Parenteral Fluid & Electrolytes Flashcards
Total Body water is _____ % of body weight
50-60
total body water divided into three places, what are they and how much weight do they contain?
Extracellular fluid (1/3)
intracellular fluid (2/3)
transcellular (<3%)
extracellular fluid consists of what two spaces?
how much of ECF are they?
interstitial space (3/4)
intravascular space (1/4)
Equation of TBW of women ?
equation for males ?
TBW (women) = Wt in kg x 0.5
TBW (men) = Wt in kg x 0.6
How does Fat affect TBW
TBW decreases with increasing body fat
How does Age affect TBW
Muscle mass declines and the proportion of fat increases; thus, TBW decreases
The pressure required to maintain equilibrium with no net movement of solvent is _______
Osmotic pressure
How does Sex affect TBW
Women have proportionally higher body fat than men; thus, women have less TBW
Osmotic pressure has Prime importance in determining the distribution of water between the ECF and ICF
Each compartment contains a major ____________ that determines its osmotic pressure
osmotically active solute
______ is the dominant extracellular osmole holding water in the ECF
Na
_____ is the primary intracellular osmole holding water within the cells
K
Activity of the ____________ allows for the maintenance of these unique solute compositions of the ECF and ICF
Na+-K+-ATPase pump
two types of commonly prescribed intravenous solutions
crystalloids
colloids
Crystalloids:
Solutions that supply ______, ______, and/or _______
Contain _____ molecules that flow easily from the _____ into ______
water
sodium
dextrose
small
blood
cells and tissues
Colloids
Solutions containing _____, ______ molecules
generally ______ or ________
Increase ___________ pressure, move fluid from ____________ to __________
large insoluble
proteins or complex polysaccharides
intravascular oncotic
interstitial space
intravascular space
Free water (D5w)
Free water distributes evenly across all compartments
Isotonic (NS or LR)
100% will stay in the extracellular space
_______________ pressures govern the movement of fluid between the intravascular and interstitial spaces
Disruption in these pressure results in a flow of fluid from one compartment to another
When this favors an ________ to ________fluid shift third-spacing occurs
Plasma oncotic and hydrostatic
intravascular
interstitial
two types of Fluid Losses
_________ – visible and measureable
_________ – usually not seen or measured
Sensible
Insensible
Daily Assessment of hydration status:
_______ and ______
physical evaluation of ____, ____, ____
evaluation of _______ and _______
_______ and assessment for _________
weights
I/O records
skin, eyes, lips and oral cavity
respiratory rate
lung sounds
blood pressure
peripheral edema
Energy based formulas for fluid requirements
_____ per kcal required
1 mL
Weight based formulas for fluid
Equation 1:
Ages ____ years: ____ mL/kg
Ages ____ years: ____ mL/kg
Ages ____ years: ____ mL/kg
Fluid restricted adults: ____ mL/kg
18-55 years: 35 mL/kg
56-75 years: 30 mL/kg
>75 years: 25 mL/kg
Fluid restricted adults: ≤ 25 mL/kg
Weight based formulas for fluid
(Holliday-Segar formula adjusted for age):
Ages ≤ 50 years: ________
Ages > 50 years:
1500 mL for first 20 kg body wt + (20 mL x remaining kg body wt)
1500 mL for first 20 kg body wt + (15 mL x remaining kg body wt)
*The use of an ___________ should be used to calculate the fluid needs in obese patients to account for their increased percentage of body fat
obesity-adjusted weight
Volume disturbance that leads to gain or loss of fluid (water and solute) result in ________ or ______
hypovolemia
hypervolemia
concentration disturbance that results in gain or loss of water alone results in _______ or _________
dehydration
overhydration
composition disturbance results in gain or loss of electrolytes lead to ________
electrolyte disorders
Loss of fluid (ie, water and solute) can come from _____, _____, _____, or _________
GI tract
Skin
Urine
Prolonged inadequate intake
Loss of fluid (ie, water and solute) symptoms
dry oral mucosa
poor skin turgor
tachycardia
hypotension
Loss of fluid (ie, water and solute) treatment
Prescribed based on ___________
In severe cases: ________________
underlying cause for fluid deficit
replacement of ECF losses which require isotonic solution (NS or LR)
dehydration is ___________
Recognized by a change in ________ & ________
loss of water alone
serum sodium concentrations
plasma osmolality
Causes of Dehydration
Diabetes Insipidus
Prolonged fever
watery diarrhea
hyperglycemia
Treatment for Dehydration
