fluid/acid-base HYPO NA

Question 1

HypoNa. what normal serum osmol?

Answer 1

275-295

Question 2

HypoNa. If osmolality increased, what released?

Answer 2

Incr. in osmolality -> incr. ADH -> incr. H2O resorption in distal tubules and collecting ducts.

Question 3

HypoNa. If osmolality decreased, what supressed?

Answer 3

Osmolality is low -> low ADH -> less water absorbed.

Question 3

ADH is secreted in response to hypovolemia and this stimulus will over-ride any response to serum osmolality.

Answer 3

.

Question 4

What is osmolality?

Answer 4

Osmolality = effective osmoles + ineffective osmoles

Question 5

What is tonicity?

Answer 5

Tonicity = effective osmoles

Question 6

Tonicity leads to driving force for water to move, since particles do not cross membrane and it leads to incr. tonicity.

Answer 6

.

Question 7

Effective osmoles how move?

Answer 7

Effective osmoles – does not move easily.

Question 8

Ineffective osmoles how move?

Answer 8

Ineffective osmoles – moves easily through compartments.

Question 9

Tonicity (effective osmoles) - what particles?

Answer 9

It is determined by endogenous (sodium and glucose) and exogenous (mannitol, raffinose) solutes with a reflection coefficient of 1.0 that are unable to pass through cell membranes.

Question 10

ineffective osmoles - what particles?

Answer 10

Freely permeable substances that have a reflection coefficient of zero (such as urea, ethanol, and methanol) are named as “ineffective osmoles” and they can easily shift through fluid compartments.

Question 11

Serum osml. formula?

Answer 11

Serum Osm = 2 x Na + Glucose + Urea (international units (all of which are in mmol/L)).

Question 12

what is osmolal gap? calculation?

Answer 12

The osmol gap is the difference between the measured and calculated osmolality
(measured – calculated)

Question 13

Inc. osmolality. 2 mechanisms?

Answer 13

1st mechanism: there may be an additional solute or solutes other than a sodium salt, glucose, or urea that is present at a concentration high enough to raise the osmolality.

2nd mechanism: Marked hyperlipidemia or hyperproteinemia.

Question 13

normal osmolal gap?

Answer 13

Normal gap =< 10 mOsm/kg water.

Above 10 - incr. osmolal gap

Question 14

Inc. osmolality. 1st mechanism - inc. solutes. it may be with or without anion gap acidosis.

WITH anion gap ACIDOSIS what particles contribute to LARGE anion gap?

Answer 14

Major causes of a large osmolal gap: ethylene glycol or methanol ingestion, propylene glycol infusion – it a diluent found in iv medications such lorazepam (Ativan), diazepam (valium), phenytoin, phenobarbital, nitroglycerin.

Question 15

Inc. osmolality. 1st mechanism - inc. solutes. it may be with or without anion gap acidosis.

WITH anion gap ACIDOSIS what particles contribute to SMALL anion gap?

Answer 15

Causes of smaller osmolal gap: severe CKD without regular dialysis, ketoacidosis (diabetic or alcohol), lactic acidosis, paraldehyde ingestion or injection.

Question 16

Inc. osmolality. 1st mechanism - inc. solutes. it may be with or without anion gap acidosis.

WITHOUT anion gap ACIDOSIS what particles contribute to anion gap?

Answer 16

Ethanol, isopropanol, diethyl ether ingestion; infusion of mannitol, infusion of nonconductive glycine (TURP syndrome), sorbitol; pseudohyponatremia (severe hyperlipidemia or hyperproteinemia)

Question 17

Inc. osmolality. 2nd mechanism.

Marked hyperlipidemia or hyperproteinemia does not affect the concentration of sodium in serum water, and it is this concentration that determines the measured serum osmolality.

Answer 17

.

Question 18

HypoNa. UW. Low osmolality. What are fluid statuses?

Answer 18

Hypovolemic, euvolemic, hypervolemic.

Question 19

HypoNa. UW. 1st step?

Answer 19

is there hyponatremia < 135?

Question 20

HypoNa. UW. normal osmol and inc. osmol. what fluid statuses?

Answer 20

,,variable”
fantastika blet

Question 21

HypoNa. UW. there is Na < 135. what next?

Answer 21

check osmolality - o

low < 275
normal,
high > 295 mOsm/kg

Question 22

HypoNa. UW. if low Na + high osmol?

