Fluid & Electrolytes

AIAH LEBBIE
M.B.CH.B
FCS (ECSA)
Welcome!

 The goal is to help you understand the basics

of writing orders for intravenous fluids.
 You will understand the composition of
intravenous fluids and know how to adapt
them.
 In some fashion, you will use these concepts
every day for the rest of your professional
career.
Our Basic Precept:

 “Teaching is the process of telling lies to

children” -- but it works!
Body Fluid Compartments

 Approximately 2/3
of the body weight
is water. The
Total
Body 2/3 of percentage is
Water total somewhat higher in
body children
weight
Body Fluid Compartments

 Approximately
2/3 of the total
Intra- body water is
cellular found within the
2/3
cells and 1/3 is
outside of the
cells.
Extra-
cellular 1/3
Body Fluid Compartments

Intra-
cellular
2/3
Inter-
stitial 2/3

Extra-
cellular 1/3
Intra- 1/3
vascular
Total body water
 2/3 -1/3 rule

 As a rule of thumb, water makes up 2/3 of the

body weight (round off to 60%). 2/3 of the
Total Body Water is Intracellular (40%); 1/3 is
Extracellular (20%). Of the Extracellular, 2/3
is Interstitial (13%) and 1/3 is Intravascular
(7%).
Caught in a lie already

 Total Body Water varies depending on

amount of body fat
 infant: 70%
 male adult: 60%
 female adult: 50%
 also affected by:
 obesity
 age (less muscle mass)
Age TBoW ECF TBlV

Premature 80% 40% 10%

1-10 days 75% 40% 9-10%

1-6 months 70% 30% 8%

6m-3yrs 60% 25% 7%

Adult 60% 20% 5-6%

 Application of the 2/3 – 1/3
rule…
 Total Body Water – 60%

Intra-
cellular
2/3 (40%)
Inter-
stitial 2/3 (13%)

Extra-
cellular 1/3 (20%)
Intra- 1/3 (7%)
vascular
Total body water
 Application of the 2/3 – 1/3
rule…
 Total Body Water – 66%

Intra-
cellular
2/3 (44%)
Inter-
stitial 2/3 (14%)

Extra-
cellular 1/3 (22%)
Intra- 1/3 (7-8%)
vascular
Total body water
Intracellular and Extracellular
Ions
Intracellular Extracellular

K +
Na+
K+
Cl- PO = 4
Mg++
Na+
Mg++ Cl -
PO =
SO
4
=
4
Proteins
Comparison of Intracellular and
Extracellular Ion Concentrations

Intracellular Extracellular
Sodium 10 mEq/l 142 mEq/l
Potassium 150 4
Magnesium 40 2.5
Chloride 0 103
Phosphates 150 3
& Sulfates
Proteins 16 40
 Extracellular Ions

 Extracellular ion concentrations can be

measured.
 Formulas can be devised to calculate
estimated deficits.
 (Desired concentration - Measured
concentration) x Body compartment x total
body weight. Example: Na+

(140 - 120) x 20% (Extracellular) x 70 kg = 280 mEq deficit

 Intracellular Ions

 Intracellular ions cannot be easily and directly

measured. Because of the need to obtain
homeostasis within the body, serum level
changes occur late and may be within normal
range even when there is a significant deficit.
 There is no good way to calculate deficits.
 Intracellular Ions

 Correction of deficits is done by the “topping

off” method. Experience (or rules of thumb)
dictates the amount needed, that amount is
given and the serum level is checked again. If
it is still low and has not risen, more is
needed.
Correction of Intracellular Ion
Deficits
End of Section 1

 You should understand and be able to use the

2/3 – 1/3 rule and calculate the sizes of a
patient’s various body compartments.
 You should understand which common
electrolytes are extracellular (and therefore
deficits can be calculated) and those which
are intracellular.
SECTION 2 – ESTIMATING WATER,
SODIUM AND POTASSIUM REQUIREMENTS
Estimating water needs - pediatrics