Provision of ____________
Expands _________, predominately in the ___
free water (ex. 5% dextrose solution)
both fluid compartments
ICF
Hypervolemia is ________
Involves water retention with a _______
Volume overload
decrease in body sodium concentrations
Hypervolemia Causes:
decreased urinary output
excessive IVF
Hypervolemia Characterized by:
weight gain
edema
ascites
elevated blood pressure
pulmonary edema
Treatment for Hypervolemia
Correction of underlying cause
Limitation of sodium and fluid intake
In some cases, diuretic therapy may be required
Review of clinical laboratory
If inconsistent, the ______ of the specimen collection should be validated
If a collection error or specimen mishandling is confirmed, a repeat specimen should be collected
If the result is ____, a treatment regimen should be developed
accuracy
valid
Treatment for levels above the normal range
Remove _________
Discontinue _________ or ______
Facilitate elimination of _______
Treat ________ that may be contributing
exogenous sources
offending agents or meds
electrolyte
condition
Treatment for levels below the normal range
_________replacement
Treatment considerations:
Available administration ______
_______ function
______ functions
______ status
_________ availability
______________ abnormalities
Electrolyte
routes
GI tract
Renal
Fluid
Product
Concurrent electrolyte
Principal cation in the ECF
Na
Sodium normal range
135-145
Sodium Functions
Major osmotic determinant in regulating ____ volume and ______ distribution in the body
Determining ___________ of cells
__________ of molecules across cell membranes
ECF
water
membrane potential
Active transport
what organ plays a pivotal role in sodium balance
kidney
Hyponatremia is when sodium is less than _____
Symptoms include
_______, ______, ______, ______
_____, ______, _____
______, ________, _______
Clinical manifestations related to CNS dysfunction are more likely to occur when the serum Na+ drops ______ and when it falls below ____ mEq/L
135
Headache, nausea, vomiting, muscle cramps
lethargy, restlessness, disorientation
depressed reflexes, seizures, and coma
rapidly
125
Assessment of Sodium:
Clinicians should determine the patient’s serum Na concentration and volume status to identify the etiology of the hyponatremia
Serum osmolality can be _____ or _____
Serum Osmolality = 2 𝑥 [(𝑠𝑒𝑟𝑢𝑚 𝑁𝑎+𝑆𝑒𝑟𝑢𝑚 𝐺𝑙𝑢𝑐𝑜𝑠𝑒)/18)+(𝐵𝑈𝑁/2.8)]
___________: mOsm/kg
_______: mEq/L
______________: mg/dL
measured or calculated
Serum Osmolality
Serum Na
Serum Glucose and BUN
Hypotonic hyponatremia causes
volume depletion
SIADH
CHF
cirrhosis
isotonic hyponatremia causes
hyperglycemia
hyperlipidemia
hypertonic hyponatremia causes
severe hyperglycemia with dehydration
Hypovolemic Hypotonic Hyponatremia
What happens in this ?
Causes: _______
Treatment: ______
Patients lose more Na in relation to water, but both are going down still
renal and extrarenal losses
Isotonic Fluids
Hypervolemic Hypotonic Hyponatremia
What happens in this ?
Causes: _______
Treatment: ______
Patients retain more water than Na, but Na and water are both increasing
some element of end-organ failure resulting in fluid retention or third spacing
fluid and sodium restriction
Euvolemic hypotonic hyponatremia
What is this?
commonly associated with _____
Other causes?
Treatment ?
Na same in and out, but increased body water
SIAD (excess ADH = retain water)
psychogenic polydipsia, hypothyroidism
treatment of underlying cause and fluid restriction
In Eucolemic Hypotonic Hyponatremia … Urine osmolality is always_____serum osmolality and urine Na_____ mEq/L
Indicating the ______ are inappropriately concentrating urine and volume status is adequate
> 20
kidneys
hypernatremia is above ____ mEq/L
assessment includes….
_____ status
all hypernatremia is ____
145
volume
hypertonic
symptoms of hypernatremia
MILD: headache, dizziness, confusion
SEVERE: seizures, coma, death
HYPOVOLEMIC HYPERNATREMIA
what is it?
above normal serum osmolality
low Na and more low water
HYPOVOLEMIC HYPERNATREMIA
Causes
Causes: renal and extrarenal losses
HYPOVOLEMIC HYPERNATREMIA treatment
Treatment: hypotonic fluids via enteral or parenteral route
EUVOLEMIC HYPERNATREMIA
what is it?
Patients have water losses that exceed sodium losses
Equal sodium but losing water
EUVOLEMIC HYPERNATREMIA
Causes?
Causes: diabetes insipidus
EUVOLEMIC HYPERNATREMIA
Treatment:
replacement of water via enteral or parenteral route and normalization of serum Ca and K+
HYPERVOLEMIC HYPERNATREMIA
what is it?
more high Na
high TBW
HYPERVOLEMIC HYPERNATREMIA
Causes?
