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Clin med 3 - GU and Nephro > Acid base and Fluids > Flashcards

Acid base and Fluids Flashcards

1
Q

describe Acid-Base Homeostasis

normal arterial pH?

  • Respiratory mechanism
  • Renal mechanism
A

•Arterial pH is maintained between 7.35 – 7.45 by extracellular and intracellular chemical buffering systems along with respiratory and renal mechanism

•Respiratory mechanism:control arterial CO2 tension (PaCO2 )

•Renal mechanism: control plasma bicarbonate (HCO3 - )

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2
Q

components of Abg

uses?

A

pH

Oxygen tension (Pa02 )

Carbon dioxide tension (PaCO2 )

Oxyhemoglobin saturation (Sa02 )

Bicarbonate concentrations (HCO3 -)

USES

Identify acid-base disturbances

Measures partial pressures of O2 and CO2

Assessment of the response to therapeutic interventions

Procurement of blood samples in emergencies when venous blood is not feasible

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3
Q

blood pH values identify:

  • Acidemia –
  • Alkalemia –
  • Acidosis –
  • Alkalosis –
A
  • Acidemia – arterial pH < 7.35
  • Alkalemia – arterial pH > 7.45
  • Acidosis – ↓extracellular fluid pH
  • Alkalosis – ↑extracellular fluid pH
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4
Q

describe changes seen in (pH, HCO3, CO2)

  • Metabolic acidosis –
  • Metabolic alkalosis –
  • Respiratory acidosis –
  • Respiratory alkalosis -
A
  • Metabolic acidosis – ↓serum HCO3- & pH
  • Metabolic alkalosis – ↑serum HCO3- & pH
  • Respiratory acidosis – ↑arterial pCO2 & ↓ pH
  • Respiratory alkalosis - ↓ arterial pCO2 & ↑pH
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5
Q

define

  • Primary respiratory disturbance →
  • Primary metabolic disturbances →
A

•Primary respiratory disturbance →

  • primary change in PaCO2 →
  • invokes compensatory metabolic response →
  • secondary change in HCO3 –

•Primary metabolic disturbances →

  • primary change in HCO3 - →
  • invokes compensatory respiratory response →
  • secondary change in PaCO2
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6
Q

arrows in

  • Metabolic acidosis –
  • Metabolic alkalosis –
  • Respiratory acidosis –

Respiratory alkalosis

A

pH & CO2

Opposite = respiratory process

Same direction = metabolic process

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7
Q

CO2 in

Respiratory Acidosis

Respiratory Alkalosis:

A

Respiratory Acidosis: TOO MUCH CO2 = TOXIC

Respiratory Alkalosis: LOSING TOO MUCH CO2

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8
Q

Hyperventilation Syndrome: panic attack causes what ?

A

Respiratory Alkalosis

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9
Q

arrow in

Respiratory Acisodis

Respiratory Alkalosis

A

pH & CO2 going in OPPOSITE directions!!!

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10
Q

arrows in

Metabolic acid

Metabolic Alk

A

OPPOSITE DIRESTION

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11
Q

resp acidosis is caused by?

tx?

A
  • Severe pulmonary failure
  • Respiratory muscle fatigue
  • Abnormalities in ventilatory control

Reverse underlying cause

Tracheal intubation and assisted mechanical ventilation

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12
Q

si/sx of Respiratory Alkalosis:

A

Dizziness

Mental confusion

Seizures

Hypotension

Decreased cardiac output

Cardiac arrhythmias

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13
Q

metabolic acidosis causes

A
  • ↑ endogenous acid production (lactate or ketoacid)
  • Loss of bicarbonate (diarrhea)
  • ↑endogenous acid bc of ↓ excretion of acid by the kidneys (CKD)
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14
Q

si/sx of metabolic acidos

A

LOOK SICK

  • Increase in ventilation and TV (Kussmaul respirations)
  • ↓cardiac contractility
  • Peripheral arterial vasodilation
  • Central venous constriction
  • Decrease in central and pulmonary vascular compliance → pulmonary edema
  • Depressed CNS function → headache, lethargy, stupor, coma
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15
Q

normal anion gap acidosis is defines as

A

The presence of a metabolic acidosis with a normal anion gap and hyperchloremia

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16
Q

causes of high anion gap met acidosis

A

MUD PILES

  • Methanol
  • Uremia
  • Diabetes
  • Paraldehyde
  • Iron (and Isoniazid)
  • Lactate
  • Ethylene glycol
  • Salicylate
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17
Q

non-anion gap avidosis is describes ad

A

Bicarbonate loss from the GI tract or kidneys – kidneys over excrete bicarb

  • Vomiting
  • Diarrhea
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18
Q

si/sx of Metabolic Alkalosis

what electro;yte abnorm are seen?

