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Fluid and electrolyte balance
The document provides an extensive overview of fluid and electrolyte balance, detailing normal physiology, the regulation of water and electrolyte balance, and managing conditions like hypovolemia and hypervolemia. It discusses various fluid replacement therapies, including crystalloids and colloids, their indications, contraindications, and management strategies for disturbances in body fluid composition. Finally, it emphasizes the importance of maintaining normovolemia and hemodynamic stability in medical treatment.
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Fluid and electrolyte balance
- 2. FLUID AND ELECTROLYTES BALANCE By: DrChirag M A 1st year PG Dept of Oral & Maxillofacial Surgery
- 3. CONTENTS: • Introduction • NormalAnatomy and Physiology • Regulation of water intake • Electrolyte balance • IV Fluids
- 4. INTRODUCTION: • When unicellularorganisms evolved into multicellular organism, they faced several physiological challenges including the maintenance of water and salt balance in an environment. • Rather than being surrounded by an external sea, they carried their own internal sea or Extracellular Fluid (ECF), in which their cells could bathe in a constant chemical environment, which the great French physiologist Claude Bernard called the ‘milieu interieur’.
- 5. • Water comprises60%(40L) of the body weight of an average adult. • the percentage is lower in obesity, since adipose tissue contains less water than lean tissue. Normal anatomy and physiology
- 6. • Fluid balancerefers to the proper levels of water and electrolytes being in the various body compartments according to their needs. • Osmotic pressure (created by the dissolved electrolytes in body fluids) and hydrostatic pressure (created by the water in body fluids) are the main forces behind any molecular movement between body compartments.
- 7. Total Body Water IntercellularFluids (25L, 40% of body Extracellular Fluids (15L, 20% of body weight) Intravascular/Blood Plasma (within the Interstitial (extravascular fluid surrounding the cells)
- 8. Rich in K+,Mg++, HPO42-, SO42-, and protein anions.ICF Rich in Na+, Cl-, HCO3-, and Ca++.ECF
- 10. WATER BALANCE • Waterbalance occurs when water intake equals water output. • A normal adult consumes about 2,500 ml of water daily, At the same time, this adult is releasing about 2,500 ml of water daily.
- 11. Excess water loss •Fever : 100 ml / degree fever / day • Tracheostomy (unhumidified air) : >1.5 L / day • Children – 1.5 to 2 L/m2
- 12. REGULATION OF WATERINTAKE • The body loses as little as 1% of its water. • An increase in osmotic pressure of extracellular fluid due to water loss stimulates osmoreceptors in the thirst center (hypothalamus). • Activity in the hypothalamus causes the person to be thirsty and to seek H2O.
- 13. • Drinking andthe resulting distension of the stomach by water stimulants nerve impulses that inhibit the thirst center. • water is absorbed through the wall of the stomach, small intestine, and large intestine. • The osmotic pressure of extracellular fluid returns to normal.
- 14. EVENTS IN REGULATIONOF WATER OUTPUT Dehydration ECF osmotic pressure Stimulation of Osmoreceptors in the hypothalamus Release ADH into the blood Increases water reabsorption in Kidney Urine output
- 15. ELECTROLYTE BALANCE • Electrolytesare chemical substances that release cations (positively charged ions) and anions (negatively charged ions) when they are dissolved in water. • The most important electrolytes include Na+, K+, Cl-, Ca+2, and HPO4.
- 16. BODY FLUID &ELECTROLYTES DISTURBANCES VOLUME CHANGES • Hypovolemia • Hypervolemia CONCENTRATION CHANGES • Hyponatremia • Hypernatremi COMPOSITION CHANGES • Potassium Abnormalities • Calcium Abnormalities • Magnesium Abnormalities
- 17. HYPOVOLEMIA • diminished ECF. •CAUSES :- • GI losses from vomiting, • nasogastric suction, • diarrhea, • fistula drainage • soft-tissue injuries HYPERVOLEMIA • INCRESED ECF. • CAUSES :- • Iatrogenic or Secondary to renal insufficiency • Cirrhosis VOLUME CHANGES
- 18. HYPOVOLEMIA • SIGNS • Dryoral mucus membrane • Tachycardia • Dry axilla • Diminished skin turgor HYPERVOLEMIA • SIGNS • CVS: elevated JVP, venous distension – pulmonary edema. • GI: edema of bowel • Tissue: pitting edema – ascites
- 19. HYPOVOLEMIA • MANGAEMENT • Haemorrhage– whole blood transfusion 1st line of choice. • 6% dextran • 6% hetastarch • 5% albumin • 3.5% urea-bridged gelatin • 1lt of ringer’s lactate • Burn – 4ml/kg/% of body area HYPERVOLEMIA • MANAGEMENT • Prevention is the best way • Diuretics • Increase oncotic pressure: or albumin infusion (may followed by diuretics) • Dialysis
- 20. CONCENTRATION CHANGES HYPERNATRIUM • Asymptomatic • •Symptomatic (Na>160 mEq/L) HYPONATRIUM • Na+ is the most abundant positive ion of ECF compartment and is critical in determining the ECF and ICF osmolality. • Normal amount 135-145 mEq/l. • Sign & symptoms : <120 mEq/l.