Iatrogenic: excessive administration of isotonic or hypertonic sodium
Mineralocorticoid excess: Cushing’s syndrome or adrenal malignancy
HYPERVOLEMIC HYPERNATREMIA
Treatment?
Correcting the underlying disorder
Administering diuretics
Replacing water
What is the major Intracellular cation
potassium
Functions of potassium
Plays a critical role in cell metabolism including _____ and ______ synthesis
Maintains ___________
Abnormal concentrations -> ______
protein and glycogen synthesis
resting membrane potential
EKG Changes
Important to remember that ____ is a co-factor for the Na+-K+ATPase pump
Hypo__________ -> refractory hypokalemia
Mg
magnesemia
Normal daily requirements of K+ : _____ mEq/kg
0.5-2
H+/K+ ATPase Pump
Allows K to shift in/out of the cell in exchange for _______
hydrogen
Metabolic Acidosis:
H+ ions _______ -> body corrects by moving H+ back __________ and pumping K+ _________ -> _____kalemia
outside of cell
into the cell
outside of the cell
Hyper
Metabolic Alkalosis:
not enough H+ ions _________ -> pump moves H+ ions ______________ and K+ will move _________ -> _____kalemia
in the plasma
outside of the cell into the plasma
into the cell
Hypo
Hypokalemia (_____mEq/L)
<3.5
Hypokalemia Causes:
Abnormal losses via urine and stool
Inadequate intake
Medications
Transcellular shifts from ECF into cells
Causes: Metabolic alkalosis and increases in insulin and catecholamines
Hypokalemia Clinical Presentation:
Generalized weakness, Lethargy, Constipation
More severe consequences:
Muscle necrosis, Paralysis, Arrhythmias, Death
Hypokalemia Treatment Goals:
Avoidance/resolution of symptoms
Restoring serum K+ to normal
Preventing hyperkalemia
Treatment Options for Hypokalemia
Oral or IV potassium supplements
HYPOKALEMIA TREATMENT
______ correction is generally safer and reduces the risk of rebound hyperkalemia
Commonly used oral K+ replacements:
_______ and ______
Oral
potassium chloride
potasium phosphate
IV supplementation is reserved for treatment of severe hypokalemia or when the condition of the GI tract precludes use of oral agents
Infusion rates typically will not exceed ____ mEq/hr
Rates higher than ___ mEq/hr, continuous _____ monitoring is recommended to detect signs of hyperkalemia
If possible, ______ solutions should be avoided
________ deficit should be corrected
10-20
10
cardiac
dextrose
Magnesium
IV K+ supplements are available in ____, _____, and ______
IV treatment recommendatons:
Serum K 3-3.5: _____ mEq
Serum K 2.5-2.9: _____ mEq
Serum K <2.5: _____ mEq
Decrease dose by ___% for renal insufficiency
10 mEq K+ should increase serum K+ by ____
20-40
40-80
80-120
50%
0.1
Hyperkalemia (>____ mEq/L)
5.0
Hyperkalemia Causes
Most often occurs in CKD
Shifts in K+ from ICF to ECF: metabolic acidosis, tissue catabolism, pseudohyperkalemia
Increased K+ intake alone rarely causes hyperkalemia
Medications
Hyperkalemia Clinical Presentation:
Muscle twitching, cramping, weakness, paralysis, arrhythmias, cardiac arrest
Hyperkalemia Treatment goals:
Prevent cardiac effects
Reversing symptoms
Returning serum K+ to normal
HYPERKALEMIA TREATMENT
If feasible, discontinuation of all exogenous _______ and ________ that can cause hyperkalemia
Consider use of ____________
K+ sources and medications
loop or thiazide diuretic
HYPERKALEMIA TREATMENT for asymptomatic patients
Sodium Bicarbonate (50-100 mEq)
Dextrose infusion (25-100 gm with 5-10 units insulin)
HYPERKALEMIA TREATMENT for symptomatic patients or EKG changes
IV Calcium gluconate: 1-2 gm
Magnesium (Mg 2+)Normal range: ____ mg/dL
Found predominantly in the ____
Absorption occurs primarily in ____ and ____
Regulated by the ___, ___, and ___
1.8-2.4
ICF
distal jejunum and ileum
GI tract, kidney, and bone
MAGNESIUM
Essential in the activation of >300 _______
_________ metabolism
________ synthesis and breakdown
____ and ______ metabolism
Co-factor for __________
enzymatic reactions
Glucose
fatty acid
DNA and protein
Na+-K+ATPase pump
Hypomagnesemia (<____ mg/dL)
1.8
Hypomagnesemia causes
Decreased absorption or intake
- Protein-calorie malnutrition
