Who is at risk for fluid imbalance

Verifying if the patient is on a fluid restraint is necessary. Note the presence of nausea, vomiting, and fever. These factors influence intake, fluid needs, and route of replacement. Auscultate and document heart sounds; note rate, rhythm, or other abnormal findings.

Cardiac alterations like dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypocalcemia. Monitor serum electrolytes and urine osmolality, and report abnormal values. Elevated blood urea nitrogen suggests fluid deficit. Urine-specific gravity is likewise increased. Ascertain whether the patient has any related heart problem before initiating parenteral therapy.

Cardiac and older patients are often susceptible to fluid volume deficit and dehydration due to minor changes in fluid volume. They also are susceptible to the development of pulmonary edema. Weigh daily with the same scale, and preferably at the same time of day. Weight is the best assessment data for possible fluid volume imbalance. An increase in 2 lbs a week is considered normal.

Identify the possible cause of the fluid disturbance or imbalance. Establishing a database of history aids accurate and individualized care for each patient.

Monitor active fluid loss from wound drainage, tubes, diarrhea , bleeding, and vomiting; maintain accurate input and output record. Fluid loss from wound drainage, diarrhea, bleeding, and vomiting cause decreased fluid volume and can lead to dehydration. During treatment, monitor closely for signs of circulatory overload headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough.

Close monitoring for responses during therapy reduces complications associated with fluid replacement. These direct measurements serve as an optimal guide for therapy. Monitor for the existence of factors causing deficient fluid volume e. Early detection of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss. Urge the patient to drink the prescribed amount of fluid.

Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink. Being creative in selecting fluid sources e. Oral hydrating solutions e.

Chronic and mild-moderate hyponatremia have been associated with attention or gait deficits, increased risk of falls, and bone fractures. Bone is a reservoir for Na. Observational retrospective cross sectional and epidemiological surveys have established an association between chronic hyponatremia and osteoporosis and major osteoporotic fracture [ , , , , , ].

Unfortunately, there is a lack of evidence to suggest that osteoporosis is reversed with correction of hyponatremia [ 2 ]. The brain which is contained in the hard skull is not able to accommodate any swelling or increase in brain volume.

This is evident especially in patients who develop acute hyponatremia. Cerebral edema occurs when cells within the brain swell, when there is an increase in extracellular fluid volume in the brain or both. Brain cells swell when there is a large osmotic force favoring an intracellular shift of water, owing to a higher effective osmolality in brain cells than the effective osmolality in plasma in capillaries near the blood—brain barrier [ , , , ].

The elevated intracranial pressure with the resultant acute cerebral edema can potentially lead to serious symptoms that ranges from seizures, coma to brain herniation causing irreversible midbrain damage and death [ , ]. Incidence of fatal brain damage secondary to severe hyponatremia is unknown, majority of the cases have been reported during the perioperative period secondary to infusion of hypotonic fluids or self-water intoxication like marathon runners and psychiatric patients [ ].

Most cases of hyponatremia in the ambulatory setting are mild. A large cross sectional observational study by the National Health and Nutrition Examination Survey in the United States with 15, individuals demonstrated that hyponatremia was an independent risk for increased mortality across age, gender, and comorbid conditions. They also showed that prevalence of hyponatremia increased with age and was more frequent among women than men [ ].

Others studies looking at the association of hyponatremia with specific comorbid conditions like heart failure, HIV, pneumonia, renal failure among others, concluded that hyponatremia is an independent risk factor for mortality regardless the levels of sNa [ 58 , , , , , , , , , ]. Among patients presenting with acute pulmonary emboli, hyponatremia is common and several studies has shown to be an independent risk factor for increased short-term mortality.

This result could be encountered as a variable in determining of pulmonary emboli severity and mortality [ , ]. In Wald et al. Mortality was increased among older patients. A larger prospective study by Waiker and colleagues with approximately , individuals followed up to 5 years showed that irrespective of the severity of hyponatremia, presence of hyponatremia independently increased risk of dead with an odd ratio of 1. It was more pronounced among patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system.