Answer 22

evaluate 2 things.

1st - glucose - it may be result of hyperglycemia

2nd - exogenous solutes eg mannitol, contrast agents, alsa was mentioned advanced renal failure.

Question 23

HypoNa. UW. if Na low and there is no increase in serum osmol (it means osmol low or normal). what to evaluate then?

Answer 23

urine osmolality.

Question 24

HypoNa. UW. urine osmolality range?

Answer 24

Urine osmolality varies between 50 and 1200 mmol/kg. For diagnostic - 100 mOsm/kg

Question 25

HypoNa. UW. Na low and there is no increase in serum osmol. evaluated urine osmol > 100 mOsm/kg. what that means? causes

Answer 25

Indicates impaired ability to dilute the urine. Urine is concentrated, it means that water is lack in urine. It means ADH is released. Causes: SIADH (also U Na > 40), hypothyroidism, glucocorticoid deficiency (aka secondary adrenal insufficiency).

Question 26

HypoNa. UW. Na low and there is no increase in serum osmol. evaluated urine osmol < 100 mOsm/kg. What that means? causes

Answer 26

It indicates diluted urine. Urine is dilated, it means there is too much water, that need to excrete. It means ADH is suppressed. Primary polydipsia, beer drinkers potomania.

Question 27

what is beer potomania?

Answer 27

Beer potomania, a unique syndrome of hyponatremia (5 or more drinks/day). It is described as the excessive intake of alcohol, particularly beer, together with poor dietary solute intake that leads to fatigue, dizziness, and muscular weakness. The low solute content of beer, and suppressive effect of alcohol on proteolysis result in reduced solute delivery to the kidney. The presence of inadequate solute in the kidney eventually causes dilutional hyponatremia secondary to reduced clearance of excess fluid from the body.

Question 28

HypoNa. UW. Na low and there is no increase in serum osmol. evaluated urine osmol > 100 mOsm/kg. what evaluate next?

Answer 28

Urine sodium

Question 29

HypoNa. UW. Na low and there is no increase in serum osmol. evaluated urine osmol > 100 mOsm/kg. esant >100 toliau tesiasi algoritmas siekiant ivertinti (pagal U Na) kokia yra priezastis - renal or extrarenal. cia jau priklauso prie hypovolemic. nes jeigu <100 - tai normovolemija, bet jeigu > 100, tai reikia issdifernecijuoti ar tai nera hypovolemine bukle.

Answer 29

.

Question 30

HypoNa. UW. Na low and there is no increase in serum osmol. evaluated urine osmol > 100 mOsm/kg. pagal UW algo yra rodiklis U Na 25. U Na < 25? causes

Answer 30

Volume depletion CHF, cirrhosis (decr. effective circulating volume) - siaip schemoj yra prie hypervolemia, nes bendrai paemus skysciu yra daug, bet tas efektyvus turis yra sumazejes, todel pvz U Na yra zemas, nes bando kunas issaugoti natri, nes neva ,,hipovolemija"

Question 31

HypoNa. UW. Na low and there is no increase in serum osmol. evaluated urine osmol > 100 mOsm/kg. pagal UW algo yra rodiklis U Na 25. what means if U Na > 25? causes

Answer 31

SIADH, adrenal insuffieciency, hypothyroidism.

Question 32

Hypovolemic hypoNa. symptoms?

Answer 32

decr. intake and decr. output of water, orthostatic lightheadness, dry mucous membranes, poor skin turgor, tachycardia, orthostatic hypotension.

Question 33

Hypovolemic hypoNa. Extrarenal loses U Na =< 20?

Answer 33

burns, diarrhea, vomiting, pancreatitis

Question 34

Hypovolemic hypoNa. Renal loses U Na > 20?

Answer 34

Diuretics, mineralcorticoid deficiency

Question 35

Hypovolemic hypoNa. decreased effective circulating volume? nu cia bendrai yra hypervolemia, bet del sumazejusio efektyvaus turio organizas galvoja kad yra hipovolemija

Answer 35

CHF, cirrhosis

Question 36

Mechanism of hypovolemic hyponatremia. Solute and water loss --> 3 results?

Answer 36

1. decr. renal perfusion 2. hypotension 3. hypovolemia

Question 37

Mechanism of hypovolemic hyponatremia. Solute and water loss --> 1. decr. renal perfusion --?

