V7 PROFIBUS-DP® Option Technical Manual - Yaskawa

Fluids and Electrolytes

R. Lawrence Reed, II, MD, FACS, FCCMR. Lawrence Reed, II, MD, FACS, FCCM

Professor of SurgeryProfessor of Surgery

Loyola University Medical CenterLoyola University Medical Center

Maywood, ILMaywood, IL

Importance

nn Critical aspect in patient managementCritical aspect in patient management

nn Altered in:Altered in:

uu Major traumaMajor trauma

uu Disease StatesDisease States

uu Operative traumaOperative trauma

Anatomic Distribution

nn Total body water = 50Total body water = 50--70% weight70% weight

uu Higher in men than womenHigher in men than women

uu Higher in slim than fatHigher in slim than fat

uu Steadily decreases with ageSteadily decreases with age

nn Example: 70 kg male: 42 liters of waterExample: 70 kg male: 42 liters of water

Total Body Weight

Total Body Water (60%)Total Body

Water=60% of

Body Weight

Body Fluid Compartments

Dry Weight (40%)

Intracellular Fluid (40%)

Extracellular Fluid (20%)ECF=

20% Body

Wt.Interstitial Fluid (15%)

Blood Volume

(5%)

Functional

(5%)Non-Functional/Transcellular

(10%)

Osmotic Pressures

MgMg++

KK++

POPO44--

ProteinsProteins--

NaNa++

ClCl--

HCOHCO33--

290-310 Osm 290-310 Osm

ExtracellularExtracellular IntracellularIntracellular

Definitions

nn OsmosisOsmosis

uu From the Greek From the Greek osmososmos (impulse), derived from (impulse), derived from otheootheo

(to push)(to push)

uu Refers to the tendency, when 2 solutions of differing Refers to the tendency, when 2 solutions of differing concentrations are separated by a concentrations are separated by a semipermeablesemipermeablemembrane, for the permeable substance to diffuse membrane, for the permeable substance to diffuse through the membrane from its higher to its lower through the membrane from its higher to its lower concentration until the pressures across the membrane concentration until the pressures across the membrane become equalbecome equal

uu In most biologic systems, water is freely permeable In most biologic systems, water is freely permeable across membranesacross membranes

FF Hence, any change in osmotic pressure will lead to shifts in Hence, any change in osmotic pressure will lead to shifts in water distribution (since Hwater distribution (since H22O is usually the only molecule that O is usually the only molecule that can move)can move)

Definitions

nn Total Osmotic PressureTotal Osmotic Pressure

uu Sum of all Sum of all osmoticallyosmotically active particles in the solutionactive particles in the solution

FF NaClNaCl = 2= 2

FF NaNa22SOSO44 = 3= 3

FF Glucose = 1Glucose = 1

Definitions

nn OncosisOncosis

uu From the Greek, From the Greek, onkosisonkosis (swelling), derived from (swelling), derived from onkosonkos

(bulk, mass)(bulk, mass)

uu A condition characterized by the formation of one or A condition characterized by the formation of one or

more more neoplasmsneoplasms, tumors, or other swelling, tumors, or other swelling

uu i.e., the term i.e., the term ““oncologyoncology”” derives from the same rootderives from the same root

nn In common usage, In common usage, ““oncosisoncosis”” and and ““oncoticoncotic”” refer refer

to osmotic properties induced by colloidsto osmotic properties induced by colloids

Definitions

nn ColloidColloid

uu From the Greek From the Greek kollakolla ((glue) +glue) + eidoseidos ((appearance)appearance)

uu Aggregates of atoms or molecules in a finely divided Aggregates of atoms or molecules in a finely divided

state dispersed in a gaseous, liquid, or solid medium, state dispersed in a gaseous, liquid, or solid medium,

and resisting sedimentation, diffusion, and filtration, and resisting sedimentation, diffusion, and filtration,

thus differing from precipitatesthus differing from precipitates

Definitions

nn Colloid Colloid oncoticoncotic pressure pressure

(COP)(COP)

uu the osmotic pressure the osmotic pressure

exerted by colloids in exerted by colloids in

solutionsolution

uu designated as designated as π.π.

