Fluid & Electrolyte Disorder 2015

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1 Goals 1. Identify & develop complete pharmacotherapy plan for patient with fluid &/or electrolyte disorder 2. Explain pharmacotherapy recommendations Objectives 1. State common signs/symptoms of fluid & electrolyte disorders 2. Identify common causes of fluid, Na, K, Ca, Mag, phosphate disorders 3. Assess electrolyte depletion 4. Identify/Interpret laboratory/diagnostic information in determining fluid / electrolyte disorders 5. Develop complete pharmacotherapy plans for patients with fluid & electrolyte disorders Take home message Role of clinical pharmacist 1. Develop therapeutic plan using evidence-based medicine 2. Maximize outcomes 3. Minimize unwanted effects 4. Use most cost-effective therapies Pharmacotherapy Plan Template - 5 Problem Goal of therapy Pharmacotherapy Plan Monitoring strategy 1. Identify specific problem i.e. hypokalemia, hyperkalemia, severe hypercalcemia 2. Design appropriate therapy goal 3. Design patient specific pharmacotherapy plan 4. Design appropriate monitoring strategy to evaluate plan effectiveness Pathophysiology Review 7, 8, 9 1. Total Body Weight composition changes with age younger you are higher total body weight = fluid; % decreases with age o adults = 50 60% o pediatrics = 65-70% o newborns = 70 75% o preemies = 75 80% 2. Fluid is contained in two compartments intracellular compartment extracellular compartment o contains multiple components 1. interstitial 2. plasma/intravascular 3. transcellular ICF = Intracellular fluid ECF= Extracellular fluid Extracellular Space 1 Renal

2 Pathophysiology Review (Continued) 3. Fluid distribution example Age Weight (kg) % Total Body H20 Total Liters Intracellular Extracellular (2/3 rds of total H20) (1/3 rd of total H20) Adult % (presumed) 70(50%)= 35 L 35 L x 2/3rds = 24 L 11 L Natural fluid distribution = 2/3 rds intracellular; 1/3 rd extracellular 4. IV Fluid Selection Must determine where fluids distribute Osmolality of intracellular space = extracellular osmolality 280 mosm D5W distributes just as natural fluid distribution occurs 2/3 rds extracellular / 1/3 rd intracellular IV Fluid % distribution % distribution Intracellular Compartment Extracellular Compartments 1. D5W 2/3rds = 66.6% 1/3rd=33.3% 2. NS 0 % 100 % in all of the 3 extracellular compartments 3. Colloids 0 % 100 % plasma/intravascular part of extracellular space NS introduces sodium into the extracellular space changing the osmolarity of this space. This results in differing osmolarity between the intracellular and extracellular spaces. End result NS distributes to all of compartments within the extracellular space. IV fluids come in 4 different forms: 1. Crystalloids 2. Colloids 3. Blood / blood products 4. Oxygen-carrying solutions Crystalloid 9, 10 a substance whose particles are smaller than those of a Intravenous crystalloid fluids COLLOID, form a true solution, and are therefore capable of passing through a semipermeable MEMBRANE ( IV fluids containing varying concentrations of electrolytes Crystalloids are classified based on tonicity Tonicity describes the concentration of electrolytes (solutes) dissolved in the water in comparison with that of body plasma (fluid that surrounds cells) Crystalloid Concentration Definitions Isotonic Crystalloid 1. Iso = same Crystalloid concentration = plasma concentration 2. Tonic = concentration Tonicity of isotonic crystalloid = plasma tonicity Hypertonic Crystalloid 1. Hyper = high Crystalloid concentration > plasma concentration 2. Tonic = concentration Tonicity of hypertonic crystalloid > plasma tonicity Hypotonic Crystalloid 1. Hypo = low Crystalloid concentration < plasma concentration 2. Tonic = concentration Tonicity of hypotonic crystalloid is < plasma tonicity 2 Renal

3 Colloid IV Fluids -10 IV fluids containing large proteins and molecules that tend to stay within the vascular space (blood vessels) 1. Albumin; 2. blood products (i.e. PRBC, single donor plasma); 3. plasma protein fraction (Plasmanate); 4. synthetic colloids (hetastarch [Hespan R, Hextend R ], dextran) Pathophysiology Review -11 Osmolality = the measure of the number of dissolved particles in a fluid. Where will the fluid bolus go in each example below? 70 X 0.6 = 42 2/3rds = ICF = 28 L; 1/3 ECF = 14 L Intracellular osmolality is equivalent to the Extracellular osmolality fluid freely moves between these spaces normally. Assumption: pt. has normal volumes: 28 L intravascular space; 14 L in extracellular space Example 1: Adult; 70 kg.; D5W 1500 ml bolus Example 2: Adult; 70 kg; NS 1500 ml bolus Example 3: Adult; 70 kg; D5NS 1500 ml bolus Intracellular Extracellular Osm Normal Vol. 28 L 14 L Add Volume After Addition Volume After Addition D5W 29 L 14.5 L 1 L; 2/3 rds of 1500 ml 0.5 L; 1/3 rd of 1500 ml NS 28 L 15.5 L No change 1.5 L; all 1500 ml D5NS 28.5 ml 15 L 500 ml D5W 750 ml NS ml D5W D5NS: ½ volume = 750 ml is NS and ½ volume = 750 ml is D5W NS (750 ml): All 750 ml distributes into the extracellular space. D5W (750 ml): 2/3rds (66.6 % x 750 ml 500 ml) distributes into the intracellular space; 1/3 rd (33.3 % x 750 ml 250 ml) distributes into the extracellular space Dextrose distributes into intracellular & extracellular compartments in a 2/3rds, 1/3 rd distribution. 3 Renal

