Fluids &

Electrolytes
Scott G. Sagraves, MD, FACS
Assistant Professor
Trauma & Surgical Critical Care
The recognition and
management of fluid,
electrolyte, and related
acid-base problems are
common challenges on the
surgical service.
Lawrence, Essentials of General Surgery
Goals
Review concept of total body fluids

Review types of crystalloids

Review electrolytes disturbances & their
treatment strategies.

Body Fluids
Intercellular
Intravascular
Interstitial
40%
16%
4%
Body Water = 60% of a patients body weight
Why do you give
D
5
NS + 20 mEq/L KCl
at 125 cc/hr to a
patient?
Fluid Requirements
typically 35 mL/kg/day
insensible loss = 700 mL/day or 0.2
cc/kg/day for every 1 C > 37
1-10 kg = 100 mL/kg/day {4mL/kg/hr}
11-20 kg = 50 mL/kg/day {2mL/kg/hr}
> 21 kg = 20 mL/kg/day {1mL/kg/hr}
Trick for hourly maintenance = 40 + weight (kg)
Serum Values of
Electrolytes
Cations Concentration, mEq/L
Sodium 135 - 145
Potassium 3.5 - 4.5
Calcium 4.0 - 5.5
Magnesium 1.5 - 2.5
Anions
Chloride 95 - 105
CO2 24 - 30
Phosphate 2.5 - 4.5
Daily Requirements for
Electrolytes
Sodium: 1-2 mEq/kg/d
Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/d
IV Solutions
Solution Na
+
Cl
-
K
+
Ca
+2
HCO3
-
Glu

Plasma 141 103 4-5 5 26 0

NS 154 154 0 0 0 0

D5W 0 0 0 0 0 50 G

LR 130 109 4 3 28 0
Serum Osmolality = [2 x Na] + [BUN/2.8] + [glucose/18]
Replacement Strategies
Sweat: D
5
NS + 5 mEq KCl/L
Gastric: D
5
NS + 20 mEq KCl/L
Biliary/pancreatic: LR
Small Bowel: LR
Colon: LR
3
rd
space losses: LR
Resuscitation
Crystalloids
Replace blood loss at a 3:1 ratio
Initial bolus 1-2 liters, usually normal
saline

If they have transient response, give
additional fluids. Once 3-4 liters of
crystalloid has been given consider
blood.
INDICATORS OF SUCCESSFUL
RESUSCITATION
PULSE 100 - 120 bpm
URINARY OUTPUT
CHILDREN = 1.0 ml/kg/hr
ADULT = 0.5 ml/kg/hr
Clearance of lactate
Resolution of base deficit

BLOOD PRESSURE POOR
INDICATOR
Fluid Status
[Na]
ECV
low normal
high
160
140
120
140
GI loss
SIADH
Hypothyroid
Cortisol
CHF
Cirrhosis
NaHCO
3

3% NaCl
Seawater
DI
Insensible
GI Loss
Renal loss
Osmotic
Renal Regulatory
Mechanisms
Aldosterone
distal tubules
sodium exchanged for K
+
and H
+
released by volume reduction

Antidiuretic Hormone (ADH)
increased tubular water reabsorption
posterior pituitary release
Acid/base
7.4
BE = 0
HCO3 = 24
Respiratory
Acidosis
Metabolic
Acidosis
Metabolic
Alkalosis
Respiratory
Alkalosis
ABG Rules
Rule 1: An increase or decrease in
PaCO
2
of 10 mm Hg, respectively, is
associated with a reciprocal decrease or
increase of 0.08 pH units.

Rule 2: An increase or decrease in
[HCO3
-
] or 10 mEq/L respectively is
associated with a directly related
increase or decrease of 0.15 pH units.
Acidosis
pH < 7.2
decreased responsiveness to catecholamines
cardiac dysfunction
arrhythmias
increased potassium serum levels
Case Studies
Found Down
45 yo WM, found down, presumed to be
assaulted, well known to ED for EtOH
CT head - hygromas, small ICH
labs:
Na = 118
K = 2.4
Cl = 74

What do you think? What do you do?
Severe Hyponatremia
Correct sodium to above 120 mEq/dl
NaCl + 40 mEq/L KCl
3% Saline
furosemide diuresis (euvolemic)
serial electrolytes
be prepared to handle seizures
Replace potassium
Cl should correct itself
Hyponatremia
1% of hospitalized are hyponatremic
Neurologic conditions:
Seizures, coma, encephalopathy
Results from rapid + [Na]

