1. Fluid and electrolytes

2. Body Fluids 16% 40% 4% Body Water (~40L) = 60% of body weight

3. Body fluid compartments Interstitial fluid s Intracellular fluid Intravascular fluid

4. Intracellular Fluid (ICF) Fluid within the cells Located primarily in skeletal muscle mass Provide nutrients for metabolism: High in potassium, phosphate, & protein Moderate levels of Mg, SO4 Assists in cellular metabolism

5. Extracellular fluid (ECF) Intravascular - plasma (half of total blood volume) Interstitial - surround all cells (eg. lymph) * Some interstitial fluid is TRANSCELLULARor under the influence of metabolic activity - respiratory fluid - pericardial fluid - GI digestive fluid - peritoneal fluid - CSF - intraocular fluid - pleural fluid - synovial fluid - gland secretions (sweat, enzymes)

6. Extracellular fluid (ECF) Surrounds cells Transport medium for nutrients, gases, waste products and other substances between blood and body cells Back-up fluid reservoir Nutrients for cell functioning Na Ca Cl Glucose Fatty acids Amino Acids

7. Fluid Movement Fluid movement is constant and is influenced by: 1. membrane permeability Active : require energy to transport eg. Na/K pump Passive : osmosis, diffusion, hydrostatic force 2. colloid osmotic pressure (plasma proteins) 3. hydrostatic pressure (cap. bed pressure) Mechanical force of water pushing against membrane Forces H2O, Na, glucose to go across membrane to interstitial fluid

8. Renal Regulation Kidneys are the most important regulators of volume and composition of body fluids Hormonal Control Antidiuretic hormone (ADH) Renin-angiotensin-aldosterone system(RAA) Natriuretic peptides (NUP)

9. ADH regulatory mechanism

10. NUP regulatory mechanism

11. RAA regulatory mechanism

12. Daily Intake & Output Intake 2,500 – 3,000 ml Liquids 1,500 – 2,000 ml Water in food 700 ml Water of oxidation 250 ml Output 1,400-2,300 ml Respiration & Perspiration (insensible) 600-900 ml Urine 800-1500 ml Stool 250 ml

13. Water loss

14. Serum Osmolarity (Concentration) Normal value = 275 -295 >295 = concentrated (dehydrated) <275 = dilute (fluid overloaded) Serum Osmo = 2(Na) + glucose/18 +BUN/2.8 Serum Osmo = Sodium x 2 (quick reference)

15. Serum Laboratory Findings (Normal) Serum sodium : 135-145 mEq/L Serum potassium : 3.5 – 5 mEq/L Serum chloride : 95 – 105 mEq/L Serum osmolarity : 275-295 mOsm/L Urea : 15 – 40 mg/dL Creatinine : 0.6 – 1.5 mg/dL BUN: creatinine : 10:1 ratio Hematocrit (males 40-52% , females 37-46%) Total protein : 6.5 - 8.0 g/dL

16. Fluid volume deficit Output > Intake -> Water extracted from ECF ECF hypertonic (water moves out of cell -> cell dehydration) + osmotic pressure increased (stimulates thirst receptor in hypothalamus) ICF hypotonic with decreased osmotic pressure -> posterior pituitary secretes more ADH Decreased ECF volume -> adrenal glands secrete Aldosterone Lab Increased HCT Increased BUN out of proportion to Cr High serum osmolarity Increased urine osmolarity Increased specific gravity Decreased urine volume, dark color

17. Signs and symptoms Acute weight loss Decreased skin turgor Oliguria Concentrated urine Weak, rapid pulse CRT >2s Decreased BP Increased pulse Sensations of thirst, weakness, dizziness, muscle cramps Sunken eyeballs Depressed fontanels

18. Management Major goal : correction and prevention of ARF Encourage oral fluids IV fluids Isotonic solutions (0.9% NS or Hartmann) until BP back to normal, then hypotonic (0.45% NS) Monitor I & O, urine specific gravity, daily weights Monitor skin turgor Monitor VS and mental status Evaluation Normal skin turgor, increased UOP with normal specific gravity, normal VS, alert and conscious, good oral intake of fluids

19. Fluid volume excess Hypervolemia Isotonic expansion of ECF caused by abnormal retention of water and sodium Fluid moves out of ECF into cells and cells swell Causes Cardiovascular – Heart failure Urinary – Renal failure Hepatic – Liver failure, cirrhosis Other – Cancer, thrombus, PVD, drug therapy (i.e., corticosteriods), high sodium intake, protein malnutrition

20. Signs and symptoms Physical assessment Weight gain Distended neck veins Periorbital edema, pitting edema Lungs crepitation Dyspnea Mental status changes Generalized or dependent edema VS High CVP/PAWP ↑ cardiac output Lab data ↓ Hct (dilutional) ↓ BUN (dilutional) Low serum osmolality Low specific gravity

21. Signs and symptoms Radiography Pulmonary vascular congestion Pleural effusion Pericardial effusion Ascites

22. Management Sodium restriction (foods/water high in sodium) Fluid restriction, if necessary Closely monitor IVF If dyspnea or orthopnea > Semi-Fowler’s Strict I & O, lung sounds, daily weight, degree of edema, reposition q 2 hr Promote rest and diuresis

