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4.fluid and Electrolyte Balance Part 2

The document discusses fluid and electrolyte balance, including causes and signs of hypovolemia and hypervolemia. It covers using history, physical exam findings, and lab tests to assess volume status. Specific lab abnormalities seen with hypovolemia are outlined, as well as intravenous administration methods and risks.

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Muhammad Makki
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28 views22 pages

4.fluid and Electrolyte Balance Part 2

The document discusses fluid and electrolyte balance, including causes and signs of hypovolemia and hypervolemia. It covers using history, physical exam findings, and lab tests to assess volume status. Specific lab abnormalities seen with hypovolemia are outlined, as well as intravenous administration methods and risks.

Uploaded by

Muhammad Makki
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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FLUID & ELECTROLYTE

BALANCE
PART II
Presented by: Mr. NAZIM JAT
FRCS
HYPOVOLEMIA

 Hypovolemia or FVD is result of water & electrolyte loss


 Compensatory mechanisms include: Increased
sympathetic nervous system stimulation with an increase
in heart rate & cardiac contraction; thirst; plus release
of ADH & aldosterone
 Severe case may result in hypovolemic shock or prolonged
case may cause renal failure
CAUSES OF FVD=HYPOVOLEMIA:

 Gastrointestinal losses: N/V/D (nausea, vomiting,


diarrhea)
 Renal losses: diuretics

 Skin or respiratory losses: burns

 Third-spacing: intestinal obstruction, pancreatitis


EFFECT OF HYPOVELOMIA

 A variety of disorders lead to fluid losses that deplete the


extracellular fluid.

 This can lead to a potentially fatal decrease in tissue


perfusion.

 Fortunately, early diagnosis and treatment can restore


normovolemia in almost all cases.
 There is no easy formula for assessing the degree of
hypovolemia.
 Hypovolemic Shock, the most severe form of hypolemia,
is characterized by tachycardia, cold, clammy
extremities, cyanosis, a low urine output (usually less
than 15 mL/h), and agitation and confusion due to
reduced cerebral blood flow.
 This needs rapid treatment with isotonic fluid boluses (1-
2L NS), and assessment and treatment of the underlying
cause.
 But hypovolemia that is less severe and therefore well
compensated is more difficult to accurately assess.
HISTORY FOR ASSESSING
HYPOVOLEMIA
 The history can help to determine the presence and etiology
of volume depletion.

 Weight loss!

 Early complaints include lassitude, easy fatiguability, thirst,


muscle cramps, and postural dizziness.

 More severe fluid loss can lead to abdominal pain, chest


pain, or lethargy and confusion due to ischemia of the
mesenteric, coronary, or cerebral vascular beds,
respectively.
HISTORY FOR ASSESSING
HYPOVOLEMIA CONTINUED…..
 Nausea and malaise are the earliest findings of
hyponatremia, and may be seen when the plasma sodium
concentration falls below 125 to 130 meq/L. This may be
followed by headache, lethargy, and obtundation

 Muscle weakness due to hypokalemia or hyperkalemia

 Polyuria and polydipsia due to hyperglycemia or severe


hypokalemia

 Lethargy, confusion, seizures, and coma due to


hyponatremia, hypernatremia, or hyperglycemia
BASIC SIGNS OF HYPOVOLEMIA

 Urine output, less than 30ml/hr

 Decreased BP below 100 mmHg (systolic) , Increase


pulse more than 100 /min.
PHYSICAL EXAM FOR ASSESSING
VOLUME
 physical exam in general is not sensitive or specific

 acute weight loss; however, obtaining an accurate weight


over time may be difficult

 decreased skin turgor - if you pinch it, it stays put

 dry skin, particularly axilla

 dry mucus membranes

 low arterial blood pressure (or relative to patient's usual


BP)
PHYSICAL EXAM FOR ASSESSING
VOLUME
 orthostatic hypotension can occur with significant
hypovolemia; but it is also common in euvolemic elderly
subjects.

 decreased intensity of both the Korotkoff sounds (when


the blood pressure is being measured with a
sphygmomanometer) and the radial pulse ("thready")
due to peripheral vasoconstriction.

 decreased Jugular Venous Pressure

 The normal venous pressure is 1 to 8 cmH2O, thus, a


low value alone may be normal and does not establish
the diagnosis of hypovolemia.
SIGNS & SYMPTOMS OF FLUID
VOLUME EXCESS
 SOB (Shortness of Breath) & orthopnea
 Edema & weight gain
 Distended neck veins & tachycardia
 Increased blood pressure
 Crackles & wheezes
 pleural effusion
FOR THE EBM(Evidence based medicine)
AFICIONADOS OUT THERE.
 A JAMA 1999 systematic review of physical diagnosis
of hypovolemia in adults
 CONCLUSIONS: A large postural pulse change (> or
=30 beats/min) or severe postural dizziness is required to
clinically diagnose hypovolemia due to blood loss,
although these findings are often absent after moderate
amounts of blood loss. In patients with vomiting,
diarrhea, or decreased oral intake, few findings have
proven utility, and clinicians should measure serum
electrolytes, serum blood urea nitrogen, and creatinine
levels when diagnostic certainty is required.
WHICH BRINGS US TO:
LABNORMALITIES SEEN WITH HYPOVOLEMIA
 a variety of changes in urine and blood often accompany
extracellular volume depletion.
 In addition to confirming the presence of volume
depletion, these changes may provide important clues to
the etiology.
BUN/CR
 BUN/Cr ratio normally around 10
 Increase above 20 suggestive of “prerenal state”

 (rise in BUN without rise in Cr called “prerenal


azotemia.”)
 This happens because with a low pressure head
proximal to kidney, because urea (BUN) is
resorbed somewhat, and creatinine is secreted
somewhat as well
HGB/HCT

 Acute loss of EC fluid volume causes hemoconcentration


(if not due to blood loss)

 Acute gain of fluid will cause hemodilution of about 1g


of hemoglobin (this happens very often.)
PLASMA NA
 Decrease in Intravascular volume leads to greater avidity
for Na (through aldosterone) AND water (through ADH),

 So overall, Plasma Na concentration tends to decrease


from 140 when hypovolemia present.
URINE NA
 Urine Na – goes down in prerenal states as body tries to
hold onto water.
 Getting a FENa helps correct for urine concentration.

 Screwed up by lasix.

 Calculator on PDA or medcalc.com


IV MODES OF ADMINISTRATION
 Peripheral IV
 PICC (peripherally inserted central catheter)

 Central Line

 Intraosseous ( the process of injecting directly into the


marrow of a bone)
IV PROBLEM:
EXTRAVASATION / “INFILTRATED”
 The most sensitive indicator of extravasated fluid or
"infiltration" is to transilluminate the skin with a small
penlight and look for the enhanced halo of light diffusion
in the fluid filled area.

 Checking flow of infusion does not tell you where the


fluid is going

That’s it folks.

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