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Surgical Recall > Fluids and Electrolytes > Flashcards

Fluids and Electrolytes Flashcards

1
Q

What are the two major body fluid compartments?

A
  1. Intracellular

2. Extracellular

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2
Q

What are the two sub compartments of extracellular fluid?

A
  1. Interstitial

2. Intravascular

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3
Q

What percentage of body weight is in fluid?

A

60%

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4
Q

What percentage of body fluid is intracellular?

A

66%

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5
Q

What percentage of body fluid is extracellular?

A

33%

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6
Q

On average, what percentage of body weight does blood account for in adults?

A

7%

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7
Q

How many liters of blood are in a 70-kg man?

A

5 liters

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8
Q

What is the daily water requirement?

A

30-35 mL/kg

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9
Q

What is the daily potassium requirement?

A

1 mEq/kg

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10
Q

What is the daily chloride requirement?

A

1.5 mEq/kg

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11
Q

What is the daily sodium requirement?

A

1-2 mEq/kg

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12
Q

What are the levels and sources of normal daily water loss?

A

Urine: 1200-1500 mL (25-30 mL/kg)
Sweat: 200-400 mL
Respiratory losses: 500-700 mL
Feces: 100-200 mL

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13
Q

What are the levels and sources of normal daily electrolyte loss?

A

Sodium and potassium: 100 mEq

Chloride: 150 mEq

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14
Q

What are the levels of sodium and chloride in sweat?

A

40 mEq/L

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15
Q

What is the major electrolyte in colonic feculent fluid?

A

Potassium: 65 mEq/L

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16
Q

What is the physiologic response to hypovolemia?

A

Sodium/water retention via renin/aldosterone; water retention via ADH; vasoconstriction via angiotensin II and sympathetics; low urine output and tachycardia (early), hypotension (late)

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17
Q

What is third spacing?

A

Fluid accumulation in the interstitial of tissues, as in edema (e.g. loss of fluid into the interstitium and lumen of a paralytic bowel following surgery)

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18
Q

When does third-spacing occur postoperatively?

A

Third-spaced fluid tends to mobilize back into the intravascular space around POD #3 (switch to hypotonic fluid and decrease IV rate)

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19
Q

What are the classic signs of third spacing?

A

Tachycardia, decreased urine output

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20
Q

What is the treatment for third spacing?

A

IV hydration with isotonic fluids

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21
Q

What are the surgical causes of metabolic acidosis?

A

Loss of bicarbonate (e.g. diarrhea, ileus, fistula, high-output ileostomy, carbonic anhydrase inhibitors).
Increase in acids (e.g. lactic acidosis from ischemia, ketoacidosis, renal failure, necrotic tissue).

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22
Q

What are the surgical causes of hypochloremic alkalosis?

A

NGT suction, loss of gastric HCl through vomiting/NGT

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23
Q

What are the surgical causes of metabolic alkalosis?

A

Vomiting, NG suction, diuretics, alkali ingestion, mineralocorticoid excess

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24
Q

What are the surgical causes of respiratory acidosis?

A

Hypoventilation (e.g. CNS depression, drugs, PTX, pleural effusion, parenchymal lung disease, acute airway obstruction)

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25
Q

What are the surgical causes of respiratory alkalosis?

A

Hyperventilation (e.g. anxiety, pain, fever, wrong ventilator settings)

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26
Q

What is the classic acid-base finding with significant vomiting or NGT suctioning?

A

Hypokalemic hypochloremic metabolic alkalosis

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27
Q

Why hypokalemia with NGT suctioning?

A

Loss of HCl causes alkalosis, driving K into cells

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28
Q

What is the treatment for hypokalemic hypochloremic metabolic alkalosis?

A

IVF, Cl/K replacement

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29
Q

What is paradoxic alkalotic aciduria?

A

Seen in severe hypokalemic, hypovolemic, hypochloremic metabolic alkalosis with paradoxic metabolic alkalosis of serum and acidic urine

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30
Q

How does paradoxic alkalotic aciduria occur?

A

H is lost in the urine in exchange for Na in an attempt to restore volume

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31
Q

With paradoxic alkalotic aciduria, why is H preferentially lost?

A

H is exchanged preferentially into the urine instead of K because of the low concentration of K

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32
Q

What can be followed to assess fluid status?

A

Urine output, base deficit, lactic acid, vital signs, weight changes, skin turgor, JVD, mucosal membranes, rales, central venous pressure, PCWP, CXR

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33
Q

With hypovolemia, what changes occur in vital signs?

