0:04 [music] So the major causes uh of this includes uh heart failure as you can see causes of edema and volume overload would lead to high in the in the it's all in the condition you can observe these uh heart failure, renal failure, liver cerosis where you can find asitis which is the abdominal distension, nephroic syndrome uh syndrome of approp inappropriate antidiurotic hormone, excessive uh uh IV fluid administration and primary polyypipssia.
0:50 The management includes these things. So remember this is very important. Treat the underlying cause. If it's because of heart or liver or kidney, just find out that if it is sodium restriction in uh that would lead to uh because of isotonic overhydration, please check that. If it is because of the diuretics, you have to find out uh if it's the furosomide which is a diuretic which promotes the water and sodium excretion. And please treat the underlying condition and also the fluid restriction. If the prescribed daily water intake is this much please see to that. So these are some of the management that we should look into. If it is a over uh hydration we have to look into the diuretics which will
1:35 promote the water excretion. If it is because of heart failure or liver failure or kidney failure we have to treat that first and there should be sodium restriction and fluid restriction. Always remember fluid and salt should go as hand in hand with regard to the restrictions. Next we move on to a condition called water intoxication. This is nothing but uh we term it as dilutional hyponetriia where it becomes a life-threatening condition caused by excessive water intake that overwhelms the renal excretion capacity severely diluting the blood sodium levels which is about uh when the sodium levels fall below 120 m equivalent per liter. This could be
2:22 because of excessive water intake, cellular swelling or hyponetriia [snorts] and brain edema, systemic and multiorgan failure could be led to this. So when the sodium levels drop very much below 120 m equivalent per liter. How does it occur? It could be because of uh excessive water intake. Uh there are conditions where water is being consumed excessively where uh there will be a no sensation of to stop that greater than 20 liters per day or rapid intake which happens with psychiatric polyypsia endurance [snorts] athletes and sometimes the forced water intake or uh happening and uh when the kidneys cannot
3:07 excrete uh that much uh load. So maximum excretion happens with one liter per hour. Uh sodium blood sodium diluted hyponetriia also occurs when great less less than 120 mquans per liter. It is in severe condition where you can see plasma osmolarity falls. So the [snorts] water moves into the brain cells leading to osmosis that is from a lower to higher concentrations. So water moves uh into the brain cells and cerebral edema where brain swelling can be seen. This could be fatal if it is untreated.
3:52 So the clinical features uh defined by severity of sodium includes 130 to 135 m equivalent per liter we can identify uh via nausea, headache and malise which is the fever [snorts] and uh 125 to 130 m equivalent per liter could lead to vomiting, confusion, disorientation and all that. 120 to 125 mill equivalence per liter. uh there will be seizures, lethargies, stuper. If it's less than 120 mill equivalents per liter, it could lead to coma, respiratory arrest and death. The high risk group group groups include marathon runners where there will be overrinking during races, psychiatric
4:38 patients where a polyypsia is seen, MDMA where you can see ecstasic ecstasy use users, infants given uh excessive diluted formula post-operative patients given excess hypotonic IV fluids management include fluid restriction definitely hypertonic saline for severe Symptomatic cases correct the slowly uh and maximum of 8 to 10 millolins per uh 24 hours to prevent osmotic demilination syndrome. [snorts] That's it with regard to the water balance, hydration, dehydration and overhydration. Next we move on to the next topic with regard to electrolytes.
