FLUID and ELECTROLYTE CONCEPT

LESTARI SUKMARINI, MNS KMB 2008

Objectives:
A. Review mechanism of fluid and electrolyte

balance. 1. body water distribution 2. body electrolyte component 3. mechanism for fluid and electrolyte movement 4. regulation of fluid and electrolyte balance B. Fluid and electrolyte imbalances 1. fluid imbalance a. fluid deficit b. fluid excess 2. electrolyte imbalance a. electrolyte deficit K+, Na+, Ca, Mg b. electolyte excess K+, Na+, Ca, Mg

Body Fluid distribution

Body fluids constitute 5560% of body weight

Higher in males due to greater muscle mass and lower fat

Total body water declines throughout life with changes in muscle mass and fat Water occupies 2 main fluid compartments: Intracellular (~2/3 of total water) Extracellular (~1/3 total water) plasma (20%) interstitial fluid (80%)

Hydrostatic pressure Plasma

Oncotic pressure

Fluid exchange

Fluid dynamics at the capillary

CHP = Capillary Hydrostatic Pressure COP = Capillary Osmotic Pressure IFHP = Interstitial Fluid Hydrostatic Pressure IFOP + Interstitial Fluid Osmotic Pressure

Electrolytes: the mineral salts that conduct the electrical energy of the body, perform a cellular balancing act by allowing nutrients into the cell, while helping to remove waste products.

 Normally body fluid volume

Water balance

remains constant

water loss = water gain ~60% ingested liquids ~30% ingested in foods ~10% metabolic water (from oxidation) ~4% faeces ~28% insensible water loss (skin & lungs) ~8% sweat ~60% urine

Water gain:

Water loss:

Additional fluid loss in menstrual flow in females of reproductive age

Normal fluid and electrolyte requirements

Daily water requirements

Weight (kg) x 25-35 mL = mL fluid required daily 25 mL/kg for CHF or renal disease 30 mL/kg for average adults 35 mL/kg for patients with infection or draining wounds

Daily electrolyte requirements

Sodium 2 - 3 mEq/100ml H2O /day Potassium 1 - 2 mEq/100ml H2O /day Chloride 2 - 3 mEq/100ml H2O /day

Examinations to identify fluid/electrolyte problems

Electrolytes

This provides information about serum Na+, K+, Cl-, HCO3-

These measures provide an indication of renal perfusion. An elevated BUN and Cr BUN generally reflects intravascular depletion. Creatinine is a useful indicator of acute renal failure. The CBC may provide some indication of hemoconcentration in cases of dehydration. The WBCs and differential cell count are useful indicators of infection. Platelets can elevate as acute phase reactants. The specific gravity of the urine is related to the patient's hydration state. In cases of renal disease, it can help classify the condition. Urine ions can be specifically requested, and are helpful in determining whether sodium is being retained or not.

CBC

Urine Analysis

Serum/Urine Osmolarity

A true measure of serum osmolarity can be compared to the calculated osmolarity. Normally, true osmolarity is about 10 mEq/L higher than calculated due to the presence of particles which are not in the basic osmolarity equation. If there is a greater "osmolar gap" than this, the presence of additional particles should be considered (such as alcohol or mannitol). The osmolarity of serum determines whether a patient is in an isotonic state or if this state has been disturbed. Urine osmolarity is helpful in determining if the kidney is doing its job of concentrating urine.
Total protein, and sometimes albumin levels, are indirect measures of both liver function (where they are produced), dietary protein intake, and renal loss. If serum protein levels fall, the intravascular oncotic pressure falls and fluid migrates to "third spaces". This can be seen in liver disease, nephrotic syndromes, malnutrition and other cases. In addition to providing information about the patient's blood gases and assisting in classification of acidosis or alkylosis, the ABG yields information about bicarbonate levels. Usually, STAT electrolytes can also be obtained from a blood gas sample, with turn around time better than serum chemistry.

Total Protein

Arterial Blood Gas

Water homeostasis and serum osmolality

Major factors Normal cellular function requires normal serum osmolality. Water homeostasis maintains serum osmolality. contributing to serum osmolality are Na, glucose and BUN. Serum osmolality estimation: (2 x plasma Na) + (plasma glucose/18) + (BUN/2.8)

Normal serum osmolarity = 280-300 mOsm

Type of intravenous fluid for replacement therapy: Isotonic same osmotic pressure as body fluids (240-349 mOsm) Hypotonic lower osmotic pressure than body fluids (less than 240 mOsm) Hypertonic higher osmotic pressure than body fluids (greater than 340)

Fluid Imbalances
Fluid excess: CHF Kidney failure

Fluid deficit: Diarrhea Blood loss

Responses to imbalances ?

