Electrolytes and Fluid Imbalance

complications of fluid overload/hypervolemia

• pulmonary edema

• arrhythmias bc of dilated electrolytes and Hgb

• third spacing bc of excessive hydrostatic pressure → pressure on vital organs

• heart failure

• portal HTN

• esophageal varices

• aneurysm

• stroke

complications of fluid deficit/hypovolemia

• hypoperfusion

• multiorgan dysfunction syndrome (MODS)

• falls

• ortho hypotension

• weakness

• altered MS

• concentrated electrolyte levels

cues of fluid imbalance

• medical record

  • age, sex, obesity

  • PMHx (CKD, CHF, cirrhosis vs hypermetabolic and wound)

  • meds

  • labs

  • provider orders and context

• LDA’s

• V.S

key assessment findings of fluid imbalance

• weight change >1kg gain/loss

• urine output of <30 mL/hr or 0.5 mL/kg/hr discrepancy

• I/O of >500-1000mL discrepancy

• dry skin

• xerostomia

• pulse quality

• venous distention

• dyspnea

• edema

risk factors for dehydration

• elderly females

• individuals with high body fat content bc of decreased muscle mass to store water

• older adults have reduced thirst reflex, renal function, and ability to concentrate urine

• difficult to assess fluid status bc of lower skin elasticity and baseline skin turgor

• hypermetabolic and wound conditions

• NPO status

• environment that causes excess sweating

• labs: elevated Hct, sodium, and increased urine concentration

• diuretics

risk factors for excess fluid

• CKD

• HF

• cirrhosis

• anticholinergics

• liver harming drugs

s/s of hypovolemia/dehydration

• dry skin/mucous membranes

• poor skin turgor

• weak pulses

• weight loss of >1kg indicates a 1L fluid loss

s/s of hypervolemia/excess fluid retention

• JVD

• adventitious heart sounds

• third spacing fluid → edema, crackles, ascites

• weight gain of >1kg indicates a 1L fluid gain

what controls INPUT of fluid balance?

• hydration (IV and PO)

• foods

• other sources (ex: enemas, irrigations)

what controls OUTPUT of fluid balance?

• urine (diuresis)

• bowels (enemesis and stool)

• drains

• insensible water loss (about 0.5-1L/D)

what controls FLUID COMPARTMENTS/DISTRIBUTION of fluid balance?

• intracellular

• extracellular

  • vascular

  • interstitial

  • other

conditions that interfere decreased UO

• AKI oliguric phase

• CKD

• obstructive urinary conditions

• hormones (hyperaldosteronism, SIADH, HF, BNP-induced CKD)

conditions that interfere with increased output

• AKI diuresis phase

• GI issues

• hypermetabolic state

• hyperventilation

• wounds, burns, bleeding

• hypoaldosteronism

• DI

factors that interfere with UO

• AKI acute oliguric phase (first 48h of recovery)

• CKD can interfere with UO bc of inability to excrete sodium and water or can increase UO bc inability to reabsorb sodium and water

• hormones

  • aldosterone (renal cortex function)

  • antidiuretic hormone

  • hypercortisolism

  • hyperaldosteronism

  • excess RAAS

  • excess ADH (SIADH)

• HF → increased release of natriuretic peptides from heart cells which initially causes natriuresis → increased sodium and water excretion via kidneys → eventually become into renal damage and decreased UO

factors that increase UO

• AKI diuresis phase

• GI issues

• metabolism

  • fever

  • extreme stress

  • thyroid crisis (increases water loss)

• high RR and distress or ventilation bc of increased water loss

• wounds/burns

• bleeding

• hormonal: renal failure, adrenal insufficiency → hypoaldosteronism, diabetes insipidus

what is syndrome of inappropriate diuretic hormone (SIADH)?

condition where the body produces or releases too much antidiuretic hormone (ADH), leading to excessive water retention and low blood sodium levels (hyponatremia)

diabetes insipidus

condition that causes excessive thirst and urination due to a deficiency or resistance to antidiuretic hormone (ADH)

fluid compartments in extracellular spaces

• vascular

• interstitial (brain interstitial fluid/synovial/peritoneal/pleural compartments)

• bone

• lymph

• connective tissues

where should most body fluid be?

intracellular and vascular spaces to promote cellular function and perfusion

fluid being where starts causing issues for a patient

• stuck in limb or in third spacing to the interstitial

• causes pulmonary edema, ascites, etc

conditions that cause third spacing

• decreased blood osmolarity

  • albumin bc of liver failure

  • sodium

  • glucose/insulin levels bc of diabetes

• increased blood hydrostatic pressure (HTN)

• porous membranes/leaky capillaries bc of inflammation

how can someone be fluid overloaded but hypovolemic?

insufficient vascular osmolarity d/t hypoalbuminemia or leaky capillaries

albumin

protein in blood made by the liver that is responsible for pulling in and holding water in the bloodstream to maintain adequate vascular volume and blood circulation

how can cirrhosis/liver disease cause fluid overload but hypovolemia at the same time?