Internal Environment

nn Homeostasis must be preserved for optimal Homeostasis must be preserved for optimal

cellular functioning and viabilitycellular functioning and viability

uu Balance between input and output must be maintainedBalance between input and output must be maintained

uu Maintained byMaintained by

FF KidneysKidneys

FF BrainBrain

FF LungsLungs

FF SkinSkin

FF GI tractGI tract

uu Compromised by major surgical stressCompromised by major surgical stress

Why do anything?

nn Why bother with Why bother with ““insins”” and and ““outsouts””??

uu That is, if we did nothing, couldnThat is, if we did nothing, couldn’’t we achieve balance t we achieve balance

by letting it all stay in?by letting it all stay in?

nn Answer: NoAnswer: No

uu The body produces metabolites that are eliminated in The body produces metabolites that are eliminated in

the urine:the urine:

FF UreaUrea

FF CreatinineCreatinine

FF AcidAcid

uu You must excrete 500 You must excrete 500 -- 800 ml of urine a day to excrete 800 ml of urine a day to excrete

products of metabolismproducts of metabolism

“Ins”

nn Normal person: Oral Normal person: Oral

intakeintake

uu 1 to 2.5 liters per day1 to 2.5 liters per day

FF 100 to 1,500 ml liquid100 to 1,500 ml liquid

FF 400 400 -- 1000 ml1000 ml’’s s

•• extracted from solid extracted from solid

foodfood

•• oxidative metabolism oxidative metabolism

(~400 ml/day)(~400 ml/day)

“Outs”

nn UrineUrine

uu ~800 ~800 -- 1500 ml daily1500 ml daily

nn StoolStool

uu ~250 ml daily~250 ml daily

nn Insensible lossInsensible loss

uu 600 ml daily600 ml daily

FF 75% lungs75% lungs

FF 25% skin25% skin

uu Increased due to fever, Increased due to fever,

hyperventilation, hyperventilation,

hypermetabolismhypermetabolism, arid , arid

environment, evaporation environment, evaporation

(i.e., from exposed viscera)(i.e., from exposed viscera)

Fundamental Concepts

nn Electrolytes are measured in terms of their Electrolytes are measured in terms of their

concentrationconcentration within a fluid, not their contentwithin a fluid, not their content

Normal Concentrations of Plasma

Electrolytes

Mg++

HCO3-

Cl-

K+

Na+

Electrolyte

1.7 1.7 –– 2.32.3

22 22 –– 3232

95 95 –– 106106

3.5 3.5 –– 4.84.8

135 135 –– 145145

Normal plasma

concentration (mEq/L)

Normal Volume and Composition of

Body Fluids

2020--1601602020--40401010--20202020--8080~1,000~1,000Saliva

00120120--16016055--10102020--1001001,000 1,000 ––

2,0002,000

Gastric juice

2020--60604040--606055--1010150150--250250~1,000~1,000Bile

8080--1201201010--606055--10101201201,000 1,000 ––

2,0002,000

Pancreatic

juice

VariableVariableVariableVariable551401401,000 1,000 ––

2,0002,000

Succus

entericus

00303030307575200200--1,5001,500Colon

[HCO3-]

(mEq/L)

[Cl-]

(mEq/L)

[K+]

(mEq/L)

[Na+]

(mEq/L)

Daily loss

(ml)

Source

004040--606055--10102020--7070200200--1,0001,000Sweat

Volume Disorders

nn Occur due to adding or subtracting an Occur due to adding or subtracting an ISOISOtonictonic

fluidfluid

uu Primarily affects extracellular fluid volumePrimarily affects extracellular fluid volume

uu No impact on intracellular fluid volumeNo impact on intracellular fluid volume

uu No fluid shifts between compartmentsNo fluid shifts between compartments

FF (unless volume deficit is so severe than cell membrane pumps (unless volume deficit is so severe than cell membrane pumps

fail to maintain fail to maintain transcellulartranscellular balance)balance)

Causes of Extracellular Volume Deficits

nn Loss of both sodium and Loss of both sodium and

waterwater

uu not necessarily in the same not necessarily in the same

proportionproportion

nn Acute or chronic GI fluid Acute or chronic GI fluid

losseslosses

uu DiarrheaDiarrhea

uu VomitingVomiting

uu FistulaeFistulae

uu NG suctionNG suction

nn Fluid sequestration (Fluid sequestration (““third third

spacingspacing””))

uu PostinjuryPostinjury

FF BurnsBurns

FF Multiple traumaMultiple trauma

uu PostsurgicalPostsurgical

nn Excessive urinary sodium Excessive urinary sodium

losseslosses

uu Renal diseaseRenal disease

uu Adrenal diseaseAdrenal disease

uu Diuretic administrationDiuretic administration

Extracellular Volume Deficits:

Signs and Symptoms

nn Orthostatic hypotensionOrthostatic hypotension

nn Narrowed pulse pressureNarrowed pulse pressure

nn TachycardiaTachycardia

nn Evidence of reduced venous fillingEvidence of reduced venous filling

nn OliguriaOliguria

uu Concentrated urineConcentrated urine

nn DrowsinessDrowsiness

nn Mild decrease in body temperatureMild decrease in body temperature

nn Small, soft tongueSmall, soft tongue

nn Reduced skin turgorReduced skin turgor

nn More severe volume deficits eventually lead to stupor or More severe volume deficits eventually lead to stupor or comacoma

uu reduced deep tendon reflexesreduced deep tendon reflexes

uu muscle muscle atonyatony


Management

nn Replacement with Replacement with parenteralparenteral fluidsfluids

uu CrystalloidsCrystalloids

uu ColloidsColloids

nn Rapidity of replacement depends upon severity of deficit Rapidity of replacement depends upon severity of deficit and underlying general health of the patientand underlying general health of the patient

uu Severe deficits: 500 ml to 1,000 ml bolusesSevere deficits: 500 ml to 1,000 ml boluses

uu Lesser volumes with the elderly and infirmLesser volumes with the elderly and infirm

nn Monitor clinical responseMonitor clinical response

uu Blood pressure, urine output, correction of other signs that iniBlood pressure, urine output, correction of other signs that initially tially signalledsignalled volume deficitvolume deficit

nn Set a volume administration thresholdSet a volume administration threshold

uu If administered volume is exceeded, a more specific indication oIf administered volume is exceeded, a more specific indication of f nature and degree of volume status is requirednature and degree of volume status is required

FF Typically a central venous pressure monitor or, more precisely, Typically a central venous pressure monitor or, more precisely, pulmonary artery catheterpulmonary artery catheter


Maintenance

nn VolumeVolume

uu Determine total quantity of fluid volume loss over 24 hour perioDetermine total quantity of fluid volume loss over 24 hour periodd

uu Add constant for insensible lossesAdd constant for insensible losses

FF ~ 500 ml at sea level~ 500 ml at sea level

FF ~ 1,000 ml at elevations, in arid environments~ 1,000 ml at elevations, in arid environments

FF Higher insensible losses with fevers, Higher insensible losses with fevers, hypermetabolismhypermetabolism

nn ConcentrationConcentration

uu Determine sodium concentration of each fluidDetermine sodium concentration of each fluid

FF Measure concentrations if necessaryMeasure concentrations if necessary

uu Divide total by the total fluid volume to arrive at the requiredDivide total by the total fluid volume to arrive at the requiredsodium concentrationsodium concentration

uu Same process can be used for other specific electrolytes when Same process can be used for other specific electrolytes when necessarynecessary

nn RateRate

uu Divide the total volume by 24 (hours) to calculate the total fluDivide the total volume by 24 (hours) to calculate the total fluid id raterate

Example Case #1

nn You are providing care for a 32 yearYou are providing care for a 32 year--old male who old male who

was involved in a motor vehicle collision, was involved in a motor vehicle collision,

sustaining a left sustaining a left pneumohemothoraxpneumohemothorax, a , a

retroperitoneal hematoma, and a pancreatic retroperitoneal hematoma, and a pancreatic

transection.transection.

nn He is now 6 days postHe is now 6 days post--injury and has a paralytic injury and has a paralytic

ileusileus and what appears to be an antibioticand what appears to be an antibiotic--

associated enterocolitisassociated enterocolitis

uu He cannot eat and he has diarrheaHe cannot eat and he has diarrhea


Maintenance

2.9802.980TotalTotal

0.1800.180JP drainJP drain

0.5600.560Chest tubeChest tube

0.4000.400DiarrheaDiarrhea

0.6000.600InsensibleInsensible

1.2401.240UrineUrine

Volume Volume

(L)(L)

SourceSource

What

happens if

these losses

continue

without

replacement?

