Fluid and Electrolyte imbalance

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Fluid and Electrolyte imbalance

• 
  Jeeraluck Limim
• Department of
  Anesthesiology
• 
  Srinakharinwirot University

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Fluid Transfusion

• ???????????? - ?????? 50-80 ??? BW
• - Infant ?????? 80
• - Adult ?????? 60
• - Elderly ?????? 52
• - ??? gt
  ????

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???????????????????????

• 1. ICF - ???????? 40 ??? BW
• - K,Mg cation
• - PO42-, protein anion
• 2. ECF - ???????? 20 ??? BW
• - Na cation
• - Cl- , HCO3- anion
• ???????? - Intravascular volume ?????? 5 ???
  BW
• - Interstitial volume ?????? 15
  ??? BW
• -Transcellular fluid ?????? 1-3
  

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• - ??????????????? osmosis
• - ??????????????????????
  ????????????????????????
• ?????????????????????
• - ICF ?????? ECF ??? cell membrane
• - Na -K ATPase pump
• - Capillary endothelial membrane
  ??????? plasma
• ??? interstitial fluid
• - ?????????????? ????????????????????
  ???, Protein ?????????
• ???????

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??????????????????????????????????????????????????
??

• - ????????????????????????????
• - ???????????? plasma
  ??????????????? plasma ?????????????????????
  ????????????????????????????????????????

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• ??????????????????????? ??????
• 1. ???????????? protein
  ????????????????????????????
• 2. Baroreceptor ??? carotid sinus ???
  aortic arch ?????????????????????
  ????????????????????? vasomotor center
  ??????????????????? sympathetic
• - HR, contractility
  vasoconstriction
• - ????? venous return

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• 3. renin-angiotensin-aldosterone
  ???????????? ???????????????????? ????
  ???????????????????????????????????
• 4. ??????????????????????????????
  ????????????
• posterior hypothalamus ?????????? ACTH ???
  ADH ??? anterior ??? posterior pituitary
• - ACTH aldosterone
• - ADH
  ?????????????????????

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???????????????????????????????

• ???????? 2 ????
• 1.???????????????? ECF
• 2.??????????? tonicity ??? ECF
• - Isotonicity
• - Hypotonicity
• - Hypertonicity

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?????????? Intravascular volume

• ????? - History
• - PE
• -
  Urine
• -
  Blood chemistry
• -
  Chest x-ray
• -
  CVP, PCWP

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Fluid challenge test
??? CVP/PCWP ????????????????? 10 ???? (Isotonic)
CVP lt 8 cmH2O ???? PCWP lt 12 mmHg load 200 cc
CVP 8-14 cmH2O ???? PCWP 12-16 mmHg load 100 cc
CVP gt 14 cmH2O ???? PCWP gt 16 mmHg load 50 cc
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Fluid challenge test (cont.)

• Measurement
• 1. CVP lt 2 cmH2O or PCWP lt 3 mmHg
  loading or rate
• 2. CVP 2-5 cmH2O or PCWP 3-7 mmHg
  wait 10 min
• repeated measurement
• - CVP lt 2 cmH2O or PCWP lt 3 mmHg
  loading
• - CVP gt 5 cmH2O or PCWP gt 7 mmHg
  low rate
• - CVP 2-5 cmH2O or PCWP 3-7 mmHg
  fluid challenge
• 3. CVP gt 5 cmH2O or PCWP gt 7 mmHg
  stop

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?????????????

• Crystalloid -???????????,?????????
• - ??????????????? ¼ ??????? ¾
  leak ??????
• Intravascular
• - ??????
  intravascular 30-60 ????
• -
  ???,????????????
• - ???,??????

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Crystalloid (cont.)

• Indications - Maintenance
• - Deficit
• - Third space loss
  
• - replace Blood loss
  
• ?????? 1. 5 dextrose
• 2. Isotonic saline
• 3. Hypertonic saline
• 4. LRS
• 5. ARS

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• 5 dextrose (5 DW,5 D/N/2)
• - ??? callories
• - ???????? resuscitation
• - ???? osmotic diuresis
• - ???? hypo-osmolar ????? cell ??????

