Fluid and electrolytes

Dr. Nupur Sarkar

• A 5-years-old boy weighing 15 kg was
admitted with h/o frequent vomiting and
watery, large volume diarrhea for 1 day.
• O/E, PR-110/min, normal volume; BP-
90/79mmHg; RR-25/min
• He was lethargic with deeply sunken eyeballs
and skin pinch which took >2 sec to go back.
• Outline and explain his fluid management.
• What are the different components of fluid
therapy applicable for this child?
 A 7-year-old girl is admitted with acute esophageal variceal bleed. On day-
2 of admission, her bleeding has subsided after variceal ligation and she is
hemodynamically stable. But, she not allowed to take food or fluid orally .

• Calculate the volume of fluid requirement for the next 24 hours.

(Weight=22kg)
• What should be the constituent electrolytes in the fluid to be
given?
• Enumerate the electrolyte composition of i/v
Normal saline; both in terms of molarity and
weight / volume percentage.
• What do you understand by N/2, N/3 and
N/5?
• How is Ringer’s lactate different from Normal
saline?
• A 6-month-old infant is admitted with
puffiness of the face and limbs for 2 days and
reduced urine output for 3 days. The parents
also give a history of bloody diarrhea 5 days
back. O/E- she is pale and edematous; BP-
118/76mmHg; Systemic examination is
normal.
• Outline her fluid management in the next 24
hours. She has passed around 30 ml urine in
the previous 24 hours. Her weight is 6 kg;
length-66cm.
 Electrolyte report of the infant reveals
Sodium-129meq/L; Potassium-5.8 meq/L

• Outline the normal serum sodium and

potassium level.
• How will you manage the abnormal
electrolyte levels?
 What are abnormalities in the ECG ?

What electrolyte
abnormality is suggested?
 Manifestations of potassium level
abnormalities
• Hyperkalemia • Hypokalemia
• Early-Hyperactive • Muscular weakness,
muscles, parasthesias, cramps, flaccid paralysis
• Late-Muscle weakness, • Constipation, ileus
flaccid paralysis • Postural hypotension,
• Dysrhythmias, heart dysrhythmias,
block, arrest. appearance of U wave,
cardiac arrest
• Polyuria, nocturia,
polydipsia
 Enumerate 10 important causes of
hyperkalemia/ hypokalemia
• Hyperkalemia • Hypokalemia
• Failure to excrete in urine • ↑ loss in urine
• Deficiency of hormone
(which?)
• Excess of hormone
• Drugs (which?)
• Shift out of the cells. • Drugs
• Massive cellular destruction. • Shift into cells
• High potassium load • PEM
enteral/ parenteral
• Pseudohyperkalemia.
• GI loss
 Emergent management of hyperkalemia
• Indications
– ECG changes or >6meq/L.
– Renal failure
– Metabolic acidosis
– Rapid and recent rise
• Management
– Stabilize myocardium with i/v calcium gluconate.
– Temporarily shift K+ into cells using
• Insulin-glucose drip
• Nebulized salbutamol
• I/v sodium bicarb- only if metabolic acidosis
Non-emergent management of hyperkalemia

• Intravenous frusemide for renal excretion.

• kayexalate orally or as enema for ↑git
excretion.
• Hemodialysis in severe/ refractory cases.
• For Safety C BIG K+ Drop
 Manifestations of Na+ abnormalities

– Hyponatremia • Hypernatremia
• Nausea, vomiting, – Thirst
headache, – Neuromuscular
seizures, coma, excitability, ↑DTR,
respiratory arrest confusion, seizures,
• Lethargy, coma, subarachnoid
hemorrhage, venous
confusion, muscle
sinus thrombosis
cramps
– Woody tongue, doughy
skin on examination
 Hyponatremia