Regulation of body water loss (dehydration)

Release ADH

Water retention

Aldosterone Na+&Water reabsorbtion in renal tubules

Electrolyte Imbalances

Hyponatremia: serum Na < 130 mEq/L Sodium deficit calculation: [(normal Na(mEq/L)) (measured Na(mEq/L)] x TBW (L)

Fluid electrolyte management

Estimating the fluid problem

1) Check the weight Rapid changes in weight likely represent changes in TBW. (2) History Ask about losses (diarrhea, vomiting, how much, how often), attempts at replacement (what fluids used, how much given, how successful), urine output. (3) Physical exam findings Mental status, pulse, BP, body weight, mucous membranes, skin turgor, skin color. (4) Laboratory evaluation Serum chemistries, hematocrit, and urine studies can guide therapy and check forcomplications.

Oral therapy Oral rehydration with electrolyte solutions is safe, efficacious and convenient. Can be used as first line therapy in nearly all fluid and electrolyte aberrations except severe circulatory compromise.

IV therapy reestablish effective circulating volume

a) What IV fluid should be used?

Initial IV therapy should be with isotonic fluid to improve effective circulating volume.

b) How much IV fluid should I give initially?

Use clinical findings to determine if patient is responding (mental status, vital signs, urine output). Repeat this infusion if necessary.

c) How should continue IV fluids?

do not require continued IV fluids after effective circulation has been restored. Continue IV fluids in situations where oral rehydration will be difficult, such as high ongoing losses, severe electrolyte abnormalities, poor mental status or inability to tolerate enteral fluids.

Continuing IV therapy considers:

(a) Estimate remaining deficits Volume: Check current weight and compare to desired baseline. If using preresuscitationweight, consider the amount of volume given in resuscitation. (b) Estimate daily needs Estimate daily needs for water and electrolytes, as for any patient. Adjust based on the clinical situation (e.g., fever, coma, ventilator, etc.) (c) Consider ongoing losses Monitor for losses such as stool, drains, etc. Consider replacing these as needed. (d) Provide therapy Add up water and electrolyte needs from deficits and daily requirements.

Hypernatremia: serum Na > 150 mEq/L

Significant neurological effects usually seen

with Na > 160 mEq/L Free water deficit calculation:

measured Na (mEq/L) desired Na (mEq/L)

X TBW (L)} - TBW (L)

Use 145mEq/L as desired Na; estimate TBW as

0.6L/kg x body weight (kg)

References:
Bennet, G.2001.Cecl Textbook of medicine 21st ed. Philadelphia: WB

Saunders. Kobriger AM. Hydration: Maintenance: Dehydration, Laboratory Values, and Clinical Alterations. Chilton, WI: Kobriger Presents, Inc; 2005. Mahan LK, Escott-Stump, S. Krauses Food and Nutrition Therapy. 12th ed. St. Louis, MO: WB Saunders; 2008. National Academy of Science, Institute of Medicine, Food and Nutrition Board.Dietary reference intakes for water, potassium, sodium, chloride, and sulfate (2004). Available at: http://fnic.nal.usda.gov/ nal_display/index.php?infocenter=4&tax_level=4&tax_subject=256& topic_id=1342&level3_id=5141 &level4_id=10592. Accessed February 25, 2008. http://www.rd411.com/article.php?ID=9

Regulation of the acid-base balance (pH regulation)

Definition: pH = unit of measure for the concentration of hydrogen ions in aqueous solutions; these ions determine the acid/base content of the solution. " Acidic solutions : pH < 7.0 (and down to not more than 0) and have an excess of hydrogen ions. " Basic solutions : pH > 7.0 (to a maximum of 14). These solutions are capable of absorbing hydrogen ions.

Regulation of the acid-base balance

 Kidney & lung excreting an excess acid or

base. Buffer system: HCO3, protein, phospate, haemoglobin, etc.

Haemostasis == H+excretion & buffering

Thank you ..