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BALANCE
MODERATOR
Dr. ALOK
BHATNAGAR
( READER )
Balance
CONTENTS
INTRODUCTION
REGULATION OF BODY FLUIDS
COMMON DISTURBANCES IN ELECTROLYTES BALANCE
ACID BASE REGULATORS
CAUSES OF FLUID VOLUME DEFICETS
PATHOPHYSIOLOGY OF FLUID VOLUME DEFICITS
PATHOPHYSIOLOGY OF FLUID VOLUME OVERLOAD
PRINCIPLE OF FLUID THERAPY
CLASSIFICATION OF IV FLUIDS
METHODS OF DELIVERING IV FLUIDS
CALCULATION FOR ROUTINE IV SET
FLUID THERAPY IN SURGICAL PATIENTS
CONCLUSION
REFERENCES
BODY FLUIDS
Composed of water and
dissolved substances (solute)
WATER
- transport & exchange of
nutrients & metabolic wastes
- medium for metabolic
reactions within cells
- constitutes about 60% of the
total body weight.
Provides structural
form
shock absorber
Provides insulation
Lubricant
regulating body
temperature through
Evaporation and
Persipiration
Body weight
varies:
Age, gender, amount of body fat
- Normal Value of
osmolality in ICF and ECF
ranges between 275-295
mOsm/kg.
- Osmolality of ECF
depends on the value of
sodium (NA+)
concentration.
1. OSMOSIS
Movement of water across
selectively semi permeable
membrane from an area of lower
solute concentration to an area
of higher solute concentration.
Osmosis continues until the
solute concentration on both
sides of the membrane is equal.
a. Osmotic Pressure the
power of a solution to draw water
across membrane.
Ex. Fluids in IVS & Interstitial
space is essentially same
except for the higher
concentration albumin in plasma.
This exert osmotic pressure,
pulling fluid from the Interstitial
space towards the IVS, to hold
water inside vascular system.
Types of Tonicity
A. Isotonic solution
21
ISOTONIC SOLUTIONS
0.9% Sodium
Chloride Solution
Ringers Solution
Lactated Ringers
Solution
HYPERTONIC SOLUTIONS
3% SODIUM CHLORIDE
5% SODIUM CHLORIDE
WHOLE BLOOD
ALBUMIN
CONCENTRATED
DEXTROSE (>10%)
24
solute
concentration than in plasma. When red
blood cells are
placed in a hypotonic solution,
water moves into the cells, causing them to swell
and rupture (hemolyze).
Ex. 0.45% sodium chloride has a lower
concentration of solute than plasma.
HYPOTONIC SOLUTIONS
5%DEXTROSE &
WATER
0.45% SODIUM
CHLORIDE
0.33% SODIUM
CHLORIDE
26
2. Diffusion
The process by which solute molecules
move from area of high
solute
concentration to an area of low solute
concentration to become evenly distributed.
Hydrostatic Pressure
(arterial blood
pressure)
Direction of fluid
And solute movement
Osmotic Pressure
(colloid osmotic
pressure)
Interstitial
Space
Direction of fluid
And solute
movement
Active Transport
Interstitial
fluid
Na+
Na+
Na+
K+
Na+
Na+
Na+ Na+
K+
K+
Na+
K+
Na+
K+
Na+
Na+
K+
K+
K+
Na+
Na+
K+
K+
K+
Na
+
Intracellular fluid
1. Thirst Mechanism
2. Renin-Angiotensin-Aldosterone
Systemit works to maintain intravascular fluid balance
and blood pressure.
Renal Perfusion
Renin produced
Angiotensinogen converted to
Angiotensin I
Angiotensin I
Converted to
Angiotensin II
In the lungs
Secretion of
Aldosterone in the
Adrenal cortex
Absorption of
Na+
Absorption of
H2O
Excretion of K+
Excretion of H+
ions
KIDNEYS
- Are primary responsible for regulating fluid
volume and electrolyte balance in volume and
osmolality of body fluids by controlling the
excretion of water and electrolytes.
- About 99% glomerular filtrate is reabsorbed,
and only about 1500 ml of urine is produced over
a 24-hour period.
4. ANTIDIURETIC HORMONE
Blood pressure
Blood urine
Blood osmolality
Osmo receptors in
Hypothalamus stimulate
Posterior pituitary to
secrete ADH
Urine output
Blood pressure
Blood volume
Blood osmolality
ANF affects several body systems: the cardiovascular, renal, neural, gastrointestinal, and
endocrine systems., but mainly the renin-agiotensinaldosterone system.
