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Surgical Recall > SR 18 - Fluids and Electrolytes > Flashcards

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
Q

Surgical causes of respiratory acidosis?

A

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

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26
Q

Surigcal causes of respiratory alkalosis?

A

Hyperventilation (i.e. anxiety, pain, fever, wrong vent setting)

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27
Q

Classic acid-base finding with sinigicant vomiting or NGT suctioning?

A

Hypokalemic hypochloremic metabolic alkalosis

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28
Q

Why do you get hypokalemia with NGT suctioning?

A

Loss of gastric fluid:

  • Loss of HCL causes alkalosis
  • Alkalosis drives K+ into cells
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29
Q

Treatment for hypokalemic hypochloremic metabolic alkalosis?

A

IVF

Cl/K replacement

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30
Q

What is paradoxic alkalotic aciduria? Why does it happen?

A

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

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31
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 (crackles)
Central venous pressure
PCWP
CXR findings
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32
Q

With hypovolemia, what changes occur in vital signs?

A

Tachycardia
Tachypnea
Initial rise in diastolic pressure due to clamping down (peripheral vasoconstriction) with subsequent decrease in both systolic and diastolic blood pressure

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33
Q

What are the insensible fluid losses?

A

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)

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34
Q

What is the quantity of daily secretions of bile?

A

1000mL/24hrs

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35
Q

What is the quantity of daily gastric secretions?

A

2000mL/24hrs

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36
Q

What is the quantity of daily pancreatic secretions?

A

600mL/24hrs

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37
Q

What is the quantity of daily small intestine secretions?

A

3000mL/day

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38
Q

What is the quantity of daily saliva secretions?

A

1500mL/day

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39
Q

What happens to bile, gastric, pancreatic, small intestines and salivary secretions?

A

Most of them are reabsorbed

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40
Q

Mnemonic for remembering daily secretions from bile, gastric and small-bowel sources?

A

BGS 123
Bile = 1L
Gastric = 2L
Small-bowel = 3L

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41
Q

Per liter, components of NS?

A

154 mEq of Cl and Na

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42
Q

Per liter, components of 1/2 NS?

A

77 mEq of Cl and Na

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43
Q

Per liter, components of 1/4 NS?

A

39 mEq of Cl and Na

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44
Q

Per liter, components of LR?

A 
130 mEq of Na
109 mEq of Cl
28 mEq of lactate
4 mEq K
3 mEq Ca
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45
Q

Per liter, components of D5W

A

5% dectrose (50g) in water

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46
Q

What accounts for tonicity?

A

Electrolytes
NS/LR are both isotonic
1/2 NS is hypotonic

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47
Q

What happens to the lactate in LR in the body?

A

Converted to bicarbonate

Cannot use LR as maintanance fluid because the patient will become alkalotic

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48
Q

IV replacement based on anatomic site of losses - Gastric (NGT)?

A

D5 1/2 NS + 20 KCl

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49
Q

IV replacement based on anatomic site of losses - Biliary?

A

LR +/- sodium bicarbonate

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50
Q

IV replacement based on anatomic site of losses - pancreatic?

A

LR +/- sodium bicarbonate

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51
Q

IV replacement based on anatomic site of losses - Small bowel (ileostomy)?

A

LR

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52
Q

IV replacement based on anatomic site of losses - colonic (diarrhea)?

A

LR +/- sodium bicarbonate

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53
Q

What is the 100/50/20 rule associated with calculation of maintenance fluids?

A

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

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54
Q

What is the 4/2/1 rule associated with calculation of maintenance fluids?

A

Maintenance fluids for hourly rate:

  • 4mL/kg for first 10kg
  • 2mL/kg for next 10kg
  • 1mL/kg for every kg over 20kg
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55
Q

What is the common adult maintenance fluid?

A

D5 1/2 NS with 20mEq KCl/L

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56
Q

What is the common pediatric maintenance fluid?

