Solvent Volume Dielectric constant Surface tension Some more

Seizures in pyogenic meningitis Had seizure on 2nd day . On Dilantin. 10 months female with meningitis. Second L.P.( 3rd day ) showed improvement Refractory seizure on 6th day

S.I.A.D.H.

Hyponatremia.. K/C of Thalassemia Admitted for G / E improved Was found to be Hyponatremic on admission ( 112 ) Correction done twice but Hypon. Cont. Asymptomatic all throughout.

PSEUDO HYPONATREMIA..

Respiratory failure..
5 months male with R.A.D. was doing well On extensive nebulization and supportive therapy. Deteriorated on 4 the day , lethargic, look exhausted . Respiratory rate is less now. ABG day 2..pH 7.34.,pO2 80 on FiO2 of 50. CO2 30 ABG day 4..pH 7.23.,pO2 85 on FiO2 of 30. CO2 67

Electrolytes gave the answer

Seizures in falciparum malaria

Status on 4 th day On mannitol Blood sugar 377 mg % Serum sodium 151. BUN 38

Osmolality (mOsm/kg) = 2 [mEq/L Na+] + (mg/dL glucose) / 18 + (mg / dL BUN) /2.8 = 336

14 months male with RTA Hypo tonic no h/o seizures

ECG : suggestive of Hypokalemia with extra systoles Plasma sodium = 140 Plasma potassium = 1.3 Chloride = 117 Bicarbonate = 10 Ca = 6.3 Arterial pH = 7.26 PCO 2 = 23 What effect would correction of acidosis have on plasma K + ? Would correction of Ca be part of initial management . ?

 What effect would correction of acidosis

have on plasma K + ?

Would correction of
initial management ?

Ca be part of

Correction of acidosis will drive k + into the cells Further worsening hypokalemia.Acidosis is not sever and can wait. Hypokalemia first.

Hypocalcaemia protects against hypokalemia

Thus treatment of hypokalemia should precede Hypocalcaemia. Correction of hypokalemia may precipitate Tetany , this is a less serious than hypokalemia.

1. Anions - Negatively charged ions, such as chloride . 2. Cations - Positively charged ions as sodium . 3. Colloid/Colloid solution - Liquid containing suspended substances that do not settle out of the liquid/solution 4. Crystalloid - a substance that in solution can pass through a semi permeable membrane and be crystallized. 5. Electrolytes - cations or anions which have the ability to conduct electrical current in solutions.

Age Premature Newborn 1 Year Old Adolescent Male Adolescent Female

TBW as % of body weight 75-80 70-75 65 60 55

ECF as % of body weight

ICF as % body weight

50 25 20 18

35 40-45 40-45 40

MAINTENANCE REQUIRMENT Up to 10 Kg 10 to 20 Kg 20 Kg onwards 100 ml/Kg 1000 ml + 50 ml / Kg above 10. 1500 ml + 25 ml / Kg above 20.

3 mEq Na and K per 100 ml of water

Maintenance requirements
Usually estimated from body weight insensible water loss averages 50 ml per 100 kcal consumed. Provision of 50 ml of water per 100 kcal consumed allows the excretion of isotonic urine. Thus, 100 ml of water is required for each 100 kcal consumed. Empirically, 1-3 mEq Na+ and K+ are required for each 100 kcal . Five percent dextrose is necessary to prevent protein and lipid catabolism. Maintenance requirements are best replaced with [5% dextrose, 0.2% NaCl + 20 mEq KCl/liter].

