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APPROACH TO FLUID , ELECTROLYTES AND ACID BASE DISORDERS

APPROACH TO FLUID , ELECTROLYTES AND ACID BASE DISORDERS. DR.S.SHIVAKUMAR PROF.OF.MEDICINE STANLEY MEDICAL COLLEGE & HOSPITAL. INTRODUCTION:. Fluid & Electrolytes can occur as single or multiple disorders Hyponatremia is a very common disorder Pottassium disorders can be life threatening

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APPROACH TO FLUID , ELECTROLYTES AND ACID BASE DISORDERS

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  1. APPROACH TO FLUID , ELECTROLYTES AND ACID BASE DISORDERS DR.S.SHIVAKUMAR PROF.OF.MEDICINE STANLEY MEDICAL COLLEGE & HOSPITAL

  2. INTRODUCTION: • Fluid & Electrolytes can occur as single or multiple disorders • Hyponatremia is a very common disorder • Pottassium disorders can be life threatening • Acid base disorders common in ICU & medical wards • Choice of fluid therapy should be appropriate • Treat individual disorders, but should be combined in multiple disorders.

  3. APPROACH: • Disorders of volume - Volume depletion - Fluid overload • Dysnatremia - Hyponatremia / Hypernatremia • Dyskalemia - Hypokalemia / Hyperkalemia • Acid base disorders Acidosis Alkalosis Metabolic/ Respiratory Metabolic / Respiratory

  4. CLINICAL APPROACH: • CLINICAL FEATURES: • Volume depletion ------- Skin turgor loss / Hypotension • Volume excess -------- Oedema / HT • Hyponatremia/ Hypernatremia ------ CNS Manifestations • Hypokalemia ----- Muscle weakness • Hyperkalemia ---- Cardiac arrythmias Metabolic acidosis Respiratory alkalosis Hyperventilation

  5. MULTIPLE DISORDERS:

  6. SINGLE DISORDERS:

  7. FLUID & ELECTROLYTE HOMEOSTASIS • Regulation of Volume (Na+) Na+ GFR Renin Angiotensin Aldosterone Renal retention of Na+ • ECF Volume is regulated by Na.( BP & Interstitial volume) 2.Regulation of Osmolality ( Water) H2O Osm ADH Kidney retains H2O ICF Volume is regulated by osmolarity of plasma. Normal plasma osmolarity = 285-300 mOsm/L Calculation= 2(Na + K)+ Sugar/18+Urea/6 Ratio of Na+ to H2O decides plasma osmolality. 3.Regulation of Acid Base:

  8. VOLUME & OSMOLALITY DISORDERS: • Volume Disorders: Only clinical signs(PNa+- Normal) • Volume depletion ---- ECF Na+ loss ( Diarrhea,Diuretics ) • Volume excess ----- Na Retention( Cardiac failure, renal failure) Osmolar Disorders:- Plasma Na+ altered. 1. Water Excess ---- Hyponatremia (SIADH) 2.Water depletion -- Hypernatremia ( D.Insipidus ) • Volume & Osmolar Disorders: (Clinical & Altered P. Na+) • Volume depletion & Water excess – ECF Na loss & H2O retention / Hyponatremia ( Diarrhea & 5%GDW) • Volume depletion & excess water depletion - Na < H2O loss / Hypernatremia (HONK )

  9. Normal 20% (ECF) 40% (ICF) INTRACELLULAR VASCULAR (4%) Interstitial (16%) Total body sodium determines ECF Volume. Plasma Na determines ICF volume. Plasma osmolarity (PNa+) determines fluid movement into cell.

  10. Volume depletion (ECF ) Normal PNa+ INTRACELLULAR Loss of skin turgor Hypotension 40% 10% Eg: Diarrhea, Vomiting & Diuretics Total body Na loss leads ECF volume depletion. No change in plasma Na.

  11. Volume excess (ECF ) Normal PNa+ 30% 40% edema INTRACELLULAR HT Eg: Cardiac failure,Nephrotic syndrome, Renal failure & Cirrhosis Increased total body Na leads to ECF volume excess. Plasma Na normal

  12. Hyponatremia (ICF ) 45 % INTRACELLULAR PNa+ 20% Eg: SIADH Increased ADH Increased total body H2O leads to decreased plasma Na ( Osmolarity ) Increased ICF due to shift of H2O from ECF to ICF.

  13. Hypernatremia (ICF ) 20% 30% PNa INTRACELLULAR Eg: D.Insipidus Polyuria Pure water depletionDecreased body H2O leads to increased plasma Na ( Osmolarity) H2O shifts from ICF to ECF.