 First 10 kilograms: 100 cc/kg/day

 Second 10 kilograms: 50 cc/kg/day
 Thereafter: 20 cc/kg/day
Example: 8 kg. child
8 kg x 100 cc/kg/day = 800 cc/day
800 cc/day / 24 hrs/day = 33 cc/hr
24 kg. child: 1st 10 kg -- 10 x 100 = 1000 cc
Next 10 kg - 10 x 50 = 500 cc
Next 4 kg - 4 x 20 = 80 cc
Total = 1580 cc
or 66 cc/hr
Your New Mantra

 2/3 – 1/3
 100
 50
 20
Estimated water needs -
adults
 For healthy adults: 35 - 40 cc/kg/day
 For older adults or with limited ability to
handle fluids: 30-35 cc/kg/day

Example: 75 kg. 30 y.o. Male

75 kg x 40 cc/kg/day = 3000 cc/day
3000 cc/kg/day/24 hrs/day = 125 cc/hr
40 kg. 85 y.o. Female
40 kg x 30 cc/kg/day = 1200 cc/ day
1200 cc/day / 24 hrs/day = 50 cc/hr
Your New Mantra

 2/3 – 1/3
 100 – 50 – 20
 35-40
 30-35
Newborn Fluid Requirements

 Term Neonate

DOL 1:
50-60mL/kg/d
DOL 2:
100mL/kg/d
>7d:
100-150mL/kg/d
Unstressed neonates require
less fluid

 1-2 days old 65cc/kg/d


 3-7 days old 85 cc/kg/d

 7+ days old 100cc/kg/d
Sodium requirements

 Pediatrics: 2 - 3 mEq/kg/day
 VLGA/critically ill : 4-5mE/kg/day
 Adults: 1 - 2 mEq/kg/day
Examples: 14 kg. toddler

14 kg x (2 - 3 mEq/kg/d) = 28 - 42 mEq/d

60 kg. adult

60 kg x (1 - 2 mEq/kg/d) = 60 - 120 mEq/d

 Sodium excretion of a term neonate is only
10% that of a 6y old

 Premature infants are “salt wasters”

FENa =
3-9%
vs.
1% for a term 3d old
In a study of 20 newborn surgical patients, the
total sodium intake during the intraoperative
and immediate postoperative period was 4.7
times what usually is considered normal daily
sodium intake (3mEq/kg/24h).”
-O’Neill, Principles of Pediatric Surgery, 2nd Ed.
(Extracted from Coran, Drongowski, JPS 1989)
Potassium requirements
 Pediatrics: 1 - 2 mEq/kg/day
 More is needed in critically ill or preterm
neonates
 Ensure patient has voided
 Adults: 0.5 - 1 mEq/kg/day

Examples: 14 kg. toddler

14 kg x (1 - 2 mEq/kg/d) = 14 - 28
mEq/d

60 kg. adult
Calcium requirement

 0.5 – 3 mEq/kg/d
 Replace, especially in premies
 Immature renal and parathyroid function
 Small bone reserves
 All sick neonates: 2gm Ca gluconate/500cc
 1gm CaGluc = 4.65mEq Calcium
3.0kg, 3d/o: 300mL/d  5.6mEq/d
Your New Mantra

 2/3 – 1/3
 100 – 50 – 20
 35-40
 30-35
 2-3 & 1-2
 1-2 and .5 – 1
 0.5-3
Example for 14 kg. Child

Water: First 10 kg: 100 x 10 = 1000 cc

Next 4 kg: 50 x 4 = 200 cc
Total: 1200 cc

Sodium:
14 kg x (2 - 3 mEq/kg/d) = 28 - 42 mEq/d

Potassium:
14 kg x (1 - 2 mEq/kg/d) = 14 - 28 mEq/d

Anabolism, inability to concentrate urine and high

insensible losses account for the larger numbers.
Your New Mantra

 2/3 – 1/3
 100 – 50 – 20
 35-40
 30-35
 2-3 & 1-2
 1-2 and .5 – 1
 0.5-3
End of Section 2

