FLUID BALANCE

TOTAL BODY WATER (AS PERCENTAGE OF BODY WEIGHT) IN

RELATION TO AGE AND SEX
AGE MALE FEMALE

UNDER 18 65% 55%

18-40 60% 50%

40-60 50-60% 40-50%

OVER 60 50% 40%

Ions

NORMAL VALUES AND MASS CONVERSION FACTORS

Normal Plasma Values Mass Conversion
Sodium (Na+) 135 – 145 meq/L 23 mg = 1 meq
Potassium (K+) 3.5 – 5.0 meq/L 39 mg = 1 meq
Chloride (Cl-) 98 – 107 meq/L 35 mg = 1 meq
Bicarbonate (HCO3-) 22 – 26 meq/L 61 mg = 1 meq
Calcium (Ca2+) 8.5 – 10.5 mg/dL 40 mg = 1 mmol
Phosphorus 2.5 – 4.5 mg/dL 31 mg = 1 mmol
Magnesium (Mg2+) 1.8 – 3.0 mg/dL 24 mg = 1 mmol
Osmolality 285 – 295 mosm/kg -
265 - 305 mosm/kg
Sodium Regulation

Increased ADH secretion, Decreased

INCREASED urine volume and increased plasma DECREASED
SODIUM volume SODIUM

Decreased aldosterone secretion,

decreased sodium reabsorption

NORMAL Na+

Decreased ADH secretion, Increased

urine volume and decreased plasma
volume INCREASED
DECREASED
SODIUM
SODIUM
Increased aldosterone secretion,
increased sodium reabsorption
Potassium Regulation

Increased aldosterone secretion with

INCREASED increased potassium secretion by the DECREASED
POTASSIUM kidneys and increased potassium in POTASSIUM
urine

NORMAL K+

DECREASED INCREASED
Decreased aldosterone secretion with
POTASSIUM POTASSIUM
decreased potassium secretion by the
kidney and decreased potassium in
the urine
Calcium Regulation
Increased Calcitonin secretion with
decreased bone resorption

INCREASED DECREASED
Decreased parathyroid hormone
CALCIUM CALCIUM
secretion with decreased bone
resorption, decreased intestinal
calcium absorption, and decreased
kidney calcium reabsorption

NORMAL Ca++

DECREASED INCREASED
CALCIUM Increased parathyroid hormone CALCIUM
secretion with increased bone
resorption, increased intestinal
calcium absorption, and increased
renal calcium reabsorption
 Parenteral Solutions
COMMONLY USED PARENTERAL SOLUTIONS
IV Solutions Osmolality Glucose Sodium Chloride
(mosm/kg) (g/liter) (meq/liter) (meq/liter)
5% D/W 252 50 - -
10% D/W 505 100 - -
50% D/W 2525 500 - -
0.45% NaCl 154 - 77 77
0.9% NaCl 308 - 154 154
3% NaCl 1026 - 513 513
Ringer’s lactate 282 - 130 109
5% D/NR 294 50 147 147
5% D/NM 290 50 77 77
Hyponatremia

SERUM OSMOLALITY

Normal Low High

HYPOTONIC
ISOTONIC HYPERTONIC
Hyponatremia
Hyponatremia Hyponatremia
Hyperglycemia
Hyperproteinemia
Mannitol, sorbitol,
Hyperlipidemia
Glycerol, maltose
VOLUME STATUS
 Hyponatremia

VOLUME STATUS

Hypovolemic Euvolemic Hypervolemic

Una <10 meq/L Una >20 meq/L SIADH Edematous states:

