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SR 18 - Fluids and Electrolytes Flashcards

1
Q

Two major body fluid compartments?

A

Intracellular and extracellular

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2
Q

Two subcompartments of ECF?

A 
Interstitial fluid (inbetween cells)
Intravascular fluid (plasma)
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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

What is the composition of body fluid?

A 
Fluids - 60% of TBW 
ICF - 40% TBW
ECF - 20% TBW
(60, 40, 20)
Mnemonic TIE (Total body fluid, Intracellular, Extracellular)
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7
Q

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

A

7%

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8
Q

How many liters of blood in a 70kg man?

A
  1. 07 x TBW

0. 07 x 70kg = 5 liters

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9
Q

Fluid requirments every 24hrs for Water?

A

30-35 mL/kg

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10
Q

Fluid requirments every 24hrs for Potassium?

A

1 mEq/kg

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11
Q

Fluid requirments every 24hrs for Chloride?

A

1.5 mEq/kg

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12
Q

Fluid requirments every 24hrs for Sodium?

A

1-2 mEq/kg

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13
Q

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

A

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

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14
Q

What are the levels of normal daily electrolyte loss?

A

Sodium and potassium - 100mEq

Chloride - 150mEq

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15
Q

What are the levels of sodium and chloride in sweat?

A

40mEq/L

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16
Q

What is the major electrolyte in colonic feculent fluid?

A

Potassium - 65mEq/L

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17
Q

What is the physiologic response to hypoveolemia?

A

Sodium/H2O retention via renin

  • -> aldosterone, water retention via ADH, vasoconstriction via ATII and sympathetics
  • -> low urine output and tacycardia (early) and hypotensions (late)
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18
Q

What is third spacing?

A

Fluid accumulation in the interstitium of tissues
Edema
Loss of fluid into the interstitium and lumen of a paralytic bowel following surgery

Intravascular and intracellular spaces are the first two spaces

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19
Q

When does third-spacing resolve postoperatively?

A

Third-spaced fluid tends to mobilize back into the intravascular space around POD #3
You need to be mindful of fluid overload when the fluid returns intravascularly - Switch to hypotonic fluid and decrease IV rate

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20
Q

Classic signs of third spacing?

A

Tachycardia

Decreased urine output

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21
Q

Treatment of third spacing?

A

IV hydration with isotonic fluids

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22
Q

Surgical causes of Metabolic acidosis?

A

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

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23
Q

Surgical causes of hypochloremic alkalosis?

A

NGT suction, loss of gastric HCL through vomiting/NGT

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24
Q

Surgical causes of metabolic alkalosis?