Cumulative Fluid Balance without

Replacement

--20,86020,860--17,88017,880--14,90014,900--11,92011,920--8,9408,940--5,9605,960--2,9802,980Net Net

balancebalance

2,9802,9802,9802,9802,9802,9802,9802,9802,9802,9802,9802,9802,9802,980

Daily Daily

fluid fluid

losseslosses

Day 7Day 7Day 6Day 6Day 5Day 5Day 4Day 4Day 3Day 3Day 2Day 2Day 1Day 1


Maintenance

2092092.9802.980TotalTotal

25251401400.1800.180JP drainJP drain




373730301.2401.240UrineUrine

Total NaTotal Na++

lost (lost (mEqmEq))[Na[Na++] ]

((mEqmEq/L)/L)Volume Volume

(L)(L)

SourceSource


Maintenance

7070Average [Na+] (Average [Na+] (mEqmEq/L) = /L) =

209/2.98 =209/2.98 =

2092092.9802.980TotalTotal

25251401400.1800.180JP drainJP drain




373730301.2401.240UrineUrine

Total NaTotal Na++



(L)(L)

SourceSource

Electrolyte Content of Parenteral Fluids

(mEq/L)


Maintenance


209/2.98 =209/2.98 =

2092092.9802.980TotalTotal

25251401400.1800.180JP drainJP drain




373730301.2401.240UrineUrine

Total NaTotal Na++



(L)(L)

SourceSource

= D5½ NS at 2,980 ml/24 hours

= D5½ NS at 125 ml/hr

Example Case #2

nn You are caring for a patient on his 2You are caring for a patient on his 2ndnd day day

following an open cholecystectomy and a common following an open cholecystectomy and a common

bile duct exploration for acute bile duct exploration for acute suppurativesuppurative

cholangitischolangitis

nn He has a nasogastric tube and a JacksonHe has a nasogastric tube and a Jackson--Pratt Pratt

drain in placedrain in place


Maintenance

1461463.0803.080TotalTotal

25251401400.1800.180JP drainJP drain


242460600.4000.400NG lossesNG losses


Total NaTotal Na++



(L)(L)

SourceSource


Maintenance


146/3.08 =146/3.08 =

1461463.0803.080TotalTotal

25251401400.1800.180JP drainJP drain




Total NaTotal Na++



(L)(L)

SourceSource

General Rule: Replace no more than 1,500 ml of

daily urine output

─or you’ll be chasing your own volume infusions as

the urine output cumulatively increases


Maintenance


146/3.08 =146/3.08 =

1461463.0803.080TotalTotal

25251401400.1800.180JP drainJP drain




Total NaTotal Na++



(L)(L)

SourceSource


Maintenance


146/3.08 =146/3.08 =

1221222.2802.280TotalTotal

25251401400.1800.180JP drainJP drain




Total NaTotal Na++



(L)(L)

SourceSource

= D51/3 NS at 2,280 ml/24 hours

= D51/3 NS at 100 ml/hr

Volume Excess

nn Causes:Causes:

uu IatrogenicIatrogenic

uu Renal InsufficiencyRenal Insufficiency

uu CirrhosisCirrhosis

uu CHFCHF

Fluid & Electrolyte Abnormalities

nn Hypernatremia (ICDHypernatremia (ICD--9 code 276.0)9 code 276.0)

nn Hyponatremia (ICDHyponatremia (ICD--9 code 276.1)9 code 276.1)

nn Hyperkalemia (ICDHyperkalemia (ICD--9 code 276.7)9 code 276.7)

nn Hypokalemia (ICDHypokalemia (ICD--9 code 276.8)9 code 276.8)

nn Hypercalcemia (ICDHypercalcemia (ICD--9 code 275.42)9 code 275.42)

nn Hypocalcemia ( ICDHypocalcemia ( ICD--9 code 275.41)9 code 275.41)

nn Hyper/hypomagnesemia (ICDHyper/hypomagnesemia (ICD--9 code 275.2)9 code 275.2)

nn Hyper/hypophosphatemia (ICDHyper/hypophosphatemia (ICD--9 code 275.3)9 code 275.3)

nn Hypervolemia (ICDHypervolemia (ICD--9 code 276.6)9 code 276.6)

nn Hypovolemia (ICDHypovolemia (ICD--9 code 276.5)9 code 276.5)

