Fluids & Electrolytes

Scott G. Sagraves, MD, FACS

Assistant Professor Trauma & Surgical Critical Care

The recognition and management of fluid, electrolyte, and related acid-base problems are common challenges on the surgical service.
Lawrence, Essentials of General Surgery

Goals
Review concept of total body fluids Review types of crystalloids Review electrolytes disturbances & their treatment strategies.

Body Fluids
16%
Intercellular Intravascular Interstitial

4%

40%

Body Water = 60% of a patients body weight

Why do you give D5NS + 20 mEq/L KCl at 125 cc/hr to a patient?

Fluid Requirements
typically 35 mL/kg/day insensible loss = 700 mL/day or 0.2 cc/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)

Serum Values of Electrolytes

Cations
Sodium Potassium Calcium Magnesium Concentration, mEq/L 135 - 145 3.5 - 4.5 4.0 - 5.5 1.5 - 2.5 95 - 105 24 - 30 2.5 - 4.5

Anions
Chloride CO2 Phosphate

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

IV Solutions
Solution Plasma NS D5W LR Na+ 141 154 0 130 Cl103 154 0 109 K+ 4-5 0 0 4 Ca+2 HCO3- Glu 5 0 0 3 26 0 0 28 0 0 50 G 0

Serum Osmolality = [2 x Na] + [BUN/2.8] + [glucose/18]

Replacement Strategies
Sweat: D5NS + 5 mEq KCl/L Gastric: D5NS + 20 mEq KCl/L Biliary/pancreatic: LR Small Bowel: LR Colon: LR 3rd space losses: LR

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 of crystalloid has been given consider blood.

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

Fluid Status
120 GI loss
SIADH Hypothyroid Cortisol CHF Cirrhosis

140 [Na]
GI Loss Renal loss Osmotic

140

160

DI Insensible

NaHCO3 3% NaCl Seawater

low

normal ECV

high

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

Acid/base
Respiratory Acidosis BE = 0 HCO3 = 24 Metabolic Acidosis Respiratory Alkalosis Metabolic Alkalosis

7.4

ABG Rules
Rule 1: An increase or decrease in PaCO2 of 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 is associated with a directly related increase or decrease of 0.15 pH units.

Acidosis
pH < 7.2
decreased responsiveness to catecholamines cardiac dysfunction arrhythmias increased potassium serum levels

Case Studies

Found Down
45 yo WM, found down, presumed to be assaulted, well known to ED for EtOH CT head - hygromas, small ICH labs:
Na = 118 K = 2.4 Cl = 74

What do you think? What do you do?

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

Hyponatremia
1% of hospitalized are hyponatremic Neurologic conditions:
Seizures, coma, encephalopathy Results from rapid q [Na]

Peripheral symptoms:
Cramping, twitches, fasciculations Results from ion conduction aberrations

Hints
Na+ deficit (mEq) = (140 Naserum) x 0.6 x Kg Glucose increase 100 mg/dL or a BUN increase of 30 mg/dL E decrease of 1.5 2 mEq/L Sodium

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

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

HDU Code
A Code Blue is called in the HDU. 65 yo male with ESRD has arrested awaiting his dialysis treatment. CPR and BVM resuscitation are in progress and an IV has been established. What do you think? What do you do?

Pre-Arrest Rhythm Strip

Arrest Strip

Diagnosis? HYPERKALEMIA
yTreatment
 CaCl2 10% - 1 ampule  Sodium Bicarbonate - 1 ampule  D50 & Insulin 10 U  F2 - agonist nebulizer- cellular K o  Kayexalate

Causes of Hyperkalemia
Renal dysfunction Acidemia Hypoaldosteronism Drugs Excessive intake WBC > 100,000 Platelets > 600,000 Cell Death
Rhabdomyolysis Tumor lysis Burns Hemolysis

Potassium Metabolism
Normal daily intake 100 mEq Renal filters & reabsorbs prox. Tubule Potassium E 1/[aldosterone] Acidosis o [potassium] with H+ out Alkalosis q [potassium] with H+ in

Post op patient
42 year old female admitted to the ICU post 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 a prolonged QT interval. What do you think? What do you do?

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

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 think? What do you do?

