Fluids & Electrolytes

James Nixon, MD
Assistant Professor
Internal Medicine/Pediatrics
 Goals

• Dehydration
• IV Fluids
• Sodium
• Potassium
• Calcium
• Magnesium
 Case #1:
HPI
• 25 yo female comes in to ER with 5 day
history of watery diarrhea and vomiting.
• Not able to keep anything down.
• For the last day feels dizzy when gets up.
• Roommate in Law School has similar sx.
• Otherwise healthy.
 Case #1
Exam
• Vital Signs
– Supine tachycardia or hypotension
• Orthostatic BP/P changes
– P increase > 30/min SBP drop of >20 mm Hg
• Wait 2 minutes before check BP/P after lying
• Wait 1 minute before check BP/P after standing
– Sitting not as good as standing
– Normovolemic P +10.9, SBP – 3.5, DBP +5.2
 Case #1
Exam
• Capillary Refill
– Compress distal phalanx of middle finger,
positioned level with heart, for 5 seconds and
then time the return of normal color to finger
– Normal
• 2 seconds men
• 3 seconds women
• 4 seconds elderly
 Case #1
Exam
• Skin Turgor
• Dry mucous membranes
• Sunken eyes
• Tongue furrows
Percent Dehydration Clinical Symptom

• Rapid heart rate • Concentration of urine

<5%
• Dry mucous • Poor tear production*
membranes
• Increased severity • Sunken eyeballs
5-8% • Decreased skin turgor • Oliguria

• Pronounced severity • Delayed capillary

of above signs refill
• Supine Hypotension • Acidosis (large base
>9% deficit)
 Volume Depletion

• Refers to loss of sodium from the extracellular

space
– Interstitial fluid
– Intravascular fluid
• Examples
– GI Hemorrhage
– Vomiting
– Diarrhea
– Diuretics
 Dehydration

• Elevated plasma sodium concentration and

osmolality with loss of intracellular water
causing cellular dessication.
• Example
– Elderly with fluid losses in heat and poor
access to water
 Hypovolemia / Dehydration

• Practically used interchangeably

 Our Patient’s Exam

• BP 122/60 P 100 supine afeb Resp 16

• Looks tired, but not in distress
• BP 108/52 P131 standing
• MM dry
• Well perfused
• Lung, Heart, Abd, Ext -Nl
Percent Dehydration Clinical Symptom

• Rapid heart rate • Concentration of urine

<5%
• Dry mucous • Poor tear production*
membranes
• Increased severity • Sunken eyeballs

5-8% • Decreased skin turgor • Oliguria

• Pronounced severity • Delayed capillary

of above signs refill
• Supine Hypotension •
>9% Acidosis (large base
deficit)
 What Next?

• Labs
– Electrolytes
– BUN/Cre
• Anything else?
 Fluid Bolus

• How Much?
– 10-20 cc/kg
– 500cc-1000cc
• How Fast?
– Healthy vs Premorbid Illness
• Of What?
 Fluids For Bolus

• Crystalloid • Colloid
– D5W – Whole
– ½ NS Blood/PRBC
– NS – Plasma
– Albumin
– Synthetic
(Hetastarch)
 1% LBM

Plasma=
6% LBM
4.2L

Average
70 Kg Male
with 10-15% Interstitial Fluid= 19% LBM
body fat 14L
0.6 X 70 Kg=
42L TBW Intracellular Fluid=
45% LBM
31L

Non-Aqueous Tissue=29% LBM

 E
x
t
Plasma 6% r
a
c
Interstitial e
l
Fluid l
u
19% l
a
r
I
n
t
r
1000 cc D5W ICF a
c
45% e
l
l
u
l
a
Non- r

Aqueous
29%
 E
x
t
80cc Plasma 8% r
a
c
Interstitial e
l
270cc Fluid l
u
27% l
a
r
I
n
t
650cc ICF
r
1000 cc D5W a
c
65% e
l
l
u
l
a
r
 E
x
t
Plasma 8% r
a
c
Interstitial e
l
Fluid l
u
27% l
a
r
I
n
t
r
1000 cc NS ICF a
c
65% e
l
l
u
l
a
Non- r

Aqueous
29%
 E
x
t
230cc Plasma 23% r
a
c
Interstitial e
l
770cc Fluid l
u
77% l
a
r
I
n
t
r
1000 cc NS a
c
e
l
l
u
l
a
r
 E
x
t
Plasma 6% r
a
c
Interstitial e
l
Fluid l
u
19% l
a
r
I
n
t
r
1000 cc PRBC ICF a
c
45% e
l
l
u
l
a
Non- r

Aqueous
29%
 E
x
1000cc Plasma 6% t
r
a
c
Interstitial e
l
Fluid l
u
19% l
a
r
I
n
t
r
1000 cc PRBC ICF a
c
45% e
l
l
u
l
a
Non- r

Aqueous
29%
 Fluids For Bolus

• Crystalloid • Colloid
– Cheap – Expensive
– Infuse rapidly – Risk of infection
 Maintenance IV Fluids

• Who Needs Them?