DIAGNOSIS
LOSS
Total intake > total output; reflects
massive leak of fluid;
IMPORTANT: replace lost proteins by
giving albumin or plasmanate
(Plasmanate contains 5 g selected
plasma proteins buffered with sodium
carbonate)
In managing colloid replacement, give
diuretic to pull tissue fluid into vascular
space for renal excretion
Second phase:
Reabsorption
After healing, fluid in tissues begin to be
reabsorbed back into vascular area
Recognized by increased urine output
Limit amount of external replacement
May see weight loss
Watch for circulatory overload
Rale (an abnormal rattling sound heard
when examining unhealthy lungs with a
stethoscope
Shortness of breath
Distended neck veins
A)Fluid losses
Vomiting
diarrhea
intestinal fistulas
Burns
b. failure of
regulatory
mechanism kidney
disorders, endocrine
disorders
c. excessive exercise
or increased
environment
temperature causing
excess sweating.
d. hemorrhage (loss
of blood)
e. chronic abuse of
laxatives and/or
enemas
drugs ex. Diuretics
Causes
Inadequate intake
lack of fluids
Inability to
swallow fluidsdue to oral
trauma
Altered thirst
mechanism
(severe
Altered
mental
status is
most
evident
to
patient
with
water
and
sodium
imbalanc
e
Diagnostic Tests
1. Serum electrolytes In an
isotonic fluid deficit, sodium
levels are within normal
limits; when the loss is water
only, sodium levels are high
K+ are common.
2. Serum osmolality
Differentiates isotonic fluid
loss from water loss. With
water loss, osmolality is
high; it may be within
normal limits with an
isotonic fluid loss.
3. Serum hematocrit- The
hematocrit often is elevated
due to loss of intravascular
fluid
Manageme
nt:and output
Assess intake
Administer
intravenous fluid.
Monitor for
indicators of fluid
overload.
Monitor laboratory
values.
Replacement of
electrolytes
through
intravenous, oral
routes etc.
Home Care:
a.
Manifestations
:
1. Increase in total body water causes
weight gain (more than 5% of body weight)
over a short period.
2. Circulatory overload causes
manifestations such as:- Full, bounding pulse(pounding or racing)
- Distended neck and peripheral veins
venous pressure
- Cough, Dyspnea (labored or difficult
breathing)
orthopnea (difficulty in breathing
when in supine).
Diagnostic Tests:
Management
Semi 30-45degree) to
high-fowlers ( 60 degree) position for
dyspniec patient.
ELECTROLYTE
BALANCE
Are substances
that dissociate in solution
ELECTROLYTES
to form charged particles called ion.
Cations are positively charged ions.
Anions are negatively charged electrolytes.
Example:
(NaCl) in solution dissociates into :
a sodium ion, a cation carrying a
positive charge (Na+)
Functions of Electrolytes:
Assist in regulating
water balance.
Help regulate and
maintain acid-base
balance
Contribute to
enzymatic reactions.
Are essential for
carrying out
neuromuscular activity.
VALUES
mEq/L and mg/dL:
Note: Concentration of electrolytes in body fluids
Sodium
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
Hyponatremia
(Na < 135mEq/L)
Occurs with net loss of sodium or net water
excess
Kidney disease with salt wasting, adrenal
insufficiency, GI losses, increased
sweating,
diuretics.
S&S: Altered mental status, postural
hypotension, postural dizziness, abdomen
cramping, diarrhoea, tachycardia,
convulsions and coma
Treatment
Determine if hyponatremia
Acute
Chronic
Acute serum sodium
<110-115mEq/Lt
Symptomatic - Seizures
Coma
Rapid correction
Till serum sodium 120125mEq/Lt
If it is asymptomatic
gradual correction over 48
hrs
Hypernatremia
(Na > 145mEq/L)
Caused by
- Increased water
loss
- Water deprivation
- Excess salt intake
- Hypertonic
solutions
- Excess
aldosterone
- Diabetes
Insipidus
Correction of
Hypernatremia
Treat the underlying
cause
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
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
Potassium
Major cation in 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 3.5-5.0mEq/L
Body conserves potassium poorly
Increased urine output decreases serum K +
- For every 3 k+ ions going out 2 Na+ ions and 1 H+
enter the cell resulting in intracellular acidosis and
extracellular alkalosis
Potassium Balance
Treatment
Correction of alkalosis/acidosis, Volume deficits
1. Other electrolyte disturbances.
2. Replace GI fluids upto upper limits of loss if person has
normal
renal function.
4. Oral supplements : Increased intake of fresh fruits and
vegetables
or potassium supplements of 20 to 40mmol daily.
5.
