By, Dr.

Henley Punnen Andrews

Under the guidance of: DR. B.SHASHIDHARAN. Professor and Chief Unit-III

Water is the most abundant constituent in the body comprising about 50% of the body weight in women and 60% in men

1.

INTRACELLULAR COMPARTMENT :
Largest compartment,55 to 75% is the intracellular compartment ICF primarily a solution of potassium and organic anions, proteins

2.

EXTRACELLULAR COMPARTMENT :
Fluid that is not contained inside a cell comprises the extracellular compartment 25 to 45 % of the total body water ECF primarily a NaCl and NaHCO3 solution

Intravascular (Blood Plasma) Circulating Compartment

Extravascular (Interstitial Lymph)

ECF Transcellular Fluid Made of CSF, Digestive Juices, mucus etc

1. Internal balance 2. External balance

Considered in terms of :

Internal balance [flux]:

This is the movement of water across the capillaries of the body and movement of water between interstitial and intracellular fluids.

Diffusional turnover of water in the bodys capillaries is about 80,000 liters a day. Lymph flow is about 1 to 25 L/day. GFR is 180 L/day and majority of this is reabsorbed in the renal tubules. Turnover of fluids in the bowel is about 8 to 9 L/day.

Some examples:

Name given to the interstitial fluid which enters the lymphatic vessels Lymphatic capillaries are present in all the tissues except the CNS and bone FUNCTIONS OF THE LYMPHATIC SYSTEM
Return of protein and fluid from the interstitial space to the circulation to maintain oncotic pressure gradient across the capillary membrane. Edema will occur if interstitial oncotic pressure is not kept low. Role in absorption and transport of fat from small intestine. Immunological role lymph glands and circulation of immune cells.

There are about one million glomeruli in each kidney. Glomerulus consists of a tightly coiled network of capillaries surrounded by podocytes. Blood passes through each glomerulus filtering water and metabolic waste through capillary walls by the surrounding podocytes. The net excess in the glomerular capillaries is 180 litres per day and is known as GFR.

Fluid in the bowel is considered as part of transcellular compartment. Around 9 10 liters of fluid enters the gut each day. 98% of this fluid is reabsorbed resulting in a fecal water loss of only 200 ml per day. Reabsorbtion predominantly occurs in the jejunum and ileum with over a liter per day absorbed in the colon.

2.

EXTERNAL BALANCE
External balance refers to the comparison between the water input from and the water output to the external environment. Over any period of time, input equals output and the organism is in water balance

The afferent or sensor mechanisms which sense abnormalities in ECF volume homeostasis include the following
i. ii. iii. iv.

1.

Low pressure baroreceptors

Carotid atria Great veins Cardiac ventricles Pulmonary capillaries

2.

3. 4.

i. ii. iii.

High pressure baroreceptors CNS osmoreceptors. Intrahepatic receptors.

Carotid sinus Aortic arch Intrarenal(juxtaglomerular apparatus)

Exactly what is sensed by these receptors is not completely defined.

The term effective circulatory volume describes the factors which are sensed by these receptors.
Cardiac output Arterial resistance Mean arterial pressure Blood volume Venous capacitance

OSMORECEPTORS
Osmoreceptors are specialized cells in the hypothalamus. Responds to changes in extracellular tonicity.

BARORECEPTORS
Regulation of arterial blood pressure is accomplished by negative feed back system incorporated in baroreceptors. Arterial baroreceptors are located in the carotid sinus at the bifurcation of external and internal carotids and also in the aortic arch. Carotid sinus is innervated by the sinus nerve, branch of the glossopharyngeal nerve(9th nerve) which synapses in the brain stem.

Aortic arch baroreceptors are innervated by the aortic nerve, combines with vagus nerve and travels to the brain stem. Aortic arch receptors are more sensitive in detecting hypovolemia while carotid sinus receptors are more sensitive in detecting hypotension. Hence the carotid sinus receptors are the dominant arterial baroreceptors.
Steady or mean arterial pressure. Rate of pressure change: Decreasing the pulse pressure decreases the baroreceptor firing rate.