Hypervolemic- Isovolemic- Hypovolemic-

Hypoosmolar Hypoosmolar Hypoosmolar Normoosmolar Hyperosmolar

Water intoxication, SIADH, hypothyroidism, Diarrhea (GI), severe burns (skin), pancreatitis, Pseudohyponatremia
CCF, nephrotic syndrome, Addison’s, diuretic use,other drugs like pleural effusion (3rd space) Renal losses like chronic Hyperglycemia, hypertonic
amitryptiline, carbamazepine, NSAIDs, pain, thiazide, interstitial nephritis, polycystic, medullary (hyperlipidemia), isotonic
Renal failure, cirrhosis postop state, stress cystic kidney disease, Addison's, osmotic diuresis infusion of glucose, mannitol etc. infusions-mannitol
 Hypernatremia
causes

11β Central Diarrhea, Hypertonic

hydroxylase diabetes profuse saline,
deficiency insipidus, sweating, NaHCO3,
nephrogenic tachypnea, TPN, ↓
diabetes osmotic water for
insipidus, diuresis making
primary esp in formula
hypodipsia, DKA, loop milk or ORS
↓ access to diuretics,
water

Note: impaired thirst and lack of access to water often present with
above causes
 Management principles of hyponatremia

 Chronic (>48hours) hyponatremia correction slower

than acute. (idiogenic osmoles in brain tissue)
otherwise ↑↑ risk of central pontine myelinosis.
 Symptomatic cases- correction faster.
 Correction NOT >0.5meq/L/hr and NOT> 8meq/L/24
hours.
 If severe hyponatremia with seizures, correction rate
may be ≈ 1meq/L/hour in the 1st 2 hours.
 Mostly 3-7meq/L correction of sodium enough to stop
seizures.
 Management of hyponatremia
• Hypovolemic-
• dehydration correction with NS
• Stop diuretics.
• Also 3% saline, if seizures.

• Isovolemic-
• Fluid restriction+ use of NS or HS with Frusemide in
SIADH if severe or symptomatic.

• Hypervolemic-
• 2/3 of maintenance fluids (fluid restriction)+
diuretics+ treatment of underlying cause.

• Normoosmolar & Hyperosmolar

• Treat underlying cause.
 Management of hypernatremia
• For patients with hypovolemia (tachycardia,
hypotension, shock)→correct hypovolemia
with normal saline first→then correct
hypernatremia; preferably orally, if possible.
• Rate of decrease of Na+ should not exceed
1meq/L/hr.
• Change in serum Na+ =([Na] infused-[Na]
serum)/TBW+1 (TBW=0.6xBwt.)
 Management of hypernatremia
• For central DI, replacement with
desmopressin.
• For nephrogenic DI, salt restriction, thiazide
diuretics, PG synthetase inhibitors.
• For those with renal failure, dialysis may be
needed.
A boy severe diarrhea, dehydration
An exam-going adolescent c/o perioral tingling
A case of bulbar polio
Hypertensive on long-term diuretics

• pH-7.21
• pO2- 68mmHg
• pCO2-70mmHg
• HCO3-27meq/L
• BE- +1meq/L
• SaO2—94%
Diarrhea with dehydration
Acute onset severe vomiting
Post-marathon
Patient on morphine drip

• pH-7.31
• pO2- 90mmHg
• pCO2-33mmHg
• HCO3-16meq/L
• BE- -9meq/L
• SaO2—99%
Hydrocephalus on chronic acetazolamide
Anxiety with hyperventilation
Severe pneumonia
Infant with pyloric stenosis

• pH-7.49
• pO2- 92mmHg
• pCO2-28mmHg
• HCO3-24meq/L
• BE- +0.8meq/L
• SaO2—100%
Septic shock
Pneumothorax
Mild acute exacerbation of asthma
A 2-month infant with projectile vomiting for 2 days

• pH-7.49
• pO2- 92mmHg
• pCO2-40mmHg
• HCO3-30meq/L
• BE- +6.5meq/L
• SaO2—100%
THANK YOU