- 21. HYPERNATRIUM • SIGNS &SYMPTOMS • CNS: Restlessness, ataxia, irritability, tonic spasms, delirium, seizures, coma • Musculoskeletal: Weakness • CVS: Tachycardia, hypotension, syncope HYPONATRIUM • SIGNS & SYMPTOMS • CNS: confusion, lethargy, headache, seizure, coma • GI: nausea, vomiting • Skeletal system : muscle twitches • TREATMENT • Diuretics like Frusemide
- 22.
- 23. HYPOKALEMIA •Serum K+ <3.5 mEq /L Etiology : •Excessive potassium excretion •Hyperaldosteronism Treatment : •KCl 10 mEq/L/hr IV - pripherally •KC1 20 mEq/L/hr IV - centrally HYPERKALEMIA Serum K+ > 5.1 mEq /L Etiology : •Blood transfusions •Acidosis •Impaired excretion of potassium Treatment : •IV Dextrose 50gms •Sodium bicarbonate 50- 100mmol •10% calcium chloride
- 24. CALCIUM ABNORMALITIES • Majorityof the 1000 to 1200gm of calcium in the average-sized adult is found in the bone . • Normal daily intake of calcium is 1 to 3 gm. • Normal serum level = 8.8-10.5 mg/dl • Ionized portion (1.2 mg/dl) is responsible for neuromuscular stability • Most is excreted via the GI tract
- 27. MAGNESIUM ABNORMALITIES • Totalbody content of magnesium 2000 mEq, about half of which is incorporated in bone. • Normal daily dietary intake of magnesium is approximately 240 mg • Normal serum level = 1.5- 2.4 mg/dl • Deficiency causes impaired repletion of Na+ & CA 2+
- 28. HYPOMAGNESEMIA • Plasma levelless than 1mmol/l CAUSES: • starvation, • malabsorption syndromes, • GI losses, • prolonged IV with magnesium-free solutions • Drugs – aminoglycosides. • Sign & symptoms – similar to that of hypocalcemia • Treatment :- IV 49.3% MgSO4 5-10ml
- 29. ACID-BASE BALANCE • pH– 7.4 • Three primary system regulates acid-base balance in our body :- a) Chemical acid-base buffer systems of the body fluids. b) Respiratory centre c) Kidneys. • A pH < 7.4 – Acidosis • A pH > 7.4 – alkalosis
- 30. SIGNS AND SYMPTOMS •Acidosis – a) Increased respiratory rate b) Increased in heart rate c) Cyanosis d) Fruity smell • Alkalosis – a) Decreased respiratory rate
- 31. TREATMENT• Acidosis :- a)7.5% sodium bicarbonate iv b) Sodium lactate c) Sodium gluconate • Alkalosis :- a) Ammonium chloride b) Lysine monohydrochloride
- 33. BASED ON USE MAINTENANCE FLUIDS REPLACEMENT FLUIDS SPECIALFLUIDS 5% D, 5% D + 0.45% Nacl NS, DNS, RL, Isolyte -G, Isolyte-e, Isolyte-m, Isolyte-p Inj.NaHCO3, Mannitol, NS 1.6%, 3%, 5% Inj. KCl 25% Dextrose
- 34. Based on property Crystalloids (solutionof large molecules) Colloids (solution of electrolytes) Life saving RL NS DNS D-5% ISOLYTES 5% Albumin 25% Albumin 10% Pentastarch 10% Dextran -40 6% Dextran -70 10% Hetastarch
- 35. 5% DEXTROSE Composition :Glucose 50 gms Pharmacological basis : Corrects dehydration and supplies energy( 170Kcal/L) Indications : • Prevention and treatment of dehydration • Pre and post op fluid replacement • IV administration of various drugs
- 36. Contra indications • Cerebraledema, neuro surgical procedures • Acute ischaemic stroke • Hypovolemic shock Rate of adminstration – 0.5 gm/kgBW/hr or 666ml/hr 5 % D or 333ml/hr %D
- 37. INVERTED SUGAR SOLUTION Composition: inverted sugar 100 gms Pharmacological basis : half dextrose + half fructose Indications : • Prevention and treatment of dehydration (specially pregnancy) • Liver diseases (prevents glycogen depletion)
- 38. Adverse effects : 1.Lactic acidosis 2. Hyperurecemia 3. hypophosphatemia Contra indications • hereditory fructose intolerance • Caution in renal & hepatic impairment • >25gm fructose should be avoided • more expansive
- 39. ISOTONIC SALINE(0.9 %NS) • Composition : Na+ 154 mEq, Cl- 154 meq • Pharmacological basis : provide major ECF electrolytes.. corrects both water and electrolyte deficit. increase the iv volume substantially • Contra indications 1. Avoid in pre eclamptic patients 2. Dehydration with severe hypokalemia 3. Large volume may lead to hyperchloremic acidosis.
