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Students Topic. Fluid Electrolyte & Blood component . . . . . . . Basic knowledge. Total body water. . - PowerPoint PPT Presentation

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  • Students TopicFluid Electrolyte & Blood component. . . . .

  • Basic knowledgeTotal body water

  • 1 ( Intracellular fluid)

    2 (Extracellular fluid)2.1 Plasma2.2 Interstitial fluid

  • Normal exchange of fluid and electrolytes

  • Composition of GI secretion

  • Acid - Base balance

  • Acid - Base balancepH 7.35 7.45 pH Intracellular pH protiens , phosphates Extracellular pH bicarbonate carbonate acid system Hb Intracellular red blood cell

  • Acid - Base balance Hendreson-Hasselbalch equation pH extracellular fluid bicarbonate carbonate acid system pH bicabonate carbonic acid

  • Acid - Base balancepH = pK + log baseHCO3/ H2CO3 = pK + log (HCO3 / 0.03Paco2) = 6.1 + log 27 mEq / L / 1.33 mEq / L = 6.1 + log20/1 = 7.4 20 : 1 pH= 7.4 compensate 20 : 1

  • Acid - Base balance respiratory Metabolic Pure combine compensate disturbance Paco2 , pH HCO3

  • Classification of body fluid changes body fluid 3 1 (Volume)

    2 (Concentration)

    3 (Composition)

  • 1. (Volume change) volume clinical examination indirect laboratory extracellular fluid blood urea nitrogen (BUN) creatinin (Cr) hematocrit concentration sodium fluid

  • Volume deficitExtracellular fluid volume deficit most common Loss of gastrointestinal fluids suction NG tubeFistula drainageInfectionPeritonitisIntestinal obstructionBurn

  • Volume excess Iatrogenic Renal insufficiency Cirrhosis Congestive heart failure

  • Signs and symptoms of volume disturbances

  • 2. (concentration change)Changes in serum sodium concentration are inversely proportional to TBW. Therefore, abnormalities in TBW are reflected by abnormalities in serum sodium levels.

  • HyponatremiaAcute hyponatremia serum Na < 130 mEq/LChronic hyponatremia serum Na < 120 mEq/L--------------------------------------------------------------------------- chronic hyponatremia sodium 120 mEq/L Severe hyponatremia oliguric renal failure

  • Causes of hyponatremia

    Causes of hyponatremiadilution ----- excess extracellular water Excessive oral water intake iatrogenic IV excessPostoperative patients ---SIADH ( reabsorption of free water from the kidneys) drugs cause water retention (elderly) --- antipsychotics and TCA, ACEI

  • Causes of hyponatremia (cont.)

    causes of hyponatremiadecreased intake consumption of a low-sodium diet use of enteral feeds, which are typically low in sodiumincreased loss of sodium-containing fluidsGI losses --- vomiting, prolonged nasogastric suctioning, or diarrhearenal losses --- diuretic use , primary renal disease

  • Hyponatremiacan be seen with an excess of solute relative to free wateruntreated hyperglycemia mannitol administrationGlucose exerts an osmotic force in the extracellular compartment--- shift of water from the intracellular to the extracellular spacecan be seen when the effective osmotic pressure of the extracellular compartment is normal or even high

  • HyponatremiaWhen hyponatremia in the presence of hyperglycemia is being evaluatedthe corrected sodium concentration should be calculated as followsplasma glucose every 100 mg/dL above normal

    plasma Na 1.6 mEq/L

  • Hyponatremia systematic review of the etiology Hyperosmolar causes?depletional or dilutional causes ?Depletional causesNo renal disease --- urine sodium 20 mEq/LRenal disease --- urine sodium 20 mEq/L Dilutional causeshypervolemic circulationnormal volume status --- evaluation for SIADH

  • Hypernatremiaresults from either a loss of free water or a gain of sodium in excess of water. it can be associated with an increased, normal, or decreased extracellular volume-------------------------------------------------------------------- serum sodium 160 mEq/L central nervous system tissue sign

  • HypernatremiaHypervolemic hypernatremia usually is caused either by iatrogenic administration of sodium-containing fluids, including sodium bicarbonatemineralocorticoid excess as seen in HyperaldosteronismCushing's syndromecongenital adrenal hyperplasiaurine sodium concentration is typically >20 mEq/L urine osmolarity is >300 mOsm/L.

