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sodium/ water states Flashcards

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1
Q

hypotonic hyponatraemia versus non-hypotonic hyponatraemia= plasma osmolality levels

A

hypotonic hyponatraemia= <275 (urine osmolality >100)

non-hypotonic hyponatraemia >275 (urine osmolality <100)

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2
Q

what are non-hypotonic causes of hyponatraemia 5

A 
ethanol- beer potonmania
hyperglycaemia
pseudohypo-natraemia
low sodium intake
polydipsia
=pure water gain
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3
Q

what is pseudohyponatraemia

A

paraproteinaemia causes it

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4
Q

2 ways of classifying hyponatraemia

A
  1. ECF- hypo, euv, hypervolaemia

2. urine osmolality <20 or >20

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5
Q

causes of hypervolaemia hyponatraemia with a urinary sodium <30 5

A

Increased interstitial salt

  • liver failure
  • cirrhosis
  • hepato-renal syndrome
  • CCF-cardiac
  • nephrotic syndrome
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6
Q

mechanism behind hypervolaemic hyponatraemia with <20 urine sodium

A

due to the above diseases- blood pressure drops

  • causes release of AVP which causes salt and water to be retained
  • but more water retained than salt
  • salt and water excess
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7
Q

causes of euvolaemic hyponatraemia with urine osmolality < serum

A 
(aka trick question= non-hypotonic hyponatraemia)
water intoxification
-polydipsia
-beer potomaina 
water overload
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8
Q

causes of euvolaemic hyponatraemia with urine osmolality >serum or urine sodium >30
7

A
  1. SIADH
  2. secondary adrenal insufficiency
  3. hypothyroidsim- myxoedema
  4. lung disease
  5. cancer-siadh small cell
  6. chest
  7. CNS
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9
Q

causes of hypovolaemic hyponatraemia with urine sodium <30 3 main ones

A 
pre renal: sodium loss in excess of water
GI loss
3rd space losses
previous diuretic use 
-diarrhoea
-sweat
-vomiting 
-burns
-fistula
-cirrhosis
-SBO
-villous adenoma rectum
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10
Q

causes of hyponatraemia hypovolaemic with urine sodium >30 4

A

renal?: salt and water lost through kidney but more salt loss than water

  • kidney failure
  • addison’s-primary adrenal failure
  • vomiting
  • CSWS
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11
Q

treatment for each type of hyponatraemia

A

hypervolaemic: restrict salt and water
euvolaemic: restrict water
hypovolaemic: give salt and water

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12
Q

2 body compartments

A
  • extracellular: intravascular and intercellular

- intracellular

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13
Q

what compartments should sodium and potassium be found in

A

sodium=extracellular (so plasma sodium good estimate)

potassium- intracellular (so plasma potassium bad estimate eg in DKA)

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14
Q

hyponatraemia complication of going down too low and the symptoms

A

=cerebral oedema

  • nausea, vomiting, headache and confusion
  • reduced consciouscness
  • 6th nerve palsy
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15
Q

hyponatraemia complication of coming up too quickly

A

=central pontine myelinolysis (osmotic demyelination) affects brain stem

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16
Q

symptoms of central pontine myelinolysis

A 
dysarthria
mutism
dysphagia
lethargy
mood change
spasitc quadriparesis
seizure
coma
death 
neuro (focal, cranial, bulbar signs)
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17
Q

when does central pontine myelinolysis appear

A

3-4 days after sodium corrects

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18
Q

how does hyperglycaemia cause hyponatraemia

A

glucose level high increases osmolality
-> so body pushes sodium down to maintain osmolality level
seen in DKA

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19
Q

classification of mild, moderate and profound hyponatraemia

A

mild: 130-135
moderate: 125-129
severe <125

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20
Q

moderately severe symptoms of hyponatraemia

A

nausea without vomiting, confusion headache

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21
Q

severe symptoms of hyponatraemia

A

vomiting
cardio-resp distress
abnormal and deep somnolence seizure
coma

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22
Q

difference between acute and chronic hyponatraemia and risks

A

acute: develops <48 hours- more at risk of cerebral oedema
chronic: develops >48 hours more at risk of pontine myelinolysis on repletion

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23
Q

guideline for use of hypertonic fluid for hyponatraemia

A

-300mls of sodium chloride 1.8% over 30 minutes=hypertonic
-needs urgent treatment
-monitor sodium aim for a 5mmol/l increase in na with no more than 10mmol/l rise in 1st 24 hrs
then 8mmol/l rise every 24 hrs after
-not for hypervolaemic

