Fluids and Electrolytes Flashcards
(93 cards)
1
Q
Fluid movement - Pressures
A
Hydrostatic pressure
Osmotic pressure
2
Q
Hydrostatic pressure
A
increased pressures forces fluid out
3
Q
Osmotic pressure
A
Water moves from low solute to higher solute
In blood, large molecules (ie Albumin) helps keep fluid in
4
Q
67yo M, nephrotic syndrome, with bilateral LE edema.
What pressure is at work?
A
Osmotic Pressure
5
Q
52 yo F with CHF and pulmonary edema.
What pressure is at work?
A
Hydrostatic pressure
6
Q
Ascites in a cirrhotic.
What pressure is at work?
A
Hydrostatic pressure
7
Q
Types of fluids
A
Colloids
Cystalloids
8
Q
Colloids - in general
A
Protein or complex carb/starch
“theoretically help keep fluid in blood stream
9
Q
Colloids - Examples
A
Albumin (protein)
Hespan / Hetastarch (starch derivative)
Dextran (Complex branched polysaccharide)
10
Q
Crystalloids - In general
A
Most widely used type of fluid
11
Q
Crystalloids - examples
A
Isotonic
Hypotonic
Hypertonic
12
Q
Crystalloids - Isotonic
A
0.9% NaCl (NS)
Lactated Ringer’s solution (LR)
D5W
13
Q
Crystalloids - Hypotonic
A
1/2 NS (Half the Na+ / Cl- content of the NS)
14
Q
Crystalloids - Hypertonic
A
3% NaCl
D10 NS
15
Q
Extracellular Fluid - Components
A
Na - 142 K - 4 Ca - 5 Mg - 3 Cl - 103 HCO3 - 27 Osmolality - 280
16
Q
Ringers Lactate - Components
A
Na - 130 K - 4 Ca - 3 Cl - 109 HCO3 - 28 Osmolality - 278
17
Q
0.9% NaCl - Components
A
Na - 154
Cl - 154
Osmolality - 308
18
Q
NS
A
154 mEq/L of Na and Cl
19
Q
LR
A
130 mEq/L of Na 109 mEq/L of Cl 28 mEq/L of lactate 4 mEq/L of K 3 mEq/L of Ca
20
Q
D5
A
50g Dextrose /L
21
Q
Which solution has potassium?
A
LR
22
Q
Which solution has more Cl than plasma?
A
NS
23
Q
T or F
NS and LR both have bicarb.
A
False
Neither has bicarb
24
Q
Maintenance Rate
A
Based on sensible and insensible losses for a healthy person
25
Healthy person - sensible losses
Can be measured for visualized
Urine, feces
26
Healthy person - insensible losses
Cannot be measured or visualized
Sweat / skin, lungs
27
Hospital pts - sensible / insensible losses
```
+/-
Wounds
Vomiting
Diarrhea
Bile, etc
```
28
Fluids not taken into account by maintenance rate
```
Wounds
Vomiting
Diarrhea
Bile
Ostomies, etc
```
29
Maintenance rate 4-2-1 rule
First 10kg --> 4 ml/kg/hr
Second 10kg --> 2 ml/kg/hr
Each kg >20kg --> 1 ml/kg/hr
30
Saliva - components
```
Volume ml/day - 1500
Na - 10
K - 26
Cl - 10
HCO3 - 30
```
31
Stomach - components
Volume ml/day - 1500
Na - 60
K - 10
Cl - 130
32
Duodenum - components
Volume ml/day - 100-2000
Na - 140
K - 5
Cl - 80
33
Pancreas - components
```
Volume ml/day - 100-800
Na - 140
K - 5
Cl - 75
HCO3 - 115
```
34
Bile - components
```
Volume ml/day - 50-800
Na - 145
K - 5
Cl - 100
HCO3 - 35
```
35
Ileum - components
```
Volume ml/day - 3000
Na - 140
K - 5
Cl - 104
HCO3 - 30
```
36
Colon - components
Na - 60
K - 30
Cl - 40
37
Excess fluid losses
```
In addition to maintenance rate
+/- Additional fluids
+/- bicarb
+/- potassium
Importance of "Strict I and O's"
```
38
Fluid in burns
Parkland formula
4 cc * kg * % (20 or 30)
Half in the first 8h
Half in remaining 16h
39
Fluid in trauma - What fluid to you give
Blood
40
Why would you not give excessive IV fluid in a bleeding pt?
