Fluid disturbance and

Therapy
2021
Buku-buku
• Di Piro Pharmacotherapy,
a Pathophysiology
Approach
• DiPiro Pharmacotherapy,
science and practice of
therapy
• https://sg.docworkspace.
com/d/sIACkooNVr_vRgQ
Y
• Washington manual of
therapy
Goals
• To able to estimate the volumes of various body fluid compartments.
• To understand the type of fluid disturbances
• To able to manage different types of fluid disturbance
• To able to review the etiology, clinical presentation, and management
for disorders of sodium and potassium,
• To able to differentiate among currently available fluids for volume
resuscitation
• To be able to calculate the needs of volume resuscitation
 Body Fluid Compartments
• The percentage of total body water: 45-75% of LBW
• Intracellular compartment
• 2/3 of body water (40% body weight)
• Extracellular compartment
• 1/3 of body water (20% body weight)
• Intra vascular = 0.25 x ECF
• Interstitial Fluid = 0.75 x ECF

• Distribution of substances within the body is NOT HOMOGENEOUS. ecf

LBW for fat patients
• LBW as calculated by the Devine–Devine method:
• males’ LBW= 50 kg + (2.3 kg/in. × [height in inches – 60]) and
• females’ LBW = 45.5 kg + (2.3 kg/in. × [height in inches – 60])

• Note that 1 kg is equivalent to 2.2 lb, 1 inch is equivalent to 2.54 cm,

and 1 L of water weighs 1 kg (2.2 lb).
• TBW = 60% LBW
Homeostasis
• The maintenance of normal volume and normal composition of the
extracellular fluid is vital to life.
• Homeostasis: the various physiologic arrangements which serve to
restore the normal state, once it has been disturbed

• Fluid balance
• Electrolyte balance
• Osmotic balance
• Acid-base balance
Solute Overview:
Intracellular vs. Extracellular

• Ionic composition very different

• Total ionic concentration very similar
• Total osmotic concentrations virtually
identical
 Composition of fluids (mmol/l)
Fluid Na+ K+ HCO3- Cl -
ICF 12 140 12 4
Plasma 140 4-5 26 112
ISF 145 4,4 27 117
Liquor 147 3 23 113
Verejték 20-40 5 - 15-40
Nyál 10 26 15 10
Gastric juice 20-80 5-20 - 100-150
H+: 40-60
Intestinal juice 120-140 5-15 20-40 10
Ionic composition
Protein
Organic Phos.
400 Inorganic Phos.
Bicarbonate
300 Chloride
Magnesium
200 Calcium
Potassium
100 Sodium

0
Plasma Interstitial Cell
H2O H2O H2O
Fluid balance
Fluis Osmolality

• Normal: 280 – 300 mOsm/kg (280 – 300 mmol/kg)

• Must be kept constant.
• Disturbances: hyperosm or hypoosm
Primary Disturbance:
Increased ECF Osmolarity

• Water moves out of cells

• ICF Volume decreases (Cells shrink)
• ICF Osmolarity increases
• Total body osmolarity remains higher
than normal
Primary Disturbance:
Decreased ECF Osmolarity

• Water moves into the cells

• ICF Volume increases (Cells swell)
• ICF Osmolarity decreases
• Total body osmolarity remains lower than
normal.
KIDNEY MANAGEMENT OF BODY FLUID
 Fluid and electrolytes disturbancee

Euvolemic
Hypovolemic
Hypervolemic
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Hypo and hypercalcemia
EUVOLEMIC
• To maintain homeostatis
• Only if the patient needs to, when he-.she could not drink/eat
• Consider water and food needs when prescribing IVFluid therapy
• estimation urine output (eq to 500-600 mL/day)
• Water loose in stool 200 mL/day
• Insencible water loose 350=400 mL/day
• Body Temperatur water lose: 100 – 150 mL/day every 1 degree of Celsius
above 37oC

• The needs of maintenance fluid ➔ 1400 mL/day or 60 mL/hr

Physiological Fluids
Electrolytes need

• Na{ 75- 150 mEq/ day (consider Na in diet 2 g/day eq to 86 mEq Na)
• 20 – 60 mEq K+/ day (if kidney function is normal)
• 100 – 150 g dextrose /day (to prevent protein catabolisme)
CASE 1
 (hypovolemic) Dehydration
Management

