Sodium disorders (___- ____)
Physiology
- 135-145
- Predominant cation of the ECF
- Primary electrolyte in establishing osmostic pressure between the ICF and ECF
- All body fluids are in osmotic equilibrium and changes in serum sodium concentration (Na) are associated with shifts of water in and out of body fluid compartements
- Adding Sodium in the intravascular compartment from the interstitial fluid and, ultimately from ICF
- Adding Sodium in the intravascular compartment from the interstitial fluid and, ultimately from ICF
Sodium disorder
A pts Na concentration should not be used because it doesnt reflect?
Na imbalances cannot be properly assesses without?
Na disorders are ___ disorders?
Normal sodium maintenance is?
- Not be used as an index of sodium because it does not reflect total body sodium content, Na primarily reflects disturbances in TBW
- Without first assessing the body fluid status
- Water disorder
- 80-120 meq/day
Hyponatremia: Signs and Symptoms
Usually exhibited at < 120 meq/L
Usually as <110
- Agitation
- Fatigue
- HA
- Muscle cramps
- Nausea/anorexia
- Confusion
- Seizures
- Coma
Hypertonic Hyponatremia
Usually associated with _____
Treat the ___ as this is corrected the [Na] will?
hyperglycemia
Treat the hyperglycemia na with return to normal
Diagnostic algorithm for hyponatremia

Diagnostic algorithm for hyponatremia
continued

Calculation of sodium deficit in a 75 kg male with a serum sodium of 123 mEq/L
Sodium deficit = (45 liters)(140 mEq/L - 123 mEq/L) = 765 mEq
STOPPED at HYPERNATREMIA
Causes of Hypernatremia
First 4 lead to?
5
- Dehydration = loss of hypotonic fluid (respiratory, skin losses)
- Decreased water intake
- Osmotic diuresis
- Diabetes insipidus (decreased ADH activity)
- May be induced by certain drugs (lithium, phenytoin)
- Latrogenic- Admin of too mich hypertonic saline-uncommon
- May be induced by certain drugs (lithium, phenytoin)
Hypernatremia treatment
Calculate TBW deficit?
replace deficit over? with?
- Water def= Normal TBW - Present TBW
- Over 48-72 hours with solution hypotonic to pts serum
Hypernatremia treatment
Overly-___ correction may lead to?
The rate at which hypernatremia should be corrected depends on the severity of symptoms and the degree of?
For ____ pts, the rate of correction probably should not exceed?
Rule of thumb?
- Rapid may lead to cerebral edema and death
- Hypertonicity
- Asymptomatic, 0.5 mEq/L/hour
- Replace half the calculated deficit with hypotonic solutions over 12 to 24 hours
Hypernatremia example
Calculate the water deficit in a 75 kg patient male with a serum sodium of 156 mEq/L
Water Def (L) = TBW x [(serum sodium/140)-1]
45 x 0.1 = 5 L
Calcium disorders (__-__)
Ca and phos concentrations regulated by?
Normal calcium maintenance requirement
Corrected calcium accounts for? Calculation?
- 9-10.5 mg/dL
- Parathyroid hormone (Increased, increases calcium concentration
- Vit D
- Calcitonin increased, decreases calcium
Maintenance- 800-1200
CC- accounts for a decrease in percent of protein binding due to decrease albumin concentration
CC= observed [Ca] + 0.8 (normal albumin*-observerd albumin)
Normal = 4 g/dL
Hypocalcemia sign/symptoms and causes

Checking Trousseaus Signs?
- Apply a BP cuff to pts upper arm and inflate
- Pt will experience adducted thumb, flexed wrist and metacarpophalangeal joints
- Carpopedal spasm=tetany
- Carpopedal spasm=tetany
Checking for Chvosteck signs
- Tap on pts focial nerve adjacent to the ear
- Brief contraction of upper lip, nose, or side of face indicated tetany
Calcium supplements