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• Isotonic saline (NSS)
• - Na, Cl- 154 mEq/L
• - pH 6.4
• - hyperchloremic metabolic acidosis
• Hypertonic saline (3,5 Nacl)
• - Na, Cl- ??????? 513 ??? 855 mEq/L
• - treat hypo Na
• - ?????? resuscitation case burn
• - ???? pulmonary edema

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• Lactated Ringers solution (LRS)
• - K, Ca , lactate
• - ???? lactic acidosis
• - ????? third space loss ?????
• - ?? form 5 DLRS
• Acetated Ringers solution
• - ?? acetate ??? lactate
• - ????? muscle,peripheral tissue
  ??????????? HCO3-

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• Colloid -???????????,??????????
• - ????? oncotic pressure
  ???????????,molecular weight
• - ?????? Intravascular
  3-5 ??.
• - ????????????? bleed
  ?????????????????????????
• - ???????
• - ??????????????????????
• - ??????? coagulopathy

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• Indication - replacement blood loss, protein
• - hemodilution
• - plasma phoresis
• - increase microcirculation
• ?????? 1. Albumin
• 2. Dextran (40,70)
• 3. Hydroxyethyl
  starch (6HES, 10HES)
• 4. Gelatin

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• Albumin (5,20,25)
• - MW 60,000
• - ????????? interstitial space ???????
  intravascular ???
• ? 500 cc.?? 30-60 min
• - plasma half-life 16 hr.
• - ?????????????? 4 ??.
• - ????? ionized calcium ????
• - ????? bradykinin BP drop

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• Dextran
• - synthetic glucose polymer, MW
  40,000-70,000
• - ????????? renal tubule
  renal failure
• - ????????????? crystalloid
• - anaphylactoid reaction
• - ?? platelet aggregration,?? F.5,7,8
• - ???????? crossmatch
• - ?? reticuloendothelial system

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• - dextran 40 ???????????
  microcirculation ?????????
• microsurgery
• - dextran 70 ?? complication ???????
  dextran 40

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• Hydroxyethyl starch (HES)
• - ??????????????, MW 60,000 -100,000
• - ??????????? complement
  ??????????????????
• antibody
• - coagulopathy ?????????? F.8 ???
  platelet
• - ??????????????? histamine
  anaphylactoid reaction
• - 6 starch ?????????? plasma
  substitute
• - 10 starch ???? hyperoncotic
  plasma expander

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• Gelatin (Haemaccel, Gelofusine)
• - maintain oncotic pressure ???????????
  starch ??? dextran
• - ??????????? 48 ??. ?????????????
• - ??? 1-2 ???? ??? blood loss
  ?????????? 2,000 cc
• - Hemodilution,hemodialysis
• - ??????????????? histamine
  anaphylactoid reaction
• - ????? serum amylase

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?????????????????????????

• ?????????? 1. Maintenance fluid (M)
• 2. Deficit fluid (D)
• 3. Third space loss
  (3rd)
• 4. replace Blood
  loss (Bl.)

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Maintenance fluid 1-10 kg
4 ml/kg/hr 11-20 kg 2
ml/kg/hr gt 21 kg 1
ml/kg/hr
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Deficit fluid maintenance fluid NPO
time(hr) replace 50 in 1st hour of
surgery replace 25 in 2nd 3rd hours of
surgery
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Third space loss
Degree of tissue trauma Fluid requirement
Mild 1 - 3 ml/kg/hr
Moderate 4 - 6 ml/kg/hr
Severe 7 - 9 ml/kg/hr
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Blood loss Acceptable red cell
(actual Hct acceptable Hct)/100
BVAcceptable blood loss Acceptable red cell
3 replace crystalloid 1 3
replace colloid 1 1
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????????????? ???? 48 ?? ??????????? HT
, IHD??????????????? CA head of
pancrease?????????????????? Whipples
operationBW 70 kg Hct 42??????????????????????
???????? 300 ml ????????????? 2 ??? 200
ml????????????????????????????????? 1 ???2
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Maintenance fluidEx BW 60 kg 10(4) 10(2)
40(1) 40 20 40
100 ml/hr
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Deficit fluid maintenance fluid NPO
time(hr) 100 10 1,000 ml
500 ml in 1st hour of surgery 250 ml in 2nd
3rd hours of surgery
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Third space loss
Severe 8 ml/kg/hr 3rd space loss
860 480 ml/hr
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Blood loss Blood loss 300 ml
Acceptable blood volume loss
3 acceptable red cell loss
3 (42-30)/100 (6070)
1,512 ml replace crystalloid 900ml
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1st hour 100 500 480 900
1,980 ml 2nd hour 100 250
480 600 1,480 ml
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????????????????????????? ??? close
observed 2-3 ?????????? major operation
????????????????? intravascular pulmonary
edema
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Anesthetic considerationforElectrolyte
imbalance
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Hypernatremia
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Anesthetic considerations with hypernatremia