4 Volume depletion can result in Δs in hemodynamics, behavior, thirst, mucous membranes, etc Physical Exam Mild Moderate Severe 1. Weight loss: Peds 5 % 10 % 15 % Adults 3 % 4-6 % 7-9 % 2. Pulse Normal Slight Very 3. BP Normal Normal - orthostatic Orthostatic to shock 4. Behavior Normal Irritable, thirsty Hyper irritable to lethargic 5. Thirst Slight Moderate Intense 6. Mucous membranes Normal Dry Parched 7. Tears Present Decreased Absent 8. Ext. jugular vein Visible when supine Not visible Not visible 9. Skin Capillary refill < 2 sec Slowed 2-4 sec Very delayed > 4 sec 10. Urine specific gravity > > 1.020; oliguria Oliguria/anuria Indications for Fluid Management Expand intravascular volume 2. Correct imbalance in fluid or electrolyte 3. Manage fluid and electrolyte needs in an ongoing disease state where there is continuous loss 4. Daily fluid maintenance Fluid Selection for Volume Expansion 15, 16 Questions to Ask 1. What compartment needs volume? 2. What fluid will fill that compartment? NS, LR, PRBC, hetastarch, or albumin 3. What factors justify the selection? Fluid Compartment Justification NS Extracellular Shock, hypotension, immediate LR Extracellular Shock, hypotension, acidemia present PRBC Intravascular Add to a crystalloid, acute blood loss present Hetastarch Intravascular Add to crystalloid to sustain longer results when albumin is low & not due to blood loss Albumin Intravascular Acceptable only when serum albumin < 2 gm/dl & cause not due to blood loss Infusion rates are based on fluid, age, & condition - 16 Age Rate Monitoring Adult Any acceptable rate BP hourly Pediatric > 1 yr. 20 ml/ kg bolus HR hourly Pediatric > 0-1 yr. 10 ml/ 10 ml/hr. bolus HCT Neonate Albumin 5 10 ml/ kg. bolus K +/- all lytes 1. Adults usually can accept any rate except those with: heart failure; renal failure; or end stage liver failure 2. Clotting factors may not be necessary unless giving multiple blood products/large volumes of crystalloids 3. ABG only necessary in shock state with acid based disorders I/O daily ABG +/- Clotting factors +/- 4 Renal

5 Maintenance Fluid Requirements - 17 Goal: balance input/output Maintenance Needs Calculation Holliday Segar Weight (kg) ml/kg/day >20 20 Holliday Segar method classic for pediatric; also used in adults; In adults most often 30 To 35 ml/kg/day used. Practice time 18, 19 Calculate maintenance/electrolyte needs for 65 kg. pt. Holliday-Segar Method: Weight ml/kg/day 10 kg 100 ml/kg (10 kg)/day = 1000 ml 10 kg 50 ml/kg (10 kg)/day = 500 ml 45 kg 20 ml/kg (45 kg)/ day = 900 ml Total Maintenance Fluids 2,400 ml / day ml/kg/day method: 35 ml/kg/day (65 kg) = 2,275 ml/day Assumption: Volume loss = 2,300 ml Average Electrolyte Losses Electrolyte meq lost / 100 ml/day Na 3 K 2 Cl 2 Estimated Electrolytes Lost/Day - 19 Electrolyte meq lost / 100 ml/day Maintenance Volume Total lost/day Na 3/100 ml x 2,300 ml 69 meq/day K 2/100 ml x 2,300 ml 46 meq/day Cl 2/100 ml x 2,300 ml 46 meq/day Fluid selection: Multiple solutions are appropriate i.e. D51/4 NS; NS¼ K+: 46 meq/ 2,300 ml =0.02 meq/ml; 0.02 meq/ml x 1,000 ml = 20 meq per liter IV bag Rate: 2,300 ml/24 hrs. = 90 ml/hr. 5 Renal

6 Volume Depletion (Replacement) - 20 Determine cause of volume loss Goal: immediate deficit correction (fluid; lytes); correct cause Plan: Correct Volume losses within 24 hrs % volume correction in 8 hrs. 1,200 ml/8 hrs. = 150 ml/hr. x 8 hrs % correction in remaining 16 hrs. 1,200 ml/ 16 hrs. = 75 ml/hr. x 16 hrs. Volume Depletion Electrolyte Losses Electrolyte meq lost/100 ml/day Na 8 K 6 Cl 6 Electrolyte Loss by Specific Body Fluid (losses/l of fluid) - 21 Fluid Na Cl K HC03 Volume(ml)/day Liters/day Saliva L Gastric (NG Tube) L Duodenal L Bile L Pancreatic L Ileal L Diarrhea Practice 22, 23, 24 Jimmy, 3 yr. old; 36 ; 12 kg; lethargic Family attending family reunion outside all day. Both parents thought Jimmy had been taking in fluids. Neither parent knew how frequently he urinated or how much. Outdoor temperature = 90 0 F + with 60 % humidity Physical exam: hypotensive; tachycardic; weak pulses; skin turgor tented for 3 seconds; mucous membranes dry 1. What is the problem? 2. What is the intervention? 1. Volume loss 2 0 to lack of intake and great insensible losses Volume loss estimate = 10 % (See Volume Depletion Chart bottom pg. 3 of notes- Based on physical exam noted above- pt. is moderately volume depleted which = 10% estimated volume loss): (12 kg) (10 %) = 1.2 L. Electrolyte loss estimate (profuse sweating) (see table bottom pg. 4: Electrolyte meq loss/100 ml/day Total Loss Na (1200 ml)(8 meq/100 ml) 96 meq K (1200 ml)(6 meq/100 ml) 72 meq Cl (1200 ml)(6 meq/100 ml) 72 meq Volume Depletion Electrolyte Losses Electrolyte meq lost/100 ml/day Na 8 K 6 Cl 6 6 Renal