- Malabsorption syndromes
- Alcoholism
- SBS
GI or renal losses
- Acute tubular necrosis
- Hyperaldosteronism
- Drug-induced
Intracellular Shifts
- Refeeding Syndrome
- Diabetic ketoacidosis
- Hyperparathyroidism
- MI
Hypomagnesemia clinical manifestations
Neuromuscular hyperexcitability
Cardiac complications
May reduce insulin sensitivity
Hypomagnesemia treatment goals
IV route preferred due to GI side effects of PO supplementation
HYPOMAGNESEMIA TREATMENT
Commonly used oral Mg replacements: (3)
Magnesium chloride
Magnesium Gluconate
Magnesium Oxide
IV treatment recommendations (Magnesium _____)
Serum Mg 1.0-1.5: ____________
Serum Mg <1.0: ___________
Decrease dose by ___% for renal insufficiency
____ mEq Mg sulfate should increase serum Mg by 0.1
Maximum infusion rate: ________
Sulfate
6-32 mEq, <1 mEq/kg
32-80 mEq, <1.5 mEq/kg
50
8
≤ 8 mEq/hr (1 g)
Hypermagnesemia (>____ mg/dL)
2.4
Hypermagnesemia causes
Primarily in the setting of CKD in combination with Mg intake
clinical presentation for hypermagnesemia
Generally well tolerated
Levels >4.8 mg/dL can affect neurologic, neuromuscular and cardiac function
hypermagnesemia treatment
Asymptomatic patients ?
symptomatic patients ?
Removal of exogenous sources of Mg
Mg restriction
Loop diuretics
IV Calcium
Calcium (Ca 2+)Normal range: ______ mg/dL
One of the most abundant cations in the body
99% of total body Ca is found in teeth and bones
Serum calcium exists in 3 forms: _______
8.6-10.2
complexed
protein bound
ionized
Calcium Functions:
Essential for ____ metabolism
_____ conduction
functionality of _______
coagulation cascade and regulation of ______functions
bone
nerve
cell membranes
secretory
Hypocalcemia
Serum Ca <____ mg/dL
Ionized Ca <____ mmol/L
8.6
1.12
Hypocalcemia Causes:
Decreased Vitamin D activity
Decreased PTH activity
Renal Impairment
Critical Illness
Medications: bisphosphonates, calcitonin, furosemide, long-term use of phenobarbital and phenytoin
Hypocalcemia clinical presentation
Cardiovascular (hypotension)
Neuromuscular (muscle cramps, tetany or seizures)
Hypocalcemia Treatment:
Oral or IV replacement and vit D for asymptomatic patients
Commonly used Ca supplements (3)
Calcium acetate:25% elemental Ca
Calcium carbonate: 40% elemental Ca
Calcium citrate: 21% elemental Ca
Acute Symptomatic patients with hypocalcemia
IV treatment recommendations:
Ionized Ca 1-1.12 mmol/L: __________
Ionized Ca <1 mmol/L: __________
1-2 g calcium carbonate over 1-2 hours
2-4 g calcium carbonate over 2-4 hours
Hypercalcemia
- Serum Ca >_____ mg/dL
- Ionized Ca >___ mmol/L
10.2
1.3
Hypercalcemia
Hyperparathyroidism
Cancer with bone metastases
Toxic levels Vitamin A or Vitamin D
Chronic ingestion of milk or Ca containing antacids in the setting of renal insufficiency
Hypercalcemia Clinical Presentation:
Fatigue, nausea, vomiting, anorexia, confusion, cardiac arrhythmias
Hypercalcemia mild is _____ mg/dL
severe is _____ mg/dL
10.3-11.9 mg/dL
>14 mg/dL
Hypercalcemia treatment for mild
Hydration and ambulation
Hypercalcemia treatment for severe
IV hydration using 0.9% NS at 200-300 ml/hr
- to reverse volume depletion caused by hypocalcemia
Controversial treatment: Once adequate hydration is achieved, 40-80 mg IV furosemide to enhance renal Ca excretion
*HD may be necessary
what is the main intracellular anion
phosphorous
Phosphorus normal range is _______ mg/dL
found mostly in ____ and _____
2.5-4.5
bones and soft tissue
Phosphorus functions
____ and ____ membrane composition
Maintenance of normal ___
Required in all cellular functions that require ____
bone and cell
pH
energy
Hypophosphatemia (<____ mg/dL)
2.5
Hypophosphatemia Causes
Chronic alcoholism, critical illness, respiratory & metabolic alkalosis, refeeding syndrome, pt’s receiving phosphate binding medications
Hypophosphatemia clinical presentation
Neurologic: ataxia, confusion
Neuromuscular: weakness, myalgia
Cardiopulmonary: cardiac and ventilatory failure
Hematologic: hemolysis
Hypophosphatemia treatment
Oral or IV replacement
Asymptomatic mild hypophosphatemia treatment is ___________.
