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Fluid and electrolyte balance
The document discusses the importance of water in the human body, detailing its role in various chemical and physiological processes, and the distribution of body fluids. It outlines the consequences of variations in fluid balance, including symptoms of hypovolemia and hypervolemia, as well as the regulation of electrolytes such as sodium, potassium, and calcium. Additionally, it emphasizes principles of fluid therapy and considerations for fluid resuscitation during medical treatment.
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Introduces the presenter and poses questions about water consumption and its significance.
Details the importance of water in chemical reactions, nutrient transport, body weight, and variations across demographics.
Describes body fluid distribution, intracellular and extracellular fluid compartments, and the dynamics of fluid exchange. Explains homeostasis, kidney fluid control, osmotic pressures, and movement of fluids and ions across compartments.
Discusses the physiological detection of thirst, influence on ADH release, and factors affecting urine output.
Covers ADH regulation, normal fluid composition, body fluid abnormalities, and considerations for fluid maintenance.
Details sodium management, normal range, hyponatremia and hypernatremia signs, and correction strategies.
Discusses potassium and magnesium imbalances, their physiological impacts, and treatment options.
Explains hypophosphatemia and hyperphosphatemia, related symptoms, and treatment methods.
Explores the osmolarity of body fluids, causes of fluid deficits, and the significance of hydration levels.
Outlines key questions for fluid therapy, crystalloid vs. colloid considerations, and fluid resuscitation strategies.
Discusses assessment for loss, crystalloid use, formulas for burn resuscitation, and fluid strategies. Addresses fluid management in burn injuries, the importance of early diagnosis in shock, and treatment protocols.
Presents the references used in the presentation and concludes with a thank you.
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Fluid and electrolyte balance
- 1. Presenter : Diwakarvasudev PG 2nd year
- 2. Why dowe need to drink water… Where does all this water go… Why we drink only this much of water…
- 3. 1 All chemicalreactions occur in liquid medium. 2 It is crucial in regulating chemical and bioelectrical distributions within cells. 3 Transports substances such as hormones and nutrients. 4 O2 transport from lungs to body cells. 5 CO2 transport in the opposite direction. 6 Dilutes toxic substances and waste products and transports them to the kidneys and the liver. 7 Distributes heat around the body
- 4. Where does allthis water go… • Water constitutes an average 50 to 70% of the total body weight Young males - 60% of total body weight Older males – 52% Young females – 50% of total body weight Older females – 47% • Variation of ±15% in both groups is normal • Obese have 25 to 30% less body water than lean people. • Infants 75 to 80% - gradual physiological loss of body water - 65% at one year of age
- 5. Functional Components ofthe Body Fluid The water of the body makes up 50%-70% of total body weight. (TBW – 60%) Intracellular Fluid – 40% of the body weight 67% total body water Extracellular Fluid – 20% of the body weight 33% total body water interstitial fluid 15% of BW 25% total body water Intravascular 5% of BW 8% total body water
- 6.
- 7. In HOMOEOSTASIS 1. output= intake 2. Dynamic fluid equilibrium at a) Blood & interstitial fluid level b) Interstitial fluid and cell level 3. Thirst & Satiety 4. Kidney fluid control 5. Hormonal regulation
- 8. Compartmental exchangeis regulated by osmotic and hydrostatic pressures. Net leakage of fluid from the blood is picked up by lymphatic vessels and returned to the bloodstream. Exchanges between interstitial and intracellular fluids are complex due to the selective permeability of the cellular membranes. Two-way water flow is substantial.
- 9. Ion fluxesare restricted and move selectively by active transport. Nutrients, respiratory gases, and wastes move unidirectionally. Plasma is the only fluid that circulates throughout the body and links external and internal environments. Osmolalities of all body fluids are equal; changes in solute concentrations are quickly followed by osmotic changes.
- 10. Driving force forintake ...thirst Baroreceptors and Osmo receptors - detectors ↓ of 10% plasma volume or ↑ in plasma osmolality by 1% & Hypernatremia ↓ dry mouth ↓ impulses sent to Thirst Control Centers in the Hypothalamus which also controls ADH release ↓ relay information to the Cerebral Cortex where thirst becomes a conscious sensation
- 11. 1. Blood Pressure:An increase causes a greater rate of filtration. 2. Increased Concentration of Salts or Glucose in Blood : It results in decrease in urine output. 3. Decreased Plasma Protein: It decreases urine output. 4. Vasopressor Hormone: It prevents diuresis. 5. Water Loss from Other Sources: Urine volume varies inversely with water lost from other systems eg. perspiration or diarrhoea. 6. Diuretics : promotes diuresis.
