FLUID-ELECTROLYTE BALANCE

1. FLUID-ELECTROLYTE BALANCE YTÜ Hastanesi Anesteziyoloji A.D Dr. Özge Köner

2. LearningObjectives Fluidcomposition of the body Diagnosis of hypo-hypervolemiabymeans of physicalandlaboratoryevaluation Centralvenouspressure & evaluation of thevolumestatus Crystalloidsandcolloids Definitionandmeasurement of osmolality Clinicalfindingsandtreatment of hypoandhypernatremia.

3. BODY FLUID COMPARTMENTS 70 kg MALE TOTAL BW. % 60 = 42 L Extracelular fluid

4. Fluid composition according to age Extracelular fluid

5. Interstitium (-5 mmHg) If the fluid is incresased pressure becomes (+) and the amount of fluid is increased EDEMA Protein content is LOW (2g/dL) Electrolytecontent is similarwithinterstitium PlasmaProteins Osmoticactivesolute EXTRACELLULAR Compartment(Na+ is the major determinant of osmotic pressure & volume) Intravascular space

6. TISSUE Capillary hydrostatic P 30 Inters. HP 5 Interstitium OP 6 28 Pls Onkotic P. NET balance(13) 10 Capillary HP Inters. HP 5 6 Inters. OP 28 Pls Onkotic P. NET (7)

7. EVALUATION OF BODY FLUID BALANCE

8. HYPOVOLEMIAPHYSICAL EXAMINATION • Skin turgor • Mucosalhydration • Peripheralpulsestrenght • Urinaryoutput • Resting HR & BP & Orthostaticchanges • Indirectfindings: Bloodpressurefluctuations in responsetopositivepressureventilation & vasodilators.

9. LABORATORY • Hct Serum Na • pH (progressivemetabolicacidosis) • Urinarygravity (>1015)-1.035 is consistent with frank dehydration Urinaryosmolality > 450 mOsm/kg • UrinaryNa & Cl (Na <10 mEq/l) • Serum BUN / Creatinineratio ( > 10:1)

10. HYPERVOLEMIA • PhysicalExamination: Sacral, pretibialedema Increasedurinaryoutput Crepitantraleswithlungauscultation Weightgain • LAB: Chest X-ray:Interstitiumedema (Kerley B lines)

11. HEMODYNAMIC EVALUATION CentralVenousPressuremonitorization • <5 mmHgwith no sign of hypovolemia:Normovolemia 250 mL fluidchallengewith 09% NaCl 1-2 mmHg CVP : fluiddeficit > 5 mmHgincrease: slowfluidreplacementor re-evaluation. • >12 mmHgHypervolemia: Ifthere is NO Rightventricledysfunction, restrictiveperikardialdisease, intrathoracicpressureincrease.

12. PULMONARY ARTERY PRESSURE RV dysfunction (LV dysfunction, Pulmonary disease) • PAOB < 8 mmHg + clinical findings: hypovolemia • PAOB < 15 mmHg + low LV compliance + clinical findings: hypovolemia • PAOB > 18 mmHg: LV dysfunction • Mitral valve disease, Ao. stenosis, LA mixoma-thrombus, • intrathoracic pressure & PAP : interferes with the normal PAOP-LVEDV relationship.

13. IV FLUIDS CRYSTALLOIDS vs COLLOIDS

14. CRYSTALLOIDS

15. Crystalloidsprovide as much iv volume as colloids do. = COLLOIDS CRYSTALLOIDS • 4-5 L CRYSTALLOID infusion: Severe TISSUE EDEMA. • Tissue EDEMA : decreased DO2, poorwoundhealing, intestinaldysfunction .

16. 5% Dextrose Hypotonic Replacespurefluid losses Treatment of hypernatremiaorhypoglycemia Maintenance & Replacemantfluids Isotonic, Slightlyhypotonic Replacewater+electrolytelosses. FluidTherapy (adult) 0.9% NaCl Isolyte /S/P Lactated Ringer

17. LACTATED Ringer 09% NaCl • Contains 100 mL water per liter. • Most physiologic fluid • Replaces surgical fluid losses • LACTATE liver HCO3 • E.R, periop. period • Hypochloremic alkalosis treatment • Red blood cell dilution • Hyponatremia treatment • SE: Hyperchloremic metabolic acidosis HYPERTONIC FLUID:%3 NaCl Severe HYPONATREMIA %7.5 NaCl HEMORRHAGIC SHOCK

18. Maintenance fluid for children: Hypotonic losses Diuresis Sweat Gastrointestinal losses Insensible losses 5% dextrose, ¼saline 5% dextrose, ½saline via skin & respiratory tract

19. mEq/L mOsm/L

20. ECF > IVF deficit in mostsurgicalcases Extracellular fluid

21. COLLOIDS Severe iv fluiddeficits can be replacedfasterwithcolloids

22. Indications • Severe iv volumedeficit (hemorrhagicshock) • Severe hypoalbuminemiaorburns • >4 L fluidneeds, beforebloodtransfusioncombinedwithcrystalloids ATTENTION ! HyperchloremicMetabolicAcidosis (Na 154-Cl 154 mEq/L)