Remember
Cardiac
1.
2.
3.
4.
5.
6.
7.
Peaked T wave
QRS widening.
ST depression
Bradycardia
Heart block
Asystole
Ventricular fibrillation
Neuromuscular
1.
2.
Weakness
Paresthesia
Respiratory Faliure
Diagnosis
ECG changes
Serum potassium level
ECG Feature
Hypokalaemia
Hyperkalaemia
P wave
Normal / amplitude
QRS interval
QT interval
Normal
T wave
flat or inverted
/ absent
MANAGEMENT OF SEVERE
ACUTE HYPERKALAEMIA (K+ >
7mmol/L)
Identify and treat 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 23min
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.
Calcium
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
- hypoalbuminemia,
hypoparathyroidism
- Vitamin D deficiency,
Pancreatitis, Alkalosis
- Massive blood transfusion with
citrate
S&S: numbness and tingling, hyperactive
reflexes,
Chloride Balance
Major anion in ECF
Normal level 95-108mEq/L
Follows sodium
Regulated by dietary intake and the kidneys
Disturbance usually seen with acid-base imbalance
Hyperchloremia (Na >145, Bicarb <22)
Serum bicarbonate values fall or sodium rises
Hypochloremia (pH > 7.45)
Excess vomiting or N/G drainage; loop diuretics
because of sodium excretion
Leads to metabolic alkalosis due to
reabsorption of bicarbonate to maintain
electrical neutrality .
Magnesium Balance
Normal conc. 1.5 2.4 mg%
Essential for proper functioning of enzyme systems
Depletion characterised by neuromuscular & CNS
hyperactivity.
Mg+2
Chvostek & Trousseau sign
PR & QT interval
Treatment
if < 1.5mg% = 1 mEq/ Kg
if 1.5 1.8mg% = o.5mEq/ kg
Mg+2
Respiratory Depression
BP, Cardiac arrest, Hyporeflexia
Treatment
-Calcium Infusion
-Loop diuretics with NS
-MgCl2 / MgSo4
Solute Overview
Intracellular v/s Extracellular
Ionic composition very different
Total ionic concentration very similar
Total osmotic concentrations virtually
identical
Osmolarity is identical in all body fluid
compartments
Disturbances of
- Volume
- Concentration
- Composition
ECF EXCESS
Renal insufficiency, Chronic heart faliure
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.
ECF osmotic
pressure falls
ECF Deficit
CAUSES
1. Loss of GI fluids due to:
a. Vomiting
b. Diarrhea
c. Nasogastric suction
d. Fistular drainage
2. Soft tissue injuries and infections
3. Intra-abdominal and Intra-peritoneal
inflammatory
processes
4. Burns
5. Insensible losses
6. Sweat
Dehydration
1 Excessive loss of H2O from
ECF
ECF osmotic
pressure rises
ECF Deficit : When salt depletion is greater, fluid loss is borne by ECF
Lab Test: Hematocrit value of 45% indicates an ECF deficit.
ICF Deficit : When water depletion is predominant, the greatest fluid loss
is sustained by the intracellular compartment
Lab Test :The sodium concentration is an indirect measure of the
fluid.
Higher sodium value indicates an ICF Deficit
Clinical Evaluation
Changes in body 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
Diuretics
Metabolic alkalosis, hyperkalemia, hypokalemia
Steroids
Metabolic alkalosis
Potassium supplements
GI disturbances
Respiratory center depressants (narcotic analgesics)
Respiratory acidosis
Antibiotics
Nephrotoxicity, hyperkalemia, hypernatremia
Calcium carbonate
Metabolic alkalosis
Magnesium hydroxide (Milk of Mag)
hypokalemia
Diagnostics
Hematocrit
If no anemia, can indicate hydration status
Blood creatinine
Measure kidney function
Excreted at constant level if no kidney disease
BUN
Indicates kidney function
May be affected by cell destruction or steroid therapy
Decrease may indicate malnutrition or hepatic
damage
Increases with decrease in ECF volume
Serum and urinary electrolyte levels
Urine specific gravity
Assessment of Intravascular
Depletion
5%
10%
tachycardia, oliguria,
UO 0.5-1 ml/kg/hr
Crystalloids:
- contain Na as the main osmotically active particle
- useful for volume expansion (mainly interstitial
space)
- for maintenance infusion
- correction of electrolyte abnormality
Crystalloids
Isotonic crystalloids
- Lactated Ringers, 0.9% NaCl
- only 25% remain
intravascularly
Hypotonic solutions
- 0.45% NaCl
- less than 10% remain intravascularly, inadequate for fluid
resuscitation
Colloid Solutions
Contain high molecular weight
substances do not readily migrate
across
capillary walls
Preparations
- Albumin: 5%, 25%
- Dextran
Colloid
Intravascular persistance
Poor
Good
Haemodynamic stabilisation
Transient
t1/2 ~ 30 mins
Prolonged
t1/2 ~ 90 mins
Large
Ratio 4:1 to loss
Moderate
Ratio 2:1 to loss
Obvious
Insignificant
Poor
Good
Risk of anaphylaxis
Nil
Low to moderate
Reduced
Maintained
Inexpensive
Expensive
Cost
Dextrose 5% in Water
Colloid Solutions
Human Plasma
- Used for resuscitation of shock patient and for
maintenance of I.V. fluid therapy
- It has a composition and osmolality similar to ECF.