7 Plan Replace the lost 1.2 Liters, over 24 hrs. 20% as a bolus; 50% of remaining volume over 8 hrs; remaining volume replaced over 16 hrs. NS 240 ml (20% of loss) bolus leaving 960 ml (1200ml-total lost 240 ml bolus = 960 ml) Bolus given because symptomatic Then, 60 ml/hr. x 8 hrs.= 480 ml (this is ½ or 50% of 960 ml) Then, 27 ml/hr. x 16 hrs. = 480 ml Add K+ once pt. urinates Once ECF volume is replaced, may change fluid to D51/2NS Practice Continued = 25 If Jimmy needed long term care in the hospital, what change should be made to recommendation? 1. Daily maintenance calculation using Holliday-Segar Method: Pts. normal wt. = 13 kg. (10 kg)(100 ml/kg) + (3 kg)(50 ml/kg) = 1000 ml ml = 1150 ml Fluid could be dextrose +/- saline Extra Insensible Loss 26 Add 12 % for each 1 degree > C (rectally) / 24 hr. Other settings: add 0-30 %/ 24 hr. 1. hyper metabolic conditions such as: trauma; burns; sepsis 2. status epilepticus (continuous active seizure) Practice month old; diarrhea x 3 days; symptomatic of fluid loss Current wt. 10 kg; normal wt. 11 kg Outline your steps and recommend a plan. Practice Symptomatic: give bolus (10 ml/kg) (10 kg) = 100 ml 2. Volume deficit: = 1 kg so 1 L Volume remaining: 1,000 ml 100 ml (bolus) = 900 ml 900 ml x 50 % = 450 ml. 450 ml/8 hrs. 55 ml/hr. Then, 450 ml/16 hrs. = 28 ml / hr. Electrolyte depletion (refer to Electrolyte Lost by Fluid Type Table pg.6) Electrolyte meq lost /L / day Diarrhea Pt. Volume loss Electrolyte Deficit Na 120 1, 000ml (= 1kg) 120 meq K 25 1, 000ml (= 1kg) 25 meq Maintenance: (10 kg)(100 ml/kg) + (1kg)(50 ml/kg) = 1050 ml + daily output 7 Renal

8 Practice yr. old; crohn s pt. post GI surgery with JP drain placement. Currently NPO, including fluids. Ht. 6 3 ; Wt. 72 kg. BP 120/80; HR 90 BPM; RR 12 BPM; T C (rectal) I/O: 1000/2350 (JP 1750 ml) What to do? Q1: Is pt. volume deficient? Yes Input = 1000 ml; Output (TOTAL) = 2350 ml ml (JP Drain) ml (fever) = 4,557 ml Q2: Does pt. need volume replacement? Q3: What is his daily maintenance needs? Assessment - 30 Fever losses = (Temperature variance) x [12 % x Daily Maintenance] (1.5)[(12%) (2540)] = 457 ml Replacement: Electrolyte JP Loss meq /1000 ml Loss Total to replace Na 1750 ml 130 = 228 meq K 1750 ml 5 = 9 meq Maintenance: Holliday-Segar Method: Weight ml/kg/day 10 kg 100 ml/kg (10 kg)/day = 1000 ml 10 kg 50 ml/kg (10 kg)/day = 500 ml 52 kg 20 ml/kg (52 kg)/ day = 1040 ml Total Maintenance Fluids 2540 ml / day Order: Start: NS + 10 meq 105 ml x 8 hr. Then, 55 ml/hr. x 16 hrs. (Replaces JP drain losses 1750 ml) Convert to: D5NS + 10 meq 200 ml 1750 ml ml ml = 4747 ml 8 Renal

9 SODIUM DISORDERS Causes Na Disorders Gains, Losses, Disruption - 32 Sodium Disorder Causes 32,33 Depletion of Effective SIADH Hormonal Δs Advanced 1 0 Polydipsia Low Salt Intake Circulating Volume Kidney Failure 1. True Volume 1. Adrenal 1. filtration 1. Ecstasy 1. Beer Drinkers depletion insufficiency volume (May also Potomania 2. Heart Failure 2. Hypothyroidism Stimulate ADH) 2. Tea & Toast 3. Cirrhosis severe Diet 4. (?) Nephrotic 3. Reset Osmostat Syndrome (i.e. pregnancy) 5. Thiazide diuretics Drug Induced HYPOnatremia 34 Drug Induced HYPOnatremia - 34 ADH analogs ADH release Potentiate ADH Effects??? Etiology DDAVP Antidepressants Acetaminophen Amitriptyline Oxytocin Antipsychotics Chlorpropamide Fluoxetine Carbamazepine Cyclophosphamide Fluphenazine Chlorpropamide NSAIDs Haloperidol Ifosfamide Thioridazine Narcotics Thiothixene Nicotine Vincristine Na & H20 follow one another sodium is married to water - 35 Volume Assessment (Always Assess) 1. Physical Exam 2. Serum osmolality See calculation below & MEMORIZE it Serum Osmolality (sosm) = 2(Na) + (BUN/2.8) + (glucose / 18) Uosm = Urine osmolality U na = Urine sodium Steps to solving Sodium Problems Step 1: What is the patient s volume status? Step 2: Is the patient isotonic? (serum osmolality sosm) Step 3: Determine if other disease states are present. Step 4: Assess urine and Na osmolality. 9 Renal

10 SODIUM DISORDERS Renal

11 SODIUM DISORDERS Steps to solving Sodium Problems - 37 Step 1: What is the patient s volume status? Step 2: Is the patient isotonic? (serum osmolality sosm) Step 3: Determine if other disease states are present. Do they link if another present? Step 4: Assess urine and Na osmolality. Assess if Na+ disorder suspected. Case yr. old male with watery diarrhea. Comes to ER lightheaded and tachycardic. Not orthostatic. Has dry mucous membranes. Neurologic exam is normal. Pt is alert. Lab results: Na+ 129 / Cl - 95 / BUN 5 / BG 75 / K+ 4.2 / HC03 24/ SrCr 0.8 sosm = 2(129) + (5/2.8) + (75 / 18) sosm = = Ht. 6 2 ; Wt. 70 kg. (current), 80 kg. baseline BP: 90/53; HR 115; RR 16 Urine Osm = 520 (concentrated urine) Urine Na = 5 Case 1 Pharmacotherapy Plan 39, Estimate ECFV deficit 2. ECF volume deficit Equation: Pg.10 of notes [(TBWn) (0.6) (0.33)] - [(TBWc) (0.6) (0.33)] KNOW THIS CALCULATION 3. [(80kg)(0.6)(0.33)]-[(70kg)(0.6)(0.33)] = 2 L volume depleted Note: 0.6 = % of body that is water; 0.33 = % of body water wt. in extracellular space. What to use for IV Fluid Case 1 Pharmacotherapy Plan - 42 Problem Goal Plan Monitoring 1. HYPOvolemia 1. Correct ECFV NS 100 ml/hr. x 2 L 1. Na+ q 24 hrs. 2. HYPOtonic deficit. 2. I/O daily 3. HYPOnatremia 2. Na 0.5mEq/hr. 3. VS (BP;HR) 4. Wt. daily 11 Renal