Extrarenal salt Renal salt loss Postop HypoNa Congestive heart failure
Dehydration Diuretics Hypothyroidism Hepatic disease
Diarrhea ACE-inhibitors Psychogenic Nephrotic syndrome
Vomiting Nephropathies polydipsia Advanced CHF
Mineralo- Beer potomania
Corticoid lack Drug reactions
 Hypokalemia: Treatment
ORAL POTASSIUM REPLACEMENTS
AMOUNT meq OF K ANION NAMES
LIQUIDS 15 ml 10 Cl 5% Potassium chloride
15 ml 20 Cl 10% Potassium chloride
15 ml 40 Cl 20% Potassium chloride
15 ml 20 Gluconate Potassium gluconate
POWDERS Packet 15 Cl K-lor
Packet 20 Cl Potassium chloride
Packet 25 Cl K-lyte
TABLETS 1 8 Cl Slow-K
1 8 Cl Micro-K extencaps
1 10 Cl K-dur 10
1 20 Cl K-dur 20
 Hypokalemia: Treatment
POTASSIUM CONTENT OF FOODS
VERY HIGH HIGH
(12-20 meq) (5-12 meq)
BEANS Garbanzo beans Kidney beans Navy beans
Soy beans Lima beans Pinto beans
FRUIT (1/2 cup or as stated) Papaya (one medium) Apricots (3 halves)
Banana (6”)
Cantaloupe (1/4”)
Honeydew melon (1/4”)
Orange (3”) and orange juice
Pear (one large)
Prunes (4) and prune juice
Rhubarb
 Hypokalemia: Treatment
POTASSIUM CONTENT OF FOODS
VERY HIGH HIGH
(12-20 meq) (5-12 meq)
VEGETABLES (1/2 cup or as Artichoke (one)
stated) Avocado (1/4)
Brussel sprouts
Carrot (7 ½”) and chard
Ketchup (1 tbsp)
Potato (one baked, one
broiled, 10 fries, ½ cup
mashed)
Pumpkin and spinach
Tomato (one) and tomato
juice
 Hyperkalemia: Treatment
EMERGENCY TREATMENT OF HYPERKALEMIA
MODALITY MECHANISM ONSET DURATION PRESCRIPTION K REMOVED
OF ACTION FROM BODY
Calcium Antagonizes 0-5 min 1 hour Ca gluconate 10%, None
cardiac 5-30 ml IV;
conduction CaCl 5%, 5-30 ml
abnormalities IV
Bicarbonate Shifts K into 15-30 1-2 hours NaHCO3 44-88 None
cells min meq IV
Insulin Shifts K into 15-60 4-6 hours SAI, 5-10 u IV, None
cells min plus glucose 50%,
25 g IV
Albuterol Shifts K into 15-30 2-4 hours Nebulized None
cells min albuterol, 10-20
mg in 4 ml saline
 Hyperkalemia: Treatment
NON-EMERGENCY TREATMENT OF HYPERKALEMIA
MODALITY MECHANISM DURATION OF PRESCRIPTION K REMOVED
OF ACTION TREATMENT FROM BODY
Loop diuretic Increased 0.5-2 hours Furosemide 40-160 mg IV Variable
renal K or orally with or without
excretion NaHCO3, 0.5-3 meq/kg
daily
Sodium Ion exchange 1-3 hours Oral: 15-30 g in 20% 0.5-1 meq/g
polystyrene resin binds K sorbitol (50-100 ml)
sulfonate Rectal: 50 g in 20%
(Kayexalate sorbitol
Hemodialysis Extracorporeal 48 hours Blood flow > 200-300 200-300 meq
K removal ml/min; Dialysate K = 0
Peritoneal Peritoneal K 48 hours Fast exchange, 3-4 L/hr 200-300 meq
dialysis removal
 Hypocalcemia: Treatment

TREATMENT OF HYPOCALCEMIA
MODALITY AMOUNT OF CALCIUM ONSET DOSE
Intravenous 93 mg (4.7 meq) per 10 ml Immediate 93-186 mg over 10-15 mins;
calcium (Calcium then 10-15 mg/kg over 4-6
gluconate) hours.
Oral calcium 40% elemental calcium; < 1 hour 250-500 mg calcium 3 to 5
(calcium 250 mg/624 mg tablet or times a day.
carbonate) 500 mg/1250 mg tablet or
500 mg/1500 mg tablet
 Hypercalcemia
CAUSES OF HYPERCALCEMIA
INCREASED INTAKE OR Milk-alkali syndrome
ABSORPTION Vitamin D or vitamin A excess
ENDOCRINE DISORDERS Primary and secondary hyperparathyroidism
Acromegaly
Adrenal insufficiency
NEOPLASTIC DISEASES Tumors producing PTH-related proteins
Metastases to bone
Lymphoproliferative disease
Secretion of prostaglandins and osteolytic factors
MISCELLANEOUS CAUSES Thiazide diuretics and renal transplant complications
Sarcoidosis and Paget’s disease of the bone
Hypophosphatasia, immobilization, iatrogenic
 ABG Interpretation
SUMMARY OF EXPECTED COMPENSATION FOR SIMPLE ACID-BASE DISORDERS
DISORDER INITIAL CHANGE COMPENSATORY RESPONSE
Metabolic Acidosis Decrease in HCO3- Decrease in pCO2:
-
Δ pCO2 = 1.1 – 1.3 (ΔHCO3 )
Metabolic Alkalosis Increase in HCO3- Increase in pCO2:
-
Δ pCO2 = 0.6 – 0.7 (ΔHCO3 )
Respiratory Acidosis Increase in pCO2 Increase in HCO3
-

-
ACUTE: ΔHCO3 = 0.1 Δ pCO2 + 2
CHRONIC: ΔHCO3-= 0.3 – 0.35 Δ pCO2
-
Respiratory Alkalosis Decrease in pCO2 Decrease in HCO3
-
ACUTE: ΔHCO3 = 0.2 – 0.25 Δ pCO2
CHRONIC: ΔHCO3-= 0.4 – 0.5 Δ pCO2