Fluid

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Fluid Electrolyte Emergencies In Critically Ill

• Dr.Patibandla.Sowjanya
• Dept Of Accident , Emergency Critical Care
  Medicine
• Vinayaka Missions Kirupanandavariyar Medical
  College

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Introduction

• Total body water (60)
• Two third is intracellular fluid (40)
• One third is extra cellular fluid (20)
• - Interstitial fluid (15)
• - Intravascular fluid (5)

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Fluid shifts
INTRACELLULAR 30 LIT 40
EXTRACELLULAR
INTERSTITIAL 9 LIT 15
IV 5 LIT 5
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Electrolyte Components
142
Na
150
K
Ca2
Mg2
Cl-
HCO3-
HPO42-
SO42-
Organic acid
Protein
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ICF ECF
Major Cation Potassium Magnesium Sodium
Major Anion Phosphate Sulphate Protein Chloride Bicarbonate
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Osmolarity

• Measurement of the total solutes in a water
  solution per liter.
• Osmolarity sodiumx2 urea/2.8glucose/18
• Serum osmolarity is 280-300 mOsm/L
• 280-300 mOsmol/L- Isotonic
• gt 300 mOsmol/L Hypertonic
• lt 280 mOsmol/L - Hypotonic

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Three categories of fluids

• Isotonic - Fluid has the same osmolarity as
  plasma
• Eg Normal saline
• Ringers lactate

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• Hypotonic - Fluid has fewer solutes than plasma
• Eg Water, 1/2 N/S (0.45 NaCl)

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• Hypertonic - Fluid has more solutes than plasma
• 
  
  Eg5 Dextrose in Normal Saline (D5
  N/S) , 3 saline solution.

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Isotonic Infusion
2 litres of blood
9 litres
30 litres
3 litres
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Intravascular Volume increases to 5 liters
9 litres
30 litres
5 litres
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Hypertonic Infusion
2 litres of colloid
9 litres
30 litres
3 litres
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Initially it becomes 5 L
9 litres
30 litres
5 litres
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Hypertonicity of Colloid shifts I/C fluid into I/V
8 litres
29 litres
7 litres
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If 2 L of Crystalloid infused
2 litres of 0.9 saline
9 litres
30 litres
3 litres
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Initially I/V becomes 5L
9 litres
30 litres
5 litres
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Isotonicity of Crystalloid shifts I/C I/V
volume into interstitial space
29 litres
10.5 litres
4.5 litres
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Hypotonic Infusion
2 litres of 5dextrose
9 litres
30 litres
3 litres
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Hypotonicity Shifts the fluid into the I/C space
9.7 litres
31 litres
3.3 litres
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Signs of Volume depletion

• Postural hypotension
• Tachycardia
• Absence of JVP
• Dry mucosa
• Decreased skin turgor
• Oliguria

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Signs of Volume overload

• Hypertension
• Raised JVP/gallop
• Pedal edema
• Pulmonary edema
• Ascites
• Organ failure

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Basic principles of fluid therapy
Abnormal loss GIT, 3rd space,Ongoing loss,
septic and Hypovolemic shock
Replace
Insensible water loss urine
Maintain
Acid base, electrolyte imbalances
Repair
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The rules of fluid replacement

• Replace blood with blood
• Replace plasma with colloid
• Resuscitate with colloid / crystalloid
• Replace ECF depletion with saline
• Rehydrate with dextrose

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Case Scenario

• 45 yr old was brought to ER with h/o loose stools
  vomiting since 2 days
• Drowsy and lethargic with signs of severe
  dehydration, BP-80/50 , PR-120
• What is initial fluid of choice?

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• Isotonic saline / Ringers lactate
• No dextrose containing fluid initially

Why?
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Critically ill
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Case Study 1

• HPI
• A 55 year old man is in the Neuro ICU for acute
  non hemorrhagic stroke.
• Hospital course
• Decreasing urine output (lt 0.5 ml/kg/hr) over the
  last 24 hours.
• What is your differential diagnosis?What
  diagnostic studies would you order?