- 40. Indications • Water andsalt depletion • Hypovolemic shock • Alkalosis with dehydration • Hypercalcemia • Irrigation – washing of body fluids
- 41. DNS 5%Dextrose + 0.9%Normal saline • Supply major EC electrolytes, energy and fluid to correct dehydration Pharmacological basis • Conditions with salt depletion ,hypovolemia • Correction of vomiting • Compatible with blood transfusion Indications • Anasarca – cardiac, hepatic or renal • Severe hypovolemic shock (osmotic diuresis) • >25gm/hr should be avoided Contra indications
- 42. RINGER’S LACTATE SOLUTION Pharmacologicalbasis : • Most physiological fluid , rapidly expand s iv volume.. • Lactate metabolised in liver to bicarbonate providing buffering capacity • Acetate instead of lactate advantageous in severe shock.
- 43. Contra indications • Liverdisease, severe hypoxia and shock • Severe CHF , lactic acidosis takes place • Addison’s disease • Vomiting or NGT induced alkalosis • Simultaneous infusion of RL and blood • Certain drugs – amphotericin, thiopental, ampicillin, doxycycline Indications • Correction in severe hypovolemia • Replacing fluid in post op patients, burns • Diarrhoea induced hypokalemic metabolic acidosis • Fluid of choice in diarrhoea induced dehydration in paediatrics • Maintaining normal ECF fluid and electrolyte balance
- 44.
- 45. Isolyte G : •Vomiting or NGT induced hypochloremic, hypokalemic metabolic alkalosis • NH4 gets converted to H+ and urea in liver • Treatment of metabolic alkalosis • Contraindications : Hepatic failure, renal failure, metabolic acidosis Isolyte M • Richest source of potassium (35 mEq) • Ideal fluid for maintenance • Correction of hypokalemia • Contraindications : Renal failure, burns, adrenocortical insufficiency
- 46. Isolyte P • Maintenancefluid for children – as they require less electrolytes and more water • Excessive water loss or inability to concentrate urine • Contraindications : hyponatremia, renal failure Isolyte E • Extracellular replacement solution, additional K and acetate (47mEq) • Only iv fluid to correct Mg deficiency • Treatment of diarrhoea, metabolic acidosis • Contraindications – metabolic alkalosis
- 47.
