Transcript No Slide Title

FLUID AND ELECTROLYTES
DISASTERS
JOSE-MARIE EL-AMM
NEPHROLOGY DIVISION
WSU/DMC/HUH
AUGUST, 2006
COMPOSITION OF BODY FLUID
COMPARTMENTS
COMPOSITION OF ECF AND ICF
ECF
ICF
Na
K
Cl
HCO3
PHOSPHATE
141
4.1
113
26
2.0
10
120-150
3
10
140(ORGANIC)
TOTAL BODY WATER= 0.6 X TOTAL
BODY WEIGHT
(0.5 IN THE ELDERLY OR OBESE, 0.7 IN
INFANTS AND VERY YOUNG CHILDREN)
¼ IVV
¾ ISV
2/3 ICF
1/3 ECF
(Principal Cells)
CLINICAL APPROACH TO
HYPONATREMIA
IS HYPONATREMIA REALLY
HYPOTONICITY?
Translocational vs. isotonic
WHAT IS THE VOLUME STATUS?
What are the physiological signals to the
kidney and the brain
WHAT IS THE URINE SODIUM AND
OSMOLALITY?
Is ADH present and is it physiologically
appropriate
CASE STUDY 1
A 30 year old woman is admitted for an increase
in edema and worsening jaundice. She is a known
alcoholic and has had several admissions for
jaundice and ascites. She stopped taking her
diuretic approximately 10 days ago.
Physical examination: blood pressure 128/80,
heart rate 76 supine. No orthostatic change in
BP noted. She has icteric sclera, ascites, sacral
and pedal edema. Her liver span is 10 cm.
Labs:
125 89
3.2
28
5
80
0.8
bilirubin= 12mg/dL
albumin= 2.5 g/Dl
UNa = 1mEq/L
Uosm= 300mOsm/kg H2O
What is her Posm?
What is her cell
size?
CASE STUDY 1
What is her effective arterial
volume?
mild volume depletion(4%)
history
change in body weight
no orthostatic changes BP or pulse
moderate volume depletion(5% to 10%)
HR  15/min on standing
systolic BP  15mm Hg on standing
severe volume depletion(10%)
supine hypotension
supine tachycardia
CASE STUDY 1
Is her total body water high, low
or normal?
Is her total body sodium high,
low or normal?
EDEMA=INCREASED TOTAL
BODY SODIUM AND WATER BUT
DOES NOT! NOT! NOT! TELL
YOU THE PROPORTIONS
(SODIUM CONCENTRATION)
ORTHOSTATIC HYPOTENSION=
DECREASED TOTAL BODY
SODIUM AND WATER BUT DOES
NOT! NOT! NOT! TELL YOU THE
PROPORTIONS (SODIUM
CONCENTRATION)
BODY COMPARTMENT
VOLUMES
70 kg person  0.6 =42 liters total
body water
25 liters intracellular (ICF)-3/5 TBW 28 liters
intracellular (ICF)-2/3 TBW
17 liters extracellular (ECF)-2/5 TBW 14 liters
extracellular (ECF)-13 TBW
3.5 liters intravascular (IVV)-1/5 ECF 3.5 liters
intravascular (IVV)-1/4 ECF
13.5 liters interstitial (ISV)-4/5 ECF 10.5 liters
interstitial (ISV)-3/4 ECF
PRINCIPAL SENSORS IN
VOLUME REGULATION
EFFECTIVE
CIRC VOL/
/  SYMPATHETIC
TONE
VENOUS
RETURN /
VENOUS
CONSTRICTION/
RELAXATION
/  CARDIAC
CONTRACTILITY
/  CARDIAC
OUTPUT
ARTERIAL CONSTRICTION
or RELAXATION
/  BP
/  A II
BARORECEPTOR
STIMULATION/ 
/  ALDO
/  RENIN
SECRETION
/  TUBULAR Na+
REABSORPTION
CASE STUDY 1
Can you tell if ADH is being
secreted? How?
Why is her ADH status the way it
is?
