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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
Q

Treatment of CHRONIC SIADH
Which causes:
Euvolemic HypoTonic HypoNatremia

A

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
Q
  • *TREATMENT** of
  • *HypoVolemic** HypoTonic HypoNatremia

Causes:
Renal Loss - cereb salt wasting / diuresis / adrenal insufficiency
Non-Renal Loss - bleed/ NVD / wounds / sweat

A

Mild-Moderate Symptoms (symptoms & <135)
NaCl Tablet + 0.9% NaCl

_SEVERE Symptoms_ (\<110 + s/sx)
**3% NaCl**
27
Q

Indications for HYPERnatremia

A

Serum Sodium >145 mEq / L
HYPERnatremia is a:
HYPERosmolar State ALWAYS = HYPERtonic always

Usually a TBW deficit

28
Q

MODERATE HYPERnatremia
S/sx

A

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
Q

SEVERE HYPERnatremia
S/Sx

A

>160 mEq / L

CNS Manifestations:
Intense THIRST

Confusion

Lethargy

Irritabilty / Stupor

COMA

30
Q

HYPERvolemia HYPERnatremia
Caused By?

A

Iatrogenic = Caused by Medical exam/treatment
3% NaCl
Excessive Na Ingestion // Hypertonic Dialysis
Antibiotics containing Na:
-CILLINS // Cephalosporins // Carbapenem

HYPERaldosteronism

Cushing’s Syndrome

31
Q

Euvolemia HYPERnatremia
Caused By?

A
  • 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
Q

CENTRAL DI
Define & What can it cause?

A

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
Q

Nephrogenic DI
Define & What can it cause?

A

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
Q

HypoVolemia + HYPERnatremia
Caused by what?

A

Renal Loss
Osmotic Diuresis // LOOP DIURETIC
Acute+Chronic Renal Disease

Non-Renal Loss
Diarrhea / Vomiting
Fistulas
Burns / Excessive Sweating

35
Q

Rapid Sodium DECREASE
leads to WHAT?

A

Water Loss = High Osm Brain
VVV
RAPID CORRECTION of HYPERTONIC STATE
Accumulation of Organic Osmolytes in brain
VVV
CEREBRAL EDEMA

36
Q
  • *TREATMENT** for ACUTE + SEVERE
  • *HYPERnatremia**

<48 hours + Symptoms:
Confusion / Lethargy / Coma / Irritability Stupor
> 160

A

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
Q
  • *TREATMENT** for Chronic + Mild
  • *HYPERnatremia**

>48 hours + >145 mEq / L
Moderate Symptoms:
Muscle Weakness / Restlessness / N+V

A

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
Q

What FLUIDS used to treat
HypoNatremia?

Change in Serum Na+ per 1L of infusate =

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

A

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
Q

What FLUIDS used for:
HYPERnatremia

A

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
Q

Free Water Deficit
Calculation

A

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
Q
  • *TREATMENT** for:
  • *HYPERvolemia** + HYPERnatremia

Caused by:
Iatrogenics: 3% NaCl / Antibiotics / Excessive Na
HYPERaldosteronism
Cushing’s Syndrome

A
  • *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
Q
  • *TREATMENT** for:
  • *Euvolemia** + HYPERnatremia

Caused by:
Renal Loss = Central or Neurogenic Diabetes Insipidus
Non-Renal Loss = Fever / HYPERventilation

A

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
Q
  • *TREATMENT** for:
  • *Euvolemia** + HYPERnatremia

Caused by:
CENTRAL DIABETES INSIPIDUS

A

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
Q

Desmopressin

Used for / ADR / Etc

A
  • *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
Q

Aqueous Vasopressin

A

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
Q
  • *TREATMENT** for
  • *Euvolemic HYPERnatremia**

Caused by:
NEUROGENIC DIABETES INSIPIDUS

A

HCTZ
Thiazide diuretic, must be combined with Na Restriction
Paradoxical effect of ↓UOP by causing EC volume contraction –> 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
Q
  • *TREATMENT** for
  • *HypoVolemia HYPERnatremia**

Causes:
Renal Loss = Osmotic diuresis / Loop Diuretic / Renal disease
Non-Renal Loss = Diarrhea / Vomit / Fistula / Sweat / burns

A
  • *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
Q

Which ELECTROLYTE issue causes
SEIZURES?

A

HypoNatremia

Headache Lethargy Restlessness Disorientation

Coma

Brain damage Brain stem herniation

Death

49
Q

When do you have to
REPLACE THE FREE WATER DEFICIT?

TBW Deficit = Normal TBW * (1 – [140/Naserum])

A

HYPERkalemia

All forms of Volemia.

1/2 deficit over 24 hours

Other half over next 24-72 hours

PDAT3 (23 decks)

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