Sie sind auf Seite 1von 139

FLUID AND ELECTROLYTE

BALANCE

Dr. SUNDEEP SHARMA (MDS


1st yr)
Dept. Of Oral & Maxillofacial
Surgery

MODERATOR
Dr. ALOK
BHATNAGAR
( READER )

Balance

CONTENTS

INTRODUCTION
REGULATION OF BODY FLUIDS
COMMON DISTURBANCES IN ELECTROLYTES BALANCE
ACID BASE REGULATORS
CAUSES OF FLUID VOLUME DEFICETS
PATHOPHYSIOLOGY OF FLUID VOLUME DEFICITS
PATHOPHYSIOLOGY OF FLUID VOLUME OVERLOAD
PRINCIPLE OF FLUID THERAPY
CLASSIFICATION OF IV FLUIDS
METHODS OF DELIVERING IV FLUIDS
CALCULATION FOR ROUTINE IV SET
FLUID THERAPY IN SURGICAL PATIENTS
CONCLUSION
REFERENCES

OVERVIEW OF NORMAL FLUIDS &


ELECTROLYTES

BODY FLUIDS
Composed of water and
dissolved substances (solute)

WATER
- transport & exchange of
nutrients & metabolic wastes
- medium for metabolic
reactions within cells
- constitutes about 60% of the
total body weight.

Provides structural
form
shock absorber
Provides insulation
Lubricant
regulating body
temperature through
Evaporation and
Persipiration

Why women have less water


than men if they are the same
weight?
The water content of adipose (fat)
tissue is less than that of muscle,
while women have more adipose tissue
at the effect of feminine hormone.

Distribution of Body Solids & Fluids

BODY FLUID COMPARTMENTS


RULE OF THIRDS
1. Intracellular: 2/3
(40% TBW)
2. Extracellular: 1/3
(20% TBW)
a. Interstitial + Lymph: 2/3 (15% TBW)
b. Intravascular:
1/3 (5% TBW)

BODY FLUID DISTRIBUTION


Total body fluid is 60% of the body
weight.

1. INTRACELLULAR fluid (ICF) 40%


of the total body weight

2. EXTRACELLULAR fluid (ECF) 20%


of the total body weight

EXTRACELLULAR CELL- 20% of total body


weight
a. Interstitial fluid- 15% of the total body
weight. Located in the spaces between
most of the cells of the body.
b. Intravascular fluid- 5% of the total body
weight. It is a plasma fluid, contained
within the arteries, veins and capillaries.
c. Transcellular fluid - includes urine;
digestive secretions; perspiration; and CSF,
pleural; synovial; intraocular, gonadal, and
pericardial fluids.
A trace amount of water is found in bone,
cartilage, and other dense connective
tissues; this water is not exchangeable
with other body fluids.

What separates these


different compartments?

1. Cell membranes- separate interstitial


fluid from intracellular fluid.

2. Capillary membranes- separate plasma


from interstitial fluid

3. Epithelial membranes- separate


transcellular fluid from interstitial fluid and
plasma. It includes mucosa of the
stomach, intestines, gallbladder, pleural,
peritoneal, synovial membranes, and
tubules of the kidney.

Body weight
varies:
Age, gender, amount of body fat

Body water decreases when age


over 65 about 45-50%

Note: To maintain normal fluid balance,


body water intake and output should
be approximately equal.
NOTE: Body fluids contain both water
molecules & chemical compounds
can either remain intact in solution
or
separate (dissociate) into discrete
particles.

BODY FLUID MOVEMENT

Four chemical and


physiologic processes control
the movement of fluid,
electrolytes and other
molecules across membranes
between the intracellular and
interstitial space and the
interstitial space and plasma.

These processes are


osmosis, diffusion,
filtration, and active
transport.

Osmolarity and Osmolality.


Osmolarity refers to the amount of solutes
per liter of solution (By volume). In
milliosmoles per liter (mOsm/L)
Osmolality refers to the number of solutes
per kilograms of water (By weight); In
milliosmoles per kilograms (mOsm/kg)
Note: Osmotic activity in the body is regulated
by the number of active particles (solutes)
per kilogram of water, osmolality is used to
describe the concentration of body fluids.

Body weight is the best way to


measure body fluid

- Normal Value of
osmolality in ICF and ECF
ranges between 275-295
mOsm/kg.

- Osmolality of ECF
depends on the value of
sodium (NA+)
concentration.

1. OSMOSIS
Movement of water across
selectively semi permeable
membrane from an area of lower
solute concentration to an area
of higher solute concentration.
Osmosis continues until the
solute concentration on both
sides of the membrane is equal.
a. Osmotic Pressure the
power of a solution to draw water
across membrane.
Ex. Fluids in IVS & Interstitial
space is essentially same
except for the higher
concentration albumin in plasma.
This exert osmotic pressure,
pulling fluid from the Interstitial
space towards the IVS, to hold
water inside vascular system.

Tonicity refers to the effect


of the solutions osmotic
pressure has on water
movement across the cell
membrane of cells within
that solution.

Types of Tonicity
A. Isotonic solution

- solutions had the same

concentration of solution as in plasma. Cells placed in the


isotonic solution neither shrink nor swell as there is no gain or
loss of water within the cell.
No change in cell volume.

Ex. Normal saline solution (0.9% sodium chloride solution)

21

ISOTONIC SOLUTIONS
0.9% Sodium
Chloride Solution
Ringers Solution
Lactated Ringers
Solution

B. Hypertonic Solution - solutions have a greater


concentration of solutes than in plasma. In
their presence, water is drawn out of the cell,
causing them to shrink.

Ex. A 3% sodium chloride solution is hypertonic.

