Documente Academic
Documente Profesional
Documente Cultură
Dr Hussain Azhar
Topic Outline
Important Electrolytes Sodium Potassium Clinical Features Calcium Well Discuss: Main causes of excess and deficiency
Management
Acid Base Disturbances
Sodium
Hyponatremia
Sodium
Normally, the extracellular-fluid and intracellular-fluid compartments make up 40 percent and 60 percent of total body water, respectively
With the syndrome of inappropriate secretion of antidiuretic hormone, the volumes of extracellular fluid and intracellular fluid expand
Water retention can lead to hypotonic hyponatremia without the anticipated hypo-osmolality in patients who have accumulated ineffective osmoles, such as urea (ARF / CRF)
A shift of water from the intracellular-fluid compartment to the extracellular-fluid compartment, driven by solutes confined in the extracellular fluid, results in hypertonic (translocational) hyponatremia e.g. hyperglycemia
Sodium depletion (and secondary water retention) usually contracts the volume of extracellular fluid but expands the intracellular-fluid compartment e.g. diarrhea
Hypotonic hyponatremia in sodium-retentive states involves expansion of both compartments, but predominantly the extracellular-fluid compartment e.g. nephrotic syndrome Hypotonic hyponatremia due to water retention in association with sodium gain and potassium loss e.g. CCF treated with diuretics)
Hyponatremia
UNa> 20 FENa> 1%
DIFFERENTIAL DIAGNOSIS OF HYPONATREMIA BASED ON CLINICAL ASSESSMENT OF EXTRACELLULAR FLUID VOLUME (ECFV)
Hyponatremia
Clinical Features
Asymptomatic Mild and chronic state:
Headache, nausea, vomiting, muscle cramps, lethargy, restlessness, disorientation, and depressed reflexes
Treatment of Hyponatremia
Practical Exercise
A 58-year-old man with small-cell lung carcinoma presents with severe confusion and lethargy. Clinically, he is euvolemic, and he weighs 60 kg. The serum sodium concentration is 108 mmol per liter, the serum potassium concentration is 3.9 mmol per liter, serum osmolality is 220 mOsm per kilogram of water, the serum urea nitrogen concentration is 5 mg per deciliter , the serum creatinine concentration is 0.5 mg per deciliter and urine osmolality is 600 mOsm per kilogram of water
Answer
Formula:
The retention of 1 liter of 3 percent sodium chloride is estimated to increase the serum sodium concentration by 10.9 mmol per liter ([513 108] [36 + 1]=10.9). The initial goal is to increase the serum sodium concentration by 5mmol per liter over the next 12 hours.
Therefore, 0.46 liter of 3 percent sodium chloride (5 10.9), or 38 ml per hour, is required.
2. Isotonic Saline
Patients initially improve neurologically with correction of hyponatremia, but then, 1 to several days later, new, progressive, and sometimes permanent neurologic decits emerge e.g. quadriplegia, dysphagia, dysarthria etc.
Most patients with the osmotic demyelination syndrome survive, and those with persistent decits can be diagnosed with magnetic resonance imaging
Diagnosis of SIADH
1. 2. 3. 4. 5. 6. Hyponatremia [Na] < 136 mEq / L Decreased Serum Osmolality < 280 mOsm / kg Increased Urine Osmolality > 150 mOsm / kg Absence of cardiac, liver, renal disease Normal Thyroid and Adrenal function Urinary sodium > 20 mEq / L
Treatment of SIADH
1. 2. 3. 4. 5. Treatment of underlying cause Free water restriction Hypertonic saline +/- furosemide Demeclocycline or Lithium V2 Vasopressin Receptor Antagonist: Conivaptan
Hypernatremia
Hypernatremia
Extracellular-Fluid and Intracellular-Fluid Compartments under Normal Conditions and during States of Hypernatremia.
Normal Condition
Pure water loss reduces the size of each compartment proportionately e.g. Diabetes Insipidus Hypotonic sodium loss causes a relatively larger loss of volume in the extracellularfluid compartment than in the intracellularfluid compartment e.g. vomiting
Potassium loss in addition to hypotonic sodium loss further reduces the intracellular-fluid compartment e.g. osmotic diuresis Hypertonic sodium gain results in an increase in extracellular fluid but a decrease in intracellular fluid e.g. hypertonic bicarbonate infusion
Causes of Hypernatremia
Causes of Hypernatremia
Hypovolemic Hypernatremia 1. Extra Renal Losses Euvolemic Hypernatremia 1. Cental Diabetes Insipidus Hypervolemic Hypernatremia 1. Hypertonic saline infusion
2. Renal Losses
2. Mineralocorticoid excess
Work up of Hypernatremia
Urinary Osmolality Urinary Sodium Volume status
Work up of Hypernatremia
Treatment of Hypernatremia
Treatment of Hypernatremia
Hypovolemic Hypernatremia
1. Extra Renal Losses 2. Renal Losses
Euvolemic Hypernatremia
1. Cental Diabetes Insipidus 2. Nephrogenic Diabetes Insipidus
Hypervolemic Hypernatremia
1. Hypertonic saline infusion 2. Mineralocorticoid excess
1. Restore access to water 2. Replace Volume 3. Calculate and give Free Water Deficit
Treatment of Hypernatremia
Managing the underlying cause may mean:
Stopping gastrointestinal fluid losses; Controlling pyrexia, hyperglycemia, and glucosuria; Withholding lactulose and diuretics; Treating hypercalcemia and hypokalemia; Moderating lithium-induced polyuria; or Correcting the feeding preparation
Answer
The estimated volume of total body water is 34 liters (0.5 68). According to formula 1, the retention of 1 liter of 5 percent dextrose will reduce the serum sodium concentration by 4.8 mmol per liter ([0168] [34+1]= 4.8).
The goal of treatment is to reduce the serum sodium concentration by approximately 10 mmol per liter over a period of 24 hours. Therefore, 2.1 liters of the solution (10 4.8) is required. With 1.5 liters added to compensate for average obligatory water losses over the 24-hour period, a total of 3.6 liters will be administered for the next 24 hours, or 150 ml per hour.