Human Albumin
- 20% purified human albumin is commercially available. Its
volume
expansion capacity is 400 per cent.
- Rarely, anaphylactoid reaction has been reported with
albumin and
may cause post resuscitation hypotension.
Dextran
Its a polysaccharide in 0.9% NaCl / 5%
Dextrose
Two types
40 lasts for 6 hrs
70 lasts for 24 hrs
Facilitates agglutination of RBC. Thus
interferes with susequent cross matching of
blood
0 24 hrs.
Increased secretion of aldosterone & ADH
Na+ & water retention
If blood loss is there, replace it
Replace NPO fluid deficit
DNS or RL
Should not administer K+ unless definitive
deficiency present
24 48 hrs
Replace insensible losses which may vary
from
900 1500 ml/ hr because of
- Hyper Ventilation
- Fever
- Tracheostomy upto 1200 ml/ day
Loss replaced by DNS since kidneys conserve
Na+ even at this stage .
If N-G aspiration is going on then add 1 Lt. of
0.9 NaCl
48 72 hrs.
Replace insensible losses
Better to give isotonic DNS & RL
1 Lt Darrows solution to combat K+ loss. This is
more important if N-G aspiration is still going on
to cover K+ loss via GI secretions
Importance of I/O charts
Output = urine + vomitus + aspiration
Total this has to
+ 1000 ml insensible losses be replaced
+ 500 1000 ml sweating loss
Blood Replacements
Blood weightage males 66 ml / kg
- females 60 ml / kg
Indications
1. If Hb. < 6 gm%
2. Ongoing fluid loss of 100 ml/ hr
3. Severe Haemorrhage
4. Give early in active bleeding
Hemodilution
Indicated in surgeries where intra op. blood loss of 2 or
more units is anticipated.
Removal of arterial/ venous blood pre op. followed by
plasma volume restoration with crystalloids/ colloids
Blood reinfused only after cessation of bleeding
Conclusion
Surgical management & medical
management of oral and maxillofacial surgery
patients are intertwined intimately.
The management of fluids & electrolytes &
the usage of blood products are governed by
basic principles outlined in this seminar.
A favourable surgical outcome is predicated
on optimal comprehensive care.
Assessment of intravascular
depletion
5% Deficit thirst, dry mucous membranes,
UO 1-2 ml/kg/hr
10%
tachycardia, oliguria,
UO 0.5-1 ml/kg/hr
Minimal trauma
Moderate trauma
Severe trauma
1o
Maintainance of fluids
Holiday Segar formula:
4ml/kg for 1st 10kg body wt.[wt.X4ml/hr]
2ml/kg for the next 10kg body
wt[40+2Xwtml/hr]
1ml/kg of body wt over20kg [60+1Xwt ml/hr]
4/2/1 Rule
4 ml/kg/hr for first 10 kg (=40ml/hr)
then 2 ml/kg/hr for next 10 kg (=20ml/hr)
then 1 ml/kg/hr for any kgs over that
This always gives 60ml/hr for first 20 kg
then you add 1 ml/kg/hr for each kg over 20 kg
Maintenance of
fluids
For the first 0 to 10 kg give 100
ml/kg/day
For the next 10 to 20 kg give an
additional 50ml/kg/day
For weight > 20 kg give 20 ml/kg/day.
+
Maintenance Requirement for the period of
surgery :
= duration of surgery in hours X 2 ml/kg
+
Correction of operative loss
REFERENCES :
REFERENCES :
Fluid And Electrolytes Physiology Alan .D .Kaye &W. Grogono
Fluid And Electrolytes & Shock Richard Mullins
Text Book Of Physiology Sherwood
Guidelines On Fluid Balance Dr .
Sanjay Pandey
Disorders Of Fluid & Electrolute
Balance Glen Matfin & Carol Porth
THE END
Thank you