1. Fluid and Electrolyte Abnormalities

2. Introduction
Fluid and eclectrolyt balance is a dynamic process that is crucial for life.
Any disturbance will cause disorder.
Approx. 60% of the body weight is fluid (water and electrolytes.
Body fluid is located in 2 compartment:
Intracellular (ICF): 2/3 of TBF
Extrecellular (ECF): 1/3 of TBF compose of IVF + 3rd space (interstitial space)

3. Definitions Diffusion: Hydrostatic pressure:
Osmotic pressure (oncotic pressure):
Osmolarity:
Osmolality:

4. IVFs Could be Crystalloids or collids
Crystalloids : isotonic, hpertonic, hypotonic
Colloids: poroteins (albumin, plasmagel) or non proteins (starch, dextran)

5. IVFs Hypotonic fluids: e.x: NS 0.45%, D10W%, dehyration.
Isotonic fluids: e.x: NS 0.9%, hypovelemic
Hypertonic fluids: e.x: 3% NS, edema
Colloids : Albumin, Tx hypovemia, # in spesis, hemorrhage

6. Normal Values Na: 135- 145 mEq/L K: 3.5- 5.3 mEq/L
Blood Urea Nitrogen (BUN): 7-20 mg/dl
Creatinine: mg/dl
Albumin: 3.5 – 5.3 g/dl
Cl: mEq/L
Ca: mg/dl
Mg: mEq/L
Po4: mg/dl

7. Normal Values HEMATOCRIT (HCT)
Normal Adult Female Range: % Normal Adult Male Range %  
HEMOGLOBIN (HGB)
Normal Adult Female Range: g/dl Normal Adult Male Range: g/dl
WBC: cell/Cubic mm.
Platelets: cell/Cubic mm.

8. Hypovolemia Mild: 4% loss TBW or < 15% blood volume
Moderate: 6% TBW or 15-30% BV
Severe: 8% TBW or 30-40% BV
Shock: >8% TBW or > 40% BV
S/Sx:
Sleepy, apathy, coma weakness
orthostatic, tachycardia, decreased pulse pressure, low CVP.
Poor turgor, hypothermia, dry membranes
Oliguria.

9. Hypovolemia, continued
Lab:
BUN: Cr ratio greater than 20
Inc. hematocrit, 3% per liter deficit
increased urine spec. gravity and osmolality

10. Hypovolemia, continued
Treatment:
Acute: 2L LR via large bore IV then blood
Subacute:
Isotonic or hypotonic deficits give isotonic NS or hypotonic 0.45 NS or LR (e.g. vomiting = NS, diarrhea = LR)

11. Hypervolemia
Etiology: Cardiac failure, Renal failure, mobilization of fluid, iatrogenic, psychologic.
S/Sx:
Wt gain over baseline. (Fasting losses are kg/day)
wheezing, pedal/sacral edema
elevated CVP
Pulmonary edema on CXR

12. Hypervolemia, continued
Lab:
Decreased Hct and albumin
Treatment:
Water restrict to 1500 cc/day
+/- Diuretics
Sodium restrict to 0.5 gm/day
(Albumin followed by diuretics)

13. Hyponatremia Low Na in blood serum Causes: fluid overload
Low NA in diet

14. Hyponatremia, continued
S/Sx:
Neurologic: muscle twitching, hyperreflexia, seizures and HTN
Salivation, lacrimation, diarrhea
Often asymptomatic if slow until below 120 mEq/L. (130 mEq/L if acute)
Treatment: correct underlying disorder
Fluid restrict, + diuretics
Hypertonic saline to increase level 2-3 mEq/L/hr and max rate 100cc of 5% saline/hr

15. Hypernatremia Free water deficit or water loss greater than salt loss.
Always assoc with hyper osmolar state.
S/Sx:
Neurologic: restless, seizure, coma, delirium and mania
THIRST, weakness

16. Hypernatremia, continued
Sticky mucus membranes, poor salivation/lacrimation, hyperpyrexia, Red swollen tongue
Treatment: correct underlying disorder.
Slow administration of IV fluids to reduce plasma sodium level, at rate not more than 2 mEq/l/hr.
Diuretics.