- 12. ADH regualtion ofurine output
- 13. Composition of BodyFluids • Water is the universal solvent • Solutes – Electrolytes – inorganic salts, all acids and bases, and some proteins. – Non-electrolytes –Most non electrolytes are organic molecules – glucose, lipids, creatinine and urea • Electrolytes have greater osmotic power than non electrolytes • Water moves according to osmotic gradients
- 15. The concentration ofosmotically active particles is expressed in ‘osmoles’ Osmolarity - mOsm/L of solution Osmolality - mOsm/Kg of water (solvent) Osmolality defines concentration of solution
- 16. 1) changesin volume (hypovolemia and hypervolemia) 2) changes in concentration (hyponatremia and hypernatremia) 3) changes in composition (acid base imbalances and concentration changes in calcium, magnesium, and potassium)
- 17. Hypovolemia Poor skinturgor Dry mucous membrane Dry axilla Flat neck vein Tachycardia Hypotension Weightloss Sunken eyes Hypervolemia Shortness of breath at rest and exertion. Hepatojuglar reflex Ascites Pitting edema Weight gain
- 18. Hypovolemia Serum electrolyte SUN/Cr Hematocrit Urine electrolytes and specific gravity serum albumin 24-hour urine for Cr clearence Hypervolumia Serum electrolytes Urine specific gravity 24-hour urine for Cr clearence Total protein Cholesterol Liver enzyme bilirubin
- 19. Goal offluid maintenance therapy is to replace fluids lost normally during the course of a day. Standard recommendations Hourly maintenance 0-10 kg = 4ml/Kg 11-20 kg= 2ml/kg >20 kg = 1ml/kg
- 20. Normal level: 135-145mEq/L. It is the single most abundant electrolyte in the ECF Holds a central position in fluid and electrolyte balance It is the only electrolyte exerting significant osmotic pressure Sodium salts: ◦ Account for 90-95% of all solutes in the ECF ◦ Contribute 280 mOsm of the total 300 mOsm ECF solute concentration Regulated by dietary intake, aldosterone & kidneys
- 23. Signs andsymptoms of hyponatremia Confusion Lethargy Coma Nausea Vomiting Headache seizures
- 25. Acute serumsodium <110- 115mEq/Lt Symptomatic – Seizures, Coma Rapid correction Till serum sodium 120-125mEq/Lt If it is asymptomatic gradual correction over 48 hrs. If it is asymptomatic gradual correction over 48 hrs.
- 26. Hypernatremia is definedas serum sodium greater than 145 mEq/L. SIGN AND SYMPTOMS OF HYPERNATREMIA Confusion Lethargy Coma Seizures hyperreflexia
- 28. Correction of Hypernatremia Treat theunderlying cause Asymptomatic 5% dextrose in H2O 0.45% Saline preferable in hyperosmolar diabetic coma. Very large volumes of 5litres a day may be needed to be given. Symptomatic Serum sodium > 160mEq/Lt Serum osmolality > 350mOsm Treatment 1. 0.9% saline to correct volume deficit after volume restoration changed to a hypotonic I.V. fluid 2. Correct over a period of 48 hrs as rapid correction may lead to cerebral oedema.
- 29. The rateof correction of plasma osmolality should not exceed 2 mOsm/kg/h. Overly aggressive correction may lead to central pontine myelinolysis.
- 30. Major cationin intracellular compartments ◦ Regulates metabolic activities, necessary for glycogen deposits in liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction and skeletal and smooth muscle contraction . ◦ Regulated by dietary intake and renal excretion. ◦ Normal level – 3.5-5.1mEq/L Body conserves potassium poorly. Increased urine output decreases serum K+
- 31. Serum K> 3.5mEq/L Signs and symptoms of hypokalemia Neuromuscular Muscle weakness, Paralysis, Rhabdomyolysis, Hyporeflexia Gastrointestinal Paralytic ileus Renal Polyuria, Polydipsia Cardiac EKG findings: T-wave flattening/ inversion, U-wave, ST depression Cardiac toxicity to digitalis Causes of hypokalemia Decreased dietary intake Gastrointestinal losses Renal losses Cellular shift
- 32. Treatment forhypokalemia initially is aimed at correcting the existing metabolic abnormalities. Potassium chloride is administered at 10 mEq/L/h peripherally or 20 mEq/L/h centrally if EKG changes are present.Hypokalemia alone rarely produces cardiac arrhythmias. Oral supplements : Increased intake of fresh fruits and vegetables or potassium supplements of 20 to 40mmol daily. Patients with high renal losses (use potassium sparings diuretics E.g. Spironolactone.)
