Fluids and Electrolytes Ex: 70 Kg Male Patient:

 I INTRODUCTION  TBW= Wt. in kg x 60% = 70 x 0.60 = 42 liters

 II BODY FLUIDS  ICF= Wt. in kg. x 40 % = 70 x 0.40 = 28 liters
 III BODY FLUID CHANGES  IF= Wt. in kg. x 15% = 70 x 0.15 = 10.5 liters
 PV= Wt. in kg. x 5% = 70 x 0.05 = 3.5 liters
 IV FLUID AND ELECTROLYTE THERAPY
3. Composition of Fluid Compartments:
 ECF Compartment:
I. INTRODUCTION  Principal Cation- Soduim
 Fluids and electrolyte management is paramount  Principal Anions- Chloride and
to the care of surgical patient. Bicarbonate
 BODY FLUIDS  ICF Compartment:
o 1. Total Body Water  Principal Cations- Potassium and
o 2. Fluids Compartments Magnesium
o 3. Composition of Fluid  Principal Anions- Protein and Phosphates III. BODY FLUID CHANGES
Compartments 1. Normal Exchange of Fluid and Electrolytes:
o 4. Osmotic Pressure 4. Osmotic Pressure:  The normal person consumes an average of 2000
 A pressure that develops in a solution separated ml. of water per day
II. BODY FLUIDS by a semi-permeable membrane.  approximately 75%/1500 ml. from oral intake
1. Total Body Water:  the rest is extracted from solid foods
o 50-60% of total body weight is water  Daily water losses = 1600-2300 ml/day
o TBW (liters) = Weight in kg x 60%  800-1200 ml in urine
o TBW = 70 x 0.60 = 42 liters  250 ml in stool
 Lean Tissues  600 ml as insensible losses
o Skeletal muscle  occur through both the
o Kidneys  skin (75%)
o Heart & Lungs  lungs (25%)
o Spleen, Intestine, Skin, Brain  Deprivation of all external water- 500-800 ml
o Bone urine/day
o Adipose tissue  NaCl/Salt = 3-5 g/day, Kidney 1 mEq/day or
 Effect of age 5000mEq/day
o Newborn 80%
o Infants 65% 2. Classification of body Fluid Changes
o Adults 60%  a. Changes in Volume
o Elderly 45%  b. Changes in Concentration
 Gender  c. Changes in Composition
o Male 60%
o Female 50% a. Changes in Volume
 If isotonic solution is added or lost fr. the body
2. Fluids Compartments: only the ECF volume changed, little chaged in
 60% of body weight ICF.
 40% intracellular (ICF)  No net movement of water.
 20% extracellular (ECF)  Volume Deficit or Volume Excess
 15% interstitial fluid (IF)
 5% plasma volume (PV)

