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Pharmacotherapy 1 > 1 - Fluids and Electrolytes > Flashcards

1 - Fluids and Electrolytes Flashcards

1
Q

ex of sensible fluid losses

A

urination
defectation
wounds

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2
Q

ex of insensible fluid losses

A

skin

lungs

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3
Q

normal tonicity

A

275-290 mOsm/L

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4
Q

crystalloid fluids are __tonic

A

iso
hypo
hyper

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5
Q

colloid fluids are __tonic

A

hyper

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6
Q

ex of crystalloid fluids

A

NS, 1/2NS
D5W
LR
bal’d salt sln

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7
Q

ex of colloids

A 
albumin (5 or 25%)
hetastarch (Hespan)
tetrastarch(Voluven)
blood
plasmanate
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8
Q

What is the place of NS in therapy

A

fluid replacement: resus, hypoTN, shock

Na/Cl replacement

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9
Q

What is the place of 1/2 NS in therapy?

A

maintenance fluids

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10
Q

What is the place of LR in therapy?

A

resuscitation

–replacement of blood loss, traums, burn

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11
Q

What is the place of D5W in therapy?

A

used for free water replacement if dehydrated

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12
Q

What are examples of balanced salt solution?

A

lactated ringers (LR)
normosol-R
plasma-lyte

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13
Q

How much sodium is in NS?

A

154 mEq/L

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14
Q

What is the place of colloids in therapy?

A

increase plasma oncotic pressure
volume expansion,
intravscular repletion in sympomatic pts
hemorrhagic shock

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15
Q

adverse effects of albumin therapy?

A

hypervolemia
azotemia
infused-relation rxn/anaphylaxis

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16
Q

Why are synthetic colloids falling out of favor?

A

ass’d w increased mortality and tox

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17
Q

What is the place in therapy of blood?

A

acute blood loss
inadeuate resus from fluids alone
pre-op
low hemoglobin (<7-8 g/dL)

1 U RBCs incr Hgb by approx 1 g/dL

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18
Q

What is the most common maintenance fluid?

A

D5W + 1/2 NS + 20 mEq KCl/L

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19
Q

Signs of dehydration

A

PE:
decr skin turgor
dry mucus membranes
delayed capillary refill

tachycardia, hypoTEN

periph pulses weak
decr UOP, dark urine
BUN/SCr >20

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20
Q

Signs of shock

A 
heart-->tachycardia, hypoTN
brain-->AMS
kidneys-->decr UOP
liver-->incr INR
skin--> cool, cyanotic
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21
Q

shock resuscitation goals

A

CVP 8-12 mmHg
MAP >65 mmHg
UOP >0.5 mL/kg/hr

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22
Q

normal range of serum sodium

A

135-145 mEq/L

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23
Q

what is an osmol gap?

A

difference btw measured and calc’d osmolality is greater than 15

indicates prescence of unidentified particles (such as alcohol)

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24
Q

describe pseudohyponatremia

A

extreme levels of lipids and proteins incr total plasma volume

calc’s Osm is low –> OG

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25
Q

Describe hypertonic hyponatremia.

A

most fequently seen in elevated BG.

serum sodium falls in attempt to maintain serum Osm.

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26
Q

what are the causes of hypovolemic hyponatremia?

A 
renal (urine Na >20 mEq/L):
diuretics/excessive diuresis
adrenal/mineralcorticoid deficiency
salt losing nephropathy
cerebral salt wasting

non-renal causes:
blood loss/hemorrhage
skin losses
GI losses

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27
Q

What are the causes of isovolemic hypotonic hyponatremia?

A

adrenal/glucocorticoid def
hypothyroidis
psychogenic polydipsia
SIADH

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28
Q

What is the cause of SIADH

A

tumors
CNS disorders
DRUGS

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29
Q

What are some drugs that cause SIADH?

A 
antineoplastics
antipsychotics
carbamazepine
SSRIs (fluoextine, sertraline)
NSAIDs
TCAs
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30
Q

How to treat SIADH

A

remove underlying cause if possible
first line: free H20 restriction
Vaptans if above fails

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31
Q

Causes of hypervolemic hypotonic hyponatremia

A

cirrhosis
HF
RF
nephrotic syndromes

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32
Q

What is the max rise in serum sodium allowed during hyponatremia therapy?

A

0.5 mEq/L/h or NMT 8-12 mEq/L/d

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33
Q

How to treat hypotonic hypontremia if symptomatic?

A

3% NaCl

furosemide if eu or hypervolemic

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34
Q

How to treat non-symptomatic hypotonic hyponatremia

A

hypovol: isotonic NaCl
isovol: isotonic and water restriction
hypervol: furosemide

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35
Q

How do you replace sodium?

