BEFORE the session. Sodium & Water Assessment & Therapeutics. LMPS Residents

Transcription

1 BEFORE the session 1. Get Loewen s Sodium & Water Assessment & Therapeutics 1-pager at 2. Read McGee S, Abernethy WB, Simel DL. Is this patient hypovolemic? JAMA 1999;281: Install MedCalX, QxCalculate, Medal, Mediquations, or equivalent on your phone and find these calculators in there: Water deficit or Free water deficit Change in serum sodium Fractional excretion of Na LMPS Residents Sodium & Water Assessment & Therapeutics Dr. Peter Loewen B.Sc.(Pharm), ACPR, Pharm.D., FCSHP, RPh Associate Professor, University of British Columbia peter.loewen@ubc.ca

2 Why does it matter? Your patient is on multiple antihypertensives and today complains of dizziness on rising. BP reasonably well controlled. Should you decrease the dose of an antihypertensive? Your patient with Parkinson's disease seems to be developing postural hypotension. Does he need midodrine? You're consulted about a patient with severe hyponatremia and recent SSRI initiation. Is the hyponatremia drug-induced? Your CHF patient needs to be started on ACE-I. Her SCr is 155. How worried about a rise in SCr upon starting ACE-I are you? Your CHF patient is stable on ramipril 10mg, B-blocker, and furosemide 40mg. Lately his SCr has been creeping up. Physicians intends to decrease the ramipril dose because everybody knows ACE-I can cause renal failure. Is this a good idea? Your patient with HTN is admitted to hospital with CAP and has a serum Na of 129. Admitting physicians documents that the patient's HCTZ is being held due to "HCTZinduced hyponatremia" and that it should not be restarted. Is this sensible? Your patient has recurrent angina despite amlodipine+ntg patch. You believe metoprolol will be indicated, but are worried about his standing BP of 110/70 and postural drop. Can his anti-ischemic therapy be augmented? Ever been asked to "please procure some demeclocycline"? Know what tolvaptan is? Your vancomycin-treated patient is starting to show signs of GFR decline. Is it due to vancomycin? BY THE END OF THE SESSION, AND UPON REFLECTION & PRACTICE, STUDENTS SHOULD BE ABLE TO 1.Describe the difference between water and volume, dehydration, and volume depletion 2.Using physical assessment and laboratory parameters, diagnose the type of water-related defect a patient exhibits (e.g. hypovolemia, hyponatremia, hypernatremia, SIADH) 3.Demonstrate an APPROACH to evaluating water-related problems in a patient and their potential causes 4.Design a detailed therapeutic plan for treating the water-related disorder, including: Selecting and writing orders for an appropriate crystalloid solution (if required) or other drug therapy. Quantitative determination of quantities of crystalloid required and infusion rates Writing orders for (or conducting themselves) an appropriate monitoring plan.

3 The Plan Concepts Approach to assessing our patients Therapeutic options for our patients Treatment plans hypovolemia hypernatremia hyponatremia hypervolemia

4 To deepen and reinforce your knowledge & skill:

5 Where s your water? Total body water (TBW) = 0.6* x total body weight *More precisely: 0.45 for elderly female, 0.5 for non-elderly female or elderly male, 0.6 for non-elderly male. Intracellular fluid (ICF) Intracellular osmolality must be maintained for cells to function. Plasma osmolality will be sacrificed in either direction to achieve this. H2O freely crosses cell membranes. Na+ doesn t. Intracellular osmoles are mostly large proteins that don t move. H 2 O cell membrane Extracellular fluid (ECF) interstitial water 2/3 1/3 H 2 O Na+ intravascular water 3/4 1/4 Biological Imperatives maintain BP maintain intracellular environment (ph, temperature, osmolality)

6 tonicity= the effective osmolality and is equal to the sum of the concentrations of the solutes which have the capacity to exert an osmotic force across the membrane ( effective osmoles ). Intracellular fluid (ICF) proteins Extracellular fluid (ECF) Na+ albumin EFFECTIVE OSMOLES Na K glucose mannitol (proteins - not solutes, but very effective) INEFFECTIVE OSMOLES urea ethanol methanol Spasovski G, et al. Eur J Endocrinol Feb 4;170(3):G1 G47. Words matter hypervolemia excess excess ICF hyponatremia euvolemia ECF ICF hypovolemia depletion dehydration

7 CASE 1: RK CASE 1: RK RK is an 83 y/o F admitted to your medical unit from assisted living with a 5-day history of coughing, difficulty breathing and increasing confusion. HPI: RK was in her usual state of health until one week ago when she developed what appeared to be an URTI. Her cough gradually got worse, being occasionally productive of yellowish sputum. She became increasingly confused over the following days. PMH: Stroke 6 months ago with some residual R sided weakness, Mild HTN, GERD, OA (knees) O/E: Wt. 50 kg (usually 54 kg), Temp 40C. Chest dull to auscultation and percussion. RR 27. Oriented x 1. CXR shows some RLL consolidation.

