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GU 1 > 19 - Clinical Problem Solving: Electrolytes > Flashcards

19 - Clinical Problem Solving: Electrolytes Flashcards

1
Q

What should I know

A
  1. IV fluid management
  2. Types of fluid
  3. Fluid assessment
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2
Q

What should you ask before giving IVF?

A
  • is my patient euvolaemic, hypovalaemic, hypervolaemic
  • do they need IV fluid i.e. can they just drink? Why?
  • how much do they need?
  • what type of fluid do they need?
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3
Q

If they are hypovolaemic they are…

A

Dehydrated (low fluid vol)

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4
Q

Fluid overload?

A
  • weight gain
  • high BP
  • swollen ankles and puffy eyes
  • breathless
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5
Q

Dehydrated

A

weight loss, dry mouth, low bp, dizzy

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6
Q

When does a patient NOT need IV fluids?

A

They are already drinking enough, they are on enteral feeding, fluid overloaded/not dehydrated

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7
Q

When DOES a patient need IV fluids?

A

They are not drinking and has lost or is losing fluids (nil by mouth and can’t keep up orally)

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8
Q

3 reasons someone may need IV fluids

A
  1. Mainenance (keep eurovolaemic if nil by mouth)
  2. Replace losses
  3. Rescuscitation
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9
Q

What is a good level of maintenance fluids?

A

2-3L a day (how much we lose a day)

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10
Q

How do you lose fluid?

A
  • (pee - not enough to get dehydrated)

- sweat (not much), diarrhoea, vomit, breathing

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11
Q

What fluid might you be replacing?

A

blood
diarrhoea
vomitting
third spacing (third spacing is fluid in a space where it shouldn’t be i.e. ascites! Although over all there is a lot of fluid in the body it is not in the right place to do any good)

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12
Q

In what situation is third spacing more likely to occur

A

When there is low albumin.

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13
Q

Fluid replacement summary

A
  • need 2-3L a day to replace losses
  • constantly assess fluid status i.e. weight and JVP
  • patient record of losses (fluid balance charts)
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14
Q

When may you need IVF to rescuscitate?

A
  • shocked patient i.e. sepsis, dehydration, bleeding
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15
Q

What do you need to consider when deciding what type of fluid?

A
  • look at the patient’s fluid status

- what is their serum sodium (hyponatremic?)

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16
Q

What is generally the safest fluid

A

Isotonic (0.9% saline or plasmalyt)

> this assumes that there is free flow/passage of water from the cells into the ECF

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17
Q

When may you not use isotonic fluid?

A

Unless you are only doing maintenance fluid and you’re worried about overloading them (pul odema) or the sodium is very HIGH

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18
Q

When may you use a hypotonic solution? Eg?

A

5% dextrose (isotonic but metabolised)
> doing a little bit of maintenance but patient is on the verge of being overloaded
> if drugs need to be given to an overloaded patient
> hypotonic solutions may be useful if the serum sodium is very high (i.e. not enough water - need fluid but don’t want to make more salty. Need to do carefully don’t want to change sodium levels quickly!!)

19
Q

What IVF do you give a patient that is overloaded i.e. doesn’t pee and has odema?

A

DON’T GIVE THEM FLUID

Will make worse

20
Q

Hypertonic saline e.g.

A

3% saline

21
Q

When do you use hypertonic solutions

A
  • severe hyponatraemia as it makes water go into cells and make ECF conc of sodium increase
22
Q

Hyponatraemia

A
  • problem is water excess (BUT can still be dehydrated)

- low sodium conc

23
Q

Fluid compartments?

A 
(MALE)
60% fluid 
2/3 ICF
1/3 ECF
    20% plasma 80% interstitial
24
Q

What fluid compartment does IVF go into

A

ECF

25
Q

How does water absorption work?

A
  • osmoreceptors detect increased osmotic pressure and baroreceptors detect decreased BP
  • both stimulate ADH release from post pit
  • ADH causes aquaporin insertion and vasoconstriction
  • increase BV and BP
26
Q

what plays the major role in determining how much water we hold on to?

A

ADH!! And so osmolality and to a lesser extent bp

27
Q

What are the 3 causes of hyponatraemia?

A
  1. Sodium loss
  2. Water excess
  3. Pseudohyponatraemia (abnormal tests but actually normal)

Vast majority are due to water excess.

28
Q

How can you lose sodium?

A
  • GI loss (vomit/diarrhoea)
  • hypo-aldosteronism (ENaC reabsorption)
  • sweat (unusual)
  • diuretics (pee more sodium)
29
Q

Aldosterone?

A
  • reabsorbs NA+ into blood

- low means more is excreted

30
Q

What does low Na+ reabsorption mean for K+?

A

Na is reabsorbed by Na/K ATPase. Means that if less Na+ is being reabs, less K+ is being secreted and K+ in the blood will increase.

31
Q

What can cause pseudohyponatremia?

A

hypertriglyceridemia/proteinemia

32
Q

What are 3 syndromes that are associated with water excess?

A
  • cirrhosis
  • heart failure
  • nephrotic syndrome

> SIADH (increased ADH when not needed)
polydipsia

33
Q

How do you sort out hyponatraemia?

A

History (are they vomiting, diarrhoea, dehydrated, medications, drinking lots, IVF?
Examine fluid status
Check osmolality

34
Q

Are people who have water excess hypervolaemic?

A

Not always they CAN be euvovolaemic
Can be fluid overloaded i.e.
> heart failure, nephrotic syndrome, cirrhosis
(doesn’t take a lot of fluid to change salt con but does to become fluid overloaded)

35
Q

What do you most commonly see with hyponatraemia?

A

Water excess with euvolaemia.

- means there are no signs of dehydration, odema, JVP changes,

36
Q

What can cause water excess with euvolaemia?

A
  • SIADH
  • polydipsia
  • overhydration with hypotonic fluids
  • diuretics
37
Q

What is the urine osmolality like in people that drink too much?

A

Low osmolality

In other cases of hyponatraemia the urine osmol is usually high?

38
Q

SIADH?

A

Produce ADH even when euvolaemic and sodium levels are normal

39
Q

What can cause SIADH

A
  • tumours
  • CNS (being unconcious, seizures, menigingitis)
  • drugs (anticonvulsants)
  • lung disease
  • infection
  • chronic lungdisease
  • diuretics can cause hyponatraemia
40
Q

Diuretics and hyponatraemia?

A

Thiazide diuretics cause the loss of sodium. They cause a shift in ADH/osmol curve so that more ADH is released at the same osmol so more water is retained for the amount of salt you’re losing causing hyponatraemia

41
Q

What is the most common cause of low Na in the hispital

A

Bad IVF selection i.e. hypotonic fluids

42
Q

How do you treat a dehydrated patient with sodium loss?

A

Isotonic fluid (saline)

43
Q

How do you treat a patient with water excess hyponatraemia?

A

Fluid restriction (1L a day) resets the ADH and fixes Na+. Rapid correction is unadvisable.

GU 1 (19 decks)

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