HYPERTONIC SOLUTIONS
3% SODIUM CHLORIDE
5% SODIUM CHLORIDE
WHOLE BLOOD
ALBUMIN
CONCENTRATED
DEXTROSE (>10%)

24

C. Hypotonic Solution - solutions have a lower

solute
concentration than in plasma. When red
blood cells are
placed in a hypotonic solution,
water moves into the cells, causing them to swell
and rupture (hemolyze).
Ex. 0.45% sodium chloride has a lower
concentration of solute than plasma.

HYPOTONIC SOLUTIONS
5%DEXTROSE &
WATER
0.45% SODIUM
CHLORIDE
0.33% SODIUM
CHLORIDE

26

The concept of osmotic draw and tonicity


are important in understanding the
pathophysiologic changes that occur with
fluid and electrolyte imbalances, as well as
the treatment measures.

Ex. An increased sodium concentration of


ECF causes water to shift from ICF to ECF
compartment.

In this case administering a hypotonic


intravenous solution will facilitate water
movement back into the intracellular space.

2. Diffusion
The process by which solute molecules
move from area of high
solute
concentration to an area of low solute
concentration to become evenly distributed.

Diffusion - The process by which solute molecules move from area of


high
solute concentration to an area of low solute
concentration to
become evenly distributed.

2.1 Types of Diffusion

a. Simple diffusion occurs by the random


movement of particles through a solution.
(water, carbon dioxide, oxygen, and
solutes move between plasma and
interstitial space by simple diffusion
through the capillary membrane.

b. Facilitated diffusion also called a


carrier- mediated diffusion, allows large
water- soluble molecules, such as glucose
and
amino acids, to diffuse across cell
membranes.

Proteins embedded in the cell membrane


function as carriers, helping large
molecules cross the membrane.

The rate of diffusion is influenced by a


number of factors, such as concentration
of solute and the availability of
carrier proteins in the cell membrane.

The effect of both simple and facilitated


diffusion is to establish equal
concentration of the molecules on both
sides of a membrane.

3. Filtration (Hydrostatic Pressure) -

The process by which water dissolved


substances
(solutes) move from an area of
high hydrostatic pressure to an area of low
hydrostatic pressure.
Capillary Bed
Arterial side of the
capillary

Venous side of the


capillary

Hydrostatic Pressure
(arterial blood
pressure)

Direction of fluid
And solute movement

Osmotic Pressure
(colloid osmotic
pressure)

Interstitial
Space

Direction of fluid
And solute
movement

These usually occur across capillary


membranes. Hydrostatic pressure
is created by the pumping action of
the heart and gravity against the
capillary wall.
Note: Fluid balance between the IVS
and interstitial spaces is maintained
in the capillary beds by a balance of
filtration at the arterial end and
osmotic draw at the venous end.

4. Active Transport - allows molecules to


move across cell membranes and
epithelial membranes against a
concentration gradient.

This movement requires energy (adenosine


triphosphate, or ATP) and a carrier mechanism
to maintain a higher concentration of a
substance on the other side of the membrane
than on the other.
High concentration of K+ in ICF and Na+ in
ECF fluids are maintained because cells
activity transport K+ from interstitial fluids.
(where the k+ concentration is about 150
mEq/L).

Active Transport
Interstitial
fluid
Na+

Na+
Na+

K+

Na+

Na+
Na+ Na+

K+

K+

Na+

K+

Na+

K+

Na+

Na+
K+

K+
K+

Na+

Na+

K+

K+
K+
Na
+

Intracellular fluid

The sodum-potassium pump. Sodium and potassium ions are


moved across the cell membranes against their concentration
gradients. This active transport process is fueled by energy from
adenosune
triphosphate (ATP).

BODY FLUID REGULATION

Homeostasis requires several


regulatory mechanisms and processes
to maintain the balance between fluid
intake and excretion.
These include thirst, the kidneys, reninangiotensin-aldosterone mechanism,
anti-diuretic hormone (ADH), and atrial
natri-uretic factor (ANF).
These mechanisms affect the volume,
distribution and composition of body
fluids.

1. Thirst Mechanism

The effect after drinking.

2. Renin-Angiotensin-Aldosterone
Systemit works to maintain intravascular fluid balance
and blood pressure.
Renal Perfusion

Glomerular filtration rate

Renin produced

Angiotensinogen converted to
Angiotensin I

Angiotensin I
Converted to
Angiotensin II
In the lungs

Secretion of
Aldosterone in the
Adrenal cortex

Absorption of
Na+
Absorption of
H2O
Excretion of K+
Excretion of H+
ions

KIDNEYS
- Are primary responsible for regulating fluid
volume and electrolyte balance in volume and
osmolality of body fluids by controlling the
excretion of water and electrolytes.
- About 99% glomerular filtrate is reabsorbed,
and only about 1500 ml of urine is produced over
a 24-hour period.

4. ANTIDIURETIC HORMONE

Regulates water excretion from the kidneys.


Osmoreceptors in the hypothalamus
respond to increases in serum osmolality
and
decreases in blood volume,
stimulating ADH production and release.

2 disorders of ADH production


a. Diabetes insipidus deficiency of ADH.
b. SIADH excess in ADH release.

Blood pressure
Blood urine
Blood osmolality

Osmo receptors in
Hypothalamus stimulate
Posterior pituitary to
secrete ADH

ADH increases distal


Tubule permeability to
reabsorption of H2O

Urine output
Blood pressure
Blood volume
Blood osmolality

5. ATRIAL NATRIURETIC FACTOR (ANF)


It is a hormone released by atrial muscle cells in
response to distension from fluid overload.

ANF affects several body systems: the cardiovascular, renal, neural, gastrointestinal, and
endocrine systems., but mainly the renin-agiotensinaldosterone system.

