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Seizures in pyogenic meningitis………
Had seizure on 2nd day . On Dilantin. 10 months female with meningitis. Second L.P.( 3rd day ) showed improvement Refractory seizure on 6th day
S.I.A.D.H.
Hyponatremia………………………………..
K/C of Thalassemia Admitted for G / E improved Was found to be Hyponatremic on
admission ( 112 ) Correction done twice but Hypon. Cont. Asymptomatic all throughout.
PSEUDO HYPONATREMIA…..
Respiratory failure………………………………..
5 months male with R.A.D. was doing well On extensive nebulization and supportive therapy. Deteriorated on 4 the day , lethargic, look exhausted . Respiratory rate is less now. ABG day 2..pH 7.34.,pO2 80 on FiO2 of 50. CO2 30 ABG day 4..pH 7.23.,pO2 85 on FiO2 of 30. CO2 67
Electrolytes gave the answer…
Status on 4 th day On mannitol Blood sugar 377 mg % Serum sodium 151. BUN 38
= 336
Seizures in falciparum malaria
Osmolality (mOsm/kg) = 2 [mEq/L Na+] + (mg/dL glucose) / 18 + (mg / dL BUN) /2.8
14 months male with RTA Hypo tonic no h/o seizures
ECG : suggestive of Hypokalemia with extra systoles Plasma sodium = 140 Plasma potassium = 1.3 Chloride = 117 Bicarbonate = 10 Ca = 6.3 Arterial pH = 7.26 PCO 2 = 23
What effect would correction of acidosis have on plasma K + ? Would correction of Ca be part of initial management . ?
Correction of acidosis will drive k + into the cellsFurther worsening hypokalemia.Acidosis is not sever and can wait. Hypokalemia first.
Hypocalcaemia protects against hypokalemia Thus treatment of hypokalemia should precedeHypocalcaemia.Correction of hypokalemia may precipitate Tetany , this is a less serious than hypokalemia.
What effect would correction of acidosis
have on plasma K + ?
Would correction of Ca be part of
initial management ?
1. Anions - Negatively charged ions, such as chloride . 2. Cations - Positively charged ions as sodium . 3. Colloid/Colloid solution - Liquid containing suspended substances that do not settle out of the liquid/solution 4. Crystalloid - a substance that in solution can pass through a semi permeable membrane and be crystallized. 5. Electrolytes - cations or anions which have the ability to conduct electrical current in solutions.
AgeTBW as % of body weight
ECF as % of body weight
ICF as % body weight
Premature 75-80
Newborn 70-75 50 35
1 Year Old 65 25 40-45
Adolescent Male
60 20 40-45
Adolescent Female
55 18 40
MAINTENANCE REQUIRMENT……
Up to 10 Kg 100 ml/Kg
10 to 20 Kg 1000 ml + 50 ml / Kg above 10.
20 Kg onwards 1500 ml + 25 ml / Kg above 20.
3 mEq Na and K per 100 ml of water
Usually estimated from body weight insensible water loss averages 50 ml per 100 kcal consumed. Provision of 50 ml of water per 100 kcal consumed allows the excretion of isotonic urine. Thus, 100 ml of water is required for each 100 kcal consumed. Empirically, 1-3 mEq Na+ and K+ are required for each 100 kcal . Five percent dextrose is necessary to prevent protein and lipid catabolism. Maintenance requirements are best replaced with [5% dextrose, 0.2% NaCl + 20 mEq KCl/liter].
Maintenance requirements
RESUSCITATION MAINTENANCE
Crystalloid
Replace acute loss
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
ELECTROLYTES
FLUID THERAPY
Colloid NUTRITION
Percent Dehydration
Infant
Child
Clinical Signs and Symptoms
Mild 5%3-4%
Increased thirst, tears present, mucous membranes moist, ext. jugular visible when supine, capillary refill > 2 seconds centrally, urine specific gravity > 1.020
Moderate 10%6-8%
Tacky to dry mucous membranes, decreased tears, pulse rate may be elevated somewhat, fontanels may be sunken,oliguria, capillary refill time between 2 and 4 seconds, decreased skin turgor
Severe 15% 10%Tears absent, mucous membranes dry, eyes sunken, tachycardia, slow capillary refill, poor skin turgor, cool extremities, orthostatic to shocky, apathy, somnolence
Shock>15%
>10%
Physiologic decompensation: insufficient perfusion to meet end-organ demand, poor oxygen delivery, decreased blood pressure.
I .C .F BLOOD
K = 140Osm = 280
Na = 140Osm = 280
I .C .F In. S F
K = 140Osm = 280
Na = 140Osm = 280
BLOOD
In. S F
E.C.F. E.C.F.I.C.F. I.C.F.
DEHYDRATION
Isonatremic dehydration….
Correction over 24 hours…
20 Kg child10 % Dehy.Na = 140
Maintenance Replacement Total
½ N.S. X X
2000 ml10 % of 20 Kg
1500 ml 3500 ml 5 % dext.
H20
Na3 mEq / 100 ml.15 3 = 45 10 20 = 200 mEq
245 mEq / 3.5 Lt.Loss = 10mEq / Kg
Hyponatremic dehydration….
Slow correction , over 48 hours…Not more than 10 mEq in 24 hours
20Kg child10 % Dehy.Na = 110
Maintenance Replacement Total
( As 5 % dextrose )
1 / 2 N.S. X Na
3 mEq / 100 ml.30 3 = 90
140-110 ½ wt. X
300 mEq
390 / 5 Lit.
