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Fluid_and_Electrolyte_Abnormalities

Fluid_and_Electrolyte_Abnormalities - Fluid and Electrolyte...

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Unformatted text preview: Fluid and Electrolyte Abnormalities Hypovolemia Hypovolemia Mild: 4% loss TBW or < 15% blood volume Moderate: 6% TBW or 15­30% BV Severe: 8% TBW or 30­40% BV Shock: >8% TBW or > 40% BV S/Sx: MS changes, sleepy, apathy, coma orthostatic, tachy, decreased pulse pressure, low CVP, low PCWP Poor turgor, hypothermia, dry membranes Oliguria, ileus, weakness Hypovolemia, continued Hypovolemia, continued Lab: BUN:Cr ratio greater than 20 Inc. hematocrit, 3% per liter deficit FeNa < 1%, increased urine spec. gravity and osmolality Hypovolemia, continued Hypovolemia, continued Treatment: Acute: 2L LR via large bore IV then blood Subacute: Isotonic or hypotonic deficits give isotonic NS or hypotonic 1/2NS or LR (e.g. vomiting = NS, diarrhea = LR) Hypertonic deficits (e.g. dehydration with jejunal feedings) give D5W. Seen in fever, ventilator, or diaphoresis Hypervolemia Hypervolemia Etiology: Cardiac failure, Renal failure, mobilization of fluid, iatrogenic, psychologic or Ecstasy S/Sx: Wt gain over baseline. (Fasting losses are 0.25­0.5 kg/day) JVD, rales or wheezing, pedal/sacral edema elevated CVP or PCWP Pulmonary edema on CXR Hypervolemia, continued Hypervolemia, continued Lab: Decreased Hct and albumin Na may be low, normal or increased but total body Na is usually increased Treatment: Water restrict to 1500 cc/day +/­ Diuretics Sodium restrict to 0.5 gm/day (Albumin followed by diuretics) Hyponatremia Hyponatremia Forms Hypotonic Hypovolemic with loss of isotonic fluid and hypotonic replacement Hypervolemic due to retention states Isovolemic due to free water overload, SIADH, renal dx, hypokalemia (ADH sensitization) Isotonic or “pseudohyponatremia” Occurs with hypertriglyceridemia or hyperproteinemia Hypertonic Non sodium osmotics induce redistribution (glucose, mannitol) for each 100mg/dl of glucose over 100 Na is decreased by 3 mEq/L Hyponatremia, continued Hyponatremia, continued S/Sx: Neurologic: muscle twitching, hyperreflexia, seizures and HTN Salivation, lacrimation, diarrhea Often asymptomatic if slow until below 120 mEq/L. (130 mEq/L if acute) Treatment: correct underlying disorder Fluid restrict, + diuretics Hypertonic saline to increase level 2­3 mEq/L/hr and max rate 100cc of 5% saline/hr Hypernatremia Hypernatremia Free water deficit or water loss greater than salt loss. Always assoc with hyper osmolar state. Forms: Hypervolemic: loss of hypotonic fluids with inadequate replacement with hypertonic fluids Isovolemic is subclinical hypovolemia seen in diabetes insipidus Hypervolemic usually iatrogenic, also Cushing’s, Conn’s, CAH Hypernatremia, continued Hypernatremia, continued S/Sx: Neurologic: restless, seizure, coma, delirium and mania Sticky mucus membranes, poor salivation/lacrimation, hyperpyrexia, Red swollen tongue THIRST, weakness Treatment: correct underlying disorder Free water replacement: (0.6 * kg BW) * ((Na/140) – 1). Slow infusion of D5W give ½ over first 8 hrs then rest over next 16­24 hrs to avoid cerebral edema. Hypokalemia Hypokalemia Etiology: Intracellular uptake with redistribution seen in acute alkalosis, inmsulin therapy, and anabolism Depletion due to GI losses, renal/diuretics, steroids, and renal tubular acidosis S/Sx: Clinical: muscle weakness/fatigue, decreased DTR’s, ileus. Insulin resistance in DM EKG: low, flat T­waves, ST depression, and U waves Hypokalemia, continued Hypokalemia, continued ECG changes in hypokalemia Hypokalemia, continued Hypokalemia, continued Treatment: Check renal function Treat alkalosis, decrease sodium intake PO with 20­40 mEq doses IV: peripheral 7.5 mEq/hr, central 20 mEq/hr and increase K+ in maintenance fluids. Hyperkalemia Hyperkalemia Etiology: Psuedohyperkalemia in leukocytosis, hemolysis and thrombocytosis Redistribution in acidosis, hypoinsulinism, tissue