They also showed that resolution of hyponatremia attenuated the increased risk of mortality [ ]. There are no many studies evaluating outcomes of treatment of hyponatremia. Two studies evaluated the impact of treatment on mortality among patients with congestive heart failure and concluded that treatment confers no mortality benefit, however, there was symptomatic improvement and decreased length of stay [ 94 , 95 ].

Other studies suggested that correction of mild hyponatremia could reverse attention and gait deficits [ , ]. When hyponatremia develops over a slower rate, 24—48 h, the brain cells are able to adapt to expel enough of anions and organic solutes along with water to maintain its size. Rapid correction of hyponatremia can lead to inability to regain the organic solutes causing osmotic demyelination, a process still poorly understood [ 5 ].

Osmotic demyelination syndrome ODS and central pontine myelinolysis CPM are terms usually used interchangeably, but they represent separate, not well understood and highly feared complications of the treatment of hyponatremia. The effect of rapid correction of hyponatremia is termed as ODS and it is specific to the central nervous system and not always localized to the pontine region.

Extrapontine myelinolysis is as frequent as CPM [ , ]. Risk factors making patients more susceptible to the development of ODS include severity and chronicity of hyponatremia, the increment of sNa, the treatment used for sodium correction, concomitant hypokalemia, presence of liver disease and the nutritional status [ 98 ].

However, rate of correction was not associated with demyelination [ ]. The clinical manifestations of ODS are variable depending on the location of demyelination. They range from pontine and bulbar symptoms such as dysarthria, dysphagia, and dystonia to more severe forms like locked-in state and coma [ ].

In the past, prognosis of ODS and CMP was considered to be very poor; however, several studies have reported near complete neurological recovery. Some investigators in small, nonrandomized studies suggest concomitant use of desmopressin and hypertonic saline for better control of the rate of sNa correction in hyponatremia [ , ].

Experiments on rats have shown little success with the combination regimen of D5W and desmopressin for the treatment of overcorrection of hyponatremia [ , ]. The role of urea for ODS have not been well studied. A difference of the complexity of hyponatremia, the finding of hypernatremia invariably denotes hypertonic hyperosmolality and always causes cellular dehydration. It can be a frequent finding in hospitalized patients or high risk patients with poor access to water like the elderly, infants, patients on mechanical ventilation, and patients with altered mental status.

In the elderly, a physiologic decrease in the thirst mechanism have been reported; however, there can be a pathological decrease in free water intake as well [ 60 ]. In general, clinical manifestations of hypernatremia correlate with the severity of sodium abnormalities and are related to central nervous system dysfunction and ranges from weakness, confusion to seizure and coma.

In addition, sign of hypovolemia and hemodynamic abnormalities can be found on examination. The complications of hypernatremia vary from mild to life threatening [ ].

Brain shrinkage induced by hypernatremia can cause vascular rupture, with cerebral bleeding, subarachnoid hemorrhage, and permanent neurologic damage or death. Causes of hypernatremia can be loose classified in two: either net water losses due to gastrointestinal or renal etiologies or hypertonic solution administration [ , ]. The focus of management is addressing the underlying cause leading to hypernatremia and the correction of serum sodium. Initial evaluation includes evaluation of vital signs.

In hemodynamically unstable patients, administration of isotonic 0. Goal in those patients is fluid resuscitation hemodynamic stabilization. Patient who are hemodynamically stable can be managed with oral or IVF replacement.

The preferred route for fluid administration is the oral route or a feeding tube; otherwise IVF are required. The more hypotonic the infusate, the lower the infusion rate required.

An easy and efficient way to calculate this is by using Adrogue-Madias formula, which allows to calculate rate of infusate [ ]. Pearls: Serum sodium abnormalities are common and carry significant morbidity and mortality. Evaluation of sodium abnormalities should focus in the underlying condition as well as management. Resuscitation of an unstable patient takes precedence over correction of sodium levels.

There is no rush to correct sNa levels, risk of overcorrection, or rapid increase in sNa can lead to serious complications. We reviewed issues related to fluids and sodium disturbance and the clinical implications of these issues. The dysregulation of fluid and sodium homeostasis leads to many direct and indirect effects and carries significant morbidity and mortality in a wide variety of patients and clinical settings.

Those range from mild cases of dehydration to more severe cases of patients in shock or with severe hypo- or hypernatremia.

