done by dr nasibdin kishki

8/3/2019 Done by Dr Nasibdin kishki

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Done by :GROUP B

Supervisor :DR MUHAMAD

YASIN

FLUID

AND

ELECTROLYTES



Surah AL- MURSALAT (Those Sent Forth)

“ألم خقكم ن اء هين”

20سورة المست آيه

“Have We not created You from a fluid

(Held) despicable?” Holy Qur’an



INTRODUCTION

•To maintain good health, a balance of fluids andelectrolytes, acids and bases must be normallyregulated for metabolic processes to be in workingstate.

•A cell, together with its environment in any part of thebody, is primarily composed of FLUID.



BODY FLUIDS

A. Function

1.Transporter of nutrients , wastes, hormones, proteinsand etc.

2.Medium or milieu for metabolic processes

3.Body temperature regulation

4.Lubricant of musculoskeletal joints

5.Insulator and shock absorber



BASIC PHYSIOLOGY :• Total body water :

• Total body water content is about 60% of body weightin an young adult male and about 50% in an youngadult female. Since fat contains less water, an obeseperson will have proportionately less body water as

compared to lean person.• Infants = more water

• Elderly = less water

• More fat = ↓water

• More muscle = ↑water

• Infants and elderly - prone to fluid imbalance



Percentage of Body Water

(depending on age & gender)75%

60%

55%

45%



Total Body Fluid by Compartment

Total Body Water



Body Fluid Transport

• DIFFUSION

Higher to lower concentration

• OSMOSIS

Lower to higher concentrationSemi permeable membrane

• FILTRATION

Particles• ACTIVE TRANSPORT

Na-K Pump

Requires ATP



Diffusion

High Solute Concentration Low Solute Concentration

Fluid

Solutes

Figure 3.



OsmosisFigure 2.

Fluid

High SolutionConcentration,

Low Fluid

Concentration

Low SoluteConcentration,

High Fluid

Concentration



Active transport

K +

K +

K +

K + K +

K + K +

K +K + K +

K +

K +

K +

K +

K +

K +

K +ATP

ATP

ATP

ATP Na +

Na +Na +

Na + Na +Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +

Na +Na +

.INTRACELLULAR

FLUID

EXTRACELLULARFLUID



Third Spacing

• Occurs when the fluid is “trapped” in the

interstitial spaces.

• Fluids shifts from the vascular space into an

area where it is not readily accessible asextracellular fluid.

• This fluid is remains in the body but is essentiallyunavailable for use, causing an isotonic fluidvolume deficit.

• Pt. may not manifest fluid loss or weight loss.



Causes of Fluid Shifts• Albumin losses can occur in liver failure, liver

dysfunction, and malnutrition

• Albumin losses can lead to fluid shifting into the

peritoneum, causing ascites

• Destruction of endothelial cells, such as in bowelsurgery, can cause fluid to move and be trappedin the interstitial spaces

• Fluid trapped in the lungs can lead to pulmonary

edema



Regulation of Body Fluid1. The Kidney

• Regulates primarily fluid output by urine formation

1.5L

• Releases RENIN-

• Regulates sodium and water balance



2. Endocrine regulation

• thirst mechanism – thirst

center in hypothalamus• ADH increase water

reabsorption on collectingduct

• Aldosterone increasesSodium and water retentionretention in the distalnephron

G



3. Gastro-intestinal regulation

- GIT digests food and absorbs water

- Only about 200 ml of water is excreted in the fecal

material per day

4. Heart and Blood Vessel Functions - pumping action of heart circulates blood throughkidneys

5. Lungs – insensible water loss through respiration



FLUID BALANCE

• BODY INPUT

Fluids1500mL

Food500mL

Digestion500mL

Total>2500mL

• BODY OUTPUT

Urine 1500mL

Feces 200-400mL

Respiration200-400mL

Skin 200-400mL

Total

>2500mL



INTRAVENOUS FLUIDS

ISOTONIC:Equal in concentration

• 0.9% Na Cl

• D5 Water, Lactated Ringer’s

HYPOTONIC:

↓ Salt or solute

Cellular swelling

• 0.45% NaCl, Distilled water

HYPERTONIC:

↑ Solute

Cellular shrinkage

• D5 NSS, D10 Water

• D5 0.45 % NaCl, D5 LRS



The rules of fluid replacement:• Replace blood with blood

• Replace plasma with colloid

• Resuscitate with colloid

• Replace ECF depletion with saline

• Rehydrate with dextrose



WATER LOSS



CAUSES OF WATER LOSS

• Poor intake, Vomiting, diarrhea, GI suctioning, sweating

• Diabetes Insipidus

• Adrenal insufficiency

• Osmotic diuresis

• Hemorrhage

• 3rd space fluid shift



CLINICAL FEATURES

Drop in ECF is balanced by Drop in ICF so clinically

Patient is not dehydrated even though there is waterloss.

• Thirst ,confusion and hypothermia are the clinical

features.

• INVESTIGATION:

• Raise in plasma sodium and urea

•

TREATMENT:

Oral water or IV isotonic fluid .5% Destrose



WATER INTOXICATION

CAUSES:

-Excessive amount of intravenous dextrose 5%

-During colorectal bowel wash for preparation of

large bowel for Surgery, if water is used instead ofsaline especially in children

-in TURP when excess irrigating fluid water or

Glycine is used (commonly used)-in SIAHD which is commonly associated withlobar pneumonia ,empyema and head injury



WATER INTOXICATION



• CLINICAL FEATURES

• - Drowsiness ,weakness

• -convulsion and coma• - Nausea and vomiting

• -passage of dilute urine

INVESTIGATION:

-Haematocrit and sodium level-low potassium and low blood urea

TREATMENT:

-Water restriction and observation

- Monitoring on ICU

- Management of fluid and electrolyte balance

- Infusion of hypotonic sodium chloride

ECF LOSSES



• ECF LOSSES• Here only ECF loss is present with normal ICF

• It is seen in vomiting, diarrhoea and intestinalobstruction

• TTT: Is infusion of normal saline

• ECF EXCESS• Only ECF excess without an ICF excess

• Excessive infusion of saline with impaired excretion

• Raised JVP(earliest and best clinical sign),Cardiacfailure and peripheral oedema

• TTT: Is fluid restriction and diuretics like Frusemide



ELECTROLYTES

Electrolytes are charged ions capable ofconducting electricity and are solutes found in allbody compartments.

• 1. Sources of electrolytes

Foods and ingested fluids, medications; IVF and

TPN solutions



FUNCTIONS OF ELECTROLYTES

Electrolytes serve four general functions in the body.1-Because they are more numerous than nonelectrolytes,electrolytes control the osmosis of water between bodycompartments.2-Maintain the acid-base balance required for normalcellular activities.3-Carry electrical current, which allows production of actionpotentials and graded potentials and controls secretion ofsome hormones and neurotransmitters. Electrical currentsare also important during development.4-Cofactors needed for optimal activity of enzymes.

Concentration expressed in mEq/liter or milliequivalents per literfor plasma, interstitial fluid and intracellular fluid



Fluids & Electrolytes

Ions = Charged particles

• Cation: PositivelyCharged particles.

• Sodium ( Na +)

• Potassium ( K+)

• Calcium (Ca++)

• Magnesium (Mg++)

• Anion: Negativelycharged particles.

• Chloride (Cl-)• Bicarbonate (HCO3-)

• Phosphate (HPO4 -)

5/4/2012 31



Ion ECF(mmol/l) ICF(mmoll/l)

CATIONS

Na 135-145 4-10

K 3.5-5 150

Ca ionised 1.0-1.25 0.001

Ca total 2.12-2.65 ----

Mg 1.0 40

ANIONS

Bicarbonate 25 10

Cl 95-105 15

phosphate 1.1 100

Organic anions 3.0 0

Protein 1.1 8



Sodium• Most abundant extracellular cation.

• Regulates body water distribution.

• Aids nerve impulse transmission.

• Aids transfer of calcium into cells.

• Recommended adult intake 50-140mmol in food and drinks,1-2mmol/kg IV

• Na levels are controlled by the kidneys; 80% reabsorbed in the

proximal convoluted tubule

Aldesterone( mechanism involves renin angiotensin system)

ADH mechanism- retention of Na leads to retension of H2O.