Common causes
• Renal looses : diuresis, aldosterone deficiency,
impaired renal concentrating mechanisms
• Extrarenal looses:
• include insufficient oral intake, excessive insensible
losses, diarhea, vomiting, over sweating etc
• Elderly → long-term lack of adequate oral intake,
often with concurrent excessive insensible losses
 SIGNS AND SYMPTOMS
• Fatigue, thirst, muscle cramp, CNS disturbances dizziness, mental
status changes, seizures, and coma),
• excessive thirst, dry mucous membranes, decreased skin turgor,
elevated serum sodium, increased plasma osmolality, concentrated
• urine, and acute weight loss
• Orthostasis hypotension, tachycardia, decreased urine output,
• increased hematocrit, decreased central venous pressure, and/or
hypovolemic shock
• Urine NA < 15 mEq
• FNa excretion < 1% (UNa x serum Cr): (UCr x serum Na)
MANAGEMENT OBJECTIVES

• improved skin turgor

• adequate urine output
• normalization of heart rate, BP,
• etc.
 MANAGEMENT

• Replace the devisit ( fluid resuscitation) ( 1 – 2l bolus +

• Maintain fluid balance
• Bolus dose may reduce for patien with cardiac
problem or oedema
• volume of “maintenance” fluid = basal fluid
requirement + ongoing losses
• Acute ECF depletion → rapid and aggressive fluid
replacement to maintain adequate organ perfusion.
• Closely monitored serum electrolytes
 Body fluid requirement

For an adult, this represents 1500 mL/day for the first 20 kg of body weight
plus 20 mL/day for each additional kilogram.
The fluid deficit/requirement can be estimated
by the acute weight change in the patient (1 kg = 1 L of fluid).
fluid deficit = normal TBW – present TBW
 Fluid replacement
• 0-10 kg: 100 ml/kg/d
• 11-20 kg: 50 ml/kg/d
• > 20 kg: 20 ml/kg/d
• 4-2-1 (ml/kg/h)

Patient (70 kgs) (4-2-1)

• 1-10 kg 4 ml/kg/h 40 ml/h

• 11-20 kg 2 ml/kg/h 20 ml/h
• >20 kg 1 ml/kg/h 50 ml/h

Together: 110 ml/h 2640ml/d

Strategy
• determine the type of fluid problem (TBW vs ECF
depletion
• start therapy accordingly:
• For patients with signs of impaired tissue perfusion,
→ goal is to increase the intravascular volume and
restore tissue perfusion → normal saline given at 150
to 500 mL/hour (for adult patients)
Notes

volume of fluid required to correct

TBW depletion equals the basal fluid
requirement + ongoing exceptional
losses + the fluid deficit
Notes
• The calculated serum osmolality helps determine
deviations in TBW content
• Use these eqs to calculate Serum Osm:

• Serum osmolality (mOsm/kg) = 2 (Na mEq/L) +

(glucose [mg/dL])/18 + (BUN [mg/dL])/2.8.

• Serum osmolality using SI units (mmol/kg) = 2

(Na mmol/L) + (glucose mmol/L) + (BUN
mmol/L)/2.8.
Osm gap
• The difference between the measured serum osmolality and the
calculated serum osmolality,
• Under normal circumstances the osmolar gap should be 10 mOsm/kg
(10 mmol/kg) or less.

