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PDAT3 > 3/4 - Sodium Disorders > Flashcards

3/4 - Sodium Disorders Flashcards

1
Q

Normal Value for SODIUM

A

135 - 145 mEq / L

Primarily EXTRAcellular cation

Major Determinant of Plasma Osmolality:
2[Na] + Glucose/18 + BUN/2.8

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2
Q

Indications of HypoNatremia

A

Serum Sodium <135 mEq/L

Most commonly an EXCESS of Water vs Sodium

Hyper / hypo / isotonic

  • *Non-Osmotic release of AVP**
  • hypovolemia*, reduction in circulating volume, cirrhosis
  • *SIADH**
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3
Q

MILD
Symptoms of HypoNatremia

A

< 135

None

Nausea / Malaise

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4
Q

MODERATE
Symptoms of HypoNatremia

A

< 120

HA / Lethargy

Restlessness / Disorientation

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5
Q

SEVERE
Symptoms of HypoNatremia

A

< 110

Seizure / Coma / Brain Dmg

Brain Stem Herniation / DEATH

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6
Q

CHRONIC HypoNatremia

A

CAN BE TOLERATED because of:
BRAIN ADAPTATION

Prevent SWELLING
Transport solutes EXTRAcellularly –> out
NaCl / K / Organic Solutes (glutamate / taurine / myo-inositol)
reduction in Brain Osmolality

induce water LOSS

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7
Q

Effect of RAPID SODIUM CORRECTION
on the BRAIN

A

Normal Brain & Normal Osmolality –> HypoTonic State
VVVV
Water Gain in Brain & low Osm –> RAPID ADAPTATION
VVVV
Loss of SODIUM / K / Cl & low osmolality
RAPID CORRECTION
VVVV
OSMOTIC DEMYELINATION
this is BAD, we need to correct the Sodium SLOWLY

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8
Q

HypoNatremia + HYPERtonic
Caused by what?

A

HYPERGLYCEMIA
or
Mannitol

Every ^100 mg/dL Glucose(serum) –> reduction of 1.7 mEq/L of Na

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9
Q

Increase of 100 mg/dL of Glucose
has what effect on Sodium?

A

↓1.7 mEq/L Na(serum)

HyperGlycemia / Mannitol
can cause:
HYPERtonic HypoNatremia

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10
Q

HypoNatremia + Isotonic
Caused by what?

A

PseudoHypoNatremia
HYPERlipidemia
HYPERproteinemia

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11
Q

HypoNatremia + HypoTonic
HYPERvolemic
Caused by what?

A

HYPERvolemic ↑ECF

CHF
Liver Failure
Nephrotic Syndrome
Acute/Chronic Renal Failure

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12
Q

HypoNatremia + HypoTonic
Euvolemic
Caused by what?

A

unchanged ECF
Euvolemic
HypoThyroidism
Addison’s Disease
SIADH
(Syndrome of Anappropriate ADH)

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13
Q

Causes of:
SIADH
Syndrome of Antidiuretic Hormone

A
  • *CNS Disorders**
  • *Stroke** / Mass Lesions
  • *Trauma** / Acute Psychosis

Malignancy (Lung) // Infections / HIV

Pain / Severe Nausea

  • *Medications**
  • *Haloperidol** / Chlorpropamide / Carbamazepine
  • *TCA / SSRI / Desmopressin**
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14
Q

Medications that can cause
SIADH

A

Syndrome of Inappropriate Antidiuretic Hormone
VV
Euvolemic HypoTonic HypoNatremia

TCA // SSRI

CARBAMAZEPINE

Chlorpropamide

DESMOPRESSIN

Haloperidol

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15
Q

HypoVolemic + HypoTonic + HypoNatremia
Caused by what?

A

Decreased ECF

  • *RENAL LOSS**
  • Cerebral Salt Wasting** / excessive Diuresis / Adrenal *Insufficiency
  • NON-Renal Loss*
  • *Bleeding / Vomiting / Diarrhea / Burns / Wounds / Sweating**
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16
Q

Acute / Severe Symptoms of HypoNatremia

HOW TO TREAT?

<48 hours & <110 mEq/L
Seizure / Coma / Brain Dmg
Brain Stem Herniation

A

3% NaCl , 1-2 mEq/L/Hr
with a SERUM SODIUM GOAL + TIMEFRAME
<125-130 mEq /l + monitor every 2-4 hours
HYPERnatremia is a SERIOUS issue
DO NOT EXCEED 8 mEq/L/DAY

vvv
Once stable –> treat underlying etiology

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17
Q

Chronic / Mild Symptoms of HypoNatremia

HOW TO TREAT?

