FLUID & ELECTROLYTE FLUID & ELECTROLYTE THERAPYTHERAPY

BYBY

under supervision of Dr. under supervision of Dr. ASHRAF THABETASHRAF THABET

FLUIDS & FLUIDS & ELECTROLYTESELECTROLYTES

TOTAL BODY WATERTOTAL BODY WATER 60% 60% of total body weight in of total body weight in malesmales.. 55% 55% of total body weight in of total body weight in femalesfemales.. 75% 75% of total body weight in of total body weight in infantsinfants..

WATER SOURCES & LOSSESWATER SOURCES & LOSSES

sourcessources Exogenous 2 – 3 l per dayExogenous 2 – 3 l per day Endogenous ( metabolic water )350 ml/d Endogenous ( metabolic water )350 ml/d

LossesLosses -Sensible urine & faeces-Sensible urine & faeces -Insensible sweat & resp-Insensible sweat & resp water input = water outputwater input = water output

ELECTROLYTES ELECTROLYTES METABOLISMMETABOLISM

NaNa is the main is the main extracellularextracellular cation 135-145 cation 135-145 mEq/ litre mEq/ litre

Avearge daily requirements is about Avearge daily requirements is about 5 gm 5 gm daily equivalent to daily equivalent to 5oo ml 5oo ml of isotonic saline 0.9 of isotonic saline 0.9 % %

KK is the main is the main intracellularintracellular cation 3.5-5.5 mmol/l cation 3.5-5.5 mmol/l A normal daily intake 1mmol/kgA normal daily intake 1mmol/kg Total normal serum level of Total normal serum level of CaCa 8.5-10.5 mg/dl 8.5-10.5 mg/dl Ionized “ “ “ 3.5-4.5 mg/dl Ionized “ “ “ 3.5-4.5 mg/dl Hypoalbuminemia causes total hypocalcemia without Hypoalbuminemia causes total hypocalcemia without

affecting the physiologically active ionized Caaffecting the physiologically active ionized Ca

PERIOPERATIVE FLUID THERAPYPERIOPERATIVE FLUID THERAPY

To maintain normovolemia.To maintain normovolemia.

To maintain electrolyte balanceTo maintain electrolyte balance

To maintain normoglycemia.To maintain normoglycemia.

Types of FluidsTypes of Fluids

Crystalloids.Crystalloids.

Colloids.Colloids.

CrystalloidsCrystalloids

Aqueous solutions of low mol.wt. ions(salts)Aqueous solutions of low mol.wt. ions(salts)With or without glucose.With or without glucose.

Sodium is the major osmotically active Sodium is the major osmotically active particle.particle.

Crystalloid replacement shoud be 3 to 6 Crystalloid replacement shoud be 3 to 6 times the volume of lost blood.times the volume of lost blood.

CrystalloidsCrystalloids

Normal saline(NS).Normal saline(NS). Lactated Ringer’s solution(LR).Lactated Ringer’s solution(LR). 5% dextose in water (D5W).5% dextose in water (D5W). Ringer’s acetate.Ringer’s acetate. D5LR.D5LR. D5 NS.D5 NS. D5 ½ NS.D5 ½ NS. Hypertonic saline(HS)3%.Hypertonic saline(HS)3%.

Normal SalineNormal Saline

0.9% NaCl (isotonic) 0.9% NaCl (isotonic) 308308 mOsm/L. mOsm/L. Na Na 154154 mEq/L. Cl mEq/L. Cl 154154 mEq/L.PH 5.7 mEq/L.PH 5.7 Uses: Hyponatremia.Uses: Hyponatremia. Brain injuryBrain injuryLarge quantity--Large quantity--hyperchloremic hyperchloremic metabolic acidosis.metabolic acidosis.The predominant effect of volume resuscitation with The predominant effect of volume resuscitation with

crystalloid fluids is to expand the interstitial fluid volume crystalloid fluids is to expand the interstitial fluid volume rather than the plasma volumerather than the plasma volume

Lactated Ringer LRLactated Ringer LR

Osmolarity Osmolarity 273273 mOsm/L mOsm/L Na Na 130130 Cl Cl 109109 mEq/L mEq/L K K 4 4 Ca Ca 33 mEq/L mEq/L Lactate Lactate 28 28 mEq/L mEq/L The most physiological solution.The most physiological solution. Lactate is converted into HCO3 in the liverLactate is converted into HCO3 in the liver Ringer AcetateRinger Acetate Acetate Acetate 28 28 mEq/L mEq/L Metabolism 2.5-4 times faster than lactate(in muscles).Metabolism 2.5-4 times faster than lactate(in muscles).