• liver does not make enough albumin

• insufficient pulling and water leaks into the interstitial spaces

• leads to a perpetuating cycle of fluid retention bc hypovolemia leads to less urinary excretion → AKI → impaired ability to create urine

• s/s

  • ascites

  • extremity pitting edema

  • pleural effusions

  • less vascular volume (hypovolemia)

how can someone be fluid overloaded but cellularly dehydrated?

• sodium is more abundant in the ECF (particularly in the interstitial) than ICF and water follows sodium

• intake of high salt → water shifts outside of cell into interstitial space → cellular dehydration while overall body fluid continues to build up in ECF compartments

management for hypovolemia

• rehydrate to maintain perfusion (PO/enteral pref first)

• prevent falls

• monitor at least pulse quality and urine output q2h

• strict I/O’s

• q8hr daily weights

• address underlying cause (antiemetics, antidiarrheals, ABX, antipyretics, desmopressin for diabetes insipidus)

• potentially albumin infusion if pt has hypovolemia with excess interstitial fluid

hypotonic IV fluids

• 0.3% NaCl

• 0.45% NaCl

• D5W*

• indications: cellular dehydration

isotonic IV fluids

• crystalloids (NS, LR)

• indications: ICF/ECF dehydration

hypertonic IV fluids

• colloids

• albumin

• 10-15% D5W

• 3% NaCl

• NaHCO3 5%

• D5W + 0.9% NaCl

• indications

  • hypovolemic but fluid overloaded so it draws fluid into vascular space

D5W

starts isotonic but goes hypotonic once body metabolizes the sugar

complications of infusions

• infiltration

• hematoma

• embolism

• thrombosis/endarteritis

types of infiltration

• phlebitis

• thrombophlebitis

phlebitis

inflammation of vein

thrombophlebitis

condition where a blood clot (thrombus) forms in a vein and causes inflammation

management of infiltration

1. discontinue IV

2. compress

3. sometimes extremity elevation

4. restart IV proximal

hematoma

localized collection of blood outside of a blood vessel

hematoma management

1. discontinue IV

2. pressure dressing

3. cool compress for 24 hours then warm compress

clot management

give alteplase

circulatory overload management

1. SLOW infusion

2. assess V.S and labs

3. Notify HCP

hypervolemia management

• prevent falls

• monitor cardiorespiratory complications

  • pulmonary edema

  • HF

  • arrhythmias

  • impaired skin integrity

• maintain skin integrity (assess and reposition q2h)

• give diuretics (loop, thiazide, potassium sparing, osmotic)

• strict I/O’s

• daily weights at same time each day (best before breaky and w same amount of clothing and linen - upon admission ensure bed is zero’d with standard linen count)

• PRN HF agents (ARBs, BBs, inotropics like dig)

• give vasopressin antagonist in cases of hypervolemic hyponatraeemia (ex: conivaptan/tolvaptan)

• restrict fluid and sodium intake

loop and thiazide diuretics

• natriuretic diuretics blocking reabsorption of NaCl and passive water reabsorption

• thiazides are slower and weaker and Cl’d in renal impairment bc its mechanism depends on kidneys ability to excrete sodium and chloride in first place

• loop diuretics work in renal disease because they work even when GFR is low

• thiazide SE similar to those of loop diuretics except ototoxicity

• ex of loop: furosemide, bumetadine, torsemide

potassium sparing diuretics

often contraindicated in cases of renal failure

ex: spirinolactone

mannitol

• freely passes through glomerulus into nephron and minimally reabsorbed

• with osmotic pressure it draws nephron for diuresis

many s/s of electrolyte imbalance share these SE…

• anorexia

• N/V

• numbness

• tingling

acidosis and electrolyte levels

• associated with high electrolyte levels

• less excitable tissue

• acid is WEAKER, LOOSER, and SLOWER

alkalosis and electrolyte levels

associated with low electrolyte levels

alkaline is HYPER, TENSER, FASTER, IRRITABLE

normal potassium levels

3.5-5.0

hypokalemia causes

• excessive diuresis/excretion

  • loop/thiazide diuretics

  • mineralocorticoid steroids

  • insulin

• NG suctioning

• abd surgery

• liver/renal disease

• too much water intake

• K+ depletion

• dilution

• mass transfusion

hypokalemia s/s

• weak CV

• digoxin potentiation

• arrhythmias

• variable HR

• weak thready pulses

• inverted T waves

• depressed ST segment

• reduced tissue excitability

hypokalemia management

• PO/enterally best

  • if giving supplement give it with food to decrease irritation and increase absorption

  • foods: raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery

• if IV infusion do 10-20 mEq/hr

• monitor cardiac

• correct K+ before pH

• correct Mg+ before K+

why do you correct K+ before pH?

hypokalemia contributes to alkalosis so correcting potassium will help correct pH

why do you correct Mg+ before K+?