Peripheral symptoms:
Cramping, twitches, fasciculations
Results from ion conduction aberrations
Hints
Na
+
deficit (mEq) =
(140 Na
serum
) x 0.6 x Kg

Glucose increase 100 mg/dL or a BUN
increase of 30 mg/dL o decrease of 1.5
2 mEq/L Sodium
Central Pontine
Myelinosis
Results from overcorrection of
sodium
Correction of > 25 mEq per 24-48 hrs
Concurrent hypoxia
Presence of liver disease
Acute correction limit 25 mEq /day
Chronic correction limit 10 mEq/day
Treatment Strategies
Hypovolemic Hyponatremia
expand intravascular volume
0.9% NS or 3% Hypertonic Saline
Hypervolemic Hyponatremia
water restriction
treat medical condition
hemodialysis
Euvolemic Hyponatremia
SIADH
restrict fluid: 7-10 ml/kg/d
demeclocycline antagonizes vasopressin
HDU Code
A Code Blue is called in the HDU.

65 yo male with ESRD has arrested
awaiting his dialysis treatment. CPR and
BVM resuscitation are in progress and an
IV has been established.

What do you think? What do you do?
Pre-Arrest Rhythm Strip
Arrest Strip
Diagnosis?
HYPERKALEMIA
-Treatment
CaCl
2
10% - 1 ampule
Sodium Bicarbonate - 1 ampule
D
50
& Insulin 10 U
|
2
- agonist nebulizer- cellular K |
Kayexalate

Causes of
Hyperkalemia
Renal dysfunction
Acidemia
Hypoaldosteronism
Drugs
Excessive intake
WBC > 100,000
Platelets > 600,000
Cell Death
Rhabdomyolysis
Tumor lysis
Burns
Hemolysis
Potassium Metabolism
Normal daily intake 100 mEq
Renal filters & reabsorbs prox. Tubule
Potassium o 1/[aldosterone]
Acidosis | [potassium] with H
+
out
Alkalosis + [potassium] with H
+
in

Post op patient
42 year old female admitted to the ICU
post op after undergoing a
thyroidectomy for thyroid cancer.

She is complaining of peri-oral
numbness and tingling. Her DTRs are
hyperactive and her ECG has a
prolonged QT interval.

What do you think? What do you do?
HYPOCALCEMIA
Chvosteks sign - facial muscle spasm
Trousseaus sign - carpal spasm
Treatment
monitor ECG
IV calcium
follow up labs
oral calcium supplements
normal is 1 gram/day
Blunt Trauma
23 year old male, s/p MVC with blunt
abdominal and orthopedic trauma

HD#3 develops fever, N/V, abdominal
pain, refractory hypotension, with
oliguria.

Na
+
130, K
-
5.5, Glu 65, pH 7.29

What do you think? What do you do?
ACUTE ADRENAL
INSUFFICIENCY
Treatment
fluid and vasopressor support
treat precipitating conditions
draw baseline cortisol level
administer dexamethasone
ACTH stimulation test
hydrocortisone 100 mg IV q 8
Hydrocortisone Stimulation
Test
Baseline cortisol
> 20 - no further therapy
15 - 20 - test
< 15 empiric therapy

Administer Cortrosyn 250 g IV
Obtain levels 30 & 60 minutes post
injection
You are called to the
Bedside
What Do You Think? What Do You Do?
55 yo male, s/p fall with isolated,
repaired fractured femur.

Pts LOC decreased and patient began
to seize.

EKG showed
Hypomagnesemia
Mg plays role in energy metabolism,
protein synthesis, cell division, &
calcium regulation in muscle.

Definition < 1.6 mg/dL

Causes: poor diet, diuretics, gut losses,
& massive diarrhea, resuscitation.
Mg Rx
Replacement Magnesium Sulfate
1 gram = 8 mEq
Infuse at rate of 2 gram/hour
Emergency: 2 grams over 5
minutes
Closed Head Injury
32 year old female, MVC, GCS -7,
intubated, with CT scan showing SAH,
cerebral edema. ICP monitor shows a
pressure of 27. CPP 55.

Over the next several days, Na
+
> 150.

