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Fluids and Electrolytes

Fluids and Electrolytes. James Zeng. Complicated?. Simple?. Body Compartments. Plasma 3L. Na. K. Interstitial 12L. Intracellular 30L. Extracellular 15L. Replacement. Lost Ongoing losses Maintenance. Sources of Loss. Renal GI Skin Haemorrhage “Third Space”. Basal Fluids. 1.6L.

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Fluids and Electrolytes

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  1. Fluids and Electrolytes James Zeng

  2. Complicated?

  3. Simple?

  4. Body Compartments Plasma 3L Na K Interstitial 12L Intracellular 30L Extracellular 15L

  5. Replacement Lost Ongoing losses Maintenance

  6. Sources of Loss • Renal • GI • Skin • Haemorrhage • “Third Space”

  7. Basal Fluids 1.6L Lungs 400 Urine 500 Stool 200 Skin 500

  8. Basal Electrolytes Na • 2mmol/kg/d (140mmol) K • 1mmol/kg/d (70mmol)

  9. Input Enteral • Oral, NG, stomas Parenteral • IV, subcutaneous

  10. Parenteral Fluids Crystalloids Colloids Larger insoluble molecules High oncotic pressure Albumin, Synthetics (gelofusine, pentastarch), blood • Aqueous solutions • Solutes in water normal saline, 5% dextrose, 4% and 1/5, hartmann’s (CSL)

  11. Composition of Fluids

  12. Simple 25yo male MBA. Weber C # (nothing else) Theatre some time tomorrow.

  13. Replacement Lost Ongoing losses Maintenance

  14. A Bit Harder 30yo female. Stabbed a few times. HR120. BP80/60. Conscious. For theatre.

  15. Replacement Lost Ongoing losses Maintenance

  16. Estimating Blood Loss

  17. Back to the Stabbing Replace! • 2x 16G • 1+1L Stat • Consider blood products

  18. More Complicated 74yo lady LBO Difficult hartmanns x2 PRC intraop Hb90 IHD, diabetic D2 post op UO 15mL Lost Lost

  19. Replacement Lost Ongoing losses Maintenance

  20. Whoa! • Is she dry? • If dry, how much? • How do I give it? • Monitoring?

  21. History Dry Wet SOB SOA Distension Thirst Weakness Dizziness

  22. Exam Look at the chart, fasting status. Arterial (dry) • Hr, bp (postural), urine output trend, GCS Venous (wet) • JVP, Chest, ascites, oedema

  23. Tests? • Not really useful acutely • Worth doing for monitoring

  24. So What Do I Do? • Is she dry? • If dry, how much? • How do I give it? • Monitoring? It Depends!

  25. Dry? Maintenance • 1.5L/d Lost • ~1L Blood, probably replaced • Correct any imbalances, estimate hydration status Ongoing • Probably increased in third space

  26. Wet? Poor renal perfusion • Pump failure, sepsis, drugs Renal • Drugs, ATN, GN Post renal

  27. Hyponatraemia Dry Wet (or normal) Inappropriate free water retention SIADH (central, peripheral) Cirrhosis CCF Restrict fluid Treat cause • Excessive loss of sodium containing fluids • Renal, GI, skin • Give slow replacement

  28. Hypernatraemia Dry (or normal) Wet Inappropriate sodium retention Hyperaldosteronism (adenoma, poor perfusion, low oncotic pressure) Renal failure Treat cause • Excess free water loss • Diabetes insipidus (central or peripheral) • Loss from GI and skin • Replace free water

  29. Hyperkalaemia Shift from cells • Acidosis, Rhabdo, tumour lysis Inappropriate retention • Hypoaldosterone, addisons, drugs Fatal arrythmias • Small P, tented Ts, sinusoidal rhythm

  30. Hyperkalaemia • Ca carbonate 10mL 10% centrally • Insulin 10U (50ml 50% dextrose) • Bicarb • Salbutamol • Risonium • Dialysis

  31. Hypokalaemia • Usually lost somewhere (GI, renal) or redistributed (alkalosis) • Replacement (oral or IV) • Also replace Mg

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