Sodium Concentration Abnormalities

Hypernatremia = Dehydration

Hyponatremia = Overhydration

Dehydration = Hypovolemia

Overhydration = Hypervolemia

H2O H2O H2O

Concentration Changes

Normal hydrationOverhydration Dehydration

Na+ Na+ Na+

EunatremiaHyponatremia Hypernatremia

Concentration Changes

Normal hydrationOverhydration Dehydration

EunatremiaHyponatremia Hypernatremia

Body water

Decreased Normal Increased

Decreased

Normal

Increased

Volu

me

stat

us

Hypervolemichypernatremia

HypervolemiaHypervolemichyponatremia

Hypovolemic

hypernatremiaHypovolemia

Hypovolemic

hyponatremia

Hypernatremia HyponatremiaNormal

(Eunatremia, normovolemia)

Hypernatremia & hyponatremia

nn Abnormalities of sodium concentration most Abnormalities of sodium concentration most

commonly result primarily from alterations in commonly result primarily from alterations in

water balancewater balance

nn Hypernatremia typically results from loss of Hypernatremia typically results from loss of

water, not from excess sodium content of the bodywater, not from excess sodium content of the body

nn Hyponatremia most commonly results from Hyponatremia most commonly results from

overhydrationoverhydration (i.e., excess water), not from (i.e., excess water), not from

inadequate salt contentinadequate salt content

Hyponatremia

nn Symptoms:Symptoms:

uu Mental obtundationMental obtundation

uu SeizuresSeizures

nn Differential diagnosis:Differential diagnosis:

uu Total body water excessTotal body water excess

uu Factitious (i.e., hyperglycemia)Factitious (i.e., hyperglycemia)

FF [Na+] is reduced by 1.6 [Na+] is reduced by 1.6 mEqmEq/L for every 100 mg/dl (5.5 /L for every 100 mg/dl (5.5 mmolmmol/L) rise /L) rise in glucose above normalin glucose above normal

uu SIADHSIADH

uu SepsisSepsis

uu Renal FailureRenal Failure

FF Associated with increased total body sodium contentAssociated with increased total body sodium content

FF Pitting edemaPitting edema

Management of Hyponatremia

nn Assessment of volume statusAssessment of volume status

uu HypervolemiaHypervolemia

FF Seen with excess free water intake or SIADHSeen with excess free water intake or SIADH

FF Treated with fluid/free water restrictionTreated with fluid/free water restriction

uu EuvolemiaEuvolemia

FF May be factitiousMay be factitious

FF Free water restriction usually helpfulFree water restriction usually helpful

uu HypovolemiaHypovolemia

FF Hypotension & Hypotension & oliguriaoliguria must be treated promptly to avert acute renal must be treated promptly to avert acute renal failurefailure

uu Severe hyponatremia: < 120 Severe hyponatremia: < 120 mEqmEq/L/L

FF Calculate sodium deficit & replace accordinglyCalculate sodium deficit & replace accordingly

Treatment of Severe Hyponatremia

Normal NaNormal Na++ ((mEqmEq/L) /L) –– actual Naactual Na++ ((mEqmEq/L) = Na/L) = Na++ deficit (deficit (mEqmEq/L)/L)

Example: 140 Example: 140 –– 110 = 30110 = 30

0.6 x body wt. (kg) = Total body water (L)0.6 x body wt. (kg) = Total body water (L)

Example: 0.6 x 60 = 36Example: 0.6 x 60 = 36

TBW (L) x NaTBW (L) x Na++ deficit (deficit (mEqmEq/L) = estimated Na/L) = estimated Na++ deficit (deficit (mEqmEq))

Example: 36 x 30 = 1,080Example: 36 x 30 = 1,080

3.0% hypertonic saline solution contains 0.5 mEq/ml

Therefore, replacement is calculated:

(Estimated Na+ deficit [mEq])/0.5 = volume of 3% saline (ml)