  14. Volume depletion & Hyponatremia (ECF & ICF ) 45 % Hypotension, skin turgor loss, Drowsiness INTRACELLULAR H2O PNa 10 % Na + Eg: Diarrhea, replaced by 5 % GDW Total body Na decreased by Diarrhea Increasaed H2O retention due to 5 % GDW ( Plasma Na low) ECF volume depletion + Increased ICF volume

  15. Volume excess & Hyponatremia ( ECF & ICF ) 25 % 45 % INTRACELLULAR H2O edema & P Na + Eg: Cirrhosis + 5 % GDW Cirrhosis leads to increased total body Na & ECF Excess H2O leads to decreased plasma Na & increased ICF

  16. Volume depletion & Hyperosmolarity ( ECF & ICF ) 30 % 10% INTRACELLULAR Osmolarity Na+ H2O Eg: Hyperosmolar Non- Ketotic syndrome ( DM) Polyuria of DM leads to ECF volume depletion ( H2O> Na) Increased plasma Glucose leads to hyperosmolarity & ICF depletion Plasma Na can be Normal OR High ( Instead of being low)

  17. Why do we need fluids? FLUIDS --- Healthy individuals ---Regulation of temperature --- loss by sweating ---Excretion of waste products -- Renal / GI 1.5 – 2.5 L / Day Salt – 5 gm / day Sick patients: 1.Replacement for losses --- GI losses – Vomiting / Diarrhea --Renal losses -- DKA / Diuretics -- Skin loss – Burns / sweating 2.Maintenance --- for daily requirements

  18. Concentration of ions in IVF (In Meq/L)

  19. Concentration of ions in IVF (Poly-ionic fluids)

  20. DISORDERS OF VOLUME

  21. Volume depletion • Isotonic volume depletion • Diarrhea • Vomiting Hypotonic volume depletion Hypertonic volume depletion Diarrhea replaced by H2O D.Insipidus HONK DKA Excess sweating PNa H2O > Na loss PNa-Normal Na+ = H2O loss PNa H2O < Na loss

  22. ISOTONIC VOLUME DEPLETION: Causes - vomiting / Diarrhea Assess severity - mild / moderate / severe Body weight: 5 %- mild : skin turgor loss / dry Tongue 5 % - 10 % : Mild + postural hypotension 10 % - severe: moderate + hypotension Correction: Volume depletion: 0 - 8 hrs 0- 1 hrs --- shock 1- 8 hrs -- rest of calculated fluids 8- 24 hrs -- maintanance fluids & concurrent losses Choice of fluids: Diarrhea --- RL Vomiting - 0.9 % NaCl

  23. A 50 year old male is admitted for severe diarrhea of 3 days duration. He is drowsy & has loss of skin turgor & dry mouth. BP: 80 / 50 mmHg.Lungs are clear. • Urea : 72 mg% S.Cr : 1.7 mg% Na+ : 122 meq/L • K+ : 2.6 mg% • Ph: 7.2 pCo2 : 32mmHg pO2 : 100 mmHg • HCO3 :12 mmHg • Problems: • Severe volume depletion • Hyponatremia • Hypokalemia • Metabolic acidosis • Azotemia- prerenal

  24. 50 year Individual ( 50 kg) Severe Volume depletion - 10 % - 5 L Diarrhea – Na, K, HCO3 loss Replacement fluids - RL 0-1 hr – 1 L ( Treatment of Shock) 1- 8 hr – 4 L Maintanence fluid + concurrent loss : 1.5 – 2.5 L ( 8- 24 Hrs) Decreased Na – Corrected by Volume correction RL – Lactate HCO3 in liver

  25. Hypertonic volume depletion ( Volume depletion & water depletion - PNa ) Na < H2O Depletion Pure H2O depletion Extrarenal Insensible losses Renal DI NDI Extra renal ( sweating) Esp.pt not taking oral fluids • Renal loss • DKA • HONK • Salt losing nephritis Treatment -- HONK / DKA – 0.45 % NaCl -- 0.9 % NaCl + 5 % GDW D.Insipidus---- 5 % GDW

  26. DYSNATREMIAS

  27. Hyponatremia Hypovolemia Euvolemia Hypervolemia Diuretics Diarrhea Post-operative SIADH Drugs CNS & Pulmonary diseases (Menstruating women) CCF Nephrotic syndrome Cirrhosis

  28. Hyponatremia Asymptomatic Chronic ( > 48 hrs) Symptomatic Chronic > 48 hrs Acute < 48 hrs Symptoms: CNS: Cerebral edema -- Headache, Drowsy / coma / Seizures. Lab: PNa < 135 meq/L

  29. Management Symptomatic Hyponatremia Treatment: Emergency: 3 % NaCl 1- 2 ml/ kg/ hr with co-administration of Furosemide STRATEGY: Removal of H2O Furosemide: Natriuresis -- Na + H2O Replace Na with 3 % NaCl – Excretion of H2O Urine output > fluid intake

