needs to conserve sodi um, i t can reduce renal excreti on to l ess than 1 mEq/day.

Dai l y homeostasi s i s easi l y

mai ntai ned wi th 12 mEq/kg/day.
Potassium. The normal dai l y i ntake of potassi um i s approxi matel y 40120 mEq/day, wi th about 10%15%
excreted i n uri ne. An amount of 0.51 mEq/kg/day i s appropri ate to mai ntai n homeostasi s.
What is a good maintenance IV? (Tabl e 1-3) Usi ng the previ ous esti mates for a 70-kg mal e, the wei ght
formul a for IV fl ui d woul d equal 110 cc/hour. Mi ni mal sodi um mai ntenance woul d requi re 70140 mEq/day,
and mi ni mal potassi um requi rements woul d be 3570 mEq/day. In 0.5% normal sal i ne (NS), there i s 77
mEq/L sodi um, and i f one adds 20 mEq/L of potassi um, then usi ng 0.5% NS wi th 20 mEq/L KCL at 110
cc/hour woul d equal about 2.6 L of fl ui d, 200 mEq of sodi um, and 52 mEq of potassi um pretty cl ose!
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TABLE 1-3 Electrolyte Concentration in Various Intravenous Fluids
Fluid
Na
+
mEq/L
K
+
mEq/L
Mg
++
mEq/L
Ca
++
mEq/L
Cl
-
mEq/L
Lactate
mEq/L
Osmolarity
mOsm/L
Normal saline (0.9%
NaCl)
154 0 0 0 154 0 308
1/2 normal saline
(0.5% NaCl)
77 0 0 0 77 0 154
Hypertonic saline (3%
saline)
513 0 0 0 513 0 1027
Lactated Ringer's 130 4 0 2.7 98 28 525
Plasmalyte* 140 5 3 0 98 0 294
*Plasmalyte also contains 27 mEq/L acetate and 23 mEq/L gluconate.
C Water and electrolyte deficits and excesses
Water
Hypovolemia:
Signs of acute volume loss i ncl ude tachycardi a, hypotensi on, and decreased uri ne output.
Signs of gradual volume loss i ncl ude l oss of ski n turgor, thi rst, al terati ons i n body
temperature, and changes i n mental status.
Replacing water deficits. Acute defi ci ts shoul d be repl aced acutel y; chroni c defi ci ts shoul d be
repl aced more sl owl y, wi th hal f of the defi ci t repl aced over the fi rst 8 hours and the rest i n 24
48 hours. In the case of hypernatremi a wi th hypovol emi a, do not al l ow the sodi um
concentrati on to drop more than 0.51 mEq/hour.
Hypervolemia: Wel l tol erated i n heal thy pati entsthey wi l l j ust uri nate the excess.
Signs of acute hypervolemia: Acute shortness of breath, tachycardi a.
Complications of acute CHF can ari se i n pati ents wi th poor cardiac function gi ven too
much fl ui d acutel y. Therefore, i t i s i mportant to moni tor these pati ents cl osel y.
Signs of chronic hypervolemia: Peri pheral edema, pul monary edema.
Di uresi s may be needed i n some pati ents to reduce vol ume.
Sodium: close relationship to volume status
Hyponatremia
Definition and categories. Hyponatremi a i s defi ned as a serum sodi um l evel of 130 mEq/L or
l ess. The fi rst step i n di agnosi s and treatment i s to assess the osmol ar and vol emi c state.
Hyperosmolar: Di l uti onal hyponatremi a from hypergl ycemi a, manni tol i nfusi on, or
presence of other osmoti cal l y acti ve parti cl es.
Normo-osmolar: Pseudohyponatremia. Hypergl ycemi a, hyperl i pi demi a, and
hyperprotei nemi a i nterfere wi th the l ab measurement of sodi um.
Hypo-osmolar: True hyponatremia.
Hypovolemic: Most common. Normal l y, hypovol emi a l eads to ADH secreti on and
the i nabi l i ty to excrete free water. Intake of free water vi a thi rst mechani sms or
i nfusi on of hypotoni c sol uti on l eads to hyponatremi a. Total body sodium usually
is low.
Hypervolemic: Total body sodium usually is high. The pathol ogy i s often rel ated
to l ow cardi ac output (the ki dneys see l ess bl ood fl ow, and free water i s not
excreted) or hypoal bumi nemi c (e.g., ci rrhosi s) or other edematous states where
sal t (reni n-angi otensi n system) and free water (ADH) cannot be excreted by the
ki dneys.
Euvolemic: Coul d be ei ther of the states above, or more frequentl y i n the
peri operati ve pati ent, syndrome of inappropriate antidiuretic hormone (SIADH)
P.7
secretion. ADH secreti on can be sti mul ated by the stress response to
trauma and surgery. Free water i s retai ned.
Symptoms. Acute hyponatremi a i s associ ated wi th acute cerebral edema, sei zures, and coma.
Chroni c hyponatremi a i s wel l tol erated to Na concentrati ons of 110 mEq/L. Symptoms general l y
i ncl ude confusi on/decreased mental status, i rri tabi l i ty, and decreased deep tendon refl exes.
Diagnosis and categorization. Cl i ni cal exam and l ab determi nati on of osmol ar state are often
enough for di agnosi s, but i f i n doubt, especi al l y wi th hypo-osmol ar hyponatremi a, check uri ne
osmol ari ty and sodi um concentrati on.
Hypovolemic, hypo-osmolar hyponatremia: Uri ne osmol ari ty hi gh; Na l ow.
Hypervolemic, hypo-osmolar hyponatremia: Si mi l ar pi cture.