A

Tachycardia, tachypnea, initial rise in diastolic BP because of peripheral vasoconstriction with subsequent decrease in both systolic and diastolic BP

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34
Q

What are the insensible fluid losses?

A

Loss of fluid not measured: feces, breathing (increased with fever, tachypnea), sweat (increased with fever)

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35
Q

What quantity of bile is secreted daily?

A

1000 mL

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36
Q

What quantity of gastric secretions are secreted daily?

A

2000 mL

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37
Q

What quantity of pancreatic secretions are secreted daily?

A

600 mL

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38
Q

What quantity of small intestinal secretions are secreted daily?

A

3000 mL

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39
Q

What quantity of saliva is secreted daily?

A

1500 mL

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40
Q

What comprises NS?

A

154 mEq of Cl

154 mEq of Na

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41
Q

What comprises 1/2 NS?

A

77 mEq of Cl

77 mEq of Na

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42
Q

What comprises 1/4 NS?

A

39 mEq of Cl

39 mEq of Na

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43
Q

What comprises lactated Ringer’s?

A 
130 mEq of Na
109 mEq of Cl
28 mEq lactate
4 mEq K
3 mEq Ca
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44
Q

What comprises D5W?

A

5% dextrose (50 g) in water

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45
Q

What accounts for tonicity?

A

Mainly electrolytes (thus NS and LR are both isotonic)

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46
Q

What happens to the lactate in LR in the body?

A

Converted into bicarbonate, thus LR cannot be used as a maintenance fluid because patients would become alkalotic

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47
Q

What is the IVF replacement for gastric fluid loss (NGT)?

A

D5 1/2 NS + 20 KCl

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48
Q

What is the IVF replacement for biliary fluid loss?

A

LR +/- sodium bicarbonate

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49
Q

What is the IVF replacement for pancreatic fluid loss?

A

LR +/- sodium bicarbonate

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50
Q

What is the IVF replacement for small bowel fluid loss (ileostomy)?

A

LR

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51
Q

What is the IVF replacement for colonic fluid loss (diarrhea)?

A

LR +/- sodium bicarbonate

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52
Q

What is the 100/50/20 rule?

A

Maintenance IV fluids for a 24-hour period:
100 mL/kg for the first 10 kg
50 mL/kg for the next 10 kg
20 mL/kg for every kg over 20

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53
Q

What is the 4/2/1 rule?

A

Maintenance IV fluids for hourly rate:
4 mL/kg for the first 10 kg
2 mL/kg for the next 10 kg
1 mL/kg for every kg over 20

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54
Q

What is the maintenance for a 70-kg man?

A

110 mL/hr

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55
Q

What is the common adult maintenance fluid?

A

D5 1/2 NS with 20 mEq KCl/L

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56
Q

What is the common pediatric maintenance fluid?

A

D5 1/4 NS with 20 mEq KCl/L (children have decreased ability to concentrate urine)

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57
Q

Why should sugar be added to maintenance fluid?

A

To inhibit muscle breakdown

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58
Q

What is the best way to assess fluid status?

A

Urine output (unless the patient has cardiac or renal dysfunction, in which case central venous pressure or wedge pressure is often used)

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59
Q

What is the minimal urine output for an adult on maintenance IV fluids?

A

30 mL/hr (0.5 mL/kg/hr)

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60
Q

What is the minimal urine output for an adult trauma patient?

A

50 mL/hr

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61
Q

How many mL are in 12 oz?

A

356 mL

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62
Q

How many mL are in 1 oz?

A

30 mL

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63
Q

How many mL are in 1 tsp?

A

5 mL

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64
Q

What are common isotonic fluids?

A

NS, LR

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65
Q

What is a bolus?

A

Volume of fluid given IV rapidly.

Used for increasing intravascular volume, and isotonic fluids should be used.

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66
Q

Why not combine bolus fluids with dextrose?

A

Hyperglycemia may result

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67
Q

What is the possible consequence of hyperglycemia in the patient with hypovolemia?

A

Osmotic diuresis

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68
Q

Why not combine bolus fluids with a significant amount of potassium?

A

Hyperkalemia may result

69
Q

Why should isotonic fluids be given for resuscitation?

A

If hypotonic fluid is given, the tonicity of the intravascular space will be decreased and water will freely diffuse into the interstitial and intracellular spaces (thus, use isotonic fluids to expand the intravascular space)

70
Q

What portion of 1 L NS will stay in the intravascular space after a laparotomy?

