Fluid and Electrolyte Physiology

Dr. Raymon Grogan 11/6/06

Total Body Fluid by Compartment

Total Body Water

Electrolyte Composition of Body Fluid Compartments

Composition of Parenteral Fluids (mEq/L)

Fluid
ECF LR .9% NaCl .45% NaCl .2% NaCl 3% NaCl 5% NaCl 5% Albumin

Na+
142 130 154 77 30 513 855 145

K+
4 4

Ca2+ ClCl5 2.7 103 109 154 77 30 513 855

HCO3- pH HCO327 28 7.4 6.5 4.5 4.5 4.5 4.5 4.5 7.4

Composition of GI Fluids (mEq/L)

Source Saliva Gastric Panc Bile SB LB Sweat Daily Loss Na+ 1000 30-80 30K+ 20 15 5-10 5-10 20 30 5-10 ClCl70 100 60-90 60100 100 30 40-60 40HCO3HCO330 0 40-100 4040 25-50 250 0

1000-2000 60-80 1000601000 1000 2000-5000 2000200-1500 200200-1000 200140 140 140 75 20-70 20-

Hyponatremia
 Defined

as serum [Na+] less than 136

mEq/L  Water shifts into cells causing cerebral edema  125 mEq/L nausea and malaise  120 mEq/L headache, lethargy, obtundation  115 mEq/L seizure and coma

Hyponatremia
  

1. Assess plasma osmolality 2. Assess volume status of patient



Hypervolemic, Euvolemic, Hypovolemic Needed for definitive diagnosis, not needed for treatment purposes 0.6 x weight (kg) x (130 plasma [Na+])

3. Assess Urine Sodium Concentration



 

4. Calculate Na+ Deficit



5. Correct at no more than 0.5mEq/L per hour or 12 mEq/L per 24 hours

Isosmotic and Hyperosmotic Hyponatremia

 

Iso and Hyperosmotic hyponatremia are due to excessive solutes in plasma. Isosmotic
Pseudohyponatremia No treatment necessary
 

Hyperlipidemia Hyperproteinemia Glycine Mannitol

Isotonic Infusions
 

Hyperosmotic Treat underlying cause

Hyperglycemia


Each 100 mg/dl of glucose reduces [Na+] by 1.6 mEq/l Glycerol Mannitol Glycine

Hypertonic Infusions
  

Hyposmotic Hyponatremia
 1.


Assess volume status

Hypervolemic cirrhosis, heart failure, nephrotic syndrome Euvolemic polydipsia, SIADH Hypovolemic most common cause
Excessive renal (diuretic) or GI (emesis, diarrhea) losses

 

Treatment of Hyponatremia
 Iso


or Hyperosmotic

Correct underlying disorder Iso or hypervolemic fluid restriction Hypovolemic

Asymptomatic fluid resuscitate with isotonic saline Symptomatic or plasma [Na+] less than 110 mEq/L
 

 Hyposmotic
 

Calculate Na+ deficit Correct at a rate no greater than 0.5 mEq/L/hour or 12 mEq/L/day

Correction of Sodium Deficit

Example: A 60 kg woman with a plasma sodium concentration of 120mEq/L: Sodium deficit = TBW x (130 [Na+]p) Sodium deficit = 0.5 x 60 x (130-120) = 300mEq (1303% NaCl contains 513 mEq sodium/L Volume of 3% NaCl needed = 300/513 = 585 mL At 0.5 mEq/L/hr a correction of 10 mEq should be done over 20 hours So, 585 mL/20 hours = 29 mL/hour of 3% NaCl

Hypernatremia
 Defined

as serum [Na+] greater than 146

mEq/L  Lethargy, weakness, and irritability that progress to seizure, coma, and death  Usually occurs in adults with altered mental status or no access to water

Hypernatremia
 1.

Assess volume status  2. Measure urine [Na+]  3. Calculate water deficit



0.6 x weight (kg) x ([Na+]/140 -1)

 4.

Correct with free water no faster than 0.5 mEq/L/hour or 12 mEq/L/day

Hypernatremia
 Hypovolemic


loss of hypotonic fluids

Diuresis, vomiting, diarrhea

 Isovolemic


loss of free water gain of hypertonic fluids

Diabetes insipidus, hypodipsia Hypertonic saline administration

 Hypervolemic


Treatment of Hypernatremia
 Hypovolemic


Replace the free water deficit Diuretics (lasix) to excrete sodium in urine combined with hypotonic saline for partial volume replacement

 Hypervolemic


Treatment of Hypernatremia


Isovolemic
 

 

Diabetes Insipidus Loss of hypotonic urine secondary to lack of ADH production (central) or lack of response to ADH by kidney (nephrogenic) Hallmark is hypotonic urine (200-500 mOsm/L) with (200hypertonic plasma Treat by correcting free water deficit In central DI must also administer 5 10 units of DDAVP Q6H to prevent ongoing free water loss

Hyperkalemia
  

   

Defined as a serum [K+] greater than 4.6 mEq/L Changes in cellular transmembrane potentials can lead to lethal cardiac arrhythmias Most often associated with renal impairment coupled with exogenous K+ administration or drugs that increase K+ Transcellular shifts acidosis, succinylcholine, insulin deficiency, massive tissue destruction Massive blood transfusions Pseudohyperkalemia - Thrombocytosis, hemolysis, leukocytosis Urine K+ excretion rate can be used to determine exact cause of hyperkalemia

Hyperkalemia
 Drugs

causing hyperkalemia K+ sparing diruetics, ACEI, NSAIDs, Heparin, Cyclosporin, Tacrolimus, Bactrim  EKG Changes
  

5.5 6.5 mEq/L peaked T-waves T6.5 7.5 mEq/L loss of P-waves P> 8.0 mEq/L widened QRS

Treatment of Hyperkalemia
 1.

If EKG changes administer 10 mL of 10% Calcium Gluconate  2. 1 amp D50 with 10 units IV insulin (onset 10-20 minutes, duration 2-3 hours) 102 3. Albuterol 10 -20 mg (onset 4-5 hours, 4duration 2-3 hours) 2 4. Kayexalate 15-30 g (oral onset 4-5 154hours, enema onset 1 hour)  Dialysis

Hypokalemia
 Defined

as serum [K+] less than 3.6

mEq/L  Occurs in up to 20% of hospitalized patients  2.5 mEq/L muscular weakness, myalgia  <2.5 mEq/L cramps, parasthesias, ileus, tetany, rhabdomyolisis, PVCs, A-V block, AV-tach, V-fib V-

Hypokalemia
 Inadequate

intake  Increased excretion diarrhea, diuretics, alkalosis, glucocorticoids, RTA  Transcellular shifts beta-agonists, betatheophylline, insulin, hyperthyroidism, barium  Replace no faster than 20 mEq/H peripherally and 100 mEq/H centrally