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Case Study 1Differential diagnosis

• Oliguria
• 1) Pre-Renal (decreased effective renal blood
  flow)
• Diminished intravascular volume, cardiac
  dysfunction, vasodilatation
• 2) Post-Renal
• Outlet obstruction (intrinsic vs. extrinsic),
  foley catheter occlusion
• 3) Renal
• Acute tubular necrosis, acute renal failure,
  SIADH, ...

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Case Study 1Laboratory studies

• Serum studies
• Sodium 120 mEq/L BUN 4 mg/dL
• Chloride 98 mEq/L Creatinine 0.4 mg/dL
• Potassium 3.7 mEq/L Glucose 129 mg/dL
• Bicarbonate 25 mEq/L Osmolality 260
  mosmol/kg
• Urine studies
• Specific gravity 1.025 Sodium 58 mEq/L
• Osmolality 645 mosmol/kg
• What are the primary abnormalities?

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Case Study 1Laboratory studies

• Major abnormalities
• 1) Hyponatremia
• 2) Oliguria (inappropriately concentrated urine)
• What is the most likely explanation for these
  findings?

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In Hyponatremia
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Case Study 1 Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)

• Variable etiology
• Trauma
• Infection
• Psychosis
• Malignancy
• Medications
• Diabetic ketoacidosis
• CNS disorders
• Positive pressure ventilation
• Stress

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SIADH

• By definition, inappropriate implies having
  excluded normal physiologic reasons for release
  of ADH
• 1) In response to hypertonicity.
• 2) In response to life threatening hypotension.
• Hyponatremia
• Oliguria
• Concentrated urine
• elevated urine specific gravity
• inappropriately high urine osmolality in face
  of hyponatremia
• Normal to high urine sodium excretion

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Case Study 1 SIADH

• Diagnosis
• Critical level of suspicion.
• Demonstration of inappropriately concentrated
  urine in face of hyponatremia
• ? urine osmolality, ? SG, ? urine sodium
  excretion
• Be certain to exclude normal physiologic release
  of ADH

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Case Study 1 SIADH

• Treatment
• Fluid restriction
• Avoid hypotonic fluids
• Hypertonic saline / oral sodium chloride
• Frusemide.

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Cerebral Salt wasting Syndrome

• Development of excessive natriuresis with
  hyponatremic dehydration in patients with
  intracranial disease
• Seen in Head injury, Brain tumor, Intracranial
  Surgery or stroke

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CSW vs SIADH
features CSW SIADH
Volume status Low Normal
Wt Loss No change
Orthostatic signs Present Absent
Sr Na Decreased Decreased
Hematocrit Increased Normal
Uric acid Normal or inc Decreased
Resp to hydration Improvement Dec Na
Resp to fluid rest Possible shock improve
Urine Na gt100 gt20
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Case Study 1The saga continues.

• Hospital course
• Four hours after beginning fluid restriction,
  you are called because the patient is having a
  generalized seizure. There is no response to two
  doses of IV lorazepam and a loading dose of
  fosphenytoin
• What is the most likely explanation?

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Case Study 1The saga continues

• Seizure
• 1) Worsening hyponatremia
• 2) Intracranial event
• 3) Meningitis
• 4) Other electrolyte disturbance
• 5) Medication
• 6) Hypertension
• What diagnostic studies would you order?

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Case Study 1The saga continues

• Stat labs
• Sodium 110 mEq/L
• What would you do now?

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Case Study 1 Hyponatremic seizure

• Treatment
• Hypertonic saline (3 NaCl) infusion
• To correct sodium to 125 mEq/L, the deficit is
  equal to
• 0.6 X weightkg X (125 - measured sodium)
• 0.6 X 60 X (125-110) 54O mEq

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Newer method

• Rate of infusion of 3NaCl Na Requirement
  x 1000
• 
  infusate sodium x time
• (Desired-Actual
  Na) x 0.6.body wt x 1000
• 513 x
  no of hours
  
• As patient is symptomatic, rate of correction is
  1 mEq/hr,
• Required rate of infusion of 3 NaCl 1 x 0.6 x
  60 x 1000
• 
  513 x 1
• 
  70 ml/hr
• Check sodium after 4 hours and correct accordingly

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Hyponatremia
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Case Study 2

• 60 year old retired engineer presented to ER
  with history of inability to speak and move all 4
  limbs since today morning. Detailed history
  revealed that he has been on naturopathy diet
  since 6 months and had developed GTCS 2 days
  back. He was treated outside for GTCS and
  following the treatment he is unable to
  communicate or use his limbs

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• His previous lab reports showed Na is 117 mEq/L
  and rest of the parameters are within normal
  Limits
• Repeat Sodium in our hospital showed 145 mEq/L
• What could be the possibility?

