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Fluids & Electrolytes Flashcards

1
Q

Hyperkalemia

A

Serum K+ > 5.5mEq

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2
Q

Sx of Hyperkalemia

A

Fatigue
Muscle weakness
EKG changes—> potentially life threatening arrythmias
Risk for sever negative outcomes increases as K+ levels increase

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3
Q

Causes of Hyperkalemia

A

Decreased renal excretion (renal failure)
Heart failure (due to decreased renal function)
Increased K+ intake
Shift of K+ from IC—> EC via
Β adrenergic blockade
Insulin deficiency
Acidosis

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4
Q

Medications that increase serum K+ (7)

A

Potasium sparing diuretics
ACE
NSAIDS
Digoxin Toxicity
ARBs
Sulfamethoxazole/Trimethoprim

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5
Q

If a patient has moderate elevation of serum K+ WITHOUT EKG changes, how would you treat his hyperkalemia?

A

Increase excretion of K+ via cation exchange resin or diuretics

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6
Q

Goals of treatment for a patient with severe (>6.5) hyperkalemia

A

Immediate stabilization of myocardial membrane
Rapid shifting of K+ to ICS
Increase K_+ elimination (d/c exogenous K+)

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7
Q

What is the medication and dose that is given to someone with SEVERE HYPERKALEMIA to stabilize their myocardial cell membrane?

A

IV Calcium 1g IVPG over 1 hour (IV piggy back)

**Calcium Gluconate preferred

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8
Q

Why is Calcium Gluconate preferred over calcium carbonate?

A

Calcium Carbonate—> Brady cardia and increased tissue damage & extravasation

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9
Q

What do we check within 30min-1 hour of administering IV insulin to a patient with hyperglycemia and why?

A

Check BG; because Insulin can cause hypoglycemia

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10
Q

Why do we give insulin to a patient with hypglycemia?

A

Shifts K+ from ECS—> ICS

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11
Q

When do we treat hyperkalemia with sodium bicarb

A

In the setting of acidosis

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12
Q

What does sodium bicarb do to treat hyperkalemia?

A

Shifts K+ from ECS to ICS
Raises systemic pH

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13
Q

What is the dose of sodium bicarb given to patients with hyperkalemia who are in acidosis?

A

50 mEq IV

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14
Q

What do Β 2 agonists do in the setting of hyperkalemia (2)?

A

Shift K+ from ECS—> ICS BY:
1) stimulating NaK-ATPase to promote intracellular K+
2) stimulates pancreatic B-receptors to increase insulin secretion

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15
Q

What β-2 agonist is used to treat severe hyperkalemia and how much?

A

Albuterol 10-20mg via nebula er over 10 min

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16
Q

Why are β-2. Agonists not recommended as solo treatment for hyperkalemia?

A

Some patients are resistant to the effects

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17
Q

Who are β-2 agonists less effective in?

A

Patients already on a non selective β blocker

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18
Q

Why are loop diuretics used in the setting of hyperkalemia?

A

They promote K+ excretion

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19
Q

What 2 loop diuretics are used in the setting of hyperkalemia? What are their doses?

A

Furosimide: 40-80mg IV
Bumetanide 2-4mg IV

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20
Q

When may loop diuretics be less effective in treating hyperkalemia?

A

Severe renal failure

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21
Q

How does SPS work to treat hyperkalemia?

A

Binds potassium in the GI tract to reduce absorption and increase elimination

Resting passes through intestines—> SPS exchanges 1mEq of Na+ for 1mEq K+ (1:1 equal exchange)

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22
Q

Why cant SPS be used ALONE in life- threatening hyperkalemia?

A

Takes too long to work
Onset= >2 hours

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23
Q

Who should we avoid using SPS in?

A

Patients with bowel problems

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24
Q

Since SPS works best when in the colon what cathartic is most commonly given with it?