A

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

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25
Surgical causes of respiratory acidosis?
Hypoventilation (i.e. CNS depression), drugs (i.e. morphine), PTX, pleural effusion, parenchymal lung disease, acute airway obstruction
26
Surigcal causes of respiratory alkalosis?
Hyperventilation (i.e. anxiety, pain, fever, wrong vent setting)
27
Classic acid-base finding with sinigicant vomiting or NGT suctioning?
Hypokalemic hypochloremic metabolic alkalosis
28
Why do you get hypokalemia with NGT suctioning?
Loss of gastric fluid: - Loss of HCL causes alkalosis - Alkalosis drives K+ into cells
29
Treatment for hypokalemic hypochloremic metabolic alkalosis?
IVF | Cl/K replacement
30
What is paradoxic alkalotic aciduria? Why does it happen?
Seen in severe hypokalemic, hypovolemic, hypochloremic metabolic alkalosis with paradoxic metabolic alkalosis of serum and acidic urine Due to H+ loss in the urine in exchange for Na+ in an attempt to restore volume. H+ is preferentially lost over K+ due to the hypokalemia
31
What can be followed to assess fluid status?
``` Urine output Base deficit Lactic acid Vital signs Weight changes Skin turgor JVD Mucosal membranes Rales (crackles) Central venous pressure PCWP CXR findings ```
32
With hypovolemia, what changes occur in vital signs?
Tachycardia Tachypnea Initial rise in diastolic pressure due to clamping down (peripheral vasoconstriction) with subsequent decrease in both systolic and diastolic blood pressure
33
What are the insensible fluid losses?
Loss of fluid that cannot be measured Feces - 100-200mL/24hrs Breathing - 500-700mL/24hrs (increases with fever and tachypnea) Skin - 300mL/24hrs (increases with fever)
34
What is the quantity of daily secretions of bile?
1000mL/24hrs
35
What is the quantity of daily gastric secretions?
2000mL/24hrs
36
What is the quantity of daily pancreatic secretions?
600mL/24hrs
37
What is the quantity of daily small intestine secretions?
3000mL/day
38
What is the quantity of daily saliva secretions?
1500mL/day
39
What happens to bile, gastric, pancreatic, small intestines and salivary secretions?
Most of them are reabsorbed
40
Mnemonic for remembering daily secretions from bile, gastric and small-bowel sources?
BGS 123 Bile = 1L Gastric = 2L Small-bowel = 3L
41
Per liter, components of NS?
154 mEq of Cl and Na
42
Per liter, components of 1/2 NS?
77 mEq of Cl and Na
43
Per liter, components of 1/4 NS?
39 mEq of Cl and Na
44
Per liter, components of LR?
``` 130 mEq of Na 109 mEq of Cl 28 mEq of lactate 4 mEq K 3 mEq Ca ```
45
Per liter, components of D5W
5% dectrose (50g) in water
46
What accounts for tonicity?
Electrolytes NS/LR are both isotonic 1/2 NS is hypotonic
47
What happens to the lactate in LR in the body?
Converted to bicarbonate | Cannot use LR as maintanance fluid because the patient will become alkalotic
48
IV replacement based on anatomic site of losses - Gastric (NGT)?
D5 1/2 NS + 20 KCl
49
IV replacement based on anatomic site of losses - Biliary?
LR +/- sodium bicarbonate
50
IV replacement based on anatomic site of losses - pancreatic?
LR +/- sodium bicarbonate
51
IV replacement based on anatomic site of losses - Small bowel (ileostomy)?
LR
52
IV replacement based on anatomic site of losses - colonic (diarrhea)?
LR +/- sodium bicarbonate
53
What is the 100/50/20 rule associated with calculation of maintenance fluids?
Maintenance fluids for 24hrs: - 100mL/kg for first 10kg - 50mL/kg for next 10kg - 20mL/kg for ever kg over 20 Divide by 24 for hourly rate
54
What is the 4/2/1 rule associated with calculation of maintenance fluids?
Maintenance fluids for hourly rate: - 4mL/kg for first 10kg - 2mL/kg for next 10kg - 1mL/kg for every kg over 20kg
55
What is the common adult maintenance fluid?
D5 1/2 NS with 20mEq KCl/L
56
What is the common pediatric maintenance fluid?
D5 1/4 NS with 20mEq KCl/L | Due to children's decreased ability of children to concentrate urine
57
Why should sugar (dextrose) be added to maintenance fluid?
To inhibit muscle breakdown
58
What is the best way to assess fluid status?
Urine output | Unless patietn has cardiac or renal dysfunction - then use CVP or PCWP
59
What is the minimal urine output for an adult on maintenence IV?
Approximately 30mL/hr | 0.5cc/kg/hr
60
What is the minimal urine ouptut for an adult trauma patient?
50mL/hr
61
How many mL are in 12 oz?
356mL
62
How many mL are in 1oz?
30mL
63
How many mL are in 1tsp
5mL
64
What are common isotonic fluids?
NS, LR
65
What is a fluid bolus?
Volume of fluid given IV rapidly (i.e. 1L over 1 hour) Used for increasing intravascular volume Use isotonic fluid (NS, LR)
66
Why not combine bolus fluids with dextrose?
Hyperglycemia may result
67
What is the possible consequence of hyperglycemia in the patient with hypovolemia?
Osmotic diuresis
68
Why not combine bolus fluids with a significant amount of potassium?
Hyperkalemia | Remember, LR only has 4mEq/L
69
Why should isotonic fluids be given for recuscitation?
