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Fluid & Electrolyte Emergencies In Critically Ill Dr.Patibandla.Sowjanya Dept Of Accident , Emergency & Critical Care Medicine Vinayaka Missions Kirupanandavariyar Medical College A&E(VINAYAKA) Introduction • Total body water (60%) • Two third is intracellular fluid (40%) • One third is extra cellular fluid (20%) - Interstitial fluid (15%) - Intravascular fluid (5%) A&E(VINAYAKA) Fluid shifts EXTRACELLULAR INTRACELLULAR 30 LIT 40% INTERSTITIAL 9 LIT IV 5 LIT 15% 5% A&E(VINAYAKA) Electrolyte Components mEq/L Na+ K+ Ca2+ Mg2+ ClHCO3- HPO42SO42Organic acid Protein ICF 15 150 150 2 27 ECF Plasma 142 142 4 5 3 1 10 100 20 63 103 27 2 1 5 16 Interstitial 144 4 2.5 1.5 114 30 2 1 5 A&E(VINAYAKA) 6 ICF ECF Major Cation Potassium Magnesium Sodium Major Anion Phosphate Sulphate Protein Chloride Bicarbonate A&E(VINAYAKA) Osmolarity Measurement of the total solutes in a water solution per liter. Osmolarity = [sodiumx2 ]+urea/2.8+glucose/18 Serum osmolarity is 280-300 mOsm/L 280-300 mOsmol/L- Isotonic > 300 mOsmol/L – Hypertonic < 280 mOsmol/L - Hypotonic A&E(VINAYAKA) Three categories of fluids • Isotonic - Fluid has the same osmolarity as plasma Eg: Normal saline Ringers lactate A&E(VINAYAKA) • Hypotonic - Fluid has fewer solutes than plasma Eg : Water, 1/2 N/S (0.45% NaCl) A&E(VINAYAKA) • Hypertonic - Fluid has more solutes than plasma Eg:5% Dextrose in Normal Saline (D5 N/S) , 3% saline solution. A&E(VINAYAKA) Isotonic Infusion 2 litres of blood 30 litres 9 litres 3 litres A&E(VINAYAKA) Intravascular Volume increases to 5 liters 30 litres 9 litres 5 litres A&E(VINAYAKA) Hypertonic Infusion 2 litres of colloid 30 litres 9 litres 3 litres A&E(VINAYAKA) Initially it becomes 5 L 30 litres 9 litres 5 litres A&E(VINAYAKA) Hypertonicity of Colloid shifts I/C fluid into I/V 29 litres 8 litres 7 litres A&E(VINAYAKA) If 2 L of Crystalloid infused… 2 litres of 0.9% saline 30 litres 9 litres 3 litres A&E(VINAYAKA) Initially I/V becomes 5L 30 litres 9 litres 5 litres A&E(VINAYAKA) Isotonicity of Crystalloid shifts I/C & I/V volume into interstitial space 29 litres 10.5 litres 4.5 litres A&E(VINAYAKA) Hypotonic Infusion 2 litres of 5%dextrose 30 litres 9 litres 3 litres A&E(VINAYAKA) Hypotonicity Shifts the fluid into the I/C space 31 litres 9.7 litres 3.3 litres A&E(VINAYAKA) Signs of Volume depletion • • • • • • Postural hypotension Tachycardia Absence of JVP Dry mucosa Decreased skin turgor Oliguria A&E(VINAYAKA) Signs of Volume overload • • • • • • Hypertension Raised JVP/gallop Pedal edema Pulmonary edema Ascites Organ failure A&E(VINAYAKA) Basic principles of fluid therapy Replace Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock Maintain Insensible water loss + urine Repair Acid base, electrolyte imbalances A&E(VINAYAKA) The rules of fluid replacement • • • • • Replace blood with blood Replace plasma with colloid Resuscitate with colloid / crystalloid Replace ECF depletion with saline Rehydrate with dextrose A&E(VINAYAKA) Case Scenario 45 yr old was brought to ER with h/o loose stools & vomiting since 2 days Drowsy and lethargic with signs of severe dehydration, BP-80/50 , PR-120 What is initial fluid of choice? A&E(VINAYAKA) • Isotonic saline / Ringer’s lactate • No dextrose containing fluid initially Why? A&E(VINAYAKA) A&E(VINAYAKA) Case Study #1 • HPI: – A 55 year old man is in the Neuro ICU for acute non hemorrhagic stroke. • Hospital course: – Decreasing urine output (< 0.5 ml/kg/hr) over the last 24 hours. What is your differential diagnosis? What diagnostic studies would you order? A&E(VINAYAKA) Case Study #1 