ANF opposes the system by inhibiting renin secretion


and blocking the secretion and sodium-retaining
effects of aldosterone.

It promotes sodium wasting and diuresis (increase


urine output) and causes vasodilation, which all help
in reducing blood pressure.

DIAGNOSIS

A. FLUID VOLUME DEFICIT


Decreased Cardiac Output;
Ineffective Tissue Perfusion; Risk for
Injury.

B. FLUID VOLUME EXCESS


Risk for Impaired Skin Integrity; Risk
for Impaired Gas Exchange; Activity
Intolerance

A. FLUID VOLUME DEFICIT is a decrease


in
intravascular, interstitial, and/or
intracellular fluid in the body.

Note: Third spacing (fluid shift)


shift of fluid from the vascular
space into an area where it is not
available to support normal
physiologic processes.

The trapped fluid is considered a


fluid loss. Assessment of fluid is
maybe difficult and might not be
reflected by changes in weight or
intake and output records.

Phases of Third Spacing


First phase- LOSS

Immediately following surgery or trauma; 48-72 hours


Increased capillary permeability
Allows protein leakage in area
Fluid shifts from vascular to interstitial space.
Patient may become hypovolemic
Decreased blood pressure
Increased pulse rate
Decreased urine output
Increased urine specific gravity

LOSS
Total intake > total output; reflects
massive leak of fluid;
IMPORTANT: replace lost proteins by
giving albumin or plasmanate
(Plasmanate contains 5 g selected
plasma proteins buffered with sodium
carbonate)
In managing colloid replacement, give
diuretic to pull tissue fluid into vascular
space for renal excretion

Goals during LOSS phase


Prevent hypovolemia:
Monitor blood pressure, pulse, urine output
Precise reporting
Replace fluids as soon as it is ordered
Monitor potassium if diuretics used
Prevent renal failure:
Monitor renal function
Blood Urea & Creatinine
Weigh patient daily
Quantity of urine reflects vascular volume
Quality of urine reflects kidney function

Second phase:
Reabsorption
After healing, fluid in tissues begin to be
reabsorbed back into vascular area
Recognized by increased urine output
Limit amount of external replacement
May see weight loss
Watch for circulatory overload
Rale (an abnormal rattling sound heard
when examining unhealthy lungs with a
stethoscope
Shortness of breath
Distended neck veins

Causes: fluid losses, insufficient fluid intake,


or
failure of regulatory
mechanisms, fluid
shifts within the
body.

A)Fluid losses

Vomiting
diarrhea
intestinal fistulas
Burns

b. failure of
regulatory
mechanism kidney
disorders, endocrine
disorders
c. excessive exercise
or increased
environment
temperature causing
excess sweating.
d. hemorrhage (loss
of blood)
e. chronic abuse of
laxatives and/or
enemas
drugs ex. Diuretics

Causes

Inadequate intake
lack of fluids
Inability to
swallow fluidsdue to oral
trauma
Altered thirst
mechanism

Multisystem Effect of Fluid Volume


Deficit (FVD)

1. Mucous Membrane dry, sticky, longitudinal


furrows

2. Urinary urine output (oliguria)


FVD)
urine specific gravity

3. Musculoskeletal fatigue caused due to FVD.

4. Neurologic Altered mental status; anxiety,


restlessness; diminished alertness/cognition;
possible coma in cases of severe FVD.

(severe

Altered
mental
status is
most
evident
to
patient
with
water
and
sodium
imbalanc
e

5. Integumentary diminished skin turgor, dry


pale skin and cold extremities.

6. Cardiovascular tachycardia and


hypotension in cases of moderate FVD
falling systolic/diastolic pressure in Severe
FVD,
flat neck veins, decrease venous filling,
decrease pulse volume( weak pulse), decrease
capillary refill, increase hematocrit value

7. Potential complication hypovolemic shock

8. Metabolic processes body temperature


(isotonic FVD), increase body temperature
(dehydration), thirst, weight loss
>2% mild FVD; >5% moderate FVD; >8%
severe FVD.

Diagnostic Tests

1. Serum electrolytes In an
isotonic fluid deficit, sodium
levels are within normal
limits; when the loss is water
only, sodium levels are high
K+ are common.
2. Serum osmolality
Differentiates isotonic fluid
loss from water loss. With
water loss, osmolality is
high; it may be within
normal limits with an
isotonic fluid loss.
3. Serum hematocrit- The
hematocrit often is elevated
due to loss of intravascular
fluid

4. Urine specific gravity and osmolality as


the kidneys conserve water, both specific
gravity and osmolality of the urine

5. Central venous pressure (CVP)


measures the mean pressure in the superior
vena cava or right atrium, providing an
accurate assessment of fluid volume status.

Primary Goal to prevent deficits in

patients at risk and to correct deficits and


their underlying causes too.

Manageme
nt:and output
Assess intake

collect assessment data


through the health history
interview and physical
examination.
Assess vital signs- BP, Pulse,
temperature.
Weigh the patient daily
Monitor the intake of oral
fluids as prescribed.
Oral fluid replacement is
preferred when the patient is
able to drink and retain
fluids.

Administer
intravenous fluid.
Monitor for
indicators of fluid
overload.
Monitor laboratory
values.
Replacement of
electrolytes
through
intravenous, oral
routes etc.

Home Care:

Maintaining adequate fluid intake


learn how to monitor fluid
imbalance.
How to prevent fluid deficit
avoid exercise in extreme heat
increase fluid intake during hot
weather.
when vomiting take small
frequent amount of ice chips,
clear liquid, ice tea, flat cola, or
ginger ale; Reduce intake of
coffee, tea, and alcohol.
(dehydrating agents).
Replacement of fluid lost in
diarrhea with clear fluids like
juice, coconut water etc and ORS
Solutions.
Alternate sources of fluid; gelatin,
frozen fruits, or ice cream.