Example: 1,080/0.5 = 2,160

Treatment of Severe Hyponatremia

nn To avoid neurologic complications, [NaTo avoid neurologic complications, [Na++] should ] should

not be raised by more than 12 not be raised by more than 12 mEqmEq/L during the /L during the

first 24 hoursfirst 24 hours

nn Once [NaOnce [Na++] ] ≥≥ 120 120 mEqmEq/L or symptoms have /L or symptoms have

resolved, further aggressive correction generally is resolved, further aggressive correction generally is

not requirednot required

Hypernatremia

nn CausesCauses

uu Inadequate free water intakeInadequate free water intake

FF Elderly, debilitatedElderly, debilitated

uu Excessive free water lossesExcessive free water losses

FF Gastrointestinal (diarrhea, vomiting), sweating (without water Gastrointestinal (diarrhea, vomiting), sweating (without water

replenishment)replenishment)

uu Inadequate postoperative fluid replacementInadequate postoperative fluid replacement

uu Diabetes Diabetes insipidusinsipidus

FF CentralCentral

FF NephrogenicNephrogenic

uu Sodium overloadSodium overload

FF Intake of hypertonic sodium solutionsIntake of hypertonic sodium solutions

Causes of Diabetes Insipidus

nn CentralCentral

uu IdiopathicIdiopathic

uu TraumaticTraumatic

uu NeurosurgicalNeurosurgical

uu CNS CNS neoplasmsneoplasms

uu AlcoholAlcohol

uu DiphenylhydantoinDiphenylhydantoin

uu EosinophilicEosinophilic granulomagranuloma

uu SarcoidosisSarcoidosis

nn NephrogenicNephrogenic

uu Congenital (usually sexCongenital (usually sex--

linked dominant)linked dominant)

uu LithiumLithium

uu DemeclocyclineDemeclocycline

uu AmphotericinAmphotericin

uu MethoxyfluraneMethoxyflurane

uu PropoxyphenePropoxyphene overdoseoverdose

Treatment of Hypernatremia

nn Overly rapid correction can produce cerebral Overly rapid correction can produce cerebral

edema, seizures, permanent neurologic damage, or edema, seizures, permanent neurologic damage, or

deathdeath

nn No sequelae observed when [NaNo sequelae observed when [Na++] lowered at rate ] lowered at rate

of 0.5 of 0.5 mEqmEq/L/hr or less/L/hr or less

uu Thus, 14 Thus, 14 mEqmEq/L concentration excess should be /L concentration excess should be

lowered over 28 hours or morelowered over 28 hours or more

uu 4.8L/28 hours = 170 ml/hour D4.8L/28 hours = 170 ml/hour D55WW

uu DonDon’’t forget to keep up with ongoing losses in t forget to keep up with ongoing losses in

addition to replacing this deficitaddition to replacing this deficit

Diabetes Insipidus Management

nn Ideally, Ideally, hypernatremiahypernatremia can be corrected by can be corrected by

supplementing with free watersupplementing with free water

nn In cases where water alone is inadequate, In cases where water alone is inadequate, dDAVPdDAVP

(a 2(a 2--AA substitute of ADH) can be usedAA substitute of ADH) can be used

uu usual dose 5 to 20 mg QDusual dose 5 to 20 mg QD--BIDBID

uu nasal spraynasal spray

uu no no vasopressorvasopressor activityactivity

uu DisadvantagesDisadvantages

FF Long duration of actionLong duration of action→→water retention & hyponatremiawater retention & hyponatremia

FF Can be a problem in acute head injury with cycling between Can be a problem in acute head injury with cycling between

SIADH & DISIADH & DI

FF ExpensiveExpensive

Case #3

nn A 28A 28--yearyear--old 72 kg male sustained a severe old 72 kg male sustained a severe intracerebralintracerebral hemorrhage following a motorcycle hemorrhage following a motorcycle crash 4 hours ago. He underwent arteriography to crash 4 hours ago. He underwent arteriography to embolizeembolize a bleeding a bleeding splenicsplenic vessel. He has received vessel. He has received 3,500 ml of crystalloid resuscitation. He is now 3,500 ml of crystalloid resuscitation. He is now producing 600producing 600--1,200 ml of urine per hour.1,200 ml of urine per hour.

nn What are the possible causes of his high urine output?What are the possible causes of his high urine output?

A.A. SIADHSIADH

B.B. Contrast loadContrast load

C.C. Diabetes Diabetes insipidusinsipidus

D.D. Diuretic administrationDiuretic administration

Case #3

nn Which of the following tests would most quickly Which of the following tests would most quickly

distinguish between IV contrast load and distinguish between IV contrast load and

diabetes diabetes insipidusinsipidus??