A
  • ↑ in HCO3 –
  • ↓ nonvolatile acid (usually HCl) from the extracellular fluid (vomiting or NG tube suction)
  • Failure of the kidneys to eliminate HCO3 –

Often accompanied by hypochloremia and hypokalemia

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19
Q

si/sx Metabolic Alkalosis

A

Similar to those of hypocalcemia

  • Mental confusion
  • Obtundation
  • Predisposition to seizures
  • Paresthesia
  • Muscle cramping
  • Tetany
  • Aggravation or arrhythmias
  • hypoxemia
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20
Q

_Frequently occurs as a mixed disorder in association wit_h

  • respiratory acidosis
  • respiratory alkalosis,
  • metabolic acidosis
A

Metabolic Alkalosis

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21
Q

tx of Metabolic Alkalosis

A

Treat hypokalemia with potassium replacement

  • Stop loop / thiazide diuretics
  • Acetazolamide – Diamox = weak diuretic makes you hold onto your bicarb!
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22
Q

arrows in

metabolic acid

metabolic alk

A

pH CO2 in SAME direction

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23
Q

causes of high anion gap acidosis

Lactic Acidosis= ↑lactateKetoacidosis

Drug/Toxin Induced

Chronic Kidney Disease

A

Lactic Acidosis= ↑lactate

  • Poor tissue perfusion (type A)
  • Aerobic disorders (type B)
  • D-Lactic acid acidosis

Ketoacidosis

  • Diabetic Ketoacidosis (DKA)
  • Alcoholic Ketoacidosis (AKA)

Drug/Toxin Induced

  • Salicylates
  • Ethylene Glycol
  • Methanol
  • Propylene Glycol
  • Isopropyl Alcohol
  • Pyroglutamic Acid

Chronic Kidney Disease

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24
Q

caused by injestion of asprin & accompanied by a respiratory alkalosis

A

high anion gap met acidosis - Salicylates

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25
Q

Often accompanied by a high osmolar gap

urine oxalate crystals

A

Ethylene Glycol

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26
Q

Methanol / ___ alcohol: lead to severe damage of???

A

Wood Alcohol : Leads to severe damage of: Optic nerve & CNS

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27
Q

toxicity Seen in ICU settings with patients on continuous infusions of medications

what meds?

A

Propylene Glycol

Diazepam • Lorazepam • Phenobarbital • Nitroglycerine

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28
Q

Increase is osmolar gap is present, but Labs might not show high anion

FALSe NORMAL ANION GAP)

A

Isopropyl Alcohol

Labs might not show high anion gap because isopropyl alcohol is metabolized to acetone, which is excreted rapidly (FALSO NORMAL ANION GAP)

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29
Q

Accumulation of 5-oxoproline is seen w/ what toxicity

A

Pyroglutamic Acid: Acetaminophen overdose

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30
Q

CKD w/ high anion gap causes

A

Caused by poor filtration and reabsorption of organic anions → uremic acidosis

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31
Q

Steps to Interpreting ABGs

A

•Step 1 – Determine the primary disorder

•Step 2 – Determine appropriate compensation verse the presence of mixed acid-based disorder by calculating the range of compensation

•Step 3 – Calculate the ion gap

•Step 3a – Calculate the corrected HCO3- concentration if the anion gap is increased

•Step 4 – Examine the patient to determine whether the clinical signs are compatible with the acid base analysis

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32
Q

•If the compensation is not appropriate, this is evidence of ??

A

a second acid base disorder

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33
Q

•Primary metabolic acidosis: INC/DEC in ____ indicates?

