Date post: | 08-Aug-2018 |
Category: |
Documents |
Upload: | asad-khan-khalil |
View: | 214 times |
Download: | 0 times |
of 59
8/22/2019 s a Graves Ms Fluids Lytes 2004
1/59
Fluids &
Electrolytes
Scott G. Sagraves, MD, FACSAssistant Professor
Trauma & Surgical Critical Care
8/22/2019 s a Graves Ms Fluids Lytes 2004
2/59
The recogni t ion andmanagement of f lu id,
elec tro ly te, and related
acid -base prob lems are
common challenges on the
surg ical service.
Lawrence, Essentials of General Surgery
8/22/2019 s a Graves Ms Fluids Lytes 2004
3/59
Goals Review concept of total body fluids
Review types of crystalloids
Review electrolytes disturbances & theirtreatment strategies.
8/22/2019 s a Graves Ms Fluids Lytes 2004
4/59
Body Fluids
Intercellular
Intravascular
Interstitial40%
16%
4%
Body Water = 60% of a patients body weight
8/22/2019 s a Graves Ms Fluids Lytes 2004
5/59
Why do you give
D5NS + 20 mEq /L KClat 125 cc /h r to a
pat ient?
8/22/2019 s a Graves Ms Fluids Lytes 2004
6/59
Fluid Requirements typically 35 mL/kg/day
insensible loss = 700 mL/day or 0.2cc/kg/day for every 1 C > 37
1-10 kg = 100 mL/kg/day {4mL/kg/hr}
11-20 kg = 50 mL/kg/day {2mL/kg/hr} > 21 kg = 20 mL/kg/day {1mL/kg/hr}
Trick for hourly maintenance = 40 + weight (kg)
8/22/2019 s a Graves Ms Fluids Lytes 2004
7/59
Serum Values of
ElectrolytesCations Concentration, mEq/L
Sodium 135 - 145
Potassium 3.5 - 4.5
Calcium 4.0 - 5.5
Magnesium 1.5 - 2.5
AnionsChloride 95 - 105
CO2 24 - 30
Phosphate 2.5 - 4.5
8/22/2019 s a Graves Ms Fluids Lytes 2004
8/59
Daily Requirements for
Electrolytes
Sodium: 1-2 mEq/kg/d Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d Phosphorus: 800 - 1200 mg/d
8/22/2019 s a Graves Ms Fluids Lytes 2004
9/59
IV Solutions
Solution Na
+
Cl
-
K
+
Ca
+2
HCO3
-
Glu
Plasma 141 103 4-5 5 26 0
NS 154 154 0 0 0 0
D5W 0 0 0 0 0 50 G
LR 130 109 4 3 28 0
Serum Osmolality = [2 x Na] + [BUN/2.8] + [glucose/18]
8/22/2019 s a Graves Ms Fluids Lytes 2004
10/59
Replacement Strategies
Sweat: D5NS + 5 mEq KCl/L
Gastric: D5NS + 20 mEq KCl/L Biliary/pancreatic: LR
Small Bowel: LR
Colon: LR 3rdspace losses: LR
8/22/2019 s a Graves Ms Fluids Lytes 2004
11/59
Resuscitation
Crystalloids Replace blood loss at a 3:1 ratio
Initial bolus 1-2 liters, usually normal
saline
If they have transient response, give
additional fluids. Once 3-4 liters ofcrystalloid has been given consider
blood.
8/22/2019 s a Graves Ms Fluids Lytes 2004
12/59
INDICATORS OF SUCCESSFUL
RESUSCITATION PULSE 100 - 120 bpm
URINARY OUTPUT
CHILDREN = 1.0 ml/kg/hr ADULT = 0.5 ml/kg/hr
Clearance of lactate
Resolution of base deficit
BLOOD PRESSURE POOR
INDICATOR
8/22/2019 s a Graves Ms Fluids Lytes 2004
13/59
Fluid Status
[Na]
ECV
low normal high
160
140
120
140
GI loss
SIADH
HypothyroidCortisol CHFCirrhosis
NaHCO33% NaCl
Seawater
DI
Insensible
GI LossRenal loss
Osmotic
8/22/2019 s a Graves Ms Fluids Lytes 2004
14/59
Renal Regulatory
Mechanisms Aldosterone
distal tubules
sodium exchanged for K+and H+
released by volume reduction
Antidiuretic Hormone (ADH) increased tubular water reabsorption
posterior pituitary release
8/22/2019 s a Graves Ms Fluids Lytes 2004
15/59
Acid/base
7.4
BE = 0
HCO3 = 24
Respiratory
Acidosis
Metabolic
Acidosis
Metabolic
Alkalosis
Respiratory
Alkalosis
8/22/2019 s a Graves Ms Fluids Lytes 2004
16/59
ABG Rules Rule 1:An increase or decrease in
PaCO2of 10 mm Hg, respectively, is
associated with a reciprocal decrease or
increase of 0.08 pH units.