Symptomatic moderate/severe hypophosphatemia treatment is _________.
oral supplements
IV phos unles K+ is >4 or renal insufficiency
Commonly used oral phosphate supplements?
Maximum infusion ratefor IV: ____ mmol/hr
K-Phos
Phos-NaK
OsmoPrep
7
Hyperphosphatemia (>____ mg/dL)
4.5
Hyperphosphatemia causes
CKD
Endogenous release of Phos into ECF from cellular destruction
- Massive trauma, cytotoxic agetns, hypercatabolism, hemolysis, malignant hyperthermia
Transcellular shifts from the ICF to the ECF
- Respiratory and metabolic acidosis
Hyperphosphatemia clinical presentation
Anorexia, nausea, vomiting, dehydration
Hyperphosphatemia complications
Soft tissue and vascular calcification
- when total serum Ca x serum Phos exceeds 55 mg/dL
Secondary hyperparathyroidism
Renal osteodystrophy
Hyperphosphatemia treatment
Decrease or eliminate exogenous sources
Phosphate binders
HD may be necessary
Clinical Conditions Warranting Cautious Use of PN
Glucose >_____ mg/dL ?
BUN >____ mg/dL
Osmolarity > ____ mOsm/kg
Na >____ mEq/L
K < _____ mEq/L
Phos <_____ mg /dL
Cl >______ mEq/L
Cl <_____ mEq/L
300 Hyperglycemia
100 Azotemia
350 Hyperosmolarity
150 Hypernatremia
3 Hypokalemia
2 Hypophosphatemia
115 Hyperchloremic metabolic acidosis
85 Hypochloremic metabolic alkalosis
Sodium daily requirement is ____mEq/kg
what are factors that increase needs?
1-2
Diarrhea
vomiting
NG suction
GI losses
Potassium daily requirement is ____mEq/kg
what are factors that increase needs?
1-2
Diarrhea
Vomiting
NG suction
Medications
Refeeding
GI losses
Calcium daily requirement is ____mEq
what are factors that increase needs?
10-15
high protein intake
Magnesium daily requirement is ____mEq
what are factors that increase needs?
8-20
GI losses
Medications
Refeeding
Phosphorous daily requirement is ____mMol
what are factors that increase needs?
20-40
High dextrose intake
refeeding
Electrolyte Requirements
Na: NS = ____ mEq/L
½ NS = ____ mEq/L
Mg: 1 gm Mg = ___ mEq Mg
Ca: 1 gm Ca = ____ mEq
KPO4: 1 mMol KPO4 contains _____ mEq K
NaPO4: 1 mMol NaPO4 contains _____ mEq Na
154
77
8
4.56
1.47
1.33
Monitor these every…
Capillary blood glucose?
grams of fat?
Mg, K+, Ph?
serum CO2?
triglyceride?
6 hrs until stable
daily
daily until stable
daily
at baseline then weekly
BG - Start with low dose sliding scale insulin. If BG >180, recommend increasing insulin in PN. Initial dose of ____ previous day’s sliding scale.
FAT - Calculate as fat gm/kg/day. If no lipids given, check for last date of dose given. If ______, recommend adding lipids.
MAGNESIUM, K+, PHOSPHOROUS - If Mg, K and Phos are all low, recommend adding __________ daily for possible re-feeding syndrome. Give replacement therapy.
SERUM CO2 - If >______, evaluate for possible ______
TRIGLYCERIDES - If >____ at baseline, hold lipids and re-check in 1 week. If >____ at repeat, consider giving minimal lipid dose to prevent EFAD
2/3
> 3 weeks
thiamine 100 mg
30
overfeeding
400
400
If glucose ≥ _____ mg/dL -> stop TPN -> run _____ at ordered TPN rate
If glucose <____ mg/dL -> Initiation of ____, Administration of ________ & stop ______
If TPN stopped, taper rate by ________ then infuse ________at the TPN rate until new bag hung
If TPN must be stopped suddenly, infuse ______ at TPN rate x ___ hour then ______ at the TPN rate until new bag hung
400
½ NS
70
D10
1 amp, 50% dextrose
insulin
½ x 1 hour
D5 ½ NS
D10
1
D5 ½ NS