 You should be able to calculate the water,

sodium and potassium requirements for
maintenance of a child or adult.
 You should have the following part of the
mantra in your memory: “2/3, 1/3, 100-50-20,
35-40, 30-35, 2-3, 1-2, 1-2, half – 1”
SECTION 3 – THE COMPOSITION
OF INTRAVENOUS FLUIDS
Example for 14 kg. child
Water: First 10 kg: 100 x 10 = 1000 cc
Next 4 kg: 50 x 4 = 200 cc
Total: 1200 cc

Sodium:
14 kg x (2 - 3 mEq/kg/d) = 28 - 42 mEq/d

Potassium:
14 kg x (1 - 2 mEq/kg/d) = 14 - 28 mEq/d

Converting to standard one liter containers:

Sodium: (28 - 42 mEq/d) / 1.2 liters/d = 23 - 35 mEq/l

Potassium: (14 - 28 mEq/d) / 1.2 l/d = 12 - 23 mEq/l

!200 cc/day / 24 hours/day = 50 cc/hr

Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170
Your New Mantra

 2/3 – 1/3
 100 – 50 – 20
 35-40
 30-35
 2-3 & 1-2
 1-2 and .5 – 1
 308 – 275
Dextrose in water

 D5W = 5 grams dextrose per deciliter

 C6H1206. H20 ,the hydrated intravenous form of
dextrose, has 3.4 kcal/gram
 5 gm/dl x 3.4 kcal/gm x 10 dl/liter = 170
kcal/liter
Your New Mantra

 2/3 – 1/3
 100 – 50 – 20
 35-40
 30-35
 2-3 & 1-2
 1-2 and .5 – 1
 308 – 275
 3.4
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170
Why not use hypotonic
fluids?
 D5W is used to ensure that fluids are isotonic or
more commonly, hypertonic. The dextrose also
has some protein-sparing effect.
 Hypotonic fluids cause fluid shifts resulting in
lysis of red cells

H20

H20
H20
Why not use hypotonic
fluids?
 Hypotonic fluids cause fluid shifts resulting in
lysis of red cells

H20
H20
H20
Why not use hypotonic
fluids?
 Hypotonic fluids cause fluid shifts resulting in
lysis of red cells

H20
H20
H20
Why not use hypotonic
fluids?
 Hypotonic fluids cause fluid shifts resulting in
lysis of red cells
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170
D5W/.45 77 77 - - - 429 170
NS
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170
D5W/.45 77 77 - - - 429 170
NS
Ringer’s 130 109 4 28 2.7 274 -
(as
lactate lactate)
End of Section 3

 You should be able to create a table which tells

you the concentrations of sodium and
potassium, the osmolality and the caloric
content of basic intravenous fluids.
 You should have the complete mantra in your
memory: “2/3, 1/3, 100-50-20, 35-40, 30-35, 2-3,
1-2, 1-2, half – 1, 308-275, 3.4”
SECTION 4 – SELECTING (AND CREATING)
THE RIGHT IV FLUID FOR YOUR PATIENT
Your New Mantra

 2/3 – 1/3
 100 – 50 – 20
 35-40
 30-35
 2-3 & 1-2
 1-2 and .5 – 1
 0.5-3
 308 – 275
 3.4
Choosing the right IV fluid
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170
D5W/.45 77 77 - - - 429 170
NS
Ringer’s 130 109 4 28 2.7 274 -
(as
lactate lactate)

For our hypothetical 14 kg. child:

Sodium: (28 - 42 mEq/d) / 1.2 liters/d = 23 - 35 mEq/l
Potassium: (14 - 28 mEq/d) / 1.2 l/d = 12 - 23 mEq/l
1200 cc/day / 24 hours/day = 50 cc/hr
Which I.V. fluid?
Choosing the right IV fluid
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9Normal 308
saline 154 154 - - - mEq -
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170