Receptors are sensitive to

Control of water input Thirst which is mechanism for adjusting water input via the GIT. Control of water output ADH which provides a mechanism for adjusting water output via the kidney.

1.

Molarity it is the number of moles of solute per 1 liter of solution. Molality it is the number of moles of solute in 1000gm solvent. m = moles solute / 1000gm solvent. Normality it is the gram equivalent of solute in 1 liter of solution. Osmolarity of a solution is the number of moles of solute per liter of solution. Osmolality of a solution - is the number of osmoles of solute per kg of solvent.

2.

1.

2.

3.

PLASMA OSAMOLALITY = GLUCOSE IN MG% 18 BLOOD UREA IN MG% 5.9

2 x PLASMA Na+ + (275 290mOSM/kg)

IV fluids supply two things Need for IV fluids:

fluid volume electrolytes

To expand intravascular volume acutely and produce enough urine volume to excrete solutes. To correct an underlying imbalance in fluids or electrolytes lost from urine, skin and gut. To supply necessary vitamins and minerals. To satisfy the calorie needs there by decreasing tissue catabolism.

Several methods proposed to relate maintenance needs to body weight, these include:
Basal calorie method based on metabolic rate. Surface area method Holliday-Segar System based on weight.

The basal calorie method requires a table and involves most calculations. The Surface area method also requires a table to determine surface area and ideal knowledge of patients height and weight.

The Holliday-Segar System is used most frequently because of the ease with which the formulae can be remembered.

Requirement of fluid of a 10year old boy weighing 32kg using the Holliday-Segar method (10100) + (1050) + (1220)=1740 mL (104) + (102) + (121)=72 mL/hr

CRYSTALLOIDS-Clear solutions fluids- made up of water & electrolyte solutions & small molecules. ADVANTAGES:
Inexpensive. Easy to store with long shelf life. Readily available. Very low incidence of adverse reaction. Effective for use as replacement fluids or maintenance fluids.

DISADVANTAGE:

It takes approximately 2-3 x volume of a crystalloid to cause the same intravascular expansion as a single volume of colloid. Causes peripheral edema. Dilute plasma proteins.

CLASSIFICATION:

1) Replacement solutions 2) Maintenance solutions 3) Special Solutions

Replacement solutions:

Used to replace ECF. Isotonic Solution. Solutions have Na+ similar to that of ECF. It is used to replace blood loss; 3 to 4 times the volume lost must be administered as only 1/3 to remains intravascular after 1 hour. Solutions used are Normal Saline and lactated Ringers Solution.

 Ringers Lactate :

Has small amounts of K+ and Lactate.

Lactate is metabolized in the liver to bicarbonates and helps if acidosis is present.

Maintenance Solutions:

Used to provide maintenance fluids. They are isosmotic when administered and do not cause haemolysis. Dextrose 5% has no Na+ so it is distributed throughout the total body water with each compartment getting fluid in proportion to its contribution to the Total Body Water.

Special Solutions:
Crystalloid solutions used for special purposes are grouped together:
Hypertonic 3% saline. Half normal saline. 8.4% bicarbonate solution. Potassium Chloride. Mannitol 20%. 25% Dextrose.

5% DEXTROSE SOLUTION

Maintenance solution. Dextrose used is dextrose monohydrate. pH range is 3.6 6.5. Indications

As a caloric nutrition to provide the patient with carbohydrate calories. As a water supply in hypertonic dehydration cases. Correction of hypernatraemia. To increase blood sugar in cases of hypoglycemia. Hepato-protective. As an emergency fluid to prevent the risk of shock which occurs due to sudden decrease of blood or plasma volume.

 As a carrier solution for infusion of drugsAmphotericin B, Noradrenalin, Sodium Nitroprusside, Amiodarone, Propofol.

Contraindications
Cerebral edema Causes reduction of Na+ in plasma and water passes into the brain where Na+ concentration is higher causing raised ICT.