A

D5 1/4 NS with 20mEq KCl/L

Due to children’s decreased ability of children to concentrate urine

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57
Q

Why should sugar (dextrose) 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 patietn has cardiac or renal dysfunction - then use CVP or PCWP

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59
Q

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

A

Approximately 30mL/hr

0.5cc/kg/hr

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60
Q

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

A

50mL/hr

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61
Q

How many mL are in 12 oz?

A

356mL

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62
Q

How many mL are in 1oz?

A

30mL

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63
Q

How many mL are in 1tsp

A

5mL

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64
Q

What are common isotonic fluids?

A

NS, LR

65
Q

What is a fluid bolus?

A

Volume of fluid given IV rapidly (i.e. 1L over 1 hour)
Used for increasing intravascular volume
Use isotonic fluid (NS, LR)

66
Q

Why not combine bolus fluids with dextrose?

A

Hyperglycemia may result

67
Q

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

A

Osmotic diuresis

68
Q

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

A

Hyperkalemia

Remember, LR only has 4mEq/L

69
Q

Why should isotonic fluids be given for recuscitation?

A

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
Q

What is the most common trauma resuscitation fluid?

A

LR

71
Q

What is the most common postoperative IVF after a laparotomy?

A

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

72
Q

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

A

POD 3 - third-space fluid starts moving back into the intravascular space

73
Q

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

A

LR - for the bicarbonate loss

74
Q

What is a common cause of electrolyte abnormalities?

A

Lab error

75
Q

What is a a major extracellular cation?

A

Na+

76
Q

What is a major intracellular cation?

A

K+

77
Q

What are the surgical causes of hyperkalemia?

A 
Iatrogenic overdose
Blood tranfusion
Renal failure
Diuretics
Acidosis
Tissue destruction (injury/hemolysis)
78
Q

What are the signs and symptoms of hyperkalemia?

A 
Decreased deep tendon reflexes or areflexia
Weakness
Paraesthesia
Paralysis
Respiratory failure
79
Q

What are the EKG findings of hyperkalemia?

A 
Peaked T waves
Depressed ST segment
Prolonged PR
Wide QRS
Bradycardia
Ventricular fibrillation
80
Q

What are critical values for potassium?

A

> 6.5

81
Q

What is the urgent treatment for hyperkalemia?

A

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
Q

What is the nonacute treatment for hyperkalemia?

A

Furosemide (Lasix), sodium polystyrene sulfonate (Kayexalate)

83
Q

What acid-base change lowers the serum potassium?

A

Alkalosis

84
Q

What nebulizer treatment can help lower K+ levels?

A

Albuterol

85
Q

What are surgical causes of hypokalemia?

A 
Diuretics
Certain antibioitics
Steroids
Alkalosis
Diarrhea
Intestinal fistulae
NG aspiration
Vomiting
Insulin
Insufficient supplementation
Amphotericin
86
Q

Signs and symptoms of hypokalemia?

A 
Weakness
Tetany
Nausea
Vomiting
Ileus
Paresthesia
87
Q

What are the ECG findings in hypokalemia?

A 
Flattening of T-waves
U-waves (second wave after a t-wave)
ST segment depression
PAV, PVC
Atrial fibrillation
88
Q

What is the rapid treatment of hypokalemia?

A

KCl IV

89
Q

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

A

10mEq/hour

90
Q

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

A

20mEq/hour

91
Q

What is the treatment of chronic hypokalemia?

A

KCl PO

92
Q

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

A

Hypokalemia

93
Q

What electrolyte conditions exacerbates digitalis toxicity?

A

Hypokalemia

94
Q

What electrolyte deficiency can cause hypokalemia?

A

Low magnesium

95
Q

What electrolyte must you replace before replacing K?

A

Magnesium

96
Q

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

A

Hypomagnesemia inhibits K+ reabsoprtion from the renal tubules

97
Q

What are the surgical causes of hypernatremia?

