Beruflich Dokumente
Kultur Dokumente
Imbalance
Ali Hallal, MD, FRCS
Assistant Professor of Clinical Surgery
AUBMC
Wat
er
Intracellular
Volume 40%
Volume of
TBW
Female (60
Kg) (50%)ml
Plasma
3500
2500
Interstitial
10500
7500
Extracellular
ECF
14000
Intracellular
28000
20000
42000
30000
8%
10000
Body weight %
Total
60
100
Intracellular
40
67
Extracellular
20
33
Intravascular
15
25
Interstitial
Transcellular
153
mEq/L
Cations
153 mEq/L
153
mEq/L
153 mEq/L
Anions
Cations
Anions
200
mEq/L
200 mEq/L
Cations
Anions
K+
15
HPO430
150
SO42-
Na/K
Pump
Na+
H
14
2
Cl-
10
3
HCO3-
27
SO42PO43K+
Ca2
Mg2
+
Na+ 144
K+
Cl-
114
HCO3-
30
SO42PO43-
Organ
ic
acids
Protei
n
16
Ca2
Mg2
+
10
Protei
n
40
Organ
ic
acids
Mg2+
40
Protei
n
Na+
10
HCO3-
Disturban
ce of Body
Fluid
Volume
Concentrati
on
Compositio
n
Adding NS to ECF will have little effect on ICF but will expand ECF volume
Adding H2O will to ECF will casue water to shift between ECF and ICF and thus
Adding
K+the
willconcentration
affect neitherofvolume
nor concentration
of other solute but will have maj
changing
electrolytes
in compartments
effect on myocardial function
Extreme of ages.
Volume deficit
Volume gain
Generalized
Weight loss
Weight gain
Peripheral edema
Tachycardia
Increased CO
Orthostasis
Increased CVP
Cardiac
Murmur
Renal
Oliguria
Azotemia, urine Na <
20meQ/ L
Urine Osm > Plasma
Osm
GI
Pulmonary
Ileus
Bowel edema
Congestion
Iatrogenic
Renal Dysfunction
Congestive heart failure
Cirrhosis
Elderly
patients > 65
y
All affected
All affected
Infection,drugs
depression,
hypothyroid
Volume Change
Osmorecept
or
Thirst
Diuresis or
Water
Retention
(vasopressin)
Barorecepto
rs
Neural (symp
parasympathe
tic)
Hormonal
(ReninAngiotensin,
ADH
NG Losses
Vomitting
Diarrhea
Enterocutaneous Fistula
Sequestration
Soft tissue injuries
Burns
Peritonitis
Obstruction
Postoperative bleeding
concentration
changes
[Na+]
[K+]
[Cl-]
[HCO3]
135150
3.5-5
98-106
22-30
10002000
10-150
4-12
120160
Bile
300-800
120170
3-12
80-120
30-40
Pancreas
600-800
135150
3.5-5
60-100
35-110
20003000
80-150
2-8
70-130
20-40
50-100
10-30
80-120
25-30
30-50
30-50
Plasma
Stomach
S.Intestine
Colon
Perspiratio
Maintenance
electrolyte
Maintenance fluid
Fluid Order
Correction for
electrolyte
disturbances
1500mL/m2
sodium
50-75mEq/m2
potassium
50mEq/m2
chloride
50-75mEq/m2
Calculated
by body
weight
Children
1st
10kg:100mL/k
g
2d
>20kg:
10kg:50mL/kg 20mL/kg
Adults
2555yr:35mL/kg
5565yr:30mL/kg
Sodium
1.0-1.5 mEq/kg
>65yr:25mL/k
g
Solution
Na
Cl
ECF
14
2
10
3
LR
13
0
10
9
0.9% NaCl
15
4
15
4
308
D5 0.45% NaCl
77
77
407
253
51
3
51
3
1026
D5W
3% NaCl
Ca
Mg
mOsm
27
280310
28
273
Osmolality / Tonicity
Osmolality
Tonicity
The concentration of
osmotically active
particles in Solution
Osmolality / Tonicity
Both impermeant and permeant
solute can contribute to
hyperosmolar or hyoposmolar state.