• Sodium deficit (mEq or mmol) = (TBW [in liters]) (desired Na+

concentration [mEq/L or mmol/L] – current Na+ concentration).
• Change in serum Na+ (mEq/L or mmol/L) = (infusate Na+ – serum
Na+)/(TBW + 1).
Note:
• Hypertonic saline (3% or 5% NaCl) is generally reserved for patients
with severe hyponatremia (less than 120 mEq/L [120 mmol/L])
accompanied by coma, seizures, or high urinary sodium losses.
• Roughly one-third of the sodium deficit can be replaced over the first
12 hours as long as the replacement rate is less than 0.5 mEq/hour
(0.5 mmol/hour).
• The remaining two-thirds of the deficit can be administered over the
ensuing days.
• Overly aggressive correction of symptomatic hyponatremia (greater
than 12 mEq/L [12 mmol/L]) can result in central pontine
myelinolysis.
Specific electrolytes disturbances
• Hyponatermia
• Hypertonic hyponatremia
• Hypotonic hyponatremia and ECF >
• Hypotonic hyponatremia and normal ECF
• Hypernatremia
• Hypokalemia >< hyperkalemia
• Hypomagnesemia>< hypermagnesemia
• Hypophosphatemia><hyperphosphatemia
CASE
A.B., a 17-year-old girl, presented to the emergency department
(ED) with complaints of anorexia, nausea, vomiting, and
generalized weakness for the past 3 days. She denied other medical
problems and had not used any medications. On examination,
her supine blood pressure (BP) was 105/70 mm Hg, with a pulse
of 80 beats/min. Her standing BP was 85/60 mm Hg with a pulse
of 100 beats/min, and she complained of feeling dizzy when she
stood up. Her mucous membranes were dry but her skin turgor
was normal. The jugular vein was flat, and peripheral or sacral
edema was not present. Laboratory blood tests showed serum Na
134 mEq/L (normal, 134–146); K, 3.5 mEq/L (normal, 3.5–5.1);
Cl, 95 mEq/L (normal, 92–109); total CO2 content, 35 mEq/L
(normal, 22–32); BUN, 18 mg/dL (normal, 8–25); creatinine, 0.8
mg/dL (normal, 0.5–1.5); and glucose, 70 mg/dL (normal, 60–
110). Random urinary Na was 40 mEq/L, K was 40 mEq/L, and
Cl was <15 mEq/L. The hemoglobin (Hgb) was 14 g/dL (normal,
12–16), and white cell and platelet counts were normal.
Problems
• Explain patient status and the reason
• What is /are the objective and subjective information regarding the
status
• What is the management of patient problem and why
Q&A
HYPERVOLEMIA
ETHIOLOGY
• Renal failure
• Cardiac failure
• Sirrhosis
• hypoalbuminemua
Signs and symptoms
• No symptoms until water retention upto 3 – 4 L
• Dyspnea
• Abdominal distention
• Swelling extremities

• Urine Na < 15 mEq/L

• Pulmonary edema or pleural effusion
Goals of therapy
• Reduce body fluid volume
• Correct electrolyte balance (may hyperNa)
• Correct symptoms
Therapy
• Reduce Na intake
• Diuretics (block Na reabsorption mechanism) (thiazid, loop and K
sparing diuretics)
Hyponatremia (Plasma Na < 135 mEq/L)
ETHIOLOGY
• LOW Na intake
• Any condition that retain body water

• Pseudohyponatremia → in hyperpppprotein and hyperlipidemia

• Hyperosmotic hyponatremia → diabetes mellitus, ADH deficiency
• Hypovolemic hyponatremia → Na lost od in adequate Na intake
• Hypervolemic hyponatremia → water retention due to CHF, AKI/CKD and
sirrhosis
Signs and symptoms
• Edema and neurologic symptoms
• < 125 mg/dL → headache, lethargy, confution
• < 115 mg/dL for > 3 days → coma

• Plasma osm < 275 mOsm/L

Therapy based on
ethiology (see
diagram → )
Treatment
• Hypertonic Na+ solution (3%)
• Remember: too fast Na correction will result in CPM (central pontine
myelinolysis)
• 0nly 1 – 2 mEq/L/h for 3 -4 hours of solution is allowed for rapid Na
correction
• If raise in [plasma Na 10 – 12 mEq /L /24 h → tapered off
• For chronic asymptomatic hyponatremia → 5 – 8 mEq/L/ 24 h
Medication
• Loop Diuretic
• ADH
Hypernatremia
• Plasma Na > 145 mEq/L

• ETHIOLOGY
• High Na intake
• Impair thirst response
• Water loss
• Non renal
• Renal
• Nephrotic Diabetes Insipidus (NDI)
• Central diabetes Insipidus (CDI)
• hypermineralocorticoid
Signs and symptoms

• Neurologic symptoms { mental status, weakness, neuromuscular irritability,

seizure and coma (ocationaly)}
• In CDI and NDI
• Polyuria
• Polydipsia

• Urine osmolality > 800 mOsm/L

• Urine osm < 300 mOsm/L → CDI or NDI
• Urine osm 300 – 800 mOsm/L → DI, Diuretic therapy
Diagnosa
Treatments

• Reduce Na by 10 – 12 mEq/L/Day
• Free water
• Diuretic
Case 3
• A 50-year-old homeless man is brought to the emergency department
staggering and smelling like beer. Rapid respiration, tachycardia, and a
BP of 90/60 mm Hg were noted. The sodium is 140 mEq/L (140
mmol/L), potassium 3.6 mEq/L (3.6 mmol/L), chloride 100 mEq/L (100
mmol/L), bicarbonate 12 mEq/L (12 mmol/L), glucose 200 mg/dL (
11.1 mmol/L), and BUN 28 mg/dL (10.0 mmol/L). The measured
osmolarity is 360 mOsm/kg (360 mmol/kg). Calculate the osmolality.
Calculate the osmolar gap. What is the likely cause of an increased
gap in this patient?