12 SODIUM DISORDERS Case yr. old female admitted from nursing home with lethargy & confusion. Baseline: dementia. Normally animated & interactive. Poor appetite x 1 yr. with significant wt. loss. Currently eats very little. Hydrochlorothiazide added 2 weeks ago to medications. N/V x several days. No diarrhea; fever or other complaints. Physical Exam: Dry oral mucosa; no orthostasis; no evidence of CHF; ascites or edema. Awake but lethargic. Neuro exam normal. Labs: Na+ 121 / Cl 91/ BUN 6/ K+ 5.3/ HC03 22/ SrCr 0.4/ BG 83 Na+ four weeks prior: 138 meq/ L Urine Osm: 220 Urine Na+ 30 Steps to solving Sodium Problems Step 1: What is the patient s volume status? Step 2: Is the patient isotonic? (serum osmolality sosm) Step 3: Determine if other disease states are present. Step 4: Assess urine and Na osmolality. 1. What is the problem? 2. What is the treatment goal? Syndrome of Inappropriate Antidiuretic Hormone (SIADH) - 45 Syndrome of Inappropriate Antidiuretic Hormone (SIADH) SIADH Criteria Lab Values SIADH Causes H20 intake > output 1. Urine osmolality > 100 mosm 1. Cancers 2. Urine Na > 20 meq/l 2. CNS disorders 3. Pulmonary disorders 4. Drugs 5. Hypothyroidism Drugs that Induce SIADH (See Table pg. 9 Also) - 46 Antineoplastic Antipsychotics Carbam azepine Drugs that Induce SIADH DDAVP NSAIDS Diuretics Opiates SSRI * Cyclophosphamide Chlorpropamide ibuprofen Thiazides MS04 Amitriptyline Vincristine Haloperidol meperidene Imipramine Thioridazine Thiothixene *SSRIs: fluoxetine; sertraline SIADH vs SIADH H20 Intoxication vs H20 Intoxication Differences Differences - 47 Clinical Disorder Urine Sodium Urine Osmolality SIADH > 20 meq/l > 100 mosm/kg H20 < 20 meq/l < 100 mosm/kg 12 Renal TCAs Li++ Ecstasy

13 Case 2 Pharmacotherapy 48, 49, 50 SODIUM DISORDERS Problem Goals SIADH 1. Induce (-) H20 balance 2. Correct SIADH cause drug Tx. 3. Maintain Na+ > 125 meq/l Baseline Na+ = 138 meq/l Serum Na+ < 125 meq/l associated with seizure disorder Serum Na+ Correction: Serum Na+ Correction: meq/l/hr. 1. Rate limited by hr. & day 2. Corrections > 1.5 meq/l/hr. could result in sentinel event! Maximum Na+ correction: 12 meq/l/day 1. Prevents cerebral edema complications 2. Prevents i.e. Osmotic demyelination Na Δ = [IV Na-S Na] [(total body H20) + 1] BW = Total Body Water in Liters estimated as a fraction of body wt. (kg) Children & men < 70 yrs.: 0.6 x wt. (kg) Men > 70 yrs.: 0.5 x wt.(kg) Women > 70 yrs.: 0.45 x wt. (kg) Designing Plan of Care Goal Na Δ Case 2 SIADH Intervention; Plan Correct Na to 125 meq/l minimum with NS NS = 154 meq Na+/L = [IV Na-S Na] (total body H20) + (IV Volume) = (154 meq/l 121 meq /L) [(0.45)(50) + 1 L] = 1.4 meq/ L = 3 L to achieve goal = 125 meq/l Problem Goal Plan Monitoring SIADH 1. Correct Na 1. H20 restriction &/or 1. Na+ q 1-2 hrs. till normal 2. Restrict H20 2. IVF = 100 ml/hr. x 3 L 2. I/O 3. Wt. daily 4. Labs: K+. Mg++ daily Cells swell as fluid is repleted to this too fast demyelination can occur leading to death. Rate Calculation to Na+ by 0.5 meq/l/hr. 1.4 meq/l (Na+ Δ) 1000 ml = 0.5 meq/l/hr. (Na+ Serum Correction) X ml X 360 ml 360 ml/hr. might be too aggressive maybe consider 3% NaCl Questions and Considerations 1. Can pt. tolerate volume i.e. 360 ml/hr.? 2. 3% NaCl caution when using this concentrated of solution 3% NaCl = Na+ 513 meq/l 13 Renal

14 SODIUM DISORDERS Recommendations in Heart Failure Heart failure means volume limitations Is there another IV solution that can be used in HF? 2. Na Δ = [IV Na-S Na] [(total body H20) + 1 L] Na Δ = (513 meq/l 121 meq/l) [(0.45) (50) + 1 L] Na Δ = 17 meq/ L or 1.7 meq/ 100 ml 3. How many ml to achieve Serum Na+ = 125 meq/l? 1.7 meq/ 100 ml = 0.5 meq/hr. / X ml X 30 ml/hr.; 235 ml = 4 meq 4. How many ml to achieve Serum Na+ = 135 meq/l? 135 meq/l 121 meq/l = 14 meq 235 ml/4 meq = X / 14 meq X 823 ml 5. Can this be replaced in 24 hrs? NO! Cannot be replaced in 24 hrs. See Case 2 Pharmacotherapy pg. 13 notes Maximum Na+ correction: 12 meq/l/day 1. Prevents cerebral edema complications 2. Prevents i.e. Osmotic demyelination Chronic SIADH Management H20 restriction 2. Alternatives when H20 restriction not enough Demecloycline 300 mg PO BID or QID Tolvaptin 15 mg PO daily, may to max dose = 60 mg/day NaCl 900 mg PO daily + loop diuretic (not usually considered) 14 Renal