Since the high prevalence of these disorders, clinicians in virtually every medical specialty will interact with patients requiring fluid administration and need for electrolyte evaluation and correction.

Appropriate and timely administration of fluids and electrolyte correction with focus in avoidance of complications and improvement of outcomes is fundamental. Licensee IntechOpen.

This chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers. Login to your personal dashboard for more detailed statistics on your publications. Edited by Usman Mahmood. Edited by Thomas Rath. We are IntechOpen, the world's leading publisher of Open Access books.

Built by scientists, for scientists. Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals. Downloaded: Abstract Fluids and electrolytes are basic components of the human body and essential for the survival of most species.

Keywords hypernatremia hyponatremia fluids normal saline ringer lactate albumin. Introduction The serum sodium sNa concentration and thus serum osmolality sOsm are closely controlled by water homeostasis, which is mediated by thirst, arginine vasopressin, and the kidneys. Table 1. Composition of crystalloids. Table 2. Composition of colloids. Question 1: which fluids are more effective—colloids or crystalloids?

Question 3: what are the common indications for hypertonic saline? Question 4: how do we manage fluids in sepsis and septic shock? Question 5: fluid management in diabetic ketoacidosis Patients with diabetic ketoacidosis DKA present with high anion gap metabolic acidosis, dehydration, and fluid deficits. Question 6: does my patient need maintenance fluids? Question 7: is there an ideal IV fluid? In most instances, balanced solutions may be adequate.

Hypertonic saline or colloids are fluids of choice in TBI with cerebral edema. Use maintenance fluids only when indicated and review need daily. Hyponatremia 3. Question 8: what is the importance of hyponatremia? Table 3. Prevalence and outcome of hyponatremia. Medically reviewed by Angela M. Definition Causes Symptoms In children In older adults Treatment Home remedies Summary An electrolyte imbalance can occur if the body has too much or too little water. What are electrolytes? What causes an electrolyte imbalance?

In children. In older adults. Home remedies. Exposure to air pollutants may amplify risk for depression in healthy individuals. Costs associated with obesity may account for 3. Related Coverage. Foods that are high in electrolytes. Everything you need to know about electrolytes. Medically reviewed by Grant Tinsley, PhD. How can you tell when a toddler is dehydrated? How to recognize a dehydration headache. Medically reviewed by Deena Kuruvilla, MD.

What you should know about dehydration. Your doctor may want to perform a physical exam or order extra tests to confirm a suspected electrolyte disorder. These additional tests will vary depending on the condition in question. For example, hypernatremia too much sodium can cause loss of elasticity in the skin due to significant dehydration. Your doctor can perform a pinch test to determine whether dehydration is affecting you.

They may also test your reflexes, as both increased and depleted levels of some electrolytes can affect reflexes. In general, certain treatments are used to restore the proper balance of minerals in the body.

These include:. Intravenous IV fluids , typically sodium chloride, can help rehydrate the body. This treatment is commonly used in cases of dehydration resulting from vomiting or diarrhea. Electrolyte supplements can be added to IV fluids to correct deficiencies. IV medications can help your body restore electrolyte balance quickly.

The medication you receive will depend on the electrolyte disorder you have. Medications that may be administered include calcium gluconate, magnesium chloride, and potassium chloride. Oral medications and supplements are often used to correct chronic mineral abnormalities in your body. They can help replace depleted electrolytes on a short- or long-term basis, depending on the underlying cause of your disorder.

Once the imbalance has been corrected, your doctor will treat the underlying cause. Although some of the supplements can be purchased over the counter, most people with electrolyte disorders get a prescription for supplements from their doctor.

One way to get the blood to flow to this artificial kidney is for your doctor to surgically create a vascular access, or an entrance point, into your blood vessels. This entrance point will allow a larger amount of blood to flow through your body during hemodialysis treatment.

This means more blood can be filtered and purified. Your doctor may also decide on hemodialysis treatment if the electrolyte problem has become life-threatening. Anyone can develop an electrolyte disorder.

Certain people are at an increased risk because of their medical history. Conditions that increase your risk for an electrolyte disorder include:. Follow this advice to help prevent electrolyte disorders:.

If the electrolyte disorder is caused by medications or underlying conditions, your doctor will adjust your medication and treat the cause.