Fluids TBW = .6 X wt (kg) = (42L)

Fluid & Electrolyte Emergencies

ICFV = 2/3 TBW (28)

Bryce Lund MD [email protected]

ECFV = 1/3 TBW (14)

ICFV Interstitial = ¾ ECFV (10.5)

Intravascular = ¼ ECFV (3.5)

Na 140 mEq/L

85% venous

7/27/2004

1

1L D5:

666 ml

250

84

1L NS:

0

750

250

ISFV

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15 % arterial

IVFV

2

ECFV

Fluids Glu Gm /L

Osm

Na+

ClCl-

Ca+ +

K +

Sodium Lact ate

pH

Salt/ d@ 100c c/hr

Use

in volume indicate salt changes

► Changes

in sodium indicate free water changes

ƒ Edematous states or hypovolemic states (Na normal)

D5W

50

252

0

0

0

0

0

4

0

Free water

0.45% NS

0

154

77

77

0

0

0

4-5

1080 mg

Volume & free water

0.9% NS

0

308

154

154

0

0

0

5.5

2160

IVF Volume

3% NS

0

1026

513

513

0

0

0

7.6

NA

Hyponatremia

D5W & 3 amps NaHCO3

50

560

150

0

0

0

0

8

2100

Acidosis

LR

0

272

130

109

3

4

28

6.5

1823

Volume

7/27/2004

► Changes

Others: D10, D5NS, D5LR

ƒ Dehydration, over hydration (TBW may be normal)

► Osmolality: Osmolality: ► All

Total solute concentration

osmoles: osmoles: Na, K, BUN, Glucose, alcohols, mannitol

► Tonicity:

The effect from limiting movement of certain osmoles by cell membrane ► Effective osmoles: osmoles: Na, K, ► Ineffective osmole: osmole: BUN,

3

Glucose, mannitol alcohols

ƒ Hypernatremia Hypernatremia = hypertonicity ƒ Hyponatremia Hyponatremia = hypo, iso, iso, or hypertonicity

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4

Price: NS $2.10/bag, LR $2.60/bag

Salt (NaCL) – Sodium (Na)

Hypernatremia ►

Symptoms: CNS changes, cerebral contraction leads to easy bleeding bleeding

►

Three categories

ƒ Hypervolemic: Hypervolemic: CAH, Cushings, Cushings, Conn’ Conn’s ƒ Euvolemic: Euvolemic: DI, reset osmostat ƒ Hypovolemic: Hypovolemic: free water loss (loop diuretics), osmotic diuresis {glucose(correct Na), urea with good UOP}, NG/diarrhea/burns, nursing home patient

►

Treatment (free water)

ƒ Correct with 1/2NS or D5 by IV, PO is preferred ►

Use NS to correct any cardiovascular instability ƒ

May lower serum sodium

ƒ Rapid correction leads to cerebral edema/coma/death ►

Accumulation of idiogenic osmoles

ƒ Has a 50% mortality rate ƒ Maximum correction is 0.50.5-1 mEq/L/hr mEq/L/hr ► ►

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Fluids & Electrolytes

5

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If possible ½ corrected in first 24 hours Follow serum sodium regularly, q4 hours 6

1

Hypernatremia Calculating free H2O deficit ► Classic

equation

► Intravascular

ƒ Total body deficit H2O = 0.6 X (wt) X [{Na/140} – 1] H2O = 0.6 X (wt) X [160/140 – 1] H2O = 0.6 X (wt) X [1.14[1.14-1] H2O = 0.6 X (wt) X [0.14]

Euvolemic Hypernatremia: Hypernatremia: Diabetes Insipidus

deficit

► ADH

70 kg X 0.6 = 42 L TBW 42 L X 1/3 = 14 L ECFV 14 L X ¼ = 3.5 L IVF

► Causes ► Main

ƒ Na is main determinant: osm = 2(Na) + BUN/2.8 + Glucose/18 ► Secondary

3.5 L X (160/140 -1) = 0.49 L 0.49 more/3.5 L IVF = 0.14

► DI

14% higher Na

H2O = 5.88 L

is lack of ADH ► Patients

presenting with hypernatremia and low urine osmolality means there is a lack of ADH, or Diabetes Insipidus

0.49 L needed to correct IVF

For this patient 5.88 L needed to correct entire deficit (20 mEq).