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Central Pontine Myelinolysis

• Develops with
• Aggressive treatment of Chronic hyponatremia
• Raising Sr.Na gt25mEq/L in first 48 hours
• Raising Sr.Na to Normal or Above normal in 48
  hours

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CPM

• Focal demyelination in the Pons extrapontine
  areas.
• Causes ? Mutism / dysarthria
• Spastic Quadriplegia
• Pseudobulbar palsy
• Seizures
• Altered Mental Status
• Coma Death

CPM is irreversible
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Principles of Hyponatremia Management

• Asymptomatic Hyponatremia? Use 0.9NaCl
• Symptomatic Hyponatremia? Use 3 NaCl
• Correct only 12mEq/L defecit only perday
• Chronic Hypernatremia with severe symptoms should
  receive hypertonic saline only to arrest the
  symptoms and followed by slow correction _at_ 0.5
  mEq/L

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Hyponatremia Management is Double Edged Sword
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Case Study 3

• HPI
• A 5 month-old girl presents with a one day
  history of irritability and fever. Mother reports
  three days of bad vomiting and diarrhea.
• Home meds
• Paracetamol and ibuprofen for fever
• PE
• BP 70/40, HR 200, R 60, T38.3 C. Irritable,
  sunken eyes and fontanelle.

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Case Study 3
No one can obtain IV access after 15 minutes,
what would you do now?
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Case Study 3

• Place intraosseous line
• Bolus 40 ml/kg of isotonic saline
• Reassessment (HR 170, RR 40, BP 75/40)
• Serum studies
• Sodium 164 mEq/L BUN 75 mg/dL
• Chloride 139 mEq/L Creatinine 3.1 mg/dL
• Potassium 5.5 mEq/L Glucose 101 mg/dL
• Bicarbonate 12 mEq/L
• pH 7.07 pCO2 11
• pO2 121 HCO3 8

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Case Study 3
What is the most likely explanation of this
patients Condition?
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Case Study 2Treatment of Hypernatremia

• To stop ongoing fluid loss
• To correct water deficit
• plasma Na 140 x 0.6 x body wt. in kg
• 140
• Water deficit can be replaced with water by mouth
  or IV 5 dextrose or 0.45 NaCl
  

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Rate Of Correction

• Acute Hypernatremia? ½ body water defecit in 24
  hours
• Chronic Hypernatremia? ½ body water defecit in 48
  hours
• Rapid correction ? cerebral edema Neurological
  deterioration

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Case Study 4

• HPI
• A 50 year old man was involved in a motor vehicle
  accident two days ago. He sustained an isolated
  head injury with intraventricular hemorrhage and
  multiple large cerebral contusions. Three hours
  ago, he had an episode of severe intracranial
  hypertension (ICP 90mm Hg, MAP 50mm Hg, requiring
  volume plus epinephrine infusion for hypotension.
  Over the last two hours, his urine output has
  increased to 150 - 200 ml/hour

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• What is your differential diagnosis?
• What test would you order?

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Case Study 4Differential diagnosis

• Polyuria
• 1) Central diabetes insipidus
• Deficient ADH secretion (idiopathic, trauma,
  pituitary surgery, hypoxic ischemic
  encephalopathy)
• 2) Nephrogenic diabetes insipidus
• Renal resistance to ADH (X-linked hereditary,
  chronic lithium, hypercalcemia, ...)
• 3) Primary polydipsia (psychogenic)
• Primary increase in water intake (psychiatric),
  occasionally hypothalamic lesion affecting thirst
  center
• 4) Solute diuresis
• Diuretics (lasix, mannitol,..), glucosuria,
  high protein diets, post-obstructive uropathy,
  resolving ATN, .