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 8r

Hydrocortisone Stimulation Test

Baseline cortisol
> 20 - no further therapy 15 - 20 - test < 15 empiric therapy

Administer Cortrosyn 250 Qg IV Obtain levels 30 & 60 minutes post injection

You are called to the Bedside

55 yo male, s/p fall with isolated, repaired fractured femur. Pts LOC decreased and patient began to seize. EKG showed
What Do You Think? What Do You Do?

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.

Mg Rx
Replacement Magnesium Sulfate
1 gram = 8 mEq Infuse at rate of 2 gram/hour Emergency: 2 grams over 5 minutes

Closed Head Injury

32 year old female, MVC, GCS -7, intubated, with CT scan showing SAH, cerebral edema. ICP monitor shows a pressure of 27. CPP 55. Over the next several days, Na+ > 150. What do you think? What do you do?

DIABETES INSIPIDUS
Signs
[Na+] u 150 Urine specific gravity 1.007 polyuria, clear urine
dDAVP 1Qg sq raises urine osmolality in 2 hours

Treatment
free water deficit = (0.6) x (Kg) x ([Naserum/140] -1) dDAVP 2Qg sq every 12 hours for every L water deficit [Na+] will rise 3 mEq above 140

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 think? What do you do?

Work up?
ABG Electrolyte panel urine analysis CBC Serum Ketones

Hyperglycemia
Characteristic Glucose Acidosis Ketones Dehydration DKA 400-800 Severe High Mod. NKHC > 1000 min. low High

Na

1.6 for every 100

glucose above 200

Treatment
Adequate fluid replacement narrowing of anion gap crystalloids: LR, NS, NS Insulin 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, PO4 replacement

The drunk
37 year old male, h/o EtOH abuse fell from a deer hunting tree stand. C5 fracture without cord involvement. HD #2 develops delirium tremors moved from SIU 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 think? What do you do?

HYPOPHOSPHATEMIA
Refeeding Syndrome
malnutrition alcoholism

Hypophosphatemia
limits oxygen unloading immunocompromise muscle weakness p failure to wean

Treatment
IV supplementation in emergent cases
sodium or potassium phosphorous

PO supplementation routinely Keep (phosphorous x calcium) ratio < 60 Magnesium should be replenished simultaneously

The burn patient

25 year male, caught fire after his lawnmower exploded as he was filling it with gasoline while smoking a cigarette. The patient sustained second and third degree burns estimated at 40 % total body surface area.

Parkland Formula
4 cc x WEIGHT (kg) x (% TBSA)

Parkland Example
25 year old male weight = 220 pounds 40% TBSA 2 - 3 burns How much fluid do you need to give?
During the first 8 hours? During the next 16 hours?

Parkland Example
4 cc x weight x %TBSA 4 x 100 x 40 = 16,000 cc/24 hours
first 8 hours = 16,000/2 =8,000/8 = 1,000cc/hr next 16 hours = 8,000/16 = 500cc/hr

Diarrhea Dysrhythmia
68 yo female on digoxin for chronic CHF, presents to the SIU for colitis as evidenced by copious diarrhea. The patient is weak and lethargic and ectopic beats are noted on her ECG. What do you think? What do you do?

Hypokalemia
Deficits
Serum K =
3-4 is a 100-200 mEq deficit 2-3 is a 200-400 mEq deficit

Treatment
replacement 10 mEq/hr via peripheral IV 10 mEq E 0.1 mEq/L increase in serum K Remember to check the Mg level too

Paradoxical Aciduria
A rule: o 0.1 pH E q 0.4 - 0.5 mEq [K+] pathophysiology
loss of K, severe alkalosis, o[Na+] load hydrogen exchanged for K independent of alkalosis remaining

requires emergent replacement

Cancer
72 yo female with stage 4, metastatic breast cancer. Patient is confused, cachetic, and nauseated Na+= 147, Ca+2 = 14mg/dl What do you think? What do you do?

HYPERCALCEMIA
Cancers associated with hypercalcemia bone breast kidney colon thyroid multiple melanoma

Treatment
hydration diuretics-lasix mithramycin corticosteroids calcitoninosteoclast resorption phosphate

Labor and Delivery

32 year old P3G3 being treated by OB for eclampsia. You are called for a somnolent patient in second-degree heart block and paralysis. What do you think? What do you do?

Hypermagnesemia
Signs
Prolonged PR interval Hypotension, hyporeflexia, paralysis

Treatment
Calcium gluconate Normal saline Loop diuretics dialysis

Questions?