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FLUID & ELECTROLYTE IMBALANCE

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:20 AM

A condition where losses of bodily fluids from

whatever cause has led to significant disturbance in

the normal fluid and electrolyte levels needed to

maintain physiological functions.

 

Water and electrolyte exchange

 

z

Fluid consumption is 2-2.5L in 24 hours (1.5L by

mouth and 0.5-1L in solid food)

 

z

Daily fluid loss is through:

-

urine (800-1,500mL)

-

stool (250mL)

-

insensible loss through skin and lungs (600mL)

 

which is affected by hyperventilation, fever and

 

high environmental temperatures

z

Daily sodium intake is 100-200mmol

z

Daily potassium intake is 50-100mmol

z

There will be a deficiency of salts if:

 

-

there are increased losses, eg. excess sweating,

urinary losses or GIT losses through diarrhoea

and vomiting

 

-

there is reduced intake, eg. post-operative

patients

 

 

Disorders of fluid and electrolytes

 

Disorders may occur in the fluid volume,

concentration (sodium composition) and distribution

of fluid and other electrolytes and PH. The main

disorders likely to cause such problems are:

z

Diarrhoea -prolonged

z

Vomiting -prolonged

z

Burns - excessive

z

Haemorrhage -severe

z

Intestinal obstruction

z

Peritonitis

z

Diabetes

z

Nasogastric drainage

z

Paralytic ileus

 

UCG 2010

415

 

 

 

18. Miscellaneous conditions

z

Fistula drainage (especially if high output)

z

Third spacing eg. Peritonium

z

Major organ failure (eg. renal, hepatic, cardiac)

 

 

Caution

 

U

Over-infusion of IV fluids may also cause fluid

 

and electrolyte imbalance

Mild to moderate fluid loss will lead to varying

degrees of dehydration

 

Severe fluid loss will lead to shock

 

IV fluid and electrolyte therapy HC2

 

This has three main objectives:

z

To replace lost body fluids and continuing losses.

z

To correct electrolyte and acid-base disturbances

z

To maintain daily fluid requirements

 

 

Always use an IV drip in patients who are seriously ill

(except patients in congestive heart failure – for these

use only an indwelling needle) and may need IV drugs

or surgery.

If the fluid is not needed urgently, run it slowly to keep

the IV line open.

 

 

f

Administer daily fluid and electrolyte

requirements to any patient not able to feed

 

f

The basic 24-hour requirement for a 60kg adult

is 3L and for children is 150mL/kg

 

f

One third of these daily fluids (1L in an adult)

should be (isotonic) sodium chloride 0.9%

infusion

 

f

The other two thirds (2L in an adult) should be:

glucose 5% infusion

or half-strength Darrow’s solution in glucose

2.5% infusion or compound sodium lactate

infusion (Ringer-Lactate solution)

 

f

As well as the daily requirements replace

increased fluid lost due to the particular condition

according to the assessed degree of dehydration.

 

UCG 2010 416

 

 

 

18. Miscellaneous conditions

Caution

 

U

Closely monitor all IV drips to ensure that the

rate is adjusted as required and that the drip is

not allowed to run dry as this will introduce air

bubbles into the circulation with the potentially

fatal risk of air embolus.

 

U

If the drip has been neglected and allowed to run

dry, remove it and set up a new drip at another

site.

 

U

Check the drip site daily for any signs of

infection, change drip site every 2-3 days or

when the drip goes into tissues (extravasation).

 

Clinical features of severe dehydration

 

z

Inelastic skin (loss of skin turgor)

z

Low urinary output

z

Rapid, thready pulse

z

Low BP

z

Reduced level of conciousness

 

Clinical features of hypovolaemia

 

z

Tachycardia (rapid pulse, often thready, small

volume)

 

z

Low BP

 

z

Postural change (eg. supine to sitting/standing –

change in heart rate and BP)

 

In diarrhoea and vomiting with severe

dehydration, paralytic ileus, etc:

 

f

Replace fluid losses with isotonic solutions

containing potassium, eg. compound sodium

lactate infusion (Ringer-Lactate solution) or

half-strength Darrow’s solution in 2.5%

glucose infusion (see also Dehydration)

 

If there is blood loss and the patient is not in

shock:

 

f

Use sodium chloride 0.9% infusion for blood

volume replacement giving 0.5-1L in the 1st hour

and not more than 2-3L in 4 hours

 

UCG 2010

417

 

 

 

18. Miscellaneous conditions

If there is blood loss >1L:

 

f

Give 1-2 units of blood to replace volume and

concentration

 

In severe burns:

 

f

See pError! Bookmark not defined. for calculation

of IV fluid requirements and details of

rehydration regimes

 

In patients undergoing aspiration of fluid in

the non-functioning compartments:

 

e.g. in ascites, pleural effusion and chronically

distended urinary bladder

z

intravascular fluid redistribution will lead to a fall

in BP

 

f

Give isotonic solutions to correct this:

eg. sodium chloride 0.9% infusion

or compound sodium lactate infusion

(Ringer-Lactate solution)

 

In patients with shock:

 

f

Give compound sodium lactate infusion

(Ringer-Lactate solution) or sodium chloride

0.9% infusion 20mL/kg IV over 60 mins for

initial volume resuscitation

 

- start rapidly, closely monitor BP

-reduce the rate according to BP response

In patients with severe shock and significant

haemorrhage:

 

.. Give a blood transfusion

 

In Intestinal obstruction:

 

.. patient may be dehydrated due to vomiting; if

dehydration is severe, replace fluid losses with

isotonic solutions containing potassium, eg.

compound sodium lactate infusion (Ringer-

Lactate solution) or half-strength Darrow’s

solution in 2.5% glucose infusion

 

¾

aspirate upper gastrointestinal fluids using a

nasogastric tube and large syringe

 

UCG 2010

418

 

 

 

18. Miscellaneous conditions

¾

consult a surgeon

 

¾

give pain relief parenterally

 

¾

avoid metoclopramide as it would worsen colic,

instead use haloperidol 1 – 2 mg nocte sc.

 

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