• Central nervous system complications may
  include- increased MAC requirements
• - agitation- lethargy- confusion-
  seizures- coma death

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• Cardiovascular system complications may
  include- decreased MAP with associated
  hypovolemia
• Hepatic system complications may include-
  decreased Vd- decreased i.v dose requirement
• Renal system complications may include-
  associated with hypovolemia

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Anesthetic considerations in hyponatremia

• - often is associated with a serious
  underlying disorder- Na gt 130 mEq/L for
  elective surgery
• - associated with cerebral edema- decreased
  MAC requirements

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Hyperkalemia

• CAUSES
• increased uptake of potassium- plasma K gt
  5.5 mEq/L
• decreased renal loss of potassium

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• Hyperkalemia due to increased movement of K -
  acidosis - cell lysis S/P chemotherapy -
  hemolysis - rhabdomyolysis - massive tissue
  trauma - hyperosmolality - digitalis
  overdose - ß2 adrenergic blockade -
  succinlycholine

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• CLINICAL MANIFESTATIONS
• Skeletal muscles- when K gt 8 mEq/L-
  sustained spontaneous depolarization-
  inactivation of Na channels of muscle
• membrane

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• Cardiac muscle- when K gt 7 mEq/L- peaked
  T wave with shortened QT interval- widening of
  QRS complex- prolongation of PR interval-
  VF- asystole

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Anesthetic considerations in hyperkalemia

• - elective surgery should not continue
• - succinylcholine is contraindicated-
  avoid K containing solutions ex. lactated
  ringers - avoid metabolic acidosis and
  respiratory acidosis
• - controlled ventilation with slight
  hyperventilation may be beneficial- close
  neuromuscular function monitoring

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Hypokalemia

• CAUSES
• decreased potassium uptake - marked reduction
  K intake
• - kidneys ability to conserve plasma K-
  kidneys ability to decrease urinary K as
• low as 5 15 mEq/L

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• increased potassium losses
• - renal loss urinary K gt 20 mEq/L- GI
  loss urinary K lt 20 mEq/L
• decreased intracellular movements
• - acute alkalosis- insulin therapy-
  hypothermia- vitamin B12 treatment

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Anesthetic considerations in hypokalemia

• - lower limits K 3 3.5 mEq/L without ECG
  changes- not appear to be significant anesthetic
  risk
• - exception in patients taking digoxin- should
  have K maintained at 4 mEq/L
• - augment NDMR

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• Anesthetic consideration may be based on- rate
  of K loss- presence or absence of organ
  dysfunction
• Intraoperative management
• intravenous K supplementation if
• - atrial or ventrilcular dysrhythmias
• - avoid glucose containing solutions -
  avoid hyperventilation

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Anesthetic considerations in hypermagnesemia

• May require close monitoring of- blood
  pressure- electrocardiogram- neuromuscular
  junction function- urinary foley
  catherization- reduced muscle relaxants 20
  25 of regular dosing

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Anesthetic considerations in hypercalcemia

• - medical emergency- NDMR unpredictable
  response- avoid hypovolemia related to
  diuresis- monitor volume status with CVP, PAP-
  monitor serial K and Mg- controlled
  ventilation- avoid acidosis which may raise
  serum calcium levels

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Anesthetic considerations in hypocalcemia

• - medical emergency therefore correct
  hypocalcemia preoperatively- avoid alkalosis to
  prevent further decrease in Ca2 levels
• - negative inotropic effects may potentiate
  the effects of barbiturates and volatile
  anesthetics- inconsistent effects on
  neuromuscular blockade

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• correction of electrolyte imbalance that
  can precipitate hypocalcemia i.e hypokalemia,
  hypomagnesemia.
• important to prevent peri-operative
  arrhythmias associated with hypocalcemia.

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Anesthetic considerations in hypophosphatemia

• - closely monitor neuromuscular junction function
  esp with use of muscle relaxants- may require
  postoperative mechanical ventilation
• prevent further decreases in plasma phosphorus
  avoid-hyperglycemia-respiratory alkalosis

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Good Luck