A

Sorbitol

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25
Sodium Zirconium Cyclosilicate
Potassium binder Exchanges K+ for Both H+ and Na+ Onset:1 hr
26
Patiromer
Potassium binder Exchanges Ca+ for K+ Onset: 7 hrs
27
What are the 3 potassium binders
Sodium polystyrene sulfonate Sodium zirconium Cyclosilicate Paritomer
28
What is the treatment of choice for hyperkalemia when pharmacologic treatments fail?
Dialysis
29
Definition of hypokalemia
Serum K+ <3.5
30
Causes of hypokalemia
Decrease in K+ intake Increase in K+ loss (diuretics) Excess GI loss (v/d) Shifts from ECS (β adrenergic agents, insulin, alkalosis)
31
Signs and symptoms of hypokalemia
Often asx Sx are nonspecific and predominantly related to muscular or cardiac function: - weakness and fatigue - muscle cramps and pain - palpitations - psychological sx - EKG changes - Dysrhythmias - hypotension
32
What are the goals of treatment for hypokalemia?
Reduction of K+ losses Replenishment of K+ stores
33
Methods of reduction of potassium loss?
D/c diuretics./ laxatives Use K+ sparing diuretics Treat diarrhea and vomiting
34
What methods can be used for K+ replenishment of MILD hypokalemia
Oral
35
What methods can be used for replenishment of K+ in MODERATE hypokalemia?
IV or Oral
36
What method can be used for K+ replenishment in SEVERE hypokalemia?
IV
37
Most commonly used salt in treatment of hypokalemia
KCl-
38
Serum K+ will increase ________ for every __________mEq of supplementation
.1mEq/L for ever 10mEq
39
T/F: oral and Parenteral K+ CANOT be used simultaneously
False
40
Try to limit oral single doses to 10-20mEq due to the risk of __________
GI irritation
41
Infusions >10mEq of Serum K replenishment require ______________
EKG monitoring
42
____________ is necessary for K+ uptake therefore it must be checked and replaced as needed in order to correct the potassium levels
Magnesium
43
Hyponatremia
Sr Na+ <135mEq/L
44
Mild Hyponatremia
Sr Na+ 130-134mEq
45
Moderate Hyponatremia
Sr Na+ of 120-129mEq/L
46
Severe Hyponatremia
Sr. Na+ <120mEq/L
47
Causes of Hyponatremia
Advanced kidney disease SIADH Heart Failure True Volume depelation (Na and water loss GI tract or urine) Medications- diuretics
48
S&S of mild Hyponatremia
Nausea and malaise
49
Sx of severe Hyponatremia
Lethargy Decreased level of conciousness Headache (If severe) seziures and coma
50
Overt neurologic sx most often are due sodium levels that are:
<115mEq/L
51
Over neurologic sx most often are due to very low serum levels (usually <115mEq/L) resulting in ___________________
Resulting in Intracerebral osmotic fluid shifts and brain edema
52
What are the 2 treatments for Hyponatremia?
Tolvaptan 3% (hypertonic) saline
53
Indications for Tolvaptan
Clinically significant hypervolemic or euvolemic Hyponatremia Less marked Hyponatremia that is SYMPTOMATIC AND RESISTANT to fluid restriction (pt with HF & SIADH)
54
Euvolemic Hyponatremia
Low Na lev les with normal extracellular volumes and no signs of edema of Ascites SIADH
55
Hypervolemic Hyponatremia
Low Na levels with greatly elevated extracellular volume (pitting edema and Ascites) HF and cirrhosis
56
MOA of Tolvaptan
Vasopressin (Anti-Diuretic Hormone) antagonist HF: blocks the action of ADH at the V2 receptor resulting in decreased free water reabsorption in the kidney. This results in an AQUARESIS which is free water loss without electrolyte loss
57
Initiate and reinitiate tolvaptan in patient where and why?
In the hx; Na+ needs to be closely monitored
58
when is Tolvaptan NOT indicated for use?
when the patient needs urgent treatment for hyponatremia to treat serious neuro probelems