D5W/.45 77 77 - - - 429 170

NS
Ringer’s 130 109 4 28 2.7 274 -
lactate as
lactate

For our hypothetical 14 kg. child:

Sodium: (28 - 42 mEq/d) / 1.2 liters/d = 23 - 35 mEq/l
Potassium: (14 - 28 mEq/d) / 1.2 l/d = 12 - 23 mEq/l
1200 cc/day / 24 hours/day = 50 cc/hr
Which I.V. fluid?
Choosing the right I.V.
fluid:
Wait a minute!!! That
fluid is too hypotonic
and doesn’t provide the
necessary potassium!

He’s right, you know!

Choosing the right IV fluid
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9Normal 308
saline 154 154 - - - mEq -
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170

D5W/.45 77 77 - - - 429 170

NS
Ringer’s 130 109 4 28 2.7 274 -
lactate as
lactate

Step 1: Add D5W to make it somewhat hypertonic.

Step 2: Add the necessary potassium as KCl

Order: D5W/.2NS + 20 mEq KCl/l @ 50 cc/hr

Choosing the right IV fluid
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9Normal 308
saline 154 154 - - - mEq -
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170

D5W/.45 77 77 - - - 429 170

NS
Ringer’s 130 109 4 28 2.7 274 -
lactate as
lactate

Example 2: 70 kg. adult

Water: 70 kg. x 35 cc/kg = 2450 cc (102 cc/hr)
Sodium: 70 x (1-2 mEq/kg/d) = 70 - 140 mEq/d
Potassium: 70 x (0.5 - 1 mEq/kg/d) = 35 - 70 mEq/d
Per liter: 29 - 58 mEq Sodium; 14 - 28 mEq Potassium
Order: D5W/.2NS + 20 mEq KCl/l @ 100 cc/hr
(Alternatively: D5W/.45 NS + 20 mEq KCl/l @ 100 cc/hr)
Choosing the right IV fluid

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9Normal 308
saline 154 154 - - - mEq -
0.45 NS 77 77 - - - 154 -
0.2 NS 34 34 - - - 68 -
D5W - - - - - 275 170

D5W/.45 77 77 - - - 429 170

NS
1/s 61.5 52 18 28 as 160 0
strength lactate
Darrow’s
solution
Ringer’s 130 109 4 28 2.7 274 0
lactate as
lactate
Potassium replacement

 For initial serum levels of 4.0 – 3.0 mEq

 25 – 50 mEq drop in total body potassium for each
0.25 mEq/dl change
 To drop from 4.0 – 3.0, it could represent a 100 –
200 mEq change in total potassium
 From 3.0 – 2.5 mEq/dl
 For each fall of .25 mEq/dl, there is 100 – 200 mEq
change
 To drop from 3.0 – 2.5 could represent a 200 – 400
mEq increased deficit
End of Section 4

 Using all you have learned, you should be

able to select an appropriate maintenance IV
fluid and write an order that adds an
appropriate amount of potassium to be
administered at an appropriate rate.
Homework from today’s
lecture
 Pick patients that fall in various weight
categories and calculate estimated water,
sodium, potassium requirements.
 For those same patients, determine which IV is
most appropriate and calculate the needed
amount of potassium per liter as well as the
administration rate.
 Do it ad nauseum!
Homework for Section 5

 Review the amount of output and the

concentration of GI secretions (saliva, gastric,
bile, pancreatic fluid, jejunal, ileal and colonic)
Fluid & Electrolytes – Mantra

100-50-20

30-35; 35-40

2-3, 1-2; 1-2, 0.5 – 1

Composition of GI Fluids --
Saliva

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Salivary 1500 10 26 10 30
(500- (2-10) (20-30) (8-18)
2000)

In this setting, need for replacement is unusual, but….