Excessive IV fluid in bleeding can cause hemodilution of remaining blood products
41
What does hemodilution lead to?
Worsening coagulopathy
Acidosis
Morbidity
42
End goals of resuscitation
```
Vitals
Urine Output
Lactic acid
Weight
CVP
CO
```
43
What is considered adequate urine output?
0.5 cc / kg / hr
44
Elective Sx on inguinal hernia on a 24yo healthy M.
| What kind of IV fluids do you order pre-op?
NS
D5
LR
45
AV graft placement for dialysis on a 65yo F.
| What kind of IV fluids do you order pre-op?
NS
| D5
46
40yo M, 100kg, 3rd degree burns to 20% of his body.
What kind of IV fluids do you order?
How much total fluid?
What rate?
NS or LR
4 * 100 * 20 = 8,000 ml total fluid
For the first 8h --> 500 ml/h
For the next 16h --> 250 ml/h
47
40yo M, 100kg, 3rd degree burns to 20% of his body. He has been given fluids properly for the first 24h. He is now producing 30 ml/h urine in 3h.
What do you do?
Should be 50 ml/h
Increase fluids
48
76 yo M who has CHF, renal failure, lymphedema among other health problems. GSW to the leg. He is hypotensive in the trauma bay with a SBP 85.
What do you do?
Give blood
49
You're massively resuscitating a pt in profound septic shock. Despite stabilized vitals, good urine output and good CO, he remains acidotic.
Why?
B/c of the Cl in the NS he received
50
Post-op pt now has a bile leak from a duodenal stump blowout.
What fluids should you use?
One that contains bicarb
51
You did a subtotal colectomy with end ileostomy for fulminant colitis due to C.diff.
What should you watch for?
Dehydration
Fluid loss
Electrolyte losses
52
Sodium
Most abundant particle in extracellular fluid
| Regulated by various mechanisms (ADH, kidneys, and aldosterone)
53
Hyponatremia - S/S
Neurological symptoms
- Ha
- Fatigue
- Confusion
- Lethargy
54
SIADH
Excess ADH (trauma, brain tumors, certain meds)
Excess water reabsorption
Dilutional / hypervolemic hyponatremia
55
Hyponatremia - Tx
Assess volume status
+/- fluid restrict
Correct underlying condition
Replace Na (NS)
56
Hyponatremia - Rate of correction and why
Slow
Rapid correction can result in Central Pontine Myelinolysis
57
Hyponatremia - calculations
Na Deficit = (total body water) * (desired Na - Actual Na)
58
Hypernatremia - In general
Usually due to water deficit
| S/s similar to hyponatremia (weakness, lethargy, neuro s/s)
59
Hypernatremia - Tx
Assess volume status
Calculate water deficit
Replace fluid
60
Calculation of water deficit
Water deficit = TBW * [(serum Na -140) / 140]
61
At what speed should the rate of correction for hypernatremia be and why?
Slow
Rapid correction can result in cerebral edema
62
Potassium - in general
97-98% found intracellularly
Normal - 3.5-5.0 mEq/L
80% taken in is excreted by kidneys
63
Factors that affect potassium
GI absorption
Renal regulation
pH level
Insulin
64
Hypokalemia - s/s
```
Weakness
Fatigue
Muscle cramps
Decreased bowel sounds
Constipation
Ileus, etc.