59
Do not use tolvapan for >30 days due to
risk of hepatotoxicity
60
what do we monitor in patients on tolvaptan
Serum Na+ concentration Rate of Sr. Sodium increase
61
Indications of use for 3% hypertonic saline
* Severe Hyponatremia (<115) * If patient bceomes symptomatic
62
Danger of using 3% Hypertonic saline
overcorrection of sodium--> osmotic demyelination syndrome (ODS)
63
ODS
occurs when the damage to the myelin sheath is caused by an acute decrease in brain cell volume
64
How does overcorrection of hyponatremia with 3% saline cuase ODS>
if Na+ correction done too quickly--> rapid fall in brain volume--> astrocytes need to replace osmolytes to pull volume back into the brain (SLOWER PROCESS) Brain cant catch up with the rapid need for osmolytes rapid fall in brain volume--> demylination
65
ODS is rare when intial serum sodium is __________________-
> 120mEq/L
66
Risk factors for ODS
Serum sodium <120 mEq/L Hyponatremia for 2-3 days +
67
Clinical Manifestations of ODS
Behavioral disturbances Movement disorders Seziures Coma Quadraparesis
68
How long does it take for the sx of ODS to arise
2-6 days after overcorrection—> irreversible
69
Safe rate to administer hypertonic saline to avoid ODS
Avoid increase more than 12 mEq/L in 24 hrs Usual rate= .5-1mEq/L PER HOUR MONITOR SERUM SODIUM LEVELS (some recommendations call for every 2-3 hrs)
70
What is hyppmagnesemia
Serum magnesium <1.5mg/dL
71
Mild-moderate hypomagnesemia
1.2-1.5mg/dL
72
Severe hypmagnesemia
<1.2mg/dL
73
Causes of Hypomagnesemia
Excessive GI loss Malnutrition Renal Loss Sepsis Alcoholism
74
S&S Of hypomagmesemia
Sinus tachy, SVT, ventricular arrythmias Muscle weakness Ataxia Vertigo Tetany Seizures Irritability, delerium. Psychosis
75
Treatment of severe hypomagnesemia typically recommends
IV replacement 1-2g MAG SULFATE IVPB over 1 hour
76
Mild-moderate hypomagnesemia treatment route options
IV or Oral
77
What is the issue with oral agents for hypomagnesemia
All suffer from limited bioavailability SE such as GI discomfort and diarrhea
78
Indications of fluid management
Expand IV volume Correct an imbalance in fluid or electrolyte Manage Fluid and electrolyte needs in an ongoing disease state Maintenance
79
What are the 2 types of IV fluids?
Crystalloids Colloids
80
What are the fluids of choice when resuscitating a patinet?
Crystalloids
81
Crystalloids
Aqueous solutions of ions with or without glucose that flow easily across the cell membrane
82
What are the Crystalloids IV Fluids
D5W D10W D20W D50W 1/2 NS 3%NS NS D51/4NS D51/2MS D5NS D5LR LR
83
.9% NaCl-NS (Normal saline) is used to treat what?
fluid deficit, shock, mild Hyponatremia and for resuscitation
84
When you administer 1L of NaCl.9% how much stays in the Intravascular space?
250ml
85
What is used for replacement of pure water deficits and maintenance fluids for patients on Na+ restriction?
D5W
86
D5W
Provides water to ICS and ECS WITH CALORIES Helpful in dehydration
87
Why is D5W not a good option for fluid resuscitation?
1L of D5W only 100mL remain in the intravascular space—> only get 100ml fluid expansion
88
Why do we avoid giving D5W to patients with neurologic injury and elevated ICP?
Bc D5W can freely cross al barriers—> will further increase ICP
89
Contents of Lactated solution (LR)
Sodium Potassium Chloride Bicarb
90
What is LR used for
GI fluid losses Fistula drainage Burn and Trauma fluid loss
91
LR is preferred in…
Surgery and Trauma patients
92
When 1L of LR is administered, how much remains in the intravascular space?
250ml
93
Is LR good for fluid resuscitation?
Yes
94
