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Surgery Week 2
fluids and electrolytes
112
Health Care
Professional
10/09/2012

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Term
In a female, total body weight is __% solids and __% fluids.
Definition
45
55
Term
In a male, total body weight is __% solids and __% fluids.
Definition
40
60
Term
Of the fluids making up our total body weight, _/_ is ICF and _/_ is ECF.
Definition
2/3
1/3
Term
What are the cation electrolytes in the plasma?
Definition
sodium
potassium
calcium
magnesium
Term
What are the anion electrolytes in the body?
Definition
chloride
bicarbonate
phosphate
sulfate
organic acids (lactate)
total protein
Term
Know these normal ranges. of cations and anions
Definition
Term
How are the compositions of ICF and ECF ions maintained?
Definition
selective permeability of cell membranes
active ion pumps
Term
The movement of water about a cell membrane is what?
Definition
passive:
-colloid osmotic gradients intravascular vs. interstitial spaces (extracellularly
-osmolar gradients intracellularly vs extracellularly
Term
Which electrolytes are in the ICF?
Definition
K
Mg
PO4
SO4
proteins
Term
Which electrolytes are in the ECF?
Definition
Na
Ca
Mg
Cl
HCO3
lactate
Term
When balancing fluid and sodium, what is the normal osmolarity?
Definition
280-300
Term
What are the driving forces for osmolarity?
Definition
Na resorption and excretion
Term
Where is sodium resorbed?
Definition
in distal tubules in exchange for potassium and hydrogen ion
Term
What does ECV reduction stimulate?
Definition
juxtaglomerular apparatus to secrete renin then promotes secretion of angiotensin I and conversion to angiotensin II, aldosterone
Term
What else senses reduction in ECV?
Definition
volume receptors in the right atrium (bc don't have enough blood coming back from the body to the heart)
Term
What does aldosterone help maintain?
Definition
ECV and osmolarity
Term
What suppresses aldosterone?
Definition
ECV expansion (increases Na and decreased K)
Term
Where is ADH produced? what does it regulate?
Definition
posterior pituitary
regulates volume and osmolarity
Term
What does ADH increase?
Definition
tubular resorption of water
Term
When are intracranial receptors initiated to tell ADH to be released?
Definition
when the plasma osmolarity is increased
(so if have a lot of protein (increased osmo) receptors will be stimulated to produce more fluid)
Term
Can the right and left atrial receptors also stimulate ADH production?
Definition
yes
Term
When aldosterone triggers sodium to be resorbed, where does this occur and what does it actively exchanged for?
Definition
distal convoluted tubules
exchanged for K and H ions
Term
When water is resorbed secondary to ADH, where does this resorption occur?
Definition
collecting ducts
Term
What does dysfxn of this renin-angiotensin system lead to?
Definition
decreased amt of water in body
increased amount of Na in the body
increased blood osmolality
decreased circulating blood volume (bc have less body water)
Term
What stimulates ADH and thirst?
Definition
decreased amt of water in body
increased amt of Na in body
increased blood osmolality
decreased circulating blood volume
Term
Osmoreceptors are stimulated where that stimulate the release of ADH?
Definition
hypothalamus
Term
Osmoreceptors are stimulated where that stimulate the release of ADH?
Definition
hypothalamus
Term
stopped at slide 16.
Definition
Term
What is pH the measurement of?
Definition
the mgmt of hydrogen ions
-maintained at 7.4 +/- 0.5
Term
What 3 mechanisms maintain the pH?
Definition
burrfering systems in plasma
ventilatory changes for CO2 excretion
renal tubular excretion of hydrogen ions
Term
What are the 2 main determinants of intracellular buffering?
Definition
excessive CO2 retention or excretion
& reciprocal K ion exchange
Term
What effects CO2 retention or excretion?
Definition
50% of fixed acid loads (lactate)
95% of hydrogen ion changes
Term
In alkalosis, _ moves extracellularly and _ moves intracellularly.
Definition
H
K
Term
In acidosis, _ moves extracellularly and _ move sintracellularly.
Definition
H
K
Term
Intracellular regulation of acid/base balance can have significant clinical effect, especially regarding what?
Definition
myocardial function
Term
What are important determinants of intracellular pH?
Definition
pulmonary regulation of PaCO2.
renal tubular regulation of HCO3.
Term
