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Normal sodium level
135-145 mEq/L
normal plasma osmolality
275 - 290 mOsm/kg
distribution of total body water
IC - 60%
EC - 40%
interstitial - 75%
intravascular - 25%
Crystalloid distribution
EC - 100%
interstitial - 75%
intravascular - 25%
D5W distribution
IC - 60%
EC - 40%
interstitial - 75%
intravascular - 25%
S/S of hypovolemia
increased BUN/Cr ratio > 10:1
tachycardia > 100bpm
hypotension SBP < 80 mmHg
orthostatic changes in HR or BP
dry mucous membranes
decreased skin turgor
reduced urine output
dizziness
3 issues to consider with Tx of hypovolemia
rate of fluid replacement
type of fluid infused
role for buffer therapy
rate of fluid replacement for hypovolemia
1-2 L of 0.9% NaCl administer as rapidly as possible
500-1000mL bolus then reevaluate patient
maintenance IV fluid dosing
1500 mL + 20 mL/kg for every kg over 20 kg
what is the typical maintenance fluid
D5W with 0.045% NaCl + 20 - 40 mEq of KCl
Tx for severe symptomatic hyponatremia
prompt correction with
free water restriction &
IV administration of hypertonic saline (3%)
may need to add a loop diuretic
definition and Tx rate for acute symptomatic hyponatremia
change in serum Na concentration > 0.5 mEq/L/hr or onset in less than 48 hours
1-2 mEq/L/hr
definition and Tx rate for chronic symptomatic hyponatremia
develops over more than 2-3 days
0.5 mEq/L/hr
maximum recommended increase in serum sodium concentration and what happens if exceeded
8-12 mEq/L per 24 hours
neurologic complications - myelinolysis
Tx of hypovolemic hypotonic hyponatremia
0.9% NaCl or LR
causes of hypovolemic hypotonic hypnatremia
renal - thiazides
nonrenal - GI losses (vomiting, diarrhea)
Tx of isovolemic hypotonic hyponatremia
water restriction
mild diuresis with a loop
most common cause of isovolemic hypotonic hyponatremia
SIADH
Tx of chronic SIADH
demeclocyline HCl - caution may have negative effects on renal function
Tx of primary acute SIADH
correct underlying disorder
water restriction
meds that can cause SIADH
carbamazapine
sertraline & possibly fluoxetine
Tx of hypervolemic hypotonic hyponatremia
optimizing underlying cause
Na & fluid restriction
: 1000-1500 mL daily
diuresis with loop
cause of isotonic hyponatremia
hyperlipidemia
cause of hypertonic hyponatremia
hyperglycemia
cause of hypovolemic hypotonic hyponatremia
thiazide diuretics
GI losses
causes of hypervolemic hypotonic hyponatremia
CHF
cirrhosis
renal failure
S/S of hypernatremia
lethargy
irritability
restlessness
thirst muscle irritability & spasticity
hyperreflexia
seizure
coma
death
Tx of hypernatremia
0.225% NaCl and D5W
Na correction rate for acute hypernatremia
no faster than 1-2 mEq/L/hr
acute is occurring in less than 48 hours
Na correction rate for chronic hypernatremia
0.5 mEq/L/hr
chronic occurs in more than 2-3 days
formula for water deficit
total body water (TBW) x [(serum sodium conc./140)]-1 and multiply by dosing factor
replacement of water deficit
half should be replace over the first 24 hours
remainder replaced over following 24 - 72 hours
maximum rate of Na decrease in hypernatremia
10-12 mEq/L per 24 hours
Tx of hypovolemic hypernatremia and hemodynamically unstable
0.9% NaCl of LR
Tx of hypovolemic hypernatremia and hemodynamically stable
hypotonic
: 0.45% NaCl or 0.225% NaCl + D5W
NEVER use sterile water
Tx of isovolemic hypernatremia
sodium restriction
when is isovolemic hpernatremia seen
diabetes insipidus
central - inablility to produce ADH
nephrogenic - inability of kidney to respond to ADH
causes of NDI
hypokalemia
hypercalcemia
lithium
Tx of hypervolemic hypernatremia
removal of sodium products
sodium restriction
diuretics
normal potassium level
3.5 - 5 mEq/L
S/S of hypokalemia
changes in muscle and cardiovascular function
N/V
weakness
constipation
paralysis
respiratory compromise
Rhabdo
causes of hypokalemia - intracellular shifts
metabolic alkalosis
beta adrenergic agonist (albuterol)
insulin
theophylline
caffeine
causes of hypokalemia
K sparring diuretics
sodium polystyrene sulfonate
corticosteroids
aminoglycosides