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Volume Deficit:
□ ECF volume deficit most
common
Causes:
□GIT losses- GI secretions
5-8 liters/day
□Soft tissue injury
□Intra-abdominal infections
□Surgery
Lab Exams:
□BUN, Creatinine,
Hematocrit
S/Sx:
□CNS: Sleepiness, slow
response
□CVS: Hypotension,
tachycardia, collapsed neck
vein
□Tissue: Skin turgor, dry
lips, dry tongue,
□Oliguria, Ileus
b. Changes in Concentration:
 If water only is added or lost fr. ECF the
concentration of osmotically active particles change.
 90% of osmotically active particles in ECF is Na.
 Na reflects the tonicity of body fluids compartments.
 1 – 2 mEq/kg/day
Hyponatremia:
□Serum Na < 135 mEq/L
(135-145 mEq/L)
Causes:
□ Dilutional – Excessive
intake, Iatrogenic, Drugs
□ Depletional- Decrease Na
intake, GIT losses,
Diuretics
□ DM/Glucose, Lipids,
Protein
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Volume Excess:
Causes: Iatrogenic, Organ
Diseases
S/Sx:
□Pulmonary overload
□CVS: Increased CO, CVP,
Distended neck vein,
Murmur
Tissue: Edema, Wt. gain
Hypernatremia:
□Serum Na >145 mEq/L
(135-145 mEq/L)
Causes:
□ Lack of free access to
water
□ GIT losses
S/Sx:
□ CNS: Restlessness,
Lethargy, Seizures, Coma
□ CVS: Hypotension,
Tachycardia
S/Sx: □ MNS: Weakness 2] Calcium:
□ CNS: Headache, □ Tissue: Dry sticky  Most abundant electrolyte in the body
confusion, DTR, Coma mucous membrane,  99% in bone
□ CVS: HPN, Bradycardia Decreased saliva/tears  < 1% in ECF
□ MNS: Weakness, Fatigue, □ GUT: Oliguria  1-3 g/day
Muscle cramps/twiching □ Metabolic: Fever  3 forms : Protein bound, Complex w/ phosphate,
□ GIT : Anorexia, Nausea, Ionized
Vomiting
□ Tissue: Lacrimation, Hypercalcemia: Hypocalcemia:
Salivation □ >10.5 mEq/L (8.5 -10.5 □ <8.5 mEq/L (8.5 -10.5
□ GUT: Oliguria mEq/L) mEq/L)
□ Ionized Calcium >4.8 □ Ionized Calcium <4.2
c. Changes in Composition: mg/dl ( 4.2-4.8 mg/dl) mg/dl ( 4.2-4.8 mg/dl)
 Changes in Potassium, Calcium, Phosphorus,
Magnesium Causes: Causes:
□ Cancer w/ bone mets., □ Pancreatitis,
1] Potassium: Hyperparathyroidism Pancreatic/S.I. fistulas,
 90% ICF Massive tissue infection,
 Excreted in the urine ECG Changes: Renal failure, Surgical
 50-100 mEq/day □ Shortened QT interval, removal of Parathyroid,
 0.5 to 1 mEq/kg/day Prolonged PR and QRS Hypoparathyroidism
intervals, Flattening of
Hyperkalemia: Hypokalemia: Twaves ECG Changes:
□ >5.0 mEq/L (3.5 -5.0 <3.5 mEq/L (3.5 -5.0 □ Prolonge QT interval
mEq/L) mEq/L) S/Sx:
□ The most dangerous □ Anorexia, N/V, Abdominal S/Sx:
electrolyte disorder Causes: pain, Weakness, Confusion, □ Asymptomatic,
□Inadequate intake, Bone pain, HPN, □ <2.5 mg/dl Paresthesias,
Causes: □GIT losses, Arrhythmia □ Muscle cramps,
□ Renal failure, □Excessive renal excretion, □ Carpopedal spasm,
□ Hemolysis , □Alkalosis Chvostek’s sign, Tetany
□ Rhabdomyolisis
□ Drugs, Acidosis ECG changes:
□ Flattening of Twaves, St 3] Phosphorous:
ECG changes : segment depression, U  80% in the bone
□ High peak Twaves, waves  <1% in ECF
Widened QRS complex,  Multiple function
Prolonged PR interval S/Sx:
□ Asymptomatic Hyperphosphatemia: Hypophosphatemia:
S/Sx: □ CVS: Arrest □ >4.5 mg/dl (2.7 -4.5 □ <2.7 mg/dl (2.7 -4.5
□ CVS: Arrhythmia, Arrest □ MNS: Decreased reflexes, mg/dl) mg/dl)
□ MNS: Weakness, fatigue, weakness,
Paralysis, Resp. failure paralysis Causes: Causes:
□ GIT: Colic, Nausea, □ GIT: Ileus, C0nstipation □ Renal Failure, □ Decreased intake, AlMg
Vomiting, Diarrhea Hypoparathyroidism, salts, Diuretics
□ GUT: Oliguria Sepsis, Rhabdomyolysis,
Increased intake S/Sx: Alternative Resuscitative Fluids: Volume Deficit:
□ Asymptomatic,  Colloids- Plasma volume expander Principles:
S/Sx: □ Confusion, Seizures,  Albumin, Dextran, Hydroxy ethyl ester starch,  Compute for daily requirements
□ Asymptomatic, S/Sx of □ Weakness, Heart/Resp. Gelatins  Quantify total deficit
Hypocalcemia failure  Quantify on going losses
Maintenance Fluid:  Identify concomitant electrolytes imbalance
Wt. in Kg Fluid Vol. Ml/Kg/Hr
4] Magnesium: Ml/Kg/Day Quantify Replacement
 4th most common mineral in the body  Daily Requirments+Deficit+Active Losses
 ICF  1st 10 Kg  100  4  For Patient w/ fever + 500 ml/ C >38
 20 mEq/L  For Patient w/ 4 hours abdominal exposure + 5000
 Excreted both in the urine and feces  2nd 10 Kg  50  2 ml
 ATP
 Each Kg  20  1 Fluid type:
Hypermagnesemia: Hypomagnesemia: >20 Kg  LRS, NSS
□ >2.5 mEq/L (1.5 -2.5 □ <1.5 mEq/L (1.5 -2.5  Ex. 70 Kg. Patient = 2500 ml/day or  For GIT losses 0.9% NSS/LRS
mEq/L) mEq/L) 27ml/cc/Kg/Hr  For Pancreatic fistulas LRS 0.9% NSS
□ Hypokalemia,  Biliary fistulas LRS
Causes: Renal Failure, Hypocalcemia co-exist w/ 70 kg= 1st 10kg x 100 =1000 ml  For insensible Losses D5W
Thermal injury Hypomagnesemia 2nd 10 kg x 50 = 500 ml
Each kg 20 kg, 50 kg x 20 =1000 ml Hypernatremia:
ECG Changes: Similar to Causes: Poor nutritional ------------ Water Deficit in Liter = Serum Na – 140 x TBW
Hyperkalemia intake, GIT lose =2500 ml/kg/day ----------------------------
 2500 ml/24 hrs = 104/uggts/mim 140
S/Sx: S/Sx:  104/4 = 26 gtts/min Ex .70 kg male TBW 35 = 150 – 140 x 35
□ Lethargy, □ Lethargy, Decreased  1 ggts =4 ugtts ------------------- = 2.5 L D5W
□ Decreased reflexes, reflexes, Weakness, 140
Weakness, Hypotension, Arrest Serum Na 150 mEq/L
□ Hypotension, Arrest 70 kg= 1st 10kg x 4 =40 ml
2nd 10 kg x 2 =20 ml  2.5 L of D5W or 0.4% NaCl
Each kg 20 kg, 50 kg x 1 =50 ml  ½ of this should be given in 24 hrs
------------  ½ of this should be given in 24-48 hrs
IV. FLUID AND ELECTROLYTE THERAPY
=110 ml/kg/hr  The correction should not exceed 0.5-1 mEq/hr or
IV Solution Sodium Potassium Dextrose  110 uggts/mim 12-24 mEq/day
 104/4 = 27 gtts/min  Brain edema and herniation
D5W 0 meq/L 0 meq/L 50 gm/L
 1 gtts =4 ugtts
Hyponatremia:
D5NSS 154 0 50
Na Deficit mEq = (140 – Serum Na) x 0.6 x wt. kg
D5LR 130 4 50 Volume Excess: = ( 140- 120) x 0.6 x 70= 840 mEq
 Stop all ongoing IVF
D5NM 40 13 50  Give Diuretics 3% NaCl Na 513 and Cl 513 mEq
 Give 50% of maintenance fluid for patient w/ Cardiac, ½ for 24 hrs, ½ for 24-48 hrs
3% NaCl 510 Correction should not exceed 8-10 mEq/day
Renal and Liver failure
D50.3%NaCl 51 50 Myelonosis

