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Fluid and electrolyte emergencies in critically ill patients

Fluid and electrolyte emergencies in critically ill patients. Dr.V.P.CHANDRASEKARAN HOD, Dept. of Emergency & Critical Care Medicine, VMKVMC , Salem. Introduction. Total body water (60%) Two third is intracellular fluid (40%) One third is extra cellular fluid (20%)

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Fluid and electrolyte emergencies in critically ill patients

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  1. Fluid and electrolyte emergencies in critically ill patients Dr.V.P.CHANDRASEKARAN HOD, Dept. of Emergency & Critical Care Medicine, VMKVMC , Salem

  2. Introduction • Total body water (60%) • Two third is intracellular fluid (40%) • One third is extra cellular fluid (20%) - Interstitial fluid (15%) - Intravascular fluid (5%)

  3. Fluid shifts INTRACELLULAR 30 LIT EXTRACELLULAR INTERSTITIAL 9 LIT IV 3 LIT

  4. 142 Na+ 150 K+ Ca2+ Mg2+ Cl- HCO3- HPO42- SO42- Organic acid Protein

  5. Osmolarity • Measurement of the total solutes in a water solution per liter. • Osmolarity = [sodiumx2 ]+urea/2.8+glucose/18 • Serum osmolarity is 280-300 mOsm/L • 280-300 mOsmol/L- Isotonic • > 300 mOsmol/L – Hypertonic • < 280 mOsmol/L - Hypotonic

  6. 2 litres of blood 9 litres 30 litres 3 litres

  7. 9 litres 30 litres 5 litres

  8. 2 litres of colloid 9 litres 30 litres 3 litres

  9. 9 litres 30 litres 5 litres

  10. 8 litres 29 litres 7 litres

  11. 2 litres of 0.9% saline 9 litres 30 litres 3 litres

  12. 9 litres 30 litres 5 litres

  13. 29 litres 10.5 litres 4.5 litres

  14. 2 litres of 5%dextrose 9 litres 30 litres 3 litres

  15. 9.7 litres 31 litres 3.3 litres

  16. Basic principles of fluid therapy Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock Replace Insensible water loss + urine Maintain Acid base, electrolyte imbalances Repair

  17. The rules of fluid replacement • Replace blood with blood • Replace plasma with colloid • Resuscitate with colloid / crystalloid • Replace ECF depletion with saline • Rehydrate with dextrose

  18. Case Scenario • 45 yr old was brought to ER with h/o loose stools & vomiting since 2 days • Drowsy and lethargic with signs of severe dehydration, BP-80/50 , PR-120 What is initial fluid of choice?

  19. Isotonic saline / Ringer’s lactate • No dextrose containing fluid initially

  20. Case Study #1 • HPI: • A 55 year old man is in the Neuro ICU for acute non hemorrhagic stroke. • Hospital course: • Decreasing urine output (< 0.5 ml/kg/hr) over the last 24 hours. What is your differential diagnosis?What diagnostic studies would you order?

  21. Case Study #1Differential diagnosis Oliguria 1) Pre-Renal (decreased effective renal blood flow) Diminished intravascular volume, cardiac dysfunction, vasodilatation 2) Post-Renal Outlet obstruction (intrinsic vs. extrinsic), foley catheter occlusion 3) Renal Acute tubular necrosis, acute renal failure, SIADH, ...

  22. Case Study #1Laboratory studies Serum studies Sodium 120 mEq/L BUN 4 mg/dL Chloride 98 mEq/L Creatinine 0.4 mg/dL Potassium 3.7 mEq/L Glucose 129 mg/dL Bicarbonate 25 mEq/L Osmolality 260 mosmol/kg Urine studies Specific gravity 1.025 Sodium 58 mEq/L Osmolality 645 mosmol/kg What are the primary abnormalities?

  23. Case Study #1Laboratory studies Major abnormalities 1) Hyponatremia 2) Oliguria (inappropriately concentrated urine) What is the most likely explanation for these findings?