15 SODIUM DISORDERS Case yr. old male; Heart Failure 2 0 to MI. Admitted to hospital with: dyspnea on exertion; orthopnea; paroxysmal nocturnal dyspnea Current TX: Lisinopril; furosemide ran out 1 week ago Physical Exam: Jugular venous distention; rales over lower ½ of lung fields; Normal S1 & S2 heart sounds. S3 gallop present at apex. 2+ pitting edema lower extremities. Vitals: BP 110/70; HR 110; RR 20 Labs: Na+ 130/ Cl 94/ BUN 28/ K+ 3.8/ HC02 25/ SrCr 1.1/ Glucose 116 Urine Osm 600 / Urine Na 10 Pg. 10 of notes Case 3 Pharmacotherapy Plan - 55 Problem Goals Plan Monitoring 1. HYPERvolemia Remove excess H20 1. Restrict H20: 1 L/day Volume status daily 2. HYPOtonic 2. Restrict Na+ to 2 gm/day Na+ daily 3. HYPOnatremia 3. Optimize HF Meds ACEi ARB +/- diuretic Tachycardia pushes fluid in extracellular space start NS to fill space. Continue NS or change 15 Renal

16 Case yr. old male found unresponsive. Pt. not seem by mother x 24 hrs. She found him lying on couch unresponsive. Copious quantity of black colored vomit evident. Pt. is diabetic; self-administers medications. Last medications taken: unknown. Pt. offers no history. Physical Exam - 57 BP 101/72; HR 123; RR 32; T 0 Oral C; Pulse oximetry 100 % room air. Wt. = 65 kg. Response to questions with moans. Responsive only to loud or painful stimuli. Head/neck normal except for oropharynx: very drug mucous membranes; moderate dried, black hemocult (+) material. Lungs: clear to auscultation; breathing pattern: Kussmaul (rapid & deep breathing) Abdomen: Negative Labs - 58 Na+ 162/ Cl 87/ BUN 32/ K+ 5.2/ HC02 5/ SrCr 1.5/ Glucose 782 ABG: 6.92 / 9 / 98 Urine: Ketone +; WBC +; WBC 22,000; Hgb/HCT 14.4 / 43.5 Paramedic TX Course: Accucheck too high to read. Peripheral line inserted; IV fluids = 200 ml/hr. Pt. Problem List: 1. DKA; 2. Volume depletion; 3. Acid/Base disturbance; 4. R/O UTI Case 4 Problem List - 59 Na+ Assessment 1. Na+ needs correction in setting of hyperglycemia 100 mg/dl glucose = 1.7 meq/l Na+ [( ) 100] (1.7 meq/l) meq/l Na+ of 166 meq/l Volume Assessment (Depletion) 2. Volume Deficit = (Present TBW) x [(Sr Na+ 140) - 1] Volume Deficit = (0.6) (65 kg) x [(166 meq/l 140) - 1] Volume Deficit 7.24 L 1 kilogram (kg) = 1 liter (l). Kilogram (kg) is a unit of Weight used in Metric system. Question: What IV Fluid to use? Case 4 Pharmacotherapy Plan -60 Problem Goals Plan Monitoring 1. HYPOvolemia 1. Correct volume 1. Begin IVF = NS until ECF 1. Volume status daily 2. HYPERtonic 2. Correct glucose volume is filled - (BP) 2. Chemistries q 2 h & daily 3. HYPERnatremia 3. Replace lytes 2. Then, switch to IV fluids 4. Treat infection with dextrose +/- saline 16 Renal

17 HYPERnatremia (Na > 145 meq/l) HYPERnatremia (Na > 145 meq/l) - 61 Findings Problem Signs/Symptoms total body H20 relative Inadequate H20 intake to total serum Na + 1. Net H20 loss 1. Defective thirst mechanism 1. Anorexia 2. Na+ gain 2. Lack access to H20/Fluid 2. Coma 3. Unable to take in H20 3. Insomnia 4. Lethargy 5. Muscle weakness 6. Restlessness 7. Seizures 8. Tachypnea HYPERnatremia Etiologies Sodium Excess 1 0 Water Loss 1. Excess Na+ intake 1. Poor H20 Intake 2. urinary Na+ excretion Impaired H20 access Hyperaldosteronism (i.e. infants; elderly w. dementia) Impaired thirst sensation Hypothalamic lesions 2. Increased Urinary H20 Loss ADH deficiency (Central DI) ADH resistance (Nephrogenic DI) 3. Increased GI loss of H20 Classifications HYPERnatremia 63, 64 HYPOvolemia, HYPERnatremia - 63 Euvolemia, HYPERnatremia - 64 Causes Causes Extra renal loss Urine Na+ < 10 meq 1. Profuse sweating polydipsia Osmolality > 700 mosm/kg 2. Open skin Thirst center Burns destruction Pemphigus vulgaris 1. Hypothalamic tumors 3. GI losses 2. Granulomatous disease 3. Trauma Renal Loss Urine Na+ > 20 meq/l 1. Diuretics 1. Central DI Osmolality < 700 mosm/kg 2. Severe osmotic diuresis 2. Nephrogenic DI Diabetes Insipidus (DI) Euvolemia, HYPERnatremia - 65 Characteristics 1. Normal ECF 2. Slight serum Na+ 3. Urine volume > 3 L/day This is key high urine output > 3 L /day. Diagnosis 1. H20 deprivation test. Detects Δs in urine Osm Central DI: urine Osm > 600 mosm/kg Nephrogenic DI: Urine Osm 300 mosm/kg To determine Central DI vs. Nephrogenic DI do H20 deprivation test measure Δ in urine Osm 17 Renal