Mg+ helps correct the kidneys so they hold onto K+ better

hyperkalemia causes

• renal failure

• mass transfusion

• burns

• fractures

• severe infection

• K+ sparing diuretics

• ACE’s

• lysis of stored and irradiated RBC’s

hyperkalemia s/s

• slower CV conduction

• peaked T waves

• bradycardia/heart block

• widened QRS

• prolonged PR

• general tissue excitability is increased

• muscle twitching

hyperkalemia management

• C.A.B.I.G.K.Drop

• administer glucose before the insulin to avoid causing the pt to go into hypoglycemia

C.A.B.I.G.K.Drop meaning

a treatment for hyperkalemia in emergency situations

• calcium

• albuterol

• bicarb

• insulin and glucose

• kayexalate

• dialysis, diuretics, diarrheal agents, dietary restriction

normal calcium range

9-10.5

hypocalcemia causes

• hypoparathyroidism/post-op

• vitamin D deficiency

• renal failure

• pancreatitis

• mass transfusion

how does mass transfusion cause hypocalcemia?

mass transfusion of citrate containing pRBC’s causes citrate to bind with calcium to prevent clotting

hypocalcemia s/s

• chvostek sign

• trousseaus sign

• tetany

• seizures

• hyperactive reflexes

• bronchospasm

• bleeding

chvostek sign

twitch of the facial muscles that occurs when gently tapping an individual's cheek, just in front of the ear

trousseaus sign

when inflating BP cuff, the hand will twitch/goose hand

hypocalcemia management

• PO calcium

• calcitriol with vitamin D

• chloride with vitamin c for max absorption

• seizure precautions

• maintain airway

• regular exercise

• phosphate binders

• push Mg+ if necessary

hypercalcemia causes

• malignancy

• hyperparathyroidism

• prolonged immobilization

hypercalcemia s/s

• lack of coordination

• ALOC

• dyrhythmias

• nephrolithiasis

• decreases excitability of tissues overall

hypercalcemia manegement

• important to HYDRATE bc risk for kidney stones (NS, ½ NS IV, PO)

• loop diuretics

• calcitonin

• mobilization

• dietary restriction

• antiacid restriction

normal sodium levels

135-145

hyponatremia causes

• excessive diuresis/excretion

• sodium depletion

• dilution

• SIADH

• HF

hyponatremia s/s

• neuro: seizures, ALOC, coma, death

• GI: n/v/d, cramping

why does hyponatremia have serious neuro symptoms?

hyponatremia causes cerebral edema → coma → death

hyponatremia management

• correct slowly IV

• correct rapidly PO

• isotonic IVF

• H2O restriction

• I/O

• daily weights

hypernatremia causes

• prerenal failure

• hypertonic tube feedings

• diabetes insipidus

• hyperosmolar hyperglycemic state (HHS)

• dehydration

• drugs (ASA, citric acid, NaHCO3)

diabetes insipidus

• cause of insufficient ADH which leads to polyuria

• neurogenic: not enough ADH released

• nephrogenic: renal tubules not able to use ADH

• s/s

  • high serum osmolality

  • polyuria (>200 mL/hr x 2 hr)

  • polydipsia

  • s/s of dehydration

• treatment

  • hydration (ex: .45% NaCl

  • ADH

  • hydrochlorothiazide

hypernatremia s/s

• thirst

• febrile

• dry

• swollen

• s/s of dehydration

hypernatremia management

• hypotonic solutions only in extreme situations

• decrease PO sodium

• daily weights

normal magnesium levels

1.5-2.5

magnesium is like…

like a sedative/muscle relaxant

hypomagnesemia causes

• alcoholism

• other K+ or Na+ causes

hypomagnesemia s/s

• coronary spasm (torsades)

• hypokalemia

• twitching

• tremors

hypomagnesemia management

• PO or IV magnesiumSO4 (can push if needed)

• cardiac and seizure precautions

• assess airway

• BP

• reflexes

• K+ and Ca+

hypermagnesemia causes

• renal failure

• excess Mg from antacids or laxatives

• acidosis

• DKA

hypermagnesemia s/s

• drowsiness

• depressed

hypermagnesemia management

• diuresis with fluid replacement

• support ABC’s

• IV calcium gluconate