A

In 5 hours, only 200 mL will remain in the intravascular space

71
Q

What is the most common trauma resuscitation fluid?

A

LR

72
Q

What is the most common postoperative IV fluid after laparotomy?

A

LR or D5LR for 24-36 hours, followed by maintenance fluid

73
Q

After a laparotomy, when should a patient’s fluid be mobilized?

A

Classically, POD #3 (the patient begins to mobilize the third-space fluid back into the intravascular space)

74
Q

What IVF is used to replace duodenal or pancreatic fluid loss?

A

LR (bicarbonate loss)

75
Q

What is a common cause of electrolyte abnormalities?

A

Lab error

76
Q

What is a major extracellular cation?

A

Na

77
Q

What is a major intracellular cation?

A

K

78
Q

What is the normal range for potassium level?

A

3.5-5.0 mEq/L

79
Q

What are the surgical causes of hyperkalemia?

A

Iatrogenic overdose, blood transfusion, renal failure, diuretics, acidosis, tissue destruction, hemolysis

80
Q

What are the signs and symptoms of hyperkalemia?

A

Decreased DTRs or areflexia, weakness, paresthesias, paralysis, respiratory failure

81
Q

What are the ECG findings with hyperkalemia?

A

Peaked T waves, depressed ST segment, prolonged PR, wide QRS, bradycardia, ventricular fibrillation

82
Q

What are the critical values for potassium?

A

K > 6.5

83
Q

What is the urgent treatment for hyperkalemia?

A

IV calcium (cardioprotective); ECG monitoring; sodium bicarbonate IV (alkalosis drives K intracellularly); glucose and insulin; albuterol; sodium polystyrene sulfonate (Kayexalate) and furosemide (Lasix); dialysis

84
Q

What is the non-acute treatment for hyperkalemia?

A

Furosemide (Lasix), sodium polystyrene sulfonate (Kayexalate)

85
Q

What is the acronym for the treatment of acute symptomatic hyperkalemia?

A

CB DIAL K:

Calcium, Bicarbonate, Dialysis, Insulin/dextrose, Albuterol, Lasix, Kayexalate

86
Q

What is pseudohyperkalemia?

A

Spurious hyperkalemia as a result of falsely elevated K in sample from sample hemolysis

87
Q

What acid-base change lowers the serum potassium?

A

Alkalosis

88
Q

What nebulizer treatment can help lower K level?

A

Albuterol

89
Q

What are the surgical causes of hypokalemia?

A

Diuretics, certain antibiotics, steroids, alkalosis, diarrhea, intestinal fistulae, NG aspiration, vomiting, insulin, insufficient supplementation, amphotericin

90
Q

What are the signs and symptoms of hypokalemia?

A

Weakness, tetany, N/V, ileus, paresthesia

91
Q

What are the ECG findings with hypokalemia?

A

Flattening of T waves, U waves, ST segment depression, PAC, PVC, atrial fibrillation

92
Q

What is the rapid treatment for hypokalemia?

A

IV KCl

93
Q

What is the maximum amount of KCl that can be given through a peripheral IV?

A

10 mEq/hr

94
Q

What is the maximum amount of KCl that can be given through a central line?

A

20 mEq/hr

95
Q

What is the chronic treatment for hypokalemia?

A

PO KCl

96
Q

What is the most common electrolyte-mediated ileus in the surgical patient?

A

Hypokalemia

97
Q

What electrolyte condition exacerbates digitalis toxicity?

A

Hypokalemia

98
Q

What electrolyte deficiency can actually cause hypokalemia?

A

Low magnesium

99
Q

What electrolyte must you replace first before replacing potassium?

A

Magnesium

100
Q

Why does hypomagnesemia make replacement of potassium with hypokalemia nearly impossible?

A

Hypomagnesemia inhibits K reabsorption from the renal tubules

101
Q

What is the normal range for sodium level?

A

135-145 mEq/L

102
Q

What are the surgical causes of hypernatremia?

A

Inadequate hydration, diabetes insipidus, diuresis, vomiting, diarrhea, diaphoresis, tachypnea, iatrogenic (e.g. TPN)

103
Q

What are the signs and symptoms of hypernatremia?

A

Seizures, confusion, stupor, pulmonary or peripheral edema, tremors, respiratory paralysis

104
Q

What is the usual treatment supplementation given slowly over days for hypernatremia?

A

D5W, 1/4 NS or 1/2 NS

105
Q

How fast should you lower the sodium level in hypernatremia?

