Fluid, Electrolytes and Acid Base Disorders Flashcards Preview

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Flashcards in Fluid, Electrolytes and Acid Base Disorders Deck (27):
1

Normal urine output for adults

.5 to 1.0 mL/kg/hour
Low urine output could be a sign of volume depletion

Daily weights may be more accurate

2

Normal saline indications

dehydration or lost blood

3

D51/2NS indications

Standard maintenance fluid often with 20 mEq of KCl/L of fluid
Dextrose added to inhibit muscle breakdown

4

D5W indication

Sometimes used for hypernatremia

5

Lactated Ringer's solution indications

Replacement of intravascular volume used for trauma resuscitation

Not used in hyperkalemia

6

Hypovolemia diagnosis and treatment

Diagnosis: Monitor urine output and daily weights
Critically ill (cardiac or renal dysfunction)-consider placing Swan Ganz catheter to measure CVP and PCWP
Elevated serum sodium, low urine sodium, and BUN/Cr ratio>20:1
Increased hematocrit

Treatment: use bolus to achieve euvolemia: normal saline or ringer's solution
Maintain urine output at .5-1 ml/kg/hr
Replace blood loss with crystalloid at a 3:1 ratio

Maintenance fluid: D51/2NS with 20 mEq KCl/L

7

Hypervolemia diagnosis and treatment

Diagnosis: elevated CVP and PCWP, pulmonary rales
Low hematocrit and albumin concentration

Treatment: diuretics
Fluid restriction
Monitor urine output and daily weighs, consider Swan Ganz catheter

8

Hypotonic hyponatremia-hypovolemic causes and diagnosis

Low urine sodium less than 10-increaed sodium retention by kidneys to compensate for extrarenal losses
Diarrhea, vomiting, dipahoresis, burns, pancreatitis

High urine sodium: renal salt loss
Diuretics, Ace inhibs, ATN

Treatment: Na=120-130: restrict free water
Na=110-120: loop diuretics with saline
Na=less than 110 and symptomatic: hypertonic saline
Do not increase more than 8 mmol/L during first 24 hours

9

Hypotonic hyponatremia-euvolemic causes and diagnosis

SIADH, polydipisa, hypothyroidism, haloperidol, cyclophosphamide,

Urinary excretion of Na increased

Treatment: Na=120-130: restrict free water
Na=110-120: loop diuretics with saline
Na=less than 110 and symptomatic: hypertonic saline
Do not increase more than 8 mmol/L during first 24 hours

10

Hypotonic hyponatremia-hypervolemic causes and diagnosis

CHF, nephrotic syndrome, liver disease-urinary excretion of sodium decreased

RF: sodium urinary excretion increased

Treatment: Na=120-130: restrict free water
Na=110-120: loop diuretics with saline
Na=less than 110 and symptomatic: hypertonic saline
Do not increase more than 8 mmol/L during first 24 hours

11

Isotonic hyponatremia

An increase in plasma solids lowers the plasma sodium concentration but sodium in plasma is normal

elevated protein or lipid levels

Diagnosis: nromal (280-295) osmolality

Treatment: treat underlying disorder

12

Hypertonic (shrink) hyponatremia

osmotic shift of water out of the cell

Hyperglycemia, mannitol, glycerol, raidiocontrast agents

Diagnosis: high serum osmolality (>295)

Treatment: treat underlying disorder

13

Hypovolemic hypernatremia

Sodium decrease but water loss more
Renal loss: diutrics, osmotic diuresis (glycosuria), renal failure
Extrearenal loss: diarrhea, diaphoresis, respiratory losses

Diagnosis: low urine volume
urine osmolarity>800

Treatment: isotonic NaCl, hemodynamically stable then free water replacement

14

Isovolemic hypernatremia

Sodium stores normal, water loss
Diabetes insipidus, tachypnea

Diagnosis: low urine volume
urine osmolarity>800

Treatment: DI=vasopressin
oral fluids or D5W if they cannot drink

15

Hypervolemic hypernatremia

Iatrogenic
Exogenous glucocorticoids, cushigns, hyperaldosteronism

Diagnosis: low urine volume
urine osmolarity>800

Treatment: diuretics (furosemide), D5W to remove excess sodium
Dialyze if renal failure

16

Hypocalcemia treatment

Symptomatic: IV calcium gluconate
Long term management: oral calcium supplements (calcium carbonate) and Vitamin D

PTH deficiency: replacement therapy with Vitamin D plus high oral calcium intake
Thiazide diuretics