23. Colloids vs Crystalloids

24. HumanAlbumine, 5-20% • SyntheticColloids • Gelatin (SE: allergicrxnrelatedtohistamin) • HES (SE: bleeding > 0.5-1 L) • Dextran 40 – volumeexpander 70 – viscosity microcirculation

25. Commonly used colloids

26. COLLOIDS SALINE GLUCOSE

27. CRYSTALLOID ORCOLLOID ?

28. CochraneDatabaseSystematicReview, 2012 • Randomizedcontrolledstudyresults: “TRAUMA, BURN, POSTOPERATIVE period. There is no evidenceshowingthebenefit of using COLLOIDS instead of crystalloids in regardto DEATH rate. • As colloidsaren’tassociatedwith an improvement in survivaland as theyaremoreexpensivethancrystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.

29. SAFE StudySaline vs AlbumineEvaluationStudy N=7 000 ICU patients • ShorttermfluidresuscitationwithAlbumin is as safe as withSaline. • FluidresuscitationwithAlbumin in SepticShockdecreases MORTALITY by 4%. • Albuminincreasesmortality in TRAUMATIC BRAIN INJURY.

30. FLUID & ELECTROLYTE BALANCE

31. Fluid exchange between the cell and interstitium is determined by the concentration gradient HYPEROSMOLAR HYPOOSMOLAR Net fluidshift

32. PlasmaOsmolality: 2x(Na+) + glucose/18280-290 mosm/kgOsmalalGap = Measured (lab)- Calculatedosm. OsmolalGap : Ethanol, Methanol, Mannitol, Ethyleneglycol, increasedIsopropilalcohol in plasma, Chronicrenalfailure, TURP, Ketoacidosis. (Hyperlipidemia, Hyperproteinemia: rareanymore)

33. Plasma Osmolality Control ADH release Nonosmotic ADH release Thirst ADH secretion markedly increases the water reabsorbtion from the collecting tubules

34. Hypernatremia (>145 mEq/L) Cell Dehydration Restlesness, Lethargia, Hyperreflexia Seizure, Coma, Death If serum Na is increased fast: Brain Volume is decreased Cerebral venous ruptur IC & SAH Pediatric: acute Na > 158 mEq/L: Severe neurologic damage If chronic better tolered, compansated 24-48 hr later.

35. Hypernatremia Treatment • 70 kg M, Pls. Na 160 mEq/L. Calculatethefluiddeficit? N. TBW x PlsNa = actuelplasmaNa x TBW (70 x 0.6) x 140 = 160 x TBW 36,7 L Fluiddeficit = 42 – 36,7 = 5,3 L Replacedwithin 48 hrswith 5% DW : 110 mL/hr. Ifthere is alsoisotonicloss: fluid of choice is 09% NaCl. 42 L

36. Hyponatremia(Na < 135 mEq/L) Anorexia, nausea, weakness Progressive cerebral edema Confusion, Lethargia Seizure, Coma, Death If Na > 125 mEq/L, generally asymptomatic Severe symptoms are observed at Na < 120 mEq/L Compansation occurs via increased intracellular volume by means of increased intracellular solutes (Na, K, aa).

37. HyponatremiaTreatment • 80 kg F, Pls. Na 118 mEq/L. HowmuchNaCl has to be giventoreach a PlsNalevel of 130 mEq/L? Nadeficit = TBW x (Desired-actuelNa) = (80 x 0,5) x (130-118) 480 mEq/L Fluiddeficit = 3,12 L isotonicNaClinfusedwithin 24hrs. 130 mL/hr (0.5 mEq/L/hr) ifincreasedfaster: centralpontinemyelinolysis • FastTreatment: Loopdiuretic

38. Hiponatremi Na Na+water loss ECF decreased Normal Na & ECF Na Na+water ECF increased Renal Una>20 Extrarenal Una<10 Adrenal– Thyroid hypofunc. UNa>20 heart fail Cirrhosis Nephrotic synd Renal insuff Replace Na & isotonic loss Cortisol v Thyroid hormone Fluid restriction Fluid restriction +Loop diuretic Fluid restriction Hyponatremia Fluid restriction Una < 20 Una > 20

39. Hypernatremia water + Na loss (water > Na) water loss (D.Insipidus) Na concentr (hypertonic saline) Replace isotonic losses Replace water deficit LOOP Diuretic Replace water deficit Replace water deficit

40. Hypo-osmolality & Hyponatremia • Hyponatremia & low total body Na • Hyponatremia & increased total body Na • Hyponatremi & normal total body Na • Pseudohyponatremia: N. Pls. Osmolality (severe hyperlipidemia, hyperproteinemia, TURP -glycineabsorbtion-) Pls. Osmolality (Hyperglycemia, Mannitol)

41. Hyperosmolality & Hypernatremia • Hypernatremia & low total body Na waterloss > Naloss Renal: osmoticdiuresisUNa > 20 mEq/L Extrarenal: sweat, diarrheaUNa < 10 mEq/L • Hypernatremia & Normal total body Na (D.Insipidus) Waterloss • Hypernatremia & high total body Na (Incase of HypertonikSalineinfusion)