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24
Q

what should not be used for a hypovolaemic hyponatraemic patient treatment

A

hypertonic sodium chloride due to already volume depletion

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25
mangement of hypovolaemic hyponatraemia
-fluid but no more than 10mmol/l in first 24 hours -use an isotonic fluid for resuscitation eg normal saline 0.9% or Hartman or plasmalyte -check sodium 4 hourly at least
26
how is hypovolaemia diagnosed
``` clinical diagnosis tachycardia hypotension absent JVP postural hypotension ```
27
what is management of hyponatraemia based on 2
acute or chronic development | prescence of neurological symptoms
28
management of euvolaemic hypervolaemia
restrict water
29
management of hypervolaemic hyponatraemia
restrict salt and water
30
key difference between CSWS and SIADH
CSWS=hypovolaemic | SIADH=euvolaemic
31
what causes CSWS
cerebral salt wasting syndrome | sub-arachnoid haemorrhage
32
management of CSWS
hypovoleamic so give normal saline sodium chloride 0.9%
33
management of SIADH
euvolaemic so restrict water
34
diagnoses of SIADH 6 steps
1. hypo-osmolality <275 or plasma sodium <135 2. inappropriate urinary concen. >100mosmo 3. patient euvolaemic 4. elevated urinary sodium >30 with normal intake 5. exclude hypothyroidism, steroid deficiency through SST and diuretic use 6. normal renal and cardiac function
35
causes of SIADH 5
1. drugs related 2. pulmonary 3. tumours 4. CNS disorders 5. others
36
drug related causes of SIADH 3
1. stimulate ADH-nicotine, antidepressants, dopamine agonists, MDMA 2. potentiate ADH: DDAVP, cyclophosphamide 3. ACEI and PPI-omeprazole
37
pulmonary causes of SIADH
1. infection: tb, pneumonia | 2. mechanical/ ventilators: ARDS, COPD
38
tumour causes of SIADH 5
``` pulmonary mediastinal small cell cancer duodenum pancreas ```
39
CNS disorder causes of SIADH 6
1. mass lesions 2. inflammatory disease 3. degenerative disease 4. trauma- subarachnoid haemorrhage 5. psychosis 6. transsphenoidal adenomectomy
40
what is the triple phase response of transsphenoidal adenomectomy
1. CDI 2. remission or SIADH 3. then recurrence of permanent DI
41
other cause of SIADH 3
1. aids 2. strenuous exercise 3. idiopathic
42
management of SIADH 8
1. withold meds 2. identify and treat underlying cause 3. obtain CXR in all patients with SIADH 4. CT 5. restrict fluid 800-100ml per day 6. oral demeclocycline 7. loop diuretic and oral sodium chloride alternative 8. tolvaptan v2 receptor antagonist for euvolaemic or hypervolaemic not hypovolaemic
43
management if hyponatraemia is corrected too quickly
discontinue active treatment consult for sodium free IV infusion of 10ml/kg body weight -Desmopressin DDAVP 2mcg
44
causes of hypernatraemia
pure water loss | water gain
45
hypernatraemia symptoms
``` reduced cerebral function dehydration dizziness confused weak coma ```
46
hypovlaemic causes of hypernatraemia
``` haemorrhage vomit diarrhoea burns diuretic state fever hyperventilation ```
47
iatrogenic causes of hypernatraemia
diuretic therapy | high sodium intake
48
reduced water intake causes of hypernatraemia
psychosocial-elderly glycosuria excessive sweating
49
euvolaemic causes of hypernatraemia
water deficit alone | Diabetes insipidus
50
hypervolaemic causes of hypernatraemia
enteral feeds IV salt chronic renal failure
51
management of hypernatraemia
acute= iv fluid isotonic 6% dextrose or hypotonic 0.45% saline
52
causes of polyuria 4
1. DI 2. habitual psychogenic 3. osmotic diuresis (from glucose DM), mannitol, hypercalcaemia 4. renal impairment
53
definition of polyuria
urine rate >2ml/kg/hour
54
what receptors does ADH act on in the kidney
v2 receptors
55
causes of cranial DI 4
``` inadequate ADH release congenital pituitary/ hypot head injury intracranial infection ```
56
nephrogenic DI causes AND 2 drugs 7
``` renal insensitivity congenital hypercalcium hypopotasium obstructive uropathy chronic renal failure drugs -lithium -demeclocycline (for SIADH) ```
57
criteria for DI
polyuria that is hypotonic <600mosmol/kg when plasma is hypertonic >300mosmol/kg
58
conditions for the water deprivation test 3
during test for 8 hours - no fluids and dry snacks - hourly weight, bp and urine sample - 2 hourly blood - then give DDAVP
59
what would the results be for a water deprivation test for cranial DI -after dehydration then -after giving DDAVP
- <300 after dehydration (no ADH so cant stop loosing water so urine osmolality low) - after ddavp >600 as stop loosing water
60
water deprivation test for nephron DI
<300 after dehdration and after DDAVP as problem with the receptors
61
what would be the result for partial DI
after dehydration would be 300-600 | and then after ddavp would be <600
62
treatment of DI cranial
give DDAVP ie desmopressin
63
treatment of DI nephrogenic
- thiazide diuretic/ amiloride diuretic to cause increased sodium excretion and water - indomethacin to lower intra-renal prostaglandins that oppose ADH - low salt and low protein diet
64
treatment for partial DI
use meds that promote SIADH eg chlopropamide which may upregulate renal ADH receptors when ADH partially deficient
65
pathway of ADH release
``` high plasma osmolality -> adh release -> kidney v2 receptors -> concentrates and retains water ```
66
signs of dehydration
- absent jvp - dry mucosal membranes - postural hypotension - tachycardia - thirst - reduced skin turgor - supine hypotension - oligouria - organ failure - dizziness - dysphagia
67
signs of volume excess
- hypertension - tachycardia - raised jvp - nausea - gallop rhythm - oedema - third space gain

Endocrine (14 decks)

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