>48 hours & <135 mEq/L + Symptomatic
Nausea / Malaise

Moderate <120
HA / Lethargy / Restlessness / Disorientation

A

0.9% NaCl or LR @ 0.5 mEq/L/Hr
with a SERUM SODIUM GOAL + TIMEFRAME
<125-130 mEq /l + monitor every 2-4 hours
HYPERnatremia is a SERIOUS issue

DO NOT EXCEED 8 mEq / L / DAY!

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18
Q

Calculating:
Change in Serum Na+ per 1L of Infusate

Management of HypoNatremia

A
  • ( Infusate Na+** **- Serum Na*+** )
  • *( TBW* + 1 )**

TBW = X(weight in kg)
Male X = 0.6 // Female X = 0.5
Elderly = 0.5 // 0.45

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19
Q

Maximum Increase in Serum Na+?

Goal Serum Na+?

A

8 mEq/L/ DAY
or risk for CPM = Central Pontine Myelinosis (osmotic demyelination)
from correcting hyponatremia too fast (>12 mEq/L/day)

125-130 mEq/l or lower
&
Monitor Na+ Q2-4 hours

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20
Q

What is CPM?

A

Central Pontine Myelinolysis

Loss of OLIGODENDROCYTES & MYELIN in the PONS
associated with:
TOO FAST of a correction rate of HypoNatremia = >12 mEq/L/day
Severity = <120 mEq/L
Chronicity = >48 hours

(Osmotic Demyelination)

21
Q

Clinical Manifestations & @Risk Population of
CPM
Central Pontine Myelinolysis

A

Dysarthria / Dysphagia / Quadraplegia
Speech / Swallow / 4limb paralysis

Seizure / Coma / Death

@Risk Population:
Hepatic Failure / HypoKalemia / Malnutrition
(Alcoholics + malnutrition)

22
Q
  • *TREATMENT** for
  • *HYPERvolemic** + HypoTonic + HypoNatremia

Caused by:
CHF / Liver Failure
Nephronic Syndrome / Acute+Chronic Renal Failure

A

Treat the UNDERLYING Cause

Na Restriction

Loop Diuretics
Furosamide / Bumetanide

Conivaptan // Tolvaptan
not used too often, shouldnt be used for LONG
Vasopressin Receptor Antagonist

23
Q

Conivaptan // Tolvaptan

Use / Drug Type / MoA

A

for HYPERVolemic or Euvolemic
HypoTonic HypoNatremia

VASOPRESSIN RECEPTOR ANTAGONIST
inhibits AVP
(AVP normally would INCREASE REABSORPTION)
VVVV
Inhibit Reabsorption
VVVV
Diuresis / Reduction in Sodium

Side effects : HypoTension / HypoKalemia / HypoVolemia

24
Q
  • *TREATMENT** of
  • *Euvolemic** HypoTonic HypoNatremia

Caused by:
HypoThyroidism // Addison’s Disease
SIADH

A

Mild-Moderate Symptoms (<135)

