@MD1TALK
Fluid therapy + electrolytes!
Fluids compartments → Intracellular or Extracellular Fluid
(divided into interstitial & Intra-vascular fluid)
% of Fluids in → IntraCellular (66%) - ExtraCellular (33%)
Composition of Fluids → 60% of weight → IC is 40% and EC is
20% (Think of 60-40-20)
Physiologic Response Against Hypovolemia → Salt & water
retention via RAAS & ADH
Types of Fluids → Crystalloids, Colloids, Blood Products
Crystalloids (M/C used fluids):
It’s an Aqueous solutions with varying concentrations of electrolytes
All Crystalloids ↑ intravascular Volume → ↑ extracellular volume (ECV)
Hypertonic saline
>
Lactate Metabolized By Liver to form
& HCO3→ not Recommended as 1st line
Maintenance → ↑ risk of Alkalosis
Glucose will be utilized by
cells→ sodium free water
@MD1TALK
Colloidal solutions:
have a high molecular weight that mostly remains confined to
intravascular compartment → generates oncotic pressure to draw
fluids into vessels
Examples:
Natural colloids → albumin, fresh frozen plasma (FFP)
Artificial colloids→ gelatins, dextrans, hydroxyethyl starch (HES)
Diuretic resistant
nephrotic
Acute management
of severe burn
Acute lung injury
Spontaneous
bacteria peritonitis
Hypoalbuminic
state following
paracentesis in
cirrhosis
DAASH
Effects of Colloids?
greater effect on intravascular volume than crystalloids
↓ blood coagulability (↓PLT adhesions)
Anti-inflammatory effect
Administration: Their use is controversial, but they may be indicated
in combination with crystalloids especially in burns after 24h
Priming extra-corporal → ↓ blood viscosity → ↓ thrombosis risk
@MD1TALK
Adverse effects → colloids is AN VIP2 " :
1. Anaphylaxis
2. Nephrotoxicity (especially in pre-existing renal damage)
3. Volume overload
4. Interfere with blood grouping and cross matching
5. Platelet aggregation Impairment after infusion with a large volume of
HES
6. Pruritus with prolonged use (Common with HES)
Blood products:
transfusion of packed RBC is indicated in massive blood loss (>30%)
General indications for Parenteral Fluids therapy:
1. Fluid Resuscitation
hypovolemic shock require rapid fluid infusion and isotonic solution is
the fluid of choice When Bolusing
Rapid infusion of a 500–1000 mL bolus of NS or RL within 15min
and observe for a response → no response? → repeat bolus
inadequate response to fluid resuscitation is characterized by:
A. Low urine output (<0.5 mL/kg/hr; best indicator unless he has
HF or renal dysfunction, in that case use CVP or wedge pressure)
B. ↑ HR & ↓ BP
C. ↓ CVP (central venous pressure)
No response to a multiple fluid challenges ? →
vasopressors and/or inotropes
Consider other causes of shock besides hypovolemia (cardiogenic,
sepsis)
2. Replacement of free water deficit:
Indicated to treat dehydration and/or hypernatremia
deficit (in liters) = K × weight × (Current [Na+]/140 – 1)
Types of fluids that can be used:
DW5%
½NS
3. Maintenance:
indicated in who cannot or not allowed to take oral fluids, cover
insensible H2O loss
Children: 4/2/1 rule to Calculate Rate per Hour or Holiday-Segar
(per day)
@MD1TALK
4 mL/kg for the first 10 kg +
2 mL/kg for the next 10 kg +
1 mL/kg for every other kg
M/C Types of Fluids in maintenance:
D5 1/2NS for adults or D5 1/4NS for children with 20 mEq KCl
• ↑ amount of Maintenance fluids with Fever, Tachypnea
• ↓ the Maintenance with CHF, low output renal failure
4. Replacement of ongoing fluid loss → ML x ML of what he
losses now:
common conditions with an ongoing fluid loss are:
I. Burns
II. Polyuria (high output renal failure, diabetes insipidus)
III. Surgical drains
IV. ongoing GI loss (vomiting, diarrhea)
composition + amount of fluid given should ideally = composition +
amount of fluid lost
Rule → All GI loss is ideally replaced by RL, except gastric Loss
Check Titration parameters for IV fluid therapy:
1. Signs of fluid overload→ pedal edema, fine crackles
2. Electrolyte imbalances
3. Fluid balance charts: record intake and fluid output (urine output,
output from surgical drains, and, if applicable, the volume of loose
stools or vomit)
Routes:
IV access → The M/C route for fluids or medication
Intraosseous (IO) access:
• In “difficult/collapsed” veins, preferred over central venous access for
resuscitation
Central venous access:
• Central venous catheters are longer and thus it’s slower flow than
peripheral venous catheters with the same lumen diameter. However,
@MD1TALK
a much higher flow rate can be achieved with special large bore (high-
flow Hickman and Shaldon catheters)
Indications of central lines placement:
1. Fluid resuscitation in “collapsed” peripheral veins (when IO access is
not feasible)
2. Hemodynamic monitoring: measurement of CVP, pulmonary artery
catheterization
3. Administration of Veno-irritant substances: vasopressors,
chemotherapeutic, TPN
Last minute telegram! →If they’re septic and you know it …
raise their legs ???!
Third spacing:
Fluid accumulation in interstitium (think of intravascular and
intracellular spaces as the first two spaces)
the classic signs of third spacing → Tachycardia + ↓ urine output
Treatment? IV isotonic fluids +- Diuretics
“third-spacing” postoperatively?
Third-spaced fluid tends to mobilize back into the intravascular space
around postoperative day 3 (POD#3) → leading to CHF, shock,
hyponatremia!!
@MD1TALK
Osmolality of NS is 154 + 154 = 308
Know the NS values and Divide at
1/2 or 1/4 to get the rest
@MD1TALK
Electrolytes !
Most abundant IC electrolytes is → K then Mg then Po4 → Expect this
to rise in tumor lysis Syndrome or any condition lead to cells rupture
Normal CHEM 10 Values:
Hyperkalemia
Normal range for K:
3.5 to 5.0 mEq/L
Causes of hyperkalemia → BRAD
Blood transfusion*, Renal failure, Acidosis, Destruction of tissue (injury/
hemolysis)
ECG findings:
prolonged PR, wide QRS, STD, Peaked T waves⛺ , bradycardia or
[Link]
The critical values:
K+ >6.5
Chronic Rx (asymptomatic or non critical value):
Lasix or sodium polystyrene sulfonate (Kayexalate®)
@MD1TALK
Rx of Acute symptomatic hyperkalemia?
1st Step order ECG → (+) finding? → C BIG K
Die (if you see a big serum K+, your patient may
die!):
1. Calcium gluconate (1st drug, to stabilize
membrane)
2. Beta agonist (Albuterol) / Bicarbonate
3. → shifters inside cells
4. Insulin + Glucose → shifters inside cells
5. Kayexalate or Diuretics (lasix) → if he can pee?→ choose Lasix
6. Dialysis if no response to the above
“pseudo-hyperkalemia”?
falsely elevated K+ due to sample hemolysis
Acid–base that lowers potassium?
Alkalosis (thus, give Bicarbonate for hyperkalemia)
nebulizer treatment can help lower K+ level? Albuterol
Hypokalemia:
Causes → DADS INVIsible ☹ %
Diuretics, Alkalosis, Diarrhea, Steroids, Intestinal fistulae, NGT
aspiration, vomiting, Insulin
signs/symptoms?
Weakness, tetany, paraesthesia, ileus
ECG of HypUkalemia? Flattening of T waves, U waves, ST segment
depression, PAC, PVC, atrial fibrillation
Rapid treatment? IV KCl + Mg correction if needed
Mg+ deficiency can cause Refractory hypokalemia→ thus you
need to replace Mg first before replacing K
Know!: Hypomagnesemia inhibits K+ reabsorption from renal tubules
Sodium disorders:
Hyponatremia: < 135 mEql/L
Hypernatremia: > 145 mEql/L
Hypernatremia
normal range for sodium level
135 to 145 mEq/L
causes → 4Ds
Dehydration, Diabetes insipidus, Diuresis,
Diaphoresis, TPN
@MD1TALK
signs/symptoms?
Seizures, confusion, pulmonary or peripheral edema
the usual Fluid Replacement slowly over days?
D5W or 1/4 or 1/2 NS
How fast should you lower sodium?
Guidelines: no more than 12 mEq/L per day
major complication of lowering the sodium level too fast is
Seizures due to cerebral edema (not central pontine myelinolysis)
Hyponatremia
Hypovolemic hyponatremia causes:
Diuretics, hypo-aldosteronism, vomiting, NGT suction, burns,
pancreatitis
Euvolemic:
SIADH
Hypervolemic: → organ failure
Renal and heart and liver failure, iatrogenic fluid overload (dilutional)
signs/symptoms:
Seizures, confusion, coma, weakness, ileus
Treatments:
Hypovolemic:
• Mild/Moderate → IV NS to correct underlying cause (Hypovolemia)
• Severe (Sx of seizure or coma) or Na+ ≤120 → IV 3%NS
Euvolemic:
• Mild/moderate → fluid restriction
• Severe → IV 3%NS
Hypervolemic:
• mild/moderate→ fluid restriction +- loop
• Severe Sx → NS
How fast should you rise sodium level?
Guidelines: no more than 12 mEq/L per day
Correction of chronic Asymptomatic hyponatremia too quickly?
Central pontine myelinolysis!
What are the signs of central pontine myelinolysis?
1. Confusion
2. Spastic quadriplegia
3. Horizontal gaze paralysis
MCC of mild postoperative hyponatremia?