If hypotonic fluid is given, the tonicity of the intravascular space will decrease and H2O will freely diffuse into the interstitial and intracellular space Use isotonic fluid allow expanding of the intravascular space
70
What is the most common trauma resuscitation fluid?
LR
71
What is the most common postoperative IVF after a laparotomy?
LR or D5LR for 24-36 hours, followed by maintenance fluid
72
After a laparotomy, when should a patient's fluid be mobilized?
POD 3 - third-space fluid starts moving back into the intravascular space
73
What IVF is used to replace duodenal or pancreatic fluid loss?
LR - for the bicarbonate loss
74
What is a common cause of electrolyte abnormalities?
Lab error
75
What is a a major extracellular cation?
Na+
76
What is a major intracellular cation?
K+
77
What are the surgical causes of hyperkalemia?
``` Iatrogenic overdose Blood tranfusion Renal failure Diuretics Acidosis Tissue destruction (injury/hemolysis) ```
78
What are the signs and symptoms of hyperkalemia?
``` Decreased deep tendon reflexes or areflexia Weakness Paraesthesia Paralysis Respiratory failure ```
79
What are the EKG findings of hyperkalemia?
``` Peaked T waves Depressed ST segment Prolonged PR Wide QRS Bradycardia Ventricular fibrillation ```
80
What are critical values for potassium?
>6.5
81
What is the urgent treatment for hyperkalemia?
IV calcium (cardioprotective), ECG monitoring Sodium bicarbonate IV (alkalosis will drive K+ intracellularly) Glucose and insulin (will also drive K+ intracellularly) Albuterol Sodium polystyrene sulfonate (Kayexalate) and furosemide (Lasix) Dialysis ``` Acronymn: CB DIAL K Calcium Bicarbonate Dialysis Insulin/dextrose Albuterol Lasix Kayexalate ```
82
What is the nonacute treatment for hyperkalemia?
Furosemide (Lasix), sodium polystyrene sulfonate (Kayexalate)
83
What acid-base change lowers the serum potassium?
Alkalosis
84
What nebulizer treatment can help lower K+ levels?
Albuterol
85
What are surgical causes of hypokalemia?
``` Diuretics Certain antibioitics Steroids Alkalosis Diarrhea Intestinal fistulae NG aspiration Vomiting Insulin Insufficient supplementation Amphotericin ```
86
Signs and symptoms of hypokalemia?
``` Weakness Tetany Nausea Vomiting Ileus Paresthesia ```
87
What are the ECG findings in hypokalemia?
``` Flattening of T-waves U-waves (second wave after a t-wave) ST segment depression PAV, PVC Atrial fibrillation ```
88
What is the rapid treatment of hypokalemia?
KCl IV
89
What is the maximum amount of KCl that can be given through peripheral IV?
10mEq/hour
90
What is the maximum amount of KCl that can be given through a central line?
20mEq/hour
91
What is the treatment of chronic hypokalemia?
KCl PO
92
What is the most common electrolyte-mediated ileus in the surgical patient?
Hypokalemia
93
What electrolyte conditions exacerbates digitalis toxicity?
Hypokalemia
94
What electrolyte deficiency can cause hypokalemia?
Low magnesium
95
What electrolyte must you replace before replacing K?
Magnesium
96
Why does hypomagnesemia make replacement of K with hypokalemia nearly impossible?
Hypomagnesemia inhibits K+ reabsoprtion from the renal tubules
97
What are the surgical causes of hypernatremia?
``` Inadequate hydrateion Diabetes insipidus Diuresis Vomiting Diarrhea Diaphoresis Tachypnea Iatrogenic (i.e. TPN) ```
98
What are the signs/symptoms of hypernatremia?
``` Seizures Confusion Stupor Pulmonary or peripheral edema Tremors Respiratory paralysis ```
99
What is the usualy treatment of hyponatremia, slowly over days?
D5W, 1/4NS or 1/2NS
100
How fast should you lower the sodium levels in hypernatremia?
101
What is the major complication of lowering sodium too rapidly?
Seizures
102
What are the surigcal causes of hypovolemic hyponatremia?
``` Diuretic excess Hypoaldosteronism Vomiting NG suction Burns Pancreatitis Diaphoresis ```
103
What are the surigcal causes of euvolemic hyponatremia?
SIADH CNS abnormalities Drugs
104
What are the surigcal causes of hypervolemic hyponatremia?
Renal fialure CHF Liver failure (cirrhosis) Iatrogenic fluid overload (dilutional)
105
Signs and symptoms of hyponatremia?
``` Seizures Coma Nausea Vomiting Ileus Lethargy Confusion Weakness ```
106
What is the treatment of hypovolemic hyponatremia?
NS IV, correct underlying cause
107
What is the treatment of euvolemic hyponatremia?
SIADH - furosemide and NS acutely, fluid restriction
108
What is the treatment of hypervolemic hyponatremia?
Dilutional - fluid restriction and diuretics
109
How fast should you increase the sodium level in hyponatremia?
110
What can happen if you correct hyponatremia too quickly?
Central pontine myelinolysis
111
What are the signs of central pontine myelinolysis?
Confusion Spastic quadriplegia Horizontal gaze paralysis
112
What is the most common cause of mild postoperative hyponatremia?
Fluid overload
113
What is pseudohyponatremia?
Spurious lab values of hyponatremia as a result of hyperglycemia, hyperlipidemia, or hyperproteinemia
114
Signs and symptoms of hypercalcemia?
Stones, bones, adbominal groans and psychiatric overtones | Polydipsia, polyuria, constipation