A.A. Serum chloride and urine Serum chloride and urine osmolalityosmolality

B.B. Serum sodium and urine specific gravitySerum sodium and urine specific gravity

C.C. Serum and urine Serum and urine osmolalityosmolality

D.D. BUN and urine BUN and urine osmolalityosmolality

Distinction between Specific Gravity and

Osmolality

nn Specific gravitySpecific gravity

uu Density of a solution relative to the density of waterDensity of a solution relative to the density of water

FF WaterWater’’s density is set arbitrarily at 1s density is set arbitrarily at 1

uu Density is defined as mass/volumeDensity is defined as mass/volume

uu Therefore, Therefore, SpGSpG is related to the is related to the weightweight a substance a substance

providesprovides

nn OsmolalityOsmolality

uu Relates to the number of particles exerting an Relates to the number of particles exerting an osmolarosmolar

effect that are in solutioneffect that are in solution

uu Therefore, Therefore, OsmOsm depends upon a molecular depends upon a molecular

concentrationconcentration

Case #3

nn The patientThe patient’’s serum sodium is 154 s serum sodium is 154 mEqmEq/L and /L and

his urine specific gravity is 1.006.his urine specific gravity is 1.006.

nn His urine concentration & volume are:His urine concentration & volume are:

A.A. Physiologically appropriatePhysiologically appropriate

B.B. Physiologically inappropriatePhysiologically inappropriate

Case #3

nn The patientThe patient’’s serum sodium is 154 s serum sodium is 154 mEqmEq/L and /L and

his urine specific gravity is 1.006.his urine specific gravity is 1.006.

nn His urine concentration & volume is:His urine concentration & volume is:

A.A. Physiologically appropriatePhysiologically appropriate

B.B. Physiologically inappropriatePhysiologically inappropriate

nn He has:He has:

A.A. Diabetes Diabetes insipidusinsipidus

B.B. Contrast loadContrast load

What is the patient’s free water deficit?

Case #3

Free HFree HFree HFree H2222O deficit (L) =O deficit (L) =O deficit (L) =O deficit (L) =[Na[Na[Na[Na++++] ] ] ] ---- 140140140140

140140140140xxxx

2222

3333Wt. (kg)Wt. (kg)Wt. (kg)Wt. (kg)xxxx

====154 154 154 154 ---- 140140140140

140140140140xxxx

2222

333372 kg72 kg72 kg72 kgxxxx

====14141414

140140140140xxxx

2222

333372 kg72 kg72 kg72 kgxxxx

==== xxxx2222

333372 kg72 kg72 kg72 kgxxxx0.10.10.10.1

==== 4.8 L4.8 L4.8 L4.8 L

Acid-Base Metabolism

nn IntracellularIntracellular

uu Renal excretion of inorganic acids anions with NHRenal excretion of inorganic acids anions with NH44

uu Metabolism of organic acid anionsMetabolism of organic acid anions

nn ExtracellularExtracellular

uu HClHCl + NaHCO+ NaHCO33 →→ NaClNaCl + H+ H22COCO33

Buffer Systems

nn IntracellularIntracellular

uu ProteinsProteins

uu PhosphatesPhosphates

nn ExtracellularExtracellular

uu Bicarbonate/Carbonic Acid systemBicarbonate/Carbonic Acid system

uu (proteins)(proteins)

uu (hemoglobin)(hemoglobin)

Differentiation of Acid-Base Status

↓↓PcoPco22↑↑Base excessBase excess

((↑↑ HCOHCO33--))

Alkalosis

↑↑PcoPco22↓↓Base excessBase excess

((↓↓ HCOHCO33--))

Acidosis

RespiratoryMetabolic

Respiratory Acidosis

nn Defined as hypoventilationDefined as hypoventilation

nn More common in medical patientsMore common in medical patients

uu COPD (chronic compensation)COPD (chronic compensation)

uu ““5050--5050”” clubclub

nn Seen with Seen with oversedationoversedation, poor pulmonary toilet, poor pulmonary toilet

uu Can cause agitationCan cause agitation

uu Needs to be evaluated before sedating patientNeeds to be evaluated before sedating patient