B. FLUID VOLUME EXCESS results when


both the water and sodium are retained in
the body.
Other

associated diagnosis are:


Risk for Impaired Skin Integrity.
Risk for Impaired Gas Exchange.
Activity Intolerance.
Causes:
It maybe caused by fluid overload (excess
water and sodium intake) or by impairment of
the mechanisms that maintain homeostasis.
The excess fluid can lead to intravascular
fluid (hypervolemia)and interstitial fluid
(edema).

a.

Organ Failure Heart


failure, liver cirrhosis, renal
failure, adrenal gland
disorders.
b. Drugs corticosteroid
administration
c. Stress conditions causing
the release of ADH and
aldosterone
d. Excessive intake of food
high in sodium content
e. Excess administration of
IVF containing high
concentration of sodium
content

Manifestations
:
1. Increase in total body water causes
weight gain (more than 5% of body weight)
over a short period.
2. Circulatory overload causes
manifestations such as:- Full, bounding pulse(pounding or racing)
- Distended neck and peripheral veins
venous pressure
- Cough, Dyspnea (labored or difficult
breathing)
orthopnea (difficulty in breathing
when in supine).

- Moist crackles (rales) in the lungs,


pulmonary
edema
Urine output (polyuria)
- Ascites (excess fluid in the peritoneal cavity)
- Peripheral edema, ANASARCA (generalized
edema)
- Dilution of plasma by excess fluid causes
Hematocrit value
- Possible cerebral edema can lead to altered
mental status.

Diagnostic Tests:

1. Serum electrolytes and serum osmolality


serum osmolality usually remain within normal
limits.

2. Serum Hematocrit and Hemoglobin often are


due to plasma dilution from excess extracellular fluid.

Additional tests of renal and liver function ( such as


KFT, serum creatinine, BUN (blood urea nitrogen)and
LFT) may be ordered to determine the cause of fluid
volume excess.

Primary Goal focuses on prevention in patients at


risk, treating and correcting the underlying causes.

Management

Monitor vital signs, heart sounds, CVP, and volume


peripheral arteries.

Presence and extent of Edema, particularly in lower


extremities, the back, sacral, and peri-orbital areas.

Obtain daily weights.

Administer oral fluids cautiously, adhering to any


prescribed fluid restriction.

Provide oral hygiene it contributes to client


comfort

Educating client and family members


about the sodium-restricted diet.

Administer prescribed diuretics.

Proper position of patient- support


pillows on extremities.

Semi 30-45degree) to
high-fowlers ( 60 degree) position for
dyspniec patient.

Monitor oxygen saturation


levels(Spo2) for evident impaired
gas exchange.

Monitor laboratory values, including


electrolytes level

ELECTROLYTE
BALANCE

Are substances
that dissociate in solution
ELECTROLYTES
to form charged particles called ion.
Cations are positively charged ions.
Anions are negatively charged electrolytes.
Example:
(NaCl) in solution dissociates into :
a sodium ion, a cation carrying a
positive charge (Na+)

and a chloride ion, an anion carrying a


negative charge (Cl-)

Functions of Electrolytes:

Assist in regulating
water balance.
Help regulate and
maintain acid-base
balance
Contribute to
enzymatic reactions.
Are essential for
carrying out
neuromuscular activity.

VALUES
mEq/L and mg/dL:
Note: Concentration of electrolytes in body fluids

generally is measured in milli equivalents per liter of


water (mEq/L).

Ex. 100 mEq of (Na+) can combine with 100


mEq/L of (Cl-) to form (NaCl).
Note: Other electrolytes are measured by weight in
milligrams per 100 ml
(1 deciliter) of water (mg/dL).

Ex. Calcium, magnesium and phosphorus are


often measured by weight in milligrams per
deciliter.

NORMAL VALUES FOR ELECTROLYTES


AND SERUM OSMOLALITY

Sodium
Normal level : 135-145mEq/L.
It is the single most abundant electrolyte in the
ECF
Holds a central position in fluid and electrolyte
balance
It is the only electrolyte exerting significant
osmotic pressure
Sodium salts:
Account for 90-95% of all solutes in the ECF
Contribute 280 mosm of the total 300 mosm ECF
solute concentration
Regulated by dietary intake, aldosterone & kidneys

Hyponatremia
(Na < 135mEq/L)
Occurs with net loss of sodium or net water
excess
Kidney disease with salt wasting, adrenal
insufficiency, GI losses, increased
sweating,
diuretics.
S&S: Altered mental status, postural
hypotension, postural dizziness, abdomen
cramping, diarrhoea, tachycardia,
convulsions and coma

Treatment
Determine if hyponatremia
Acute
Chronic
Acute serum sodium
<110-115mEq/Lt
Symptomatic - Seizures
Coma
Rapid correction
Till serum sodium 120125mEq/Lt

If it is asymptomatic
gradual correction over 48
hrs

Hypernatremia
(Na > 145mEq/L)
Caused by
- Increased water
loss
- Water deprivation
- Excess salt intake
- Hypertonic
solutions
- Excess
aldosterone
- Diabetes
Insipidus

Correction of
Hypernatremia
Treat the underlying
cause

cause
Asymptomatic
5% dextrose in
H2O
0.45% Saline
preferable in
hyperosmolar
diabetic coma.
Very large volumes
of 5litres a day
may be needed to

Symptomatic
Serum sodium >
160mEq/Lt
Serum osmolality >
350mOsm
Treatment
1. 0.9% saline to correct
volume deficit after
volume restoration
changed to a hypotonic
I.V. fluid
2. Correct over a period of
48 hrs as rapid

