Basic Concepts of Fluid and Electrolyte Therapy

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DKA and HONK represent the two extremes of the spectrum of decompensated diabetes (Table 23), although intermediate cases are not infrequent, depending on the precipitating cause and the percentage loss of insulin secretion. In both situations, hyperglycaemia causes an osmotic diuresis with excessive urinary losses of salt, water, and potassium, leading to ECF and intravascular volume depletion and the risk of prerenal acute kidney injury (AKI). With both types of decompensation, potassium is lost from cells and excreted in the urine causing a deficit, which only becomes apparent as hypokalaemia once the anabolic effect of insulin treatment is felt. In severe cases the rate of K + loss from cells, combined with pre-renal AKI, can cause hyperkalaemia (>5.5 mmol/l) with the risk of cardiac arrest. The presence of acidosis may present diagnostic problems. Although most cases with ketonuria and features of metabolic acidosis are suffering from ketoacidosis, this cannot always be assumed, particularly where there are other potential causes of acidosis, e.g. renal or circulatory failure. For this reason it is important to measure blood concentrations of lactate and of ketones, particularly -hydroxybutyrate and chloride, including the anion gap and strong ion difference in order to establish the diagnosis beyond doubt. 96
Table 23: Features of DKA and HONK compared (approximate values only) Parameters Blood glucose 3.5-11.1 mmol/l (random) Normal DKA range Mild Moderate Severe HONK >14 >14 >14 >30 Arterial pH 7.35-7.45 7.2-7.3 7.0-7.2 7.3 Normal to HCO 3– mmol/l 22-30 15-18 10-15 10 >12 >12 Variable Serum osmolality mOsm/kg Average total losses 280-295 280-320 280-320 280-320 >320 Water (litres) 3-4 4-5 >5 6-10 Sodium (mmol) 200-280 280-350 >350 350-700 Potassium (mmol) 200-280 280-350 >350 >350 Treatment Aims These are similar in both DKA and HONK, although with differences of emphasis. Restore the circulation and the ECF deficit by initially rapid fluid infusion. This also has a beneficial metabolic effect reducing the blood glucose, addresses circulatory failure and prerenal AKI, reducing both acidosis and serum K + . Seek the underlying cause of the diabetic decompensation (e.g. sepsis) and treat it. 97
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Dileep N. Lobo Andrew J. P. Lewingt
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Basic Concepts of Fluid and Electro
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Foreword This book, ‘Basic Concep
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Table of Contents 1. Normal Physiol
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ever, contains large anions such as
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Oral intake 1.5-2 L Saliva 1.5 L Ga
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Table 2: Normal maintenance require
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Kidney: this is the main organ for
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Conversely, if the intake of Na + i
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volume at all costs. It also explai
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Conclusion Appropriate fluid therap
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Intravascular fluid volume - the to
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Colloid - a fluid consisting of mic
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Base excess - Base excess is define
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Parameter Urine output Significance
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Figure 5: Example of a vital signs
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Fluid balance charts These provide
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Osmolality In the presence of AKI,
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Chloride Despite the fact that seru
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4. Properties of Intravenous Crysta
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6-12 h. The colloid should be metab
Page 45 and 46: Table 8: Advantages and disadvantag
Page 47: Plasma- Sterofundin 0.18% Plasma-Ly
Page 50 and 51: 50 Patients receiving artificial nu
Page 52 and 53: Once resuscitation has been achieve
Page 54 and 55: (3) The answer to this question is
Page 57 and 58: 6. Methods of Fluid Administration
Page 59 and 60: Central Modern single or multi lume
Page 61 and 62: 7. Acid-Base Balance Introduction M
Page 63 and 64: vide a simple description of the mo
Page 65 and 66: change in Pco 2 = respiratory proce
Page 67 and 68: Table 15: Causes of metabolic acido
Page 69 and 70: Renal HCO 3 - loss results from re
Page 71: Mixed acid-base disorders These are
Page 74 and 75: Urine output should be interpreted
Page 76 and 77: assess clinical response to fluid i
Page 78 and 79: Oliguria following surgery 48 h and
Page 80 and 81: Definition AKI is a result of a rap
Page 82 and 83: AKI is most commonly secondary to a
Page 84 and 85: History Examination Investigations
Page 86 and 87: Management Prevention Any patient a
Page 88 and 89: if no clinical response and no pulm
Page 90 and 91: acidosis pH 7.2-7.4 - there is ver
Page 92 and 93: Referral to nephrologist NOT all p
Page 94 and 95: Follow up Acute kidney injury is a
Page 98 and 99: Fluids and insulin In the absence
Page 100 and 101: Surgery in the patient with diabete
Page 102 and 103: 10 mmol/l/day. In the differential
Page 104 and 105: portionately more water is lost tha
Page 106 and 107: Hypokalaemia: a fall in serum conce
Page 108 and 109: Four common aspects of Ca 2+ disord
Page 110 and 111: Treatment depends on severity and c
Page 112 and 113: 112
Page 114 and 115: Hypophosphataemia
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Page 118 and 119: Prolonged periods of preoperative f
Page 120 and 121: position to postoperative parotitis
Page 122 and 123: 13. *Chowdhury AH, Lobo DN. Fluids
Page 124 and 125: 42. Hussein H, Lewington A, Kanagas
Page 126 and 127: 67. *Michell AR. Diuresis and diarr
Page 128 and 129: 94. *Stewart PA. Modern quantitativ
Page 130 and 131: colloids 7, 26, 41, 42, 43 44, 45,
Page 132 and 133: intravascular compartment 20, 41, 4
Page 134 and 135: Stewart approach 63, 71 sympathetic
Page 136: Dileep N. Lobo Andrew J. P. Lewingt
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Basic Concepts of Fluid and Electrolyte Therapy

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