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Hyperkalemia: Hypomagnesemia:
 Stop all K containing IVF  Milk of Magnesia
 ECG  For 1-1.8 mEq/L MgSO4 0.5 mEq/kg+250 ml NSS
 10 % Calcium Gluconate 5-10 ml for 24 hrs x 3 days.
 I ampule D5 Dextrose+10 units of regular Insulin  For <1 mEq/L MgSO4 1 mEq/kg +250 ml NSS
 Na-K exchange resin for 24 hrs then 0.5 mEq+250 ml NSS for 24 hrs x
 Diuretics 2 days.
 Hemodialysis

Hypokalemia:
 > 3 mEq/L Oral replacement
 < 3 mEq/L Parenteral replacement
 <40mEq/L → peripheral line
 >40mEq/L → central line
 Rate: 20-40mEq per hour

Hypercalcemia:
 0.9% NaCl
 IVFurosemide 40-80 mg IV Q 2-4
 Biphosphanate, Calcitonin 4 IU Q 12

Hypocalcemia:
 < 7 mEq/L or < 3 mg/dl or Symptomatic Patient
 2 g Calcium Gluconate over 1 hr
 ECG monitoring
 Oral Calcium Carbonate 4 g/day

Hyperphosphatemia:
 IV 0.9% NaCl
 Diuretics
 Hemodialysis

Hypophosphatemia:
 For 1-2.5 mg/dl Oral/Enteral Natra-Phos 2 packs
Q6
 IV KPHO4 or NaPO4 0.15 mmol/kg IV over 6 hrs
1 dose
 For < 1 mg/dl IV KPHO4 or NaPO4 0.25 mmol/kg
over 6 hrs 1 dose

Hypermagnesemia:
 10 % Calcium Gluconate 5-10 ml
 IV NSS
 Diuretics
 Hemodialysis

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