8 CASE 2: KP CASE 2: KP KP is a 77 y/o M brought to your urgent care center from home because of increasing lethargy and confusion over the past 48 hours. HPI: He has had diarrhea for the past 4 days subsequent to a course of cefuroxime for mild CAP, and has been receiving HCTZ 25 mg/d for one year for isolated systolic hypertension. PMH: HTN. CAP. O/E: Oriented x 3. ~80kg. 100/60 supine, 75/45 standing. HR 65 supine, 80 standing. JVP <2cm ASA.

9 CASE 3: BW CASE 3: BW BW is a 67 y/o white M who presents to your primary care clinic complaining of general malaise and increasing confusion for one week. PMH: - Carcinoma of the bronchus (surgical resection and radiation therapy) 4 months ago - Mild HTN x 5 y (metoprolol 100 mg po bid) - Depression (diagnosed 4 months ago and treated with fluoxetine 50 mg/d) O/E: Moderately obese, disoriented white male. BP 150/85 supine, 145/85 standing. HR 70 supine, 75 standing. Temp 36.8C, Wt. 100 kg, JVP 3 cm ASA.

10 Assessing your patient

11

12 Postural changes wait 1 minute! 2 minutes severe dizziness or HR 30 bpm or SBP 20 mmhg McGee S et al. JAMA. 1999;281: JVP

13

14 Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF) Why does serum [Na+] reflect ICF and what does it mean? H2O goes in Serum [Na+] is the best reflection of ICF status. Expanded ICF [Na+], or [Na+] reflects ICF Intracellular tonicity decreases ICF Need to maintain normal intracellular tonicity H2O moves ECF [Na+] Contracted ICF [Na+], or [Na+] reflects ICF H2O leaves [loop diuretics, fever] ICF Intracellular tonicity increases Need to maintain normal intracellular tonicity ECF H2O moves [Na+]

15 How does excess ICF cause hyponatremia? ICF ECF H2O goes in Intracellular tonicity decreases Need to maintain normal intracellular tonicity H2O moves [Na+] IV How does loss of ICF cause hypernatremia? H2O leaves [loop diuretics, fever] ICF Need to Intracellular maintain tonicity normal increases intracellular tonicity ECF H2O moves [Na+] IV

16 CASE 1: RK CASE 1: RK RK is an 83 y/o F admitted to your medical unit from assisted living with a 5-day history of coughing, difficulty breathing and increasing confusion. HPI: RK was in her usual state of health until one week ago when she developed what appeared to be an URTI. Her cough gradually got worse, being occasionally productive of yellowish sputum. She became increasingly confused over the following days. PMH: Stroke 6 months ago with some residual R sided weakness, Mild HTN, GERD, OA (knees) O/E: Wt. 50 kg (usually 54 kg), Temp 40C. Chest dull to auscultation and percussion. RR 27. Oriented x 1. CXR shows some RLL consolidation.

17 CASE 1: RK Questions about what you see here? What prompts you to be concerned about a Na/H2O problem? What is your APPROACH to assessing RK from a Na/H2O viewpoint? CASE 1: RK Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF)

18 CASE 1: RK CASE 1: RK What s your ASSESSMENT?

19 CASE 2: KP CASE 2: KP KP is a 77 y/o M brought to your urgent care center from home because of increasing lethargy and confusion over the past 48 hours. HPI: He has had diarrhea for the past 4 days subsequent to a course of cefuroxime for mild CAP, and has been receiving HCTZ 25 mg/d for one year for isolated systolic hypertension. PMH: HTN. CAP. O/E: Oriented x 3. ~80kg. 100/60 supine, 75/45 standing. HR 65 supine, 80 standing. JVP <2cm ASA.