115
ECG findings of hypercalcemia?
Short QT interval | Prolonged PR interval
116
What is the acute treatment of hypercalcemic crisis?
Volume expansion with NS, diuresis with furosemide
117
What are less traditional options for the treatment of hypercalcemia?
``` Steroids Calcitonin Biosphophonates Mithramycin Dialysis (last resort) ```
118
How do you adjust calcium levels in hypoalbuminemia?
(4 - measured albumin level) x 0.8 + measured calcium level
119
What are the surgical causes of hypocalcemia?
``` Short bowel syndrome Intestinal bypass Vitamin D deficiency Sepsis Acute pancreatitis Osteoblastic metastasis (prostate, medulloblastoma, bronchial carcinoid) Aminoglycosides Diuretics (loops) Renal failure Hypomagnesemia Rhabdomyolysis ```
120
Signs and symptoms of hypocalcemia?
``` Chvostek's and Trousseau's signs Perioral paraesthesia (early) Increased deep tendon reflexes (late) Confusion Abdominal cramps Laryngospasm Stridor Seizures Tetany Psychiatric abnormalities (paranoia, depression, hallucinations) ```
121
ECG findings in hypocalcemia?
Prolonged QT and ST interval | Possible peaked T-waves
122
Acute treatment of hypocalcemia?
IV calcium gluconate
123
What is the chronic treatment of hypocalcemia?
Calcium PO | Vitamin D
124
What is the possible complications of infused calcium if the IV infilrates?
Tissue necrosis Only administer peripherally in an absolute emergency Calcium gluconate is less toxic that calcium chloride during an infiltration
125
What is the best way to check calcium levels in the ICU?
Ceck ionized calcium
126
What is the normal range for magnesium level?
1.5-2.5 mEq/L
127
What are the surgical causes of hypermagnesemia?
TPN Renal failure IV over supplementation
128
What are the signs and symptoms of hypermagnesemia?
Respiratory failure CNS depression Decreased deep tendon reflexes
129
What is the treatment of hypermagnesemia?
Calcium gluconate IV Insulin + glucose Dialysis Furosemide (lasix)
130
What are the surgical causes of hypomagnesemia?
``` TPN Hypocalcemia Gastric suctioning Aminoglycosides Renal failure Diarrhea Vomiting ```
131
Signs and symptoms of hypomagnesemia?
``` Increased deep tendon reflexes Tetany Asterixis Tremor Chvostek's sign ventricular ectopy Vertigo Tachycardia Dysrhythmias ```
132
Acute treatment of hypomagnesemia?
MgSO4 IV
133
What is the chronic treatment of hypomagenesemia?
Magnesium oxide PO | AE - diarrhea
134
What are the surgical causes of hyperglycemia?
``` Diabetes (poor control) Decreased caloric intake Insulinoma Drugs liver failure Adrenal insufficiency Gastrojejunostomy ```
135
Signs and symptoms of hyperglycemia?
``` Polyuria Hypovolemia Confusion/coma Polydipsia Ileus DKA (Kussmaul breathing) Abdominal pain Hyporeflexia ```
136
Treatment of hyperglycemia?
Insulin
137
What is the Weiss protocol?
Sliding scale insulin
138
What is the goal glucose level in the ICU?
80-110mg/dL
139
What are the surgical causes of hypoglycemia?
``` Excess insulin Decreased caloric intake Insulinoma Drugs Liver failure Adrenal insufficiency Gastrojejunostomy ```
140
What are the signs and symptoms of hypoglycemia?
``` Sympathetic response (diaphroesis, tachycardia, palpitations) Confusion, coma Headche Diplopia Neurological deficits Seizures ```
141
What is the treatment for hypoglycemia?
IV or PO glucose
142
What is the normal range for phosphorus levels?
2.5-4.5mg/dL
143
What are the signs and symptoms of hypophosphatemia?
``` Weakness Cardiomyopathy Neurologic dysfunction (i.e. ataxia) Rhabdomyolysis Hemolysis Poor pressor response ```
144
What is a complication of severe hypophophatemia?
Respiratory failure
145
What are causes of hypophosphatemia?
``` GI losses Inadequate supplementation Medications Sepsis Alcohol abuse Renal loss ```
146
What is the critical value for phosphate?
147
What is the treatment for hypophosphatemia?
Supplement with sodium phosphate or potassium phosphate IV
148
What are the signs and symptoms of hyperphosphatemia?
Calcification (ectopic) | Heart bloock
149
What are the causes of hyperphosphatemia?
Renal failure Sepsis Chemotherapy Hyperthyroidism
150
What is the treatment for hyperphosphatemia?
Aluminum hydroxide (binds phosphate)
151
If hyperkalemia is left untreated, what can occur?
Vtach/fib --> death
152
What electrolyte is an inotrope?
Calcium
153
What are the major cardiac electrolytes?
Potassium (dysrhythmias) Magnesium (dysrhythmias) Calcium (dysrhythmias, inotrope)
154
Which electrolyte must be monitored closely in patients on digitalis?
Potassium
155
Most common cause of electrolyte-mediated ileus?
Potassium
156
What is a colloid fluid?
Protein-containing fluid (albumin)
157
An elderly patient goiens into CHF on POD 3 after a laparotomy. What is going on?
Mobilization of third-space fluid --> fluid overload --> CHF | also run cardiac enzymes and ECG to R/O an MI
158
What fluid is used to repalce NGT aspirate?
D5 1/2 NS with 20 KCl
159
What electrolyte is associated with succinylcholine?
Hyperkalemia

Surgical Recall (32 decks)

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