FLUIDS/ELECTROLYTES. Sahir Kalim, MD MMSc. Department of Medicine, Division of Nephrology, Massachusetts General Hospital Harvard Medical School
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1 FLUIDS/ELECTROLYTES Sahir Kalim, MD MMSc Department of Medicine, Division of Nephrology, Massachusetts General Hospital Harvard Medical School Dr. Kalim has no potential conflicts of interest to disclose.
2 CASE 1 A 63 year old man presents to clinic complaining of weakness and fatigue PMH notable for CAD, hypertension, type 2 DM He notes some intermittent vomiting over the past two days You send serum chemistry studies
3 QUESTION His laboratory results reveal: Na 143 K 4 Cl 97 HCO3 24 BUN 30 Cr 1.2 Glu 90 Ca 9.0 Which of the following can you diagnose? A.Normal acid-base status B.Metabolic acidosis C.Metabolic alkalosis D.Metabolic acidosis and alkalosis E.Need a blood gas
4 ANSWER His laboratory results reveal: Na 143 K 4 Cl 97 HCO3 24 BUN 30 Cr 1.2 Glu 90 Ca 9.0 Which of the following can you diagnose? A.Normal acid-base status B.Metabolic acidosis C.Metabolic alkalosis D.Metabolic acidosis and alkalosis E.Need a blood gas
5 ANSWER His laboratory results reveal: Na 143 K 4 Cl 97 HCO3 24 BUN 30 Cr 1.2 Glu 90 Ca 9.0 Anion gap = = 22 Normal AG ~ 10 meq/l Albumin adj normal AG = alb (g/dl) x 2.5 AG is elevated BUT HCO3 is normal!
6 high 32 normal HCO3 23 low
7 high 32 normal HCO3 23 metabolic acidosis low
8 high 32 normal 23 low HCO3
9 high 32 normal HCO3 23 low
10 high 32 metabolic alkalosis normal HCO3 23 low
11 high HCO3 32 normal 23 low
12 high 32 normal HCO3 23 low
13 high 32 metabolic alkalosis normal HCO3 23 metabolic acidosis low
14 high 32 metabolic alkalosis normal HCO3 23 metabolic acidosis low elevated AG
15 QUESTION Which of the following is NOT a potential cause of an anion gap metabolic acidosis? A.Increased lactic acid production from bowel ischemia B.Ethylene glycol ingestion C.Acetaminophen ingestion D.Acetazolamide ingestion E.C and D F.A and D
16 ANSWER Which of the following is NOT a potential cause of an anion gap metabolic acidosis? A.Increased lactic acid production from bowel ischemia B.Ethylene glycol ingestion C.Acetaminophen ingestion D.Acetazolamide ingestion E.C and D F.A and D
17 CAUSES OF AG ACIDOSIS Lactate Ketones Ingestions: methanol, ethylene glycol, propylene glycol, ASA Pyroglutamic acid Renal failure
18 CASE 2 A 60 year old woman with longstanding type 2 DM complicated by ESRD presents with a 5 day history of lethargy and cough. Chest X-ray shows perihilar fullness without overt edema She is not febrile.
19
20 QUESTION Her laboratory results reveal: Na 121 K 4.5 Cl 92 HCO3 25 BUN 36 Cr 3 Glu 900 Ca 8.7 What should be the next step? A.Start IV normal saline B.Start hypertonic (3%) saline C.Start insulin D. A and C E.A and B F.Immediate hemodialysis
21 ANSWER Her laboratory results reveal: Na 121 K 4.5 Cl 92 HCO3 25 BUN 36 Cr 3 Glu 900 Ca 8.7 What should be the next step? A.Start IV normal saline B.Start hypertonic (3%) saline C.Start insulin D. A and C E.A and B F.Immediate hemodialysis
22 ANSWER Her laboratory results reveal: Na 121 K 4.5 Average: Na drops by ~ 2.4 meq/l for every 100 mg/dl increase in glucose Cl 92 HCO3 25 BUN 36 Cr 3 Glu 900 Ca 8.7 Hillier TA, et al. Am J Med, 1999
23 ANSWER Her laboratory results reveal: Na 121 K 4.5 Cl 92 HCO3 25 BUN 36 Cr 3 Average: Na drops by ~ 2.4 meq/l for every 100 mg/dl increase in glucose Corrected Na: (2.4 x 8) ~ 140 meq/l Calculated osmolality: (121 x 2) + (36/2.8) + 900/18) = 305 Glu 900 Ca 8.7
24 ANSWER Her laboratory results reveal: Na 121 K 4.5 Cl 92 HCO3 25 BUN 36 Cr 3 Glu 900 Ca 8.7 What should be the next step? A.Start IV normal saline B.Start hypertonic (3%) saline C.Start insulin D. A and C E.A and B F.Immediate hemodialysis
25 WHAT ABOUT NOW? Her laboratory results reveal: Na 121 K 4.5 Cl 92 HCO3 25 BUN 36 Cr 3 Glu 90 Ca 8.7 What should be the next step? A.Start IV normal saline B.Start hypertonic (3%) saline C.Start insulin D. A and C E.A and B F.Immediate hemodialysis
26 WHAT ABOUT NOW? Her laboratory results reveal: Na 121 K 4.5 Cl 92 HCO3 25 BUN 36 Cr 3 Glu 90 Ca 8.7 What should be the next step? A.Start IV normal saline B.Start hypertonic (3%) saline C.Start insulin D. A and C E.A and B F.Immediate hemodialysis
27 Check serum osmolality Verify that hyponatremia is real. Should be lo check for hypothyroidism and adrenal insufficiency Specific causes of hyponatremia evaluate ADH status Idenitifes mechanism of hyponatremia
28 ADH ADH ADH ADH distal tubule blood
29 ADH ADH ADH ADH distal tubule blood
30 ADH ADH ADH ADH distal tubule blood
31 ADH ADH ADH ADH distal tubule blood
32 ADH ADH ADH ADH distal tubule blood
33 HYPONATREMIA: ADH Role of ADH is to retain water from urine Check urine osmolality Goal is to assess degree of ADH activity
34 HYPONATREMIA: ADH What is the urine osmolality? Low (< 100) ADH suppressed Stop drinking water Ensure adequate osmolar intake Intermediate ( ) unclear picture need context High (> 300) ADH active Determine cause Is there an appropriate stimulus?