Composition of GI Fluids --
Saliva
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)

Salivary 1500 10 26 10 30
(500- (2-10) (20-30) (8-18)
2000)
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D5W/.18 31 31 - - - 337 200
NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution (as
lactate)
Composition of GI Fluids --
Saliva
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)

Salivary 1500 10 26 10 30
(500- (2-10) (20-30) (8-18)
2000)
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.18 NS 31 31 - - - 62 -
- - Plus 30 mEq of 335 200
D5W K2HCO3 if available
or 30 mEq of or
Na2HCO3 plus 20 375
Meq KCl
Composition of GI Fluids -
Gastric

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Stomach 1500 60 10 130 -

(100- (9-116) (0-32) (8-154)
4000)
Replacement of GI Fluids -
Gastric
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Stomach 1500 60 10 130 -
(100- (9-116) (0-32) (8-154)
4000)
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Replacement of GI Fluids -
Gastric
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Stomach 1500 60 10 130 -
(100- (9-116) (0-32) (8-154)
4000)
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/.1 31 31 - - - 337 170
8 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Replacement of GI Fluids -
Gastric

 The need to preserve H2CO3= by wasting Cl- is

more important than the extra sodium,
therefore 0.9 NaCl is the fluid of choice even
if 0.45 NaCl was available.
 Composition of GI Fluids -
Duodenum

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Duodenum 1200 140 5 80 (60?)

(100-
2000)
Replacement of GI Fluids -
Duodenum
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Duodenum 1200 140 5 80 (60?)
(100-2000)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Replacement of GI Fluids -
Duodenum
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Duodenum 1200 140 5 80 (60?)
(100-2000)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Composition of GI Fluids -
Ileum

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Ileum 3000 140 5 104 30

(100- (80-150) (2-8) (43-137)
9000)
Replacement of GI Fluids -
Ileum
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)

Ileum 3000 140 5 104 30

(100-9000) (80-150) (2-8) (43-137)
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Replacement of GI Fluids -
Ileum
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)

Ileum 3000 140 5 104 30

(100-9000) (80-150) (2-8) (43-137)
Na+ Cl- K+ HCO3= Ca++ mOsm Kcal
0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Composition of GI Fluids -
Colon

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Colon Variable 60 3 40 -

With diarrhea, it is similar to ileum loss.

Composition of GI Fluids -
Pancreatic

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Pancreas 500 140 5 75 115

(100- (113- (3-7) (54-95)
800) 185)
Replacement of GI Fluids -
Pancreatic
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Pancreas 500 140 5 75 115
(100-800) (113-185) (3-7) (54-95)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Replacement of GI Fluids -
Pancreatic
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Pancreas 500 140 5 75 115
(100-800) (113-185) (3-7) (54-95)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9 154 154 - - - 308 -
Normal
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 170
D5W/.45 NS 77 77 + 70 - 100 mEq of 429 170
Na2HCO3 per liter
Ringer’s 130 109 4 28 (as 2.7 274 -
lactate lactate)
Replacement of GI Fluids -
Pancreatic
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Pancreas 500 140 5 75 115
(100-800) (113-185) (3-7) (54-95)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.18 NS 31 31 - - - 62 -
D5W/.45 NS 77 77 + 70 - 100 mEq of ~569 if 170
Na2HCO3 per liter 70 mEq
D4.3W/.18 31 31 + 70 - 100 mEq of ~557 170
NS Na2HCO3 per liter
plus 40 mEq NaCl/l
Composition of GI Fluids -
Bile

Volume Na (mEq/l) K (mEq/l) Cl HCO3

(cc/24hrs) (mEq/l) (mEq/l)

Bile 500 145 5 100 35

(50 – (131- (3-12) (89-180)
800) 164)
Replacement of GI Fluids -
Bile
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Bile 500 145 5 100 35
(50 – 800) (131-164) (3-12) (89-180)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Replacement of GI Fluids -
Bile
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Bile 500 145 5 100 35
(50 – 800) (131-164) (3-12) (89-180)