GLUCOSE 5% GLUCOSE 5% It functions as free water.It functions as free water. 5050 gm/L isotonic ( gm/L isotonic (253253 mOsm/L). mOsm/L). Uses:Uses: To maintain normoglycemia.To maintain normoglycemia. To correct hypernatremia.To correct hypernatremia. To keep an IV line open for medication.To keep an IV line open for medication. Not used for volume expantion… as the predominant Not used for volume expantion… as the predominant

effect of volume resusscitation with gluc 5 % is to effect of volume resusscitation with gluc 5 % is to expand the intracellular volume ( cellular oedema )expand the intracellular volume ( cellular oedema )

During surgery only given for patients at increased risk During surgery only given for patients at increased risk of hypoglycemia(infants,insulin T).of hypoglycemia(infants,insulin T).

Avoided in critically ill (it increases CO2 production and Avoided in critically ill (it increases CO2 production and aggravates ischemic brain injury).aggravates ischemic brain injury).

Hypertonic Saline HS 3%Hypertonic Saline HS 3%

Osmolarity Osmolarity 10261026 mOsm/L. mOsm/L. Na Na 513513 Cl Cl 513513 mEq/L. mEq/L. It expands plasma volume by the increase in IV It expands plasma volume by the increase in IV

oncotic pressure(fluids move from IC fluid).More oncotic pressure(fluids move from IC fluid).More effective than crystalloids.effective than crystalloids.

Uses:Uses: Severe hyponatremia. Severe hyponatremia. Early treatment of hypovol. shock. Early treatment of hypovol. shock. Side effects:Side effects:

hypernatremia,hyperchloremia,hypokalemia and hypernatremia,hyperchloremia,hypokalemia and coag. Problems.coag. Problems.

ColloidsColloids

Solutions containing high-molecular Solutions containing high-molecular weight substances such as proteins or weight substances such as proteins or large glucose polymers.large glucose polymers.

Plasma expanders by:Plasma expanders by: volume of colloid.volume of colloid. increasing plasma oncotic pressure increasing plasma oncotic pressure

moving fluids from moving fluids from ISIS to to IVIV spaces. spaces.

Colloids X CrystalloidsColloids X Crystalloids Colloids stay more inColloids stay more in IV IV space space (3-6 h.).(3-6 h.). Crystalloids Crystalloids (20-30 m.).(20-30 m.). Colloids 3 times potent than crystalloids.Colloids 3 times potent than crystalloids. Severe IV fluid deficits can be more Severe IV fluid deficits can be more rapidly corrected using colloids.rapidly corrected using colloids. Colloid resuscitation Colloid resuscitation more expensive.more expensive. Rapid administration of large amounts of Rapid administration of large amounts of

crystalloids crystalloids (>4-5L)(>4-5L) is more frequently is more frequently associated with significant tissue edema.associated with significant tissue edema.

Types of ColloidsTypes of Colloids

Blood derivedBlood derived Human albumin. Human albumin. SyntheticSynthetic * Starches.* Starches. * Gelatins.* Gelatins. *Dextrans.*Dextrans.

Human AlbuminHuman Albumin

5%5% (isotonic) and (isotonic) and 25%25% (hypertonic) in NS. (hypertonic) in NS. Uses:Uses: Abnormal protein loss. e.g peritonitis.Abnormal protein loss. e.g peritonitis. Severe burns.Severe burns. Expensive.Expensive. No risk of viral infection.No risk of viral infection. Rare allergic reactions.Rare allergic reactions. No effct on coagulation.No effct on coagulation.

StarchesStarches

Hetastarch Hetastarch 6%6% Pentastarch Pentastarch 10%10% in NS. in NS. More effective than More effective than 5%5% albumin,gelatins and albumin,gelatins and

dextrans.dextrans. Non antigenic;no effect on crossmatching.Non antigenic;no effect on crossmatching. Lower cost than albumin.Lower cost than albumin. Cleared by the kidneys.Cleared by the kidneys. Disadvantages:Disadvantages: Coag.abnormalities if Coag.abnormalities if >1.5L.>1.5L. Rare anaphylactic reactions.Rare anaphylactic reactions. Elevated serum amylase.Elevated serum amylase.