A 
Inadequate hydrateion
Diabetes insipidus
Diuresis
Vomiting
Diarrhea
Diaphoresis
Tachypnea
Iatrogenic (i.e. TPN)
98
Q

What are the signs/symptoms of hypernatremia?

A 
Seizures
Confusion
Stupor
Pulmonary or peripheral edema
Tremors
Respiratory paralysis
99
Q

What is the usualy treatment of hyponatremia, slowly over days?

A

D5W, 1/4NS or 1/2NS

100
Q

How fast should you lower the sodium levels in hypernatremia?

A
101
Q

What is the major complication of lowering sodium too rapidly?

A

Seizures

102
Q

What are the surigcal causes of hypovolemic hyponatremia?

A 
Diuretic excess
Hypoaldosteronism
Vomiting
NG suction
Burns
Pancreatitis
Diaphoresis
103
Q

What are the surigcal causes of euvolemic hyponatremia?

A

SIADH
CNS abnormalities
Drugs

104
Q

What are the surigcal causes of hypervolemic hyponatremia?

A

Renal fialure
CHF
Liver failure (cirrhosis)
Iatrogenic fluid overload (dilutional)

105
Q

Signs and symptoms of hyponatremia?

A 
Seizures
Coma
Nausea
Vomiting
Ileus
Lethargy
Confusion
Weakness
106
Q

What is the treatment of hypovolemic hyponatremia?

A

NS IV, correct underlying cause

107
Q

What is the treatment of euvolemic hyponatremia?

A

SIADH - furosemide and NS acutely, fluid restriction

108
Q

What is the treatment of hypervolemic hyponatremia?

A

Dilutional - fluid restriction and diuretics

109
Q

How fast should you increase the sodium level in hyponatremia?

A
110
Q

What can happen if you correct hyponatremia too quickly?

A

Central pontine myelinolysis

111
Q

What are the signs of central pontine myelinolysis?

A

Confusion
Spastic quadriplegia
Horizontal gaze paralysis

112
Q

What is the most common cause of mild postoperative hyponatremia?

A

Fluid overload

113
Q

What is pseudohyponatremia?

A

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

114
Q

Signs and symptoms of hypercalcemia?

A

Stones, bones, adbominal groans and psychiatric overtones

Polydipsia, polyuria, constipation

115
Q

ECG findings of hypercalcemia?

A

Short QT interval

Prolonged PR interval

116
Q

What is the acute treatment of hypercalcemic crisis?

A

Volume expansion with NS, diuresis with furosemide

117
Q

What are less traditional options for the treatment of hypercalcemia?

A 
Steroids
Calcitonin
Biosphophonates
Mithramycin
Dialysis (last resort)
118
Q

How do you adjust calcium levels in hypoalbuminemia?

A

(4 - measured albumin level) x 0.8 + measured calcium level

119
Q

What are the surgical causes of hypocalcemia?

A 
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
Q

Signs and symptoms of hypocalcemia?

A 
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
Q

ECG findings in hypocalcemia?

A

Prolonged QT and ST interval

Possible peaked T-waves

122
Q

Acute treatment of hypocalcemia?

A

IV calcium gluconate

123
Q

What is the chronic treatment of hypocalcemia?

A

Calcium PO

Vitamin D

124
Q

What is the possible complications of infused calcium if the IV infilrates?

A

Tissue necrosis
Only administer peripherally in an absolute emergency
Calcium gluconate is less toxic that calcium chloride during an infiltration

125
Q

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

A

Ceck ionized calcium

126
Q

What is the normal range for magnesium level?

A

1.5-2.5 mEq/L

127
Q

What are the surgical causes of hypermagnesemia?

A

TPN
Renal failure
IV over supplementation

128
Q

What are the signs and symptoms of hypermagnesemia?

A

Respiratory failure
CNS depression
Decreased deep tendon reflexes

129
Q

What is the treatment of hypermagnesemia?