- 48. COLLOIDS • Large molecularweight substances that largely remains in the intravascular compartment thereby generating oncotic pressure. • 3 times more potent than crystalloids. • 1 ml blood loss = 1ml colloid = 3ml crystalloids
- 49. TYPE OF FLUIDEFFECTIVE PLASMA VOLUME EXPANSION/100ML DURATION 5% albumin 70 – 130 ml 16 hrs 25% albumin 400 – 500 ml 16 hrs 6% hetastarch 100 – 130 ml 24 hrs 10% pentastarch 150 ml 8 hrs 10% dextran 40 100 – 150 ml 6 hrs 6% dextran 70 80 ml 12 hrs
- 50. ALBUMIN • Maintain plasmaoncotic pressure – 75-80 % • Heat treated preparation of albumin – 5%, 20% and 25% commercially available Pharmacalogical basis : • 5% albumin – COP of 20 mmHg • 25% albumin – COP of 70mmHg ,expands plasma volume to 4-5 times the volume infused within 4-5 min. Rate of infusion : • Adults – initial infusion of 25 gm • 1 to 2 ml/min – 5% albumin • 1 ml/min - 25% albumin
- 51. Indications: • Plasma volumeexpansion in acute hypovolemic shock, burns, severe hypoalbuminemia • Hypo proteinemia – liver disease, Diuretic resistant in nephrotic syndrome • Oligourea • In therapeutic plasmapheresis , as an exchange fluid Contra indications : • Severe anaemia, cardiac failure • Hypersensitive reaction
- 52. DEXTRAN • Dextran areglucose polymers produced by bacteria (leuconostoc mesenteroides) 2 forms : dextran 70(MW 70,000) and dextran 40(40,000) Pharmacological basis : • Effectively expand iv volume, but not suitable for blood transfusion. • Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapid renal excretion Indications : • Hypovolemia correction • Prophylaxis of DVT and post operative thromboembolism Adverse effects • Acute renal failure • Interfere with blood grouping and cross matching
- 53. GELATIN POLYMERS( HAEMACCEL) •500 ml Sterile, pyrogen free 3.5 % solution • Polymer of degraded gelatin with electrolytes • 2 types • Succinylated gelatin (modified fluid gelatin) • Urea cross linked gelatin ( polygeline) Composition : Na 145 mEq, Cl 145 mEq, Ca 12.5 mEq, Potassium 5.1 mEq
- 54. Indications : • Rapidplasma volume expansion in hypovolemia • Volume pre loading in general anesthesia • Priming of heart lung machines Advantages : • Does not interfere with coagulation, blood grouping • Remains in blood for 4 to 5 hrs • Side effects : • Hypersensitivity reaction • Bronchospasm, hypotension
- 55. HYDROXYETHYL STARCH • Itis composed of more than 90% esterified amylopectine. • Esterification retards degradation leading to longer plasma expansion • 6% starch - MW 4,50,000 Pharmacological basis : • Osmolality – 310 mosm/L • Higher colloidal osmotic pressure • LMW substances excreted in urine in 24 hrs
- 56. Advantages : • Nonantigenic • Does not interfere with blood grouping Disadvantages : • Increase in S amylase concentration upto 5 days after discontinuation • Affects coagulation by prolonging PT and bleeding time by lowering fibrinogen
- 57. Contra indications : •Bleeding disorders , CHF • Impaired renal function Administration : • Adult dose 6% solution – 500ml to 1 lit • Total daily dose should not exceed 20ml/kg
- 58. SPECIAL FLUIDS • InjKCl 10 ml amp – 20mEq • 25%D (25 ml amp or 100 ml infusion bottle)– in hypoglycemic shock • Inj. Sodium bicarbonate (25 ml amp. 22.5mEq Na+ & 22.5mEq HCO3- dose = 10-15 mEq/L : in metabolic acidosis • Mannitol 10% & 20% : osmotic diuretic
- 59. GOALS• Maintenance ofnormovolemia and hemodynamic stability • Acceptable plasma colloid osmotic pressure • Correction of electrolyte imbalance • Correction of acid base imbalance • Adequate urine output( 0.5 to 1 ml/kg/hr)
- 60. CONCLUSION • ‘Fluid therapyshould be directed not only to effective volume expansion of a leaky circulation but also to micro vascular protection’.
- 61. REFERENCES BOOKS 1. HELEN GIANNAKOPOULOS,LEE CARRASCO, JASON ALABAKOFF, PETER D. QUINN. FLUID AND ELECTROLYTE MANAGEMENT AND BLOOD PRODUCT USAGE. ORAL MAXILLOFACIAL SURG CLIN N AM 18 (2006) 7 – 17. 2. GYTON & HALL TEXTBOOK OF MEDICAL PHYSIOLOGY,10TH EDITION. 3. SEMBULINGAM K. SEMBULINGAM PREMA. K SEMBULINGAM - ESSENTIALS OF MEDICAL PHYSIOLOGY, 6TH EDITION 4. CONCISE TEXTBOOK OF SURGERY – DAS S.3RD ED
- 62. REFERENCES OTHERS RUTTMANN TG,JAMES MF. EFFECTS ON COAGULATION DUE TO INTRAVENOUS CRYSTALLOID OR COLLOID IN PATIENTS UNDERGOING VASCULAR SURGERY. BR J ANESTH 2002 ; 89 : 999 – 1003. SVENSEN C, PONZER S. VOLUME KINETICS OF RINGER SOLUTION AFTER SURGERY FOR HIP FRACTURE. CANADIAN JOURNAL OF ANESTHESIA 1999 ; 46 : 133 – 141. ROBERTS I, ALDERSON P, BUNN F ET AL : COLLOIDS VERSUS CRYSTALLOIDS FOR FLUID RESUSCITATION IN CRITICALLY ILL PATIENTS.. COCHRANE DATABASE SYST REV(4) : CD 000567, 2004
- 63.