IVF is 1/12 of TBW 0.49 X 12 = 5.88 L total body deficit

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7

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8

Diabetes Insipidus

Diabetes Insipidus ► Dehydration

► Lab: hypernatremia, hypernatremia, low urine Na & osm 295, urine osmolality plateaus - plasma but not maximal

ƒ Serum vasopressin low normal with central, high with nephrogenic ► DDAVP helps central more than nephrogenic

9

►5-10

test – results

DI: osmolality of urine < plasma

ƒ Serum vasopressin low with central, high with nephrogenic ► DDAVP corrects central

►Partial

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test – no water

► For clinical suspicion, not acute hypernatremia ► Follow urine osm hourly, plasma osm every 4 hours,

ƒ Hypothalamic (pituitary/production) ►Partial

stimulus is volume (can cause hyponatremia) hyponatremia)

ƒ Lack of ADH means water loss = dilute urine

14% higher Na

H2O = 0.6 X 70 X 0.14

retention of free water at collecting duct stimulus is tonicity (hypernatremia (hypernatremia))

► H2O

mcg SC/IV bid

= 0.6 X (wt) X [{Na/140} – 1]

ƒ Slow continuous correction ► 0.50.5-1

mEq/L/hour mEq/L/hour

ƒ Follow changes ► BMP 7/27/2004

Fluids & Electrolytes

11

7/27/2004

q 4 hours 12

2

Hyponatremia ► Low

Hyponatremia Classification

sodium indicates excess H2O

ƒ Hypertonic: a substance pulls more water into ECF ► mannitol, mannitol,

ƒ Acute hyponatremia causes brain edema ƒ Level of Na causing emergency dependent on acute or chronic ƒ Becomes an emergency when patient unstable ►Seizures,

► Remember

► Hyperproteinemia

(1mEq for 0.25gm/dl), hypertriglyceridemia (1mEq per 500mg/dl) ƒ Hypotonic: (most common) ► Hypervolemic: Hypervolemic: CHF, cirrhotic, CRF, nephrotic syndrome ► Euvolemic: Euvolemic: SIADH, adrenal insufficiency, hypothyroid, polydipsia, polydipsia, thiazides, thiazides, “tea & toast” toast” diet, beer potomania rd ► Hypovolemic: Hypovolemic: GI (N/V/D/NG), GU (remote diuresis), diuresis), 3 spacing (pancreatitis (pancreatitis,, burns).

coma

to correct for glucose

ƒ Change in Na = 1.6 for every 100 of glucose 7/27/2004

ƒ Measured osmolality needed to separate 13

Rule out adrenal insufficiency and hypothyroidism

►

Psychogenic polydipsia

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14

Euvolemic Hypotonic Hyponatremia SIADH

Euvolemic Hypotonic Hyponatremia ►

Diagnosis

►

ƒ Hyponatremia with Uosm> Uosm>Sosm (280), high urine Na ► ►

► ► ►

Thiazides ƒ ƒ ƒ ƒ

ƒ Mostly carbs metabolized to CO2, minimal solute (Na) intake 15

ml/hr 3% NS is safe until calculations made

correction causes osmotic demyelination syndrome

ƒ

Na deficit = TBW (0.6Xwt) X (Na (NaI – NaF) 42 X (120(120-108) 42 X (12) = 504 meq Na

ƒ

Salt available

ƒ May develop days after correction ƒ Can be fatal, or permanent neurological deficit ► Sodium

change should be 0.50.5-1 mEq/hr mEq/hr

ƒ Do calculation: TBW (0.6Xwt) X (Na (NaI – NaF) ƒ Check BMP regularly, q4 hour 7/27/2004

Fluids & Electrolytes

16

Example 80 yo F with tea and toast diet/thiazides diet/thiazides,, mild symptoms, appears euvolemic. euvolemic. Sodium 108, measured osm 236, urine osm 200, urine Na 10 mEq/L mEq/L

emergency (seizures/MS change)

ƒ One hour increases Na on average 11-2 mEq/L mEq/L ƒ Slow infusion when symptoms improve ► Acute