However hypososmolar states are
always accompanied by hypotonicity,
whereas hypersomolar state are not
always associated with hypertonicity
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Hyponatremia
Sodium
Na+ is main cation of ECF
Always coupled to water
Normal serum [Na+] = 135 145
mEq/L
Hyponatremia - Causes
Common surgical causes include
most
common
PREVENTAB
LE
Iatrogenic
SIADH: closed head injury(CHI),
post bleeding
GI obstruction
GI fistulae
Acute gastric dilatation
Severe protracted diarrhea
Acute pancreatitis. Peritonitis.
Pleural effusion
post craniotomy,
R/O
hypothyroidism
and adrenal
insufficiency,
since they mimic
SIADH
Differentiating the
cause of
hyponatremia can
be difficult
1. Exclude hyperosmolar
hyponatremia
(hyperglycemia, mannitol
contrast agent) ,
pseudohyponatremia.
2. Make a decision
1.
2.
Low Volume
High volume
3. Low Volume
1.
GI losses
(Urine Na < 20 mEq/L)
2.
Renal Losses
(Urine Na > 20 mEq/ L)
4.
High volume
1.
SIADH
Hyponatremia correction
Na should not exceed 8-12
mEq / day (actual Na 120; then
maximum correction till 132)
The rate of correction should
be 0.5-1 mEq/L(body
weight)/hour
Na required= (desired Naactual Na ) x TBW
Choose the correcting Solution
and calculate the
corresponding volume for the
Na required.
Administer either based on
rate if symptomatic or based
maximal allowed correction
Na =120
Correct to Na=130
70 Kg male ; TBW =42 L
Na that need to added =42
x10 meQ =420
3% solution 513 meQ Na/liter
420/513 = 818 cc of 35
NaCl / 24 hrs
818 cc / 24 = 34 cc / hour
The rate allowed
1mEq/L/Hr=42 mEq/hr
(42 /513 ) X 1000= 81 cc
/hour
Hyponatremia Management
Na =125 mEq
Hyponatremia Management
Common Infusates
Infusate
5% NaCl in water
3% NaCl in water
0.9% NaCl in water
Ringers lactate solution
0.45% NaCl in water
0.2% NaCl in 5% dextrose in water
5 % dextrose in water
[Na+] mmol/L
855
513
154
130
77
34
0
Hyponatremia - CPM
Central Pontine Myolinolysis or Osmotic
Demyelination
10% extra-pontine: mid brain, thalamus, basal
nuclei, and cerebellum
Proposed mechanisms:
1- osmotic injury to vascular endothelial cells
and release of myelinotoxic factors (vasogenic
edema)
2- brain dehydration resulting in seperation of
the axon from myelin sheath
T2-weighted MRI
scan of the brain
Hyponatremia - CPM
Hyponatremia Management
Hourly monitoring of the patients
electrolytes is essential
SIADH can be treated with water
restriction (800 ml/day), loop
diuretics, or 600 1200 mg qd
Demeclocycline (V2 receptor
antagonist)
Hypernatremia
Hypernatremia
Clinical conditions associated with
predominant water loss include:
Burns
Intracranial trauma
Water deprivation
Tracheostomy
Sunstroke
Hyperventilation
Hypercalcemia
Fever
Hypocalcemia
Diabetes insipidus
Hypophosphatemia
Hypernatremia
People at most risk are:
-the intubated
-the elderly
-patients with altered mental status
Since their thirst or access to water is impaired
Hypernatremia Management
What solutions must be used?
- Select the most hypotonic infusate
appropriate so as to use the least
amount of fluid.