magnesium depletion
hemodialysis
GI losses
Tx of mild - moderate hypokalemia
20-40 mEq K - IV or oral
Tx of severe hypokalemia
40-80 mEq K - oral or IV
value of mild-moderate hypokalemia
2.5-3.4 mEq/L
value of severe hypokalemia
<2.5 mEq/L
impaired renal function and Tx of hypokalemia
50% initial K dose
what coexists with hypokalemia
hypomagnesemia
S/S of hyperkalemia
arrhythmias
muscle twitching
cramping weakness
ascending paralysis
ECG changes
what drugs or condition can cause hyperkalemia
renal insufficiency
K sparring diuretics
ACEIs
NSAIDS
hypoaldosteronism
causes of hyperkalemia extracellular shifts
metabolic acidosis
succinylcholine
beta blockers
digoxin overdose
muscular injury
symptomatic ECG changes; Tx of hyperkalemia antagonizing affect
IV calcium gluconate
then increase K elimination by
potassium-wasting diuretic
sodium polystyrene sulfonate
renal replacement therapy
rapid correction of hyperkalemia
insulin & dextrose
sodium bicarbonate
albuterol
normal phosphorus level
2.7-4.5 mg/dL
causes of hypophosphatemia
malnutrition
carb loads - refeeding syndrome
insulin, diuretics, antacids, sucralfate
Tx of asymptomatic mild hypophosphatemia
PO phosphate supplementation if GI tract is functional
Tx of symptomatic mild-severe hypophosphatemia
2.3-2.7 mg/dL - 0.08-0.16 mmol/kg/dose
1.5-2.2 mg/dL - 0.16-0.32 mmol/kg/dose
<1.5 mg/dL - 0.32-0.64 mmol/kg/dose
most common clinical manifestation of hyperphosphatemia
hypocalcemia
causes of hyperphosphatemia
renal insufficiency
respiratory & metabolic acidosis
hemolysis
rhabdo
hypoparathyroidism
vit D toxicity
one of the main goals of hyperphosphatemia
maintaining serum (calcium x phosphorus) < 55-60mg
2
/dL
2
Tx of hyperphosphatemia
calcium salts - preferred in chronic renal damage
aluminum salts - increase constipation
magnesium salts - increase diarrhea
Tx of hyperphosphatemia if hypercalcemia and chronic renal failure
sevelamer
normal range of calcium
8.6-10.2 mg/dL
what do you do if a pt is hypoalbuminemia with regard to calcium
corrected calculation
serum Ca conc. + (0.8 x [4-serum albumin con])
hallmark sign of severe acute hypocalcemia
tetany
S/S of chronic hypocalemia
skin manifestations
hair loss
dermatitis
eczema
rapid Tx of hypocalcemia
calcium chloride - 3x more Ca
calcium gluconate - preferred because if you mess up the dose you are actually underdosing
Tx of asymptomatic hypocalcemia due to hypoalbuminemia
no therapy required
Tx of severe hypocalcemia
prompt correction with IV calcium
1000 mg Ca or
3g calcium gluconate given over 10 minutes
Tx of severe hypercalcemia when not in an acute setting
bisphosphonates
Tx of severe hypercalcemia
IV hydration - 0.95 NaCl 200-300 mL/hr
IV furosemide - 40-100 Q 1-4hrs
Adding the two together will reduce the serum calcium by 2-3 mg/dL within the first 48 hours
normal magnesium levels
1.5-2.4 mg/dL
what other condition can hypomagnesemia cause
hypokalemia and hypocalcemia
what is severe hypocalcemia and what can it cause
< 1.0 mg/dL
arrhythmias (torsades)
seizurescomadeath
meds that cause hypomagnesemia
thaizide
aminoglycosides
digoxin
causes of hypomagnesemia
excessive GI losses
renal losses
surgery
trauma
infection or sepsis
burns
starvation
alcoholism
Tx goal of mild - moderate hypomagnesemia
1.0-1.5 mg/dL
8-32 mEq Mg IV
1-4 g Mg sulfate
Tx of severe hypomagnesemia
32-64 mEq Mg IV/dose
4-8 Mg sulfate
renal threshold for Tx of asymptomatic hypomagnesemia
total dose should not exceed 12 g of Mg sulfate over 12 hours
Tx of severe symptomatic hypomagnesemia
32-64 mEq Mg IV/dos
doses up to 4 g Mg sulfate over 4-5 minutes
what signifies severe symptomatic hypomagnesemia
torsades
Tx of asymptomatic hypermagnesemia
discontinue exogenous Mg administration
Tx of severe symptomatic hypermagnesemia
IV calcium
what 3 electrolyte conditions do you reduce the dose by 50% in renal impairment
hypomagnesemia
hypophosphatemia
hypokalemia
Author
coal
ID
241313
Card Set
thera fluid & electrolyte
Description
thera fluid & electrolyte
Updated
2013-11-03T19:52:54Z
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