Normal solute intake 600600-900 osmoles/day osmoles/day If intake 900 osmoles & minimum Uosm 50 = 900/50 = 18 L If intake 600 osmoles & minimum Uosm 300 = 600/300 = 2 L If intake 100 osmoles & minimum Uosm 100 = 100/100 = 1 liters

Hyponatremia

ƒ 5 mEq/L mEq/L increase should be enough to reduce symptoms ► 100

Water restriction: estimate by osmoles consumed/Uosm consumed/Uosm Demeclocycline 300 mg bidbid-qid, qid, expensive Lithium daily, cheap, potential irreversible damage, CNS effects

7/27/2004

Hyponatremia Treatment ► Hyponatremic

ƒ CNS lesions, lung disease, CA (SCLC), postpost-op, drugs (TCA, SSRI, narcotics, etc), eg: eg: the middle aged post op female getting IV fluids

Estimating dilution/water restriction

►

Beer Potomania or Tea & Toast Diet

7/27/2004

Ectopic or excess physiologic ADH

ƒ Treatment

ƒ Impair solute reabsorption (Na Cl) Cl) ƒ Loops impair solute and water ►

Low uric acid, PO4, BUN

ƒ Causes

ƒ Uosm< Uosm 1M, WBC > 200, hemolysis, hemolysis, familial pseudohyperkalemia (leaky RBC)

ƒ Redistribution

► 56 mEq in ECFV normally, total body with 4200 mEq ► Metabolic Acidosis (0.6 increase for every 0.1 pH )

ƒ Respiratory Acidosis (0.3 increase for every 0.1 pH)

► Digoxin toxicity (Na(Na-K ATPase) ATPase) pump ► BetaBeta-blockers (0.2 mEq increase) ► Succinylcholine (0.5 mEq) mEq) ► Autosomal dominant hyperkalemic periodic

paralysis

ƒ Usually high K+ (6(6-8), induced by cold, high potassium diet

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22

Hyperkalemia ► Impaired

Hyperkalemia

secretion or intake?

► Treatment

ƒ TTKG = U/S K ÷ U/S Osmolality ► Renal

ƒ EKG, if no change than urgency not emergency ƒ Calcium gluconate 1 amp (1gm IV over 5 min)

defect TTKG 10, good excretion

Fluids & Electrolytes

K+ into cells after 3030-60 minutes 11-2 hours

ƒ Beta 2 agonist, albuterol neb

Causes ƒ Diet: TPN, salt substitutes ƒ Tissue breakdown: hemolysis, hemolysis, transfusion (5mEq/RBC), burns, surgery

7/27/2004

cardiac effects, immediate on EKG one hour, no change in K+

► Translocates

K+ into cells, additive to insulin & glucose mg albuterol (5mg/5ml) nebulized over 10 minutes ► Onset 30 minutes ► 1010-20

23

7/27/2004

24

4

Hyperkalemia ►

Hypokalemia

Treatment

► Clinical

ƒ HCO3 helpful when acidosis is present. ► One amp = 50 mEq NaHCO3

ƒ Sodium polystyrene sulfonate – Kayexalate ► 30

gm removes approx 30 mEq K+ (0.3 mEq/L) mEq/L) with sorbitol (2 hours) or rectally (1 hour) ► Intestinal necrosis reported ► Do not give without follow up lab ► Orally

ƒ Hemodialysis ► Definative ► Takes

findings

ƒ Weakness, paralysis, constipation, ileus, ileus, respiratory dysfunction, rhabdomyolysis, rhabdomyolysis, nephrogenic DI, spraventricular arrhythmias ƒ EKG: flattened T waves, prominent U waves

► Most

11-2 hours to begin, need line, nursing, etc

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26

Hypokalemia

Hypokalemia ► Extra

► Causes ►WBC>100

if blood sits at room temp

ƒ Redistribution

► Renal

►Insulin,

alkalemia (0.3 mEq/L mEq/L for 0.1 pH), beta agonists (Na/K ATPase), ATPase), theophylline, theophylline, B12 ►Familial hypokalemic periodic paralysis ƒ AD, recurrent flaccid paralysis in childhood ►Hypokalemic

renal losses

ƒ Urine K+ < 20, TTKG 20, TTKG > 4

ƒ RTA II-II, diuretics, low Mg, aminoglycosides, aminoglycosides, cisplatin, cisplatin, post ATN diuresis, diuresis, ketoacidosis ƒ Aldosterone excess (HTN, saline, vomiting, volume depletion) 7/27/2004