A

Guideline is

106
Q

What is the major complication of lowering the sodium level too fast with hypernatremia?

A

Seizures (not central pontine myelinolysis)

107
Q

What are the surgical causes of hypovolemic hyponatremia?

A

Diuretic excess, hypoaldosteronism, vomiting, NG suction, burns, pancreatitis, diaphoresis

108
Q

What are the surgical causes of euvolemic hyponatremia?

A

SIADH, CNS abnormalities, drugs

109
Q

What are the surgical causes of hypervolemic hyponatremia?

A

Renal failure, CHF, liver failure, iatrogenic fluid overload

110
Q

What are the signs and symptoms of hyponatremia?

A

Seizures, coma, N/V, ileus, lethargy, confusion, weakness

111
Q

What is the treatment for hypovolemic hyponatremia?

A

NS IV, correct underlying cause

112
Q

What is the treatment for euvolemic hyponatremia?

A

If SIADH: furosemide and NS acutely, fluid restriction

113
Q

What is the treatment for hypervolemic hyponatremia?

A

Dilutional fluid restriction and diuresis

114
Q

How fast should you increase the sodium level in hyponatremia?

A

Guideline

115
Q

What may occur if you correct hyponatremia too quickly?

A

Central pontine myelinolysis

116
Q

What are the signs and symptoms of central pontine myelinolysis?

A
  1. Confusion
  2. Spastic quadriplegia
  3. Horizontal gaze paralysis
117
Q

What is the most common cause of mild postoperative hyponatremia?

A

Fluid overload

118
Q

What is pseudohyponatremia?

A

Spurious lab value of hyponatremia as a result of hyperglycemia, hyperlipidemia, or hyperproteinemia

119
Q

What are the causes of hypercalcemia?

A

CHIMPANZEES:
Calcium supplementation IV; Hyperparathyroidism, Hyperthyroidism; Immobility, Iatrogenic (thiazide diuretics); Mets, Milk alkali syndrome; Paget’s disease (bone); Addison’s disease, Acromegaly; Neoplasm (colon, lung, breast, prostate, multiple myeloma); Zollinger-Ellison syndrome (MEN-I); Excessive vitamin A; Excessive vitamin D; Sarcoid

120
Q

What are the signs and symptoms of hypercalcemia?

A

“Stones, bones, abdominal groans, and psychiatric overtones”

Polydipsia, polyuria, constipation

121
Q

What are the ECG findings with hypercalcemia?

A

Short QT interval, prolonged PR interval

122
Q

What is the acute treatment of hypercalcemic crisis?

A

Volume expansion with NS, diuresis with furosemide (not thiazides)

123
Q

What are options (other than volume expansion and furosemide) for lowering the calcium level?

A

Steroids, calcitonin, bisphosphonates (pamidronate), mithramycin, dialysis (last resort)

124
Q

How can the calcium level be determined with hypoalbuminemia?

A

(4 - measured albumin level) X 0.8, then add this value to the measured calcium level

125
Q

What are the surgical causes of hypocalcemia?

A

Short bowel syndrome, intestinal bypass, vitamin D deficiency, sepsis, acute pancreatitis, osteoblastic metastasis, aminoglycosides, diuretics, renal failure, hypomagnesemia, rhabdomyolysis

126
Q

What is Chvostek’s sign?

A

Facial muscle spasm with tapping of facial nerve

127
Q

What is Trousseau’s sign?

A

Carpal spasm after occluding blood flow in forearm with blood pressure cuff

128
Q

What are the signs and symptoms of hypocalcemia?

A

Chvostek’s sign, Trousseau’s sign, perioral paresthesia (early), increased DTRs (late), confusion, abdominal cramps, laryngospasm, stridor, seizures, tetany, psychiatric abnormalities (e.g. paranoia, depression, hallucinations)

129
Q

What are the ECG findings with hypocalcemia?

A

Prolonged QT and ST interval (peaked T waves are also possible, as in hyperkalemia)

130
Q

What is the acute treatment of hypocalcemia?

A

IV calcium gluconate

131
Q

What is the chronic treatment of hypocalcemia?

A

PO calcium, vitamin D

132
Q

What is the possible complication of infused calcium if the IV infiltrates?

A

Tissue necrosis (never administer peripherally unless absolutely necessary)

133
Q

What is the best way to check the calcium level in the ICU?

A

Check ionized calcium

134
Q

What is the normal range for magnesium level?