  30. Asymptomatic Hyponatremia: ( Euvolemia& Hypervolemia) 1.Water restriction : < 1L / day 2.Demeclocycline -- 300 – 600 mg / day 3.Identify & treat the causes Hypovolemic Hyponatremia: IV Fluids -- NaCl / RL • Treatment objectives: • Gradual correction of PNa • Perform serial neurological examination • Perform serial Serum Na & Urine Electrolytes & osmolality

  31. A 60 year old male a known case of Bronchogenic carcinoma is admitted for seizures. He is unconscious & his volume is normal Urea : 28 mg % S.Cr : 0.8 mg % Na+ : 110 meq/L K+ : 4.6 meq/L Ph: 7.4 Pco2 :40mmHg HCO3: 24 mmHg PROBLEMS: 1.Volume status -- normal 2. Na+ -- Hyponatremia ( Euvolemia) 3. K+ --Normal 4. ABG-- Normal TREATMENT: 3 % Saline & Furosemide

  32. HYPERNATREMIA Hypovolemic hypernatremia Hypervolemic hypernatremia Euvolemic hypernatremia DKA,HONK Excess sweating Decreased fluid intake Peritoneal dialysis (Hypertonic fluids) Diabetes Insipidus Clinical features : CNS Manifestations Lab: PNa > 150 meq/L

  33. Treatment: Hypovolemic Hypernatremia : -- 0.45 % NaCl -- 5 % GDW -- Oral fluids Euvolemic Hypernatremia: 5 % GDW Oral fluids Hypervolemic Hypernatremia: Dialysis

  34. DYSKALEMIAS

  35. Hypokalemia : K + < 3.5 meq/ L Causes • Metabolic alkalosis • Vomiting • Diuretics Normal Ph -Periodic paralysis Metabolic acidosis Diarrhea RTA Treatment of DKA Diagnosis: Serum K+ : 3 – 3.5 meq/L - Mild 2.5 – 2.9 meq/L – Moderate < 2.5 meq/L -severe

  36. Complications: • Muscle weakness -Respiratory failure • Cardiac arrhythmias • Hepatic encephalopathy • Paralytic ileus

  37. TREATMENT: IV KCl : 15 % solution 1 cc = 2 meq/L Add to 0.9 % NaCl solution KCl 10 ml = 20 meq/L 20 ml = 40 meq/L Non- urgent situations: Not to exceed 10 meq/hr In urgent situations: 40meq/Hr Oral solution: 10 % KCl solution ( 15 ml =20 meq/L) --- Diluted in juice 80 – 120 ml / day KCl should be given for 10 – 14 days

  38. HYPERKALEMIA: Causes: Renal failure Drugs -- ACE Inhibitors, Beta-bockers, spironolactone Diagnosis: 1. ECG , 2. Serum K+ Measurement ( > 5 meq/L) Management: 1. Calcium Gluconate: 10- 30 ml of 10 % solution, acts immediately, action lasts for only 30 mts 2. Insulin- 10 units / Glucose – 50 gms, acts in 15 – 30 Mts, effective for several hours 3. Sodium Bicarbonate: 50 – 150 ml of 7.5 % NaHCO3 4.Cation ion exchange resins: Na.Polysterene sulphonate (oral/enema) 5. Dialysis

  39. ACID BASE DISORDERS

  40. ABG Disorders: Diagnosis – Ph, HCO3, Pco2 1. Check validity 2. Obtain minimal diagnosis 3. Is it a single or mixed ABG disorder 4. Determine Anion Gap 5.Is it a triple ABG Disorder

  41. Obtain minimum diagnosis • Look at pH - Acidosis / Alkalosis • Match the Pco2 or Hco3 - Metabolic / Respiratory

  42. Examples of Simple Disorder

  43. Is it a simple or mixed Acid-base disorder? Simple Disorder :

  44. Mixed Disorder

  45. Apply Compensation

  46. Example – COPD & Diarrhea pH : 7.00 Pco2 = 32 Hco3 = 8 Fall in Hco3 = 24 – 8 = 16 Compensatory Fall in Pco2 = 16 x 1.2 = 19 Anticipated Pco2 = 40 – 19 = 21 Estimated : Pco2 = 32 (Pco2  ) Diagnosis Mixed - Metabolic acidosis + Respiratory acidosis

  47. Mixed acid base disorder

  48. Mixed acid base disorder

  49. Examples of mixed acid base disorder

  50. Determine the Anion gap AG = Na+– (Hco3 + Cl ) Normal = 12 ± 4 ( 8  16 ) Valuable in Metabolic acidosis – High gap / Normal gap Metabolic alkalosis – Evaluation of “Starting Hco3” High gap acidosis : AG > 27 mEq /L 17  26 Suggestive eg. – Ketoacidosis, Lactic acidosis, Methanol intoxication, Renal failure Normal gap acidosis – Diarrhea, RTA

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