28

Hypokalemia

Calcium

► Treatment

► Vitamin

ƒ Potassium is irritating to veins ƒ PIV limit concentrations to 40 mEq/L, mEq/L, rate 10 mEq/hr mEq/hr Potassium %K mEq/g K ƒ For alkalosis ► Potassium

chloride

52

13.4

40 39 38 17

10.2 10 9.8 4.3

► PTH:

acetate ► Potassium bicarbonate ► Potassium citrate ► Potassium gluconate ► Potassium phosphate 7/27/2004

Fluids & Electrolytes

increases Ca, decreases PO4

ƒ Active on kidneys, bone ► Calcitonin: Calcitonin:

ƒ For acidosis ► Potassium

D: increases both Ca and PO4

ƒ Active on gut, kidneys, parathyroid gland

decreases Ca

ƒ Active on bone, kidney

29

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30

5

Calcium Regulation

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31

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32

Calcium regulation TAL of the loop of Henle

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33

Distal Convoluted Tubule

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34

Hypercalcemia ► Signs

and symptoms

ƒ Anorexia, N/V, acute pancreatitis, pancreatitis, stupor, coma, short QT interval, increased toxicity of cardiac glycosides, polyuria, polyuria, polydipsia, polydipsia, nephrolithiasis, nephrolithiasis, renal failure, calciphylaxis. calciphylaxis.

7/27/2004

Fluids & Electrolytes

35

7/27/2004

36

6

Hypercalcemia

Hypercalcemia ►

Elevated PTH ƒ Li (increases PTH), familial hypocalciuric hypercalcemia (inactivation of calcium receptor, AD), primary HPTH, tertiary hyperparathyroidism

►

Normal PTH, Elevated PTHrp

►

Normal PTH, normal PTHrp, PTHrp, Elevated Vitamin D

ƒ Cancer (squamous (squamous lung cancer)

a

ƒ Hypervitaminosis D, Granulomatous disease (sarcoid (sarcoid,, lymphoma, TB) ►

Normal PTH, normal PTHrp, PTHrp, normal vitamin D ƒ Thiazides, Thiazides, vitamin A toxicity, hyperthyroidism, immobilization, Paget’ Paget’s disease, MM/breast/lung/lymphoma

7/27/2004

37

7/27/2004

Hypercalcemia ►

Mild Ca 12

Hypocalcemia ► Signs

ƒ Hydration orally, correct disorder ƒ ƒ ƒ ƒ ƒ ƒ

and symptoms

ƒ Tetany, Tetany, seizures, coma, long QT, fractures, brittle nails, parasthesias ƒ Calcium changes 0.8 for each 1 of albumin ƒ Measure Ionized calcium for accuracy

IVF NS for UOP 100cc/hour Loop diuretic if needed for UOP Hemodialysis if in renal failure or nonresponsive Steroids for granulomatous disease/Vit disease/Vit D Calcitonin: Calcitonin: mild effect, short acting, tachyphylaxis Bisphosphonates ► Pamidronate: Pamidronate:

38

IV, 30/60/90 mg, dosed every 4 wks, long lasting

ƒ Association nephrotic syndrome, collapsing FSGS

► Zoledronic acid (Zometa ): IV, 4 mg, (Zometa): ► Etidronate: Etidronate: PO daily or IV X 3d then ► Alendronate, Alendronate,

risedronate PO

dose every week, short infusion q wk

7/27/2004

39

7/27/2004

Hypocalcemia ►

40

Hypocalcemia

Normal/elevated Vit D & PTH – calcium loss ƒ Loop diuretics, tumor lysis sundrome, sundrome, rhabdomyolysis, rhabdomyolysis, pancreatitis, pancreatitis, hungry bone syndrome, citrate from blood products

►

Vitamin D deficiency ƒ Low sun, low intake, low production (phenytoin (phenytoin,, barbiturates for liver, chronic kidney disease)

