3. 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.
5. 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…
6. 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
7. 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 . ?
8. Correction of acidosis will drive k +
into the cells
Further worsening hypokalemia.Acidosis is not sever
and can wait. Hypokalemia first.
Hypocalcaemia protects against hypokalemia
Thus treatment of hypokalemia should precede
Hypocalcaemia.
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 ?
9. 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.
10. Age
TBW 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
11. 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
12. 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
18. I .C .F B
L
O
O
D
K = 140
Osm = 280
Na = 140
Osm = 280
I .C .F In.
S
F
K = 140
Osm = 280
Na = 140
Osm = 280
B
L
O
O
D
In.
S
F
E.C.F. E.C.F.I.C.F. I.C.F.
DEHYDRATION
19. I S O HYPERHYPO
120 140 160
240 280 320
W W
ICF ICF
ICF
20. Isonatremic dehydration….
Correction over 24 hours…
20 Kg child
10 % Dehy.
Na = 140
Maintenance Replacement Total
½ N.S.X X
2000 ml
10 % of 20 Kg
1500 ml 3500 ml
5 % dext.
H20
Na
3 mEq / 100 ml.
15 3 = 45
10 20 = 200 mEq
245 mEq / 3.5 Lt.Loss =
10mEq / Kg
21. Hyponatremic dehydration….
Slow correction , over 48 hours…
Not more than 10 mEq in 24 hours
20Kg child
10 % Dehy.
Na = 110
Maintenance Replacement Total
( As 5 % dextrose )
1 / 2 N.S.
XNa
3 mEq / 100 ml.
30 3 = 90
140-110 ½ wt.X
300 mEq
390 / 5 Lit.
2000 ml
10 % of 20 Kg1500 2
3000ml
5000 mlXH2O
22. 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
23. Maintenance Replacement Total
1/4 N.S.
Hypertonic dehydration….
Slow correction , over 48 hours
Not more than 10 mEq in 24 hours
20 Kg child
10 % 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 = 2000
F.W.D. = 1600
Reminder as N.S.
5000 ml
151 mEq / 5 lit.
H20
Na
26. 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
27. 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 )
28. 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
29. HYPERNATREMIA IN ICU Urine output
Low High
Urine osmolality Urine osmolality
Low HighHigh
Hypo tonic fluid
loss
Insensible loss
G I Loss
Diuretics
D. Insipidus
Osmotic
diuresis
Central
Nephrogenic
36. 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
39. 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.
40. Potassium should be administered slowly,
preferably Orally, at a dosage of 4 to 6
mEq/kg per day.
42. Hypotonic Hyponatremia (Na < 135 meq. /L)
Hypovolemia Euvolemia Hypervolemia
Urinary
sodium
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
Urinary
sodium
43. 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
44. 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………………