Ischemic Brain Injury-

Hyponatraemia-

Elevated blood sugar levels worsens ischemic brain damage. Glucose is metabolized to lactic acid around the ischemic area lowering the pH and exacerbating the ischemic injury. Provides electrolyte free water which worsens the situation.

NORMAL SALINE (0.9% SALINE SOLUTION)

Contains 9g of NaCl per liter of water. pH is 5.0 The osmolality is 308mOsm/L.

Potential problems with the use of large amounts of normal saline are:
Hyperchloraemic metabolic acidosis. Development of oedema.

Indications:

As replacement fluids in dehydration. Useful for maintaining the daily requirement of salt and water.

Hypovolemia. Diabetic ketoacidosis. Vehicle for most drugs. Treatment of Hypercalcaemia. Others- Bowel wash, Peritoneal lavage, to maintain tissue hydration during bowel exposure, flushing solution for eye surgery.

HYPERTONIC SALINE SOLUTIONS

Includes 1.8%, 3%, 5%, 7.5% and 10% NaCl Solutions. Hypertonic saline 3% has an osmolality of 900 mOsm/L. Fluid shifts and osmolar changes that occur are:
Fluids pass from the cells into the extravascular compartment. The ECF volume is expanded by approx 2.5L after administering 1 liter of 3% saline. Since Na+ and Cl- cannot freely cross cell membranes, the ECF becomes slightly hyperosmolar. Decrease in ICF volume may have effects on brain causing confusion and mental obtundation due to cerebral cellular dehydration and hypertonicity.

Indications-

In critical care Brain injury-

Hyponatraemic states and diuretic overuse, Excessive losses of GI secretions, renal disease. Hypertonic saline resuscitation of patients with traumatic and non traumatic brain injury may increase survival but neurological outcomes is unknown.

In scleotherapy direct injection is put into a vein. Intra-amniotic use in midtrimester abortion. Volume resuscitation in hemorrhagic shock, septic shock and major burns.

 Advantages;

Rapid increase in intravascular volume. Relatively small intravenous fluid volumes. Decreased intracranial pressures. Small volume resuscitation prevents inflammation and the resulting organ dysfunction.

Hypertonic saline with dextran:

Tested in certain studies in trauma population. Approved for use in 14 European countries. More rapid improvement of blood pressure. Improved blood flow to the brain. Decreasing pressure in the injured brain. Decreases the risk of infection and ARDS.

HARTMANNS SOLUTION (SODIUM LACTATE)

Invented by Sydney Ringer, British physiologist. pH of 6.5 Contains Na+ -130-131 mmol/L Cl- -109-111mmol/L HCO3- -29mmol/L K+ -5mmol/L Ca2+ -2mmol/L

The Bicarbonate ions are present in solution as lactate and later converted in the liver to bicarbonate.

Indications:

Fluid resuscitation after a blood loss Trauma, surgery or a burn injury.

Used to induce urination in patients with renal failure. Ideal maintenance fluid during and after surgery. Used in treatment of lower GI tract losses like diarrhea induced hypovolaemia. In metabolic acidosis, it provides a glucose free solution and used in correcting acidosis. In DKA it has the added advantage of supplying potassium.

Contraindication:
Not suitable for maintenance therapy because the Na+ content is too high and potassium content too low, in view of electrolyte daily requirement. In hepatic insufficiency, lactated ringers solution can precipitate lactic acidosis. In chronic heart failure, there is an associated lactic acidosis more in myocardial tissues. In upper GI losses there is metabolic alkalosis and lactated ringers solution provides bicarbonate which worsens the condition.

DEXTROSE SALINE SOLUTION

Contains 0.9% normal saline and 5% dextrose. Normal saline rapidly corrects any ECF deficit of both sodium and chloride while dextrose element provides energy. Distributed mainly in the extracellular compartment and so does not correct intracellular dehydration. Since it is distributed in the extracellular compartment, can be considered for the treatment of hypovolaemic shock.

