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Fluids, Electrolytes &

Physiologic Monitoring
Brian Draper DO

7/10/2012

Lethal Triad

Acidosis
Result of inadequate tissue perfusion
Hypothermia
ATP production decreases
ATP = source of heat in all homeothermic
animals
Coagulopathy
Enzymes work best at 37 C
Coagulation cascade depends on enzymes
affected by hypothermia

Stable Internal Environment

Claude Bernard milieu interieur


stability of the internal environment is the
primary condition for a free and independent
existence.
For optimal cell, tissue and organ function
internal environment must be maintained
within narrow limits
Electrolyte concentrations
Osmotic pressure
Oxygen and carbon dioxide tensions
Glucose and other metabolites
Temperature

Electrolytes

Fluids

Total Body Water

50 60% of total body weight


Adipose tissue is __% water
Muscle tissue is __% water
Intracellular Fluid
Extracellular Fluid

Fluids

Electrolytes

Electrolyte composition in ICF and ECF

Ions exist in low concentrations in body fluids.


Because ICF and ECF cells are permeable to
different substances, these compartments
normally have different electrolyte compositions.

Electrolyte

ICF

ECF

Sodium

10 mEq/L

136 to 146 mEq/L

Potassium

140 mEq/L

3.6 to 5 mEq/L

Calcium

10 mEq/L

4.5 to 5.8 mEq/L

Magnesium

40 mEq/L

1.6 to 2.2 mEq/L

Chloride

4 mEq/L

96 to 106 mEq/L

Bicarbonate

10 mEq/L

24 to 28 mEq/L

Phosphate

100 mEq/L

1 to 1.5 mEq/L

Electrolytes

Osmolality = total solute concentration

ICF and ECF are in osmotic equilibrium


Main solute in cells is K+
Main solute in ECF is Na+

Water Balance

ADH
Renal Excretion
Thirst

Imbalance

Volume
Acute, chronic, GI loss, sequestration
Concentration
TBW as reflected by Na+
Composition
Potassium, calcium, phosphorus,
magnesium

Sodium

Sodium concentration is inversely proportional


to TBW

Hyponatremia volume status

High: increased intake, Post-op ADH, drugs


Normal: Hyperglycemia, SIADH, diuretics, water intoxication,
pseudohyponatremia (increased plasma lipid/protein)
Low: decreased intake, GI loss, Renal loss/disease, diuretics

Hypernatremia volume status

High: itrogenic, Cushings, Aldosteronism, Congenital adrenal


hyperplasia (urine Na+ <20)
Normal: DI, diuretics, renal disease, GI loss, skin
Low: DI, adrenal failure, GI loss, skin, renal disease
Symptoms related to hyperosmolarity CNS effects

Sodium

Treatment

Hyponatremia
Neurologic symptoms

3% NS increase Na+ no more than 1 mEq/hr

Assymptomatic

Free water restriction, correct 0.5 mEq/hr

Rapid correction pontine myelinolysis

Hypernatremia
Neurologic symptoms

NS increase Na+ no more than 1 mEq/hr

Assymptomatic

Oral or enteral fluid

Rapid correction cerebral edema/herniation

Potassium

2% in ECF critical to cardiac and


neuromuscular
function

Hypokalemia

Low intake, GI loss (diarrhea, vomitin, fistula), alkalosis,


insulin
drugs (amphoterincin, aminoglycosides)
Symptoms: ileus, constipation, weakness, fatigue, cardiac
arrest

Hyperkalemia

High intake, renal failure, acidosis, cell injury, rapid rise in


ECF osmolality (hyperglycemia, IV manitol)
Symptoms: GI, neuromuscular, cardiac

Potassium

Treatment

Hypokalemia
Replace IV or oral
Hyperkalemia
Removal
Kayexalate
Dialysis

Intracellular shift

Glucose + Insulin IV
Bicarbonate

Counteract cardiac effects


Calcium gluconate

Calcium

Majority in bone, serum levels adjusted for


albumin
Acidosis decreases protein binding which
increases the ionized fraction of calcium
Hypocalcemia
Low intake, pancreatitis, renal failure, hypoparathyroid,
pancreatic/small bowel fistulas, alkalosis
Symptoms: parasthesias, muscle cramps, carpopedal spasm
stidor, tetany and seizure
Tx Replace

Hypercalcemia

Primary hyperparathyroid, malignancy


Symptoms: neurologic, weakness, renal dysfunction, N/V
EKG short QT, long PR QRS, AV block
Tx IV fluids

Phosphorus

Hypophosphatemia

Low intake, intracellular shifts (resp alkalosis, insulin,


refeeding syndrome, hungry bone syndrome)
Tx replace

Hyperphosphatemia

High intake, low urinary excretion (hypoparathyroid,


hyperthyroid)
cell destruction
Prolonged can lead to metastatic deposition of soft tissue
calcium-phosphorus complexes
Tx binders (sucralfate or antacids), dialysis

Magnesium

Hypophosphatemia

Low intake, alcohol abuse, diuretics, diarrhea, pancreatitis


Hyperreflexia, tetany, delirium, seizures
Tx replace

Hyperphosphatemia

Rare, renal failure, excess intake


Similar symptoms to hyperkalemia
Tx IV fluids, correct acidosis, calcium chloride (if severe)

Acid-Base Balance

Physiologic Monitoring

Monitoring to ensure oxygen delivery is sufficient to support


aerobic metabolism

Arterial blood pressure

Noninvasive manual, photoplethysmography (measure Hgb)


Invasive Arterial line (accurate MAP)
Complications: distal ischemia, retrograde emboli, infection

EKG

12-lead provides greater sensitivity detect ischemia than 3-lead

Cardiac Output

Preload Starlings law, for RV=CVP, for LV=PAOP


Afterload MAP/CO=SVR

Physiologic Monitoring

Physiologic Monitoring

Physiologic Monitoring

Physiologic Monitoring