Correct hypomagnsemia

17

Hypercalcemia treatment

Initial treatment is IV normal saline
Diuretics: furosemide

Inhibit bone resorption in osteoclastic-bisphosphonates, Calcitonin

Glucocorticoids if Vitamin D related mechanisms and multiple myeloma

Hemodialysis in renal failure patients

18

Hypokalemia causes, diagnosis and treatment

Causes: vomiting and nasogastric drainage, diarrhea, laxatives
diuretics, excessive glucocorticoids, hyperaldosteronism, insulin, bactrim and amphotericn, epinephrine

Diagnosis: arrhytmias (Cause of death), flattened or inverted T waves, U waves, (exacerbates digitalis toxicity)

Treatment: Oral KCl safest
IV KCL if less than 2.5 or arrhythmia (monitor cardiac rhythm)
Max infusion 10 mEQ/hr if peripheral
Max infusion 20 mEQ/hr if central
Can use lidocaine to reduce pain

Treat hypomagnesemia

19

Hyperkalemia causes, diagnosis and treatment

Causes: renal failure, Addisons disease, Potassium sparing diuretics, hypoaldosteronism, ACe inhibs, blood transfusions, Acidosis, rhabdo, hemolysis, insulin deficiency, rapid administration of B blocker

Diagnosis: Arrhythmia : V fib of note
peaked T waves, prolonged QRS, PR interval prolongation, loss of P waves, sine wave pattern

Treatment: Hyperkalemia >7.0 or ECG changes present give IV calcium (watch in digoxin)-stabilizes cardiac membrane
Glucose and insulin
Sodium bicarbonate: emergency measure
Kayexalate: prevents reabsorption in GI tract
Hemodialysis: rapid and effective-reserved for intractable hyperkalemia or in renal failure

Diuretics: furoseide for moderate with saline infusion
B2 agonists

20

Hypomagnesium: clinical, causes, diagnosis and treatment

Causes: malabsorption (steatorrhea), prolonged fasting, receiving TPN, alcoholism, SIADH, diuretics, gentamicin, amphotericin B, cisplatin, renal transplantation, postparathyrodectomy, DKA, thyrotoxisis

Clinical: muscle twitching, weakness, tremors, hyperreflexia, seizures, mental status changes

Concomitant: hypocalcemia (inhibits PTH and decreases effect of PTH on bone), hypokalemia

Diagnosis: prolonged Qt (torsades), T wave flattening

Treatment: mild oral Mg (mg oxide)
Severe-parenteral Mg (Mg sulfate)'
oxide is oral, sulfate is stabbed

21

Hypermagnesium: clinical, causes, diagnosis and treatment

Causes: RF, early stage burns, massive trauma, surgical stress, severe acidosis, Adrenal insufficiency, rhabdo,

Clinical: Nausea, weakness, facial paresthesias,
progressive loss of deep tendon reflexes (first sign)
somlonence and coma-occur late
Death due to respiratory failure or cardiac arrest

Diagnosis: increased PR interval, widened QRS, elevated T waves

Treatment: IV calcium gluconate for emergent symptoms
Administer saline and furosemide
Dialysis for renal failure
Prepare to intubate

22

Hypophosphatemia: causes, clinical, diagnosis and treatment

Causes: alcohol abuse, Vit. D deficiency, excessive use of antacids, TPN, starvation
Excess PTH, hyperglycemia, ATN, hypokalemia, hypomagnesia
respiratory alkalosis, steroids, hyperthermia, DKA

Clinical: asymptomatic if mild
if Severe:
encephalopathy, seixures, paresthesia, hemolysis, RBC/WBC/platelets dysfunction, cardiomyopathy-low ATP (cardiac arrest), rhabdo, anorexia

Treatment: mild (>1 mg): oral supplementation: neutra Phos capsules, K-Phos tablets, milk
severe or NPO: parenteral supplementation

23

Hyperphosphatemia: causes, clinical, diagnosis and treatment

Causes: renal insufficiency, bisphosphonats, hypoparathyroidsm, Vit. D intoxication, rhabdo, cell lysis or acidosis

Clinical: metastatic calcification-tetany, neuromusclar irritability

Treatment: phosphate binding antacids containing aluminum hydroxide or carbonate-prevent its absorption
Hemodialysis

24

Saline responsive metabolic alkalosis

ECF contraction and hypokalemia
vomiting or nasogastric suction
Diuretics
laxative abuse

Give Saline with potassium

25

Saline resistant metabolic alkalosis

ECF expansion and hypertension, low Cl
Hyperaldosteronism, cushings, sever K deficiency, and diuretic abuse

Give spironolactone

26

Higher than what PaCO2 level implies superimposed respiratory acidosis on metabolic alkalosis

PaCO2 >50-55

27

Treatment of respiratory acidosis

if PaO2 less than 60=supplemental O2

Naloxone if morphine induced

Intubation:
severe acidosis
PaCO>60 or inability to increase O2
Deterioration of mental status
Impending respiratory fatigue