  • *FLUID RESTRICTION**, stop the free water
  • *Convivaptan / Tolvaptan**
  • *Furosemide** + NaCl tab or 0.9% NaCl 
_SEVERE SYMPTOMS_ (\<120)
**Furosemide + 3% NaCl**
25
**Treatment of CHRONIC SIADH** Which causes: Euvolemic HypoTonic HypoNatremia
**_DEMECLOCYCLINE_** ***Inhibits* Renal Response to ADH** via **cAMP *inhibition*** 300-600 mg PO BID, 1hr ac or 2hr pc 2-5 day onset *_Lithium / Phenytoin_* 2nd line because their response is ***unpredictable*** & **ADR's**
26
* *TREATMENT** of * *_HypoVolemic_** **HypoTonic HypoNatremia** Causes: Renal Loss - cereb salt wasting / **diuresis** / adrenal insufficiency Non-Renal Loss - bleed/ NVD / wounds / sweat
_Mild-Moderate Symptoms_ (symptoms & \<135) **NaCl Tablet** + **0.9% NaCl** ``` _SEVERE Symptoms_ (\<110 + s/sx) **3% NaCl** ```
27
**Indications** for **HYPERnatremia**
Serum Sodium **\>145 mEq / L** HYPERnatremia is a: **HYPERosmolar State ALWAYS** = **HYPERtonic** always Usually a **_TBW *deficit*_**
28
**MODERATE HYPERnatremia** S/sx
Most symptoms are **CNS Manifestations** * may also see* **_Intense THIRST_**, since **HIGH Osm** --\> THIRST * issue with MENTAL issues & infants, no brian mech for THIRST* **\>145** mEq / L **MUSCLE WEAKNESS** **RESTLESSNESS** **NAUSEA / VOMITING**
29
**SEVERE HYPERnatremia** S/Sx
**\>160** mEq / L CNS Manifestations: Intense THIRST **Confusion** **Lethargy** **Irritabilty / Stupor** **COMA**
30
**_HYPERvolemia_ HYPERnatremia** Caused By?
_Iatrogenic = Caused by Medical exam/treatment_ **3% NaCl** Excessive Na Ingestion // Hypertonic Dialysis **Antibiotics containing Na:** **-CILLINS** // **Cephalosporins // Carbapenem** **_HYPERaldosteronism_** **_Cushing's Syndrome_**
31
**_Euvolemia_** **HYPERnatremia** Caused By?
* _Non-Renal Loss_* * *Fever** * *HYPERventilation** _Renal Loss_ **_DIABETES INSIPIDUS_** Central DI vs Nephrogenic DI **PolyUria / PolyDipsia** **USG \< 1.005** (Urine Specific Gravity, normal = 1.010)
32
**CENTRAL DI** Define & What can it cause?
***_Lack of Production/release of_* _AVP_** ECF is Normal due to **thirst mechanism** From: **Head Trauma / Surgery** (pituitary) **_Phenytoin / EtOH_** **Diabetes Insipidus** VVV **_EUVOLEMIC HYPERNATREMIA_**
33
**_Nephrogenic DI_** Define & What can it cause?
***_Lack of RESPONSE by AVP_*** From: **Renal Disease** // ↑**Ca2+** // ↓ ***K+*** Drugs: **Lithium / Democlocycline** (treatment for SIADH -\> *HypoNatremia)* **Amphoteracin B / Foscarnet / CLOZAPINE / CIMETIDINE** Nephrogenic Diabetes Insipidus VVVV **Euvolemic HYPERnatremia**
34
**_HypoVolemia_** + **HYPERnatremia** Caused by what?
_Renal Loss_ **Osmotic Diuresis** // **LOOP DIURETIC Acute+Chronic Renal Disease** *_Non-Renal Loss_* **Diarrhea / Vomiting** Fistulas **Burns / Excessive Sweating**
35
**Rapid Sodium *DECREASE*** leads to **WHAT?**
Water Loss = High Osm Brain VVV **RAPID CORRECTION of HYPERTONIC STATE** Accumulation of Organic Osmolytes in brain VVV **_CEREBRAL EDEMA_**
36
* *TREATMENT** for **ACUTE + SEVERE** * *HYPERnatremia** **\<48 hours** + Symptoms: Confusion / Lethargy / Coma / Irritability Stupor \> 160
You would only treat **ACUTE** if you **KNOW** that it is acute from being in a **hospital** **D5W** @ **_1-2_** **mEq/L/hr** To prevent OVERCORRECTION: goal sodium is **145-150** mEq/L Maximum *decrease* is: **10 mEq/L/ DAY** monitor Na **Q2-4hours**
37
* *TREATMENT** for **Chronic + Mild** * *HYPERnatremia** **\>48 hours** + **\>145 mEq / L** Moderate Symptoms: Muscle Weakness / Restlessness / N+V
*You would only treat **ACUTE** if you **KNOW** that it is acute from being in a **hospital*** **D5W or 0.45%NaCl** @ **_0.5_** **mEq/L/hr** To prevent OVERCORRECTION: goal sodium is **145-150** mEq/L Maximum *decrease* is: **10 mEq/L/ DAY** monotor Na **Q2-4hours**
38
**What FLUIDS used to treat HypoNatremia?** Change in Serum Na+ per 1L of infusate = _( Infusate Na+ - Serum Na+ )_ ( TBW\* + 1 )
**_3% NaCl_** MOST POTENT HYPERtonic Solution **513** **Infusate Na+** & **100%+ ECF** **distribution** * *_0.9% NaCl_** * *154** Infusate Na+ & **100%** ECF distribution * *_LR_** * *130 Infusate Na+** & **97%** ECF distribution
39