18 HYPERnatremia (Na > 145 meq) DI (Euvolemia, HYPERnatremia) Treatment by Type -66 Problem Goals Plan (Therapy) Monitoring Central DI 1. urine volume to L/day 1. Intranasal Desmopressin 1. Serum Na+ q 3-4 days initial 10 mcg. daily Then, q 2-4 months 2. Adjust dose to urinary 2. Urine output daily concentration to prevent Nocturia, L/day Nephrogenic 1. Correct hypocalcemia 1. Na+ 2 gm/day 1. Serum & urine Na+ Osm DI 2. Correct hypokalemia if present 2. Thiazide diuretic Q 2-4 months 2. Urine output daily HYPERvolemia, HYPERnatremia (Rarely Occurs) - 67 Cause excess Na+ Ingestion Plan (Therapy) Monitoring 1. Volume resuscitation excess & volume 1. Loop diuretic 1. Na+ q 2-4 hrs. 2. CPR administration of NaHC03 * 2. Free water 2. Na+ q 6-12 hrs. once Na+ < 148 meq/l * Part of ACLS for cardiovascular collapse. Shortly post, Na+ if high usually resolves. If not, refer to treatment. Edema Causes - 68 Obstruction of Lymph Fluid Capillary pressure Colloidal Osm Pressure Capillary Permeability 1. Malignant obstruction 1. Vascular volume 1. loss plasma proteins 1. Inflammation 2. Lymph node removal i.e. HF, CKD i.e. CKD, burns 2. Allergic reaction Thiazolidinedione TX 2. production plasma 3. Malignancy (Glitizone) proteins 4. Tissue injury / burns 2. Venous obstruction i.e. liver disease Liver disease i.e. malnutrition Acute pulmonary edema 2. arteriolar resistance Ca++ blockers Edema - 70 Problem (Finding) Goal Plan (Therapy) 1. interstitial volume 1. Minimize/reduce 1. EF > 30% + GFR > 50 ml/min Physical exam noted as tissue edema Hydrochlorothiazide mg/day 2+ edema +/- Spironolactone mg/day 2. EF < 30 % Furosemide 40 mg q 8 hr. 18 Renal

19 POTASSIUM HYPOkalemia Causes K+ < 3.5 meq/l) - 74 K+ Intake Excess Renal Loss Excess GI Loss K+ Transcellular Shifts 1. Diet, inability to eat 1. Diuretic TX 1. Vomiting 1. β-adrenergic agent K+ free parenteral 2. Renal failure 2. Diarrhea 2. Insulin administration Nutrition (PN) Hyperaldosteronism 3. GI Suction 3. Alkalosis 4. Corticosteroid TX 4. GI Fistula drains Drug Induced HYPOkalemia (K+ < 3.5 meq/l) - 76 MOA Drug Class Agents Transcellular Shifts - 76 Β2 Receptor Agonists 1. Epinephrine 2. Albuterol 3. Terbutaline 4. Salmeterol 5. Ephedrine 6. Pseudoephedrine Tocolytic agents 1. Ritodrine Theophylline Caffeine Neonatal Population Insulin Overdose Enhanced Renal Excretion - 77 Diuretics 1. Acetazolamide 2. Thiazides 3. Metolazone 4. Furosemide 5. Torsemide 6. Bumetanide 7. Ethacrynic Acid High dose PCN 1. Nafcillin (Sometimes attributed 2. Ampicillin to rate of infusion) 3. Penicillin Mineralocorticoids Aminoglycosides Waste K+ Amphotericin* Waste K+ Cisplatin Waste K+ Enhanced Fecal Excretion - 78 Sorbitol** In many preparations Sodium polystyrene Kayexalate * Amphotericin K+ wasting not seen much with colloidal ** Elixirs have sorbitol HYPOkalemia Signs / Symptoms - 79 Urine Conc. GI Neuromuscular CV CNS Acid/Base 1. Polyuria 1. Anorexia 1. Cramps 1. EKG Δs 1. Confusion 1. Metabolic 2. Polydipsia 2. N/V 2. Tenderness Wide QT 2. Depression Alkalosis 3. Low urine Osm 3. Abdominal 3. Paresthesias 2. Dysrhythmias distension 4. Paralysis 3. Hypotension 4. Paralytic ileus 19 Renal

20 Potassium Related EKG Δs - 80 HYPOkalemia K+ QT Interval widens POTASSIUM HYPERkalemia Peaked T Waves T Wave Case 1 HYPOkalemia yr. old; tired; weak seen by MD for routine visit. Pt. states weeds are out of control & tired from too much work. PMH: HTN; Non-Insulin dependent diabetes; glaucoma Meds: Furosemide 20 mg daily; diltiazem 90 mg QID; metformin 500 mg BID Physical Exam: Unremarkable except extremities & mucous membranes dry. Labs: Na+ 154 / Cl 98 / BUN 15 / K+ 3.1 / HC03 22 / SrCr 1.6 Glucose 87 / Ca / Ma+ 1.5 / P HYPOkalemia Treatment Problem Goal Plan HYPOkalemia 1. Identify/treat 1. Assess correction target underlying cause Mild: meq/lee oral TX 2. Identify treatment Moderate: meq/l IV or PO route Severe: < 2.5 meq/l must be IV 3. K+ w/i normal limits 2. Provide TX see below Monitoring see pg. 21 of notes K+ Supplementation Formulation Dose Indication Oral K meq/day divided doses Non-urgent or maintenance Oral K+ Liquid meq/day Urgent not emergent IV K meq/hr. (usually 10 meq/hr.) Severe K+ Supplementation Key Concepts For every 10 meq K+ replaced serum K+ 0.1 meq/l K+ = 3.1 give 40 meq K+ to K+ to 3.5 meq ALWAYS use safe practices with IV K+ (usually 10 meq/hr. used) 20 Renal

21 POTASSIUM Monitoring K+ Supplementation Sustained release oral K+ product must wait longer than 2 hrs. for K+ recheck Monitoring K+ Supplementation Parameter Frequency of Recheck Range 1. K+ 1. Post every 80 meq > 3.5 meq/l < 5 meq/l 2. 1 hr. post IV; 2 hr. post PO Longer for sustained release 2. EKG (underlying CV prob.) Continuous Convert to NSR 3. EKG (underlying CV prob.) Continuous Lack of V-Fib; V-Tach 4. Digoxin Concentration Once < 2.5 ng/ml 5. Infusion site pain Q 1 hr. Minimal to none 6. Weakness, for resolving Q 1 hr. Minimal to none 7. Nausea, for resolving Q 1 hr. None HYPERkalemia (> 5 meq/l) Causes (85) Excessive Intake Intracellular Aldosterone Renal Elimination Intake > Output Compartment Release 1. Diet 1. Burns 1. No response 1. Renal failure 2. PO supplements 2. Crush injuries 2. Adrenal insufficiency 3. Parenteral 3. Extreme exercise 3. TX with K+ sparing Nutrition (PN) 4. Rhabdomyolysis diuretics 5. Seizures 4. ACEi TX 6. Tissue trauma HYPERkalemia Signs/Symptoms (86) GI Neuromuscular CV 1. Diarrhea 1. Dizziness 1. EKG Δs 2. Intestinal 2. Muscle cramps peaked T waves cramps 3. Paresthesias 2. Risk cardiac arrest 3. N/V 4. Weakness 21 Renal