23. IV fluids

24. Crystalloids

25. Content of crystalloids

26. Electrolytes Major intracellular electrolytes Potassium (cation) Phosphorus (anion) Major extracellularelectrolytes Sodium (cation) Chloride (anion) * Sodium is the determinant of osmolality (tonicity) since it is the major ECF cation

27. Sodium Normal 135-145 mEq/L Major cation in ECF Regulates voltage of action potential; transmission of impulses in nerve and muscle fibers, one of main factors in determining ECF volume Elderly at risk Helps maintain acid-base balance

28. Hypernatremia Causes Symptoms - extreme thirst - tachycardia - dry mucous membranes - low grade fever - irritability - weakness/lethargy - spasticity - oliguria/polyuria Lab Increased serum Na Increased serum osmolality Increased urine specific gravity

29. Management Water depletion Oral hydration if tolerated IV infusion D5% or 0.45% NaCl Give maintenance fluid requirement (40ml/kg/day) Salt gain Remove sodium using potent diuretic (eg. IV furosemide) with D5% infused In severe cases dialysis may be necessary *Assessment 1) Normal level of serum Na 2) Resolution of signs and symptoms

30. Hyponatremia Decrease in measured serum Na concentration below 135 mEq/L Mild 125-134mEq/L Moderate 110-124mEq/L Severe 100-109mEq/L Evaluate serum osmolarity If osmolarity is hypotonic, evaluate volume status: Hypervolemia Euvolemia Hypovolemia

31. Causes Results from excess Na loss or water gain GI losses, diuretic therapy, severe renal dysfunction, severe diaphoresis, DKA, unregulated production of ADH associated with cerebral trauma, narcotic use, lung cancer, some drugs (eg. Thiazides, carbamazepine, desmopressin, oxytocin) Clinical manifestations ↓ BP, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching and tremors, vomiting, diarrhea, and cramps

32. Lab & Management Lab investigation Increased HCT, K Decreased Na, Cl, Bicarbonate, UOP with low Na and Cl concentration Urine specific gravity ↓ 1.010 Management Mild Water restriction if water retention problem Increase Na in foods if loss of Na Moderate IV 0.9% NS, 0.45% NS, Hartmann Severe 3% NS – short-term therapy in ICU setting

33. Potassium Normal 3.5-5.5 mEq/L Major ICF cation Vital in maintaining normal cardiac and neuromuscular function, influences nerve impulse conduction, important in carbohydrate(CHO) metabolism, helps maintain acid-base balance, control fluid movement in and out of cells by osmosis

34. Hypokalemia Serum potassium level below 3.5 mEq/L Causes Loss of GI secretions (diarrhea, vomiting, villous adenoma, ileostomy or uterosigmoidostomy, fistula) Excessive renal excretion of potassium (diuretics, increased aldosterone secretion, renal tubular damage etc) Movement of K into the cells (insulin therapy) Prolonged fluid administration without K supplementation Diuretics (thiazide, loop, mannitol)

35. Signs and symptoms Skeletal muscle weakness, ↓ smooth muscle function, ↓ DTR’s ↓ BP, heart block, AF, VT, VF ECG changes (small/inverted T, prominent U, ST depression, prolonged PR intervals) Constipation, ileus Metabolic alkalosis Mental depression and confusion

36. Management Mild – moderate (K > 2.5) Oral KCl 2-4 hourly until return of serum K to at least 3.5 Monitor K level to prevent hyperK Potassium-sparing diuretics (amiloride, triamterene, spironolactone) can be given of hypoK is secondary to renal losses Severe (< 2.5) and/or with ECG changes Fast correction 2g KCl in 200ml NS to infuse in 2 hours (<3g KCl/L) With ECG monitoring When ECG and cardiac rhythm normalize, IV infusion gradually tapered down and discontinue. Oral KCl is initiated.

37. Hyperkalemia Serum potassium level above 5.3 mEq/L Causes Excessive K intake (IV or PO) especially in renal failure Tissue trauma Acidosis Catabolic state Signs and symptoms ECG changes – tachycardia to bradycardia to possible cardiac arrest Tall, tented T waves Cardiac arrhythmias Muscle weakness, paralysis, paresthesia of tongue, face, hands, and feet, N/V, cramping, diarrhea, metabolic acidosis

38. Management Stop K supplements and avoid K in foods, fluids, salt substitutes Lytic IV cocktail Calcium gluconate 10% 10ml in 10 minutes Insulin 10U in D50 50ml in 30-60min, then maintain on D5 Sodium bicarbonate 100-200mmol/L over 30min Kalimate 5-10g tds/Resonium A 15-30 tds/qid PO or PR (cation exchange solution) Beta agonist therapy IV salbutamol 0.5mg in 15min or 10mg nebulization

39. Calcium Normal 4.5-5.5 mEq/L 99% of Ca in bones, other 1% in ECF and soft tissues Total Calcium – bound to protein – levels influenced by nutritional state Ionized Calcium – used in physiologic activities – crucial for neuromuscular activity