  • HypernatremiaNormovolemic hypernatremia can result from renal causes including diabetes insipidusdiuretic userenal diseasenonrenal causeswater loss from the GI tract or skin

  • HypernatremiaHypovolemia hypernatremiaNonrenal water loss can occur secondary to relatively isotonic GI fluid losses such as that caused by diarrheahypotonic skin fluid losses such as loss due to feverto losses via tracheotomies during hyperventilationthyrotoxicosisthe use of hypertonic glucose solutions for peritoneal dialysisthe urine sodium concentration is 400 mOsm/L

  • HypernatremiaSymptoms are rare until the serum sodium concentration exceeds 160 mEq/L but, once present, are associated with significant morbidity and mortality. Because symptoms are related to hyperosmolarity central nervous system effects predominate

  • HypernatremiaCNS symptoms can range from restlessness and irritability to seizures, coma, and death. The classic signs of hypovolemic hypernatremiaTachycardiaOrthostatic hypotension the unique findings of dry, sticky mucous membranes

  • Clinical manifestations of abnormalities in serum sodium level

  • volume concentration (parenteral fluid) Extracellular fluid deficit and hyponatremia () Gastrointestinal fluids hypotonic salt solution pure water

    Extracellular fluid deficit and hypernatremia hypotonic solution

  • volume concentration Extracellular fluid excess and hypernatremia pure water sodium containing solution

    Extracellular fluid excess and hyponatremia water hypotonic salt solution oliguric renal failure

  • 3. (compositon change) - Acid base balance- Concentration potassium , calcium and magnesium

    pH 7.35 7.45 buffer system Intracellular pH protein , phosphate Extracellular pH bicarbonate-carbonic system Intracellular RBC hemoglobin

  • Potassium 50-100 mEq urine98 % intracellular compartment extracellular compartment cardiac , neuromuscular function

  • Hyperkalemiais defined as a serum potassium concentration above the normal range of 3.5 to 5.0 mEq/LIt is caused by excessive potassium intakeincreased release of potassium from cellsimpaired potassium excretion by the kidneys

  • Etiology of Hyperkalemia

  • Hyperkalemiacardiovascular gastrointestinal system effect- S&S , , ,- EKG high peaked T wave , widened QRS complex , depressed ST segment , cardiac arrest - serum potassium , exogenous potassium hyperkalemia - hyperkalemia Intravenous 10 % calcium gluconate monitor EKG - uptake serum potassium cell Bicarbonate Glucose with insulin

  • Hypokalemia

  • Hypokalemiadrugs induce magnesium depletion cause renal potassium wastageamphotericinAminoglycosidesFoscarnetCisplatinifosfamide

  • HypokalemiaThe change in potassium associated with alkalosis can be calculated by the following formula

    K 0.3 mEq/L every pH 0.1 above normal

  • Hypokalemia

    hypokalemia

    Contractility skeleton , smooth cardiac m. Flaccid paralysisTendon reflex EKG flatted T wave , depress ST segment

  • Hypokalemia potassium 40 mEq/L 40 mEq/hr monitor EKG potassium (oliguria) 24

  • Calcium 1000 1200 Bone phosphate carbonate 1-3 8.5-10.5 mg/ml55 % non ionized form plasma protein45 % ionized form neuromuscular stability

  • Hypocalcemia 8 mg/ml neuromuscular hyperactive tendon reflex muscle abdominal crampTetany with carpopedal spasmConvulsionProlong QT interval

  • HypocalcemiaAcute pancreatitisNecrotizing fasciitisAcute chronic renal failure Pancreatic small bowel fistular Hypoparathyroidism Acute symptoms calcium gluconate calcium chloride

  • Hypercalcemia 12 mg/dl , , , , , , , 15 mg/dl HyperparathyroidismCancer with bone metastasis

  • Hypercalcemia calcium 15 mg/dl extracellular fluid deficit calcium oral intravenous inorganic phosphate bone resorption calcium phosphate calcium calcitonin serum calcium acute hypercalcemic crisis hyperparathyroidism

  • Magnesium 200 mEq50 % bone 1.5-2.5 mEq/LDaily intake 20 mEq

  • Magnesium deficiency StarvationMalabsorption syndromeLoss of Gastrointestinal fluidAcute pancreatitisHyperactive tendon reflexMuscular tremorTetanyConvulsionParenteral 10-20 mEq of 50% magnesium sulfate magnesium chloride

  • Magnesium excess Early thermal injuryMassive traumaSurgical stressSevere extracellular volume deficit , Loss of deep tendon reflexMuscle paralysisComa , death

  • Magnesium excess acidosis extracellular fluid deficit 5-10 mEq calcium chloride calcium gluconate peritoneal dialysis hemodialysis

  • Fluid and electrolyte therapy fluid Volume statusType of concentration Compositional abnormality

  • Fluid and electrolyte therapy

  • Fluid and electrolyte therapyLactated Ringer s solution Gastrointestinal losses Extracellular fluid loss

    Isotonic sodium chloride Hyponatremia , Hypochloremia , Metabolic alkalosis

    D5 0.45% sodium chloride Maintenance fluid in postoperative period

  • Preoperative fluid therapy fluid

  • *Preoperative Fluid Therapy