►

PTH deficiency: Hypoparathyroidism ƒ Congenital (DiGeorge (DiGeorge Syndrome), acquired (thyroidectomy (thyroidectomy,, irradiation, hungry bone syndrome/Post op HPTH), functional (low Mg)

►

Pseudohypoparathyroidism ƒ Low calcium, high phosphorus, high PTH ƒ PTH receptor resistance

7/27/2004

Fluids & Electrolytes

41

7/27/2004

42

7

Hypocalcemia

Phosphorus

► Replacement

ƒ Calcium 1500 mg/d PO ►On

empty stomach

ƒ 1-2 gm calcium gluconate IV ƒ Vitamin D ►400

IU qd PO

► Conservation

ƒ Thiazide or potassium sparing diuretics 7/27/2004

43

7/27/2004

44

Phosphorus ► Hyperphosphotemia

ƒ Signs & Symptoms

► Acute: no significant changes ► Chronically: Uremic calcific arteriolopathy

= cardiac calcification

ƒ Increased intake ► Excess

vitamin D, fleets phosphosoda

ƒ Decreased excretion ► Hypoparathyroidism, Hypoparathyroidism, ► Kidney failure

rhabdo, rhabdo, tumor lysis, lysis, burns, trauma

ƒ Treat with phosphorus binders ► Calcium carbonate, calcium acetate, sevelamer, sevelamer, aluminum, magnesium carbonate ► Dietary restriction

7/27/2004

45

7/27/2004

46

Phosphorus

Replacement

► Hypophosphotemia

ƒ May lead to weakness (respiratory, cardiac or ileus) ileus) or rhabdomyolysis, rhabdomyolysis, potential CNS changes ƒ PO4 < 1 requires IV treatment

PO

Phosphate mg

Sodium mEq

Potassium Meq

K-Phos Neutral

250

13

1.1

NeutraNeutra-Phos

250

7.1

7.1

NeutraNeutra-Phos K

250

0

14.2

ƒ Insufficient intake

IV

Mmol/ml Mmol/ml

mEq/ml mEq/ml

mEq/ml mEq/ml

ƒ Increased loss

Potassium phosphate

3

0

4.4

Sodium phosphate 3

4

0

► Other

by PO

► Chronic

alcoholism, vitamin D deficiency, steroid therapy, Cushing’ Cushing’s, malabsorption, malabsorption, steatorrhea, steatorrhea, diarrhea

► Primary

hyperparathyroidism, PTHrp, PTHrp, tumor associated osteomalacia, osteomalacia, fanconi syndrome, foscarnet, foscarnet, ifosfamide, ifosfamide, cisplatin, cisplatin, aminoglycosides, aminoglycosides, diuresis acetozolamide > thiazides >loop

7/27/2004

Fluids & Electrolytes

3 mmol/ml of phosphate corresponds to 93 mg of phosphorus 47

7/27/2004

48

8

Magnesium ►

Magnesium

Hypermagnesemia ƒ N/V, lethargy, hypotension, bradycardia, bradycardia, loss of DTR. ► Mag

> 9 causes paralysis, heart block.

ƒ Indication for dialysis ► Requires

►

administration

Hypomagnesemia ƒ Tetany, Tetany, weakness, seizures, long QT, U waves, arrhythmias, potassium wasting, impaired PTH, osteomalacia ► GI:

nutrition, malabsorption, malabsorption, bowel resection, etc osmotic diuresis, diuresis, loop diuretics, ampho B, aminoglycosides, aminoglycosides, pentamidine, pentamidine, cisplatin, cisplatin, alcohol

► Renal:

ƒ 24 hour collection Mg > 24 mg indicates renal wasting

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50

Magnesium

Thanks ► Hypertension,

HDCN.com

Dialysis and Clinical Nephrology at

ƒ Links and presentations on all kidney diseases

► Online

clinical calculators

ƒ ABG, fluids, FENa, FENa, TTKG, BMI, GFR, steroid conversion ƒ MedCalc.com

► Palm

application: NephroToGo

ƒ OS/PC app with concise review of kidney disease ƒ nephrotogo.com

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Fluids & Electrolytes

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9