Potassium
Major cation in intracellular compartments
Regulates metabolic activities, necessary for
glycogen deposits in liver and skeletal muscle,
transmission and conduction of nerve impulses,
normal cardiac conduction and skeletal and smooth
muscle contraction
Regulated by dietary intake and renal excretion
Normal level 3.5-5.0mEq/L
Body conserves potassium poorly
Increased urine output decreases serum K +
- For every 3 k+ ions going out 2 Na+ ions and 1 H+
enter the cell resulting in intracellular acidosis and
extracellular alkalosis

Potassium Balance

Clinical Signs and Symptoms


1. Cardiac
Flattened T wave.
Dysarrhythmias
ST depression
Hypotension
2. Neuromuscular
Weakness
Respiratory failure
Confusion
3. Renal
Polyurea
Metabolic alkalosis
Decreased GFR
4. Metabolic
Glucose intolerance
secondary to decreased
insulin release

Treatment
Correction of alkalosis/acidosis, Volume deficits
1. Other electrolyte disturbances.
2. Replace GI fluids upto upper limits of loss if person has
normal
renal function.
4. Oral supplements : Increased intake of fresh fruits and
vegetables
or potassium supplements of 20 to 40mmol daily.
5.

Patients with high renal losses (use potassium

Remember

In emergency situation 20-40mEq / hr of potassium


can be given with frequent monitoring of cardiac
status and serum potassium levels.
In non-emergency situations 10mEq of potassium / hr
Use glucose free solutions as glucose drives
potassium intracellularly.
In the absence of specific indications potassium
should not be given
1. To oliguric patients
2. During the first 24 hours following severe
surgical stress or trauma.

Hyperkalemia (K+ > 5.3mEq/L)

Clinical Signs and


Symptoms
-

Cardiac
1.
2.
3.
4.
5.
6.
7.

Peaked T wave
QRS widening.
ST depression
Bradycardia
Heart block
Asystole
Ventricular fibrillation

Neuromuscular
1.
2.

Weakness
Paresthesia

Respiratory Faliure

Diagnosis
ECG changes
Serum potassium level

ECG Feature

Hypokalaemia

Hyperkalaemia

P wave

Normal / amplitude

QRS interval

Wide with normal shape wide & slurred

QT interval

Normal

T wave

flat or inverted

Tall, tent like

/ absent

MANAGEMENT OF SEVERE
ACUTE HYPERKALAEMIA (K+ >
7mmol/L)
Identify and treat cause
Specially check renal function
10 20 mL intravenous 10% Calcium Chloride/ Calcium
Gluconate over 10 min in patients with ECG abnormalities
50 mL 50% dextrose plus 10 units short acting insulin over 23min
Monitor plasma glucose and K+ over next (30-60 min)
Regular Salbutomol nebulizers
Consider oral or rectal Ca+2
Resonium (ion exchange resin)
Haemodialysis for persistent hyperkalemia.

Calcium
Stored in bone, plasma and body cells
90% in bones
1% in ECF
In plasma, binds with albumin
Necessary for bone and teeth formation, blood
clotting, hormone secretion, cell membrane integrity,
cardiac conduction, transmission of nerve impulses,
and muscle contraction
Normal level 4.5-5.5mEq/L or 8 11 mg%
Regulated by
Calitonin
Paratharmone
Calcitriol

Hypercalcemia (Ca+2 > 5mEq/L)


> 15mg %
Frequently symptom of underlying disease with excess
bone resorption and release of calcium
Hyperparathyroidism, malignant neoplastic disease,
Pagets disease, Osteoporosis, prolonged
immobization, acidosis
S&S: anorexia, nausea and vomiting, weakness, kidney
stones
Diagnosis
Radiographs show bone resorbtion
Cardiac irregularities

Hypocalcemia (Ca+2 < 4.0mEq/L)


Seen in - severe illness

- hypoalbuminemia,
hypoparathyroidism
- Vitamin D deficiency,
Pancreatitis, Alkalosis
- Massive blood transfusion with
citrate
S&S: numbness and tingling, hyperactive
reflexes,

Chloride Balance
Major anion in ECF
Normal level 95-108mEq/L
Follows sodium
Regulated by dietary intake and the kidneys
Disturbance usually seen with acid-base imbalance
Hyperchloremia (Na >145, Bicarb <22)
Serum bicarbonate values fall or sodium rises
Hypochloremia (pH > 7.45)
Excess vomiting or N/G drainage; loop diuretics
because of sodium excretion
Leads to metabolic alkalosis due to
reabsorption of bicarbonate to maintain
electrical neutrality .

Magnesium Balance
Normal conc. 1.5 2.4 mg%
Essential for proper functioning of enzyme systems
Depletion characterised by neuromuscular & CNS
hyperactivity.

Mg+2
Chvostek & Trousseau sign
PR & QT interval
Treatment
if < 1.5mg% = 1 mEq/ Kg
if 1.5 1.8mg% = o.5mEq/ kg

Mg+2
Respiratory Depression
BP, Cardiac arrest, Hyporeflexia
Treatment
-Calcium Infusion
-Loop diuretics with NS
-MgCl2 / MgSo4

Chvostek & Trousseau sign


TheChvostek signis a clinicalsignof existing nerve hyperexcitability
(tetany) seen inhypocalcemia.When thefacial nerveis tapped at the
angle of the jaw (i.e.masseter muscle), the facial muscles on the
same side of the face will contract momentarily (typically a twitch of
the nose or lips) because ofhypocalcemiawith resultant
hyperexcitability of nerves. Though classically described in
hypocalcemia, this sign may also be encountered in
respiratory alkalosis , such as that seen inhyperventilation.
Trousseau sign is amedical signobserved in patients with
hypocalcemia.
A blood pressure cuffis placed around the arm and inflated to a
pressure greater than thesystolic blood pressure and held in place for
3 minutes. This will occlude thebrachial artery. In the absence of
blood flow, the patient's hypocalcemia and subsequent neuromuscular
irritability will induce spasm of the muscles of the hand and forearm.
The wrist andmetacarpophalangeal joints flex and the fingersadduct.