- 33. In emergencysituation 20-40mEq / hr of potassium can be given with frequent monitoring of cardiac status and serum potassium levels. In non-emergency situations 10mEq of potassium / hr Use glucose free solutions as glucose drives potassium intracellularly. In the absence of specific indications potassium should not be given 1. To oliguric patients 2. During the first 24 hours following severe surgical stress or trauma. Remember
- 34. Hyperkalemia (K+ > 5.1mEq/L) Signsand symptoms of hyperkalemia Neuromuscular Weakness Paresthesia Flaccid paralysis Cardiac EKG findings: peaked T waves, flattened P waves, prolonged PR, widened QRS Ventricular fibrillation Cardiac arrest Causes of hyperkalemia Pseudohyperkalemia Transcellular shift Impaired renal excretion Excessive intake Blood transfusions
- 35. Helen Giannakopoulos, DDS, MDa, LeeCarrasco, DMD, MDa, Jason Alabakoff, DDSa, Peter D. Quinn, DMD, MDa,b,T Table taken from Oral Maxillofacial Surg Clin N Am 18 (2006) 7 – 17
- 36. Identify andtreat cause Specially check renal function 10 – 20 mL intravenous 10% Calcium Chloride/ Calcium Gluconate over 10 min in patients with ECG abnormalities 50 mL 50% dextrose plus 10 units short acting insulin over 2-3min Monitor plasma glucose and K+ over next (30-60 min) Regular Salbutomol nebulizers Consider oral or rectal Ca+2 Resonium (ion exchange resin) Haemodialysis for persistent hyperkalemia.
- 37. Stored in bone,plasma and body cells ◦ 90% in bones ◦ 1% in ECF In plasma, binds with albumin ◦ Necessary for bone and teeth formation, blood clotting, hormone secretion, cell membrane integrity, cardiac conduction, transmission of nerve impulses, and muscle contraction ◦ Normal level – 4.5-5.5mEq/L or 8 – 11 mg% ◦ Regulated by Calitonin Paratharmone Calcitriol
- 38. Signs andsymptoms hypotension, larngeal spasm, paresthesias, Pathological fractures ,tetany (Chvostek’s and Trousseau’s signs), anxiety, depression, and psychosis Etiology hypoalbuminemia, hypoparathyroidism Vitamin D deficiency, Pancreatitis, Alkalosis Massive blood transfusion with citrate. IIn adults who have normal renal function, calcium replacement is 1 g (gluconate or chloride) in 50 mL dextrose 5% in water or normal saline. Intravenous solutions should be infused for 30 minutes.
- 39. Frequently symptomof underlying disease with excess bone resorption and release of calcium Hyperparathyroidism, malignant neoplastic disease, Paget’s disease, Osteoporosis, prolonged immobization, acidosis S&S: anorexia, nausea and vomiting, weakness, kidney stones Diagnosis Radiographs show bone resorbtion Cardiac irregularities Treatments include hydration with normal saline, bisphosphonates, calcitonin, glucocorticoids, and phosphate.
- 40. Normal conc.1.5 – 2.4 mg% Essential for proper functioning of enzyme systems Depletion characterised by neuromuscular & CNS hyperactivity.
- 41. HYPOMAGNESMIA Hypomagnesemiais greater than 1.8 mg/dL. Signs and symptoms include arrhythmias, prolonged PR and QT intervals on EKG, hyperreflexia, fasciculations, and Chvostek’s and Trousseau’s Trousseau’s signs.
- 42. HYPERMAGNESMIA Hypermagnesemiais serum mangensium greaterthan 2.3 mg/dL. Signs and symptoms includerespiratory depression, hypotension, cardiac arrest,nausea and vomiting, hyporeflexia, and somnolence. Treatment for hypermagnesemia may include calcium infusion, saline infusion with a loop diuretic,or dialysis.
