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+ Cl5 2.7 103 109 154 77 30 513 855

HCO3- pH
27 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 K+ 20 15 5-10 5-10 20 30 5-10 Cl70 100 60-90 100 100 30 40-60 HCO330 0 40-100 40 25-50 0 0

1000-2000 60-80 1000 1000 2000-5000 200-1500 200-1000 140 140 140 75 20-70

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 3% 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 Diabetes insipidus, hypodipsia Hypertonic saline administration

 Isovolemic – loss of free water

 Hypervolemic – gain of hypertonic fluids

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 hypertonic 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 6.5 – 7.5 mEq/L – loss of P-waves > 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)  3. Albuterol 10 -20 mg (onset 4-5 hours, duration 2-3 hours)  4. Kayexalate 15-30 g (oral onset 4-5 hours, 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, V-tach, V-fib

Hypokalemia
 Inadequate intake  Increased excretion – diarrhea, diuretics,

alkalosis, glucocorticoids, RTA  Transcellular shifts – beta-agonists, theophylline, insulin, hyperthyroidism, barium  Replace no faster than 20 mEq/H peripherally and 100 mEq/H centrally