IV calcium replacement products which one is preferred and why?
How are they given?
Calcium gluconate- preferred less irritating
Calcium chloride- irritating to veins-->central line
Preparation given as slow push or added to 50 mL to 250 mL .9% NaCl, LR, D5W for slow infusion
Indications for IV calcium for Acute Hypocalcium
- Pt symptomatic (patesthesia, tetany, Chvostek sign)
- Clinically relevant hypocalcemia (serum Ca < 1 mmol/L)
- Massive blood transfusion (especially with preexisting cardiac disease)
- CCB overdose
- Receiving inotropic or vasopressor support
- Emergent hyperkalemia
Hypocalcemia treatment
Acute symptomatic hypocalcemia
- 200-300 mg of elemental calcium IV and repeat until symptoms fully controlled
- 1 gram of calcium chloride or 2-3 grams of calcium gluconate
- No faster then 30-60 mg of elemental calcium per minute
- Caution if serum phosphate elevated or if on digoxin therapy
- 1 gram of calcium chloride or 2-3 grams of calcium gluconate
- No faster then 30-60 mg of elemental calcium per minute
- Caution if serum phosphate elevated or if on digoxin therapy
Hypercalcemia treatment
- Consider if pt symptomatic and/or serum concentration > 12 mg/dL
- 0.9% NaCl +- furosemide
- Infusion rate as high as 200-300 ml/hr may be needed
- Only ass loop diuretic after initial ECF depletion has been corrected
- Function kidney needed (hemodialysis alternative)
- Monitor [K] and [Mg] Carefully
- Infusion rate as high as 200-300 ml/hr may be needed
- Only ass loop diuretic after initial ECF depletion has been corrected
- Function kidney needed (hemodialysis alternative)
- Monitor [K] and [Mg] Carefully
Treatment strategies and modalities for Hypercalcemia

Suggested treatment regimens for Hypercalcemia
- Because of polyuria, pt is usually dehydrated
- Normal saline 200-300 mL/hr, checking for continued dehydration or fluid overload. Goal: up tp 4 L on day one
- Once rehydrated, add furosemide (Block Ca reabsorption) 40-80 mg IV Q 1-4 hours until urine output = 200-250 mL/hour
- Monitor serum K and Mg
Phosphorus disorders (___-___)
Express phosphate in mg or mmoles not milliequivalents
# of mmoles =
Normal maintenance phosphate requirement
- 3-4.5 mg/dL
- = amount in mg/ atomic moleculat wt
- 800-1200 mg/day (250 mg = 8 mmol)
Hypophosphatemia treatment
- Mild 2-2.5
- Eat
- Moderate 1-2.5
- Oral therapy
- 1.5-2 grams/day divided into 3-4 doses
- Diarrhea may be dose limiting
- Severe <1
- Parenteral therapy indicated
- .o8-.64 mmol/kg
- Range 5-45 over 4-12 hours
- Select replacement based on need for other electrolytes (Na vs. K)
- Caution in pts with hypercalcemia, renal dysfunction, or evidence of tissue injury
- Switch to oral supplement when level 2-2.5 mg/dL
- Eat
- Oral therapy
- 1.5-2 grams/day divided into 3-4 doses
- Diarrhea may be dose limiting
- Parenteral therapy indicated
- .o8-.64 mmol/kg
- Range 5-45 over 4-12 hours
- Select replacement based on need for other electrolytes (Na vs. K)
- Caution in pts with hypercalcemia, renal dysfunction, or evidence of tissue injury
- Switch to oral supplement when level 2-2.5 mg/dL
Phosphate replacementproducts

IV Phosphate repletion protocol

Hyperphosphatemia treatment
- Dietary restriction of phosphate and protein
- If tetany (spasms) administer calcium salts IV (see hypocalciemia aboce)
- Diaylsis of caused by renal failure
- Oral phosphate binders
- Mg hydroxide (milk of Mg)
- Can cause diarrhea
- Calcium carbonate
- Inexpensive, tablen can be crushed
- Mg hydroxide (milk of Mg)
- Can cause diarrhea
- Calcium carbonate
- Inexpensive, tablen can be crushed
5 phosphate binders for treating hyperphosphatemia
- Mg hydroxide (milk of Mg)
- Can cause diarrhea
- Calcium carbonate (tums)
- inexpensive, tablets can be crushed
- Calcium acetate
- 2 tabs/each meal
- Sevelamer carbonate
- Cationic polyer, contains neither Ca ot Al
- 800-1600 mg/each meal
- Lantanim carbonate
- Initial dose 250-500 mg PO 3 x daily to max 3750 mg/day
- most need 1500-3000 mg/day
- Can cause diarrhea
- inexpensive, tablets can be crushed
- 2 tabs/each meal
- Cationic polyer, contains neither Ca ot Al
- 800-1600 mg/each meal
- Initial dose 250-500 mg PO 3 x daily to max 3750 mg/day
- most need 1500-3000 mg/day
K dissorders (___-___)
Normal maintenance
3.5-5 mEq/L
0.5-1 mEq/kg/day or 40-50 mEq/day
Causes of hypokalemia