GelatinsGelatins

Haemagel Haemagel Relatively cheap.Relatively cheap. No effect on coagulation or on No effect on coagulation or on

crossmatching.crossmatching. High incidence of allergic reactions.High incidence of allergic reactions.

DextransDextrans

Dextran Dextran 4040 and and 7070 in NS or 5% dextrose. in NS or 5% dextrose. Anti-thrombotic effects.Anti-thrombotic effects. Dextran 70 is preferrd (12h.).Dextran 70 is preferrd (12h.). Dextran 40 improves blood flow in microcirculat.Dextran 40 improves blood flow in microcirculat. Uses: Uses: *plasma expander.*plasma expander. *To prevent thromboembolism (postop.).*To prevent thromboembolism (postop.). * To improve blood flow to isch.limb (dextran * To improve blood flow to isch.limb (dextran

40).40).

DextransDextrans

Disadvantages:Disadvantages: 1- Bleeding tendency.1- Bleeding tendency. 2- Interfere with biood grouping and 2- Interfere with biood grouping and

crossmatching.crossmatching. 3- Rare anaphylactic reactions.3- Rare anaphylactic reactions. 4- Dextran 4- Dextran 4040 can precipitate in renal can precipitate in renal

tubules leading to RF.tubules leading to RF.

Perioperative Fluid TherapyPerioperative Fluid Therapy

Compensatory IV volume expansion.Compensatory IV volume expansion. Normal maintenance requirements.Normal maintenance requirements. Pre-existing deficits.Pre-existing deficits. Surgical fluid losses:Surgical fluid losses: Blood.Blood. Other fluids.Other fluids.

Peri-operative situationsPeri-operative situations factors that need to be considered in the peri-factors that need to be considered in the peri-

operative period: operative period: -Patient (age, physiological reserve, pre-op -Patient (age, physiological reserve, pre-op status) status) -Clinical context (magnitude of surgery, blood -Clinical context (magnitude of surgery, blood loss, etc.) loss, etc.) -Existing deficit -Existing deficit -Stress response - causes salt and water -Stress response - causes salt and water retention. retention.

-Anticipated losses-Anticipated losses(( Fever Respiratory rate Fever Respiratory rate Drain/NG losses, Third space)Drain/NG losses, Third space)

Compensatory IV volume expantionCompensatory IV volume expantion

5-7 ml/kg of crystalloid before anaesthesia.5-7 ml/kg of crystalloid before anaesthesia.

This to compensate for vasodilatation and This to compensate for vasodilatation and cardiac depression by anaesth. drugs. cardiac depression by anaesth. drugs.

Normal maintenance requirementsNormal maintenance requirements

For the first 10 kg: 4 ml/kg/h.For the first 10 kg: 4 ml/kg/h. For the next 10-20 kg: 2 ml/kg/h.For the next 10-20 kg: 2 ml/kg/h. For each kg above 20 kg: add 1 ml/kg/h.For each kg above 20 kg: add 1 ml/kg/h. Example:Example: Maintenance fluid needs for a 25 kg child:Maintenance fluid needs for a 25 kg child: 40+20+5= 65ml/hour.40+20+5= 65ml/hour.

PostoperativePostoperative

Water: as maintenance.Water: as maintenance. Potassium: 1 mmol/kg/day.Potassium: 1 mmol/kg/day. Sodium: 1-1.5 mmol/kg/daySodium: 1-1.5 mmol/kg/day.. 70 kg adult70 kg adult 2640 ml water2640 ml water 70-100 mmol Na70-100 mmol Na 70 mmol K70 mmol K xxx???,remember rule of 40 xxx???,remember rule of 40

Urine output at least40ml/h-Not more than 40mmoladdedto1L-Nofaster than40mmol/h Urine output at least40ml/h-Not more than 40mmoladdedto1L-Nofaster than40mmol/h

2L dextrose 5% 100gm glucose2L dextrose 5% 100gm glucose 500 ml NS 75 mmol sodium500 ml NS 75 mmol sodium

Preexisting DeficitsPreexisting Deficits

The deficit can be estimated by multiplying The deficit can be estimated by multiplying the normal maintenance rate by the the normal maintenance rate by the length of the fast.length of the fast.