20 CASE 2: KP Questions about what you see here? What prompts you to be concerned about a Na/H2O problem? What is your APPROACH to assessing KP from a Na/H2O viewpoint? CASE 2: KP Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF)

21 CASE 2: KP CASE 2: KP What s your ASSESSMENT?

22 CASE 3: BW CASE 3: BW BW is a 67 y/o white M who presents to your primary care clinic complaining of general malaise and increasing confusion for one week. PMH: - Carcinoma of the bronchus (surgical resection and radiation therapy) 4 months ago - Mild HTN x 5 y (metoprolol 100 mg po bid) - Depression (diagnosed 4 months ago and treated with fluoxetine 50 mg/d) O/E: Moderately obese, disoriented white male. BP 150/85 supine, 145/85 standing. HR 70 supine, 75 standing. Temp 36.8C, Wt. 100 kg, JVP 3 cm ASA.

23 CASE 3: BW Questions about what you see here? What prompts you to be concerned about a Na/H2O problem? What is your APPROACH to assessing BW from a Na/H2O viewpoint? CASE 3: BW Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF)

24 CASE 3: BW CASE 3: BW What s your ASSESSMENT? Why is this happening to BW? What other tests do we look at?

25 TRAP Treating deficiencies of ECF and ICF

26 CRYSTALLOIDS COLLOIDS

27 Osmolality of IV fluids matters. Why?

28 Another perspective on crystalloids Normal plasma osmolality: mosm/kg (~mmol/kg, ~mmol/l) Normal serum [Na+]: meq/l Osmolality (mosm/l) [Na] ( & Cl) (meq/l) Dextrose (g/l) NS (0.9% NaCl) Cal/L D5W /2NS D5-1/2NS /3D5-1/3NS % NaCl Seawater ~1000 ~475 Gatorade 365 ~20 ~220

29 Oral rehydration 413 mg of Na = 18 meq

30 CASE 1: RK CASE 1: RK RK is an 83 y/o F admitted to your medical unit from assisted living with a 5-day history of coughing, difficulty breathing and increasing confusion. HPI: RK was in her usual state of health until one week ago when she developed what appeared to be an URTI. Her cough gradually got worse, being occasionally productive of yellowish sputum. She became increasingly confused over the following days. PMH: Stroke 6 months ago with some residual R sided weakness, Mild HTN, GERD, OA (knees) O/E: Wt. 50 kg (usually 54 kg), Temp 40C. Chest dull to auscultation and percussion. RR 27. Oriented x 1. CXR shows some RLL consolidation.

31 CASE 1: RK Managing RK s Na & H2O issues: 1. Treat the HYPOVOLEMIA 2. Treat the HYPERNATREMIA CASE 1: RK Managing RK s Na & H2O issues: 1. Treat the HYPOVOLEMIA

32 CASE 1: RK Managing RK s Na & H2O issues: 2. Treat the HYPERNATREMIA CASE 1: RK Managing RK s Na & H2O issues: 2. Treat the HYPERNATREMIA

33 CASE 1: RK Orders for RK: Monitoring Plan: CASE 1: RK Orders for RK: 1. NS 500mL IV over 60mins 2. reassess 60mins 3. when euvolemic, start D5W ml/h Monitoring Plan: - serum electrolytes 8h after starting D5W infusion (target Na+?), frequency TBA thereafter - adjust infusion to achieve 0.5 mmol/l/h drop in serum [Na+] - continue until serum [Na+] ~145 and normal PO water intake

34 CASE 2: KP CASE 2: KP KP is a 77 y/o M brought to your urgent care center from home because of increasing lethargy and confusion over the past 48 hours. HPI: He has had diarrhea for the past 4 days subsequent to a course of cefuroxime for mild CAP, and has been receiving HCTZ 25 mg/d for one year for isolated systolic hypertension. PMH: HTN. CAP. O/E: Oriented x 3. ~80kg. 100/60 supine, 75/45 standing. HR 65 supine, 80 standing. JVP <2cm ASA.

35 CASE 2: KP Managing KP s Na & H2O issues: 1. Treat the HYPOVOLEMIA CASE 2: KP Managing KP s Na & H2O issues: 1. Treat the HYPOVOLEMIA

36 CASE 2: KP Orders for KP: Monitoring Plan: CASE 2: KP Orders for KP: 1. NS 500mL IV over 30mins 2. reassess 30mins Monitoring Plan: - serum electrolytes in 4h - decide whether to admit - manage the diarrhea - decide re: antibiotic, CAP status

37 CASE 3: BW CASE 3: BW BW is a 67 y/o white M who presents to your primary care clinic complaining of general malaise and increasing confusion for one week. PMH: - Carcinoma of the bronchus (surgical resection and radiation therapy) 4 months ago - Mild HTN x 5 y (metoprolol 100 mg po bid) - Depression (diagnosed 4 months ago and treated with fluoxetine 50 mg/d) O/E: Moderately obese, disoriented white male. BP 150/85 supine, 145/85 standing. HR 70 supine, 75 standing. Temp 36.8C, Wt. 100 kg, JVP 3 cm ASA.