  • mixed metabolic acidosis and r_espiratory acidosis_
  • metabolic acidosis and respiratory alkalosis

•Primary respiratory acidosis: INC/DEC in ____ indicates? pH

respiratory acidosis and metabolic acidosis

respiratory acidosis and metabolic alkalosis

A

•Primary metabolic acidosis

metabolic acidosis and respiratory acidosis: ↑ pCO2,

metabolic acidosis and respiratory alkalosis: ↓ pCO2,

•Primary respiratory acidosis

respiratory acidosis and _metabolic acidosi_s: ↓HCO3 ↓pH

respiratory acidosis and metabolic alkalosis: •↑HCO3, pH normal

• pH might be “normal” appearing

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34
Q

•Should suspect a mixed disorder based on:

A
  • The patient’s history
  • pCO2 or HCO3 - is abnormal and pH is normal or did not change as expected
  • pCO2 and HCO3 - move in the opposite direction
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35
Q

to check compensation you start with?

pCO2 or HCO3 ?

Resp?

Metabolic

A

Resp - pCO2 (-40)

Metabolic- HCO3 (-35)

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36
Q

pCO2 & HCO3 going in SAME direction in respiratory pathology - think??

A

– MIXED

NORMALLY

•pCO2 and HCO3 going in OPPOSITE direction

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37
Q

pCO2 and HCO3 going in OPPOSITE directions in metabolic pathology???

A

– MIXED

NORMALLY

•pCO2 and HCO3 going in SAME direction

38
Q

what must be calcukated w/ ALL patients with metabolic acidosis***

what is inportant to remeber about this calculation?

A

Anion Gap

•Normal anion gap 6 – 12 mEq/L

use CO2 value from the patient’s BMP or CMP = HCO3

  • •WE DO NOT USE Abg Value !!!
  • •If you get sodium and chloride in question always calculate anion gap*
39
Q

In patients with a high anion gap metabolic acidosis what must be calculated?

how is this interpreted?

A

dekta ration

If one metabolic acidosis is going on OR 2

40
Q
  • Anion gap, > 20 mEq/L = ???
  • Anion gap > 30 mEq/L =
A

•Anion gap, > 20 mEq/L : primary metabolic acid-base, usually acidosis

•regardless of the serum pH or serum bicarb level

•Anion gap > 30 mEq/L = metabolic acidosis

41
Q

Calculate the corrected HCO3- concentration if..?

  • If corrected bicarb is < 22 = ??
  • If corrected bicarb is > 26 = ??
A

the anion gap is increased

  • If corrected bicarb is < 22 = additional metabolic acidosis present
  • If corrected bicarb is > 26 = additional metabolic alkalosis present
42
Q

steps to calculations in metabolic acidosis

A

Metabolic acidosis:

  1. Confirm compensation: HCO3
  2. Calculate serum anion gap (HCO3 use CO2)
  3. If HIGH anion gap c_alculate delta ration_ (use CO2)
  4. Confirm delta ration w/ corrected HCO3 using measured HCO3
43
Q

when calculating anion gap & delta ration what vaules do we use?

A

anion : CO2 value from the patient’s BMP or CMP = HCO3

delta ration - patients Abg HCO3

44
Q

INC anion gap is =

A

>12

45
Q

Osmolality measured in mOsmol/L is defined as

  • Increased serum osmolality =
  • Decreased serum osmolality=
A

•Number of dissolved particles in a fluid. Range 285-295

  • •Concentration of solutes/electrolytes per liter of solution/water sodium, potassium, glucose and urea
  • •Check when sodium levels are UP!!

•Increased serum osmolality =volume depletion and concentration of electrolytes

•Decreased serum osmolality=volume overload and dilution of electrolyte

46
Q

Dysnatremias occur as a malfunction of this feedback mechanism within the kidneys

A

ADH is secreted by the posterior pituitary gland and functions to help body hold onto water

47
Q

define osmoreceptiors and their role in water balance??

A

Osmoreceptors are sensory receptors in hypothalamus which monitor serum osmolality.

