Fluid and Sodium

Question 1

Hypervolemia

Answer 1

-SOB, chest heaviness, difficulty walking long periods of time
-Edema, crackles in lungs, elevated BP, JVD, Na (NLH)

Question 2

Drug Induced Hypervolemia

Answer 2

• Corticosteroids
• NSAIDs
• Intravenous fluids
• DHP CCB
• Pioglitazone, rosiglitazone

got high PIN CD

Question 3

Hypervolemia TX

Answer 3

-Correct underlying condition
-Sodium/Fluid RESTRICTION (1-2g/d)
-Diuretics (LOOPS)
-Renal replacement therapies (last resort)

Question 4

Loop Diuretics Adverse Effects

Answer 4

• Intravascular volume depletion
• Hypotension
• Hypokalemia*
• Hypochloremic metabolic alkalosis (chronic use)
• Hyperglycemia
• Hyperuricemia
• Hypomagnesemia*

Monitor: JVD, weight, edema, pH, BP, CR, electrolytes

Question 5

First Line LOOP

Answer 5

Furosemide

PO 20-80 mg, q8-12h

IV 10-40 mg, q6-12h

Question 6

Hypovolemia

Answer 6

-Thirst, weakness, dizziness
-Weight loss, flat jugular vein, hypotension, tachycardia, dry mucous, HIGH CR BUN, no skin turgor

Question 7

Drug Induce Hypovolemia

Answer 7

• Diuretics
• Laxatives
• Mannitol

Question 8

Hypovolemia TX

Answer 8

-Underlying cause
-Replacement fluid
-Maintenance fluid

Oral: mild/modest, less invasive, no infection risk, slow correction, no oral if vomiting/mental

IV: severe, quick, risk of overcorrection/infection

Question 9

Replacement Fluid

Answer 9

1L isotonic saline over 30min-1hr

Question 10

Maintenance Fluid

Answer 10

Sum of urine output + insensible losses, 30-50 ml/hr (other losses)

Adults: IV fluid 25-30 ml/kg/day
-common: crystalloid, other colloid (more ae)
-0.9% NaCl, normal saline, ideal for most

Maintenance IV: 20-40 ml/kg/day

Question 11

Hyponatremia

Answer 11

Na < 136
-lethargy, HA, NV, confusion, seizures, coma

SEVERE < 125

Question 12

Hyponatremia TX

Answer 12

-Severe <125, with SX

acute
= emergency correction with 3% NaCl 100 ml IV bolus over 10 mins, may repeat 2x

chronic
= 0.9% NaCl or 3% NaCl 0.5-2 ml/kg/hr IV

no sx, but < 125
= correct Na at hourly rate of 0.5 mol/L

Question 13

Hyponatremia TX
-Hypo, Eu, Hyper

Answer 13

Hypovolemic
-Treat cause, d/c agents, NS 0.9 1000 ml

Euvolemic
-Treat cause, fluid restriction 750-1500, loop, VRA, urea

Hypervolemic
-Optimize, fluid/salt restriction, loop, VRA

Question 14

Chronic HypoNa Sensitive to Correction Rate

Answer 14

Do not correct Na+ > 6-10 mEq/L/day; 6 mEq/L/day if high risk for ODS (hypokalemia, alcoholism, malnutrition, or liver disease)

Question 15

0.9 vs 3 % NaCl

Answer 15

0.9
- Na 154
- ideal for most
- metabolic acidosis (can happen)

3
- Na 513
- acute, rapid
- intensive monitoring, thrombophlebitis (central line prefer!), risk of ODS

Question 16

Vasopressin Receptor Antagonists

Answer 16

-Short term hyponatremia

SHOULD NOT BE USED IN HYPOVOLEMIC HYPONA

-conivaptan (cirrhosis) (IV), tolvaptan (oral)

Question 17

Goal for HYPONA

Answer 17

raise 6-10 med/L/day
(<=6 if ODS risk)

check Na every 2-4 hr if severe

avoid overcorrecting

Question 18

Hypernatremia

Answer 18

Na > 145 (severe > 160)

-thirst, lethargy, muscle weakness, NVA, irritability, mental status

-hypotension/tachy if hypovolemic

Question 19

Hypernatremia TX

Answer 19

1: free water orally

#2: acute D5W or 0.2% nacl in D5W, chronic 0.45% nacl
-then give 1 L over 1-2 hr, replace free water deficit

Check Na every 2-4 hrs

Question 20

Euvolemic Hypernatremia Treatment
(diabetes insipidus)

Answer 20

Central DI
-desmopressin 10-20 mcg nasal spray daily
-oral 0.05 mg 2x/d, up to 1.2 1x/d

Nephrogenic DI
-HCTZ, Na restrict, water replacement

Question 21

Desmopressin DI/AE

Answer 21

Drug Interactions:
-Heparin
-Carbamazepine
-Lithium

Adverse Effects:
-Hyponatremia or water intoxication
-Facial flushing
-Headache
-Rhinitis
-Injection site reactions

Question 22

Hypervolemic Hypernatremia Treatment

Answer 22

• Loop diuretic (furosemide)
• IV D5W
• Provide hemodialysis as needed if renal failure

Question 23

When to use Ethacrynic Acid?

Answer 23

WHEN PT HAS SULFA ALLERGY

Question 24

0.9 NaCl NS

Answer 24

Hypovolemia, fluid resuscitation

Question 25

0.45 NaCl NS

Answer 25

CHRONIC hypernatremia, maintenance

Question 26

0.2 NaCl in 5 dextrose

Answer 26

ACUTE hypernatremia, maintenance

Question 27

5 dextrose D5W

Answer 27

Acute hypernatremia

Question 28

Lactated Ringers

Answer 28

Fluid resuscitation
-Preferred in trauma and surgery pts

Question 29

Preferred Colloid

Answer 29

Albumin, for cirrhosis and nephrotic syndromes

Question 30

SIADH causing meds for Euvolemic HypoNa

Answer 30

-SSRI/SNRI, tricyclic
-Haloperidol/phenothiazines
-Carb
-Anticancer (vinca, cis, cyclo)
-Opiates, Nicotine

Question 31

Urea (Ure-Na)

Answer 31

30-60 g/day
-osmotic diuresis

less expensive than VRA, but no studied

NOT for urgent correction