- 43. Hypophosphatemia isserum phosphate less than 2.5 mg/dL; however, symptomatic hypophosphatemia usually is less than 1 mg/dL. Signs and symptoms of hypophosphatemia include lethargy, hypotension, irritability, cardiac arrhythmias, and skeletal demineralization. Treatment
- 44. Hyperphosphatemia isdefined as serum phosphate greater than 5 mg/dL. Pruritus is the only remarkable symptom of hyperphosphatemia. Treatment includes dietary phosphate restriction, phosphate binders (calcium acetate or carbonate), hydration (to promote excretion), or D50 and insulin to shift phophate into cells.
- 45. Ionic compositionvery different Total ionic concentration very similar Total osmotic concentrations virtually identical Osmolarity is identical in all body fluid compartments
- 46. Renal insufficiency,Chronic heart faliure Iatrogenic Cirrhosis Drugs – NSAIDS, Mineralocorticiods ECF is diluted – sodium content is normal but excess water is present called as Hypotonic Hydration The resulting hyponatremia promotes net osmosis into tissue cells, causing swelling. These events must be quickly reversed to prevent severe metabolic disturbances, particularly in neurons.
- 47. ECF Deficit CAUSES 1. Lossof GI fluids due to: a. Vomiting b. Diarrhea c. Nasogastric suction d. Fistular drainage 2. Soft tissue injuries and infections 3. Intraabdominal and Intraperitoneal inflammatory processes 4. Burns 5. Insensible losses 6. Sweat
- 48. Clinical Evaluation Changes inbody weight should be recorded accurately and repeatedly on a day to day basis…. Weight loss > 300 to 500gms per day indicate dehydration secondary to decreased fluid intake and / or increased water losses. Water loss Degree of Dehydration 4% of body wt Mild 6% “ “ Moderate 8% “ “ Severe
- 49. Principles of FluidTherapy Whenever fluid therapy is contemplated in a patient, the following basic questions must be considered…. 1. Does the patient need fluid..? 2. Which fluid would be most suitable..? 3. How much fluid is needed..? 4. At what rate..? 5. Which route is to be used..? 6. What are the likely complications..?
- 50. Crystalliod Colloid Intravascular persistancePoor Good Haemodynamic stabilisation Transient t1/2 ~ 30 mins Prolonged t1/2 ~ 90 mins Required infusion volume Large Ratio 3:1 to loss Moderate Ratio 1:1 to loss Risk of tissue oedema Obvious Insignificant Enhancement of capillary perfusion Poor Good Risk of anaphylaxis Nil Low to moderate Plasma colloid osmotic pressure Reduced Maintained Inexpensive Expensive
- 51. When blood lossis mild (less than 15% of blood volume), no volume resuscitation is necessary. With moderate to severe blood loss, the vascular space must be filled to support cardiac output. The only effective management of hypovolumia is volume resuscitation. CRYSTALLOIDS COLLOIDS
- 52. Colloids are largemolecules that do not diffuse across membranes readily. Colloids are efficient plasma expanders.
- 53. Disadvantages of Colloidaladministration It may result in hypotension secondary to decreased systemic vascular resistance. The administration of hetastarch and dextran in large volumes can result in dilutional coagulopathies. Hetastarch, when administered in greater than 1000 mL (in a 70-kg patient), can precipitate a decrease in factor VIII. Dextran can decrease platelet adhesiveness and may cause an anaphylactoid or anaphylactic reaction. In addition, dextran also facilitates the agglutination of red blood cells
- 56. Method for determiningresuscitation volume sequence 1. Estimate normal blood volume 2. Estimate percent loss of blood volume 3. Calculate volume deficit 4. Determine resuscitation volume The allowable blood loss should be calculated preoperatively for patients in whom severe bleeding may be expected. ABL= estimated blood volume X (Hi – Hf) Hi, Where estimated blood volume =weight (kg) X average blood volume, Hi = initial hematocrit, Hf = the final acceptable hematocrit.