  1. The hypothalamus then triggered the p_ituitary glad = release ADH_
  2. ADH tells the kidney to hold onto H2O via the renin-angiotensin system.
  3. ↑ADH = ↑H2O
  4. ↑production of angiotensin II =stimulate aldosterone release from adrenals.
  5. Aldosterone =stimulates reabsorption of Na+ in distal tubules in kidney, water thus flows with sodium.
48
Q

3 classifications of fluids

A
  • Colloids- solutions that do not cross the cell membrane
  • Crystalloids are commonly prescribed for volume depletion and maintenance fluids
  • Blood Products should be used when there is acute blood loss
49
Q

•3 types of cystalloid solutions based on tonicity:

A

*Isotonic- same concentration of solutes in blood- cells content stays the same no movement between extracellular and intracellular

*Hypotonic- lower concentration of solutes than in the cell solutions move into cells causing them to enlarge- swell

Hypertonic- higher concentration of solutes in solution -solutions pull fluid from the cells- shrink

50
Q

name 3 isotonic fluids

A

Normal Saline – 0.9%

LR

D5W

51
Q

Only fluid which is compatible with blood transfusions

A

Normal Saline – 0.9%

52
Q

Most closely mimics the blood and plasma concentration

indications?

A

LR

acute blood loss

hypovolemia from third spacing fluid shifts

electrolyte imbalances

metabolic acidosis

53
Q

•Provides some minimal calories while patient is NPO – diabetics

Will hemolyze blood products

CI????

A

D5W

Should not be used for dehydration alone as it dilutes the plasma electrolytes

CI -

arly post op recovery

resuscitation

increased ICP

54
Q

CI in patients with liver failure who are unable to metabolize lactate and patients with a pH >7.5

A

LR

Careful in renal patients as Potassium chloride in solution

55
Q

Hypotonic- fluid

uses?

A

.45% NS “half normal”

treat hypernatremia

DKA

hyperosmolar hyperglycemia

Prevent dehydration w/ high sugars

56
Q

Draws water out of cells and into intravascular space Volume expanders

A

Hypertonic-

  • 3% NaCl
  • 5% Na Cl
  • concentrations of solutes
57
Q

•Cure for severe Hyperkalemia

A

Concentrated dextrose >10% Higher – followed by insulin bolus

58
Q

Indicated in the following situations:

•Shock, Severe burns, pancreatitis, peritonitis, hepatorenal syndrome

Risk of anaphylaxis**

A

Colloids

  • Albumin
  • Hespan

•“Volume” expanders – they draw fluid into the blood vessels via oncotic pressure

59
Q

Hyponatremia Si/Sx

  • Mild (
  • Mod
  • Severe
A
  • Mild (130-134)
  • Mod (120-129)
  • Severe (<120)

<125 = 1st sx is weakness

140 - 130

  • •Thirst
  • •Impaired taste
  • •Anorexia
  • •DOE
  • •Fatigue/weakness
  • •¯ sensation

130 ® 120: Severe GI Sx (ex. vomiting, abdominal cramps)

110-115

  • •Confusion
  • •Lethargy
  • •Muscle twitching
  • •Seizures
  • •Stupor/coma
60
Q

Goal rate of correction in severe hyponatremia is to raise serum sodium concentration by ____mEq/L in a 24 hour period

•Maximum rate correction no more than ___ mEq/L in 24 hours

A

Goal rate of correction in severe hyponatremia is to raise serum sodium concentration by 4-6 mEq/L in a 24 hour period

•Maximum rate correction no more than 8 mEq/L in 24 hours

61
Q

tx of hyponatremia

A

Na <130: asymptomatic

  • 50 mL bolus 3%
  • Remeasure hourly

Na <130: symptomatic

  • 100 mL of 3%
  • If sx follow à 2 more 100mL bolus in 30 mins
62
Q

si/sx of Overcorrected Tx hyponatermia

A

Central pontine myelinolysis destruction of myelin covering nerve cells in the brainstem

•Confusion, encephalopathy, lethargy Weakness, paralysis

Cerebral edema

Brain stem herniation

Osmotic demyelination syndrome

63
Q

SIADH is characterized by

A

Excess ADH secretion - DEC diuresis

DEC urine and water excretion = INC ­total body water

Dilutional hyponatremia

  • the urine is very concentrated.
  • Not enough water is excreted = too much water in the blood.
  • This dilutes many substances in the blood such as sodium.
64
Q
  • HA/confusion
  • Lethargy
  • Anorexia

