fluid & electrolytes management.ppt
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Fluid & Electrolytes
Dewi Kartikawati N.
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FLUIDS50-60% of the human body is water (decreases withage)Body fluids are classified according to their locationwith most of the bodys fluids found within the cell
Intracellular Extracellular (mainly responsible for transport of nutrients
and wastes)
Fluid compartments are separated by selectivelypermeable membranes that control movement of
water and solutesThe process of homeostasis involves delivery ofoxygen and nutrients to the cells and removal ofwaste
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Body Fluid Compartments:
ICF:55%~75%
Intravascularplasma
X 50~70%lean body weight
ExtravascularInterstitial
fluid
TBW
ECF
3/4
1/4
Male (60%) > female (50%)
Most concentrated in skeletal muscle
TBW=0.6xBW
ICF=0.4xBW
ECF=0.2xBW
2/3
1/3
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Body Fluid Compartments
Contd..2/3 (65%) of TBW is intracellular (ICF)
1/3 extracellular water
25 % interstitial fluid (ISF)
5- 8 % in plasma (IVF intravascular fluid)
1- 2 % in transcellular fluids CSF, intraocular
fluids, serous membranes, and in GI, respiratoryand urinary tracts (third space)
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Regulation of Body FluidCompartments
Osmosis is the diffusion of water caused by fluidgradient.Diffusion is the movement of a substance fromarea of higher concentration to one of lowerconcentration.Active Transport is the movement of substanceacross permeable membrane and gradient; requiresenergy and pump. Ex. Sodium/potassium pump
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Regulation of Body FluidCompartments Contd
Filtration is the movement of water and solutesfrom an area of high hydrostatic pressure to anarea of low hydrostatic pressure
Osmolality reflects the concentration of fluid thataffects the movement of water between fluidcompartments by osmosisOsmotic pressure is the amount of hydrostaticpressure needed to stop the flow of water by
osmosis
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Osmolarity
Isotonic same solute concentration; equal;no movement across membrance
Hypertonic/hyper-osmotic greater osmoticpressure (concentration); waterpulled intofluid to equalize.
Hypotonic/hypo-osmotic lesser osmoticpressure (concentration); waterpulled out of
fluid to equalize.
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Cell in a
hypertonicsolution
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Cell in ahypotonicsolution
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Regulation of Fluids:
Renal sympathetic nerves
Renin-angiotensin-
aldosterone system
Atrial natriuretic peptide (ANP)
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Regulation of Fluid Volume
Kidneys
Capillary pressure forces fluid through the
walls and into the tubule At this point H2O or electrolytes are then
either retained or excreted
The urine becomes more dilute or moreconcentrated based on the needs of thebody
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Regulation of Fluid Volume, cont.
Antidiuretic hormone (ADH) Produced by the hypothalamus
Stored in the pituitary gland
Restores blood volume by increasing or decreasingexcretion of water
Increased osmolality or decreased blood volumestimulates the release of ADH
Then the kidneys reabsorb water Also may be released by stress, pain, surgery, and
some meds
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Regulation of Fluid Volume, cont.
Renin-angiotensin-aldosterone system
Renin secreted in kidney
Amount of renin produced depends on bloodflow and amount of Na in the blood
Produces angiotensin II (vasoconstrictor)
Angiotensin causes peripheralvasoconstriction
Angiotensin II stimulates the production ofaldosterone
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Regulation of Fluid Volume, cont.
Aldosterone
Secreted by the adrenal gland response toangiotensin II
The adrenal gland may also be stimulated by theamount of Na and K + in the blood
Causes the kidneys to retain Na and H2O
Leads to increases in fluid volume and Na levels Decreases the reabsorption of K+
Maintains B/P and fluid balance
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Regulation of Fluid Volume,cont
Atrial natriuretic peptide or factor (ANP)(ANF) Cardiac hormone
Released in response to increased pressure in theatria (increased blood volume)
Opposes the renin-angiotensin-aldosterone system
Stimulates excretion of Na and H2O
Suppresses renin level Decreases the release of aldosterone
Decreases ADH release
Reduces vascular resistance by causing
vasodilation
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Regulation of Fluid Volume,cont
Atrial natriuretic peptide or factor (ANP)(ANF) Cardiac hormone
Released in response to increased pressure in theatria (increased blood volume)
Opposes the renin-angiotensin-aldosterone system
Stimulates excretion of Na and H2O
Suppresses renin level Decreases the release of aldosterone
Decreases ADH release
Reduces vascular resistance by causing
vasodilation
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Fluid shifting1st space shifting- normal distribution offluid in both the ECF compartment andICF compartment.