17. Hypokalemia S/Sx: Low K+ in blood serum
High intracellular uptake (insulin therapy).
renal/diuretics, steroids, and renal tubular acidosis
S/Sx:
Clinical: muscle weakness/fatigue. Insulin resistance in DM
EKG: low, flat T-waves, ST depression, and U waves

18. Hypokalemia, continued
ECG changes in hypokalemia

19. Hypokalemia, continued
Treatment:
Check renal function
Treat alkalosis, decrease sodium intake
PO with mEq doses
IV: peripheral /central and increase K+ in maintenance fluids.

20. Hyperkalemia high K+ level in blood serum acidosis, low insulin
tissue necrosis, digoxin poisoning
Renal insufficiency, DM,

21. Hyperkalemia, continued
S/Sx:
Clinical: nausea/vomiting, colic, weakness diarrhea
EKG: early – peaked T waves then flat P waves, depressed ST segment, widened QRS progressing to sine wave and V fib.
Cardiac arrest occurs in diastole

22. Hyperkalemia – ECG Changes

23. Hyperkalemia, continued
Treatment:
Ca-gluconate – 1 gm over 2 min IV
Sodium bicarbonate – 1 amp, may repeat in 15min
D50W (1 ampule = 50 gm) and 10U regular insulin
Emergent dialysis
Hydration and diuresis

24. Hypocalcemia
Seen in:
pancreatitis, hyperPO4, low Vitamin D, massive blood transfusion, drugs (e.g. gentamicin) renal insufficiency, hypoalbuminemia
S/Sx:
numbness, tingling, circumoral paresthesia, cramps tetany,
EKG has prolonged QT interval
Treatment:
Acute: (IV) CaCl or CaGluconate
Chronic: PO suplment, Vit D

25. ECG Changes in Calcium Abnormalities

26. Hypercalcemia Causes : S/Sx:
Usually secondary to hyperparathyroidism or malignancy.
Other causes are thiazides, acute adrenal insufficiency
S/Sx:
N/V, anorexia, abdominal pain, confusion, lethargy.

27. Treatment: Hydration with NS then loop diuretic.
Steroids for lymphoma, multiple myeloma, adrenal insufficiency, bone mets.
Vit D intoxication.
May need Hemodialysis.

28. Hypomagnesemia Causes : S/Sx:
Malnutrition, burns, pancreatitis, SIADH, parathyroidectomy, primary hyperaldosteronism
S/Sx:
weakness, fatigue, MS changes, hyperreflexia, seizure, arrhythmia
Treatment: IV replacement of 2-4 gm of MgSO4 per day or oral replacement

29. Hypermagnesemia causes :
Renal insufficiency, antacid abuse, adrenal insufficiency, hypothyroidism, iatrogenic
S/Sx:
- N/V, weakness, MS changes, hyporeflexia, paralysis of voluntary muscles, EKG has AV block and prolonged QT interval.
Treatment:
- Discontinue source, IV CaGluconate for acute Rx, Dialysis

30. Hypophosphatemia Seen in:
- hyperalimentation, after starvation, DKA, malabsorption, phosphate binding antacids, alkalosis, hemodialysis, hyperparathyroidism
S/Sx:
myocardial depression due to low ATP,bone pain, hemolysis, cardiac arrest
Treatment:
- PO replacement (Neutraphos) or IV KPhos or NaPhos mM/kg over 6 hrs

31. Hyperphosphatemia Seen in : Hyperphosphatemia
Renal insufficiency, hypoparathyroidism, may produce metastatic calcification
Treatment
- Treated with restriction and phosphate-binding antacid (Amphogel)

32. Zinc Enzyme activator and cofactor Causes :
Deficiency in malabsorption, trauma, cancer or diarrhea
S/Sx:
- “4 D’s” – diarrhea, depression, dermatitis, dementia
Treatment:
- treated with zinc sulfate 3-6mg/day if with (normal number of stools)