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Laboratory studies

• Serum studies
• Sodium 155 mEq/L BUN 13 mg/dL
• Chloride 114 mEq/L Creatinine 0.6 mg/dL
• Potassium 4.2 mEq/L Glucose 86 mg/dL
• Bicarbonate 22 mEq/L Serum osmolality 320
  mosmol/kg
• Other
• Urine specific gravity 1.005, no glucose.
• Urine osmolality 160 mosmol/kg
• What are the main abnormalities?

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Case Study 4Laboratory studies

• Major abnormalities
• 1) Hypernatremia
• 2) Polyuria (inappropriately dilute urine)
• What is the most likely explanation?

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Case Study 4Diabetes Insipidus

• Diagnosis
• Central Diabetes insipidus
• 1) Polyuria
• 2) Inappropriately dilute urine (urine
  osmolality lt serum osmolality)
• May be seen with midline defects
• Frequently occurs in brain dead patients
• What should you do to treat this patient?

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Case Study 4Diabetes Insipidus

• Treatment
• ADH preparations - dDAVP nasal spray 2-4 µg/dl
• Potentiate ADH effect chlorpropamide,
  carbamazepine, NSAIDs.
• Increase ADH release Clofibrate
• Warning
• Closely monitor for development of hyponatremia

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Hypernatremia
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Case Study 4

• HPI
• An 35 year old lady with Chronic kidney disease
  presents with irritability. She is on nightly
  peritoneal dialysis at home. The lab calls a
  panic potassium value of 7.1 meq/L. The tech
  says it is not hemolyzed.
• What do you do now?

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Case Study 4Hyperkalemia

• Treatment
• Immediately repeat serum potassium.
• Do not wait for confirmatory labs especially if
  ECG changes present.
• Anticipatory
• Stop potassium administration including feeds

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ECG

• What is this rhythm?
• What is your immediate treatment?

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Case Study 5Hyperkalemia

• Control effects
• Antagonism of membrane actions of potassium
• 10 Calcium gluconate 10-20 ml over 5 - 10
  minutes may repeat x2
• Shift potassium intracellularly
• Glucose 1 gm/kg plus 0.1 unit/kg regular insulin
• Alkali therapy - Sodium bicarbonate 1 mEq/kg IV
• Inhaled ?2 adrenergic agonist

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• Removal of potassium from the body
• Loop / thiazide diuretics
• Cation exchange resin sodium polstyrene
  sulfonate (Kayexelate) 1 gm/kg PO or PR (or
  both)
• Dialysis

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Hyperkalemia Rx
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Case Study 5

• HPI
• A three year old boy is recovering from septic
  shock. He received 150 ml/kg in fluid boluses in
  the first 24 hours and has anasarca. You begin
  him on a frusemide infusion for diuresis. He
  develops severe weakness and begins to
  hypoventilate. You notice unifocal premature
  ventricular beats on his cardiac monitor.

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• What is your differential diagnosis?
• What tests would you order?

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Case Study 6Laboratory studies

• Serum studies
• Sodium 134 mEq/L BUN 11 mg/dL
• Chloride 98 mEq/L Creatinine 0.4 mg/dL
• Potassium 2.4 mEq/L Calcium 9.2 mg/dL
• Bicarbonate 27 mEq/L Phosphorus 3.2 mg/dL
• Other
• ECG Unifocal PVCs
• What is the main abnormality?

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Case Study 6Laboratory studies

• Major abnormality
• 1) Hypokalemia
• What would you do now?

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Case Study 6Hypokalemia

• Treatment
• Oral
• Safest, although solutions may cause diarrhea
• IV
• do not exceed 40 mEq/L or 10 20 mEq/hr
  potassium.
• - never give inj.Kcl directly intravenously.
• Replace magnesium also if low
• (25-50 mg/kg MgSO4)

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Summary

• Disorders of sodium, water, and potassium
  regulation are common in critically ill.
• Diagnostic approach must be considered carefully
  for each patient
• Strict attention to detail is important in
  providing safe and effective therapy

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Thank you