Solute Overview
Intracellular v/s Extracellular
Ionic composition very different
Total ionic concentration very similar
Total osmotic concentrations virtually
identical
Osmolarity is identical in all body fluid
compartments

Principles of Body Water


Distribution

Body control systems regulate ingestion and


excretion:
- constant total body water
- constant total body osmolarity

Homeostatic mechanisms respond to changes in ECF


No receptors directly monitor fluid or electrolyte
balance.
Respond to changes in plasma volume or osmotic
concentrations

Classification of Body Fluid Changes


Disorders in the fluid balance are classified in three general
categories.

Disturbances of
- Volume
- Concentration
- Composition

ECF EXCESS
Renal insufficiency, Chronic heart faliure
Cirrhosis
Drugs NSAIDS, Mineralocorticiods
ECF is diluted sodium content is normal but excess
water is present called as Hypotonic Hydration
The resulting hyponatremia promotes net osmosis into
tissue cells, causing swelling.
These events must be quickly reversed to prevent
severe metabolic disturbances.

Disorders of Water Balance:


Hypotonic Hydration
1

Excessive H2O enters


the ECF

ECF osmotic
pressure falls

3 H2O moves into


cells by osmosis;
cells swell

ECF Deficit
CAUSES
1. Loss of GI fluids due to:
a. Vomiting
b. Diarrhea
c. Nasogastric suction
d. Fistular drainage
2. Soft tissue injuries and infections
3. Intra-abdominal and Intra-peritoneal
inflammatory
processes
4. Burns
5. Insensible losses
6. Sweat

Dehydration
1 Excessive loss of H2O from
ECF

ECF osmotic
pressure rises

3 Cells lose H2O


to ECF by
osmosis; cells
shrink

ECF Deficit : When salt depletion is greater, fluid loss is borne by ECF
Lab Test: Hematocrit value of 45% indicates an ECF deficit.
ICF Deficit : When water depletion is predominant, the greatest fluid loss
is sustained by the intracellular compartment
Lab Test :The sodium concentration is an indirect measure of the
fluid.
Higher sodium value indicates an ICF Deficit

Clinical Evaluation
Changes in body weight should be recorded accurately and
repeatedly on a day to day basis.
Weight loss > 300 to 500gms per day indicate dehydration
secondary to decreased fluid intake and / or increased
water losses.
Water loss Degree of Dehydration
4% of body wt
Mild
6%

Moderate
8%
Severe

Principles of Fluid Therapy


Whenever fluid therapy is contemplated in a patient,
the following basic questions must be
considered.
1. Does the patient need fluid..?
2. Which fluid would be most suitable..?
3. How much fluid is needed..?
4. At what rate..?
5. Which route is to be used..?
6. What are the likely complications..?

Does the Patient Need Fluids..


Pre-existing disease processes
Cancer, cardiovascular, renal, GI
Age
Infants have higher % water- loss felt faster
Elderly kidneys decreased filtration rate, less
functioning nephrons, dont excrete mediations as fast
Acute illness
Surgery, burns, respiratory disorders, head injury
Environmental
Vigorous exercise, temperature extremes
Diet
Fluids and electrolytes gained through diet
Medications
Side-effects may cause fluid and/or electrolyte
imbalances

Medications Likely to Cause


F&E Imbalances

Diuretics
Metabolic alkalosis, hyperkalemia, hypokalemia
Steroids
Metabolic alkalosis
Potassium supplements
GI disturbances
Respiratory center depressants (narcotic analgesics)
Respiratory acidosis
Antibiotics
Nephrotoxicity, hyperkalemia, hypernatremia
Calcium carbonate
Metabolic alkalosis
Magnesium hydroxide (Milk of Mag)
hypokalemia

Diagnostics
Hematocrit
If no anemia, can indicate hydration status
Blood creatinine
Measure kidney function
Excreted at constant level if no kidney disease
BUN
Indicates kidney function
May be affected by cell destruction or steroid therapy
Decrease may indicate malnutrition or hepatic
damage
Increases with decrease in ECF volume
Serum and urinary electrolyte levels
Urine specific gravity

Assessment of Intravascular
Depletion
5%

thirst, dry mucous membranes,


UO 1-2 ml/kg/hr

10%

tachycardia, oliguria,
UO 0.5-1 ml/kg/hr

15%-20% tachycardia, hypotension,


severe oliguria,
UO < 0.5 ml/kg/hr

What Fluids to Give..


