Fluids & electrolytes
• Urine 1000 – 1500ml (800ml)
• Stool 250ml
• Insensible loss 750ml
Maintainence:
1st 10kg – 100ml/kg/day
2nd10 kg – 50ml/kg/day
Susequently – 20ml/kg/day
Intraoperative fluid loss
3rd space fluid loss
Duration
Tissue trauma
Crystalloids
Mobilisation of perioperative 3rd space losses: 2nd – 3rd daym
• Hypotonic solution: replace free water loss
Albumin SAFE(Saline vs Albumin Fluid Efficacy) study: no significant
difference
Albumin: 25% 100ml 5% 500 ml
Replenish intravascular volume
Dextran: synthetic polymer of glucose. Side effects: renal failure,
osmotic diuresis, coagulopathy
Hetastarch: synthetic molecule resembling glycogen. 6% in 0.9%NaCl
Renal failure, increased use of renal replacement therapy
sodium
135 – 150 mmol/L
Tonicity
Neurologic: lethargy, confusion, nausea, vomiting, seizure
SIADH
• Low plasma osmolality <280mOsm/L
• Hyponatremia <135mmol/L
• Low urine output with concentrated urine >100mEq/L
• Elevated urine sodium >20mEq/L
Pulmonary disorders – atelectasis respiratory failure, trauma meningitis
Drugs – cyclophosphamide cisplatin
Ectopic ADH production
Transurethral resection syndrome
Intraoperative absorption of fluid loss
3%NaCl
1% glycine
Hypovolumic hypernatremia
Free water deficit = 0.60 x total body water x (serum Na/140 - 1)
½ of water deficit - 1st 24 hours
Remaining - 2 to 3 day
If oral fluids not accepted, D5W or D5 0.45% NaCl
Hypervolemic hypernatremia
• Parenteral administration of hypertonic solution, aldosteronism,
cushing syndrome
• Loop diuretic
Isovolumic hypernatremia
hypotonic lossed: skin, respiratory tract, urinary loss
Inappropriate loss of hypotonic fluid with isotonic fluid
Diabetes insipidus
Hypernatremia >150mEq/L, polyuria, polydipsia
Hypotonic urine <200mOsm/kg specific gravity<1.005
Central: ADH hyposecretion desmopressin
Neurogenic: insensitivity to ADH
Hypertonic saline – decrease ICP and cerebral edema
potassium
• 3.3 to 4.9 mmol/L
• Hypokalemia: cardiovascular ectopy, T wave depression, prominent U
wave, re-entry arrhythmia
• GI loss, renal and cutaneous loss, insulin excess, metabolic alkalosis,
myocardial infarction, delirium tremons, hypothermia refeeding
syndrome
• Oral: 40 – 100mEq
• Parenteral 40mEq
hyperkalemia
• Spurious elevation
• Insulin deficiency, beta adrenergic blockade, acute acidemia,
rhabdomylosis, cell lysis, digitalis intoxication reperfusion injury of
limb succinyl choline administration
• Discontinue beta blockers, ACE inhibitors, NSAID
• Calcium gluconate
• Dextrose with insulin
• Inhaled beta agonist albuterol
• Sodium polysterone sulfonate
• Hydration
• dialysis
calcium
8.9 – 10.3 mg/dL
Ionised 45%, protein bound 40% complex with freely diffusible 15%
Hypocalcemia
Tetany Chvostek sign, periodical numbness tingling
QT prolongation
Vitamin D deficiency, rhabdomylosis blood citrate, total thyroidectomy
acute alkemia, bicarbonate administration, hypoalbuminemia
Oral replacement
Parenteral: calcium gluconate – 1-2mg/kg
Also check Mg, phosphorous and K levels
hypercalcemia
• Altered mental status, diffuse weakness, nephrolithiasis, adynamic
ileus, nausea vomiting, severe constipation
• QT interval shortening, arrhythmia
• Malignancy vitamin D intoxication, thiazides
Normal saline and loop diuretics
Calcitonin
Pamidronate
plicamycin
• Magnesium: intracellular 1.3 – 2.2mEq/L
• Phosphorous: 2.5 – 4.5mEq/L
In which of the following patients, is there a clinically proven reduction
in mortality following resuscitation with hypertonic saline?
A 65 year old woman with mild to moderate dehydration
A 35 year old man with moderate hyponatremia from psychogenic
polydipsia
A 50 year old woman with traumatic hemorrhagic shock following RTA
and splenic laceration
5 year of child with renal insufficiency
No proven benefit in any of these patient
A patient with severe sepsis 20 to cholangitis has received 4 litres of
crystalloid resuscitation over last 6 hours. His MAP remains below 65,
but fluid responsive. Which of the following fluids should be
administered?
0.9% NS, 1L over 1 hour
0.45% NS, 2L over 1 hour
5% albumin, 500 cc over 1 hour
Dextran40, 500 cc over 2 hours
Hetastarch, 6% solution, 1L over 1 hour
A patient with a known h/o CAD presents to the ED with shortness of
breath and extensive lower extremity edema. Initial laboratory studies
reveal Na: 124. therapy includes?
1L of 0.9% NS
Fluid restriction to 1L of free water/ day
Fluid restriction to 2L of free water/ day
500 cc lactated ringer solution
A head injury patient in the ICU has large volume urine output and you
suspect central diabetes insipidus. How will you confirm?
Urine specific gravity
Serum sodium and urinary sodium
24 hour urine for electrolysis
Serum potassium and urine sodium
Serum glucose level
A patient has potassium of 6. what is the correct order of management?
Confirmatory whole blood K level, ECG, administer insulin and glucose
Order an ECG, order a confirmatory whole blood K level, administer
insulin and glucose
Order an ECG, administer, administer insulin and glucose, place a
dialysis catheter, order a confirmatory whole blood K
Order an ECG, place a dialysis catheter, administer albuterol administer
insulin and glucose, order a confirmatory whole blood K
Consult renal service for dialysis management, order an ECG,
administer insulin and glucose.
Which of the following is a manifestation of hypomagnesemia
Flaccid paralysis
Renal insufficiency
Insomnia
Ventricular arrhythmias
vertigo