What ratio basically determines extracellular pH?
Definition
HCO3/H2CO3
-As one increases, the other increases to compensate
Term
What are the normal serum values of HCO3 and PaCO2?
Definition
22-30 mEq/L
35-45 mmHg
Term
Postoperatively, what is done with regards to fluids and electrolytes?
Definition
maintenance
resuscitation
replacement of losses
Term
Children >5 kg to young adult, how is fluid replaced?
Definition
First 10 kg 100 ml/kg
Second 10 kg 50ml/kg
Weight > 20 kg 20 ml/kg
Term
Children >5 kg to young adult, how is fluid replaced?
-same slide, but different answer... read book.
Definition
4 ml/kg first 10 kg
2 ml/kg second 10 kg
1 ml/kg > 20 kg
Term
How is fluid replaced in adults who are 25-55 yrs old?
Definition
35 ml/kg
Term
How is fluid replaced in adults who are 55-65 yrs old?
Definition
30 ml/kg
Term
How is fluid replaced in adults who are >65 yrs old?
Definition
25 ml/kg
Term
What is a third space fluid loss?
Definition
fluid sequestered into extracellular and interstitial spaces (postoperatively usually)
Term
What are the 4 conditions that occur bc of third space fluid losses?
Definition
Peritonitis
Intestinal obstruction
Soft tissue inflammation/edema
Traumatic losses
Term
Diminished volume is noticed when hemodynamic changed begin to occur, name 3 hemodynamic changes that clue you into third space fluid losses.
Definition
Tachycardia
Narrowed pulse pressures
Hypotension
Term
What 2 ways help to tell you if somebody is adequately resuscitated?
Definition
urine output
resolution of symptoms.
Term
Check out slide 25 and 26 on the composition of body fluids.
Definition
Term
When there is decreased volume of body fluids, it is usually in the face of what 2 conditions?
Definition
loss of blood
loss of GI fluid
Term
When there is excessive gain in volume, it is usually in the face of what 3 conditions?
Definition
volume replacement
renal failure
SIADH
Term
Trauma can cause volume depletion in what 3 ways?
Definition
hemorrhage
burns
crush injury
Term
Surgery can cause volume depletion in what 3 ways?
Definition
blood loss
GI loss
insensible loss
Term
Drains can cause volume depletion in what 3 ways?
Definition
NG tube
PEG tube
fistulas
Term
Medical conditions can cause volume depletion in what 5 ways?
Definition
pancreatitis
bowel obstruction
peritonitis
soft tissue infection
hyperglycemia
Term
What 2 drugs can cause volume depletion?
Definition
mannitol
lithium
Term
When 10% of the ECV is depleted, what is seen on PE?
Definition
thirst
mild decrease in UOP
Term
When 20% of the ECV is depleted, what is seen on PE?
Definition
drowsiness
tachycardia
moderate decrease UOP
increase Hct
WBC
BUN/Cr
Term
When 30% of the ECV is depleted, what is seen on PE?
Definition
coma
hypotension
tachycardia
oliguria
Term
When correcting volume, what do you need to know?
Definition
what fluid was lost and how quickly?
Term
If the fluid loss deficit is moderate when should it be replaced?
Definition
over 24 hours
Term
If the fluid loss deficit is severe when should it be replaced?
Definition
ASAP if acute
Term
When monitoring UOP, what should the rate be for adults? kids?
Definition
adults: 0.5 ml/kg/hr
children: 1 ml/kg/hr
Term
Who usually has volume excess?
Definition
elderly
renal failure
CHF
hepatic disease
surgery
trauma
Term
during surgery and trauma, why does volume excess occur?
Definition
increase ADH and aldosterone
Term
Na higher than what is considered hypernatremia?
Definition
>145 mEq/L
Term
What is hypernatremia usually due to?
Definition
high sodium
decreased water
if water moves from ICF to ECF
Term
During hypernatremia cells _________.
Definition
dehydrate
Term
What are some causes of hypernatremia?
Definition
hypertonic IV solution
oversecretion of aldosterone
loss of pure water
insufficient intake of water (hypodipsia)
loss of water and salt
Term
What are 2 ways in which pure water can be lost?
Definition
respiratory infection (water vapor loss)
diabetes (polyuria)
Term
What are some conditions in which water and salt can be lost?
Definition
gastrointestinal
osmotic diuresis
DI
excessive sweating
Term
What are the clinical manifestations of hypernatremia?
Definition
thirst
lethargy
neurological dysfxn due to dehydration of brain cells
decreased vascular volume.
Term
stopped at slide 36
Definition
Term
How is hypernatremia calculated?
Definition
TBWD males = [(140 – SNa+) x 0.6 x IBW (kg)]/ 140
TBWD females = [(140 – SNa+) x 0.5 x IBW (kg)]/ 140

