s a Graves Ms Fluids Lytes 2004

8/22/2019 s a Graves Ms Fluids Lytes 2004

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Fluids &

Electrolytes

Scott G. Sagraves, MD, FACSAssistant Professor

Trauma & Surgical Critical Care


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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


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Goals Review concept of total body fluids

Review types of crystalloids

Review electrolytes disturbances & theirtreatment strategies.


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Body Fluids

Intercellular

Intravascular

Interstitial40%

16%

4%

Body Water = 60% of a patients body weight


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Why do you give

D5NS + 20 mEq /L KClat 125 cc /h r to a

pat ient?


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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)


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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


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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


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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]


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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


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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.


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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


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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


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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


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Acid/base

7.4

BE = 0

HCO3 = 24

Respiratory

Acidosis

Metabolic

Acidosis

Metabolic

Alkalosis

Respiratory

Alkalosis


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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.


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Acidosis

pH < 7.2

decreased responsiveness to catecholamines

cardiac dysfunction

arrhythmias

increased potassium serum levels


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Case Studies


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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?


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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


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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


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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


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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


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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


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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?


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Pre-Arrest Rhythm Strip


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Arrest Strip


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Diagnosis?

HYPERKALEMIATreatmentCaCl210% - 1 ampuleSodium Bicarbonate - 1 ampuleD50& Insulin 10 U

2 - agonist nebulizer- cellular K Kayexalate


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Causes of

Hyperkalemia Renal dysfunction

Acidemia Hypoaldosteronism

Drugs

Excessive intake WBC > 100,000

Platelets > 600,000

Cell Death

Rhabdomyolysis Tumor lysis

Burns

Hemolysis


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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


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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?


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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


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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



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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


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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


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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


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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.


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Mg Rx Replacement Magnesium Sulfate

1 gram = 8 mEq

Infuse at rate of 2 gram/hour

Emergency: 2 grams over 5

minutes


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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.



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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


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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



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Work up?

ABG

Electrolyte panel

urine analysis

CBC

Serum Ketones


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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


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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


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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.



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HYPOPHOSPHATEMIA Refeeding Syndrome

malnutrition

alcoholism

Hypophosphatemia

limits oxygen unloading immunocompromise

muscle weakness failure to wean


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Treatment IV supplementation in emergent cases

sodium or potassium phosphorous

PO supplementation routinely

Keep (phosphorous x calcium) ratio

Documents

s a Graves Ms Fluids Lytes 2004