Choice of a particular fluid depends on
Volume status
Concentration abnormality
Compositional abnormality

Crystalloids:
- contain Na as the main osmotically active particle
- useful for volume expansion (mainly interstitial
space)
- for maintenance infusion
- correction of electrolyte abnormality

Crystalloids

Isotonic crystalloids
- Lactated Ringers, 0.9% NaCl
- only 25% remain
intravascularly

Hypertonic saline solutions


- 3% NaCl
- 7% NaCl

Hypotonic solutions
- 0.45% NaCl
- less than 10% remain intravascularly, inadequate for fluid
resuscitation

Colloid Solutions
Contain high molecular weight
substances do not readily migrate
across
capillary walls
Preparations
- Albumin: 5%, 25%
- Dextran

Crystalloids and Colloids


Crystalliod

Colloid

Intravascular persistance

Poor

Good

Haemodynamic stabilisation

Transient
t1/2 ~ 30 mins

Prolonged
t1/2 ~ 90 mins

Required infusion volume

Large
Ratio 4:1 to loss

Moderate
Ratio 2:1 to loss

Risk of tissue oedema

Obvious

Insignificant

Enhancement of capillary perfusion

Poor

Good

Risk of anaphylaxis

Nil

Low to moderate

Plasma colloid osmotic pressure

Reduced

Maintained

Inexpensive

Expensive

Cost

What solution to give


Oral electrolyte solution:
This solution is isotonic and provides a rich source of Na +,
K+, Cl- and dextrose. The sodium citrate tends to correct any
acidosis.
IV fluids:
0.9% Sodium Chloride
- iso osmolar with plasma
- serves a good replacement solution for ECF volume
- chloride content - higher than that of plasma infusion
too much of normal saline may produce
hyperchloraemic acidosis
- indication : ECF def in the presence of hypernatremia,
hypochloremia & metabolic alkalosis

Dextrose 5% in Water

It provides 50gms of dextrose / L.

slightly hypertonic to plasma


after infusion dextrose is metabolized water is left in the ECF

too much of 5% dextrose may cause dilution and hypotonicity of


ECF and water loading, if kidneys are not functioning normally.

Dextrose 5% with 0.9% Saline.


Its twice as hypertonic as plasma

However within a few hours glucose is used and there is no


significant change in the plasma tonicity

Lactated Ringers Solution

This is slightly hypo osmolar compared to plasma

Minimum effect on pH & normal body fluid composition

Replaces both G.I. & ECF losses

Used in correcting metabolic acidosis.

Should not be given in patients with liver diseases and


in presence of lactic acidosis.

Ringers Acetate Solution


- slightly hypo osmolar to plasma
- main use is as a replacement for ECF deficits in patients
with damaged liver or lactic acidosis..
- helps in correction of mild to moderate metabolic
acidosis.

0.45% Sodium Chloride in 5% Dextrose


Solution
- It is used as maintenance fluid in postoperative period.
- Provides sodium for renal adjustment
- Potassium may be added to be used for maintenance requirements
in uncomplicated pt requiring only a short period of parenteral
fluids.

7.2-7.5 % Sodium Chloride


- Studies have shown that even with 50% blood loss, a small volume
of 7.2-7.5% NaCl restores the cardiac output and blood pressure
within one minute.
- This saline is given through a peripheral vein very fast over 2 to 5
mins. And this results in rise in the plasma sodium level and
plasma osmolality causing a shift of body water in the vascular tree

Practical Crystalloid Therapy


If you infuse NaCl 0.9% 1000ml, all the Na+
will remain in the ECF
As NaCl is isotonic there is no change in
ECF osmolality and no water exchange
occurs across the cell membrane
NaCl expands ECF only
Intravascular volume will be increased by
250ml

Practical Crystalloid Therapy


If you infuse glucose 5% 1000ml, the
glucose will enter the cell and be
metabolised
The water expands both ECF and ICF in
proportion to their volumes
The ECF volume will increase by 333ml
Intravascular volume will only increase by
approximately 100ml

Colloid Solutions
Human Plasma
- Used for resuscitation of shock patient and for
maintenance of I.V. fluid therapy
- It has a composition and osmolality similar to ECF.
Human Albumin
- 20% purified human albumin is commercially available. Its
volume
expansion capacity is 400 per cent.
- Rarely, anaphylactoid reaction has been reported with
albumin and
may cause post resuscitation hypotension.

Dextran
Its a polysaccharide in 0.9% NaCl / 5%
Dextrose
Two types
40 lasts for 6 hrs
70 lasts for 24 hrs
Facilitates agglutination of RBC. Thus
interferes with susequent cross matching of
blood

What Route to be Used..

As in normal health - 0ral Route.


- However when rapid correction of
hypovolaemia
and
other
electrolyte
abnormalities indicated i.v. route provides a quick
access to circulation.
- Other routes of parenteral therapy include
- Subcutaneous
- Per Rectal

Fluid Balance in Pre Op. Period


1. Correct 3rd space losses
2. Correct Na+ balance
3. K+ to be corrected only when adequate
urine output maintained
4. Check if blood replacement is required
5. Calculate Allowable Blood Loss
6. Prevention of volume depletion

Third Space Losses


Isotonic transfer of ECF from functional body fluid
compartments to non-functional compartments.
Depends on location and duration of surgical
procedure, amount of tissue trauma, ambient
temperature, room ventilation
Replacement of 3rd space losses
Minimum trauma : 3 4 ml / kg / hr
Moderate trauma : 5- 6 ml / kg /hr
Severe trauma : 7 8 ml / kg / hr
Surgeon must remember that by 72 hours post op.,
this 3rd space loss becomes mobilised which results in
increased intravascular volume

Intra Op. Fluid Management

If pre-op. volume deficit not addressed --- hypotension


3rd space losses to be addressed because of
Tissue Trauma
Extensive Dissection
May vary from min. to 3 Lt.
But no lab methods to exactly quantify fluid loss
So, clinically useful guidelines are
1. Replacement of ECF should begin intra op.
2. Blood should be replaced to maintain an acceptable RBC
mass irrespective of any additional fluid/ electrolyte
therapy
3. Balanced salt sol. needed intra op. ~ 0.5 1 Lt/ hr.
Only max. of 3 Lt. req. during 4 hr major abdominal
surgery

Post Op. Fluid Management

0 24 hrs.
Increased secretion of aldosterone & ADH
Na+ & water retention
If blood loss is there, replace it
Replace NPO fluid deficit
DNS or RL
Should not administer K+ unless definitive
deficiency present