70 kg person fasting 8 h:70 kg person fasting 8 h: 40+20+50 ml/h x 8h =880 ml.40+20+50 ml/h x 8h =880 ml.Consider abnormal losses.Consider abnormal losses.

Patients who are eatingPatients who are eating

Usually, patients who are eating require “supplemental” fluids (i.e., Usually, patients who are eating require “supplemental” fluids (i.e., inadequate oral intake) will only require small amounts of fluid. In inadequate oral intake) will only require small amounts of fluid. In general, intravenous potassium replacement is not required for general, intravenous potassium replacement is not required for these patients (even if they are hypokalaemic, you can usually use these patients (even if they are hypokalaemic, you can usually use oral supplementation).oral supplementation).

Try to calculate the amount of water actually required. For example, Try to calculate the amount of water actually required. For example, if they need 1L of water in addition to oral intake, then only give 1 if they need 1L of water in addition to oral intake, then only give 1 litre in a day (as normal saline or dextrose solution). If no other litre in a day (as normal saline or dextrose solution). If no other intravenous access is required and intravenous access is difficult, intravenous access is required and intravenous access is difficult, consider a consider a subcutaneous linesubcutaneous line (generally a maximum rate of fluid at (generally a maximum rate of fluid at about 80 mL/h). Do not put a dextrose solution subcutaneously.about 80 mL/h). Do not put a dextrose solution subcutaneously.

Surgical Fluid LossesSurgical Fluid Losses

Blood lossBlood loss Continuous monitoring and accurate Continuous monitoring and accurate

estimation of blood loss is v. important.estimation of blood loss is v. important. for each 1 ml loss replace 3 ml crystalloids for each 1 ml loss replace 3 ml crystalloids

or 1 ml colloids.or 1 ml colloids. Other lossesOther losses Evaporation from large exposed wounds.Evaporation from large exposed wounds. Third space losses.Third space losses.

Guidelines for fluid therapyGuidelines for fluid therapy

1- Short large-bore I.V. cannula.1- Short large-bore I.V. cannula.2- The consequences of hypovolemia carry 2- The consequences of hypovolemia carry

high mortality and must be treated promp.high mortality and must be treated promp.3- Do not give inotropes to hypovol. pt.3- Do not give inotropes to hypovol. pt.4- For old,cardiac,hepatic or renal pt,replace 4- For old,cardiac,hepatic or renal pt,replace

gradually.Only half calc. deficit is given gradually.Only half calc. deficit is given initially.CVP is mandatory.initially.CVP is mandatory.

Guidelines for fluid therapyGuidelines for fluid therapy

5- Crystalloids,when given in sufficient 5- Crystalloids,when given in sufficient amounts are just as effective as colloids.amounts are just as effective as colloids.

3-6 times.3-6 times.6- Severe deficits correct by colloids.6- Severe deficits correct by colloids.7- Rapid large amounts of crystalloids(>5L) 7- Rapid large amounts of crystalloids(>5L)

is more freq. associated with tissue edemais more freq. associated with tissue edema8- Simple monitoring8- Simple monitoring

Clinical Clinical Markers of Markers of perfusionperfusion

Capillary refill timeCapillary refill time Urine outputUrine output

Observations (Pulse-BP-CVP)Observations (Pulse-BP-CVP) CVP if central venous access present (5-12cmH2O)CVP if central venous access present (5-12cmH2O) Patient thirst Patient thirst Response to fluid challenge Response to fluid challenge Investigations Investigations E(Na&K)/E(Na&K)/HbHb /urine out put more than 0.5ml/kg/h. /urine out put more than 0.5ml/kg/h. ABGABG -CXR -CXR

CLINICAL APPLICATIONCLINICAL APPLICATION

Water imbalanceWater imbalance..Water depletion Water depletion

CausesCauses1-lack of intake1-lack of intake2-Diabetes insipidus2-Diabetes insipidus3-increased out put( fever-osmotic 3-increased out put( fever-osmotic

diuresis)diuresis)

C/PC/PIntense thirst&weakness-decreased skin Intense thirst&weakness-decreased skin

turgor-oliguria with incr specific gravityturgor-oliguria with incr specific gravity

TTTTTTInitialy increase in serum Na3mmol=1L Initialy increase in serum Na3mmol=1L

water deficitwater deficitNa free water e.g,IV5%glucoseNa free water e.g,IV5%glucose