2nd space shifting- excess accumulation ofinterstitial fluid (edema)
3rd space shifting- fluid accumulation inareas that are normally have no or little
amounts of fluids (ascites)
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Balance
Fluid and electrolyte homeostasis ismaintained in the body
Neutral balance: input = output
Positive balance: input > output
Negative balance: input < output
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Electrolytes
Major cations for extracellular fluidSodium
Major cations for intracellular -
Potassium
Cations
Calcium,phosphorus, magnesium
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Sodium (Na):
Is the most abundant cation in theextracelluar fluid and major contributor toserum osmolality.
Function of sodium: Controlling and regulating water balance.
Maintaining blood volume
Transmitted nerve impulses.
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Normal level is 135 145 mg/dl.
Hyponatremia: sodium deficit in the blood.
Hypernatremia: sodium excess in the
blood. Sodium is found in many foods, such as
processed cheese, table salt
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Potassium:
Is the major cation in intracellular fluid.Function of potassium:
Maintain ICF osmolality.
Transmitting nerve impulses.
Regulate cardiac impulses.
Skeletal and smooth muscle function.
Regulate acid base balance
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Potassium is found in many fruits andvegetables, meat, fish, milk.
Normal level of potassium is 3.55.3meq/l.
Hypokalemia: potassium deficit in theblood.
Hyperkalemia: potassium excess in theblood.
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Solutes dissolved particles
Electrolytes charged particles
Cations positively charged ions
Na+, K+ , Ca++, H+
Anions negatively charged ions
Cl-, HCO3- , PO4
3-
Non-electrolytes - Uncharged
Proteins, urea, glucose, O2, CO2
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Factor effecting fluid andelectrolyte balance:
Age: infant have greater water needand greater loss due to greater
metabolic rate.Environment: excess heat stimulatesthe sympathetic nervous system and
cause person to sweat.
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Diet: in nutritional deficiency, the bodypreserved the protein by breakingdown the fat and glycogen.
Stress: water retention and increasethe production antiduritic hormone.
Illness: burn, renal disorder
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Client at risk for fluid andelectrolyte imbalance:
Post operative client.
Client with sever trauma or burn.
Client with chronic disease ascongestive heart failure.
Client with intravenous infusion.
Client with special drainage.Client who receiving diuretic
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FLUIDS IMBALANCES.
Hypovolemia
Hypervolemia
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Signs of Hypovolemia:
Diminished skin turgor
Dry oral mucus membrane
Oliguria-
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Clinical Diagnosis of Hypovolemia:
Thorough history taking: poor intake, GI
bleedingetc
BUN : Creatinine > 20 : 1- BUN: hyperalimentation, glucocorticoid
therapy, UGI bleeding
Increased specific gravity
Increased hematocritElectrolytes imbalance
Acid-base disorder
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Parenteral Fluid Therapy:
Crystalloids:
- contain Na as the main osmotically
active particle- useful for volume expansion (mainly
interstitial space)
- for maintenance infusion
- correction of electrolyte abnormality
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Crystalloids:
Isotonic crystalloids
- Lactated Ringers, 0.9% NaCl
- only 25% remain intravascularly
Hypertonic saline solutions- 3% NaCl
Hypotonic solutions
- D5W, 0.45% NaCl
- less than 10% remain intra-vascularly, inadequate for fluid
resuscitation
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Colloid Solutions:
Contain high molecular weight
substancesdo not readily migrate across
capillary walls
Preparations
- Albumin: 5%, 25%
- Dextran
- Gelifundol- Haes-steril 10%
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Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3- Dextrose mOsm/L
ECF 142 4 5 103 27 280-310
LactatedRingers
130 4 3 109 28 273
0.9% NaCl 154 154 308
0.45%
NaCl77 77 154
D5W
D5/0.45%NaCl
77 77 50 406
3% NaCl 513 513 1026
6%Hetastarch
500 154 154 310
5%Albumin
250,500130-160
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The Influence of Colloid & Crystalloid onBlood Volume:
1000cc
500cc
500cc
500cc
200 600 1000
Lactated Ringers
5% Albumin
6% Hetastarch
Whole blood
Blood volume
Infusionvolume
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Signs of Hypervolemia:
Hypertension
Polyuria
Peripheral edemaWet lung
Jugular vein engorgement
Especially whenhypo-albuminemia
Pitt d d
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Pitted edemaFluid overload
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Pitting odema
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Management of Hypervolemia:
Prevention is the best way
Guide fluid therapy with CVP level or
pulmonary wedge pressureDiuretics
Increase oncotic pressure: FFP or
albumin infusion (may followed by diuretics)Dialysis
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Fluid Management:
Goal:
- to maintain urine output of
0.5~1.0mg/kg/h
Electrolytes require:- Na+: 1-2mmol/kg/day
- K+: 0.5~1.0mmol/kg/day
Avoid fluid overload, especially in malnutrition,
heart failure and renal insufficiency patient
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Fluid Management:
For acute blood loss
- Begin with 2-3L isotonic crystalloid to
restore blood pressure and peripheralperfusion
- Early use of colloid
- Crystalloid + 5% albumin in a ratio of 4:1- Blood transfusion
- Large borne IV line
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Electrolyte Imbalances
Hypo and Hypernatremia (Na+)
Hypo and Hyperkalemia (K+)
Hypo and Hypercalcemia (Ca+)
Hypo and Hypermagnesemia (Mg+) Hypo and Hyperphosphatemia (Phos+)
Hypo and Hyperchloremia (Cl-)
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MACAM CAIRAN :