5:23 Electrolytes are basically minerals that carry an electrical charge when dissolved in body fluids. They are essential for maintaining fluid balance, nerve conduction, muscle contraction, acid base balance and cellular function. [clears throat] There are different types of electrolytes. We should be concentrating on cations including sodium, potassium, calcium, magnesium, annions like chloride, bicarbonate, phosphate and sulfates. So talking about the composition of body fluids you can see how the intracellular fluid is being distributed as plasma interial fluid and intracellular fluid. So sodium is predominantly in the interstial fluid. So that becomes a cationon there. Potassium is in the
6:08 intracellular. Calcium is uh widely seen in all the three and chloride is high in plasma and intersticial fluid and bicarbonate is present in these two as a predominant and phosphate is in the intracellular in every fluid compartment. The total cation charge is equal to total anion charge. This balance is tightly maintained. So that is very important. [snorts] So first we are going to talk about the sodium balance where you can observe that normal serum sodium levels are 135 to 145 m equivalent per liter. So the daily sodium intake would lead to 3,000 to 5,000 mg per day. So that's the average Indian intake. WH recommendation
6:54 gives about less than 2,000 mg per day sodium. The [snorts] primary regulation happens via the renin angotensin aldoststerone mechanism where the aldoststerone increases the sodium reabsorption in distal nephron. Secondary regulation includes uh with regard to antidiuretic hormone will regulate the water balance and atrial nitriotic peptide promotes the sodium excretion. The [snorts] excretion of sodium happens via 90% through kidneys and small amounts via sweat and the feces. The potassium balance happens with uh regard to this where you can see normal sodium potassium levels are 3.5 to 5 mill equivalent per liter and the daily
7:41 potassium intake includes,500 to 2,000 mg per day. That's the average Indian intake. of WH recommends greater than uh or equal to 3,510 mill equivalent per liter milligrams per liter. The primary regulation happens via aldoststerone which promotes the sodium excretion in distal nephron and insulin effect happens with ins insulin shifting potassium into cells used in the hypercalemia treatment. [snorts] Acidosis effects are uh hydrogen enters the cells and potassium gets uh excreted which leads to hypercalemia. Whereas in alkalossis [gasps] hydrogen exits and the uh potassium enters. So
8:28 that's causing hypocalemia. [snorts] And the what is the diff uh relationship between sodium and potassium. There is the sodium potassium ATP is pumped. If you see three sodium is pumped out and two potassium is pumped into the uh membrane and this is as per the ATP which is hydrayed. So sodium is high in the outside cell you can see and the potassium is high in the inside cell. This creates a kind of resting membrane potential which is essential for the nerve and the muscle function here. So you can see the concentration of sodium in the outside cell and potassium in the inside cell. So when we talk about the electrolyte
9:14 abnormalities, hypo and hyperatriia is with regard to the sodium hypo and hypercalemia with regard to the potassium. Hyponetriia is caused by a serum potassium of less than 135 m equivalent per liter where you can see severe hyponetriia is uh lifethreatening. The causes could be dilutional, depletional and iatrogenic. Dilutional hyponetriia is because of syndrome of inappropriate antidiuretic hormone where water intoxication, heart failure, cerosis are all the causes in the depletional process, diarrhea, vomiting, diuretics and Addison's
10:01 disease has caused an effect. Irogenic causes include excess hypotonic IV fluids. Symptoms include a mild symptom would be nausea, headache and fatigue. Whereas moderate symptoms could be confusion, muscle cramps and weakness. Severe in uh including seizures, coma, respiratory failure and death. [snorts] The management of this particular hyponetriic condition would be for dilutional hyponetriia there would be a fluid restriction. For uh depletional uh hyponetriia definitely sodium should be replaced. Hypertonic saline for symptomatic severe cases correct slowly. If it is less than
10:47 10 m equivalent per liter. So that is how it should be. You should remember if it is hypo low natri means sodium anemia is in the blood. Low sodium levels in the blood. Hyperetriia is a condition where you can see the C serum sodium levels are above the 145 m equivalent per liter where severe hyperetriia leads to emergency condition. The causes could be water deficit which leads in a condition called diabetes incipidus where excessive sweating and fever condition also can be observed. Sodium [snorts] excess uh when it is seen with excess hypertonic IV saline or const syndrome
11:32 inadequate intake uh seen in elderly population infants and unconscious patients the symptoms would be uh defined as neurological where you can find restlessness irritability confusion and seizures. Cardiovascular could be tachiardia and hypotension. For real condition it is intense thirst and ooligura. Severe complication includes intraranial hemorrhage due to brain cell shrinkage. Next we move on to the potassium component where low potassium will lead to hypocalemia. The sodium uh and potassium always have a role to play. So in the electrolyte comp composition we would be talking about these two things as a major
12:19 component. So if you see uh hypocalemia leads to serum potassium below 3.5 m equivalence per liter and the critical level would be less than 2.5 m equivalence per liter that leads to life-threatening condition causes would be GI losses diarrhea vomiting nasogastric suctioning laxative abuse for renal conditions diuretic usage could be a reason uh furosmomide thiocytes hyper aloststerone cushing syndrome [snorts] could be a reason for uh hypocalemia. There will be a cellular shift in cases uh of alkalossis insulin excess uh
13:07 beta uh agnostics like salbutimol which is given [gasps] inadequate intake because of starvation or eating disorder. All these things would lead to a uh low potassium levels. Symptoms include uh cardiac there will be a flat T-wave, Uwave and prolonged QT QT wave uh ventricular arhythmias. Muscle uh would be leading to weakness, fatigue, cramps, ascending paralysis. [snorts] Under gastrointestinal we could find constipation, IAS, abdominal distension. uh in renal we can find polyura polyypipssia and also in conditions like um diabetes incipitus
13:54 hypercalemia uh is also caused when the potassium levels are above 5.5 5.0 m equivalent per liter [snorts] critical levels include greater than 6.5 millolence per liter which is majorly leading to the cardiac emergency. [snorts] Causes include renal failure which is the most common causes. The kidneys cannot excrete potassium. There is a cellular shift which leads to acidosis, severe tissue destruction where we can see rabdtomyolyis, burns and tumoris syndrome [snorts] drug induced leads to uh ACC inhibitor, potassium sparing diuretics, NSIDS which is a non-steroidal anti-inflammatory drugs, beta blockers, [snorts] excessive
14:40 intake could lead to uh potassium supplements and massive blood transfusion. The symptoms would be peaked T-wave, widened QRS and sine wave but pattern, ventricular fibrillation, cardiac arrest. Under muscle we can find weakness, paralysis and paristhesia, gastrointestinal symptoms include nausea uh and abdominal cramps. [snorts] There are other electrolyte abnormalities that we should be looking into where you can see hypocalcemia, hypercalcemia, hypomagnesmia and hyperagnesmia where [snorts] we can find that hypocalcemia is being caused by hypoparathyroidism, vitamin D deficiency, pancreatitis, hypomagnesmia.