Increased Na [ ] stimulates ADH section and vise versa. 5/4/2012 33



Disturbances of Na Balance

Hyponatraemia-[Na] <130mmol/l

May be due to;-water retention

-Na depletion separately or

-in combination



Clinical features of Hyponatraemia• With salt and water depletion are due to EC

dehydration;-sunken eyes

• -cold clammy skin

• -hypontension

• -rapid thready pulse

• -nausea,vomiting and muscle

• cramps

o -scanty urine,dark in colour ando of high specific gravity

o Plasma changes;-reduced plasma volume evidencedby raised levels of proteins PCV and Hb



Treatment of hyponatremia

• Hyponatremia due Na loss;-0.9% normal saline

• Hyponatremia due to water intoxication;-stop allfluids and prevent excess water intake



Hypernatremia [Na]>145mmol/l

Causes

• insufficient water intake

• Renal water loss(osmotic

duresis due to renal failure or DKA)

• sweating

• hyperventilation

• voluntally over ingestion by a mentallyderanged person

• excessive IV infusion of 0.9% normal saline

post operatively.



Clinical features of hypernatremia

• Puffiness of the face is the early sign

• In infants, increased tension of anteriorfontanelle

• Sacral edema( 4.5 l of fluids must haveaccumulated in tissue space)

• Increased body weight

• Pulmonary edema may kill the patient.



Treatment of hypernatremia

• If due to water depletion, give 5%dextosesolution

• If due to Na excess, restrict Na intake

• Not more than a half the water deficit should bereplaced in the first 12 -24 hrs( cns detoriation)



Potassium

• Most abundant intracellular cation.(150mmol/l)

• Necessary for transmission and conduction ofnerve impulses.

• Maintenance of normal cardiac rhythm.• Necessary for smooth and skeletal muscle

contraction.

• Intracellullar K



Hypokalemia- serum K >3.5mmol/lCauses

Inadequate intake –K free IV fluids

-reduced oral intake

Excessive loses;GIT -vomiting or diarrhoea

-fistula loss e.g deodnal fistula

-villous adenoma of rectum

RENAL-osmotic duresis-primary hyperaldesteronism(co

nns syndrome

-cushing syndrome, exogenous steroids



Clinical features of hypokalemia

• Muscular weakness

• Cardiac arrythmias

• ECG changes; -flattened T-waves with ST-

segment depression and prolonged QT-interval

• impaired concentrating ability of kidneys• leading to polyuria and polydypsia



Diagnosis of hypokalemia

• ECG findings

• Hypertension; suggests hyperaldosteronism or

glucocorticoid excess

• Renal K excretion ;- urinary excretion of >20-

25mmol/l or per day



Treatment of hypokalemia

• Increase dietary intake e.g milk, fruit juices, honey or supplementation with

K salts like effervescent tabs of Kcl 2gby mouth 6hourly

• IV Kcl -20mmol/l hourly



Hyperkalemia

• Plasma level above 7.5mmol/l produces clinical symptomsCauses

EXCESSIVE INTAKE;

• Rapid infusion of K containing IV fluids in conditions of hypokalemia

• Massive blood transfusion

INADEQUATE EXCRETION;• Patients with acute renal failure,rare in chronic renal failure

• Addison’s disese.

• K spairing duretics

SHIFT OF K from TISSUES into PLASMA

• Tissue damage• Haemolysis

• Metabolic acidosis,hypoxia and shock Na-K ATPase pump is impaired

• Insulin defficiency



Clinical features of hyperkalemia

• Confussion

• Apathy

• Paresthesia

• There may be severe muscle weakness



Diagnosis of Hyperkalemia

• Serum K estimation and

• ECG;- Peaked T-waves, loss of p-waves,abnormal QRS intervals



Treatment of hyperkalemiaRecognition and control of hyperkalemia is a medical emergency

• Stop all forms of K administration

• Maintain a good urine output; give IV fluids and if required frusemide

• In severe hyperkalemia,[K]>8mmol/l -50-100ml of 50%dextrose with10-20Units of insulin given IV every 2hrs

• Correct acidosis with IV, 1-2mmol/kg NaHCO3 in 1L of 5% dextose

• Hemo and peritoneal dialysis



CalciumMain regulators of ionised plasma Ca are PTH,Vit D and Calcitonin.