• What’s Maintenance?
– How Much H20?
• 100 cc/kg/d 1st 10 Kg
• 50 cc/kg/d 2nd 10 Kg
• 20 cc/kg/d for every Kg > 20 Kg
– Na?
– K?
– Dextrose?
 Maintenance IV Fluids

• 70 Kg person
– 1000cc + 500cc + 1000cc = 2500cc=105cc/hr
– Na 140-280 meq/d = 200 meq/2.5L = 80meq/L
• 1/2NS =77 meq/L
– KCl 70 meq/d = 70 meq/2.5L = 28meq/L
• + 20 meq KCl/L
– D5 1/2NS + 20 meq KCL/L @ 105 cc/hr
 Our Patient

• Maintenance + Replacement
 Labs

124 104 42 97
4.2 12 1.4
Hyponatremia
 Osmolality

• Measured Osmolality
• Osmolality= 2 (Na) + Glu/18 + Bun/2.8
• Osmolal gap
• Our Patient 124 104 42
97
– 269 measured 4.2 12 1.4
– 268 calculated
 Hyponatremia

Serum
%serum H20=Na decrease by 1.6
99-1.03(lipids g/L)meq
-.73for every
(prot g/dl)
100mg/dl increase in Glucose
Corrected Na = measured Na X 93/% serum H20
 Urine Sodium

• UNa
• FENa = (UNa x PCr) / (PNa x UCr) x 100
• Our Patient
– UNa =2.4
– FENa =0.4
Hyponatremia
 Our Patient

• Given 1000cc Bolus NS

• Followed by 500cc Bolus NS
• NS @ 150 cc/hr x 6 hours
• Na 130
• 1/2NS 150 cc/hr
• Next AM 135 felt great went home
Hyposmotic Hyponatremia
 Severe Hyponatremia

• Symptoms
– Confusion, coma, seizure
• Treatment
– NS or 3% Saline
– Give enough over 8-12 hours to increase Na by
10meq (do not exceed 1-2 mmol/hr Na increase)
• (0.6 X Wt (Kg) X 10 meq)
– NEVER GIVE 3% SALINE RAPIDLY
• Central Pontine Myelinolysis
 Hypernatremia

• Much less common

• Generally means lack of access to water
• Always hyperosmolar
• Free Water Deficit (L)
=0.6 X Wt (Kg) X (Naserum –145)/145
Hypernatremia
 Hypernatremia:
Treatment

• Replace Free Water Deficit over 1-2 days

– Decrease serum Na at rate of 0.5 meq/hr
– (not too fast or cerebral edema)
• If hypovolemic NS first to replenish volume
• Then use hypotonic fluids for FWD
• Free Water Deficit (L)
=0.6 X Wt (Kg) X (Naserum –145)/145
 Hyperkalemia

• Fairly Common
• Recheck to verify not hemolysis
• Check EKG
 Hyperkalemia:
Causes

• Decreased excretion
– Drugs, renal failure, hypoaldosteronism
• Increased production
– Trauma, tumor lysis
• Volume contraction
• Hypertonic states
• Acidosis
 Peaked T wave
Hyperkalemia
 Hyperkalemia
Wide QRS
 Hyperkalemia:
Treatment

• Calcium Gluconate
• Insulin/D50
• NaHC03
• Kayexalate
• Albuterol Nebs
 Hyperkalemia
After CaGluc, NaHCO3, Insulin/D50
 Hypokalemia

• Usually asymptomatic
• Symptoms usually secondary to whatever
causing the hypokalemia
 Hypokalemia

Hypertension and Hypokalemia: Think Hyperaldosteronism

Hypokalemia
 Hypokalemia:
Treatment
• Potassium
• Treat Cause
Calcium
 Hypercalcemia:
Symptoms

• Muscular weakness
• Fatigue
• Lethargy
 Hypercalcemia:
Treatment

• Fluids
• Lasix
 Hypocalcemia
Symptoms

• Neuromuscular irritability
– Chvostek’s/Trousseau’s
• Laryngospasm
• Diarrhea, increased peristalsis
• Dysrhythmia, palpitations, hypotension
For each
albumin
decrease of 1,
Ca decrease by
0.7
 Hypocalcemia:
Treatment
• Calcium
• Treat Cause
 Magnesium

• Hypermagnesemia: Rare
– Mg antacids/laxative in renal failure patients
– Sx nausea, weakness, loss of DTR, sedation,
death secondary to paralyses heart/resp muscles
– Trx Volume/Ca
 Magnesium

• Hypomagnesemia: Common
• Sx cardiac arrhythmias, low K, Low Ca
• Causes
– Diuretics, etoh withdrawal, insulin, hungry
bone syndrome
• Treatment
– Magnesium