```
65
Hypokalemia - In general
```
Often associated with hypomagnesemia
EKG changes (flattened T waves, prominent U waves)
```
66
Hypokalemia - Tx
PO or IV replacement
Monitor VS, EKG, serum K+ levels
Correct underlying cause
Replace magnesium deficiency (if any)
67
Hyperkalemia - Causes
Increased intake - diet; meds; blood products
Decreased excretion - renal failure
Leak out of cells - burns; crush injury; tumor lysis
68
Hyperkalemia - S/s
Often asymptomatic
Arrhythmias / asystole
EKG changes - peaked T waves
69
Hyperkalemia - Tx
EKG / cardiac monitoring
| Give calcium to stabilize the heart
70
Additional factors that can affect potassium levels
Decrease gut absorption (Kayexalate)
Increase urination (diuretics)
Shift from extracellular to intracellular (insulin, bicarb)
Hemodialysis
71
Hypomagnesemia - s/s
Neuromuscular excitability
- Hyperreflexia
- Positive Chvostek sign
- Trmors
- Nystagmus
- Muscle cramps
- Arrhythmias
- Confusion
- Disorientation
72
Hypomagnesemia - Tx
Replace magnesium (PO or IV)
73
Hypermagnesemia - in general
Rare in sx pts
Occurs with renal failure and excessive intake
Example - magnesium therapy for pre-eclampsia
74
Hypermagnesemia - s/s
```
Muscle weakness
Hyperreflexia
Mental obtundation and confusion
Flaccid paralysis
Ileus
Urinary retention
Hypotension
Eventually respiratory muscle paralysis and cardiac arrest
```
75
Hypermagnesemia - Tx
Stop giving magnesium!
IV saline to dilute
Dialysis in renal failure
76
Hypocalcemia - Causes
```
Hypoparathyroidism
Hypomagnesemia
Severe pancreatitis
CRF
Poor GI absorption
```
77
Hypocalcemia - Clincally
```
Neuromuscular hyperactivity
Chvostek sign
Muscle and abdominal cramps
Carpopedal spasm (Trousseau's sign)
Convulsions
Paresthesias
Diarrhea
Dry or brittle nails, hair, and bones
Decreased CO
```
78
Hypocalcemia - Tx
Check corrected Ca levels
Asymptomatic / mild - PO
Symptomatic - IV
Check for hypomagnesemia
79
Hypercalcemia - causes
Primary Hyperparathyroidism
| Malignancy
80
Hypocalcemia - S/s
```
Constipation
N/V
Fatigability
Confusion
Lethargy
Muscle weakness
Depression anorexia
Hyporeflexia
Arrhythmias
Stupor
Coma
```
81
Hypocalcemia - Tx
Isotonic saline - expand ECF; dilute Ca; increase urine flow
Furosemide - Increase excretion of Ca
Bisphosphonates - Prevent bone resorption
Calcitonin - prevent bone and kidney resorption
Corticosteroids - prevent action of Vit D
82
Refeeding Syndrome - in general
If someone has been starving for a long time, their cells are also starving.
When you feed them, the nutrients goes straight to the cells and suck it up.
This causes hypo- everything
83
Tumor Lysis Syndrome
Cell dies and leaks out everything
Hyperkalemia
Hyperuricemia
Hyperphospatemia
84
80 yo F with renal failure with planned operation tomorrow. K = 8.1
What are you first steps?
How do you manage this?
First steps - Do an EKG, looking for peaked T waves. The K level is chronic so their body is probably used to it
Management - Give Ca (IV); Dialysis or decreased with Kayexalate until she can have dialysis
85
76 yo M referred for hypercalcemia secondary to a parathyroid adenoma has a Ca=14.2
How do you manage this?
NS and Furosemide
Definitive management
- sx excision of adenoma
86
Severely, chronically, malnourished pt, POW, held for years, finally relased and is able to eat for the first time in years.
What are you worried about?
How do you prevent it?
Refeeding syndrome
Replace electrolytes and check hourly
87
67 yo M who just did a colectomy for colon cancer is receiving chemo, with good tumor response.
What do you have to be mindful of?
How do you recognize it?
Tumor lysis syndrome
Check labs for electrolyte changes (hyper)
88
44yo M with hyperaslosteronism is weak and irritable.
| Why?
Hypernatremia
89
59yo M with Addison's dz is acidotic.
| Why?
Adrenal insufficiency
Acidotic b/c Hyper-K
90
Despite trying to correct a low potassium level, it just wont correct.
Why?
Magnesium
91
30yo F with pre-eclampsia. She is being tx with IV magnesium.
How do you clinically monitor for hypermagnesemia?
Decrease in neuromuscular excitability
| Decreased DTR
92
65yo M s/p severe head trauma, now weak, lethargic.
| Why?
Head trauma can cause DI
93
75yo M. Successfully did CPR for his V fib. Now he is lethargic and confused.
Why?
Fluids are wide open
| People loose track of how much fluid the pt has received