What turns ADH off?
What turns it on?
CONTROL OF ADH
ALL
ADH
NONE
POSM
UOSM
280
300
50
1200
CASE STUDY 1
A 30 year old woman is admitted for an increase
in edema and worsening jaundice. She is a known
alcoholic and has had several admissions for
jaundice and ascites. She stopped taking her
diuretic approximately 10 days ago.
Physical examination: blood pressure 128/80,
heart rate 76 supine. No orthostatic change in
BP noted. She has icteric sclera, ascites, sacral
and pedal edema. Her liver span is 10 cm.
Labs:
125 89
3.2
28
5
80
0.8
bilirubin= 12mg/dL
albumin= 2.5 g/dL
UNa = 1mEq/L
Uosm= 300mOsm/kg H2O
CASE STUDY 1
Which IV fluids would you select?
CASE STUDY 1
What diuretic(s) would you use?
What would be the most likely or
severe complications using diuretics
in her case?
(Principal Cells)
CASE STUDY 1
CLARISSA’S TEAM HAVE BEEN WORKING ON
HER FOR THE LAST WEEK. WITH ‘JUDICIOUS’
USE OF DIURETICS AND FLUID
RESTRICTION, THEY HAVE DROPPED HER
WEIGHT BY 12 LBS AND INCREASED HER
SODIUM BY 5 MEQ/L. THE ON-CALL CHECKOUT TO YOU IS “DON’T WORRY ABOUT HER.”
AT 2 AM YOU ARE CALLED BY THE NURSE
BECAUSE CLARISSA’S BP IS 80/60 AND HER
HR IS 110/MIN.
WHAT DO YOU DO?
CASE STUDY 1
1. DON’T WORRY ABOUT IT.
2. START AN IV OF NS AT 150CC/HR
3. BOLUS HER WITH NS IN 100CC
INCREMENTS UNTIL HER BP
INCREASES
4. GIVE 25 GRAMS OF ALBUMIN IVPB
5. START DOPAMINE
CASE STUDY 2
A patient with severe congestive
heart failure and massive edema is
admitted to the hospital complaining
of progressive dyspnea.
Laboratory values
125 94
40
4.1 25
2
What is his
Posm?
What is his cell
size?
CASE STUDY 2
1-Spironolactone is administered but
no diuresis occurs despite 2 days of
treatment. Why?
2-A thiazide diuretic is then added
to spironolactone with equally
discouraging results. Why?
3-What single diuretic might result
in successful diuresis? Why?
(Principal Cells)
CASE STUDY 2
A loop diuretic is given with better results
but still not impressive diuresis
What diuretic might you add to the loop
diuretic to increase the loop diuretic
potency?
CASE STUDY 3
A 60 year old man was evaluated
for persistent cough and a 25
pound weight loss over a 3 month
period. He smoked a pack a day
for 40 years. P.E.: BP sitting
110/70, no signs of dehydration
and no evidence of edema.
A pleural effusion is present
on the right. PPD was positive.
Weight 65 kg.
CASE STUDY 4
115
88
4
105
3.7
24
0.6
Posm245 mOsm/kg H2O
Uosm340 mOsm/kg H2O
UNa39 mEq/L
In order to get rid of a water load, one
needs to produce very dilute urine.
What are the requirements for such
urinary dilution?
1)Extrarenal requirements
adequate GFR
adequate solute delivery
2)Intrarenal requirements
intact vasa recta and loop function
absence of ADH
CAUSES OF SIADH
Carcinomas (lung, pancreas, duodenum)
Pulmonary disease(pneumonia, Tb,
abscess, etc.)
CNS disorders (meningitis, encephalitis,
SDH, SAH, CVA, trauma, etc)
CASE STUDY 4
A 40 year old man is brought to the ER by EMS
after a witnessed seizure. His family states
that he has been complaining of a severe
headache and has had progressive mental
deterioration over the last week or 10 days.
They say he takes no medications and has no
significant medical history.
Physical exam is completely negative except for
meningeal signs. There is no focal neurological
deficit, no papilledema. He weighs 60 kg.