35 VOLUME STATUS What is the effective circulating volume status? Check urine sodium (caution if on diuretics) If low (e.g. <25), what is the true volume status? True volume depletion vs. CHF vs. liver disease
36 TREATMENT Is the patient symptomatic (altered mental status, seizures) YES: Get to a hospital ASAP and treat NO: How acute? How severe?
37 MILD HYPONATREMIA Stop the thiazides Avoid volume depletion Consider drug causes, especially psych drugs Cut back on water intake
38 SEVERE HYPONATREMIA Stop the thiazides Avoid volume depletion Consider drug causes, especially psych drugs Cut back on water intake
39 SEVERE HYPONATREMIA Caution with normal saline if urine osms are > 300, especially if not clearly volume depleted Close monitoring of serum sodium Mainstay of therapy is water restriction May need hypertonic saline ± ddavp if symptomatic Goal rate of correction is 4-6 meq/l/day
40 Minimal effect on sodium Normal Saline 304 mosm/kg Isoosmolar urine 304 mosm/kg
41 Sodium falls Normal Saline 304 mosm/kg Concentrated urine 608 mosm/kg
42 patient becomes volume replete stimulus for ADH is removed urine osmolality falls water excreted
43 Sodium rises Normal Saline 304 mosm/kg Dilute urine 100 mosm/kg Risk: Osmotic demyelination syndrome
44 CASE 3 A 55 year old man with hypertension. Here for routine outpatient visit Medications include amlodipine, HCTZ, atenolol.
45 QUESTION His laboratory results reveal: Na 140 K 3.0 Cl 105 HCO3 25 BUN 15 Cr 1 Glu 90 Ca 9 What should be the next step? A.Admit for IV potassium B.Stop HCTZ C.Check magnesium D. Refer to nephrology E.Ask more questions F.Banana-rich diet
46 SYMPTOMATIC? Muscle weakness Cramping Fasciculations/tetany Ileus EKG changes: QT prolongation, T wave flattening, U- wave, premature beats, heart block, cardiac arrest
47
48 CAUSES GI causes (esp. diarrhea) Renal causes (esp. medications) Endocrine causes (via actions on kidney)
49 GI CAUSES Diarrhea (including laxative abuse) Vomiting (via kidney)
50 RENAL CAUSES Magnesium deficiency Diuretics Increased sodium delivery Rare genetic diseases or channel disorders
51 ENDOCRINE CAUSES Hyperaldosteronism (primary or secondary, including renovascular disease) Cushing s
52 Food Potassium (mg) Banana Broccoli (1/2 cup) Chicken (3 oz) Orange juice (1 cup) Peanut butter ( 2 tbsp) Potato (baked) Tomato
53 Food Potassium Banana 451 Broccoli (1/2 cup) 104 Chicken (3 oz) 210 Orange juice (1 cup) 503 Peanut butter ( 2 tbsp) 240 Potato (baked) 845 Tomato 445
54 Food Potassium Broccoli (1/2 cup) 104 Chicken (3 oz) 210 Peanut butter ( 2 tbsp) 240 Tomato 445 Banana 451 Orange juice (1 cup) 503 Potato (baked) 845
55 CASE 4 A 62 year old man with h/o CAD, progressive CHF, CKD stage 3, and type 2 DM presents for a routine physical He has had a recent gastrointestinal illness with some nausea and intermittent loose stools. Medications include: metoprolol, furosemide, lisinopril, atorvastatin, and aspirin.
56 QUESTION His laboratory results reveal: Na 143 K 4.0 Cl 100 HCO3 35 BUN 30 Cr 1.4 Glu 90 Ca 8.7 UCl 50, repeat 10 Which of the following is the most likely cause of metabolic alkalosis? A.Diarrhea B.Milk-Alkali syndrome C.Contraction alkalosis D.Bartter syndrome E.Gitelman syndrome
57 ANSWER Her laboratory results reveal: Na 143 K 4.0 Cl 100 HCO3 35 BUN 30 Cr 1.4 Glu 90 Ca 8.7 UCl 50, repeat 10 Which of the following is the most likely cause of metabolic alkalosis? A.Diarrhea B.Milk-Alkali syndrome C.Contraction alkalosis D.Bartter syndrome E.Gitelman syndrome
58 METABOLIC ALKALOSIS GI: vomiting, suction Renal: Mineralocorticoid excess, diuretics, Barrter/Gitelman syndromes, post-hypercapnea, milk alkali syndrome Shift: hypokalemia Iatrogenic Contraction: diuresis, other fluid losses
59 URINE CHLORIDE Low (< 20) in vomiting, NG suction, post-diuretics, laxative abuse High during diuretic use, hyperaldosteronism (or apparent mineralocorticoid excess: Liddle s, licorice, mutations), Barrter, Gitelman
60 THANK YOU
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