Transcript Fluid and Electrolyte Emergencies in Critically Ill

Fluid & Electrolyte Emergencies
In Critically Ill
Dr.Patibandla.Sowjanya
Dept Of Accident , Emergency & Critical Care Medicine
Vinayaka Missions Kirupanandavariyar Medical College
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Introduction
• Total body water (60%)
• Two third is intracellular fluid (40%)
• One third is extra cellular fluid (20%)
- Interstitial fluid (15%)
- Intravascular fluid (5%)
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Fluid shifts
EXTRACELLULAR
INTRACELLULAR 30 LIT
40%
INTERSTITIAL 9 LIT
IV 5 LIT
15%
5%
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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
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ICF
ECF
Major Cation
Potassium
Magnesium
Sodium
Major Anion
Phosphate
Sulphate
Protein
Chloride
Bicarbonate
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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
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Three categories of fluids
• Isotonic - Fluid has the same
osmolarity as plasma
Eg: Normal saline
Ringers lactate
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• Hypotonic - Fluid has fewer solutes
than plasma
Eg : Water, 1/2 N/S (0.45% NaCl)
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• Hypertonic - Fluid has more
solutes than plasma
Eg:5% Dextrose in Normal Saline
(D5 N/S) , 3% saline solution.
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Isotonic
Infusion
2 litres of
blood
30 litres
9 litres
3 litres
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Intravascular Volume increases to 5 liters
30 litres
9 litres
5 litres
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Hypertonic
Infusion
2 litres of
colloid
30 litres
9 litres
3 litres
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Initially it becomes 5 L
30 litres
9 litres
5 litres
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Hypertonicity of Colloid shifts I/C fluid into I/V
29 litres
8 litres
7 litres
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If 2 L of Crystalloid infused…
2 litres of
0.9% saline
30 litres
9 litres
3 litres
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Initially I/V becomes 5L
30 litres
9 litres
5 litres
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Isotonicity of Crystalloid shifts I/C & I/V volume into interstitial space
29 litres
10.5 litres
4.5 litres
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Hypotonic
Infusion
2 litres of
5%dextrose
30 litres
9 litres
3 litres
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Hypotonicity Shifts the fluid into the I/C space
31 litres
9.7
litres
3.3
litres
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Signs of Volume depletion
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Postural hypotension
Tachycardia
Absence of JVP
Dry mucosa
Decreased skin turgor
Oliguria
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Signs of Volume overload
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Hypertension
Raised JVP/gallop
Pedal edema
Pulmonary edema
Ascites
Organ failure
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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
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The rules of fluid replacement
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Replace blood with blood
Replace plasma with colloid
Resuscitate with colloid / crystalloid
Replace ECF depletion with saline
Rehydrate with dextrose
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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?
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• Isotonic saline / Ringer’s lactate
• No dextrose containing fluid initially
Why?
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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?
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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, ...
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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?
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Case Study #1
Laboratory studies
Major abnormalities
1) Hyponatremia
2) Oliguria (inappropriately concentrated urine)
What is the most likely explanation for these
findings?
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In Hyponatremia……
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Case Study #1
Syndrome of Inappropriate Antidiuretic Hormone
(SIADH)
 Variable etiology
▪ Trauma
▪ Infection
▪ Psychosis
▪ Malignancy
▪ Medications
▪ Diabetic ketoacidosis
▪ CNS disorders
▪ Positive pressure ventilation
▪ “Stress”
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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
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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
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Case Study #1
SIADH
• Treatment
– Fluid restriction
– Avoid hypotonic fluids
– Hypertonic saline / oral sodium chloride
– Frusemide.
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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
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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
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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?
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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?
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Case Study #1
The saga continues
Stat labs:
Sodium 110 mEq/L
What would you do now?
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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
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Newer method
• Rate of infusion of 3%NaCl
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= 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
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Hyponatremia
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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
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• 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?
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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
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CPM
• Focal demyelination in the Pons &
extrapontine areas.
• Causes  Mutism / dysarthria
Spastic Quadriplegia
Pseudobulbar palsy
Seizures
Altered Mental Status
Coma & Death
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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
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Hyponatremia Management is Double Edged Sword
Knowledge
Wisdom
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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.
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Case Study #3
No one can obtain IV access after 15 minutes,
what would you do now?
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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
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Case Study #3
What is the most likely explanation of this
patient’s Condition?
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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
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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
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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
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What is your differential diagnosis?
What test would you order?
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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, ….
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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?
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Case Study #4
Laboratory studies
Major abnormalities
1) Hypernatremia
2) Polyuria (inappropriately dilute urine)
What is the most likely explanation?
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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
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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
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Hypernatremia
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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?
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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
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ECG
• What is this rhythm?
• What is your immediate treatment?
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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
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–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
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Hyperkalemia R
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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.
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What is your differential diagnosis?
What tests would you order?
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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?
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Case Study #6
Laboratory studies
Major abnormality
1) Hypokalemia
What would you do now?
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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)
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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
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