FLUID THERAPY
RESUSCITATION

MAINTENANCE

Crystalloid

Colloid

ELECTROLYTES

NUTRITION

Replace acute loss

1. Replace normal loss (IWL + urine+ faecal) 2. Nutrition support

Percent Dehydration

Infa nt

Chil d

Clinical Signs and Symptoms

Mild

5%

34%

Increased thirst, tears present, mucous membranes moist, ext. jugular visible when supine, capillary refill > 2 seconds centrally, urine specific gravity > 1.020

Moderate

610% 8%

Tacky to dry mucous membranes, decreased tears, pulse rate may be elevated somewhat, fontanels may be sunken,oliguria, capillary refill time between 2 and 4 seconds, decreased skin turgor

Severe

Tears absent, mucous membranes dry, eyes sunken, tachycardia, 15% 10% slow capillary refill, poor skin turgor, cool extremities, orthostatic to shocky, apathy, somnolence

Shock

>15 %

>10 %

Physiologic decompensation: insufficient perfusion to meet endorgan demand, poor oxygen delivery, decreased blood pressure.

RESTORATION OF CIRCULATING VOLUME IS THE TOP PRIORITY FLUID IS ..

NORMAL SALINE

DEHYDRATION In. B S L F O
O D
Na = 140 K = 140 Osm = 280 Osm = 280

I .C .F

I .C .F

In. S F

B L O O D

K = 140 Na = 140 Osm = 280 Osm = 280

I.C.F.

E.C.F.

I.C.F.

E.C.F.

120 240 ICF ICF

140 280 ICF

160 320

HYPO

ISO

HYPER

Isonatremic dehydration. Correction

over 24 hours
Replacement

20 Kg child 10 % Dehy. Na = 140

Maintenance

Total

H20

1500 ml

10 % of 20 Kg 2000 ml
Loss = 10mEq / Kg 10 X 20 = 200 mEq

3500 ml 5 % dext.
245 mEq / 3.5 Lt.

Na

3 mEq / 100 ml. 15 X 3 = 45

N.S.

Hyponatremic dehydration. Slow correction , over 48 hours Not more than 10 mEq in 24 hours

20Kg child 10 % Dehy. Na = 110

Maintenance

Replacement

Total

H2O

1500 X 2 3000ml

10 % of 20 Kg 2000 ml

5000 ml
( As 5 % dextrose )

Na

140-110 X 3 mEq / 100 ml. 30 X 3 = 90 300 mEq

wt. 390 / 5 Lit.

1 / 2 N.S.

HYPONATRMIC EMERGENCIES

3% hyper tonic saline

5 ml/kg over 1 hour with the goal sodium level of 125meq/ L , then correct sodium further by calculating deficit

Hypertonic dehydration. Slow correction , over 48 hours Not more than 10 mEq in 24 hours Maintenance Replacement

20 Kg child 10 % Dehy. Na = 165

Total

H20 1500 X 2 3000ml Na

3 mEq / 100 ml. 30 X 3 = 90

Deficit = 2000 F.W.D. = 1600 Reminder as N.S. 400 m.l. of N.S. = 61 mEq

5000 ml
151 mEq / 5 lit.

1/4 N.S.

Free water deficit = ( 4 X wt inKg ) X ( Serum Na 145)

160 320 ICF

160 320 ICF ICF

130 290

HYPER

HYPER CHRONIC

RAPID TREAT.

Seizure while treating hypernatremia

D 5 % with Normal Saline = 77 mEq Na / Lit. Add 150ml of 3 % Normal Saline to a Liter of 5 % Dextrose D 5 % with Normal Saline = 34 mEq Na / Lit. Add 70 ml of 3 % Normal Saline to a Liter of 5 % Dextrose

Isonatremic dehydration is best replaced with 5% dextrose, NaCl + 20 mEq KCl/L over 24 hours. ( Deduct bolus therapy ) Hyponatremic dehydration is best replaced with 5% dextrose NaCl + 20 mEq KCl/L over 48 hours. ( Deduct bolus therapy ) Hypernatremic dehydration is best replaced with 5% dextrose with NaCl + 20 mEq KCl/L over 48 hours. ( Deduct bolus therapy )

Fallacies of body fluid calculations

Lean body mass calculations Variation in body secretion Variation in renal handling Effect of body temperature Isohydric effect Variation in surface area

