate cardiac impulses.

Skeletal and smooth muscle function.

Regulate acid base balance


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Potassium is found in many fruits andvegetables, meat, fish, milk.

Normal level of potassium is 3.55.3meq/l.

Hypokalemia: potassium deficit in theblood.

Hyperkalemia: potassium excess in theblood.


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Solutes dissolved particles

Electrolytes charged particles

Cations positively charged ions

Na+, K+ , Ca++, H+

Anions negatively charged ions

Cl-, HCO3- , PO4

3-

Non-electrolytes - Uncharged

Proteins, urea, glucose, O2, CO2


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Factor effecting fluid andelectrolyte balance:

Age: infant have greater water needand greater loss due to greater

metabolic rate.Environment: excess heat stimulatesthe sympathetic nervous system and

cause person to sweat.


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Diet: in nutritional deficiency, the bodypreserved the protein by breakingdown the fat and glycogen.

Stress: water retention and increasethe production antiduritic hormone.

Illness: burn, renal disorder


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Client at risk for fluid andelectrolyte imbalance:

Post operative client.

Client with sever trauma or burn.

Client with chronic disease ascongestive heart failure.

Client with intravenous infusion.

Client with special drainage.Client who receiving diuretic


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FLUIDS IMBALANCES.

Hypovolemia

Hypervolemia


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Signs of Hypovolemia:

Diminished skin turgor

Dry oral mucus membrane

Oliguria-


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Clinical Diagnosis of Hypovolemia:

Thorough history taking: poor intake, GI

bleedingetc

BUN : Creatinine > 20 : 1- BUN: hyperalimentation, glucocorticoid

therapy, UGI bleeding

Increased specific gravity

Increased hematocritElectrolytes imbalance

Acid-base disorder


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Parenteral Fluid Therapy:

Crystalloids:

- contain Na as the main osmotically

active particle- useful for volume expansion (mainly

interstitial space)

- for maintenance infusion

- correction of electrolyte abnormality


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Crystalloids:

Isotonic crystalloids

- Lactated Ringers, 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


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Colloid Solutions:

Contain high molecular weight

substancesdo not readily migrate across

capillary walls

Preparations

- Albumin: 5%, 25%

- Dextran

- Gelifundol- Haes-steril 10%


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Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3- Dextrose mOsm/L

ECF 142 4 5 103 27 280-310

LactatedRingers

130 4 3 109 28 273

0.9% NaCl 154 154 308

0.45%

NaCl77 77 154

D5W

D5/0.45%NaCl

77 77 50 406

3% NaCl 513 513 1026

6%Hetastarch

500 154 154 310

5%Albumin

250,500130-160


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The Influence of Colloid & Crystalloid onBlood Volume:

1000cc

500cc

500cc

500cc

200 600 1000

Lactated Ringers

5% Albumin

6% Hetastarch

Whole blood

Blood volume

Infusionvolume


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Signs of Hypervolemia:

Hypertension

Polyuria

Peripheral edemaWet lung

Jugular vein engorgement

Especially whenhypo-albuminemia

Pitt d d


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Pitted edemaFluid overload


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Pitting odema


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Management of 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 by diuretics)Dialysis


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Fluid Management:

Goal:

- to maintain urine output of

0.5~1.0mg/kg/h

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


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Fluid Management:

For acute blood loss

- Begin with 2-3L isotonic crystalloid to

restore blood pressure and peripheralperfusion

- Early use of colloid

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

- Large borne IV line


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Electrolyte Imbalances

Hypo and Hypernatremia (Na+)

Hypo and Hyperkalemia (K+)

Hypo and Hypercalcemia (Ca+)

Hypo and Hypermagnesemia (Mg+) Hypo and Hyperphosphatemia (Phos+)

Hypo and Hyperchloremia (Cl-)


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MACAM CAIRAN :

1. CAIRAN NON ELEKTROLIT GLUKOSA 5% / DEKTROSE 5%

2. CAIRAN ELEKTROLIT NaCl (NS), RL. PZ, KAEN. Asering dll.

3. CAIRAN KOLOID Dextran. HES. Gelatin, Darah , Albumin dll


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PEMBERIAN CAIRAN MAINTENANCE

- JUMLAH CAIRAN :

DEWASA 50Kg / KgBB/ 24 jam

ANAK 10Kg I ------ 100cc / KgBB / 24 jam

10Kg II ------- 50cc / KgBB / 24 jam.

> 20cc/ KgBB / 24 jam.

- TETESAN / MENIT

- MACAM CAIRAN --------------------- Na+ ---------- 3 5 mg / KgBB / 24 jam.KEBUTUHAN

CONTOH :


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Laki-laki, 25 th, BB 50 Kg.

- Jumlah Cairan -------- 50 x50 / 24Jam = 2500 cc / 24 jam.

- Macam Cairan ----- kebutuhan Na+ = 150 -250 mg/ 24 jam.

RL Na+ 131 meq/L------ 1 fles = 65 meq

PZ Na+ 154 meq/L ------ 1 fles = 77 meq.

- Macam Cairan RL 3 fles --- Na+ 195 meq , jumlah 1500 cc.

kekurangan cairan 1000 cc ------ D5% = 2 fles.

- Susunan Cairan RL 3 fles + D5% 2 fles.

- Tetesan / menit otsuka --- 1cc = 15 tts

terumo 1cc = 20 tts.

- Otsuka : 2500 x 15 = 2500 = 25 -30 tts / mnt

24 x 60 24 x 4

- Terumo : 2500 x 20 = 2500 = 33-35 tts / mnt.

24 x 60 24 x 3

Anak 11 th BB 27 kg


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Anak, 11 th , BB 27 kg.

- Jumlah Cairan 10 Kg I ----- 10 x 100cc = 1000 cc

10Kg II ------- 10 x 50 cc = 500 cc

> 7Kg ------ 7 x 20 cc = 140 cc

jumlah = 1640 cc

-Macam Cairan Kebutuhan Na+ = 81 135 meq/ 24 jam.

-NS / PZ NaCl 0,9% - C I - Na+ 77 meq/fles-NaCl 0,45% in D5% -- C2 Na+38 meq/fles

-NaCl 0,225% in D5% C4 Na+19 meq/fles-NaCl 0,18 % in D5% C5 Na+ 10 meq/fles

-Macam cairan -C2 3 fles Na+ 114 meq jumlah 1.500 cc-D 5% 140 cc Jumlah 140 cc

- Total 1.640 cc

-Tetesan : Otsuka : 1640 X 15 = 1640 = 16 - 18 tts/m

- 24 X 60 96

-Terumo : 1640 X 20 = 1640 = 22 24 tts/m

- 24 X 60 96


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Perdarahan ..

1. VOLUME DARAH EFEKTIF (Effective bloodvolume/flow)

70

75 cc/kgBB 60 65 cc/kgBBAnak2 90 100 cc/kgBB

2. 15 % EBV/F hilang hypoxia (+) nadimeningkat

3. 25 % EBV/F hilang syok.

C


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Case..

Pasien laki2 BB 50 kg di IRD karena KLL dan

perdarahanWaktu masuk: N 100 x/m T 120/80 RR 24 x/m

Perhitungan : N 100 x/m pasien perdarahanHypoxia (+) kira2 15 % dari EBV/F

BB 50 kg EBV 70 X 50 cc = 3.500 cc

Darah yang hilang 15 % = 15/100 X3.500 = 525 cc

Cairan yang dimasukkan, RL = 4 X 525cc 2.100 cc


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Fluid & Electrolytes Management.ppt

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