Answer 37

Activation or RAAS --> AT II --> 1. Incr. aldosterone -> incr. Na absorb. 2. Incr. THIRST --> Incr. water intake --> decr. serum Na 3. Incr. ADH (non-osmotic stimulation) --> incr. water reabs. --> decr. serum Na

Question 38

Mechanism of hypovolemic hyponatremia. Solute and water loss --> hypotension -->?

Answer 38

BARORECEPTORS --> Incr. ADH (non-osmotic stimulation) --> incr. water reabs. --> decr. serum Na

Question 39

Mechanism of hypovolemic hyponatremia. Solute and water loss --> hypovolemia --> ?

Answer 39

Left atrial stretch receptor stimulation --> Incr. ADH (non-osmotic stimulation) --> incr. water reabs. --> decr. serum Na.

Question 40

Mechanism of hypovolemic hyponatremia. short. Solute and water loss --> decr. renal perfusion --> general result?

Answer 40

activation of RAAS --> incr. ATII

Question 41

Mechanism of hypovolemic hyponatremia. short. Solute and water loss --> hypotension --> general result?

Answer 41

baroreceptors activated

Question 42

Mechanism of hypovolemic hyponatremia. short. Solute and water loss --> hypovolemia--> general result?

Answer 42

Left atrial stretch receptor stimulation

Question 43

hypoNa. treatment. what first evaluate?

Answer 43

onset - 48h

Question 44

hypoNa. treatment. acute < 48 chronic or unknown >48

Answer 44

.

Question 45

hypoNa. treatment. acute --> what evaluate?

Answer 45

whether symptoms (mild, moderate, severe) are present?

Question 46

hypoNa. treatment. Acute + yes symptoms -->?

Answer 46

100 ml 3 proc. saline and repeat twice as needed. monitor Na hourly until serum Na has increased by 4 to 6 mmol/l after which monitoring can be reduced recurrent hypoNa may require repeat treatment as above

Question 47

hypoNa. treatment. Acute + no symptoms --> what evaluate?

Answer 47

Is the hyponatremia already autocorrecting due to a water diuresis?

Question 48

hypoNa. treatment. Acute + no symptoms --> already autocorrects due to water diuresis --> ?

Answer 48

Monitor Na hourly until serum Na has increased by 4 to 6 mmol/l above nadir (lowest value) Further decline of Na means no autocorrection or delayed absorption of ingested water If declines --> give 50 ml bolus 3 proc saline

Question 49

hypoNa. treatment. Acute + no symptoms --> DOES NOT already autocorrects due to water diuresis --> ?

Answer 49

50 ml 3 proc. saline bolus to prevent decline Monitor Na hourly to determine the need for repeated bolus

Question 50

hypoNa. treatment. Acute + no symptoms --> autocorrect pathway due to water diuresis --> further decline of Na. What 2 reasons?

Answer 50

Decline means there is no autocorrection OR occurs delayed absorption of ingested water

Question 51

hypoNa. treatment. Chronic --> evaluate for SEVERE symptoms.

Answer 51

.

Question 52

hypoNa. treatment. Chronic + SEVERE symptoms -->

Answer 52

100 ml 3 proc. saline and repeat twice as needed. monitor Na hourly until serum Na has increased by 4 to 6 mmol/l after which monitoring can be reduced. recurrent hypoNa may require repeat treatment as above

Question 53

hypoNa. treatment Chronic + No SEVERE symptoms --> EVALUATE wether has intracranial pathology - recent TBI, brain surgery or hemorrhage, or neoplasm. If yes and no?

Answer 53

if yes: manage same ar with severe symptoms (100 ml 3 proc saline) if no: evaluate wether Na < 120?

Question 54

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> what evaluate?

Answer 54

evaluate wether hyponatremia is due to self-induced intoxication? (extreme polydipsia?).

Question 55

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> YES water intoxication --> monitoring of sodium, general measures. no question

Answer 55

.

Question 56

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> what evaluate?

Answer 56

Is patient is edematous? (CHF, cirrhosis)

Question 57

hypoNa. treatment ! Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> YES edematous state --> ? treatment

Answer 57

Infusion of 3 proc. saline at 15 to 30 ml/h PLUS iv furosemide (40 mg or higher) TWICE DAILY. Monitor Na frequently (eg 2-4h) and adjust rate of 3 proc. saline to ACHIEVE a 24h increase in serum sodium of 4-6 mmol/l. Titrate furosemide to prevent severe hypervolemia Discontinue regimen when serum Na has increased at least 125.