WATER EXCESSWATER EXCESS

Causes(iatrogenic)Causes(iatrogenic) Most common cause over infusion of IV5%glucose in post operative Most common cause over infusion of IV5%glucose in post operative

patientspatients Colorectal washout with plain water instead of saline before colonic Colorectal washout with plain water instead of saline before colonic

surgerysurgery Excessive uptake of water during TURPExcessive uptake of water during TURP Moderate Moderate asymptomatic(increased urine volume-incr body weight (no asymptomatic(increased urine volume-incr body weight (no

pitting edema)-decr Na&Heamatocrit)pitting edema)-decr Na&Heamatocrit) MarkedMarked(Na below120meq/L)(Na below120meq/L) Edema of brain cellsEdema of brain cells Nausea&vomiting of clear fluidNausea&vomiting of clear fluid TTTTTT Mildwater excess require restriction Mildwater excess require restriction SEVERE induction of diuresis by Mannitol+careful infusion of5%NaClSEVERE induction of diuresis by Mannitol+careful infusion of5%NaCl

ELECTROLYTE IMBALANCE ELECTROLYTE IMBALANCE

HyponatremiaHyponatremiaCausesCauses1-abnormal GIT losses(suction,vomiting,diarrhea)as in obstruction of small 1-abnormal GIT losses(suction,vomiting,diarrhea)as in obstruction of small

bowelbowel2-loss of ECF externally(burn-marked sweating)internallyas athird space2-loss of ECF externally(burn-marked sweating)internallyas athird space3-excessive urine Na wastage(diuretics,salt wasting nephritis,adrenal failure)3-excessive urine Na wastage(diuretics,salt wasting nephritis,adrenal failure)4- blood loss 5-decrease intake 6-addision disease4- blood loss 5-decrease intake 6-addision disease

C/PC/P eyes sunken&face drawn&skin dry&wrinkled&tongue dry eyes sunken&face drawn&skin dry&wrinkled&tongue dry

Peripheral veins contracted hypovolaemia (tachycardia & orthostatic Peripheral veins contracted hypovolaemia (tachycardia & orthostatic hypotention & shock)hypotention & shock)

Low CVPLow CVPdecrease urinedecrease urine

TTT TTT NaCl0.9% blood loss replaced by blood NaCl0.9% blood loss replaced by blood

HypernatraemiaHypernatraemia

CausesCauses If patientsgiven excessive amount of 0,9%NaCl during Early post If patientsgiven excessive amount of 0,9%NaCl during Early post

operative(some degree of Na retention is to be expectedoperative(some degree of Na retention is to be expected Hyperaldosteronism ( Conn,s disease-liver cirrhosis)Hyperaldosteronism ( Conn,s disease-liver cirrhosis) Cushing syndromeCushing syndrome C/PC/P puffiness of the face is the only early sign –only reliable sign puffiness of the face is the only early sign –only reliable sign

Oedema-weight gain-HTNOedema-weight gain-HTN Serum Na is usually normalSerum Na is usually normal TTTTTT Na restriction & diuretics Na restriction & diuretics

HypokalemiaHypokalemia Since serum K small amount of total body K small reduction in its Since serum K small amount of total body K small reduction in its

serum level may reflect large body losses of Kserum level may reflect large body losses of K

CAUSESCAUSES Excessive vomiting e,g. pyloric stenosis-intestinal obstuction-Excessive vomiting e,g. pyloric stenosis-intestinal obstuction-

paralytic illeus –prolonged gastro duodenal aspiration with fluid paralytic illeus –prolonged gastro duodenal aspiration with fluid replcement by IV NaCl replcement by IV NaCl

External alimentary fistulaeExternal alimentary fistulae Diarrhoea & Diuretics as furosemideDiarrhoea & Diuretics as furosemide Alkalosis (shift of K intra cellular) & HyperaldosteronsimAlkalosis (shift of K intra cellular) & Hyperaldosteronsim

C/PC/P most patient asymptomatic –early sign of K most patient asymptomatic –early sign of K depletion,malaise& weaknessdepletion,malaise& weakness