necrosis, digoxin poisoning Renal insufficiency, mineralocorticoid deficiency, DM, spironolactone use Hyperkalemia, continued Hyperkalemia, continued S/Sx: Clinical: nausea/vomiting, colic, weakness diarrhea EKG: early – peaked T waves then flat P waves, depressed ST segment, widened QRS progressing to sine wave and V fib. Cardiac arrest occurs in diastole Hyperkalemia – ECG Changes Hyperkalemia – ECG Changes Hyperkalemia, continued Hyperkalemia, continued Treatment: Remove iatrogenic causes Acute: if > 7.5 mEq/L or EKG changes Ca­gluconate – 1 gm over 2 min IV Sodium bicarbonate – 1 amp, may repeat in 15min D50W (1 ampule = 50 gm) and 10U regular insulin Emergent dialysis Hydration and diuresis, kayexalate 20­50 g, in 100­200cc of 20% sorbitol q 4hrs or enema Calcium Calcium Hypocalcemia: Seen in hypoalbuminemia. Check ionized Ca Often symptomatic below 8 mEq/dL Check PTH: low may be Mg deficiency High think pancreatitis, hyperPO4, low Vitamin D, pseudohypoparathyroidism, massive blood transfusion, drugs (e.g. gentamicin) renal insufficiency S/Sx: numbness, tingling, circumoral paresthesia, cramps tetany, increased DTR’s, Chvostek’s sign, Trousseau’s sign EKG has prolonged QT interval ECG Changes in Calcium Abnormalities ECG Changes in Calcium Abnormalities Calcium, continued Calcium, continued Hypocalcemia cont. Treatment: Acute: (IV) CaCl 10 cc of 10% solution = 6.5 mmole Ca or CaGluconate 10cc of 10% solution = 2.2 mmole Ca Chronic: (PO) 0.5­1.25 gm CaCO3 = 200­500 mg Ca. Phosphate binding antacids improve GI absorption of Ca Vit D (calciferol) must have normal serum PO4. Start 50,000 – 200,000 units/day Calcium, continued Calcium, continued Hypercalcemia Usually secondary to hyperparathyroidism or malignancy. Other causes are thiazides, milk­alkali syndrome, granulomatous disease, acute adrenal insufficiency Acute crisis is serum Ca> 12mg/dL. Critical at 16­ 20mg/dL S/Sx: N/V, anorexia, abdominal pain, confusion, lethargy MS changes= “Bones, stone, abdominal groans and psychic overtones.” Calcium, continued Calcium, continued Treatment: Hydration with NS then loop diuretic. Steroids for lymphoma, multiple myeloma, adrenal insufficiency, bone mets, Vit D intoxication. May need Hemodialysis. Mithramycin for malignancy induced hyperCa refractory to other treatment. Give 15­25 mcg/kg IVP Calcitonin in malignant PTH syndromes Magnesium Magnesium Hypomagnesemia Malnutrition, burns, pancreatitis, SIADH, parathyroidectomy, primary hyperaldosteronism S/Sx: weakness, fatigue, MS changes, hyperreflexia, seizure, arrhythmia Treatment: IV replacement of 2­4 gm of MgSO4 per day or oral replacement Magnesium, continued Magnesium, continued Hypermagnesemia Renal insufficiency, antacid abuse, adrenal insufficiency, hypothyroidism, iatrogenic S/Sx: N/V, weakness, MS changes, hyporeflexia, paralysis of voluntary muscles, EKG has AV block and prolonged QT interval. Treatment: Discontinue source, IV CaGluconate for acute Rx, Dialysis Phosphate Phosphate Hypophosphatemia Seen in hyperalimentation, after starvation, DKA, malabsorption, phosphate binding antacids, alkalosis, hemodialysis, hyperparathyroidism S/Sx: myocardial depression due to low ATP, shift of oxyhemoglobin curve to left due to low 2,3 DPG, anorexia, bone pain, hemolysis, cardiac arrest Phosphate Phosphate Treatment: PO replacement (Neutraphos) or IV KPhos or NaPhos 0.08­0.20 mM/kg over 6 hrs Hyperphosphatemia Renal insufficiency, hypoparathyroidism, may produce metastatic calcification Treat with restriction and phosphate­binding antacid (Amphogel) Zinc Zinc 1­2 gm in body (brain, pancreas, liver, kidney, prostate and testis) Enzyme activator and cofactor Deficiency in malabsorption, trauma, IBD, refeeding syndrome, cancer or diarrhea Absorbed in terminal ileum S/Sx: “4 D’s” – diarrhea, depression, dermatitis, dementia Also alopecia, nyctalopia, tremor, loss of taste Treat with zinc sulfate 3­6mg/day if with (normal number of stools) ...
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