Differential diagnosis Oliguria 1) Pre-Renal (decreased effective renal blood flow) Diminished intravascular volume, cardiac dysfunction, vasodilatation 2) Post-Renal Outlet obstruction (intrinsic vs. extrinsic), foley catheter occlusion 3) Renal Acute tubular necrosis, acute renal failure, SIADH, ... A&E(VINAYAKA) Case Study #1 Laboratory studies Serum studies Sodium 120 mEq/L BUN 4 mg/dL Chloride 98 mEq/L Creatinine 0.4 mg/dL Potassium 3.7 mEq/L Glucose 129 mg/dL Bicarbonate 25 mEq/L Osmolality 260 mosmol/kg Urine studies Specific gravity 1.025 Sodium 58 mEq/L Osmolality 645 mosmol/kg What are the primary abnormalities? A&E(VINAYAKA) Case Study #1 Laboratory studies Major abnormalities 1) Hyponatremia 2) Oliguria (inappropriately concentrated urine) What is the most likely explanation for these findings? A&E(VINAYAKA) In Hyponatremia…… A&E(VINAYAKA) Case Study #1 Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Variable etiology ▪ Trauma ▪ Infection ▪ Psychosis ▪ Malignancy ▪ Medications ▪ Diabetic ketoacidosis ▪ CNS disorders ▪ Positive pressure ventilation ▪ “Stress” A&E(VINAYAKA) SIADH By definition, “inappropriate” implies having excluded normal physiologic reasons for release of ADH: ▪ 1) In response to hypertonicity. ▪ 2) In response to life threatening hypotension. Hyponatremia Oliguria Concentrated urine ▪ elevated urine specific gravity ▪ “inappropriately” high urine osmolality in face of hyponatremia Normal to high urine sodium excretion A&E(VINAYAKA) Case Study #1 • Diagnosis SIADH – Critical level of suspicion. – Demonstration of inappropriately concentrated urine in face of hyponatremia urine osmolality, SG, urine sodium excretion – Be certain to exclude normal physiologic release of ADH A&E(VINAYAKA) Case Study #1 SIADH • Treatment – Fluid restriction – Avoid hypotonic fluids – Hypertonic saline / oral sodium chloride – Frusemide. A&E(VINAYAKA) Cerebral Salt wasting Syndrome • Development of excessive natriuresis with hyponatremic dehydration in patients with intracranial disease • Seen in Head injury, Brain tumor, Intracranial Surgery or stroke A&E(VINAYAKA) CSW vs SIADH features CSW SIADH Volume status Wt Orthostatic signs Sr Na Hematocrit Uric acid Resp to hydration Resp to fluid rest Urine Na Low Loss Present Decreased Increased Normal or inc Improvement Possible shock >100 Normal No change Absent Decreased Normal Decreased Dec Na improve >20 A&E(VINAYAKA) Case Study #1 The saga continues…. Hospital course: Four hours after beginning fluid restriction, you are called because the patient is having a generalized seizure. There is no response to two doses of IV lorazepam and a loading dose of fosphenytoin What is the most likely explanation? A&E(VINAYAKA) Case Study #1 The saga continues Seizure 1) Worsening hyponatremia 2) Intracranial event 3) Meningitis 4) Other electrolyte disturbance 5) Medication 6) Hypertension What diagnostic studies would you order? A&E(VINAYAKA) Case Study #1 The saga continues Stat labs: Sodium 110 mEq/L What would you do now? A&E(VINAYAKA) Case Study #1 Hyponatremic seizure • Treatment – Hypertonic saline (3% NaCl) infusion – To correct sodium to 125 mEq/L, the deficit is equal to 0.6 X weight[kg] X (125 - measured sodium) 0.6 X 60 X (125-110) = 54O mEq A&E(VINAYAKA) Newer method • Rate of infusion of 3%NaCl • • • • = Na Requirement x 1000 infusate sodium x time (Desired-Actual Na) x 0.6.body wt x 1000 513 x no of hours As patient is symptomatic, rate of correction is 1 mEq/hr, Required rate of infusion of 3% NaCl = 1 x 0.6 x 60 x 1000 513 x 1 = 70 ml/hr Check sodium after 4 hours and correct accordingly