Fluid overload
Know: How can the sodium level in SIADH be remembered? SIADH
(Sodium Is Always Down Here) = Hyponatremia
@MD1TALK
New guidelines: Na+ should not be changed more than 6-8 per day for
hypo/hypernatremia
How can you remember the complications of correcting sodium
abnormality too quickly?
“Pseudo-hyponatremia”
Falsely due to Hyperglycemia, Hyperlipidemia, or Hyper-proteinemia
Hyper-calcemia
Causes is “CHIMPANZEES”:
1. Calcium supplementation IV
2. Hyperparathyroidism (1°/3°)/ hyperthyroidism
3. Immobility/Iatrogenic(thiazide diuretics)
4. METS
5. Paget’s disease (bone)
6. Addison’s disease
7. Neoplasm
8. Zollinger ellison syndrome (as part of MENI)
9. Excessive vitamin D
10. Excessive vitamin A
11. Sarcoid
signs/symptoms:
“Stones, bones and abdominal groans, and psychiatric overtones”
@MD1TALK
ECG findings?
Short QT
Acute treatment of hypercalcemic crisis?
Volume expansion with NS then IV furosemide (not thiazides) then:
options for lowering Ca+ level?
bisphosphonates +- calcitonin, consider steroid in leukemia or
lymphoma, dialysis (last resort)
HypOcalcemia
Causes:
Short bowel syndrome, pancreatitis, osteoblastic metastasis.
Signs:
Chvostek’s sign? Facial muscle spasm with tapping of facial nerve
Trousseau’s sign? Carpal spasm after occluding blood flow in forearm
with blood pressure cuff
Other signs/symptoms?
peri-oral paresthesia (early), ↑ deep tendon reflexes (late),
laryngospasm, seizures, tetany
ECG findings?
PrOlonged QT
What is the acute treatment?
IV Calcium gluconate
chronic treatment?
Calcium PO, vitamin D
complication of infused calcium if the IV infiltrates?
Tissue necrosis; never administer peripherally unless absolutely
necessary
ionized is the best way to check calcium level in ICU?
Hypermagnesemia
normal range → 1.5 to 2.5 mEq/L
@MD1TALK
Causes? TPN, renal failure
Rx? → as Acute hyperkalemia (C BIG K Die)
Hypomagnesemia
Causes?
TPN, renal failure, hypocalcemia
signs/symptoms → As hypocalcemia signs
↑ deep tendon reflexes, tetany, tremor, Chvostek’s sign, dysrhythmias
Acute treatment?
MgSO4 IV
chronic treatment?
Magnesium oxide PO (side effect: diarrhea)
Hyperphosphatemia
signs/symptoms? heart block
causes?
Renal failure, chemotherapy, hyperthyroidism
treatment?
Aluminum hydroxide (binds phosphate)
Hypophosphatemia
complication of severe hypophosphatemia?
Respiratory failure
causes?
GI losses, alcohol abuse, renal loss
critical value? <1.0 mg/dL
Treatment?
Supplement with sodium phosphate or potassium phosphate IV
(depending on potassium level)
Miscellaneous
This ECG pattern is consistent with which electrolyte abnormality?
Hyperkalemia: peaked T waves
Fire Notes& ' :
Which electrolyte is an inotrope? Calcium
@MD1TALK
What are the major cardiac electrolytes? Potassium
(dysrhythmias), magnesium (dysrhythmias), calcium (dysrhythmias/
inotrope)
MCC of electrolyte-mediated ileus? Hypokalemia
An elderly patient goes into CHF on POD #3 after a laparotomy. What
is going on?
Mobilization of the “third-space” fluid into the intravascular space,
resulting in fluid overload and resultant CHF (but also must rule out
MI)
What fluid is used to replace NGT (gastric) aspirate? D5 1/2 NS with
20 KCl
What electrolyte is associated with succinylcholine? Hyperkalemia
Tumor lysis syndrome cause (↓ Calcium + ↑ K + Mg + PO4-)
@MD1TALK
@MD1TALK
@MD1TALK
Hyperkalemia detailed mangment
MD1TALK
1-Risk assessment → Acute Hyperkalemic emergency or chronic
hyperkalemia
Acute Hyperkalemic emergency → P/O:
1-Manifestation (Paralysis or weakness or cardiotoxcity that is manifested by ECG)
2-Asymptomatic + K+ >6-6.5:
Cardiac Intracellular Enhanced K+
↓ Reduce K intake + Dialysis if no
membrane shifting → insulin + elimination → treat the underlying response to all
stabilization → IV glucose ⎮ inhaled Lasix or Kayexalate + cause measures
calcium gluconate SABA NaHCO3
Less urgent hyperkalemia with P/O:
1-Asymptomatic
2-K+ = 5.5–6.0 mEq/L
Consider one of
following:
❌ ❌ ✅
1. If predialysis CKD:
1. Cation exchange nephrology consult
medications for renal
2. Diuretics replacement therapy
3. Oral sodium
bicarbonate