Fluid and Electrolyte Fluid and Electrolyte AbnormalitiesAbnormalities

Fluid and Electrolyte Fluid and Electrolyte AbnormalitiesAbnormalities

Introduction• Fluid and eclectrolyt balance is a

dynamic process that is crucial for life.• Any disturbance will cause disorder.• Approx. 60% of the body weight is fluid

(water and electrolytes.• Body fluid is located in 2 compartment:• Intracellular (ICF): 2/3 of TBF• Extrecellular (ECF): 1/3 of TBF compose

of IVF + 3rd space (interstitial space)

Definitions • Diffusion:

• Hydrostatic pressure:

• Osmotic pressure (oncotic pressure):

• Osmolarity:

• Osmolality:

IVFs

• Could be Crystalloids or collids• Crystalloids : isotonic, hpertonic,

hypotonic

• Colloids: poroteins (albumin, plasmagel) or non proteins (starch, dextran)

IVFs

• Hypotonic fluids: e.x: NS 0.45%, D10W%, dehyration.

• Isotonic fluids: e.x: NS 0.9%, hypovelemic

• Hypertonic fluids: e.x: 3% NS, edema

• Colloids : Albumin, Tx hypovemia, # in spesis, hemorrhage

Normal Values• Na: 135- 145 mEq/L• K: 3.5- 5.3 mEq/L• Blood Urea Nitrogen (BUN): 7-20 mg/dl• Creatinine: 0.7 -1.4 mg/dl• Albumin: 3.5 – 5.3 g/dl• Cl: 95 -110 mEq/L• Ca: 8.5 -10.5 mg/dl• Mg: 1.6 -2.4 mEq/L• Po4: 2.5 -4.5 mg/dl

Normal Values• HEMATOCRIT (HCT)Normal Adult Female Range: 37 - 47%

Normal Adult Male Range 40 - 54% 

• HEMOGLOBIN (HGB)• Normal Adult Female Range: 12 - 16 g/dl

Normal Adult Male Range: 14 - 18 g/dl

• WBC: 5000 -10000 cell/Cubic mm.• Platelets: 130000- 400000 cell/Cubic mm.

Hypovolemia• Mild: 4% loss TBW or < 15% blood volume• Moderate: 6% TBW or 15-30% BV• Severe: 8% TBW or 30-40% BV• Shock: >8% TBW or > 40% BV• S/Sx:

– Sleepy, apathy, coma weakness– orthostatic, tachycardia, decreased pulse pressure,

low CVP.– Poor turgor, hypothermia, dry membranes– Oliguria.

Hypovolemia, continued

• Lab: – BUN: Cr ratio greater than 20– Inc. hematocrit, 3% per liter deficit– increased urine spec. gravity and

osmolality

Hypovolemia, continued

• Treatment:– Acute: 2L LR via large bore IV then

blood– Subacute:

• Isotonic or hypotonic deficits give isotonic NS or hypotonic 0.45 NS or LR (e.g. vomiting = NS, diarrhea = LR)

Hypervolemia• Etiology: Cardiac failure, Renal failure,

mobilization of fluid, iatrogenic, psychologic.

• S/Sx:– Wt gain over baseline. (Fasting losses are

0.25-0.5 kg/day)– wheezing, pedal/sacral edema– elevated CVP – Pulmonary edema on CXR

Hypervolemia, continued

• Lab:– Decreased Hct and albumin

• Treatment:– Water restrict to 1500 cc/day– +/- Diuretics– Sodium restrict to 0.5 gm/day– (Albumin followed by diuretics)

Hyponatremia• Low Na in blood serum

• Causes:

• fluid overload• Low NA in diet

Hyponatremia, continued

• S/Sx: – Neurologic: muscle twitching, hyperreflexia, seizures

and HTN– Salivation, lacrimation, diarrhea– Often asymptomatic if slow until below 120 mEq/L.

(130 mEq/L if acute) • Treatment: correct underlying disorder

– Fluid restrict, + diuretics– Hypertonic saline to increase level 2-3 mEq/L/hr and

max rate 100cc of 5% saline/hr

Hypernatremia• Free water deficit or water loss greater than

salt loss. • Always assoc with hyper osmolar state.