Euvolemic – but Na is LOW

Dx?? & LABS

A

SIADH

  • •↓Serum osmolality - <280
  • •↑ urine osmolality
  • INC urine Na – conc. Na
  • DEC blood Na

Urine is concentrated but sodium is LOW

65
Q

Tx SIADH

A

Treat underlying causes

•Fluid restriction

•Demeclocycline - inhibiting release of ADH

  • Vasopressors
  • Salt tablets
66
Q

Hypernatremia >145 is caused by

A

­ INC NA intake (ex. IVF)

DEC NA loss (ex. Cushing syndrome, hyperaldosteronism)

DEC free body water: (ex. GI loss, sweating, burns, diabetes insipidus, osmotic diuresis)

Psychogenic polydipsia

67
Q

si/sx ofHypernatremia >145

A
  • AMS
  • Ataxia
  • Seizures
  • Hyperreflexia
  • Spasticity/twitching
  • Irritability
  • Lethargy

•

Altered thirst mechanism psychiatric patients elderly institutionalized patients

68
Q

common cause of hypovolemic hypernatremia

A

Diabetes Insipidus Passage of large volumes of dilute urine

Cause hypovolemic hypernatremia through 2 mechanisms:

  1. Decreased secretion of ADH from posterior pituitary
  2. Increased renal resistance to ADH cannot concentrate urine

Most common cause is damage after trauma or surgery to the region of the pituitary and hypothalamus

69
Q

The goal in tx of hypernatremia is to lower serum sodium by ____ per hour in less than 24 hours

what other 2 tx??

A

The goal in tx of hypernatremia is to lower serum sodium by 1-2 mEq/l per hour in less than 24 hours

•DSW IV 3-6 mL/kg/hr - monitor every 2 hr

•Desmopressin (DI)

70
Q

complication of hypernatremia

A

Primary hyperaldosteronism- problem with the adrenals

  • usually a benign tumor
  • excess production of aldosterone- hormone responsible for NA+ and K+ balance
  • increased sodium and water and decreased potassium
71
Q

ECG changes in

Hypokalemia

Hyperkalemia

Hypocalcemia

A

Hypokalemia -

  • flat T-waves
  • ST depression
  • U waves

Hyperkalemia

  • •Tall/peaked T-waves
  • •Widened QRS
  • •Flat P-waves

Hypocalcemia: prolonged QT interval)

72
Q

Meds that cause

Hypokalemia

Hyperkalemia

A

Hypokalemia

•Cellular redistribution (insulin)

diuretics, steroids, β-adrenergic agonists)

Hyperkalemia

  • ACEI – lisinopril
  • ARBs – Losartan
  • aldosterone antagonists – spironolactone
73
Q
  • Hyperreflexia
  • Tetany
  • Muscle spasms

Dx?

A

Hypocalcemia

74
Q
  • Chvostek sign - ??
  • Trousseaus sign - ??

Dx??

A

Hypocalcemia

Chvostek sign - facial spasm following the percussion of the facial nerve

•Trousseaus sign - spasm of the hand elicited by inflation of a BP cuff

75
Q

Mag deficnecy needs to be tx FIRST in what dzs??

A

Hypokalemia

•Supp. Mg - ** It is a difficult task to replete potassium in the setting of low magnesium. Therefore be sure to replete magnesium if needed prior to the potassium

Hypocalcemia

•Supp. Mg - Because of the effect of magnesium on calcium balance You must correct a magnesium deficit first

76
Q

Tx of Hyperkalemia

A

IV Ca (ex. gluconate, chloride) – FIRST

  • •Cardioprotective does not decrease K+

IV hypertonic glucose w/ regular insulin –

  • •moves excess K+ into the cells

IV diuretics (loop or thiazide)

Kayexalate - Given resins that bind K+ and excreted in stool

Hemodialysist

77
Q

“Bones, Stones, Groans, & Psychiatric Moans”

dx?