- The more hypotonic the infusate is,
the lower the infusion rate required
Hypernatremia Management
Commonly used infusates
Infusate
Free Water
5% dextrose in water
0.2% NaCl in 5% dextrose in water
0.45% NaCl in water ( NSS)
Ringers lactate
0.9% NaCl in water (NSS)
[Na+] mmol/L
0
0
34
77
130
154
Hypernatremia Management
Reassess blood electrolyte at intervals of
at least 6 to 8 hrs
Treat DI with desmopressin (ADH analog)
Correct hypernatremia due to hypertonic
Na+ gain with both furosemide and water
Renal failure => hemodialysis,
hemofiltration, peritoneal dialysis
Hypokalemia
Hypokalemia
EKG changes do
not correlate with
hypokalemia
Flattened /
inversion of T wave
Prominent U wave
ST segment
depression
Prolongation of QT
interval
Hypokalemia - Causes
Hypomagnesemia
Delays the correction
Associated with increased frequency of
arrhythmias
Mg is the co-factor of Na/K ATPase
Hypokalemia
K level
Serum K in
mEq/L
EKG changes
and arrhythmias
Estimate of K
deficit in mEq
Mild
3.5-3.0
None or
minimal
100-200
Moderate
3.0-2.5
Yes, variable
Severe
2.5-2.0
Yes, dangerous
200- 400
400-800 or
more
With severe hypokalemia, K+ loss from the cells keeps serum K at or above 2.0 mEq/L.
Hypokalemia
Management:
K+ level = 4 to 3.0 mEq/L
-fresh fruit, vegetables, meat
-K+ replacement not necessary
Hypokalemia
Management:
K+ level < 3.0
Potassium replacement is
necessary
Hypokalemia - Management
What salts should be used?
Potassium chloride Salt of choice, esp. with Cl- depletion
Potassium
bicarbonate
(or precursor)
Hypokalemia - Management
Through what route must the salt be
administered?
-Oral, except in emergencies or if oral
route is not feasible => IV
Hypokalemia - Management
Oral route:
Risk of ulceration and GI bleeding
Dose = 20 60 mEq, 2- 4 times/day
Must be monitored with daily K+
measurements
If serum K+ does not rise by
96
Hypokalemia - Management
IV:
-Peripheral vein
-Central vein
Hypokalemia - Management
What solutions must be used for the
correction?
- Quarter or half NSS
Dextrose induces insulin response that drives K+ into cells
Hypokalemia - Management
In what rate must the solutions be
infused?
- Usual maximum rate = 1020
mEq/hr
- 40 mEq/hr can be used for only 2-3
Higher rates predispose the patient to
hrs
hyperkalemia and cardiac arrhythmias
Monitor serum K+ every 2-4 hrs and
ensure adequate urine output
Hypokalemia - Management
K+ sparing drugs:
1- spironolactone
2- triamterene
3- amiloride
If used, normal renal function must be ensured
Hypokalemia - Management
Metabolic alkalosis must be corrected
if present along with the
hypokalemia, especially if serum K+
< 2.5 mEq/L
Dehydration must also managed,
since further stress would aggravate
the hypokalemia.
Hyperkalemia
Etiology
Individual drugs
K-sparing
Spironolactone,Triamterene,
Amiloride
ACE inhibitors
Captopril,
Fosinopril
NSAIDS
Indomethacin,
Ketorolac
Anti-infective
Trimethoprimsulfamethoxazole
(Bactrim), Pentamidine
Anticoagulant
Heparin
Cardiac glycoside
Digitalis
Antihypertensives
-blockers, and
blockers (labetolol)
Enalapril,
Ibuprofen,
Hyperkalemia - Causes
Heparin:
Unfractionated native
LMWH
Heparinoids
EKG changes
ECG changes do
not correlates
closely with K
levels.
Peaked T wave
Prolonged Pr and
QRS
AV conduction
delay
Sine wave that
might terminate in
Treatment of Hyperkalemia
Treatment of Hyperkalemia
Treatment of Hyperkalemia
Treatment of Hyperkalemia
Drug
Dose
Onset of Action
Calcium gluconate
NaHCO3
44-132 mEq
Albuterol
Kayexalate
4 hours
60 min
120 min
Hyperkalemia- Mnemonic
C alcium
B icarbonate
I nsulin
G lucose
K ayexalate
D ialysis
Hypochloremia
Respiratory acidosis: tubular
resorption of bicarbonate and less Cl Causes: loss of gastric acid by
vomiting or NG, renal losses from
diuretics, ARF and CRF non-oliguric
Important to correct deficit with
other deficits like hypochloremic
hypokalemic metabolic acidosis
Hyperchloremia
Uncommon in surgical patients
In association with hypernatremia, in
RTA, excess KCL intake or ammonium
chloride.