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
 Composition of GI Fluids -
Summary
Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Salivary 1500 10 26 10 30
(500-2000) (2-10) (20-30) (8-18)
Stomach 1500 60 10 180 -
(100-4000) (9-116) (0-32) (8-154)
Duodenum 140 5 80 -
(100-2000)
Ileum 3000 140 5 104 30
(100-9000) (80-150) (2-8) (43-137)
Colon - 60 30 40 -

Pancreas 500 140 5 75 115

(100-800) (113-185) (3-7) (54-95)
Bile 500 145 5 100 35
(50 – 800) (131-164) (3-12) (89-180)
Replacement of GI fluids -
A Rule of Thumb

 Use Hartmann’s solution unless the fluid is

significantly acidic or basic. If acidic, use
normal saline. If basic, use D4.3/.18 and add
Na2HCO3 and NaCl.
 If volumes are great or electrolyte balance is
critical, send aliquot to lab for electrolyte
analysis
Hyperalimentation

 Malnourishment
 Expected to remain NPO > 5 - 7 days
 Requirements are greater than can be
voluntarily consumed
 Chemotherapy/radiation therapy
 Hyperalimentation -
Nitrogen Balance

 16% of protein is nitrogen

 Divide the total number of grams of protein
by 6.25 ( 1 / 16) to get the number of grams of
nitrogen
 Hyperalimentation -
Nitrogen Balance

 Nitrogen balance = protein intake (gms)

divided by 6.25 minus nitrogen loss -- the
urinary loss of nitrogen (as Urine Urea
Nitrogen) plus insensible and fecal loss
(approximately 4 gms for an adult)
 Insensible nitrogen loss = ~ 0.1 gm/kg
FLUID & ELECTROLYTES - PART
III

We Treat - Jesus Heals

 2/3 -1/3 rule

 As a rule of thumb, water makes up 2/3 of the

body weight (round off to 60%). 2/3 of the
Total Body Water is Intracellular (40%); 1/3 is
Extracellular (20%). Of the Extracellular, 2/3
is Interstitial (13%) and 1/3 is Intravascular
(7%).
Estimated water needs - a mantra

 100-50-20
 30-35; 35- 40
 Altogether now ….
 Mantra #2

 2-3 and 1-2 (peds)

 1-2 and .5 - 1 (adults)

And number 1
again…. 100-50-20
 30-35; 35-40
Composition of Intravenous Fluids

Na+ Cl- K+ HCO3= Ca++ mOsm Kcal

0.9
Normal 154 154 - - - 308 -
saline mEq
0.45 NS 77 77 - - - 154 -
0.18 NS 31 31 - - - 62 -
D5W - - - - - 275 200
D4.3W/ 31 31 - - - 337 170
.18 NS
Hartman’s 131 114 5.4 28 3.7 279 -
solution
(as
lactate)
Composition of GI Fluids -
Summary Volume Na (mEq/l) K (mEq/l) Cl HCO3
(cc/24hrs) (mEq/l) (mEq/l)
Salivary 1500 10 26 10 30
(500-2000) (2-10) (20-30) (8-18)
Stomach 1500 60 10 180 -
(100-4000) (9-116) (0-32) (8-154)
Duodenum 140 5 80 -
(100-2000)
Ileum 3000 140 5 104 30
(100-9000) (80-150) (2-8) (43-137)
Colon - 60 30 40 -

Pancreas 500 140 5 75 115

(100-800) (113-185) (3-7) (54-95)
Bile 500 145 5 100 35
(50 – 800) (131-164) (3-12) (89-180)
Replacement of GI fluids -
A Rule of Thumb

 Use Hartmann’s solution unless the fluid is

significantly acidic or basic. If acidic, use
normal saline. If basic, use D5/.18 and add
Na2HCO3 and NaCl.
 If volumes are great or electrolyte balance is
critical, send aliquot to lab for electrolyte
analysis
Magnesium, Phosphate and ETOH