What do you think? What do you do?
DIABETES INSIPIDUS
Signs
[Na
+
] > 150
Urine specific gravity 1.007
polyuria, clear urine
dDAVP 1g sq raises urine osmolality in 2 hours
Treatment
free water deficit = (0.6) x (Kg) x ([Na
serum
/140] -1)
dDAVP 2g sq every 12 hours
for every L water deficit [Na
+
] will rise 3 mEq
above 140
The transfer
50 year old obese female, transferred for
critical care management after a bowel
resection. Presents with obtundation,
hypotension, tachypnea, and emesis.

C/O abdominal pain and has fruity breath

amylase, lipase are elevated, Na
+
127

What do you think? What do you do?
Work up?
ABG
Electrolyte panel
urine analysis
CBC
Serum Ketones
Hyperglycemia
Characteristic DKA NKHC
Glucose 400-800 > 1000
Acidosis Severe min.
Ketones High low
Dehydration Mod. High
Na 1.6 for every 100 glucose above 200
Treatment
Adequate fluid replacement
narrowing of anion gap
crystalloids: LR, NS, NS

Insulin
bolus 0.1 - 0.5 units/kg
infusion 0.1 units/kg/hour
goal reduce plasma glucose 75-100 mg/dL/hr

Electrolytes
K replacement 10-20 mEq/hour after UOP OK
Mg, PO
4
replacement
The drunk
37 year old male, h/o EtOH abuse fell from a
deer hunting tree stand. C5 fracture without
cord involvement.

HD #2 develops delirium tremors moved from
SIU to ICU. Librium started.

HD#4, dobhoff placed and tube feeds started.
That night, the patients respiratory status
worsens and he is intubated.

What do you think? What do you do?
HYPOPHOSPHATEMIA
Refeeding Syndrome
malnutrition
alcoholism

Hypophosphatemia
limits oxygen unloading
immunocompromise
muscle weakness failure to wean
Treatment
IV supplementation in emergent cases
sodium or potassium phosphorous

PO supplementation routinely

Keep (phosphorous x calcium) ratio <
60

Magnesium should be replenished
simultaneously
The burn patient
25 year male, caught fire after his
lawnmower exploded as he was filling it
with gasoline while smoking a cigarette.

The patient sustained second and third
degree burns estimated at 40 % total
body surface area.
Parkland Formula
4 cc x WEIGHT (kg) x (% TBSA)
Parkland Example
25 year old male
weight = 220 pounds
40% TBSA 2 - 3 burns

How much fluid do you need to give?
During the first 8 hours?
During the next 16 hours?
Parkland Example
4 cc x weight x %TBSA

4 x 100 x 40 = 16,000 cc/24 hours

first 8 hours = 16,000/2 =8,000/8 = 1,000cc/hr

next 16 hours = 8,000/16 = 500cc/hr
Diarrhea Dysrhythmia
68 yo female on digoxin for chronic
CHF, presents to the SIU for colitis as
evidenced by copious diarrhea.

The patient is weak and lethargic and
ectopic beats are noted on her ECG.

What do you think? What do you do?
Hypokalemia
Deficits
Serum K =
3-4 is a 100-200 mEq deficit
2-3 is a 200-400 mEq deficit
Treatment
replacement 10 mEq/hr via peripheral IV
10 mEq o 0.1 mEq/L increase in serum K
Remember to check the Mg level too

Paradoxical Aciduria
A rule: | 0.1 pH o + 0.4 - 0.5 mEq [K
+
]

pathophysiology
loss of K, severe alkalosis, |[Na
+
] load
hydrogen exchanged for K
independent of alkalosis remaining

requires emergent replacement
Cancer
72 yo female with stage 4, metastatic
breast cancer.
Patient is confused, cachetic, and
nauseated
Na
+
= 147, Ca
+2
= 14mg/dl

What do you think? What do you do?
HYPERCALCEMIA
Cancers associated
with hypercalcemia
bone
breast
kidney
colon
thyroid
multiple melanoma
Treatment
hydration
diuretics-lasix
mithramycin
corticosteroids
calcitonin-
osteoclast
resorption
phosphate
Labor and Delivery
32 year old P
3
G
3
being treated by OB
for eclampsia. You are called for a
somnolent patient in second-degree
heart block and paralysis.

What do you think? What do you do?
Hypermagnesemia
Signs
Prolonged PR interval
Hypotension, hyporeflexia, paralysis

Treatment
Calcium gluconate
Normal saline
Loop diuretics
dialysis
Questions?