1. CAIRAN NON ELEKTROLIT GLUKOSA 5% / DEKTROSE 5%
2. CAIRAN ELEKTROLIT NaCl (NS), RL. PZ, KAEN. Asering dll.
3. CAIRAN KOLOID Dextran. HES. Gelatin, Darah , Albumin dll
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PEMBERIAN CAIRAN MAINTENANCE
- JUMLAH CAIRAN :
DEWASA 50Kg / KgBB/ 24 jam
ANAK 10Kg I ------ 100cc / KgBB / 24 jam
10Kg II ------- 50cc / KgBB / 24 jam.
> 20cc/ KgBB / 24 jam.
- TETESAN / MENIT
- MACAM CAIRAN --------------------- Na+ ---------- 3 5 mg / KgBB / 24 jam.KEBUTUHAN
CONTOH :
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Laki-laki, 25 th, BB 50 Kg.
- Jumlah Cairan -------- 50 x50 / 24Jam = 2500 cc / 24 jam.
- Macam Cairan ----- kebutuhan Na+ = 150 -250 mg/ 24 jam.
RL Na+ 131 meq/L------ 1 fles = 65 meq
PZ Na+ 154 meq/L ------ 1 fles = 77 meq.
- Macam Cairan RL 3 fles --- Na+ 195 meq , jumlah 1500 cc.
kekurangan cairan 1000 cc ------ D5% = 2 fles.
- Susunan Cairan RL 3 fles + D5% 2 fles.
- Tetesan / menit otsuka --- 1cc = 15 tts
terumo 1cc = 20 tts.
- Otsuka : 2500 x 15 = 2500 = 25 -30 tts / mnt
24 x 60 24 x 4
- Terumo : 2500 x 20 = 2500 = 33-35 tts / mnt.
24 x 60 24 x 3
Anak 11 th BB 27 kg
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Anak, 11 th , BB 27 kg.
- Jumlah Cairan 10 Kg I ----- 10 x 100cc = 1000 cc
10Kg II ------- 10 x 50 cc = 500 cc
> 7Kg ------ 7 x 20 cc = 140 cc
jumlah = 1640 cc
-Macam Cairan Kebutuhan Na+ = 81 135 meq/ 24 jam.
-NS / PZ NaCl 0,9% - C I - Na+ 77 meq/fles-NaCl 0,45% in D5% -- C2 Na+38 meq/fles
-NaCl 0,225% in D5% C4 Na+19 meq/fles-NaCl 0,18 % in D5% C5 Na+ 10 meq/fles
-Macam cairan -C2 3 fles Na+ 114 meq jumlah 1.500 cc-D 5% 140 cc Jumlah 140 cc
- Total 1.640 cc
-Tetesan : Otsuka : 1640 X 15 = 1640 = 16 - 18 tts/m
- 24 X 60 96
-Terumo : 1640 X 20 = 1640 = 22 24 tts/m
- 24 X 60 96
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Perdarahan ..
1. VOLUME DARAH EFEKTIF (Effective bloodvolume/flow)
70
75 cc/kgBB 60 65 cc/kgBBAnak2 90 100 cc/kgBB
2. 15 % EBV/F hilang hypoxia (+) nadimeningkat
3. 25 % EBV/F hilang syok.
C
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Case..
Pasien laki2 BB 50 kg di IRD karena KLL dan
perdarahanWaktu masuk: N 100 x/m T 120/80 RR 24 x/m
Perhitungan : N 100 x/m pasien perdarahanHypoxia (+) kira2 15 % dari EBV/F
BB 50 kg EBV 70 X 50 cc = 3.500 cc
Darah yang hilang 15 % = 15/100 X3.500 = 525 cc
Cairan yang dimasukkan, RL = 4 X 525cc 2.100 cc
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