22 POTASSIUM Case: HYPERkalemia 88, yr. old male; CC profound weakness this morning. Mild weakness; generalized malaise & mild nausea x 2 days. Arrival to ED with severe, bilateral weakness lower extremities greater than upper, lower extremity numbness, tingling & nausea. PMH: Small MI 3 weeks ago; also diagnosed with HTN & hypercholesterolemia. Meds: Enalapril 20 mg BID / metoprolol 50 mg BID / pravastatin 20 mg daily/ ASA 81 mg daily/ clopidogrel 75 mg daily VS: 154/83; P 67; RR 20; T C PE: Unremarkable except mild abdominal tenderness Labs: Na+ 127( )/ Cl- 94( )/ BUN 31( )/Glu 95/ K+ 7.2( ) / HC03 15 / SrCr 1.5( ) EKG: Peaked T-Waves? Remove K +or shift it intracellular What is the problem? HYPERkalemia 91, 93 HYPERkalemia (> 5 meq/l) Goals - 91 Monitoring - 93 Parameter Frequency Range 1. Cardiac stabilization 1. K+ 1. q 2-4 hr. 1. > 3.5 meq/l < 5 meq/l 2. K+ shift into ICF 2. EKG 2. Continuous 2. Convert to NSR 3. Remove K+ from body 3. EKG 3. Continuous 3. Resolve V-Fib; V-Tach 4. Find cause / correct 4. Weakness 4. q 1 hr. 4. Minimal to none 5. BP 5. q 1 hr. x 2 5. < 50 mg/dl NSR = Normal Sinus Rhythm / ICF = Intracellular Fluid HYPERkalemia Treatment - 92 Medication Dose / Route Onset Duration Notes 1. Ca Gluconate 1. 1 gm IVP over 2 min min min Stabilize cardiac tissue 2. Insulin Regular units IVP over 2 min min 2-4 hr. Shift K+ into cell Regular Insulin Know blood glucose if not, give Dextrose 50 gms. 3. Albuterol Neb mg / NaCl 4 ml min 2-4 hr. 4. Na Bicarb meq IVP over 5 min 4. < 30 min 1-2 hr. Short duration; Na+, volume load 5. Na Polystyrene gm. PO 5. 2 hr. (PO) Eliminate K+ from body gm (PR) 1 hr. (PR) 6. Furosemide mg IVP min Eliminate K+ from body 7. Hemodialysis Eliminate K+ from body To eliminate 5-6, need functioning kidneys to be able to tolerate fluid shift. 22 Renal

23 CALCIUM Calcium-Phosphate Regulation 95 Regulators of Ca ++ retention / excretion 1. Calcitriol 2. PTH Overview of Ca ++ -Phos Regulation 1. GI tract, kidneys & bones involved in Ca++ regulation Calcium Forms 96 Ca ++ in plasma 1. is in ionized form % in ionized form (physiologically active form) % bound to proteins (1 0 albumin) % complexed with anions (citrate; sulfate; phosphate) Estimating physiologic ionized Ca ++ with hypoalbuminemia Measure TOTAL calcium which = bound Ca ++ If albumin TOTAL calcium may be use Ca ++ corrected formula to determine value: [Ca ++ ] corrected = [Ca ++ ] measured + [0.8 (4 Albumin)] HYPERcalcemia (Ca++ > 10.5 mg/dl or ionized Ca++ > 2.7 mmol/l) HYPERcalcemia Etiologies - 97 GI Absorption Bone Losses Bone Mineralization Urinary Excretion 1. Milk-alkali syndrome 1. net bone resorption 1. PTH 1. Thiazide diuretics 2. Elevated Calcitriol PTH 2. Aluminum toxicity 2. Calcitriol Vitamin D Excess A. HYPERparathyroidism 3. PTH A. Excess intake Malignancy B. Granulomatous Diseases A. Osteolytic metastases PTH B. PTHrP secreting tumor HYPOphosphatemia 2. bone turnover Paget s disease of bone HYPERthyroidism HYPERcalcemia Goals, Treatment Options, Monitoring Goals - 98 TX Options - 99 Monitoring Parameter Frequency Range 1. Determine cause 1. Asymptomatic 1. Ionized Ca ++ Q 4-6 hr mmol/l 2. Prevent/treat Hydration 2. Mag ++ Q 4-6 hr meq/l severe symptoms Ambulation 3. QT (EKG) Baseline msec 3. Prevent inducing 2. Severe Acute 4. Twitching Q 1 hr. Minimal / none HYPOcalcemia NS ml/hr. 5. Fluid intake Q 1 hr. In = Out Can pt. tolerate? Hypoalbuminemic order ionized Ca++ 3. Severe non-acute Bisphosphonate Calcitonin Glucocorticoid 23 Renal

24 CALCIUM HYPERcalcemia Treatment 99 Degree HYPERcalcemia Intermittent Dosing Continuous Infusion Mild (asymptomatic) NS ml/hr. Severe (acute) NS ml/hr. Furosemide mg IVP Q 1-4 hrs. Prevents volume excess Helps excrete Ca++ Severe (non-acute) Bisphosphonate 1. Zoledronic acid 4 mg IV over 15 minutes 2. Pamidronate 60 mg IV over 2 hrs. 3. Calcitonin + Bisphosphonates in severe cases. 4 units/kg SQ effects seen in as little as 2 hrs. post administration. 24 Renal