Respiratory Alkalosis

nn More common than previously thoughtMore common than previously thought

nn Secondary to hyperventilationSecondary to hyperventilation

uu painpain

uu apprehensionapprehension

uu hypoxiahypoxia

uu CHICHI

nn Tachypnea Tachypnea ≠≠ hyperventilationhyperventilation

nn Associated with Associated with hypokalemiahypokalemia →→ arrhythmiasarrhythmias

Metabolic Acidosis

nn Anaerobic metabolism fromAnaerobic metabolism from

uu Inadequate circulationInadequate circulation

FF Volume depletionVolume depletion

FF Poor cardiac functionPoor cardiac function

FF SepsisSepsis

nn Excessive alkali lossExcessive alkali loss

uu Diarrhea, fistulaeDiarrhea, fistulae

nn Diabetic Diabetic KetoacidosisKetoacidosis

nn Renal failureRenal failure

Metabolic Alkalosis

nn Excessive alkali intakeExcessive alkali intake

nn Loss of acidLoss of acid

uu High gastric outputHigh gastric output

FF NG tubes, vomiting, pyloric obstructionNG tubes, vomiting, pyloric obstruction

FF ““Paradoxical Paradoxical aciduriaaciduria””

Paradoxical Aciduria in Metabolic

Alkalosis from High Gastric Losses

Volume loss

↑ Aldosterone secretion

↑ K+/H+ exchange for Na+ absorption

Aciduria

Hypokalemia


uu WeaknessWeakness

uu Flattened TFlattened T--waves on EKG waves on EKG


uu Metabolic alkalosis causing shift of K+ in exchange for H+Metabolic alkalosis causing shift of K+ in exchange for H+

uu Renal losses from diuretic useRenal losses from diuretic use

uu GI lossesGI losses

FF NGNG

FF DiarrheaDiarrhea

uu Inadequate supplementationInadequate supplementation

Hypokalemia

Treatment

nn No accurate calculation of potassium deficitNo accurate calculation of potassium deficit

uu Decrease of 2 Decrease of 2 mEqmEq/L = 200 /L = 200 mEqmEq deficit deficit

uu Decrease of 3 Decrease of 3 mEqmEq/L = 400/L = 400--500 500 mEqmEq deficit deficit

nn Preferable to replace by Preferable to replace by enteralenteral route (40route (40--60 60 mEqmEq

p.o./day)p.o./day)

nn IV route no more that 20 IV route no more that 20 mEqmEq/hr/hr

Hyperkalemia


uu Nausea, vomiting, abdominal painNausea, vomiting, abdominal pain

uu Cardiac arrhythmias Cardiac arrhythmias

uu Peaked TPeaked T--waves, wide QRS, ST depressionwaves, wide QRS, ST depression


uu Renal failureRenal failure

uu Iatrogenic potassium administrationIatrogenic potassium administration

Hyperkalemia

Treatmentnn Counteract cardiac toxicity Counteract cardiac toxicity

uu Administer CaAdminister Ca++++ gluconategluconate or or CaClCaCl

nn Drive KDrive K++ into the cellsinto the cellsuu Administer NaAdminister Na++ Bicarbonate Bicarbonate -- raises pH raises pH

uu Administer Insulin 25U IV and D50 Administer Insulin 25U IV and D50

uu Administer Administer AlbuterolAlbuterolFF for resistant for resistant hyperkalemiahyperkalemia

FF increases plasma insulin concentrationincreases plasma insulin concentration

FF lowers K+ level by 0.5lowers K+ level by 0.5--1.5 1.5 mEqmEq/L/L

FF Beneficial in patients when fluid overload is concern (i.e., Beneficial in patients when fluid overload is concern (i.e., renal failure) renal failure)

nn Bind KBind K++

uu KK++ binding resins binding resins -- KayexalateKayexalate (25 (25 -- 50g) 50g)

nn DialysisDialysisuu True last resort True last resort

Summary

nn The surgical patient can manifest a variety of fluid The surgical patient can manifest a variety of fluid

and electrolyte disorders in a variety of settingsand electrolyte disorders in a variety of settings

nn A thorough understanding of basic physiology A thorough understanding of basic physiology

coupled with clinical acumen is the physiciancoupled with clinical acumen is the physician’’s s

toolkit for managing these disorderstoolkit for managing these disorders

Documents

V7 PROFIBUS-DP® Option Technical Manual - Yaskawa