A

1.5-2.5 mEq/L

135
Q

What is the surgical cause of hypermagnesemia?

A

TPN, renal failure, IV over supplementation

136
Q

What are the signs and symptoms of hypermagnesemia?

A

Respiratory failure, CNS depression, decreased DTRs

137
Q

What is the treatment for hypermagnesemia?

A

IV calcium gluconate, insulin and glucose, dialysis (similar for hyperkalemia), furosemide (Lasix)

138
Q

What are the surgical causes of hypomagnesemia?

A

TPN, hypocalcemia, NG suction, aminoglycosides, renal failure, diarrhea, vomiting

139
Q

What are the signs and symptoms of hypomagnesemia?

A

Increased DTRs, tetany, asterixis, tremor, Chvostek’s sign, ventricular ectopy, vertigo, tachycardia, dysrhythmias

140
Q

What is the acute treatment for hypomagnesemia?

A

IV MgSO4

141
Q

What is the chronic treatment for hypomagnesemia?

A

PO Magnesium oxide

142
Q

Hypomagnesemia may make it impossible to correct what other electrolyte abnormality?

A

Hypokalemia

143
Q

What are the surgical causes of hyperglycemia?

A

Diabetes (poor control), infection, stress, TPN, drugs, lab error, drawing over IV site, somatostatinoma, glucagonoma

144
Q

What are the signs and symptoms of hyperglycemia?

A

Polyuria, hypovolemia, confusion, coma, polydipsia, ileus, DKA (Kussmaul breathing), abdominal pain, hyporeflexia

145
Q

What is the treatment for hyperglycemia?

A

Insulin

146
Q

What is the Weiss protocol?

A

Sliding scale insulin

147
Q

What is the goal glucose level in the ICU?

A

80-110 mg/dL

148
Q

What are the surgical causes of hypoglycemia?

A

Excess insulin, decreased caloric intake, insulinoma, drugs, liver failure, adrenal insufficiency, gastrojejunostomy

149
Q

What are the signs and symptoms of hypoglycemia?

A

Sympathetic response (diaphoresis, tachycardia, palpitations), confusion, coma, headache, diplopia, neurologic deficits, seizures

150
Q

What is the treatment for hypoglycemia?

A

Glucose (IV or PO)

151
Q

What is the normal range for phosphorus level?

A

2.5-4.5 mg/dL

152
Q

What are the signs and symptoms of hypophosphatemia?

A

Weakness, cardiomyopathy, neurologic dysfunction (ataxia), rhabdomyolysis, hemolysis, poor pressor response

153
Q

What is a complication of severe hypophosphatemia?

A

Respiratory failure

154
Q

What are the causes of hypophosphatemia?

A

GI losses, inadequate supplementation, medications, sepsis, alcohol abuse, renal loss

155
Q

What is the critical value for phosphorus level?

A
156
Q

What is the treatment for hypophosphatemia?

A

Supplement with sodium phosphate or potassium phosphate IV

157
Q

What are the signs and symptoms of hyperphosphatemia?

A

Calcifications (ectopic), heart block

158
Q

What are the causes of hyperphosphatemia?

A

Renal failure, sepsis, chemotherapy, hyperthyroidism

159
Q

What is the treatment for hyperphosphatemia?

A

Aluminum hydroxide (binds phosphate)

160
Q

If hyperkalemia is left untreated, what can occur?

A

Ventricular tachycardia or fibrillation

161
Q

Which electrolyte is an inotrope?

A

Calcium

162
Q

What are the major cardiac electrolytes?

A

Potassium (dysrhythmias), magnesium (dysrhythmias), calcium (dysrhythmias, inotrope)

163
Q

Which electrolyte must be monitored closely in patients on digitalis?

A

Potassium

164
Q

What is the most common cause of electrolyte-mediated ileus?

A

Hypokalemia

165
Q

What is a colloid fluid?

A

Protein-containing fluid (albumin)

166
Q

What is the rationale for using an albumin-furosemide “sandwich”?

A

Albumin will pull interstitial fluid into the intravascular space and the furosemide will then help excrete the fluid as urine

167
Q

An elderly patient goes into CHF on POD #3 after a laparotomy. What is going on?

A

Mobilization of the third-space fluid into the intravascular space, resulting in fluid overload and resultant CHF

168
Q

What fluid is used to replace NGT aspirate?

A

D5 1/2 NS with 20 KCl

169
Q

What electrolyte is associated with succinylcholine?

A

Hyperkalemia

Surgical Recall (68 decks)

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