Fluids & Electrolytes Notes PDF

8/16/2024 Fluids and Electrolytes Brian Hierholzer, Pharm.D., MSDEM Emergency Medicine Clinical Pharmacy Specialist [email protected] 1 Objectives Calculate water distribution or...

8/16/2024 Fluids and Electrolytes Brian Hierholzer, Pharm.D., MSDEM Emergency Medicine Clinical Pharmacy Specialist [email protected] 1 Objectives Calculate water distribution or solute amounts within total body water Describe the primary roles of common electrolytes in body fluids Understand signs and symptoms of fluid and/or electrolyte disturbances in the body Describe causes of electrolyte disturbances in the body Interpret common electrolyte disturbances and their influence on the body 2 Balancing Act! 3 1  8/16/2024 80 % Extracellintertis a 113 : Fluids m>F> elderly 4 1 1321D. /2. 2 = 60kg 60K9 X 55 % 331 = 2. 132 lb 220 lb Fish-man Drowning woman 3. 331X//3 = 111 ICFV? Plasma Sodium? TBW?. IIL X 20 % 4 = 2. 21 PV Plasma Volume? What if she was 1 00K9 X50 % 30L ·. = 85 years old? 2. 30LX13 = 10 3 102X20 %. = 21 DV 5 132 lb Woman 132 lbs / (1kg/2.2lbs)= 60kg 60 kg x 55% = 33L TBW 33L x 1/3 = 11 L ECFV 11L x 20% = 2.2 L PV 60 kg x 50% = 30L TBW 30L x 1/3 = 10L ECFV 10L x 20% = 2L PV 6 2  8/16/2024 220lb Fish-man 1. 220/2 2. = 100K9 220 lbs x (1kg/2.2lbs) = 100kg 100kg x 60% = 60L TBW 2. 100kg x 60 % = 60L 60L x 66% = 40L ICFV 3. 00LX213 = 40LICFV 60L TBW – 40L ICFV = 20L ECFV 20L ECFV x 20% = 4L PV. 001 4 - 401 = 20L ECFU Normal Sodium 135-145 mEq/L 135mEq/L x 4L = 540mEq. 5 201x20 % = 4LPV 145mEq/L x 4L = 580mEq 155x41 540 sodium normal [ mEg] = Plasma Na+ = 540-580mEq NA range 145x4) = 580 mEq range 7 A patient has a Na+ level of 125 mEq/L. Does this patient need sodium replacement? 8 26 People 26 People 9 3  8/16/2024 Must assess prior to looking at labs! Hydration Status 10 Na+ 124 mEq/L Hypovolemic : low sodium water tachyc Hyponatremia euvolemic good ! Balance : ↑ Hypervolemic high sodium & : water Hypovolemic Hypervolemic Euvolemic 11 skinturgor elasticity : of skin -pale Dehydration to snap back into place. Acute Chronic – Hot, Red, Dry Skin ↓ id overload – Constipation – Confusion – HTN – Thirst – Dry Skin – Dry, Chapped Lips – Fatigue dehydrated – Tachycardia – Achy Joints skin don't snap skin snap Shypovolemic – Headaches Decreased Skin Turgor back back Increased BUN:SCr ratio (>20:1) 12 4  8/16/2024 Fluid Overload Neurologic – Confusion, Headache, Seizures Respiratory – Pulmonary Congestion Cardiovascular – Bounding pulse, JVD, Increased BP, S3 sounds, Tachycardia GI – Anorexia, Nausea Edema 13 wheres water - anywhere Hydrostatic Pressure osmotic pressure : Wat, Glu Understanding (BP) 35/18 mmHg Edema Blood Osmotic Pressure 25 mmHg * Hyd + onc arterial filtration. : capillary : no movement Hyd. = Onc. reabsorption Hydton, Venous : ⑤ oncotic pressure dissolve things. hudrost : 14. ·amount of water too much water (fluid overload edema hydrostatic pressure : a plasma circulation : 15 5  8/16/2024 Body Fluid RAAS system Control Driven by Brain & Kidneys control ↓ pressure and concentrations everything. Controlled through the RAAS system Causes kidneys to Arginine Vasopressin retain or eliminate water and electrolytes 16 Arginine Vasopressin AUD retains water, is a : (AVP) AKA Antidiuretic Hormone antidiuretic hormone. Release: – Pituitary gland · From pituitary gland – Serum Osmolality – Angiotensin II Function: – Renal water reabsorption – Increase thirst 17 may vary Tonicity (280-300 mOsm/L) Tonicity ionic molecules , : Cations c-in blood. Sodium (Na+) Na Potassium (K+) Magnesium (Mg+) Calcium (Ca+2) Anions Chloride (Cl-) Ability of an extracellular Bicarbonate (HCO3-) solution to make water Phosphate move into or out of a cell 18 6  8/16/2024 Na+ sodium outside cell : 19 K+ Na+ Potassium inside cell : 20 Ca+2 Na+ free, ionized in blood of Ca+2 calcium inside s outside : cell K+ ↓ binds into endoplasmic reticulum 21 7  8/16/2024 Ca+2 Na+ Ca+2 mg intra outside : Mg+2 K+ Cell Mg+2 22 ECFV ICFV Sodium 135-145 mEq/L Sodium 10-20 mE/L Potassium 3.5-5 mEq/L Potassium 130-140 mEq/L Chloride 95-105 mEq/L Magnesium 20-30 mEq/L Bicarbonate 22-26 mEq/L Urea Nitrogen 10-20 mg/dL Glucose 90-120mg/dL Calcium 8.5-10 mg/dL Magnesium 1.4-2.1 mEq/L Urea Nitrogen 10-20 mg/dL (Preston, 2011, p. 5) 23 Osmolarity The number of dissolved particles in a fluid osmolarity : ions & macromolecules 270-300 mOsm/L EFFECTIVE OSMOLES Do not freely cross membranes Osmcalc = (2 Na+) + (Glucose/18) + (BUN/2.8) ↓ albumin sincose (fuel for body) 24 2xNa + glu/18 + BUN/2 8.. 8  8/16/2024 Osmosis Jones Na+ 142 mEq/L Glucose 98 mg/dL BUN 12 mg/dL 2x142 + + Calculate Osmosis’ 284 + 5 4 + 4 28.. = 293 68. Osmolarity Is he Hypo, Iso or Hypo ↳ ISOsmotic osmotic? (2 Na+) + (Glu/18) + (BUN/2.8) 25 Isosmotic 294 mOsm/L Osmolar Gap OG = OSm – Osc Absolute Value >10 means exogenous substance 26 Common Causes of Osmolar Gap ↓ Ethanol 06 = OSM-OSG Isopropanol Methanol* Ethylene Glycol* Propylene Glycol* Sorbitol Mannitol * Can cause High anion gap metabolic acidosis 27 9  8/16/2024 cationes affect all : organs Na disorder : SNS Mg+2 Ca+2 K disorder : heart Na+ K+ cat disorder muscle : mg disorder peripheral : 02 CO2. : capillaries gas exchange 28 Ca+2 Ca+2 K+ Na+ 29 Sodium Major EXTRAcellular cation responsible for majority of osmotic driving force Maintains the size of the ECFV Important to assess fluid volume as well as electrolyte levels Normal [ECF] 135-145 mEq/L Central Nervous System 30 10  8/16/2024 Hypovolemic Euvolemic Hypervolemic Hyponatremia Hyponatremia Hyponatremia SIADH 31 HYPOnatremia S/Sx Stupor/Coma Anorexia/Nausea and Vomiting Lethargy Tendon reflexes decreased Limp Muscles (weakness) “SALTLOSS” Orthostatic Hypotension Seizures/Headache Stomach Cramping 32 HYPOnatremia Etiologies Hypovolemic: Losing Na+ and H2O, Na+ > H2O – Medications – Diarrhea – Vomiting – Poor Dietary Intake – Mineral Deficiencies Increased ADH Increased ADH Release Unknown Cause Sensitivity Nicotine Acetaminophen Omeprazole Barbiturates NSAIDs ACEI Opioids Carbamazepine SSRIs Haloperidol Lamotrigine Moxifloxacin 33 11  8/16/2024 HYPOnatremia Etiologies Euvolemic Hyponatremia: Slight gain in H2O or slight loss in Na+ – Syndrome of Inappropriate Anti-Diuretic Hormone – Medications – Psychogenic Polydipsia – Chronic Malnutrition – Hypothyroidism – Alcoholism 34 HYPOnatremia Etiologies Hypervolemic Hyponatremia: Increased Na+ and H2O, H2O > Na+ – Renal Failure – Cardiac Failure – Cirrhosis – Nephrotic Syndrome 35 normal water > Aup not - doing enough too much salt - Hypovolemic Euvolemic Hypervolemic Hypernatremia Hypernatremia Hypernatremia no put Ap ↑ CENTRAL NEPHROGENIC putDH Kidneynoti ↓ Diabetes Insipidus 36 ↳ not enough too much water too much salt water to o 12 much salt  8/16/2024 HYPERnatremia S/Sx Flush skin and low-grade fever Restlessness, irritable, anxious, confused Increased Blood Pressure and Fluid Retention Edema (Peripheral and Pitting) Decreased urine output Skin Flushed Agitation “FRIED SALT” Low Grade Fever Thirst 37 HYPERnatremia Etiologies loss Of Hypovolemic Hypernatremia: water Lose H20 and Na+, H2O > Na+ ↳ – Diuretic Use – Excessive Sweating – Diarrhea – Severe Burns major 30-40 % 38 HYPERnatremia Etiologies Euvolemic Hypernatremia: Diabetes Slight H2O loss or Na+ gain l insipidus Diabetes Insipidus – Central: Lack of ADH release – Nephrogenic: Lack of sensitivity to ADH in kidneys Also – Hypodipsia – Increased insensible loss 39 13  8/16/2024 HYPERnatremia Etiologies Hypervolemic Hypernatremia: Gain Na+ and H20, Na+ > H2O Excessive Na+ Intake W Hypertonic Saline Use too much Sodium Bicarbonate Use salt Hyperaldosteronism Cushing’s Syndrome 40 Corrected Sodium sodium correction hyperglycemic : 16 X cada 100 arriba de Excessive glucose in the blood stream causes an osmotic gradient glucose over 100 Osmotic gradient shifts water from intracellular compartments to extracellular “Dilutes” sodium in the blood 1 0 X. glu-100x100 + Nameds 1.6 mEq/L for every 100 mg/dL Glucose over 100 Na+calc = Na+meas + [1.6 (Glu-100) / 100] 41 heart most deathly 4- cation narrow therap window Potassium. Major INTRAcellular Cation Plays major role in Action Potential Normal ECF : 3 5-5 0 mEqIL.. Potentiation and Resting Membrane Potential “Narrow Therapeutic Index” Cation Normal [ECF] 3.5-5.0 mEq/L Cardiac Effects 42 14  8/16/2024 HYPOkalemia S/Sx Arrhythmias ECG Changes (ST Depression) Shallow respirations Irritability Confusion and Drowsiness Weakness and Fatigue Alkalosis Lethargy Thready Pulse 43 HYPOkalemia Etiologies Medications Decreased Dietary Intake ↳glucose takes Increased Loss It as a symp Diabetic Ketoacidosis** Into cell – Levels are falsely elevated due to extracellular shift Hypomagnesemia M Alkalosis Cellular Shift Renal Excretion Fecal Elimination Beta-2 Agonists Diuretics Laxatives Tocolytics Penicillins Theophylline Mineralocorticoids Caffeine Aminoglycosides Insulin Amphotericin 44 ↳ stores blood glucose HYPERkalemia S/Sx Muscle Cramps Urine Abnormalities Respiratory Distress Decreased Cardiac Contractility ECG Changes (Peaked T-waves) Reflexes depressed 45 15  8/16/2024 HYPERkalemia Etiologies Renal Failure acute or chronic Medications Excess Intake Cellular Damage Tumor Lysis Syndrome Acidosis Hyperglycemia : 5 3 kt Shyperkalemia. Medications ACE Inhibitors ARBs Antifungals Beta-blockers Digoxin Tacrolimus Succinylcholine NSAIDs PCN (High Dose) 46 Magnesium “Cofactor of Life” Involved in just about every process in the human body Normal [ECF] 1.4-2.1 mEq/L Peripheral Nervous System 47 Magnesium S/Sx HYPOmagnesemia HYPERmagnesemia Confusion Flushing Increased Deep Tendon Decreased Deep Tendon Reflexes Reflexes Neuromuscular Irritability Muscle Weakness – Seizures Lethargy – Muscle Cramps Decreased Respirations – Tremors Bradycardia Insomnia Hypotension Tachycardia 48 16  8/16/2024 Magnesium Etiologies HYPOMagnesemia HYPERMagnesemia Malnutrition Renal Insufficiency/Failure Malabsorption Adrenal Insufficiency Alcoholism Excessive Intake (Antacids) Excess Urinary Loss 49 Calcium The “Extracellular Intracellular” cation Majority is actually intracellular, but bound Free Ca+ is mainly extracellular Obtain “free” or “ionized” calcium levels Normal [ECF] 8.5-10.0 mg/dL Peripheral Muscular System 50 Calcium S/Sx HYPOCalcemia HYPERCalcemia Convulsions Bone Pain Arrhythmias Arrhythmias Tetany Cardiac Arrest Stridor and Spasms Kidney Stones Muscle Weakness Excessive Urination 51 17  8/16/2024 Calcium Etiologies HYPOCalcemia HYPERCalcemia Decreased PTH & Vitamin D Supplementation Hypoparathyroidism Hyperparathyroidism Renal Failure Immobilization Pancreatitis Cancers Nutritional Deficiencies Milk Alkali Syndrome Inadequate Intestinal Medications Absorption – Lithium bipolar pt. S – Thiazide Diuretics Alcohol twitches 52 m F TBW (60%/55%) – 66.6%/33.3% – 80%/20% it P Hydration Status AVP/ADH Tonicity/# S electrolytes Osmolarity S/Sx electrolyte disorders Etiologies of electrolyte disorders 53 54 18