**What FLUIDS used for: HYPERnatremia**
**_D5W_** is the MOST POTENT due to **No Sodium & HypoTonicity** ***_0 Infusate Na+_*** & **40%** **ECF Distribution** * *_0.45% NaCl_** * *77 Infusate Na+ & 40** Change in Serum Na+ per 1L of infusate = _( Infusate Na+ - Serum Na+ )_ ( TBW\* + 1 )
40
**Free Water Deficit Calculation**
**TBW Deficit** = ***Normal TBW*** + **_Current TBW_** *Normal TBW* = ***BW x %water*** _Current TBW_ = **_140 / serum Na**_ x _**Normal TBW_** Normal TBW x (1 - [140/Naserum ]) **Replace 1/2 Deficit** over the **1st 24hours** VVV Replace the **other half** over the next **24-72 hours**
41
* *TREATMENT** for: * *_HYPERvolemia_** + **HYPERnatremia** Caused by: Iatrogenics: 3% NaCl / Antibiotics / Excessive Na HYPERaldosteronism Cushing's Syndrome
* *_DISCONTINUE**_ _**offending agent_** ex. 3% NaCl **_Diuretics_** to elim. Na/H2O excess * **_Hemodialysis_*** * IF RENAL FAILURE, no diuretics in renal failure* **_Replace Free Water Deficit_** TBW Deficit = Normal TBW x (1 - [140/Naserum]) 1/2 deficit over 24hr --\> remaining 1/2 over 24-72hr
42
* *TREATMENT** for: * *_Euvolemia_** + **HYPERnatremia** Caused by: Renal Loss = Central or Neurogenic Diabetes Insipidus Non-Renal Loss = Fever / HYPERventilation
_Mild-Moderate Symptoms_ **_Replace Free Water Deficit_** PO or IV TBW Deficit = Normal TBW x (1 - [140/Naserum]) 1/2 deficit over 24hr --\> remaining 1/2 over 24-72hr _SEVERE SYMPTOMS_ **Replace Free Water Deficit with _D5W_ \> 0.45% NaCl** IV For CDI: **VASOPRESSIN / DESMOPRESSIN** For NDI: **HCTZ / AMILORIDE / Indomethacin**
43
* *TREATMENT** for: * *_Euvolemia_** + **HYPERnatremia** Caused by: **_CENTRAL DIABETES INSIPIDUS_**
**_DESMOPRESSIN_** First line due to **Greater Potency & *less smooth muscle effects*** **Longer Duration of Action & Dosage Forms** Nasal / Rhinal Tube / IV / Oral **_Aqeuous Vasopressin_** Only for **initial Tx** b/c **short duration** & **Side effects** = Smooth muscle contractions only **IV or SC**
44
**Desmopressin** Used for / ADR / Etc
* *_CENTRAL DIABETES INSIPIDUS_** - -\> Euvolemia HYPERnatremia * *Dosage forms are NOT bioequivelant**, need to convert doses * *Greater Potency / Duration // *less smoothmuscle ADR*** **_Nasal Spray = 0.1 mg/mL_** 10-40 mcg/D, QD or TID **_Rhinal Tube_** dose similar to nasal spray **_IV = 4mcg / ml \*NOTE mcg_** 2-4 mcg/d IV or SC BID * *_Oral = 0.1mg or 0.2mg tab_** 0. 1 - 0.8 mg daily (BID or TID)
45
**Aqueous Vasopressin**
**_CENTRAL DIABETES INSIPIDUS_** Euvolemic HYPERnatremia Second line, only for **Initial Treatment due to *SHORT DURATION*** **\<30 min onset** --\> **3-6 hours** **IM or SC** *_NEGATIVES:_* ***HYPERSENSITIVITY to BOVINE / PORCINE*** **Fluid Overload** **SMOOTH MUSCLE CONTRACTIONS** Ab pain / Nausea / HTN / Angina / Uterine Contractions
46
* *TREATMENT** for * *Euvolemic HYPERnatremia** Caused by: **_NEUROGENIC DIABETES INSIPIDUS_**
**_HCTZ_** Thiazide diuretic, must be combined with **Na Restriction** Paradoxical effect of **↓UOP by causing EC volume contractio**n --\> proximal tube **Na/H2O reabsorption ENHANCED** ***HypoKalemia / HYPERcalcemia*** 50-100mg qd or BID, effective in **UOP *decrease by 50%*** Onset = 2-4 hours // DUration = 1-2 days * *_Amiloride_** * *K+ sparing diuretic**, *inhibit uptake of **Lithium*** in distal tubule * mild HYPEKalemia* **_Indomethacin_** NSAID, blocks prostaglandin antagonism of **AVP's action**
47
* *TREATMENT** for * *_HypoVolemia_ HYPERnatremia** Causes: Renal Loss = Osmotic diuresis / Loop Diuretic / Renal disease Non-Renal Loss = Diarrhea / Vomit / Fistula / Sweat / burns
* *_Mild-Moderate Symptoms_** * *Replace Free Water Deficit PO or IV** _**SEVERE SYMPTOMS** =_ **_hypovolemic SHOCK_** **_0.9%_ NaCl 500-1000 mL** over **30-60 Min** *still use 0.9% NaCl just to bring them OUT OF SHOCK* then: **Replace Free Water Deficit with _0.45% NaCl**_ or _**D5W_** IV
48
**Which ELECTROLYTE issue causes SEIZURES?**
**HypoNatremia** ## Footnote Headache Lethargy Restlessness Disorientation Coma Brain damage Brain stem herniation Death
49
**When do you have to REPLACE THE FREE WATER DEFICIT?** TBW Deficit = Normal TBW \* (1 – [140/Naserum])
**_HYPERkalemia_** All forms of Volemia. 1/2 deficit over 24 hours Other half over next 24-72 hours

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