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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Ashley Hawthorne, Pharm.D., BCCCP Auburn University Harrison College of Pharmacy Auburn, Alabama…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Ashley Hawthorne, Pharm.D., BCCCP Auburn University Harrison Colle…

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Learning Objectives 3 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Learning Objectives 1. Describe normal fluid requirements and common patient conditions that alter fluid needs and homeo- stasis. 2.…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 4. A 70-year-old man admitted to the intensive care unit (ICU) for sepsis was recently given a diagnosis of syndrome of inappropriat…

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Exam Content Outline 1 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examina…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support I.  FLUIDS AND ELECTROLYTES A. General Overview 1. Body water compartments a. Total body water (TBW): About 60% of body weight for m…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support b. “Normal” daily requirements Table 3. “Normal” Daily Requirements (Medicine (Baltimore) 1981;60:339-54; Crit Care Med 1995;23:1504-1…

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Data Tables 3 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Solutions Sodium (mEq/L) Potassium (mEq/L) Chloride (mEq/L) Bicarbonate (mEq/L) Calcium (mEq/L) Magnesium (mEq/L) Osmolarity (mOsm/L)…

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Data Tables 2 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Table 6. Comparative Features of Hypotonic Hyponatremia (Am J Med 2013;126:S1-42) ECF volume status Hypervolemic Euvolemic Hypovolemic…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support vi. If the patient has a TBI, it can be difficult to ascertain whether the patient has cerebral salt wasting syndrome (CSWS) or SIADH…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support (3) Recent guidelines recommend use of bolus dosing over continuous infusion because of its ability to reach target sodium concentrat…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 4. Hypernatremia: Reflects a deficit of water compared with total body sodium. Therapy should be adjusted to achieve a serum sodium c…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Patient Case Questions 1–3 pertain to the following case. A 55-year-old woman (70 kg) admitted to the ICU for pneumonia and respiratory…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 2. Hypokalemia a. Definition: Serum potassium less than 3.5 mEq/L, though most ICUs empirically prefer to keep patients at 4.0 mEq/L…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Table 11. Empiric Intravenous Potassium Dosing Serum Potassium (mEq/L) Potassium Chloride Dosage (mEq)a,b Laboratory Tests 3.5–3.6 4…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support d. Treatment i. The following regimens are for patients with symptomatic evidence of toxicity from hyperkalemia such as peaked T wav…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support D. Disorders of Magnesium Homeostasis 1. Magnesium homeostasis overview a. 99% intracellular (17% of total body content is in the mu…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support iv. Empiric intravenous magnesium sulfate dosing. This algorithm (Table 13) was designed primarily for trauma and thermally injured p…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Table 15. Oral Magnesium Content Salt Form % Elemental Magnesium Content Oxide Carbonate Hydroxide Citrate Lactate Chloride Sulfate Glu…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Patient Case Questions 4 and 5 pertain to the following case. A 65-year-old man (weight 87 kg) is admitted to the hospital with severe…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support e. Average daily requirement: 10–15 mEq/day intravenously with PN (Ann Surg 1983;197:1-6); 1–3 g/day orally f. Kidney is primary rou…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Patient Case Questions 6 and 7 pertain to the following case. A 24-year-old man (weight 90 kg) is admitted to the trauma ICU postoperat…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support iii. Calcitonin 4 units/kg intramuscularly or subcutaneously every 12 hours; can be increased to a maximum of 8 units/kg every 8 hour…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support b. Signs and symptoms: Weakness, paresthesias; severe depletion can lead to congestive cardiomyopathy, cardiac arrest, seizures, coma…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 3. Hyperphosphatemia a. Definition: Serum phosphorus concentration greater than 5 mg/dL, usually not clinically relevant until serum…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support II.  ACID-BASE DISORDERS A. Normal Homeostasis 1. Normal values Table 19. Normal Blood Gas Values Variables Arterial Blood Mixed Veno…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Box 1. Adverse Effects of Severe Acidemia (pH 7.25 or less) Impaired cardiac output Increased metabolic demands Peripheral ischemia (ce…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Primary Disorder Pco2 (mm Hg) Anticipated Serum Bicarbonate (mEq/L) Respiratory acidosis Acutea > 42 HCO3 should increase by 1 mEq/L fo…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support d. Causes of an AG acidosis: One easy pneumonic to remember (there are others) is MUDPILES: M = Methanol U = Uremia (including rhabdom…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 3. An alternative method (and perhaps a simpler approach) to the delta ratio is to calculate the “excess gap” compared with the AG (W…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Patient Case Questions 8 and 9 pertain to the following case. A 60-year-old woman (weight 80 kg) was admitted to the hospital after 1 w…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support ii. Dosage of hydrochloric acid: (a) Chloride deficit (Arch Surg 1975;110:819-21): Dose (mEq) = 0.2 L/kg x Wt (kg) x (103 − serum chl…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support ii. Nutrition Risk in the Critically Ill (NUTRIC) score (Crit Care 2011;15:R268) Table 23. Determination of Nutrition Risk by the NUTR…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support d. Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus Malnutrition Characteristics (J…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Table 25. Guideline Recommendations for Caloric Intakea Organization Recommendation Eastern Association for Surgery of Trauma (J Traum…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 4. Adverse effects of overfeeding – Do not exceed 4–5 mg/kg/minute of glucose/carbohydrate in the acute phase of critical illness (An…