Labs:
110
80
Uosm=275mOsm/kg
UNa=50 mEq/L
3.5
22
CSF: 100WBC:
75%mononuclear
CASE STUDY 5
Is ADH present? (hint: look at Uosm)
Why is this man hyponatremic?
(present TBW) (present SNa)
=present TBS
(normal TBW) (normal SNa)
=normal TBS
(0.6)(60kg) x (110) =
(???) x (140)
(36L)(110)/(140) = (???) = 28L
36 – 28 = 8 liters excess water
SYMPTOMS OF
HYPONATREMIA
Mainly neurologic
Symptoms of cerebral edema
Nausea and malaise
followed by headache, lethargy, obtundation, seizures,
coma and death
The rate at which the hyponatremia
develops determines the degree and
severity of the symptoms
Several protective responses which act to minimize cell
swelling
Within four hours of hyponatremia developing the cells
start to lose solutes & as intracellular solute amount
decreases, water moves back out of the cells, returning
the cell volumes toward normal
CASE STUDY 5
How would you treat this man?
For rapid correction of symptomatic euvolemic
hyponatremia, hypertonic (3%) saline is used
Hypertonic (3%) saline has about 0.5mEq/ml.
(500mEq/L)
What are your goals and end points?
Goal for rapid/initial SNa is to increase SNa to 120125mEq/L or until symptoms improve-whichever
is lower
Overly rapid correction of hyponatremia can lead
to an osmotic demylination state
Patients should have plasma serum sodium
concentrations increased at less than 12
mEq/L/day (0.5mEq/L/hr)
The amount of sodium needed to raise the
serum sodium can be estimated by the
sodium deficit. Multiply the total body
water (0.5xlean body weight in kg in women,
0.6x weight in men) by the plasma sodium
deficit per liter.
36L x 15 mEq/L = 540 mEq Na need
At <0.5mEq/L/hour need to change
over 30 hours
1000mL/30hours  30 mL/hour
CASE STUDY 6
A 30 year old man comes in complaining of
polyuria and polydipsia for the previous two
weeks. He has a history of sarcoidosis
diagnosed 10 years ago for which he has
been on Prednisone intermittently. Except
for bilateral pulmonary crepitants and for
uveitis, the physical exam is normal.
Labs:
152
120
30
4
25
1.0
U/A: neg glucose, acetone
Uosm=75 mOsm/kg H2O
What are the causes of polyuria?
1.Diabetes mellitus
2.Diabetes insipidus
3.Hypokalemia
4.Hypercalcemia
5.Psychogenic water drinking
HYPERNATREMIA
BY DEFINITION, HYPERNATREMIA IS A
HYPERTONIC STATE. YOU STILL DON’T
KNOW THE VOLUME STATUS WITHOUT
EXAMINING THE PATIENT. IN A VOLUME
CONTRACTED STATE, WATER AND
SODIUM ARE LOST-JUST MORE WATER
THAN SODIUM. IN AN APPARENTLY
EUVOLEMIC PATIENT, PURE WATER IS
LOST. THERE ARE FEW SIGNS OF VOLUME
DEPLETION AS MOST OF THE WATER LOSS
IS INTRACELLULAR. VOLUME EXPANDED
STATES ARE THOSE IN WHICH HYPERTONIC
VOLUME EXPANSION TAKES PLACE.