24 48 hrs
Replace insensible losses which may vary
from
900 1500 ml/ hr because of
- Hyper Ventilation
- Fever
- Tracheostomy upto 1200 ml/ day
Loss replaced by DNS since kidneys conserve
Na+ even at this stage .
If N-G aspiration is going on then add 1 Lt. of
0.9 NaCl

48 72 hrs.
Replace insensible losses
Better to give isotonic DNS & RL
1 Lt Darrows solution to combat K+ loss. This is
more important if N-G aspiration is still going on
to cover K+ loss via GI secretions
Importance of I/O charts
Output = urine + vomitus + aspiration
Total this has to
+ 1000 ml insensible losses be replaced
+ 500 1000 ml sweating loss

Post Op. Urine Output

Oliguria is common in immediate post op. period


because
1. Surgical stress affects Adrenal Cortex
- increase ADH & Aldosterone
2. Insufficient post op. analgesia sympathetic
activity increased
3. General anesthetics decrease glomerular blood
flow & thus GFR
Persistent oliguria
< 20 ml / hr in adults
< 1 ml / hr / kg in children
If urine output < 0.5 ml / hr / kg for 3 or more hrs.
indicative of Acute renal failure

End Parameters for Fluid


Replacement Therapy
Monitoring urine output, heart rate, BP on repeated
basis and comparing them to measure fluid intake
assists in determining fluid requirement .
Normal urinary output
Adult 0.5-1 ml / kg / hr
Child 2 ml / kg / hr
adequate oxygen saturation

Fluid Regulation in Young


In neonates most significant source of water loss is insensible water
loss through skin ~ 7ml / kg / hr
Under normal renal function
Infants & neonates 2 ml / kg
Toddlers & school age 1 ml / kg
Daily K+ req. = 2mEq/ kg
Na+ req. = 3 mEq/ kg
Replacement by isotonic sol. with osmolality of ~ 285
Maintenance fluid rate
0 10 kg - 4 ml / kg / hr
10 20 kg - 40 ml + 2 ml / kg / hr
> 20 kg
- 60 ml + 1 ml / kg / hr

Blood Replacements
Blood weightage males 66 ml / kg
- females 60 ml / kg
Indications
1. If Hb. < 6 gm%
2. Ongoing fluid loss of 100 ml/ hr
3. Severe Haemorrhage
4. Give early in active bleeding
Hemodilution
Indicated in surgeries where intra op. blood loss of 2 or
more units is anticipated.
Removal of arterial/ venous blood pre op. followed by
plasma volume restoration with crystalloids/ colloids
Blood reinfused only after cessation of bleeding

Conclusion
Surgical management & medical
management of oral and maxillofacial surgery
patients are intertwined intimately.
The management of fluids & electrolytes &
the usage of blood products are governed by
basic principles outlined in this seminar.
A favourable surgical outcome is predicated
on optimal comprehensive care.

Assessment of intravascular
depletion
5% Deficit thirst, dry mucous membranes,
UO 1-2 ml/kg/hr
10%

tachycardia, oliguria,
UO 0.5-1 ml/kg/hr

15%-20% tachycardia, hypotension,


severe oliguria,
UO < 0.5 ml/kg/hr

Fluid loss in different types of


surgery
Type of surgery
Least trauma

Fluid volume { ml/kg/hr }


only maintenance fluid

Minimal trauma

Moderate trauma

Severe trauma

1o

Helen G, Lee C, Jason A, Peter. Fluid and electrolyte management. Oral


maxillofacial Surg Clin N Am 18 (2006) 7 - 17

Maintainance of fluids
Holiday Segar formula:
4ml/kg for 1st 10kg body wt.[wt.X4ml/hr]
2ml/kg for the next 10kg body
wt[40+2Xwtml/hr]
1ml/kg of body wt over20kg [60+1Xwt ml/hr]

4/2/1 Rule
4 ml/kg/hr for first 10 kg (=40ml/hr)
then 2 ml/kg/hr for next 10 kg (=20ml/hr)
then 1 ml/kg/hr for any kgs over that
This always gives 60ml/hr for first 20 kg
then you add 1 ml/kg/hr for each kg over 20 kg

This boils down to: Weight in kg + 40 =


Maintenance IV rate/hour.
For any person weighing more than 20kg

4/2/1 rule a.k.a


Weight+40
I prefer the 4/2/1 rule (with a 120
mL/h limit)

Maintenance of
fluids
For the first 0 to 10 kg give 100
ml/kg/day
For the next 10 to 20 kg give an
additional 50ml/kg/day
For weight > 20 kg give 20 ml/kg/day.

Intra OP Fluid Replacement :


Guidelines
Correction fluid deficit due to starvation :
= duration of starvation in hours X 2
ml/kg

+
Maintenance Requirement for the period of
surgery :
= duration of surgery in hours X 2 ml/kg

+
Correction of operative loss

REFERENCES :

Human Anatomy & Physiology Marieb .


Bailey & Love short practice of surgery.
Text Book Of Surgery -S.Das
Helen G, Lee C, Jason A, Peter. Fluid and electrolyte
management. Oral maxillofacial Surg Clin N Am 18
(2006) 7 17
Principles of Surgery Schwartz
Principles of Surgery Sabiston
Essentials of Human Anatomy & Physiology Marieb
Human Physiology A. K. Jain

REFERENCES :
Fluid And Electrolytes Physiology Alan .D .Kaye &W. Grogono
Fluid And Electrolytes & Shock Richard Mullins
Text Book Of Physiology Sherwood
Guidelines On Fluid Balance Dr .
Sanjay Pandey
Disorders Of Fluid & Electrolute
Balance Glen Matfin & Carol Porth

THE END

Thank you