Ileal urinary conduits,
ureterosigmoidostomy. Mucosa
absorbs Cl- in exchange of Bicarb.
Calcium
40% of Ca++ in ECF bound to proteins,
10% complex with bicarb, citrate, and
phosphate
50% ionized, hormonally regulated are
active. Neuromuscular activity
8.5-11.0 Nl, ionized: 4.75-5.3.Most are
bound to Albumin. PTH regulated
Corrected total Ca++ = [ 0.8 x (4- alb)] +
total serum Ca++
Hypocalcemia
Hypocalcemia
Circumoral tingling, numbness
fingertips cramps
Hyperactive DTRs, Chvostek sign,
tetany and Trousseaus sign. Seizures
.
Confused or Depressed. Prolonged QT
Calcium gluconate or chloride IV
Oral calcium lactate. Vitamin D.
Thiazide diuretics
Hypercalcemia - Causes
Hyperparathroidism
Malignancy
Granulomatous disease
Excessive dietary intake
Thiazide Diuretics
Immobilization
Endocrine: thyrotoxicosis, adrenal
insuf.
Hypercalcemia - Treatment
Hypomagnesemia
Low Mg++: common with starvation, GI
losses, alcoholism and Drugs.
Accompanied with low K+, PO4 and low
Ca++
Neuromuscular problems: cramps,
fasciculations, tetany,confusion and
arrythmias.
Oral or IV magnesium sulfate.
1-2 mEq/kg/day
Hypermagnesemia
Renal failure
Crush injury, burns: rhabdomyolysis
Dehydration, acidosis, adrenal insuff.,
cathartics, eclampsia and antacids
Nausea, weakness, hypoventilation,
decreased DTRs. Then hypotension,
bradycardia, paralysis, respiratory dep.
And coma
Rx: hydration, IV calcium, diuretics,
dialysis
Phosphorus
Phosphorus is important in energy
production during glycolisis
The level is tightly controlled by renal
excretion
Hypophosphatemia
Etiology
Inadequate uptake
increased renal
excretion or
compartmental shifts
as result of insulin
release, resp.
alkalosis, alcoholism,
burns ,
parathyroidectomy
Treatment of DKA
Refeeding syndrome
Effect
Platelet aggregation
Impaired WBC
chemotaxis and
phagocytosis
Impairs 02 release to
tissue due to decrease
in 2-3 DPG
Cardiac dysfunction
Bone pain, anorexia
Tremors
Hypophosphatemia
Treatment
Adequate nutrition
Correction depends on the level of
depletion and tolerance to oral
supplementation
Hypophosphatemia
PO4 < 1 md/dL
Tolerating enteral nutrition
KPHO4 or NaPO4
0.25mmol/kg over 6hrs x1
dose
Not tolerating enteral
nutrition
KPHO4 or NaPO4 0.25
mmole/kg IV x 1dose .
Recheck level
0.15mmole/kg if PO4 <
2.5mg/dL
Hyperphosphatemia
Etiology
Low renal excretion, increased GI absorption or
iatrogenic
Hyperthyroidism or Hyperparathyroidism
Clinical condition associated with cell destruction
Rhabdomyolisis
Tumor lysis syndrome
Hemolysis
Sepsis
Severe hypothermia
Malignant hyperthermia
Hyperphosphatemia
Treatment:
Aluminum-based antacids, diuretics
Calcium acetate tablet when
hypocalcemia is present
Hemodialysis
Conclusion
Proper management of fluid and electrolytes
facilitates crucial homeostasis that allows
cardiovascular perfusion, organ system function
and cellular mechanism to respond to surgical
illness
Knowledge of the compartmentalization of body fluid
forms the basis for understanding pathologic shifts
in theses fluid spaces in disease states. Although
difficult to quantify a deficiency in the functional
ECF fluid compartment often requires resuscitation
with isotonic fluids in surgical and trauma patients.
Conclusion
Alteration in the concentration of
serum Na have profound effects on
cellular function due to water shifts
between intracellular and extracellular
spaces
Questions?
Thank you