A

“rules of 8s”

1/2, 1/4, 1/4

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36
Q

How to treat acute symptomatic hyponatremia?

coma, AMS, Sz

A

increase Na by 1-2 mEq/L/hr until Sx resolve.

goal=120 mEq/L

complete correction unnec

max incr of 8-12 mEq/L in the first 24 hrs

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37
Q

How do vaptans work?

A

promote excretion of free H2O

think of as aquaretics

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38
Q

What is the dosing of Conivaptan?

A

IV
load: 20 mg IV bolus over 30 min
continuous: 20 mg IV over 24 hr for 2-4 d
may incr dose to 40 mg IV over 24 hr based on sodium response

4 d max

39
Q

What is the dosing of Tolvaptan?

A

PO–> for chronic SIADH pts

intital dose: 15 mg PO daily
may incr q24-60 mg max dose based on sodium respons

40
Q

What is the place in therapy of vaptans?

A

Conivaptan: sev euvol and hypervol symptomatic hyponatremia

tolvaptan: asymp euvol, hypervol hyponatremia

41
Q

What are contraindications for

A

hypovolemic
w/o sense of thirst
anuria
strong CYP3A4 inhibs

42
Q

Acute symptomatic hyponatremia monitoring

A

heart lungs, neuro status several times over first 12 h

serum Na q2-4 hr until asymptomatic then q4-8hr until WNL

43
Q

What is the cause of hypervolemic hypernatremia?

A 
sodium overload (NaHCO3, hypertonic saline resus)
mineralcorticoid excess
44
Q

What is treatment for hypervolemic hypernatremia?

A

stop hypertonic fluids or cause

diuretic

45
Q

What is the cause of hypovolemic hypernatremia?

A 
renal
GI
adrenal
lung 
skin
46
Q

What is the treatment for hypovol hypernatremia?

A

restore hemodynamics first if needed: maybe NS

once volume resotred, replace free water def

47
Q

How to provide free water?

A

D5W continuous inf

enteral

48
Q

How quickly should free water be replaced?

A

1/2 of deficit over 24 hr

give remaining 1/2 over next 24-48 hr

49
Q

What are the monitoring parameters for replacing free water?

A

check sodium and fluid status q3-6h for 1st 24 h
after symptoms resolve and Na<145 mEq/L then check q6=12 h

I/O q8-12 h
Overall fluid bal q24h (S/sx, UOP, CVP, wt, etc.)

50
Q

What are the causes of isovolemic hypernatremia?

A 
DIABETES INSIPIDUS
skin loss
latrogenic
osmotic diuresis
primary polydipsia
51
Q

How should isovolemic hypernatremia be treated?

A

desmopression

vasopressin

52
Q

The double check sodium eqn is for how much fluid?

A

1 L

53
Q

What are the causes of hypokalemia?

A 
diuretic loss 
beta-agonist meds
NG drainage
metabolic alkalosis
diarrhea
mag depletion (cofactor for Na/K ATPase)
54
Q

How does hypokalemia present?

A

nonspecific and variable
arrhythmas
impared muscle contraction

55
Q

When ?

A

<3mEq/L always
3-3.4 for cardiac pts
<4 in ICU

56
Q

How should [K+]<3 mEq/L be treated?

A

asymp–po route
symp–IV
–correct Mg2+ also!

57
Q

For every 10 mEq of K that is given to replete, can expect serum K to increase by

A

0.1 mEq/L

58
Q

What are indications for IV potassium therapy?

A

<3 mEq/L
ECG changes
muscle spasms
can’t tolerate PO

59
Q

**What is the dose of IV potassium to treat hypokalemia?

A

10-20 mEq in 100 mL of D5W

w/o cardiac monitoring: 10mEq/hr
w/ continuous cadiac moitoring 20 mEqh

60
Q

How does hyperkalemia present?

A

peaked T wave
slow AP
VF or asystole

61
Q

How is severe hyperkalemia treated? (what actions) K+>=7 mEq/L

A
  1. antagonize membrane actions
  2. decr EC K+ conc
  3. remove excess K from body
62
Q

What is an example severe hyperkalemia treatement regimen?

A

1: 1 gm CaCl IVP
2: 10 U regular insulin IVP over 30 min + 50 mL D50W IVP over 30 min
(also consider NAHCO3, albuterol)
3. furosemide 20-40 mg IVP

63
Q

Which hyperkalemia treatment option is for chronic patients?

A

patiromer (Veltassa)

binds K in GI trac and decr systemic absorption

64
Q

What are the causes of hypomagnesemia?

A 
diarrhea
malabs
malnutr
DRUGS: amphotericin, aminoglycosides, diuretics, cyclosporine
ALCOHOL
65
Q

What is the clinical presentation of hypomag?

A

diff to isolate

oft ass’d w hypocal or hypokal

66
Q

When is hypomagnesemia corrected with PO treatment?

A

asmptomatic pt w Mg>1 mg/dL

67
Q

When in hypomagnesemia corrected w IV treatment?