Question 58

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> No edematous state --> ? evaluate rapid reversible causes of hypoNa: 3?

Answer 58

Is the case of hypoNa rapidly reversible? Specifically: 1. Due to true hypovolemia? 2. due to adrenal insufficiency? 3. transient SIADH (eg from surgery, pain, drug induced)

Question 59

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> No edematous state --> ? evaluate rapid reversible causes of hypoNa --> present. what treatment?

Answer 59

Infusion of 3 proc. saline at 15 to 30 ml/h PLUS iv or s/c desmopresin 1-2 mcg every 6-8h. Monitor Na frequently (eg 2-3h initially, and then, after water losses have been controlled with desmopressin, every 4-6h); adjust 3proc. saline rate to ACHIEVE a 24h increase in serum sodium of 4-6 mmol/l. Discontinue regimen when serum Na has increased at least 125.

Question 60

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> No edematous state --> ? evaluate rapid reversible causes of hypoNa --> not present --> what evaluate then? 5

Answer 60

Is the patient at high risk for osmotic demyelination syndrome? 1. Serum sodium =< 105 2. Concurrent hypokalemia 3. Patient with alcohol use disorder 4. Malnourished patient 5. Concurrent liver disease

Question 61

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> No edematous state --> ? evaluate rapid reversible causes of hypoNa --> not present --> if patient is at high risk for demielination syndrome --> treatment?

Answer 61

same as with rapidly reversible (saline and desmopresin)

Question 62

hypoNa. treatment Chronic + No SEVERE symptoms -->no brain pathology --> Na < 120 mmol/l --> NO water intoxication --> No edematous state --> ? evaluate rapid reversible causes of hypoNa --> not present --> if patient is NOT at high risk for demielination syndrome --> treatment?

Answer 62

Standartinis letas. Infusion of 3 proc. saline at 15 to 30 ml/h Monitor Na frequently (eg 4-6h) and adjust rate of 3 proc. saline to ACHIEVE a 24h increase in serum sodium of 4-6 mmol/l. hypervolemia Discontinue regimen when serum Na has increased at least 125.

Question 63

Hyperglycemia, exogenous solutes, advanced renal failure. status?

Answer 63

Osm > 295 Fluid status - variable

Question 64

Pseudohyponatremia (eg. paraproteinemia, hyperlipidemia). status?

Answer 64

osm normal, fluid status variable

Question 65

primary polydipsia, malnutrition (beer potomania). status?

Answer 65

osm < 275 euvolemia U Osm < 100

Question 66

SIADH, hypothyroidism, secondary adrenal insufficiency. status?

Answer 66

osm < 275 euvolemia U Osm > 100

Question 67

FA. HypoNa most common cause?

Answer 67

Increased ADH. Causes: physiologic - eg dec. effective circulating volume or pathologic - SIADH

Question 68

FA. HypoNa ADH independent causes?

Answer 68

primary polydipsia, starvation (solute deficiency), presence of a non-sodium effective osmole in the ECF (eg glucose in hyperglycemia)

Question 69

FA. HypoNa. treatment. treat underlying cause. If hypervolemic or euvolemic?

Answer 69

water restriction +/- diuretics

Question 70

FA. HypoNa. treatment. hypovolemic?

Answer 70

replete volume with NaCl.

Question 71

FA. HypoNa. treatment. If severe hypoNa < 120?

Answer 71

consider 3 proc. hypertonic saline, particularly if symptomatic (eg seizures)

Question 72

FA. HypoNa. treatment. Chronic. rate of treatment?

Answer 72

slowly < 10 mmol/l day to prevent osmotic demyelination syndrome (symptoms include paraparesis/quadriparesis, dysarthria, coma)

Question 73

UW. Iatrogenic HypoNa. 4 risk factors?

Answer 73

Hypotonic fluid hydration Children, postmenopause, elderly Hypoxia Central nervous system disorders

Question 74

UW. Iatrogenic HypoNa. clinical? 3

Answer 74

Headache Nausea/vomiting Encephalopathy (mental status changes, seizures)

Question 75

UW. Iatrogenic HypoNa. treatment 3.

Answer 75

Hypertonic 3 proc. saline Serial measurement of electrolytes Incr. in serum sodium 6-8mmol/l in first 24h.