Fluid and Electrolyte

Physiology
Dr. Raymon Grogan
11/6/06
Total Body Fluid by Compartment
Total Body Water
Electrolyte Composition of Body
Fluid Compartments
 Composition of Parenteral Fluids
(mEq/L)
Fluid Na+ K+ Ca2+ Cl- HCO3- pH
ECF 142 4 5 103 27 7.4

LR 130 4 2.7 109 28 6.5

.9% NaCl 154 154 4.5

.45% NaCl 77 77 4.5

.2% NaCl 30 30 4.5

3% NaCl 513 513 4.5

5% NaCl 855 855 4.5

5% Albumin 145 7.4

 Composition of GI Fluids (mEq/L)
Source Daily Loss Na+ K+ Cl- HCO3-
Saliva 1000 30-80 20 70 30
Gastric 1000-2000 60-80 15 100 0
Panc 1000 140 5-10 60-90 40-100
Bile 1000 140 5-10 100 40
SB 2000-5000 140 20 100 25-50
LB 200-1500 75 30 30 0
Sweat 200-1000 20-70 5-10 40-60 0
 Hyponatremia
 Defined as serum [Na+] less than 136
mEq/L
 Water shifts into cells causing cerebral
edema
 125 mEq/L – nausea and malaise
 120 mEq/L – headache, lethargy,
obtundation
 115 mEq/L – seizure and coma
 Hyponatremia
 1. Assess plasma osmolality
 2. Assess volume status of patient
 Hypervolemic, Euvolemic, Hypovolemic
 3. Assess Urine Sodium Concentration
 Needed for definitive diagnosis, not needed for
treatment purposes
 4. Calculate Na+ Deficit
 0.6 x weight (kg) x (130 – plasma [Na+])
 5. Correct at no more than 0.5mEq/L per hour
or 12 mEq/L per 24 hours
 Isosmotic and Hyperosmotic
Hyponatremia
 Iso and Hyperosmotic hyponatremia are due to
excessive solutes in plasma.
 Isosmotic
• Pseudohyponatremia – No treatment necessary
 Hyperlipidemia
 Hyperproteinemia
• Isotonic Infusions

Glycine

Mannitol

Hyperosmotic – Treat underlying cause
• Hyperglycemia
 Each 100 mg/dl of glucose reduces [Na+] by 1.6 mEq/l
• Hypertonic Infusions
 Glycerol
 Mannitol
 Glycine
 Hyposmotic Hyponatremia
 1. Assess volume status
 Hypervolemic – cirrhosis, heart failure,
nephrotic syndrome
 Euvolemic – polydipsia, SIADH
 Hypovolemic – most common cause
• Excessive renal (diuretic) or GI (emesis, diarrhea)
losses
 Treatment of Hyponatremia
 Iso or Hyperosmotic
 Correct underlying disorder
 Hyposmotic
 Iso or hypervolemic – fluid restriction
 Hypovolemic
• Asymptomatic – fluid resuscitate with isotonic
saline
• Symptomatic or plasma [Na+] less than 110 mEq/L
 Calculate Na+ deficit
 Correct at a rate no greater than 0.5 mEq/L/hour or 12
mEq/L/day
 Correction of Sodium Deficit
Example: A 60 kg woman with a plasma sodium
concentration of 120mEq/L:

Sodium deficit = TBW x (130 – [Na+]p)

Sodium deficit = 0.5 x 60 x (130-120) = 300mEq
3% NaCl contains 513 mEq sodium/L
Volume of 3% NaCl needed = 300/513 = 585 mL
At 0.5 mEq/L/hr a correction of 10 mEq should be done
over 20 hours
So, 585 mL/20 hours = 29 mL/hour of 3% NaCl
 Hypernatremia
 Defined as serum [Na+] greater than 146
mEq/L
 Lethargy, weakness, and irritability that
progress to seizure, coma, and death
 Usually occurs in adults with altered
mental status or no access to water
 Hypernatremia
 1. Assess volume status
 2. Measure urine [Na+]
 3. Calculate water deficit
 0.6 x weight (kg) x ([Na+]/140 -1)
 4.Correct with free water no faster than
0.5 mEq/L/hour or 12 mEq/L/day
 Hypernatremia
 Hypovolemic – loss of hypotonic fluids
 Diuresis, vomiting, diarrhea
 Isovolemic – loss of free water
 Diabetes insipidus, hypodipsia
 Hypervolemic – gain of hypertonic fluids

Hypertonic saline administration
 Treatment of Hypernatremia
 Hypovolemic
 Replace the free water deficit
 Hypervolemic
 Diuretics (lasix) to excrete sodium in urine
combined with hypotonic saline for partial
volume replacement
 Treatment of Hypernatremia
 Isovolemic
 Diabetes Insipidus

Loss of hypotonic urine secondary to lack of ADH
production (central) or lack of response to ADH by
kidney (nephrogenic)

Hallmark is hypotonic urine (200-500 mOsm/L) with
hypertonic plasma
 Treat by correcting free water deficit
 In central DI must also administer 5 – 10 units of
DDAVP Q6H to prevent ongoing free water loss
 Hyperkalemia
 Defined as a serum [K+] greater than 4.6 mEq/L
 Changes in cellular transmembrane potentials can lead
to lethal cardiac arrhythmias
 Most often associated with renal impairment coupled
with exogenous K+ administration or drugs that increase
K+
 Transcellular shifts – acidosis, succinylcholine, insulin
deficiency, massive tissue destruction
 Massive blood transfusions
 Pseudohyperkalemia - Thrombocytosis, hemolysis,
leukocytosis
 Urine K+ excretion rate can be used to determine exact
cause of hyperkalemia
 Hyperkalemia
 Drugs causing hyperkalemia – K+ sparing
diruetics, ACEI, NSAIDs, Heparin,
Cyclosporin, Tacrolimus, Bactrim
 EKG Changes
 5.5 – 6.5 mEq/L – peaked T-waves
 6.5 – 7.5 mEq/L – loss of P-waves
 > 8.0 mEq/L – widened QRS
 Treatment of Hyperkalemia
 1. If EKG changes administer 10 mL of
10% Calcium Gluconate
 2. 1 amp D50 with 10 units IV insulin
(onset 10-20 minutes, duration 2-3 hours)
 3. Albuterol 10 -20 mg (onset 4-5 hours,
duration 2-3 hours)
 4. Kayexalate 15-30 g (oral onset 4-5
hours, enema onset 1 hour)
 Dialysis
 Hypokalemia
 Defined as serum [K+] less than 3.6
mEq/L
 Occurs in up to 20% of hospitalized
patients
 2.5 mEq/L – muscular weakness, myalgia
 <2.5 mEq/L – cramps, parasthesias, ileus,
tetany, rhabdomyolisis, PVCs, A-V block,
V-tach, V-fib
 Hypokalemia
 Inadequate intake
 Increased excretion – diarrhea, diuretics,
alkalosis, glucocorticoids, RTA
 Transcellular shifts – beta-agonists,
theophylline, insulin, hyperthyroidism,
barium
 Replace no faster than 20 mEq/H
peripherally and 100 mEq/H centrally