Hypomagnesemia Hypophosphatemia Delirium Tremens

++ =
Electrolytes K+Ca Mg++,PO4 ,
Neurological Lethary, Irritability, coma, Agitation, confusion,
Confusion, tremor, hypotonia, disorientation,
ataxia, nystagmus paresthesias, hallucinations,
and seizures dysarthria increased autonomic
activity – fever,
tachycardia,
diaphoresis
Muscles Fasciculations, Weakness,
tetany rhabdomyolysis
Cardiac ? PR and QT Heart failure, CV collapse,
intervals cardiovascular arrhythmias
Atrial and collapse
ventricular
arrhythmias
Other Hemolysis
Intravascular volume and
shock
 Hypovolemic shock is usually well
compensated until a 15% blood loss
 A 15 - 25% reduction in blood volume may be
accompanied by tachycardia, tachypnea and
orthostatic hypotension
 Hypotension does not occur in healthy people
until 25% blood loss
How much blood is a 25%
loss?
 In the proverbial 70 kg man we know:
 Intravascular volume is 7%, therefore it is 70
kg x 7% or 4.9 liters
 A 25% blood loss is therefore 1.2 liters
Replacement of blood loss

 If we replace with an essentially isotonic fluid

(0.9NS or Hartmann’s), it will initially stay
intravascular for a brief time
 ATLS recommends the use of type-specific
blood if the pressure has not responded to 2
liters of crystalloid. Why?
Doing the math...

 If 2 liters are given without raising the

pressure to normal, it means the blood
volume was down by at least 41% (2L /4.9L)
 If the hematocrit was 40, it is at most 23.6 vol
% after the fluid and probably lower if the
pressure is not yet completely normal
Let’s assume the BP does rise -- will it
stay there?

 Based on our previous understanding, we

know that water distributes between all body
compartments
 After metabolism of the dextrose in D5W,
only water is left.
 How much would stay intravascular after
redistribution if D5W was the resuscitation
fluid?
D5W as the resuscitation
fluid
 Total body water is 60% TBW; intravascular
component is 7% of TBW
 Therefore only 7/60 (or 11.7%) will stay
intravascular
 Of a 1 liter bolus, only 117 cc will stay inside
the vascular bed. Therefore more than 8
liters would ultimately be necessary to
restore normal intravascular volume
Sodium containing fluids as resuscitation

 Isotonic fluids (0.9% NS or Hartmann’s)

distribute in the extracellular component
 The ratio of intravascular to extracellular is at
best 1:2 and may be much greater in shock
with loss of capillary endothelial integrity
 Therefore only 1/3 of these fluids stay
intravascular; 3 times the blood loss must be
given
Other IVS as resuscitation
fluids
 D5/0.18 NS can be considered the same as
200 cc of 0.9 NS plus 800 cc of water.
 Therefore, 1/3 of the 200 cc (~67 cc) and 11.7%
of the 800 cc (~93.6 cc) will stay intravascular
(total of 160 cc)
 Approximately 6 liters of such a fluid would
be necessary
Need for continued fluid in
shock
 This explains the fact that the blood pressure
may respond to a bolus, then fade again. It
may not imply ongoing loss.
 This also explains the edema after vigorous
resuscitation. 2/3 or more of the fluid is in the
interstitium and is a problem only if it causes
intracerebral edema or pulmonary diffusion
difficulties
Need for continued fluid in
shock
 These patients are total body water and salt
overloaded, but are NOT intravascularly
overloaded.
 Failure to adequately resuscitate in
hypovolemia shock is more often dangerous
than the risk of the additional fluid in the
interstitium.
Fluid boluses in shock

 Once the diagnosis of hypovolemia has been

made, it is based on a 15% or more volume
loss
 In the 70 kg. person, this is at least 750 cc and
may be twice that or more
 This volume should be replaced by immediate
bolus, not over hours