15:26 The key symptoms would be tetany uh chowski sign trouse sign seizures prolonged QT interval hypercalcemia is also caused by hyperarathyroidism mal malignancy vitamin D toxicity sarois and there uh see symptoms would be stones presence of stones bone groins uh kidney psychiatric wounds and uh kidney stones and all that uh uh is commonly seen here. Hypomagnesmia is a condition where is observed due to alcoholism, diarrhea and diuretics, diabetes and PPI usages and uh key symptoms would be tremors, muscle cramps, cardiac arithmias,
16:13 concurrent hypocalemia and hypocalcemia, hyperagnesmia could be because of renal failure, excessive magnesium usages, uh hypotension, bradicardia, loss of deep tendon reflexes, respiratory paralysis is common. So hypomagnesmia must always be corrected first before hypocalemia and hypocalcemia can be corrected. Magnesium is required for uh parathyroid hormone secretion and potassium renal conservation. So always remember [gasps] hypomagnesmia should be corrected first before hypocalemia and hypocalcemia. So therefore the clinical assessment of fluid uh in a nutshell should be like urine output is measured hourly in ICU.
17:00 The normal is greater than 0.5 ml per kg per hour. Ooligura is less than.5 ml per kg per hour. The urine color is visually inspected with pale yellow being well hydrated and dark amber is dehydrated. Urine specific gravity should be um is me measured using the dipstick method where 1.01 01001 to 1.003 is diluted greater than 1.020 1020 is concentrated skin tugger as I told you the pinch test you can observe here the slow written is referred to as dehydration mucus membrane you can see uh if it's clinical you can find dry skin dry lips and serum osmolarity is checked with the lab where you can see the normal osmolarity is normally
17:48 between 280 to 295 m os per kg and you can also check the daily weight and serum electrolytes uh composition with regard to sodium, potassium, chloride bicarbonate calcium magnesium and all that fluid requirements in daily practice. Uh this is a very uh important slide because uh the normal adult uh requirements varies from 30 to 35 ml per kg per day for uh based on the body weight. Uh if the person is having fever add another 300 ml per day per degree um Celsius rise above 37° for burns we use a partland formula where you measure like this 4 ml
18:34 into the kg body weight into the total body surface area burnt for example if it is 40%age you have to calculate like 4 into the kg into 40%. If it's a renal failure, a previous day output urine output plus 500 ml should be the fluid requirement. For diarrhea patients, it is replacing this tool losses plus the maintenance. Therefore uh we have observed about the water uh balance, water output, water intake and the electrolyte balances like sodium, potassium, uh hypocalcemia and hypomagnesmia and also how it has to be corrected with regard to the different age groups and different clinical conditions. [snorts]
19:21 Always remember that water and electrolyte balance is very much vital for normal body function and cellular homeostasis. Early detection and management of dehydration and electrolyte uh disturbances are very much essential to prevent serious complications and maintain the patient stability. We always uh recommend uh 2 to 2.5 lit of water per day. If it is uh a normal person if there is a renal condition please consult a nephrologist and the nephologist will give us a intake levels of the person. So that has to be compensated with [snorts] regard to the renal conditions. And if there is an edema with regard to heart failure, pulmonary edema or anything else, please remember that sodium also should be restricted when it comes to any kind of
20:08 edema conditions. >> [snorts] >> So these are some of the clinical tips that we would like to give and you should also know about uh hypotonic saline, hypertonic saline, isotonic saline which was discussed in the slide and uh therefore uh this is with regard to the entire uh unit of week 8 which is about macro minerals, microminerals and water and this is the last part of week 8. Therefore, uh we would like to conclude that always remember the uh assignment questions will be based on these kind of topics. And uh that's the end of the topic of week eight. Thank you and happy learning.