Rule 2:An increase or decrease in
[HCO3-] or 10 mEq/L respectively isassociated with a directly related
increase or decrease of 0.15 pH units.
8/22/2019 s a Graves Ms Fluids Lytes 2004
17/59
Acidosis
pH < 7.2
decreased responsiveness to catecholamines
cardiac dysfunction
arrhythmias
increased potassium serum levels
8/22/2019 s a Graves Ms Fluids Lytes 2004
18/59
Case Studies
8/22/2019 s a Graves Ms Fluids Lytes 2004
19/59
Found Down
45 yo WM, found down, presumed to beassaulted, well known to ED for EtOH
CT head - hygromas, small ICH
labs: Na = 118
K = 2.4
Cl = 74
What do you th ink? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
20/59
Severe Hyponatremia
Correct sodium to above 120 mEq/dl
NaCl + 40 mEq/L KCl
3% Saline furosemide diuresis (euvolemic)
serial electrolytes
be prepared to handle seizures
Replace potassium
Cl should correct itself
8/22/2019 s a Graves Ms Fluids Lytes 2004
21/59
Hyponatremia
1% of hospitalized are hyponatremic
Neurologic conditions:
Seizures, coma, encephalopathy
Results from rapid [Na]
Peripheral symptoms:
Cramping, twitches, fasciculations
Results from ion conduction aberrations
8/22/2019 s a Graves Ms Fluids Lytes 2004
22/59
Hints
Na+deficit (mEq) =
(140Naserum) x 0.6 x Kg
Glucose increase 100 mg/dL or a BUN
increase of 30 mg/dL decrease of 1.52 mEq/L Sodium
8/22/2019 s a Graves Ms Fluids Lytes 2004
23/59
Central Pontine
Myelinosis Results from overcorrection of
sodium
Correction of > 25 mEq per 24-48 hrs
Concurrent hypoxia
Presence of liver disease
Acute correction limit 25 mEq /day
Chronic correction limit 10 mEq/day
8/22/2019 s a Graves Ms Fluids Lytes 2004
24/59
Treatment Strategies Hypovolemic Hyponatremia
expand intravascular volume 0.9% NS or 3% Hypertonic Saline
Hypervolemic Hyponatremia
water restriction treat medical condition
hemodialysis
Euvolemic Hyponatremia SIADH
restrict fluid: 7-10 ml/kg/d
demeclocycline antagonizes vasopressin
8/22/2019 s a Graves Ms Fluids Lytes 2004
25/59
HDU Code
A Code Blue is called in the HDU.
65 yo male with ESRD has arrestedawaiting his dialysis treatment. CPR and
BVM resuscitation are in progress and an
IV has been established.
What do you think? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
26/59
Pre-Arrest Rhythm Strip
8/22/2019 s a Graves Ms Fluids Lytes 2004
27/59
Arrest Strip
8/22/2019 s a Graves Ms Fluids Lytes 2004
28/59
Diagnosis?
HYPERKALEMIATreatmentCaCl210% - 1 ampuleSodium Bicarbonate - 1 ampuleD50& Insulin 10 U
2 - agonist nebulizer- cellular K Kayexalate
8/22/2019 s a Graves Ms Fluids Lytes 2004
29/59
Causes of
Hyperkalemia Renal dysfunction
Acidemia Hypoaldosteronism
Drugs
Excessive intake WBC > 100,000
Platelets > 600,000
Cell Death
Rhabdomyolysis Tumor lysis
Burns
Hemolysis
8/22/2019 s a Graves Ms Fluids Lytes 2004
30/59
Potassium Metabolism
Normal daily intake 100 mEq
Renal filters & reabsorbs prox. Tubule
Potassium 1/[aldosterone]
Acidosis [potassium] with H+out
Alkalosis [potassium] with H+in
8/22/2019 s a Graves Ms Fluids Lytes 2004
31/59
Post op patient
42 year old female admitted to the ICUpost op after undergoing a
thyroidectomy for thyroid cancer.
She is complaining of peri-oral
numbness and tingling. Her DTRs are
hyperactive and her ECG has aprolonged QT interval.