A

Calcium gluconate IV
Insulin + glucose
Dialysis
Furosemide (lasix)

130
Q

What are the surgical causes of hypomagnesemia?

A 
TPN
Hypocalcemia
Gastric suctioning
Aminoglycosides
Renal failure
Diarrhea
Vomiting
131
Q

Signs and symptoms of hypomagnesemia?

A 
Increased deep tendon reflexes
Tetany
Asterixis
Tremor
Chvostek's sign
ventricular ectopy
Vertigo
Tachycardia
Dysrhythmias
132
Q

Acute treatment of hypomagnesemia?

A

MgSO4 IV

133
Q

What is the chronic treatment of hypomagenesemia?

A

Magnesium oxide PO

AE - diarrhea

134
Q

What are the surgical causes of hyperglycemia?

A 
Diabetes (poor control)
Decreased caloric intake
Insulinoma
Drugs
liver failure
Adrenal insufficiency
Gastrojejunostomy
135
Q

Signs and symptoms of hyperglycemia?

A 
Polyuria
Hypovolemia
Confusion/coma
Polydipsia
Ileus
DKA (Kussmaul breathing)
Abdominal pain
Hyporeflexia
136
Q

Treatment of hyperglycemia?

A

Insulin

137
Q

What is the Weiss protocol?

A

Sliding scale insulin

138
Q

What is the goal glucose level in the ICU?

A

80-110mg/dL

139
Q

What are the surgical causes of hypoglycemia?

A 
Excess insulin
Decreased caloric intake
Insulinoma
Drugs
Liver failure
Adrenal insufficiency
Gastrojejunostomy
140
Q

What are the signs and symptoms of hypoglycemia?

A 
Sympathetic response (diaphroesis, tachycardia, palpitations)
Confusion, coma
Headche
Diplopia
Neurological deficits
Seizures
141
Q

What is the treatment for hypoglycemia?

A

IV or PO glucose

142
Q

What is the normal range for phosphorus levels?

A

2.5-4.5mg/dL

143
Q

What are the signs and symptoms of hypophosphatemia?

A 
Weakness
Cardiomyopathy
Neurologic dysfunction (i.e. ataxia)
Rhabdomyolysis
Hemolysis
Poor pressor response
144
Q

What is a complication of severe hypophophatemia?

A

Respiratory failure

145
Q

What are causes of hypophosphatemia?

A 
GI losses
Inadequate supplementation
Medications
Sepsis
Alcohol abuse
Renal loss
146
Q

What is the critical value for phosphate?

A
147
Q

What is the treatment for hypophosphatemia?

A

Supplement with sodium phosphate or potassium phosphate IV

148
Q

What are the signs and symptoms of hyperphosphatemia?

A

Calcification (ectopic)

Heart bloock

149
Q

What are the causes of hyperphosphatemia?

A

Renal failure
Sepsis
Chemotherapy
Hyperthyroidism

150
Q

What is the treatment for hyperphosphatemia?

A

Aluminum hydroxide (binds phosphate)

151
Q

If hyperkalemia is left untreated, what can occur?

A

Vtach/fib –> death

152
Q

What electrolyte is an inotrope?

A

Calcium

153
Q

What are the major cardiac electrolytes?

A

Potassium (dysrhythmias)
Magnesium (dysrhythmias)
Calcium (dysrhythmias, inotrope)

154
Q

Which electrolyte must be monitored closely in patients on digitalis?

A

Potassium

155
Q

Most common cause of electrolyte-mediated ileus?

A

Potassium

156
Q

What is a colloid fluid?

A

Protein-containing fluid (albumin)

157
Q

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

A

Mobilization of third-space fluid –> fluid overload –> CHF

also run cardiac enzymes and ECG to R/O an MI

158
Q

What fluid is used to repalce NGT aspirate?

A

D5 1/2 NS with 20 KCl

159
Q

What electrolyte is associated with succinylcholine?

A

Hyperkalemia

Surgical Recall (32 decks)

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