Fluid_Lyte_LectureFinal_2012

Lab 78 urine osm 430 14 urine na 32 meql q what is the

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Lab: 122 / 92 / 18 78 urine Osm 430 mOsm/L 4.2 / 24 / 1.4 urine Na 32 mEq/L Q: What is the serum osmolality? Q: Is there an electrolyte abnormality? Q: What should be considered in the differential diagnosis?
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Hypotonic, Euvolemic, Hyponatremia sOsm < 280 Euvolemic Uosm > 100 Uosm < 100 U Na > 20 r/o hypothyroid, SIADH, renal failure U Na < 20 Primary polydipsia Low solute intake Increased TBW & ECF volume, decreased ECF Na Water intoxication Glucocorticoid deficiency Hypothyroidism Hypokalemia SIADH SIADH causes: CNS – head trauma, stroke, pituitary surgery CA – lung Pulmonary dz pneumonia Drugs – next slide
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Drug Induced SIADH ADH analogues DDAVP Oxytocin Enhanced ADH release Chlorpropamide Carbamazepine Vincristine Nicotine Narcotics Antipsychotics Antidepressants Ifosfamide Potentiate ADH effects Chlorpopramide Cyclosphosphamide NSAIDs Acetaminophen Unknown etiology Haloperidol Fluphenazine Amitriptyline Thioridazine Fluoxetine
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Hypertonic Conditions Sosm > 300 mOsm/kg Abnormal water balance secondary to: 1. Excessive water loss 2. Sodium/solute gain Hypernatremia does not occur unless 1. No access to water 2. Hypodipsia
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Hyponatremia with Elevated or Normal Sosm Hypertonic, hyponatremia High plasma osmolality (> 280 mOsm) Hyperglycemia Mannitol Pseudohyponatremia Normal plasma osmolality (~ 280 mOsm) Pseudohyponatremia Hyperlipidemia Hyperproteinemia Glycine solutions ↑ 100 mg/dl glucose - ↓ [Na] 1.6 128 / 98 / 10 524 3.6 / 18 / 0.8 7.21 / 35 / 92 524-100 = 424 424/100 = 4.24 4.24 (1.6) = 6.78 128+6.78 = 135 Na / Cl / BUN glucose K / HCO 3 / SCr pH / pCO 2 / pO 2
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Case # 5 Joe is an 85 y/o with advanced dementia who was sent to the ED from his skilled nursing facility. This AM the nurse found him to be unresponsive. The remainder of his PMH is unknown. Aside from his mental status, his physical exam is remarkable for a BP 100/50, HR 110. Labs: 164 / 126 / 50 98 4.8 / 28 / 2.6 Q: What is the serum osmolality? Q: Assess the volume status. Q: Are there any electrolyte abnormalities? Q: What would potentially correct this situation?
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Signs & Symptoms CNS Altered mental status Lethargy Irritability Restlessness Seizures Muscle twitching, hyper-reflexia Fever Nausea / vomiting Labored breathing
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Hypernatremia Caused by: Hypertonic Na Gain NaHCO 3 infusion Hypertonic enteral feeding formulation Ingestion of NaCl Sea water Hypertonic saline enemas Hypertonic saline infusion Hypertonic dialysis Primary hyperaldosteronism Cushing’s disease
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Causes of Hypernatremia Decreased total body sodium (loss of both water > sodium) Diarrhea Excess sweating Diabetes insipidus Osmotic diuresis Normal total body sodium (loss of water) Increased insensible losses Low humidity Increased ambient temperature Fever
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Decreased total body sodium (loss of both water > sodium) Renal causes Loop diuretics Osmotic diuresis (glucose, mannitol) Post-obstructive Polyuric phase of ATN Intrinsic CKD
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