25 CALCIUM HYPOcalcemia Causes Ca meq G.I. absorption bone resorption/ mineralization Urinary excretion 1. Poor Ca ++ intake 1. PTH (AKA HYPOparathyroidism) 1. Low PTH (s/p thyroidectomy; 2. Impaired Ca ++ absorption 2. PTH resistance (pseudo HYPOparathyroidism) s/p I 131 treatment; autoimmune Vitamin D deficiency 3. Vitamin D deficiency / calcitriol HYPOparathyroidism. Vitamin D conversion 4. Hungry bones syndrome 2. PTH resistance to calcitriol 5. Osteoblastic metastases 3. Vitamin D deficiency / low calcitriol HYPOcalcemia Goals, Treatment Options, Monitoring Goals TX Options Monitoring Parameters Parameter Frequency Range 1. Determine cause 1. Asymptomatic 1. Ionized Ca ++ q 2-4 hr mmol/l & treat PO Ca Albumin Once gm/dl 2. Prevent/treat 2. Severe, 3. Mag ++ q 4-6 hr meq/l severe symptoms Symptomatic: 4. QT (EKG) Baseline sec. 3. Prevent inducing IV replacement 5. Twitching Q 1 hr. Minimal / none HYPERcalcemia 3. HYPOcalcemia + Vit. D Deficiency: Due to Anticonvulsant: Ergocalciferol 50,000 IU daily Due to CKD: 1,25 dihydroxy Vit. D3 or Vit. D2 Analog Calcium is modestly absorbed PO HYP0calcemia Treatment 103 Degree of HYPOcalcemia Calcium Salt Intermittent Dosing Continuous Infusion Mild (asymptomatic) Gluconate 1-2 gm/ IVPB/100 ml D5W over 1 hr. Severe (symptomatic) Gluconate 3 gm. IVPB over 10 min. Severe (symptomatic; refractory) Gluconate meq/min. Gluconate less damage if extravasation occurs Chloride Delivers > elemental Ca++ but more necrotic to tissues if extravasation occurs; only use in ACLS 25 Renal

26 PHOSPHATE (Intracellular Ion) HYPERphosphatemia Causes GI Intake Urinary excretion Cell lysis 1. Fleets phosphorus soda 1. Renal failure 1. Rhabdomyolysis Provides endogenous 2. Low PTH (HYPOparathyroidism) 2. Tumor lysis syndrome phosphate S/P thyroidectomy S/P I 131 treatment for Graves disease or thyroid cancer Autoimmune HYPOparathyroidism Phosphate is an intracellular ion HYPERphosphatemia GOALS & TREATMENT Goals Treatment 107, 108 Medication Initial DOSE ( w. meals) Max DOSE 1. ID/correct cause 1. Calcium acetate 2 tab. TID 4 tabs. w. meals 2. Normalize level 2. Calcium carbonate 1-2 gms TID 7 gm. / day 3. Avoid/resolve S/S 3. Aluminum hydroxide 1-2 tab. TID/QID, HS 3-6 tab. q 4 hr. 4. Maintain Ca/Phos 4. Mag ++ hydroxide 1-2 tab. TID 2-4 tab. QID, HS product < 55 mg 2 /dl 2 to 5. Sevelamer mg TID 4 gm. TID prevent stone formation. In HYPERphosphatemia, Al +3 & Mag +2 can accumulate Most often treat with Ca +2 salts & Sevelamer HYPOphosphatemia Causes GI Absorption Bone Resorption/ Urinary Excretion Internal Redistribution* Bone Mineralization (due to stim. of glycolysis) 1. Intake 1. Vit. D deficiency / low 1. PTH i.e Refeeding syndrome** Rare in isolation calcitriol HYPERparathyroidism 2. During DKA treatment*** 2. Diarrhea/malabsorption 2. Hungry bones 2. Vit. D deficiency / low 3. Phosphate binders **** syndrome calcitriol 3. Osteoblastic mets. 3. Fanconi syndrome * Due to acute stimulation of glycolysis. Also occurs with enteral feeding. **i.e. starvation; anorexia; alcoholism ***DKA - diabetic ketoacidosis; HYPERglycemic- HYPERosmolar syndrome redistribution occurs HYPERphosphatemia can occur **** Calcium acetate, Al & Mg containing antacids. HYPOphosphatemia Goals, Treatment Goals (questions to answer) Treatment Mild PO Supplementation Severe IV Replacement 1. Symptomatic? 1. Milk 1 cup QID 1. < mmol/kg (IBW) 2. Defect magnitude? 2. Neutraphos 1-2 pkts. 3-4 x/ day mmol/kg (IBW) 3. Cause? 3. Fleets Phospha-Soda 5 ml BID mmol/kg (IBW) IV K+; Na+ salts must consider contribution to body Think of K+ amount in 15 mmol increments i.e. per dose Potassium Phosphate there may be an institutional limit on amount / dose given. IBW Estimated ideal body weight in (kg) Males: IBW = 50 kg kg x inches over 5 feet. i.e. 5 2 multiply: 2.3 x 2 Females: IBW = 45.5 kg kg x inches over 5 feet. 26 Renal

27 MAGNESIUM Magnesium Magnesium - 2 nd most abundant cation in muscle. 2 nd most abundant intracellular cation important 1. muscle integrity 2. action potential in use of muscle mass Concentration mg/dl 1. renal important system to keep Mag ++ in check Role 1. Important cofactor in biochemical reactions Homeostasis renal HYPERmagnesemia > 0.24 mg/dl Signs / Symptoms Treatment 1. N/V 1. D/C supplements 2. Deep tendon reflex loss classic symptom 2. Ca ++ IV 1 gm. over 5-10 min. 3. HYPOtension Repeat until symptoms resolve. 4. Bradycardia 5. EKG Δs HYPOmagnesemia < 1.5 mg/dl Causes Treatment Goals Treatment Alcoholism 1. Treat cause 1. PO options poor absorption 2. Excess GI losses 2. Avoid/resolve S/S Mag oxide 3. Infection 3. Normalize level Mag Citrate 4. Malnutrition 4. Avoid Mag ++ access 2. IV distributes into tissue slowly 5. Medications 50 % excreted in urine 6. Renal loss Mild-Moderate Sepsis A. Dose: 0.5 meq/kg 8. Surgery Severe < 1.2 A. 1 meq/kg Magnesium important to cardiovascular function. 8 meq = 1 gm. Premix = 4 gm. dose 27 Renal