  24. Case Study #1Syndrome of Inappropriate Antidiuretic Hormone (SIADH) • Variable etiology • Trauma • Infection • Psychosis • Malignancy • Medications • Diabetic ketoacidosis • CNS disorders • Positive pressure ventilation • “Stress”

  25. Case Study #1SIADH • Manifestations • By definition, “inappropriate” implies having excluded normal physiologic reasons for release of ADH: • 1) In response to hypertonicity. • 2) In response to life threatening hypotension. • Hyponatremia • Oliguria • Concentrated urine • elevated urine specific gravity • “inappropriately” high urine osmolality in face of hyponatremia • Normal to high urine sodium excretion

  26. Case Study #1SIADH • Diagnosis • Critical level of suspicion. • Demonstration of inappropriately concentrated urine in face of hyponatremia •  urine osmolality,  SG,  urine sodium excretion • Be certain to exclude normal physiologic release of ADH • Rule out hypothyroidism, hypoaldosteronism, renal failure or diuretic therapy before diagnosing SIADH.

  27. Case Study #1SIADH • Treatment • Fluid restriction • Avoid hypotonic fluids • Hypertonic saline / oral sodium chloride • Frusemide.

  28. Case Study #1The saga continues…. Hospital course: Four hours after beginning fluid restriction, you are called because the patient is having a generalized seizure. There is no response to two doses of IV lorazepam and a loading dose of fosphenytoin What is the most likely explanation?

  29. Case Study #1The saga continues Seizure 1) Worsening hyponatremia 2) Intracranial event 3) Meningitis 4) Other electrolyte disturbance 5) Medication 6) Hypertension What diagnostic studies would you order?

  30. Case Study #1The saga continues Stat labs: Sodium 110 mEq/L What would you do now?

  31. Case Study #1Hyponatremic seizure • Treatment • Hypertonic saline (3% NaCl) infusion • To correct sodium to 125 mEq/L, the deficit is equal to • 0.6 X weight[kg] X (125 - measured sodium) • 0.6 X 60 X (125-110) = 54O mEq

  32. Newer method • Calculation of expected change of Na with 1 litre of 3% NaCl • Change in S.Na+ concentration = infusate Na/L – S.Na total body water + 1 • = 513 – 110 / 0.6 x 60 +1 • = 403 / 37 = 10.9 mEq/L • To raise 4 mEq/L of Na, amount of 3% NaCl required is 366 ml ( 4/10.9 x 1000 = 366 ml ) • Required rate of infusion of 3% NaCl is 366/4 = 92 ml/hr

  33. Case Study #2 HPI: A 5 month-old girl presents with a one day history of irritability and fever. Mother reports three days of “bad” vomiting and diarrhea. Home meds: Paracetamol and ibuprofen for fever PE: BP 70/40, HR 200, R 60, T38.3 C. Irritable, sunken eyes and fontanelle.

  34. Case Study #2 No one can obtain IV access after 15 minutes, what would you do now?

  35. Case Study #2 Place intraosseous line Bolus 40 ml/kg of isotonic saline Reassessment (HR 170, RR 40, BP 75/40) Serum studies Sodium 164 mEq/L BUN 75 mg/dL Chloride 139 mEq/L Creatinine 3.1 mg/dL Potassium 5.5 mEq/L Glucose 101 mg/dL Bicarbonate 12 mEq/L pH 7.07 pCO2 11 pO2 121 HCO3 8

  36. Case Study #2 What is the most likely explanation of this patients acidosis?

  37. Case Study #2Metabolic acidosis and the anion gap Anion Gap Sodium - (chloride + bicarbonate) Normal 12 +/- 2 meq/L Elevated anion gap consistent with excess acid Normal anion gap consistent with excess loss of base 164 - (139 + 12) = 13