38 CASE 3: BW Managing BW s Na & H2O issues CASE 3: BW Orders for BW: Monitoring Plan:

39 CASE 3: BW Orders for BW: 1. D/C fluoxetine 2. water restriction <500mL/d 3. liberalize salt in diet >10g/d Monitoring Plan: - decide whether to refer him for possible admission, home environment, supportive care - choose an alternate antidepressant, depending on response to fluoxetine so far - daily serum electrolytes until Na steadily rising - daily assessment of confusion CASE 3: BW ADVANCED TOPIC: what if BW had severe symptoms of hyponatremia and we wanted to give 3%NaCl IV to raise his serum [Na+] quickly?

40 CASE 3: BW ADVANCED TOPIC: what if BW had severe symptoms of hyponatremia and we wanted to give 3%NaCl IV to raise his serum [Na+] quickly?

41 To deepen and reinforce your knowledge & skill:

42 Why does it matter? Your patient is on multiple antihypertensives and today complains of dizziness on rising. BP reasonably well controlled. Should you decrease the dose of an antihypertensive? Your patient with parkinson's disease seems to be developing postural hypotension. Does he need midodrine? You're consulted about a patient with severe hyponatremia and recent SSRI initiation. Is the hyponatremia druginduced? Your CHF patient needs to be started on ACE-I. Her SCr is 155. How worried about a rise in SCr upon starting ACE-I are you? Your CHF patient is stable on ramipril 10mg, B-blocker, and furosemide 40mg. Lately his SCr has been creeping up. Physicians intends to decrease the ramipril dose because everybody knows ACE-I can cause renal failure. Is this a good idea? Your patient with HTN is admitted to hospital with CAP and has a serum Na of 129. Admitting physicians documents that the patient's HCTZ is being held due to "HCTZ-induced hyponatremia" and that it should not be restarted. Is this sensible? Your patient has recurrent angina despite amlodipine+ntg patch. You believe metoprolol will be indicated, but are worried about his standing BP of 110/70 and postural drop. Can his anti-ischemic therapy be augmented? Ever been asked to "please procure some demeclocycline"? Know what tolvaptan is? Your vancomycin-treated patient is starting to show signs of GFR decline. Is it due to vancomycin? Learning Objectives/Outcomes

43 The Plan Concepts Approach to assessing our patients Therapeutic options for our patients Treatment plans hypovolemia hypernatremia hyponatremia hypervolemia

44 Where s your water? Total body water (TBW) = 0.6* x total body weight *More precisely: 0.45 for elderly female, 0.5 for non-elderly female or elderly male, 0.6 for non-elderly male. Intracellular fluid (ICF) Extracellular fluid (ECF) Intracellular osmolality must be maintained for cells to function. Plasma osmolality will be sacrificed in either direction to achieve this. H2O freely crosses cell membranes. Na+ doesn t. Intracellular osmoles are mostly large proteins that don t move. H 2 O cell membrane interstitial water H 2 O Na+ intravascular water 2/3 1/3 3/4 1/4

45 Biological Imperatives maintain BP maintain intracellular environment (ph, temperature, osmolality) tonicity= the effective osmolality and is equal to the sum of the concentrations of the solutes which have the capacity to exert an osmotic force across the membrane ( effective osmoles ). Intracellular fluid (ICF) proteins Extracellular fluid (ECF) Na+ albumin EFFECTIVE OSMOLES Na K glucose mannitol (proteins - not solutes, but very effective) INEFFECTIVE OSMOLES urea ethanol methanol Spasovski G, et al. Eur J Endocrinol Feb 4;170(3):G1 G47.