A&E(VINAYAKA) Hyponatremia A&E(VINAYAKA) Case Study # 2 • 60 year old retired engineer presented to ER with history of inability to speak and move all 4 limbs since today morning. Detailed history revealed that he has been on naturopathy diet since 6 months and had developed GTCS 2 days back. He was treated outside for GTCS and following the treatment he is unable to communicate or use his limbs A&E(VINAYAKA) • His previous lab reports showed Na is 117 mEq/L and rest of the parameters are within normal Limits • Repeat Sodium in our hospital showed 145 mEq/L • What could be the possibility? A&E(VINAYAKA) Central Pontine Myelinolysis • Develops with 1. Aggressive treatment of Chronic hyponatremia 2. Raising Sr.Na >25mEq/L in first 48 hours 3. Raising Sr.Na to Normal or Above normal in 48 hours A&E(VINAYAKA) CPM • Focal demyelination in the Pons & extrapontine areas. • Causes Mutism / dysarthria Spastic Quadriplegia Pseudobulbar palsy Seizures Altered Mental Status Coma & Death A&E(VINAYAKA) Principles of Hyponatremia Management • Asymptomatic Hyponatremia Use 0.9%NaCl • Symptomatic Hyponatremia Use 3% NaCl • Correct only 12mEq/L defecit only perday • Chronic Hypernatremia with severe symptoms should receive hypertonic saline only to arrest the symptoms and followed by slow correction @ 0.5 mEq/L A&E(VINAYAKA) Hyponatremia Management is Double Edged Sword Knowledge Wisdom A&E(VINAYAKA) Case Study #3 HPI: A 5 month-old girl presents with a one day history of irritability and fever. Mother reports three days of “bad” vomiting and diarrhea. Home meds: Paracetamol and ibuprofen for fever PE: BP 70/40, HR 200, R 60, T38.3 C. Irritable, sunken eyes and fontanelle. A&E(VINAYAKA) Case Study #3 No one can obtain IV access after 15 minutes, what would you do now? A&E(VINAYAKA) Case Study #3 Place intraosseous line Bolus 40 ml/kg of isotonic saline Reassessment (HR 170, RR 40, BP 75/40) Serum studies Sodium 164 mEq/L BUN 75 mg/dL Chloride 139 mEq/L Creatinine 3.1 mg/dL Potassium 5.5 mEq/L Glucose 101 mg/dL Bicarbonate 12 mEq/L pH 7.07 pCO2 11 pO2 121 HCO3 8 A&E(VINAYAKA) Case Study #3 What is the most likely explanation of this patient’s Condition? A&E(VINAYAKA) Case Study #2 Treatment of Hypernatremia • To stop ongoing fluid loss • To correct water deficit = plasma Na – 140 x 0.6 x body wt. in kg 140 • Water deficit can be replaced with water by mouth or IV 5% dextrose or 0.45% NaCl A&E(VINAYAKA) Rate Of Correction • Acute Hypernatremia ½ body water defecit in 24 hours • Chronic Hypernatremia ½ body water defecit in 48 hours • Rapid correction cerebral edema & Neurological deterioration A&E(VINAYAKA) Case Study #4 • HPI: – A 50 year old man was involved in a motor vehicle accident two days ago. He sustained an isolated head injury with intraventricular hemorrhage and multiple large cerebral contusions. Three hours ago, he had an episode of severe intracranial hypertension (ICP 90mm Hg, MAP 50mm Hg, requiring volume plus epinephrine infusion for hypotension. Over the last two hours, his urine output has increased to 150 - 200 ml/hour A&E(VINAYAKA) What is your differential diagnosis? What test would you order? A&E(VINAYAKA) Case Study #4 Differential diagnosis Polyuria 1) Central diabetes insipidus Deficient ADH secretion (idiopathic, trauma, pituitary surgery, hypoxic ischemic encephalopathy) 2) Nephrogenic diabetes insipidus Renal resistance to ADH (X-linked hereditary, chronic lithium, hypercalcemia, ...) 