  38. Case Study #2Metabolic acidosis and the anion gap 2. Increased gap 1. Normal gap 1.  Acid prod 2.  Acid elimination Renal “HCO3” losses 2. GI “HCO3” losses Renal disease Lactate DKA Ketosis Toxins Alcohols Salicylates Iron Proximal RTA Distal RTA Diarrhea

  39. Case Study #2Treatment of Hypernatremia • To stop ongoing fluid loss • To correct water deficit = plasma Na – 140 x 0.6 x body wt. in kg 140 • Water deficit can be replaced with water by mouth or IV 5% dextrose or 0.45% NaCl

  40. Case Study #3 • HPI: • A 50 year old man was involved in a motor vehicle accident two days ago. He sustained an isolated head injury with intraventricular hemorrhage and multiple large cerebral contusions. Three hours ago, he had an episode of severe intracranial hypertension (ICP 90mm Hg, MAP 50mm Hg, requiring volume plus epinephrine infusion for hypotension. Over the last two hours, his urine output has increased to 150 - 200 ml/hour

  41. What is your differential diagnosis? What test would you order?

  42. Case Study #3Differential diagnosis Polyuria 1) Central diabetes insipidus Deficient ADH secretion (idiopathic, trauma, pituitary surgery, hypoxic ischemic encephalopathy) 2) Nephrogenic diabetes insipidus Renal resistance to ADH (X-linked hereditary, chronic lithium, hypercalcemia, ...) 3) Primary polydipsia (psychogenic) Primary increase in water intake (psychiatric), occasionally hypothalamic lesion affecting thirst center 4) Solute diuresis Diuretics (lasix, mannitol,..), glucosuria, high protein diets, post-obstructive uropathy, resolving ATN, ….

  43. Case Study #3Laboratory studies Serum studies Sodium 155 mEq/L BUN 13 mg/dL Chloride 114 mEq/L Creatinine 0.6 mg/dL Potassium 4.2 mEq/L Glucose 86 mg/dL Bicarbonate 22 mEq/L Serum osmolality: 320 mosmol/kg Other Urine specific gravity 1.005, no glucose. Urine osmolality: 160 mosmol/kg What are the main abnormalities?

  44. Case Study #3Laboratory studies Major abnormalities 1) Hypernatremia 2) Polyuria (inappropriately dilute urine) What is the most likely explanation?

  45. Case Study #3Diabetes Insipidus Diagnosis Central Diabetes insipidus 1) Polyuria 2) Inappropriately dilute urine (urine osmolality < serum osmolality) May be seen with midline defects Frequently occurs in brain dead patients What should you do to treat this patient?

  46. Case Study #3Diabetes Insipidus • Treatment • ADH preparations - dDAVP nasal spray • Potentiate ADH effect – chlorpropamide, carbamazepine, NSAID’s. • Increase ADH release – Clofibrate Warning • Closely monitor for development of hyponatremia

  47. Case Study #4 • HPI: • An 35 year old lady with Chronic kidney disease presents with irritability. She is on nightly peritoneal dialysis at home. The lab calls a panic potassium value of 7.1 meq/L. The tech says it is not hemolyzed. What do you do now?

  48. Case Study #4Hyperkalemia • Treatment • Immediately repeat serum potassium. • Do not wait for confirmatory labs especially if ECG changes present. • Anticipatory • Stop potassium administration including feeds

  49. ECG • What is this rhythm? • What is your immediate treatment?

  50. Case Study #5Hyperkalemia • Treatment (cont) • Control effects • Antagonism of membrane actions of potassium • 10% Calcium gluconate 10-20 ml over 5 - 10 minutes; may repeat x2 • Shift potassium intracellularly • Glucose 1 gm/kg plus 0.1 unit/kg regular insulin • Alkali therapy - Sodium bicarbonate 1 mEq/kg IV • Inhaled 2 adrenergic agonist • Removal of potassium from the body • Loop / thiazide diuretics • Cation exchange resin: sodium polstyrene sulfonate (Kayexelate) 1 gm/kg PO or PR (or both) • Dialysis

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