• Normal serum Ca level is 8.5-10.5mg/dl(2.2-2.6mmol/l)

• Total Ca in body is abt 1200gms with 99% in bones and 1% in bodyfluids and soft tissues

• Normal daily intake;- 1-3gms most of is excreted by GIT and about200mg in urine per day

• Plays role in nerve impulse transmission.

• Increases force of muscle contractions.

• Functions as an enzyme co-factor in blood clotting.

• Necessary for structure of bone and teeth.

• Decreased ionised Ca in blood leads to tetany

5/4/2012 49

C l i di t b



Calcim disturbances,

Hypocalcemia, <8mg/dl or <2mmoll/l

Causes

• Hypoparathyrodism

• Vit D defficiency

• Chronic renal failure( increased plasma PO4levels,decreased vitD3 synthesis

• Acute pancreatitis(dystrophic calcification)

• Excessive transfussion of citrated blood



Clinical features of hypocalcemia

• Hypersensitivity of nerves and muscles(latenttetany)

-chevosk’s sign

-trousseau sign(carpal spasm)• Carpal pedal spasm(long standing

hypocalcemia)

• Sponteneous laryngospasm(laryngismus)• Convulsions

• Epileptic fits

• Muscle cramps and weakness



Treatment of Hypocalcemia

• IV calcium gluconate for acute symptoms

• Calcium lactate per oral for those requiringprolonged replacement



Hypercalcemia

Causes

• Malignancy;- osteolytic mets e.g breastcancer,multiple myeloma or hodgikins disease

• Hyperparathyrodism• Hypervitaminosis D

• Immobised patient

• Compulsive milk drinking



Clinical features of Hypercalcemia

• Renal stones

• Tiredness

• Mental confusion

• Comma



Treatment of Hypercalcemia

• Correct depleted ECF volume with IV Fluidswhich lowers Ca levels by dilution

• Metastatic cancer;- treatment is prophylactic with

patient place on low Ca diet and adequatehydration.



Magnesium• predominantly Intracellular cation.(20mmol/l)

• Mostly excreted in feaces and the rest in urine

• Activates (ATP-ase) the primary energy source for thesodium potassium pump.

• Plays important role in the relaxation of smooth muscle.

• Stabilizes cardiac muscle cells - decreases fibrillationthreshold.

• Mg ion is essential for proper functioning of mostenzyme systems

5/4/2012 56



Magnesium Defficiency

• Causes

• Starvation

• Prolonged IV administration of Mg free fluids

• Excess GIT fluid loss like GI fistulae,ulcerativecolitis

• Acute pancreatitis

• DKA• Late stages of major burns



Clinical features of Mg deficiency

• Neuro-mascular and CNS hyperactivity

• Muscle tremors and tetany progressing todelirium and convulsions in severe cases



Diagnosis of Mg deficiency

• A surgical patient who exhibits disturbedneuromascular or cerebral activity in the post

operative period, put Mg deficiency in mind.



Treatment of Mg defficiency

• Parenteral MgSO4 or Cl, doseis 40mmol of MgSO4 dissolved in 5%Dextrose or isotonic saline per day



Magnesium excess

• causes/etiology

• Massive trauma

• Most common cause is severerenal failure

• Acidosis also shifts Mg out ofcells

Clinical features of magnesium



Clinical features of magnesium

excess

• Drowsiness at plasma levels of

4mmol/l and comma at levels of

7mmol/l

• Peripheral vasodilation, hypotensionand mascular flacidity

• Death is due to cardiac arrest



Treatment of Mg excess

• Contol acute symptoms by slow IVinfussion of CaCl or gluconate 5-10mEq

• Presistent elavated levels treated byperitoneal or haemodialysis



Chloride

• Balances cations

• Plays role in fluid balance andrenal function.

5/4/201264



5/4/201265

Phosphate

• Plays an important role in

ATP storage.

• Chief intracellular buffer actsto maintain intracellular pH.



Thank you

done by dr nasibdin kishki

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