A

Hypercalcemia

  • Bone pain
  • Muscle weakness
  • Nephrolithiasis
  • Fatigue/lethargy
  • Confusion
  • Constipation
  • Depression
  • Nausea
78
Q

causes of Hypercalcemia

A

CHIMPANZEE

C-CALCIUM SUPPLEMENTS

H- HYPERPARATHYROIDISM

I- IATROGENIC, IMMOBILIZATION

M-MULTIPLE MYELOMA

P-PARATHYROID HYPERPLASIA

A-ALCOHOL

N-NEOPLASM

79
Q

tx of Hypercalcemia

A

ITotal Calcium <12 no immediate treatment.

  • Remove contributing factors such as thiazide diuretics, lithium, calcium carbonate.
  • Encourage hydration

12-14 mg/dL

•IVF NS and Bisphosphonates

>14 - need aggressive therapy

_Isotonic Salin_e at 200-300 ml/hr and make sure urine output is 100- 150mL/hr

Calcitonin – 4 IU/kg and then repeat Calcium level in 4 hrs

Zolendronic acid or Pamindronate

  • •If severe renal impairment - Denosumab
80
Q

causes of Hypomagnesemia

A

•Chronic ETOH use

DEC intestinal absorption

INC renal excretion

INC GI loss (ex. vomiting, diarrhea)

  • Refeeding syndromes
  • Starvation
81
Q

si/sx of

Hypomagnesemia

A
  • Lethargy
  • Confusion
  • Tremors
  • Convulsions

•Hyperreflexia

•Paresthesia’s

82
Q

si/sx Hypermagnesemia

A

DEC DTR’s

  • Bradycardia
  • Hypotension
  • Flaccid paralysis
  • Cardiac arrest
  • Nausea
  • HA
  • Hypocalcemia
83
Q

si/sx & ECG differentiating

Hypomagnesemia

Hypermagnesemia

A

Hypomagnesemia: Hyperreflexia

  • ECG (widened QRS, ST depressions)

Hypermagnesemia: DEC DTRs

  • ECG
  • peaked T-waves
  • widened QRS
  • escape beats
84
Q

tx Hypomagnesemia

A

mild asymptomatic cases - PO magnesium salts- precaution may develop osmotic diarrhea

  • •Mag-Ox- magnesium oxide
  • •Slow-Mag- magnesium chloride
  • •Mag-Tab- magnesium lactate

•

severe or symptomatic deficienc - IV replacement

  • • 1-2 g IV Magnesium sulfate over 2-15 min
  • •Careful monitoring for rebound hypermagnesemia and arrhythmias
  • •Caution when giving Mg+ to renal patients
85
Q

____Cr = ↓kidney function

A

INCREASE IN Cr = ↓kidney function

•Better indicator of renal function - Excreted only by the kidney

86
Q

Etiology : pH and ____ changes

Respiratory Acidosis

Respiratory Alkalosis

A

pH & pCO2 in OPPOSITE DIRECTION

Respiratory Acidosis: Due to inadequate ventilation

  • ↓pH < 7.35
  • ↑PaCO2 > 45 mmH

Respiratory Alkalosis : Due to hyperinflation

  • ↑pH > 7.45
  • ↓PaCO2 < 35mm Hg
87
Q

Etiollogy and pH & ____ changes

Metabolic Acidosis

Metabolic Alkalosis

A

pH & HCO3 in SAME direction

Metabolic Acidosis: Due to gain of acid or loss of base

Excessive GI loss

  • ↓pH < 7.35
  • ↓HCO3 22 mEq/L

Metabolic Alkalosis: Due to loss of acid or gain of base

Vomiting / Gastric suction

  • ↑pH > 7.45
  • ↑HCO3 >26 mEq/L
88
Q

Hyperkalemia: is assoc w/ metabolic ???

Hypokalemia: is assoc w/ metabolic ???

A

Hyperkalemia: is assoc w/ metabolic acidosis

Hypokalemia: is assoc w/ metabolic alkalosis

89
Q

ECG (flat T-waves, ST depression, U waves)

dx?

A

Hypokalemia

90
Q

ECG (TWiFP)

  • Tall/peaked T-waves
  • Widened QRS
  • Flat P-waves
A

Hyperkalemia

91
Q

•ECG (prolonged QT interval)

A

Hypocalcemia

Clin med 3 - GU and Nephro (3 decks)

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