What do you think? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
32/59
HYPOCALCEMIA
Chvosteks sign - facial muscle spasm
Trousseaus sign - carpal spasm
Treatment
monitor ECG
IV calcium
follow up labs
oral calcium supplements
normal is 1 gram/day
8/22/2019 s a Graves Ms Fluids Lytes 2004
33/59
Blunt Trauma 23 year old male, s/p MVC with blunt
abdominal and orthopedic trauma
HD#3 develops fever, N/V, abdominal
pain, refractory hypotension, with
oliguria.
Na+130, K-5.5, Glu 65, pH 7.29
What do you th ink? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
34/59
ACUTE ADRENAL
INSUFFICIENCY Treatment
fluid and vasopressor support
treat precipitating conditions
draw baseline cortisol level
administer dexamethasone
ACTH stimulation test hydrocortisone 100 mg IV q 8
8/22/2019 s a Graves Ms Fluids Lytes 2004
35/59
Hydrocortisone Stimulation
Test Baseline cortisol
> 20 - no further therapy
15 - 20 - test
< 15 empiric therapy
Administer Cortrosyn 250 g IV Obtain levels 30 & 60 minutes post
injection
8/22/2019 s a Graves Ms Fluids Lytes 2004
36/59
You are called to the
Bedside
What Do You Think? What Do You Do?
55 yo male, s/p fall with isolated,
repaired fractured femur.
Pts LOC decreased and patient began
to seize.
EKG showed
8/22/2019 s a Graves Ms Fluids Lytes 2004
37/59
Hypomagnesemia
Mg plays role in energy metabolism,
protein synthesis, cell division, &
calcium regulation in muscle.
Definition < 1.6 mg/dL
Causes: poor diet, diuretics, gut losses,
& massive diarrhea, resuscitation.
8/22/2019 s a Graves Ms Fluids Lytes 2004
38/59
Mg Rx Replacement Magnesium Sulfate
1 gram = 8 mEq
Infuse at rate of 2 gram/hour
Emergency: 2 grams over 5
minutes
8/22/2019 s a Graves Ms Fluids Lytes 2004
39/59
Closed Head Injury
32 year old female, MVC, GCS -7,
intubated, with CT scan showing SAH,
cerebral edema. ICP monitor shows apressure of 27. CPP 55.
Over the next several days, Na+> 150.
What do you th ink? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
40/59
DIABETES INSIPIDUS Signs
[Na+] 150 Urine specific gravity 1.007
polyuria, clear urine
dDAVP 1g sq raises urine osmolality in 2 hours Treatment
free water deficit = (0.6) x (Kg) x ([Naserum/140] -1)
dDAVP 2g sq every 12 hours for every L water deficit [Na+] will rise 3 mEq
above 140
8/22/2019 s a Graves Ms Fluids Lytes 2004
41/59
The transfer 50 year old obese female, transferred for
critical care management after a bowel
resection. Presents with obtundation,
hypotension, tachypnea, and emesis.
C/O abdominal pain and has fruity breath
amylase, lipase are elevated, Na+127
What do you th ink? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
42/59
Work up?
ABG
Electrolyte panel
urine analysis
CBC
Serum Ketones
8/22/2019 s a Graves Ms Fluids Lytes 2004
43/59
Hyperglycemia
Characteristic DKA NKHC
Glucose 400-800 > 1000
Acidosis Severe min.
Ketones High low
Dehydration Mod. High
Na 1.6 for every 100 glucose above 200
8/22/2019 s a Graves Ms Fluids Lytes 2004
44/59
Treatment Adequate fluid replacement
narrowing of anion gap
crystalloids: LR, NS, NS
Insul in bolus 0.1 - 0.5 units/kg
infusion 0.1 units/kg/hour
goal reduce plasma glucose 75-100 mg/dL/hr
Electrolytes
K replacement 10-20 mEq/hour after UOP OK
Mg, PO4replacement
Th d k
8/22/2019 s a Graves Ms Fluids Lytes 2004
45/59
The drunk 37 year old male, h/o EtOH abuse fell from a
deer hunting tree stand. C5 fracture withoutcord involvement.
HD #2 develops delirium tremors moved fromSIU to ICU. Librium started.
HD#4, dobhoff placed and tube feeds started.
That night, the patients respiratory status
worsens and he is intubated.
What do you th ink? What do you do?
8/22/2019 s a Graves Ms Fluids Lytes 2004
46/59
HYPOPHOSPHATEMIA Refeeding Syndrome
malnutrition
alcoholism
Hypophosphatemia
limits oxygen unloading immunocompromise
muscle weakness failure to wean
8/22/2019 s a Graves Ms Fluids Lytes 2004
47/59
Treatment IV supplementation in emergent cases
sodium or potassium phosphorous
PO supplementation routinely
Keep (phosphorous x calcium) ratio