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Lec 9 - electrolytes

Lec 9 - electrolytes

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Published by Eman Nazzal
Lec 9 - electrolytes
Lec 9 - electrolytes

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Published by: Eman Nazzal on May 06, 2013
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09/09/2014

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I.

V fluids
The I.V fluids are manly two types:
1-colloids: which are almost like plasma in composition. 2- crystalloids: which are only electrolytes. *and as a dentist you will use crystalloids, colloids are used in the hospitals more.

Crystalloids: A. lactated Ringer's solution:
compositionOne liter of lactated Ringer's solution contains: -130 mEq of sodium ion = 130 mmol/L -109 mEq of chloride ion = 109 mmol/L -28 mEq of lactate = 28 mmol/L -4 mEq of potassium ion = 4 mmol/L -3 mEq of calcium ion = 1.5 mmol/L -Lactated Ringers has an osmolarity of 273 mOsm/L the PH of Lactated Ringers in vitro ”outside the body” is acidic, but in vivo “inside the body” the lactate will be converted to bicarbonate which is an alkaline, the Lactated Ringers is important to maintain the PH of the blood (7.35-7.45), the blood is very sensitive for PH, that even a small increasing or decreasing in the PH level may be fatal (e.g. if the PH is 7.1 it is considered a sever acidosis and the patent may die). *What’s Osmolality? Term refers to the solute concentration in the body fluid by weight, the number of milliosmols (mOsm) in a kilogram (kg) of solution, in humans normally the osmolality in plasma is about 275-295 mOsm/Kg , 90% of the osmolality depends on Na , and the other 10% depends on proteins and sugar.

B. Normal saline:

Simply salt water that contains only water, sodium and chloride, it is widely used, it is called normal saline because it has the same osmolality of the plasma which is about (275-295 mOsm/Kg). In the normal saline every one bag contains 1000ml, the sodium concentration is 0.9% which = (154 mEq/1000ml) ,and the same amount of chloride 0.9% (154 mEq/1000ml) the sum of (Na +

Cl¯= 308 mEq/1000ml) and it’s almost the same the concentration of sodium and chloride in the plasma.

C. glucose solution (5% , 15% , 50%).
we have different concentration of glucose solutions , and you give the concentration according to the needs of the body . e.g 50% glucose solution it contains 500 gm of glucose , and every 1 gm of glucose gives you 4 calories (500 ×4 = 2000 calories) and the daily need of calories 1800 calories

*Why we have to use fluids?? 1. Maintenance: replaces normal ongoing losses 2. Fluid Resuscitation: corrects any existing water and electrolyte deficits. We measure the amount of fluids we need according to the body weight , for adults you need (30-50)ml\Kg \24H , for children for the first 10 kg 100ml\Kg\24h , for the second 10 kg you need 50ml\Kg\24h and for more than 20 kg 25ml\kg\24h * If the patient have renal or heart disease (old age) you give him the minimum amount “ia. 30 ml\Kg \24H “to avoid over loading on the heart or kidney  , but if the patient is young and healthy you may use 50 ml\Kg \24H and his body can tolerate this amount of fluids e.g muad al zoubi. For the quantity You replace the same amount that the patient has lost , and about the quality it’s according to other electrolytes mainly sodium Na How much sodium & potassium do your body need per day ? (2 mEq\kg\24h) and you need half the amount of potassium (1 mEq\kg\24h) e.g if you have a 70 kg healthy patient how much electrolytes and how much liters do you give him/her ? *(30-50)ml\Kg \24H  70 ×45 = 3.0 L \24h *(2 mEq\kg\24h)  70×2 = 140 mEq\24h sodium , and 70 ×1 = 70 mEq\24h potassium so the patient need 3L of fluids and 140 mEq Na daily , and as you know 1L of normal saline or lactated Ringer's contains (154 mEq) sodium, so you give the patient 1L of normal saline or lactated Ringer's and the other 2L you give the patient electrolytes-free solution (e.g distilled water 5% sugar and it’s only for quantity replacement . ) How can we calculate the daily deficit of fluids?

By recognizing the level of dehydration “from signs and symptoms “and we have three levels of dehydration: 1- Grade I (mild): -The loss is about 4% of the body fluids, it’s only have clinical symptoms and there are no signs. e.g people who are fasting , anorexia “loss of appetite” , vomiting , diarrhea those are symptoms but if we examine the patient you will find nothing ! 2- Grade II (moderate):- The loss is about 8% of the body fluids, it have all symptoms of the first grade and only one sign which is postural tachycardia (will increase 15 beats per minute) and postural hypotension (if the patient is Laing and you measure the blood pressure is normal but if the patient stands up the pressure will decrease 10mmHG. 3- Grade III (sever) :- The loss is about 10% or more of the body fluids, it has symptoms and many signs, the first sign is true hypotension and tachycardia and the next system will be affected is the brain because it’s sensitive to hypoxia, the patient will start to sleep stoppers (when you leave him he’ll fall in sleep, but once you awake him he’ll wake up), but if the hypoxia is so sever the patient may go into coma, then the kidney start to be affected, decreased urine volume, abnormally dark urine, *60% of the body mass is fluid. So to calculate how much fluid the patient needs, you have to multiply his weight by 60% by the percentage of loss of fluid “B.W×60%×degree of dehydration”(e.g.: 70 Kg patient with a moderate dehydration??  He’ll need 70 × 0.6× 0.08 = 3.36 L) *so we should replace the fluid quality and quantity, the quantity as calculated above, and the quality is according to what the patient has lost, in most of the patient the loss is isotonic (the same as the plasma) so we replace is by isotonic solution, but if you want to be more precise, you have to do serum electrolytes test and calculate the amount of electrolytes (sodium) you need to add.

When it consider a solution isotonic?!

When the concentration of the particles (solutes) is similar to that of plasma so it doesn't move into cell and remain within the extra cellular compartment thus increasing intravascular volume. But if you want to be more precious you have to do (serum electrolytes) to know the level of the sodium if it is: 1. Hypernatremia 2. Hyponatremia according that we can replace the Fluid. *Important thing: Don’t give more fluid in a critical patient such as children and old patient, because the heart couldn't call with more fluid and may end with heart failure and may die Therefore in children we have a special infusion set it’s called (micro dropper) usually contain only 100 cc = 60 drop/ml. To calculate easily how much we have given to the patient DON’T GIVE CHILDREN IN NORMAL INFUSION SET ALSO DRUGES

What is the complication in the fluid therapy? 1. over load. 2. Underestimation of the fluid amount. The worst is the overload, you give the patient over load, the heart should load it sometime cause a heart failure. 3. Infection: should give under a sterile condition, otherwise easily contaminate the fluid and the patient may develop sepsis or septicemia. 4. Thrombophlebitis: is phlebitis (vein inflammation) related to a thrombus (blood clot) so you have to insert the kit in a central vein rather than peripheral vein. When it occurs repeatedly in different locations, it is known as "Thrombophlebitis migrans" or "migrating thrombophlebitis especially when we give a hypertonic solution. 5. Cellulitis is a localized or diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or

by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, intravenous drug injection or sites of intravenous catheter insertion 6. Air embolism: we have to fill the infusion set before hanging it into the needle. . These are the serious complication of low therapy.

Sorry for being late it was the most difficult script I have ever done in my life no slides, bad record and the doctor was talking in Arabic ……… Finally done …..  Done by: Abdallah zireeni Special thanks to: Heba Radaideh Mohammad Elwir Ammar Aldawoodyeh

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