46 Words matter hypervolemia excess excess ICF hyponatremia euvolemia ECF ICF hypovolemia depletion dehydration CASE 1: RK

47 CASE 1: RK RK is an 83 y/o F admitted to your medical unit from assisted living with a 5-day history of coughing, difficulty breathing and increasing confusion. HPI: RK was in her usual state of health until one week ago when she developed what appeared to be an URTI. Her cough gradually got worse, being occasionally productive of yellowish sputum. She became increasingly confused over the following days. PMH: Stroke 6 months ago with some residual R sided weakness, Mild HTN, GERD, OA (knees) O/E: Wt. 50 kg (usually 54 kg), Temp 40C. Chest dull to auscultation and percussion. RR 27. Oriented x 1. CXR shows some RLL consolidation. CASE 2: KP

48 CASE 2: KP KP is a 77 y/o M brought to your urgent care center from home because of increasing lethargy and confusion over the past 48 hours. HPI: He has had diarrhea for the past 4 days subsequent to a course of cefuroxime for mild CAP, and has been receiving HCTZ 25 mg/d for one year for isolated systolic hypertension. PMH: HTN. CAP. O/E: Oriented x 3. ~80kg. 100/60 supine, 75/45 standing. HR 65 supine, 80 standing. JVP <2cm ASA. CASE 3: BW

49 CASE 3: BW BW is a 67 y/o white M who presents to your primary care clinic complaining of general malaise and increasing confusion for one week. PMH: - Carcinoma of the bronchus (surgical resection and radiation therapy) 4 months ago - Mild HTN x 5 y (metoprolol 100 mg po bid) - Depression (diagnosed 4 months ago and treated with fluoxetine 50 mg/d) O/E: Moderately obese, disoriented white male. BP 150/85 supine, 145/85 standing. HR 70 supine, 75 standing. Temp 36.8C, Wt. 100 kg, JVP 3 cm ASA. Assessing your patient

50

51

52 Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF)

53 Why does serum [Na+] reflect ICF and what does it mean? H2O goes in Serum [Na+] is the best reflection of ICF status. Expanded ICF [Na+], or [Na+] reflects ICF Intracellular tonicity decreases ICF Need to maintain normal intracellular tonicity H2O moves ECF [Na+] Contracted ICF [Na+], or [Na+] reflects ICF H2O leaves [loop diuretics, fever] ICF Intracellular tonicity increases Need to maintain normal intracellular tonicity H2O moves ECF [Na+] How does excess ICF cause hyponatremia? ICF ECF H2O goes in Intracellular tonicity decreases Need to maintain normal intracellular tonicity H2O moves [Na+] IV

54 How does loss of ICF cause hypernatremia? H2O leaves [loop diuretics, fever] ICF Need to Intracellular maintain tonicity normal increases intracellular tonicity ECF H2O moves [Na+] IV CASE 1: RK

55 CASE 1: RK RK is an 83 y/o F admitted to your medical unit from assisted living with a 5-day history of coughing, difficulty breathing and increasing confusion. HPI: RK was in her usual state of health until one week ago when she developed what appeared to be an URTI. Her cough gradually got worse, being occasionally productive of yellowish sputum. She became increasingly confused over the following days. PMH: Stroke 6 months ago with some residual R sided weakness, Mild HTN, GERD, OA (knees) O/E: Wt. 50 kg (usually 54 kg), Temp 40C. Chest dull to auscultation and percussion. RR 27. Oriented x 1. CXR shows some RLL consolidation. CASE 1: RK Questions about what you see here? What prompts you to be concerned about a Na/H2O problem? What is your APPROACH to assessing RK from a Na/H2O viewpoint?

56 CASE 1: RK Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF) CASE 1: RK

57 CASE 1: RK What s your ASSESSMENT? CASE 2: KP

58 CASE 2: KP KP is a 77 y/o M brought to your urgent care center from home because of increasing lethargy and confusion over the past 48 hours. HPI: He has had diarrhea for the past 4 days subsequent to a course of cefuroxime for mild CAP, and has been receiving HCTZ 25 mg/d for one year for isolated systolic hypertension. PMH: HTN. CAP. O/E: Oriented x 3. ~80kg. 100/60 supine, 75/45 standing. HR 65 supine, 80 standing. JVP <2cm ASA. CASE 2: KP Questions about what you see here? What prompts you to be concerned about a Na/H2O problem? What is your APPROACH to assessing KP from a Na/H2O viewpoint?