SODIUM BICARBONATE SOLUTION

8.4% NaHCO3 solution has an osmolality of 2000mOsm/L. (7 times the plasma osmolality) Properties:
Hypertonic- draws water out of cells until the ECF and ICF tonicities are equal. Alkalinizing load will increase the ECF HCO3 and cause metabolic alkalosis which in turn causes intracellular movement of K+ and ECF K+ will decrease. Hence used in the emergency treatment of Hyperkalemia. Recommended for emergency treatment of acute hyponatraemia.

HYPERTONIC MANNITOL SOLUTIONS

Mannitol is a six carbon sugar alcohol prepared by the reduction of dextrose. Occurs naturally in fruits and vegetables. Odorless, sweet tasting, white, crystalline powder with a melting range of 165 - 168C. Actions:

Intracellular dehydration. Expansion of ECF volume (except brain ECF) Haemodilution. Decreased blood viscosity with improved tissue blood flow. Cardiovascular effects secondary to expanded intravascular volume( increased cardiac output, hypertension, heart failure, pulmonary edema)

Cerebral effects:

Mannitol does not cross the blood brain barrier and is effective in removing fluid from the brain. This is called mannitol osmotherapy. Mannitol infusions are used to rapidly decrease elevated ICP due to an intracranial SOL. The affect is rapid in onset but only temporary (as mannitol is excreted) but buys time for urgent definitive therapy. Repeated doses of mannitol have less effect. Prolonged use decreases the osmotic effect as mannitol molecule eventually crosses into the cerebral interstitium. Rebound intracranial hypertension is a risk.

Contraindications

Anuria secondary to renal disease. Severe dehydration. Severe pulmonary congestion or pulmonary oedema.

Mannitol therapy to be stopped if following develop during mannitol therapy:

Progressive Heart failure Pulmonary congestion Progressive renal failure or damage.

Adverse Effects:

Fluid and electrolyte imbalances. Adequate monitoring and support is required. GI-nausea and vomiting. Cardiovascular-Pulmonary Edema, Congestive Heart failure. CNS Effects- dizziness, headache, etc.

Colloids are large molecular weight solutions (nominally MW > 30,000 daltons). These solutes are macormolecular substances made of gelatinous solutions which have particles suspended in solution and do NOT readily cross semi-permeable membranes or form sediments. Because of their high osmolarities, these are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries.

These work well in reducing edema because they draw fluid from the interstitial and intracellular compartments into the vascular compartments. Initially these fluids stay almost entirely in the intravascular space for a prolonged period of time compared to crystalloids. Advantages of Colloids:
plasma volume. Less peripheral edema. Smaller volumes for resuscitation. Intravascular half-life 3-6 hrs .

General

Distributed to intravascular compartment only. Readily available. Long shelf life. Inexpensive. No special storage or infusion requirements. No special limitations on volume that can be infused. No interference with blood grouping or cross matching.

Physical Properties

Iso-oncotic with plasma Isotonic Low viscosity Contamination easy to detect.

Pharmacokinetic properties

Half life should be 6 to 12 hrs. Should be metabolized or excreted and not stored in the body.

Toxicity and other adverse effects on body systems.

No interference with organ function even with repeated administration. Non-pyrogenic, non-allerginic and non-antigenic. Should not cause agglutination or damage blood cells. Should not cause acid base disorders or promote infection.

Types:
Natural colloid Human serum albumin (5%, 25%)

Synthetic colloids Dextrans Gelatins Starches

Hydroxyethyl starch (HES) Pentastarch

Used for many years as 1st line colloid for volume expansion. Properties
It is a single polypeptide consisting of 585 amino acids. MW is 66,248 D. Albumin is an intravascular protein and stays within the intravascular space unless the capillary permeability is abnormal. Expands volume 5 times its own volume in 30minutes. Synthesis is increased by thyroxine, insulin or cortisol.

Side effects:

Volume overload. Fever due to pyrogens in albumin. Rise in colloid oncotic pressure impairs renal salt and water excretion.

Indications:

Emergency treatment of shock. Acute management of burns. Hypoproteinemia.

Dextrans are highly branched polysaccharide molecules available for use as artificial colloids. Synthesised using bacterial enzyme dextran sucrase from the bacterium Leuconostoc mesenteroides grown in a sucrose medium. Formulations available are- Dextran 40 and Dextran 70. Properties:
Available as a 10% solution in NS or D5%. pH-4.5-5.7. Excretion is through urine, faeces and RE system. Dextran 40 is the commonly used dextrans and induce a marked increase in plasma volume.

Side effects:

Clotting deficits.

Defects in platlet interaction. Dilution of fibrinogen.

Interference with cross matching so the lab must be informed that dextrans have been used. Dextrans cause more severe anaphylactic reactions than the gelatins or the starches. Renal failure: in patients with pre-existing kidney disease.

Gelatine is the name give to large MW polydisperse proteins formed from the hydrolysis of collagen. Obtained from boiling the connective tissues of animals. Currently used gelatine solutions:
Succinylated fluid gelatins(e.g., Gelofusine) Modified fluid gelatins(e.g.,Plasmagel) Urea-cross linked gelatins(e.g.,Haemaccel, Polygeline) Oxy-poly-gelatins.

Indications:

Advantages

Replacement of intravascular volume.

Disadvantages

Lower infusion volume as compared to crystalloids. Cheaper and more readily available than plasma proteins solutions. Readily excreted by renal mechanisms. Long shelf-life, no refrigeration. No interference with blood cross-matching. Higher cost than crystalloids. Anaphylactoid reactions can occur.

These polydisperse colloid solutions are produced from amylopectin(obtained from maize) which is stabilized by hydroxylethylation to prevent rapid hydrolysis by amylase.

Contraindications

Known hypersensitivity to hydroxyethylstarch Bleeding disorders. Congestive Heart Failure. Renal disease with oliguria or anuria.

Side-effects:
Hypersensitivity. Anaphylactic reactions. Pentastarch has been shown to be embryocidal in rabbits and mice. Headache, Diarrhoea, nausea, weakness, temporary weight gain, insomnia, fatigue, fever, oedema, acne, malaise, dizziness, chestpain, chills, nasal congestion and increased heart rate have also been reported in clinical studies involving pentastarch.

Crystalloids need to be administered in volume 3times greater than colloids due to propensity of leakage into the extra vascular space. Colloids offer the advantage of enhancing oxygen consumption to a greater extent than crystalloids. Crystalloids are first line fluids for haemodynamically stable patient but colloids are preferred in haemodynamically compromised patients. Hypovolaemic patients with normal pulmonary function, the use of colloids maintain colloid osmotic pressure and limit the development of pulmonary oedema under elevated hydrostatic pressure.

Infection:

Any break in the skin carries a risk of infection. Although IV insertion is a sterile procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter. Phlebitis is irritation of a vein that is not caused by infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Infiltration occurs when an IV fluid accidentally enters the surronding tissue rather than the vein. It is characterized by coolness and pallor to the skin as well as local edema.

Phlebitis:

Infiltration:

Fluid overload:

This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of sodium, potassium, magnesium, and other electrolytes. A blood clot or other solid mass, as well as an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel. Extravasation is the accidental administration of IV infused medicinal drugs into the surrounding tissue.

Electrolyte imbalance:

Embolism:

Extravasation:

Sodium imbalance s

Definit ion

Risk factors/ etiology

Clinical manifestation

Laboratory findings

management

Hyponatr -aemia

Kidney diseases It is defined as a plasma sodium level below 135 mEq/ L Adrenal insufficiency Gastrointestinal losses Use of diuretics (especially with along with low sodium diet) Metabolic acidosis

Weak rapid pulse Hypotension Dizziness Apprehension and anxiety Abdominal cramps Nausea and vomiting Diarrhea Coma and convulsion Cold clammy skin Finger print impression on the sternum after palpation Personality change

Serum sodium less than 135mEq/ L serum osmolality less than 280mOsm/kg

Identify the cause and treat *Administration of sodium orally, by NG tube or parenterally *For patients who are able to eat & drink, sodium is easily accomplished through normal diet *For those unable to eat,Ringers lactate solution or isotonic saline [0.9%Nacl]is given *For very low sodium 0.3%Nacl may be indicated *water restriction in case of hypervolaemia

Sodium imbalan -ce Hypernat -remia

Defini tion

causes

Clinical manifestation

Lab findings

management

It is defined as plasma sodium level greater than 145mE q/L

*Ingestion of large amount of concentrated salts *Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion

Low grade fever Postural hypertension Dry tongue & mucous membrane Agitation Convulsions Restlessness Excitability Oliguria or anuria Thirst Dry &flushed skin

*high serum sodium 135mEq/L *high serum osmolality >295mOsm/kg

*Administration of hypotonic sodium solution [0.3 or 0.45%] *Rapid lowering of sodium can cause cerebral edema *Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes insipidus desmopressin acetate nasal spray is used *Dietary restriction of sodium in high risk clients

Potassium imbalances Hypokalemi a

Definiti on It is defined as plasma potassiu m level of less than 3.0 mEq/L

Causes

Clinical manifestatio n *weak irregular pulse *shallow respiration *hypotesion *weakness, decreased bowel sounds, heart blocks , paresthesia, fatigue, decreased muscle tone intestinal obstruction

Lab findings

Management

*Use of potassium wasting diuretic *diarrhea, vomiting or other GI losses *Alkalosis *Cushings syndrome *Polyuria *Extreme sweating *excessive use of potassium free Ivs

* K less than 3mEq/L results in ST depression , flat T wave, taller U wave * K less than 2mEq/L cause widened QRS, depressed ST, inverted T wave

3.5] can be managed by oral potassium replacement

Mild hypokalemia[3.3to

Moderate hypokalemia

*K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/

K- less than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day]

Severe hypokalemia

Definitio n

Causes

Clinical manifestatio n Irregular slow pulse, hypotension , anxiety, irritability, paresthesia, weakness

Lab findings

Management

Hyperk alemia

It is defined as the elevation of potassium level above 5.0mEq/L

Renal failure , Hypertonic dehydration, Burns& trauma Large amount of IV administration of potassium, Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad Pwave *serum potassium levels of 8mEq/L results in no arterial activity[no p-wave]

*Dietary restriction of

potassium for potassium less than 5.5 mEq/L

*Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics

*Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium 2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake 3.sodium polystyrene sulfonate [Kayexalate] given orally.

Calciu m imbala nces

Definiti on

Causes

Clinical manifestation

Lab findin gs

Management

hypocalc emia

It is a plasma calcium level below 8.5 mg/dl

Rapid administration of blood containing citrate, hypoalbuminemi a, Hypothyroidism Vitamin deficiency, neoplastic diseases, pancreatitis

Numbness and tingling sensation of fingers, hyperactive reflexes, Positve Trousseaus sign, positive chvosteks sign , muscle cramps, pathological fractures, prolonged bleeding time

Serum calcium less than 4.3 mEq/L and ECG changes

1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

Calcium imbalan ce

Definitio n

Causes

Clinical manifestation

Lab findings

Management

Hypercalc emia

It is calcium plasma level over 5.5 mEq/l or 11mg/dl

Metastatic bone tumors, pagets disease, osteoporosis prolonged immobalisatio n

Decreased muscle tone, anorexia, nausea, vomiting, weakness , lethargy, low back pain from kidney stones, decreased level of consciousnes s & cardiac arrest

High serum calcium level 5.5mEq/L, x- ray showing generalized osteoporosis, widened bone cavitation, urinary stones, elevated BUN 25mg/100ml elevated creatinine1.5m g/100ml

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium 2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same

REFERENCES

Fluid Therapy by, Rashmi Datta 2008. Harrisons Book of Internal Medicine, 18Edition. McGraw-Hill - CURRENT Medical Diagnosis & Treatment 2010. 49th Edition.