2000 ml10 % of 20 Kg1500 2
3000ml5000 ml X H2O
HYPONATRMIC EMERGENCIES
3% hyper tonic saline
5 ml/kg over 1 hour with the goal sodium level of 125meq/ L , then correct sodium further by calculating deficit
Maintenance Replacement Total
1/4 N.S.
Hypertonic dehydration….Slow correction , over 48 hoursNot more than 10 mEq in 24 hours
20 Kg child10 % Dehy.Na = 165
400 m.l. of N.S. = 61 mEq
Free water deficit = ( 4 X wt inKg ) X ( Serum Na – 145)
1500 2 3000ml
3 mEq / 100 ml.30 3 = 90X
X Deficit = 2000F.W.D. = 1600Reminder as N.S.
5000 ml
151 mEq / 5 lit.
H20
Na
D 5 % with ½ Normal Saline = 77 mEq Na / Lit.
Add 150ml of 3 % Normal Saline to a Liter of 5 % Dextrose
D 5 % with ¼ Normal Saline = 34 mEq Na / Lit.
Add 70 ml of 3 % Normal Saline to a Liter of 5 % Dextrose
Isonatremic dehydration is best replaced with
5% dextrose, ½ NaCl + 20 mEq KCl/L over 24 hours. ( Deduct bolus therapy )
Hyponatremic dehydration is best replaced
with 5% dextrose ½ NaCl + 20 mEq KCl/L over 48 hours. ( Deduct bolus therapy )
Hypernatremic dehydration is best replaced
with 5% dextrose with ¼ NaCl + 20 mEq KCl/L over 48 hours. ( Deduct bolus therapy )
Fallacies of body fluid calculations
Lean body mass calculations Variation in body secretion Variation in renal handling Effect of body temperature Isohydric effect Variation in surface area
HYPERNATREMIA IN ICU Urine output
Low High
Urine osmolality Urine osmolality
Low HighHigh
Hypo tonic fluidloss
Insensible loss G I Loss Diuretics
D. Insipidus Osmoticdiuresis
Central Nephrogenic
Common IV Solutions
Solution Glucose (g/L) Na+ K+ Ca+2 Cl- Lactate PO4
-3 Mg+2
5% Dextrose (D5W) 50 0 0 0 0 0 0 0
10% Dextrose (D10W) 100 0 0 0 0 0 0 0
Normal Saline (NS) 0 154 0 0 154 0 0 0
D5NS 50 154 0 0 154 0 0 0
D5½NS 50 77 0 0 77 0 0 0
0.2% NS 0 31 0 0 31 0 0 0
3% NaCl 0 513 0 0 513 0 0 0
Ringer's Lactate (LR) 0 130 4 3 109 28 0 0
D5LR 50 130 4 3 109 28 0 0
D10 E#48 100 30 15 0 20 25 3 3
D5 E#48 50 25 20 0 22 23 3 3
D10 E#75 100 57 35 0 40 25 12 6
D6 E#75 60 40 40 0 35 20 15 0
Note: Glucose in g/L; all ions in mEq/L.
True Hyperkalemia
Excess K+ intake
Redistribution
Decreased excretion
Renal failureOliguriaHypoaldo.NsaidsAce inhibitors
AcidosisInsulin Def.Adrenal Ins.Periodic P.
Calcium chloride: 0.2 mL /kg/dose of 10% sol IV over 5 min; not to exceed 5 mL (stop infusion if bradycardia develops)Calcium gluconate: 100 mg/kg (1 mL/kg) of 10% sol IV over 5 min; not to exceed 10 mL (stop infusion if bradycardia develops)
Soda bi carb …
2 ml / kg 25 % dextrose with .1 units /kg insulin .over 30 minutes (1 U regular insulin/5 g glucose )
Beta agonists
Hyperkalemia
Hypokalemia true Distribution
Increased loss Urinary K + Decreased
Hypertension Normal B.P.
Acidosis Alkalosis
Renin
G.I.lossBiliary ETC.
I . V . Kesol should be considered for Significant arrhythmia Sever muscle weakness Severe hypokalemia (< 2.5.0 mEq. / L). Digoxin toxicity Hepatic encephalopathy Maximum concentrations of KCl used in peripheral veins generally should not exceed 4 meq. /100 cc, due to the damaging effects on the veins , at a rate of 1 mEq/kg per hour.
Hypotonic Hyponatremia (Na < 135 meq. /L)
Hypovolemia Euvolemia Hypervolemia
Urinarysodium
More than 20 Urinary loss Less than 20 G I Loss Diuretics
SIADH Adrenal Drugs HypoTH
More than 20 C.C.F. Hepatic F. Less than 20 Renal disease
Urinarysodium
SIADH………………
Definition: AVP excess associated with hyponatremia without edema or hypovolemia. The AVP excess is inappropriate in the face of hypoosmolality.
Clinical manifestations are those of water intoxication and depend on rate more than magnitude of development of hyponatremia.
Commonest cause of euvolemic hyponatremia
HYPONATREMIA HYPO OSMOLAR U. OSM. HIGHER THAN SERUM CONTINUED URINARY Na LOSS NORMAL RENAL FUNCTION & B.P. NO OEDEMA NO ENDOCRINE DISORDER RESPONSE TO WATER REST.
SIADH………………