Indications for .45% NaCl (1/2NS)
For patients with intracellular dehydration caused by hypernatremia or DKA
95
What is the maintenance fluid for someone with HTN
1/2 NS (esp when dont want to give them all the sodium in NS)
96
Isotonic Fluids
.9% NaCl- NS D5W LR 1.2NS
97
What are the hypertonic Crystalloids
3.0-%NACL D5W w/ NS or 1/2 NS D5W with LR D10W, D20W
98
When are hypertonic Crystalloids used?
Hyponatremic or hypoglycemic patinets
99
Indications for 3% NaCl
Severe Hyponatremia Patients with cerebral edema TBI to reduce elevated ICP—> increase cerebral percussion pressure
100
How much Crystalloids do we administer for resuscitation?
500-1000mL bolus then monitor parameters
101
How much Crystalloids do we give for sepsis>
30mL/kg in 1st 3 hours
102
Maintenance IV fluids are indicated for….
Patients who are unable to tolerate oral fluids
103
To estimate daily fluid maintenance
1500mL for first 20KG 20mL for every KG >20
104
Colloids
Solutions of large molecules (typically protein or starch) that dont pass through cell membranes and remain in the intravascular compartment Mor efficient in restoring normal intravascular volume and CO but expensive
105
Indications for use of colloids
When resuscitation with Crystalloids fails or is limited by clinically significant edema Fluid resuscitation in pateints with severe intravascular fluid deficits (HEMORRHAGIC SHOCK) Fluid resuscitation in presence of severe hypoalbuminemia or conditions associated with large protein loss (Burns)
106
What are the 4 types of colloids?
Albumin Blood products Plama protein fraction Synthetic colloids
107
What are the 2 types of colloids we are responsible for knowing?
Albumin Synthetic colloids
108
Indications of use for albumin
Hypovolemic shock (pts cant receive large volume load)
109
When would we CONSIDER albumin
Hypovolemic shock (INDICATION) When fluid resuscitation with Crystalloids fils or when edema limits further Crystalloids admin
110
Main modulator of fluid distribution among the compartments of the body
Albumin
111
Most clinical use of HA (albumin) is based on
The capacity to act as a plasma expander
112
5% albumin
Used for volume expansion Increases the circulating plasma volume BY AMT EQUAL TO THE AMOUNT INFUSED Less risk of pulmonary edema
113
What is PICD?
Paracentesis-Induced circulatory dysfunction
114
What is the indication of 25% albumin
Following LVP >5 L of fluid
115
25% albumin is ___________ and pulls fluid into compartment
Hyperoncotic
116
Who do we avoid giving 25% albumin to>
Patients requiring fluid resuscitation—> can cause dehydration
117
What happens when you give someone 25% albumin
5 fold effect on patients intravascular load compared to the administered dose
118
Hydroxyethyl starches
Semi-synthetic colloid Hetastarch—> highly effective as a plasma expander, less expensive
119
When is hetastarch used?
Used after major surgeies and burns
120
Problems with Hetastartch (2 )
Prolongs PT, PTT , and bleeding times Can cause anaphylaxis
121
Why should we avoid giving hetastarch?
Increases risk of AKI, need for replacement therapy, and increased moraltiy in critically ill patinet
122
NS infusion volume and equivalent intravascular volume
1000 mL (1L)—> 250mL
123
LR infusion volume—>equivalent intravascular volume
1000ml (1L)—-> 250mL
124
5% dextrose infusion volume—> equivalent intravascular volume
1000mL (1L)—> 100mL
125
Albumin 5% infusion vol—> equivalent intravascular vol
500mL—> 500mL
126
Albumin 25% infusion volume—> equivalent intravascular vol
100mL—> 500mL

Pharm (4 decks)

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