3) Primary polydipsia (psychogenic) Primary increase in water intake (psychiatric), occasionally hypothalamic lesion affecting thirst center 4) Solute diuresis Diuretics (lasix, mannitol,..), glucosuria, high protein diets, post-obstructive uropathy, resolving ATN, …. A&E(VINAYAKA) Laboratory studies Serum studies Sodium 155 mEq/L BUN 13 mg/dL Chloride 114 mEq/L Creatinine 0.6 mg/dL Potassium 4.2 mEq/L Glucose 86 mg/dL Bicarbonate 22 mEq/L Serum osmolality: 320 mosmol/kg Other Urine specific gravity 1.005, no glucose. Urine osmolality: 160 mosmol/kg What are the main abnormalities? A&E(VINAYAKA) Case Study #4 Laboratory studies Major abnormalities 1) Hypernatremia 2) Polyuria (inappropriately dilute urine) What is the most likely explanation? A&E(VINAYAKA) Case Study #4 Diabetes Insipidus Diagnosis Central Diabetes insipidus 1) Polyuria 2) Inappropriately dilute urine (urine osmolality < serum osmolality) May be seen with midline defects Frequently occurs in brain dead patients What should you do to treat this A&E(VINAYAKA) patient? Case Study #4 Diabetes Insipidus • Treatment – ADH preparations - dDAVP nasal spray 2-4 μg/dl – Potentiate ADH effect – chlorpropamide, carbamazepine, NSAID’s. – Increase ADH release – Clofibrate Warning – Closely monitor for development of hyponatremia A&E(VINAYAKA) Hypernatremia A&E(VINAYAKA) Case Study #4 • HPI: – An 35 year old lady with Chronic kidney disease presents with irritability. She is on nightly peritoneal dialysis at home. The lab calls a panic potassium value of 7.1 meq/L. The tech says it is not hemolyzed. What do you do now? A&E(VINAYAKA) Case Study #4 Hyperkalemia Treatment Immediately repeat serum potassium. Do not wait for confirmatory labs especially if ECG changes present. Anticipatory Stop potassium administration including feeds A&E(VINAYAKA) ECG • What is this rhythm? • What is your immediate treatment? A&E(VINAYAKA) Case Study #5 Hyperkalemia Control effects Antagonism of membrane actions of potassium ▪ 10% Calcium gluconate 10-20 ml over 5 10 minutes; may repeat x2 Shift potassium intracellularly ▪ Glucose 1 gm/kg plus 0.1 unit/kg regular insulin ▪ Alkali therapy - Sodium bicarbonate 1 mEq/kg IV ▪ Inhaled 2 adrenergic agonist A&E(VINAYAKA) –Removal of potassium from the body –Loop / thiazide diuretics –Cation exchange resin: sodium polstyrene sulfonate (Kayexelate) 1 gm/kg PO or PR (or both) –Dialysis A&E(VINAYAKA) A&E(VINAYAKA) Hyperkalemia R A&E(VINAYAKA) x Case Study #5 • HPI: – A three year old boy is recovering from septic shock. He received 150 ml/kg in fluid boluses in the first 24 hours and has anasarca. You begin him on a frusemide infusion for diuresis. He develops severe weakness and begins to hypoventilate. You notice unifocal premature ventricular beats on his cardiac monitor. A&E(VINAYAKA) What is your differential diagnosis? What tests would you order? A&E(VINAYAKA) Case Study #6 Laboratory studies Serum studies Sodium 134 mEq/L Chloride 98 mEq/L Potassium 2.4 mEq/L Bicarbonate 27 mEq/L BUN 11 mg/dL Creatinine 0.4 mg/dL Calcium 9.2 mg/dL Phosphorus 3.2 mg/dL Other ECG: Unifocal PVC’s What is the main abnormality? A&E(VINAYAKA) Case Study #6 Laboratory studies Major abnormality 1) Hypokalemia What would you do now? A&E(VINAYAKA) Case Study #6 Hypokalemia Treatment Oral ▪ Safest, although solutions may cause diarrhea IV ▪ do not exceed 40 mEq/L or 10 – 20 mEq/hr potassium. - never give inj.Kcl directly intravenously. Replace magnesium also if low ▪ (25-50 mg/kg MgSO4) A&E(VINAYAKA) A&E(VINAYAKA) Summary • Disorders of sodium, water, and potassium regulation are common in critically ill. • Diagnostic approach must be considered carefully for each patient • Strict attention to detail is important in providing safe and effective therapy A&E(VINAYAKA) A&E(VINAYAKA)