-for every 3.5 mEq the Na is over 140, there is an estimated free water deficit of 1 L
Term
What are the txs of hypernatremia?
Definition
isotonic salt-free IV fluid
oral solutions preferable
Term
Hyponatremia is an overall decrease in Na in the ___.
Definition
ECF
Term
What are the types of hyponatremia?
Definition
depletional
dilutional
Term
Depletional hyponatremia is due to Na loss... what 4 things cause depletional hyponatremia?
Definition
diuretics
chronic vomiting
chronic diarrhea
decreased aldosterone
decreases Na intake
Term
what 4 things cause dilutional hyponatremia?
Definition
renal dysfxn with increased intake of hypotonic fluids

excessive sweating-->increased thirst-->intake of excessive amount of pure water

SIADH, oliguric renal failure, severe congestive heart failure and cirrhosis all lead to IMPAIRED RENAL EXCRETION OF WATER

Hyperglycemia- attracts water
Term
What is pseudohyponatremia?
Definition
spurious lab value due to hyperglycemia, hyperlipidemia or hyperproteinemia.
Term
What are the neurological manifestations of hyponatremia?
Definition
Lethargy, headache, confusion, apprehension, depressed reflexes, seizures and coma
Term
What are the muscular symptoms of hyponatremia?
Definition
cramps
weakness
fatigue
Term
What are the GI symptoms of hyponatremia?
Definition
nausea
vomiting
abd cramps
diarrhea
Term
How is hyponatremia treated?
Definition
limit water intake
discontinue meds.
Term
Hypokalemia is defined as serum K<___ mEq/L
Definition
3.5
Term
Why should you be careful if the pt is hypokalemic and diabetic?
Definition
insulin gets K into cell
Ketoacidosis can occur where H replaces K, which is lost in urine.
Term
Stopped at slide 44/
Definition
Term
What losses can cause hypokalemia?
Definition
GI losses
renal losses
hypokalemic hypochloremic metabolic alkalosis
Term
With hypokalemia, what is the rule?
Definition
increase pH 0.1 unit causes decrease serum potassium 0.4 to 0.5 mEq
Term
What should also be checked for with hypokalemia?
Definition
hypomagnesium
Term
Hypokalemia can be caused by a decreased intake of K or an increased loss of K... what are some reasons in which K will be lossed?
Definition
chronic diuretics
acid/base imbalance
trauma and stress
increased aldosterone
redistribution bw ICF and ECF
Term
What neuomuscular disorders manifest bc of hypokalemia?
Definition
weakness
flaccid paralysis
respiratory arrest
constipation
Term
What cardiovascular disorders manifest bc of hypokalemia?
Definition
dysrhythmias
appearance of U wave
flat or inverted T

Postural hypotension

cardiac arrest
Term
How is hypokalemia treated?
Definition
increased K intake (slowly and preferably by foods)
Term
Hyperkalemia is a K > ___ mEq/L.
Definition
5.5
Term
With hyperkalemia, what should be checked for?
Definition
renal dz
Term
What are some causes of hyperkalemia?
Definition
renal dz
Massive cellular trauma
Insulin deficiency
Addison’s disease
Potassium sparing diuretics
Decreased blood pH
Exercise causes K+ to move out of cells
Term
What are some early clinical manifestations of hyperkalemia?
Definition
hyperactive muscles
paresthesia
Term
What are some later manifestations of hyperkalemia?
Definition
muscle weakness
flaccid paralysis
Term
Hyperkalemia does what cardiovascularly?
Definition
peaked T wave
dysrhythmias
bradycardia
heart block cardiac arrest
Term
If there is time, how is hyperkalemia treated?
Definition
decrease intake of K and increase renal excretion.
Term
What is used to tx hyperkalemia?
Definition
Insulin 10 units + glucose 25 g
Albuterol
Kayexalate and lasix
Bicarbonate
Ca++ gluconate counters effect on heart
Term
What does hypercalcemia result from
Definition
Hyperparathyroidism
Hypothyroid states
Renal disease
Excessive intake of vitamin D
Milk-alkali syndrome
Certain drugs
Malignant tumors
Term
With hypercalcemia of malignancy, what do the tumor products promote?
tumor growth in bone causes what?
Definition
bone breakdoen
Ca release
Term
With hypercalcemia, what do you normally also see?
Definition
hypophosphatemia
Term
What are the effects of hypercalcemia? (stones, abd groans, and psych overtones)
Definition
Many nonspecific – fatigue, weakness, lethargy
Increases formation of kidney stones and pancreatic stones
Muscle cramps
Bradycardia, cardiac arrest
Pain
GI activity also common
Nausea, abdominal cramps
Diarrhea / constipation
Metastatic calcification
Term
How is hypercalcemia treated?
Definition
NS
lasix
steroids
calcitonin
phosphate
dialysis
Term
What differentiates hypocalcemia from hypercalcemia?
Definition
hypocalcemia has Hyperactive neuromuscular reflexes and tetany
Term
In severe cases, what does hypocalcemia have?
Definition
convulsions
Term
What is hypocalcemia caused by?
Definition
Renal failure
Lack of vitamin D
Suppression of parathyroid function
Hypersecretion of calcitonin
Malabsorption states
pancreatitis
Widespread infection or peritoneal inflammation
Term
What 2 signs show up with hypocalcemia?
Definition
Chvostek's
Trousseau's
Term
How is hypocalcemia treated?
Definition
IV calcium for acute
Oral calcium and vitamin D for chronic
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