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Data Tables 3 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Table 26. Guideline Recommendations for Protein Intakea Organization Recommendation SCCM/ASPEN (JPEN J Parenter Enteral Nutr. 2016;40:…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support D. Principles of EN and PN 1. Indications for EN: If the patient is unable to eat adequate amounts to achieve goal nutritional intake…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Product Category Indication Macronutrients Additional Comments Examples Increased protein needs Critically ill patients (especially…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support f. Vasopressors (Lancet Respir Med. 2023;11(7):602-612; J Clin Nutr. 2023;42(9):1671-1689). Use of EN while patients are receiving va…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support b. Safe practice recommendations for prescribing PN solutions – Should be prescribed in total amount per day (e.g., dextrose 200 g/da…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support iv. Biochemical evidence for EFAD (the “classic definition” is an increased triene/tetraene [eicosatrienoic acid/arachidonic acid] ra…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support i. Zinc 3 mg/day normal requirements; 5 mg/day during critical illness; increased requirements for patients with diarrhea, intestinal…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support vii. It is common clinical practice to withhold copper and manganese in the PN formulation for patients with hepatobiliary/cholestati…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support patients had no comorbidities and barely met the criteria for high nutrition risk with an NRS-2002 score of 3 for most patients). e.…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Patient Cases 10. A 40-kg woman admitted to the trauma ICU receives a PN solution containing 350 g of dextrose, 160 g of amino acids,…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 5. Summary: The data are confusing because several studies have used different times for the definition of early nutrition therapy: 2…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support i. Excessive insulin dose ii. Abrupt discontinuation of EN or PN without an adjustment in the insulin therapy (purported to cause 62…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support G. Nutrition considerations with coronavirus disease 2019 (COVID-19) 1. Several guidance documents have been released with specific r…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support REFERENCES Fluids and Electrolytes Adrogué HJ, Madias NE. Hypernatremia. N Engl J Med. 2000;342(20):1493-1499. https://doi.org/10.1056…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Clin Endocrinol Metab. 2019;104(9):3595-3602. https:// doi.org/10.1210/jc.2019-00044 Greenlee M, Wingo CS, McDonough AA, Youn JH, Kone…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Pharm. 2005;62(22):2355-2361. https://doi.org/10.2146/ ajhp050198 Sloan GM, White DE, Murray MS, Brennan F. Calcium and phosphorus met…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Galla JH. Metabolic alkalosis. J Am Soc Nephrol. 2000;11(2):369-375. https://doi.org/10.1681/asn.v112369 Haber RJ. A practical approac…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Parenter Enteral Nutr. 2013;37(6):714-744. https://doi. org/10.1177/0148607113499374 Cogle SV, Hutchison AM, Mulherin DW. Finding the…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6):R268. https:// doi.org/10.1186/…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support ASPEN Adult Nutrition Support Core Curriculum. American Society for Parenteral and Enteral Nutrition; 2012:580-602. Nicolo M, Heyland…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support Weijs PJ, Stapel SN, de Groot SD, et al. Optimal protein and energy nutrition decreases mortal- ity in mechanically ventilated, critic…

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Answers & Explanations 5 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: D Hyperglycemia and other causes of non-hypotonic hyponatremia have been exclude…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support concentration of less than or equal to 1.5 mg/dL is more likely to contribute to the pathogenesis of hypocalce- mia. Answer B is incor…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support problem (overfeeding) and are inappropriate manage- ment techniques. 11. Answer: A Total kilocalories per day = (300 g x 3.4 kcal/g of…

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Self-Assessment 4 min

Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: C An ileus, usually detected on radiologic examination of the lower…

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Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support 6. Answer: D Answer D, additional magnesium therapy should be given daily for the next 4–5 days, is correct because it takes 48 hour…

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