HYPERNATREMIA IN ICU Low Urine osmolality High Hypo tonic fluid loss Insensible loss G I Loss Diuretics Low

Urine output High Urine osmolality High Osmotic diuresis

D. Insipidus Central Nephrogenic

Common IV Solutions Solution 5% Dextrose (D5W) 10% Dextrose (D10W) Normal Saline (NS) D5NS D5NS 0.2% NS 3% NaCl Ringer's Lactate (LR) D5LR D10 E#48 Glucose (g/L) 50 100 0 50 50 0 0 0 50 100 50 100 60 Na+ 0 0 154 154 77 31 513 130 130 30 25 57 40 K+ 0 0 0 0 0 0 0 4 4 15 20 35 40 Ca+2 0 0 0 0 0 0 0 3 3 0 0 0 0 0 154 154 77 31 513 109 109 20 22 40 35 20 Cl0 Lactate 0 0 0 0 0 0 0 28 28 25 23 25 PO4-3 0 0 0 0 0 0 0 0 0 3 3 12 15 0 0 0 0 0 0 0 0 3 3 6 0 Mg+2 0

D5 E#48
D10 E#75 D6 E#75

Note: Glucose in g/L; all ions in mEq/L.

98 % 2%

Hyperkalemia 98 % 2%

ALKA

LOSIS LOW K
H I O N S

ACIDOSIS CAUSES HYPERKALEMIA

True Hyperkalemia Excess K+ intake Decreased excretion Redistribution Acidosis Insulin Def. Adrenal Ins. Periodic P. Renal failure Oliguria Hypoaldo. Nsaids Ace inhibitors

98 %

2%

++++

Hyperkalemia
Calcium chloride: 0.2 mL /kg/dose of 10% sol IV over 5 min; not to exceed 5 mL (stop infusion if bradycardia develops) Calcium gluconate: 100 mg/kg (1 mL/kg) of 10% sol IV over 5 min; not to exceed 10 mL (stop infusion if bradycardia develops) Soda bi carb 2 ml / kg 25 % dextrose with .1 units /kg insulin . over 30 minutes (1 U regular insulin/5 g glucose ) Beta agonists

Hypokalemia

Hypokalemia true Increased loss Urinary K +

Distribution Decreased

Hypertension

Normal B.P.

G.I.loss Biliary ETC.

Acidosis Renin

Alkalosis

I . V . Kesol should be considered for Significant arrhythmia Sever muscle weakness Severe hypokalemia (< 2.5.0 mEq. / L). Digoxin toxicity Hepatic encephalopathy Maximum concentrations of KCl used in peripheral veins generally should not exceed 4 meq. /100 cc, due to the damaging effects on the veins , at a rate of 1 mEq/kg per hour.

Potassium should be administered slowly, preferably Orally, at a dosage of 4 to 6 mEq/kg per day.

ADH excess

Water retention

E.C.Fluid ++

Serum Na low

Urinary sodium increased

Hypotonic Hyponatremia (Na < 135 meq. /L) Hypovolemia Urinary sodium More than 20 Urinary loss Less than 20 G I Loss Diuretics SIADH Adrenal Drugs HypoTH Euvolemia Hypervolemia Urinary sodium More than 20 C.C.F. Hepatic F. Less than 20 Renal disease

SIADH
Definition: AVP excess associated with hyponatremia without edema or hypovolemia. The AVP excess is inappropriate in the face of hypoosmolality. Commonest cause of euvolemic hyponatremia Clinical manifestations are those of water intoxication and depend on rate more than magnitude of development of hyponatremia.

SIADH
HYPONATREMIA HYPO OSMOLAR U. OSM. HIGHER THAN SERUM CONTINUED URINARY Na LOSS NORMAL RENAL FUNCTION & B.P. NO OEDEMA NO ENDOCRINE DISORDER RESPONSE TO WATER REST.

SIADH
Management
Restrict fluid Diuretics Emergency management and the other drugs

The right solution for correct fluid ..

Thanks
Dr Deopujari