40. Required for blood coagulation, neuromuscular contraction, enzymatic activity, and strength and durability of bones and teeth Nerve cell membranes less excitable with enough calcium Ca absorption and concentration influenced by Vit D, calcitriol (active form of Vitamin D), PTH, calcitonin, serum concentration of Ca and Phos

41. Hypocalcemia Most common – depressed function or surgical removal of the parathyroid gland Hypomagnesemia Hyperphosphatemia Administration of large quantities of stored blood (preserved with citrate) Renal insufficiency ↓ absorption of Vitamin D from intestines

42. Signs and symptoms Abdominal and/or extremity cramping Tingling and numbness (circumoral) Positive Chvostek sign (tapping over facial nerve -> twitching) PositiveTrousseau sign (inflate cuff for 5 min over diastolic P -> carpopaedal spasm) Tetany; hyperactive reflexes Irritability, reduced cognitive ability, psychosis, seizures Prolonged QT on ECG, hypotension, decreased myocardial contractility Abnormal clotting

43. Management High calcium diet or oral calcium salts (mild) - √ formulas for calcium content IV calcium as 10% calcium chloride or 10% calcium gluconate in D5W– give with caution Close monitoring of serum Ca and digitalis levels ↓ Phosphorus levels with calcium carbonate ↑ Magnesium levels Vitamin D therapy D2 (ergocalciferol) 25,000-150,000 IU/day D3 (cholecalciferol) 50,000-100,000 IU PO daily

44. Hypercalcemia Causes Mobilization of Ca from bone Malignancy Hyperparathyroidism Immobilization – causes bone loss Thiazide diuretics Thyrotoxicosis Excessive ingestion of Ca or Vit D (milk alkali syndrome)

45. Signs and symptoms Anorexia, constipation, nausea, vomiting Generalized muscle weakness, lethargy, loss of muscle tone, ataxia Depression, fatigue, confusion, coma Soft tissue and corneal calcification (band keratopathy) Dysrhythmias and heart block ECG : shortened QT intervals Deep bone pain and demineralization Polyuria & predisposes to renal calculi Pathologic bone fractures Osteitisfibrosa in hyperparathyroidism

47. Hypercalcemic crisis Emergency – level of 8-9 mEq/L Intractable nausea, dehydration, stupor, coma, azotemia, hypokalemia, hypomagnesemia, hypernatremia High mortality rate from cardiac arrest

48. Treatment NS IV – match infusion rate to amount of UOP I&O hourly Loop diuretics Corticosteroids and Mithramycin in cancer clients to inhibit osteolytic bone resorption Biphosphonates and/or calcitonin to inhibit bone resorption and increase renal Ca excretion Oral phosphate 1-3g/day Encourage fluids Dialysis

49. Magnesium Causes vasodilatation Decreases peripheral vascular resistance Balance - closely related to K and Ca balance Intracellular compartment electrolyte Hypomagnesemia - < 1.5 mEq/L Hypermagnesemia - > 2.5 mEq/L

50. Hypomagnesemia Causes Decreased intake or decreased absorption or excessive loss through urinary or bowel elimination Acute pancreatitis, starvation, malabsorption syndrome, chronic alcoholism, burns, prolonged hyperalimentation without adequate Mg Hypoparathyroidism with hypocalcemia Diuretic therapy

51. Signs and symptoms Tremors, tetany, ↑ reflexes, paresthesias of feet and legs, convulsions Positive Babinski, Chvostek and Trousseau signs Personality changes with agitation, depression or confusion, hallucinations ECG changes (PVC’S, V-tach and V-fib) Treatment Mild Diet – Best sources are unprocessed cereal grains, nuts, legumes, green leafy vegetables, dairy products, dried fruits, meat, fish Magnesium salts More severe MgSO4 IM MgSO4 IV slowly Monitor Mg q 12 hr Monitor VS, knee reflexes Precautions for seizures/confusion Check swallow reflex

52. Hypermagnesemia Most common cause is renal failure, especially if taking large amounts of Mg-containing antacids or cathartics; DKA with severe water loss Signs and symptoms Hypotension, drowsiness, absent deep tendon reflex, respiratory depression, coma, cardiac arrest ECG – Bradycardia, complete HB, cardiac arrest, tall T waves Treatment Withhold Mg-containing products Calcium chloride or gluconate IV for acute symptoms IV hydration and diuretics Monitor VS, LOC Check patellar reflexes

53. Phosphorus Normal 2.5-4.5 mg/dL Intracellular mineral Essential to tissue oxygenation, normal CNS function and movement of glucose into cells, assists in regulation of Ca and maintenance of acid-base balance Influenced by parathyroid hormone and has inverse relationship to Calcium

55. Hyperphosphotemia Causes Chronic renal failure (most common) Hyperthyroidism, hypoparathyroidism Severe catabolic states Conditions causing hypocalcemia Signs and symptoms Muscle cramping and weakness ↑ HR Diarrhea, abdominal cramping, and nausea Treatment Prevention is the goal Restrict phosphate-containing foods Administer phosphate-binding agents Diuretics Treat cause Treatment may need to focus on correcting calcium levels

56. Thank you for your attention