A

symptomatic pts or cannot tolerate PO

68
Q

What are PO hypomagnesemia treatment options?

A

Milk of Mag 5-10 mL PO QID

Mag-Ox 800 mg PO daily or 400 mg PO TID w meals

69
Q

What are IV hypomagnesemia treatment options?

A

If Mg 1-2 mg/dL use 0.5 mEq/kg, <1 mg/dL use 1 mEq/kg

8 mEq=1 g
infuse 1 g/hr

70
Q

What are he causes of hypermag?

A 
RF/insuff
excessive intake (laxatives)
71
Q

What is the treatment for hypermagnesemia?

A

CaCl 1-2 g IV and repeat prn for cardiac comp

if adequate renal func: IV hydration w NS or 1/2NS ~200 mL/hr + 1-2 g Ca OR IV furosemide

renal dysfxn: forced diruesis, HD

and suportive care prn: cardiac pacing, vasopressors, mech vent

72
Q

What are the causes of hypocalcemia?

A

Mg def
large volumes of blood products (citrate)
hypoalbuminema

post-op hypoparathyroid
vit D def
thyroid surgery
meds

73
Q

What is the treatment for acute hypocalcemia?

A

100-300 mg elemental Ca2+ IV over 5-10 min

1 g CaCl= 3 g Ca gluc = 250 mg elemental

  • CaCl during code
  • gluconate during PIV admin: lower % elemental, less risk for extravasation, but less predictable

–> usually admin 1 g cal/h

-correct hypomag

74
Q

What is the treatment for chronic hypocalcemia?

A

PO: 1-3 g/d elemental Ca2+
-CaCO3 (TUMS) 650 mg PO QID = 1 gm elemental /d

vit D supp: calcitriol 0.25 mcg PO d or qod

75
Q

What are the causes of hypercalcemia?

A

cancer and primary hyperparathyroidism:

incr bone resorption
incr GI abs
decr elmin

oft asymp

76
Q

What are the treatment options for hypercalcemia?

A

volume expansion/loop duretics
calcitonin
bisphosphonates
glucocorticoids

77
Q

How should volume expansion/loop diuretics be used to treat hypercalcemia?

A

NS 200-300 mL/hr
furosemide 40-80 mg IV q1-4h

use in pts with normal-mod imp’d renal fxn
symptomatic pts

78
Q

How should calcitonin be used in treatment of hypercalcemia?

A

for pts w CHF, mod-sev renal dysfxn: fluid restriction

inhib bone resorp
reduces renal reabs

SQ or IM 4 U/kg q12h

79
Q

How should bisphosphonates be used in treatment of hypercalcmia?

A

block bone resorp–decline ~2 d

pamidronate more eff than etidronate

pamidronate 30-90 mg IV over 2-24 hr

80
Q

How should glucocorticoids be used to treat hypercalcemia?

A

ind: multiple myeloma, leukemia, lymphoma, sarcoidosis

decr GI abs
interfer w vit D metab: incr bone resorp, decr osteoblast prolif

(-) slow, risk for hyperglycemia, infx

81
Q

What is the normal range for phsophate?

A

2.5-4.5 mg/dL

82
Q

What is the normal rnage for serum potassium?

A

3.5-5 mEq/L

83
Q

What is the normal rnage for serum magnesium?

A

1.5-2.5 mgdL

84
Q

What is the normal range for serum calcium?

A

8.5-10.5 mg/dL

85
Q

What are the causes of hypophosphatemia?

A

decr intake
imp’d abs
IC shift

86
Q

How does hypophosphatemia present?

A

nonspecific

87
Q

What is the treatment for hypophosphatemia?

A

if <1 mg/dL then IV phos (KPhos or NaPhos)

if 1-2 mg/dl then PO:
Phos-NaK –> 30-60 mMol/d in 2-3 divided doses
Fleet’s phospho soda 5 mL diluted –> 2-3 times per d

88
Q

How should phosphate be dosed?

A

Phos

  • 2.3-2.9 mg/dL: 0.32 mMol/kg
  • 1.6-2.2 mg/dL: 0.64 mMol/kg
  • <1.6 mg/dL: 1 mMol/kg
89
Q

What are the equivalences for 1 mMol NaPhos or KPhos?

A
  1. 33 mEq Na + Phos

1. 47 mEq K + Phos

90
Q

What is the max IV infusion rate for phos replacement?

A

NMT 7 mMol/hr

also check K rules!

91
Q

What are the causes of hyperhosphatemia?

A

RF/insuff
hypoparathyroidism
excessive intake

92
Q

How does hyperphosphatemia present?

A

soft tissue calcifications when Ca2+ x PO4- >60

concurrent ypocalcemia

93
Q

What is the treatment for hyperhosphatemia?

A

IV calcium

decrease phosphate GI abs

Pharmacotherapy 1 (26 decks)

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