CENTRAL DIABETES INSIPIDUS:
Idiopathic
Trauma
Hypoxic encephalopathy
Posthypophysectomy
Neoplastic
1:craniopharyngioma, pinealoma, cyst
metastatic: breast, lung
Misc:
sarcoidosis, aneurysm, Histiocytosis X, encephalitis,
meningitis
NEPHROGENIC DIABETES INSIPIDUS:
Hereditary: usually X-linked, very rare AR form
Drugs: lithium, cidofovir, foscarnet
Electrolyte disorders: hypokalemia, hypercalcemia
Misc:
sickle cell anemia or trait, renal amyloidosis,
Sjögren’s syndrome, transient DI in pregnancy
DIABETES INSIPIDUS
THERAPY
DDAVP
a 2 amino acid substitute of ADH with potent antidiuretic
effect but little to no pressor effects
Mild volume depletion(1-2 kg), a low salt
diet and a thiazide diuretic
increases proximal sodium and water resorption and
decreases water delivery to the ADH sensitive
collecting tubule
Don’t use loop diuretics
induce a relative resistance to ADH by decreasing
the maximal interstitial concentration
NSAIDs
potentiate ADH and are additive to the thiazide
effect(renal prostaglandins oppose ADH effects)
CASE STUDY 7
A 78 year old woman was admitted with
right hemiparesis. She had a 9 year
history of hypertension.
PE: Her BP was 190/95 mm Hg. Pulse 80
beats per min.
CASE STUDY 7
LABS: Hct 40%. Urine: SpGr 1.025,
negative for protein and glucose.
Sediment: Occasional WBC and RBC.
BUN 17, Creat. 1.0 mg/dl. Glucose
140 mg/dL, Na 140 mEq/L, K 3.7
mEq/L, CO2 24 mEq/L and Cl 103
mEq/L.
After admission she was managed with
tube feedings and eventually
transferred to a nursing home.
Three weeks later she was
readmitted because of vomiting and
tachypnea.
PE: Wt. 67 kg., BP 115/80. P=120,
Temp. = 101.6 F. She was
unresponsive and had poor skin
turgor.
LABS Urine: SpGr 1.022, protein
1+, glucose neg. Sediment: Few
hyaline casts. BUN 120 mg/dl,
creatinine 3 mg/dl, glucose 150
mg/dL, Na 160 mEq/L, K 5.9 mEq/L,
Cl 125 mEq/L, CO2 18 mEq/L.
Hct 48%.
CASE STUDY 7
Is total body sodium increased,
normal or decreased?
It total body water increased,
normal or decreased?
How did this occur?
Is total body sodium
increased, normal or decreased?
BP 115/80
P=120
Is total body water increased, normal
or decreased?
Normal
Water Sodium
Our patient
poor skin turgor
How did this occur?
Loss of sodium and water-more water
than sodium
Water losses: insensible (temp
101F), urine (conc.),
GI
Sodium losses: poor intake and
vomiting
THE TRAGEDY OF THE VERY
YOUNG & VERY OLD
Mobile people lose salt and water (N/V)
but as IVV , ADH and they become
thirsty/seek out fluids.
fluid intake with ADH present can lead to
hyponatremia
Non-mobile people (playpens,
restraints, strokes) cannot respond to
thirst
if they lose more water than sodium, they
become hypernatremic
CASE STUDY 7
What is the first priority in her
therapy?
IVV resuscitation
What IV would you first order?
0.9% NaCl
How much would you give?
Until she is better
CASE STUDY 7
Once she has a stable blood
pressure, her total body sodium
(TBS) has been returned to normal
How much water would be needed
to lower her serum sodium to 140
mEq/L?
PE: Wt. 67 kg.
LABS: BUN 120 mg/dl, creatinine 3mg/dl,
glucose 150 mg/dL, Na 160 mEq/L, K 5.9
mEq/L, Cl 125 mEq/L, CO2 18 mEq/L.
67kg x .5=33.5L=TBW
160 x 33.5=140 x desired TBW
desired TBW=38 liters
She needs 4.5 liters of water to drop
her serum Na to 140 mEq/L
TREATMENT OF HYPERNATREMIA
Rates of correction should be carefully controlled
as cerebral edema can occur with over-rapid
corrections. Correcting at less than 0.5mEq/L/hr
(12 mEq/day) is safe.
Eg: 5 liters of water need to be given to
replace the water deficit.
Serum sodium 165  140mEq/L
25mEq/L
This will take 50 hours to drop it less than
or equal to 0.5 mEq/hour
5000mL/50hours = 100 mL/hour of D5W or
200 mL/hour of D21/2NS