• S/Sx:– Neurologic: restless, seizure, coma,

delirium and mania

– THIRST, weakness

Hypernatremia, continued

– Sticky mucus membranes, poor salivation/lacrimation, hyperpyrexia, Red swollen tongue

• Treatment: correct underlying disorder.

- Slow administration of IV fluids to reduce plasma sodium level, at rate not more than 2 mEq/l/hr.

- Diuretics.

Hypokalemia

– Low K+ in blood serum– High intracellular uptake (insulin therapy).– renal/diuretics, steroids, and renal tubular acidosis

• S/Sx:– Clinical: muscle weakness/fatigue. Insulin resistance

in DM– EKG: low, flat T-waves, ST depression, and U waves

Hypokalemia, continued

• ECG changes in hypokalemia

Hypokalemia, continued

• Treatment:– Check renal function– Treat alkalosis, decrease sodium

intake– PO with 20-40 mEq doses– IV: peripheral /central and increase

K+ in maintenance fluids.

Hyperkalemia– high K+ level in blood serum

– acidosis, low insulin– tissue necrosis, digoxin poisoning

– Renal insufficiency, DM,

Hyperkalemia, continued

• S/Sx: – Clinical: nausea/vomiting, colic,

weakness diarrhea– EKG: early – peaked T waves then flat

P waves, depressed ST segment, widened QRS progressing to sine wave and V fib.

– Cardiac arrest occurs in diastole

Hyperkalemia – ECG Changes

Hyperkalemia, continued• Treatment:

• Ca-gluconate – 1 gm over 2 min IV

• Sodium bicarbonate – 1 amp, may repeat in 15min

• D50W (1 ampule = 50 gm) and 10U regular insulin

• Emergent dialysis

• Hydration and diuresis

HypocalcemiaSeen in: – pancreatitis, hyperPO4, low Vitamin D, massive

blood transfusion, drugs (e.g. gentamicin) renal insufficiency, hypoalbuminemia

S/Sx:– numbness, tingling, circumoral paresthesia, cramps

tetany, – EKG has prolonged QT interval

Treatment:• Acute: (IV) CaCl or CaGluconate • Chronic: PO suplment, Vit D

ECG Changes in Calcium Abnormalities

Hypercalcemia Causes : • Usually secondary to hyperparathyroidism or

malignancy.• Other causes are thiazides, acute adrenal

insufficiency

S/Sx:– N/V, anorexia, abdominal pain, confusion,

lethargy.

– Treatment:

– Hydration with NS then loop diuretic.

– Steroids for lymphoma, multiple myeloma, adrenal insufficiency, bone mets.

– Vit D intoxication.

– May need Hemodialysis.

HypomagnesemiaCauses :– Malnutrition, burns, pancreatitis, SIADH,

parathyroidectomy, primary hyperaldosteronism

S/Sx: – weakness, fatigue, MS changes,

hyperreflexia, seizure, arrhythmia– Treatment: IV replacement of 2-4 gm of

MgSO4 per day or oral replacement

Hypermagnesemia causes :

– Renal insufficiency, antacid abuse, adrenal insufficiency, hypothyroidism, iatrogenic

S/Sx:

- N/V, weakness, MS changes, hyporeflexia, paralysis of voluntary muscles, EKG has AV block and prolonged QT interval.

Treatment:

- Discontinue source, IV CaGluconate for acute Rx, Dialysis

Hypophosphatemia

Seen in:

- hyperalimentation, after starvation, DKA, malabsorption, phosphate binding antacids, alkalosis, hemodialysis, hyperparathyroidism

S/Sx: – myocardial depression due to low ATP,bone pain,

hemolysis, cardiac arrest

Treatment:- PO replacement (Neutraphos) or IV KPhos or NaPhos 0.08-

0.20 mM/kg over 6 hrs

Hyperphosphatemia

Seen in :– Hyperphosphatemia– Renal insufficiency,

hypoparathyroidism, may produce metastatic calcification

Treatment - Treated with restriction and

phosphate-binding antacid (Amphogel)

Zinc• Enzyme activator and cofactor

Causes :

- Deficiency in malabsorption, trauma, cancer or diarrhea

S/Sx:

- “4 D’s” – diarrhea, depression, dermatitis, dementia

Treatment:

- treated with zinc sulfate 3-6mg/day if with (normal number of stools)