Paralytic illeus&distention-muscular paresisParalytic illeus&distention-muscular paresis ECG prolonged QT-Tachycardia-St segment depression-U wave ECG prolonged QT-Tachycardia-St segment depression-U wave

appearanceappearance TTTTTT 1meq of K =35 ampoules1meq of K =35 ampoules SAFE rule is rule of 40SAFE rule is rule of 40

HyperkalaemiaHyperkalaemia

CausesCauses Life-threatening k excess usually withRenal failureLife-threatening k excess usually withRenal failure Acidosis lead to shift of K out side the cellsAcidosis lead to shift of K out side the cells C/PC/P arryhythmia,bradycardia,hypotention,cardiac arrest arryhythmia,bradycardia,hypotention,cardiac arrest ECG wide QRS&peaked TwaveECG wide QRS&peaked Twave TTTTTT IV Ca gluconate&IV NaHCO3&glucose,insulin&if IV Ca gluconate&IV NaHCO3&glucose,insulin&if

previous fail ion exchange resins&the end Dialysisprevious fail ion exchange resins&the end Dialysis

Calcium ImbalanceCalcium Imbalance

HypocalcemiaHypocalcemia LatentLatent e,g. hypoparathyriodism following thyriod surgeryC/P e,g. hypoparathyriodism following thyriod surgeryC/P

(Circumoral tingling,numbness&+ve chvosteks sing)(Circumoral tingling,numbness&+ve chvosteks sing) SymptomaticSymptomatic hypocalcemia in permanent hypocalcemia in permanent

hypoparathyroidism,acute pancreatitis&acute hypoparathyroidism,acute pancreatitis&acute alkalosisC/P(hyperactive deep tendon reflexes,muscle&abdominal alkalosisC/P(hyperactive deep tendon reflexes,muscle&abdominal cramps,carpopedal spasmcramps,carpopedal spasm

ECG prolonged QT intervalECG prolonged QT interval TTTTTT IV Ca gluconate or Ca Cl2IV Ca gluconate or Ca Cl2 Chronic hypocalcaemia vit D, oralCa& AL(OH)3 bind phosphate in Chronic hypocalcaemia vit D, oralCa& AL(OH)3 bind phosphate in

the intestinethe intestine

Acid Base ImbalanceAcid Base Imbalance

II

Metabolic AcidosisMetabolic Acidosis CausesCauses Over production of organic acid DKA-Lactic Over production of organic acid DKA-Lactic

acidosis of sepsis and shockacidosis of sepsis and shock[ HIGH ANION GAP ][ HIGH ANION GAP ] Renal failure(acute-chronic)Renal failure(acute-chronic) Excessive loss of HCO3(diarrhea,pancreatic or Excessive loss of HCO3(diarrhea,pancreatic or

small intestinal fistula,uretro sigmoidostmy small intestinal fistula,uretro sigmoidostmy [ NORMAL ANION GAP ][ NORMAL ANION GAP ]

C/PC/P increased rate&depth of breathing increased rate&depth of breathing TTTTTT mild to moderate ttt of cause mild to moderate ttt of cause Sever (IV HCO3 causes (1/2body weight X (15-Sever (IV HCO3 causes (1/2body weight X (15-

HCO3))HCO3))

METABOLIC ALKALOSISMETABOLIC ALKALOSIS

PH more than 7.45PH more than 7.45

CausesCauses Gastrointestinal losses of H due to vomiting,suction(pyloric stenosis)Gastrointestinal losses of H due to vomiting,suction(pyloric stenosis) Hypokalemia lead to H movement into the cells(extracellular Hypokalemia lead to H movement into the cells(extracellular

alkalosis&paradoxical intracellular acidosis)alkalosis&paradoxical intracellular acidosis) HCO3 retention(NAHCO3 administration,milk alkali syndrome)HCO3 retention(NAHCO3 administration,milk alkali syndrome) C/PC/P Chyne-Stoke & apnea-Tetany Chyne-Stoke & apnea-Tetany TTTTTT replacement of CL replacement of CL In mild cases saline NaCl is sufficient associated hypokalemia ttt by In mild cases saline NaCl is sufficient associated hypokalemia ttt by

IV KClIV KCl Sever: IV ammonium chloride NHCL or hydrogen cholride HCl very Sever: IV ammonium chloride NHCL or hydrogen cholride HCl very

slowlyslowly TETANY ttt by slow IV10ml Ca gluconateTETANY ttt by slow IV10ml Ca gluconate

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