- 58. AMERICAN RED CROSSGUIDELINES FOR BLOOD COMPONENTS ADMINSTRATION
- 59. TRANSFUSION REACTIONS Febrile Allergic Hemolytic COAGULATION DISORDERS Dilutionalthrombocytopenia Factors V and VIII deficency DIC METABOLIC ABNORMALITY Hyperkalemia Hypocalcemia Metabolic Alkalosis Hypothermia Acute lung injuery Microaggregates
- 61. Intraoperative blood salvageinvolves the collection, washing, and storage of red blood cells by a semiautomated system. The hematocrit of salvaged blood is between 50% and 60%, and the pH is alkaline. Contraindications to intraoperative blood salvage include blood- borne diseases, malignancy, and contamination. Hemodilution involves the removal of arterial or venous blood preoperatively, followed by plasma volume restoration with crystalloid or colloid fluids. The blood then is stored in the operating room and transfused to the patient after cessation of bleeding. This procedure may be used for surgeries in which intraoperative blood loss of 2 or more units is anticipated.
- 62. Blood Products donot increase blood flow adequately and in some cases impede flow as a result of incresed viscosity. Therefore crystalloid and colloids fluids should be the initial management strategy for volume resuscitation in acute hemorrhage. Favorable clinical response include the following points CPV =15 mm Hg PCWP =10-12mm Hg Adequate HR Cardiac index = 3L/min/m2 Urine output greater than = 1ml/kg/h
- 63. As innormal health - 0ral Route. -However when rapid correction of hypovolaemia and other electrolyte abnormalities indicated i.v. route provides a quick access to circulation. -Other routes of parenteral therapy include Subcutaneous Per Rectal
- 64. The goalof fluid management in major burn injuries is to maintain the tissue perfusion in the early phase of burn shock, in which hypovolemia finally occurs due to steady fluid extravasation from the intravascular compartment.
- 65. Burn injuriesof less than 20% are associated with minimal fluid shifts and can generally be resuscitated with oral hydration, except in cases of facial, hand and genital burns, as well as burns in children and the elderly. Current recommendations are to initiate formal intravascular fluid resuscitation when the surface area burned is greater than 20%.
- 66. The mostcommonly used formulas are the Parkland, Brooke, Evans and Monafo’s formulas.
- 67. Initial 24hours: Ringer’s lactated (RL) solution 4 ml/kg/% burn for adults and 3 ml/kg/% burn for children. ◦ 4 ml/kg/hour for children weighing 0–10 kg ◦ 40 ml/hour +2 ml/hour for children weighing 10–20 kg ◦ 60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higher This formula recommends no colloid in the initial 24 hours. Next 24 hours: Colloids given as 20–60% of calculated plasma volume. No crystalloids. Glucose in water is added in amounts required to maintain a urinary output of 0.5–1 ml/hour in adults and 1 ml/hour in children.
- 68. Initial 24hours: RL solution 1.5 ml/kg/% burn plus colloids 0.5 ml/kg/ % burn plus 2000 ml glucose in water Next 24 hours: RL 0.5 ml/kg/% burn, colloids 0.25 ml/kg/% burn and the same amount of glucose in water as in the first 24 hours Evans formula (1952) First 24 hours: Crystalloids 1 ml/kg/% burn plus colloids at 1 ml/kg/% burn plus 2000 ml glucose in water Next 24 hours: Crystalloids at 0.5 ml/kg/% burn, colloids at 0.5 ml/kg/% burn and the same amount of glucose in water as in the first 24 hours
- 69. Monafo formula Monaforecommends using a solution containing 250 mEq Na, 150 mEq lactate and 100 mEq Cl. The amount is adjusted according to the urine output. In the following 24 hours, the solution is titrated with 1/3 normal saline according to urinary output.
- 70. The idealburn resuscitation is the one that effectively restores plasma volume, with no adverse effects. Isotonic crystalloids, hypertonic solutions Colloids have been used for this purpose, but every solution has its advantages and disadvantages. None of them is ideal, and none is superior to any of the others.
- 76. In caseof Shock early diagnosis and aggressive treatment of all physiological derangements should be achieved to prevent irrevesible state. Surgical management and medical management of oral and maxillofacial surgery patients are both intertwined intimately . Oral and maxillofacial surgeons should have thorough understanding of the surgical and medical issues that face patients.
- 77. 1. Foncea textof maxillofacial trauma chapter Shock management. 2. Human Physiology – A. K. Jain 3. Human physiology – guyton and hall 4. Oral & MaxilloFacial Sugery Clinics of North America – HarryDym. 5. Fluid and electrolyte management and blood product usage. Helen G Clinics of north amercia 2006. 6. Fluid and electrolyte management in burns patient. Indian J Plast Surg. 2010 Sep
- 78.