59 CASE 2: KP Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF) CASE 2: KP

60 CASE 2: KP What s your ASSESSMENT? CASE 3: BW

61 CASE 3: BW BW is a 67 y/o white M who presents to your primary care clinic complaining of general malaise and increasing confusion for one week. PMH: - Carcinoma of the bronchus (surgical resection and radiation therapy) 4 months ago - Mild HTN x 5 y (metoprolol 100 mg po bid) - Depression (diagnosed 4 months ago and treated with fluoxetine 50 mg/d) O/E: Moderately obese, disoriented white male. BP 150/85 supine, 145/85 standing. HR 70 supine, 75 standing. Temp 36.8C, Wt. 100 kg, JVP 3 cm ASA. CASE 3: BW Questions about what you see here? What prompts you to be concerned about a Na/H2O problem? What is your APPROACH to assessing BW from a Na/H2O viewpoint?

62 CASE 3: BW Assess the ICF Serum [Na+] mmol/l hypernatremia ( ICF) hyponatremia ( ICF) CASE 3: BW

63 CASE 3: BW What s your ASSESSMENT? Why is this happening to BW? What other tests do we look at? TRAP

64 Treating deficiencies of ECF and ICF CRYSTALLOIDS COLLOIDS

65 Osmolality of IV fluids matters. Why?

66

67 Another perspective on crystalloids Osmolality (mosm/l) [Na] ( & Cl) (meq/l) Dextrose (g/l) NS (0.9% NaCl) Cal/L D5W /2NS D5-1/2NS /3D5-1/3NS % NaCl Seawater ~1000 ~475 Gatorade 365 ~20 ~220 Oral rehydration

68 CASE 1: RK CASE 1: RK RK is an 83 y/o F admitted to your medical unit from assisted living with a 5-day history of coughing, difficulty breathing and increasing confusion. HPI: RK was in her usual state of health until one week ago when she developed what appeared to be an URTI. Her cough gradually got worse, being occasionally productive of yellowish sputum. She became increasingly confused over the following days. PMH: Stroke 6 months ago with some residual R sided weakness, Mild HTN, GERD, OA (knees) O/E: Wt. 50 kg (usually 54 kg), Temp 40C. Chest dull to auscultation and percussion. RR 27. Oriented x 1. CXR shows some RLL consolidation.

69 CASE 1: RK Managing RK s Na & H2O issues: 1. Treat the HYPOVOLEMIA 2. Treat the HYPERNATREMIA CASE 1: RK Managing RK s Na & H2O issues: 1. Treat the HYPOVOLEMIA

70 CASE 1: RK Managing RK s Na & H2O issues: 2. Treat the HYPERNATREMIA CASE 1: RK Managing RK s Na & H2O issues: 2. Treat the HYPERNATREMIA

71 CASE 1: RK Orders for RK: Monitoring Plan: CASE 2: KP

72 CASE 2: KP KP is a 77 y/o M brought to your urgent care center from home because of increasing lethargy and confusion over the past 48 hours. HPI: He has had diarrhea for the past 4 days subsequent to a course of cefuroxime for mild CAP, and has been receiving HCTZ 25 mg/d for one year for isolated systolic hypertension. PMH: HTN. CAP. O/E: Oriented x 3. ~80kg. 100/60 supine, 75/45 standing. HR 65 supine, 80 standing. JVP <2cm ASA. CASE 2: KP Managing KP s Na & H2O issues: 1. Treat the HYPOVOLEMIA

73 CASE 2: KP Managing KP s Na & H2O issues: 1. Treat the HYPOVOLEMIA CASE 2: KP Orders for KP: Monitoring Plan:

74 CASE 3: BW CASE 3: BW BW is a 67 y/o white M who presents to your primary care clinic complaining of general malaise and increasing confusion for one week. PMH: - Carcinoma of the bronchus (surgical resection and radiation therapy) 4 months ago - Mild HTN x 5 y (metoprolol 100 mg po bid) - Depression (diagnosed 4 months ago and treated with fluoxetine 50 mg/d) O/E: Moderately obese, disoriented white male. BP 150/85 supine, 145/85 standing. HR 70 supine, 75 standing. Temp 36.8C, Wt. 100 kg, JVP 3 cm ASA.

75 CASE 3: BW Managing BW s Na & H2O issues CASE 3: BW ASIDE: what if we wanted to give 3%NaCl IV to raise BW s Na quickly?

76

77 CASE 3: BW ASIDE: what if we wanted to give 3%NaCl IV to raise BW s Na quickly? CASE 3: BW Orders for BW: Monitoring Plan:

78 Carroll AE. NY Times. Aug 24, 2015

79 Tsindos S. Aust N Z J Public Health Jun 1;36(3): Guppy MPB. BMJ 2004;328: