Acid/Base Meds Flashcards
Respiratory Alkalosis Mnemonic
PAST PH
- Panic attacks
- Anxiety attacks
- Salicylates
- Tumors
- Pulmonary embolism
- Hypoxemia
Metabolic Alkalosis Mnemonic
LAVAlUP
- Loop Diuretics ( Furosemide, Bumetanide, Torsemide)
- Antacid use
- Vomiting
- Aldosterone increase (UP)
Respiratory Acidosis Mnemonic
AS A COW
- Airway obstruction/Aminoglycosides/Anesthetics
- Sedative Use
- Acute lung disease
- Chronic lung disease
- opioids
- Weakening of the respiratory muscles
UMetabolic Acidosis with Large anion Gap Mnemonic
MUD PILES
- Methanol, metformin
- Uremia
- Diabetic ketoacidosis (or alcoholic ketoacidosis)
- Paraldehyde, phenformin
- Isoniazid, iron
- Lactic acidosis
- Ethylene glycol (antifreeze), ethanol
- Salicylates
Metabolic Acidosis with Normal Anion Gap Mnemonic
USED CAR
- Ureteral diversion
- Saline infusion
- Exogenous acid
- Diarrhea
- Carbonic anhydrase inhibitor (acetazolamide)
- Adrenal insufficiency
- Renal tubular acidosis
Treatment of Metabolic Acidosis
identify and tx underlying causes
- NaHCO3- indicated when:
- renal dysfunction→ not enough HCO3- is regenerated
- Severe acidemia: pG <7.10
- goal: increase HCO3- by 10mEq/L; and ph> 7.2
- ½ of the amount is given over 3-4 hours; then remainder given over 8-24 hours
- ****1mEq/kg/dose and monitor***
NaHCO3 IV
used to treat metabolic acidosis
- can be used with loop diuretics to avoid too much fluid (fluid overload)
- indicated when:
- renal dysfunction → not enough HCO3- regenerated
- severe acidemia: pH<7.10
- ½ of the amount is given over 3-4 hours; then remainder given over 8-24 hours
-
one amp is 50mL (or 50mEq)
- can give up to 3 amps + 1L D5W
Oral NaHCO3
used to tx metabolic acidosis
- generally preferred with chronic metabolic acidosis
- can be given as tab or powder
- indicated when:
- renal dysfunction → not enough HCO3- regenerated
- severe acidemia: pH<7.10
- ½ of the amount is given over 3-4 hours; then remainder given over 8-24 hours
K-citrate
used to tx metabolic acidosis
- helpful when the acidosis is coupled with hypoK+
- be cautious with renal impairment → needs to be avoided if pt has hyperK+ (can cause increased HyperK+)
Tx of Metabolic Alkalosis
- pts rarely have symptoms due to alkalemia
- sxs often related to volume depletion
- muscle cramps
- dizziness depending on position
- HypoK+ → muscle weakness, polyuria, polydipsia
- sxs often related to volume depletion
-
Tx: tx the underlying cause
- i.e. meds, citrate containing products (K-citrate used to tx metabolic acidosis), or acetate in parenteral nutrition → causes HCO3- levels to rise
- alkalosis caused by vomiting, NG suction, or diarrhea +/- urinary Cl- (<25mEq/L) → saline infusion
- acetazolamide (carbonic anhydrase inhibitor) → reduces HCO3- concentration
- ******Hemodialysis or HCl infusion for life-threatening metabolic alkalosis******
Tx of Respiratory Acidosis
represents ventilation failure or impaired control of ventilation
- hypoxemia + hypercapnia
- severe, acute respiratory acidosis =
- HA, blurred vision, restlessness and anxiety, tremors, somnolence, and/or delirium
- Tx = identify cause and tx that:
- opiate/opioids → naloxone
- acute bronchospasm/asthma → bronchodilators
- assisted ventilation and mod-severe acidosis → BiPAP
- NOTE: NaHCO3 may actually worsen acidemia due to increased CO2 generation so do NOT use this
- Goals:
- careful monitoring of pH
- maintain oxygenation
- improve alveolar ventilation
Tx of Respiratory Alkalosis
represents hyperventilation
- sxs: irritability of central and peripheral nervous system
- light headedness, altered consciousness, cramps, syncope
- severe cases: HypoPhos shifts from ECF to ICF
- tx: identify cause and tx accordingly
- for mild-moderate severity in spontaneously breathing pts → no specific tx
-
severe alkalosis:
- rebreathing
- rebreathing mask, or paper bag
- mechanical ventilation
- high level sedation or paralysis is a good option
- rebreathing
Change in Bicarbonate equations for acute respiratory acidosis vs alkalosis
- Acute Respiratory Acidosis: (approx normal)
- [change]HCO3- = 0.1 x [change]PaCO2
- 10% of [change]PaCO2
- [change]HCO3- = 0.1 x [change]PaCO2
- Acute Respiratory Alkalosis: (approx normal)
- [change]HCO3- = 0.2 x [change]PaCO2
- 20% of [change]PaCO2
- [change]HCO3- = 0.2 x [change]PaCO2
Change in Bicarbonate equations for chronic respiratory acidosis vs alkalosis
- Chronic Respiratory Acidosis: (increased bicarb)
- [change]HCO3- = 0.35x [change]PaCO2
- 35% of [change]PaCO2
- [change]HCO3- = 0.4 x [change]PaCO2
- 40% of [change] PaCO2
- [change]HCO3- = 0.35x [change]PaCO2
Total Body Water
- TBW = 60% of body weight
- ⅓ is ECF
- ¼ = plasma fluid
- ¾ = interstitial fluid
- ⅔ = ICF
Major Extracellular Ions
Na+, Cl-, HCO3-
Major Intracellular Ions
K+, Mg2+, PO42-, SO42-
Osmolality vs Osmolarity
- osmolality = osmoles of solute per mass (kg) of solvent
- Osmolarity = osmoles of solute per volume (L) of solvent → volume changes with temperature
Normal Plasma/Serum Osmolarity
275-290mOsmoles/L
- 2 [Na] + [glucose]/18 + [BUN]/2.8 =osm/L
What do changes in plasma tonicity cause ADH to do?
- Osmolarity >295 mOsm/L = max ADH release
- osmolarity <280 mOsm/L = inhibits release of ADH
S/sxs of Volume Deficits
- acute weight loss
- decreased skin turgor
- oliguria (production of small amounts of urine)
- >100mL/day but <400mL/day
- concentrated urine
- tachycardia
- prolonged cap refill
- decreased BP
- sensation of thirst, weakness, dizziness, muscle cramps
- orthostatic hypotension
Labs associated with Volume Deficits
- High Serum Osmolality
- increased HCT, protein, electrolytes
- Increased BUN: Scr
- usually >20:1
- Increased Urine Osmolality
- yellow urine
Causes of Volume Deficits
- Lack of intake
- GI losses: diarrhea/vomiting
- excess sweating due to exercise/fever
- burns
- diabetes insipidus
- uncontrolled DM
Crystalloid Solutions (Therapeutic Fluids)
- Normal Saline (NS), Lactated Ringer’s Solution (LR), Dextrose 5% (D5W, ½NS
Colloidal Solutions (Therapeutic Fluids)
- albumin
- hetastarch and dextran
- FFP (fresh frozen plasma)
Normal Saline (0.9% NaCl)
isotonic
- crystalloid solution
- primarily used to replace ECF
- used to maintain BP
- osmolarity = 208 mOsm/L
- 154mmol/L Na+ plus 154mmol/L Cl-
- osmolarity = 208 mOsm/L
- used to maintain BP
- 1000 L infusion = 250 mL in the intravascular space (b/c it remains in the ECF, and ¼ → intravascular, and ¾ → interstitial space)
Dextrose 5%
hypotonic → acts as “free water”
- crystalloid solution
- osmolarity = 250 mOsm/L
- not used to raise BP
- distributes via normal body water distribution (⅔ to ICF, ⅓ to ECF)
- 1000L infusion = 333mL → ECF
- ¼ → intravascular space = 83mLs
- does NOT affect BP
- ¼ → intravascular space = 83mLs
- 1000L infusion = 333mL → ECF
Lactate Ringer
Crystalloid solution
- contains Na+, K+, Cl- and lactate (buffer to increase pH) →similar to blood composition
- used to replace ECF
- osmolarity = 274 mOsm/L
- commonly used in:
- acidosis
- alkalosis
- burn/trauma patients
3% NS
3%Normal Saline
- crystalloid solution
- hypertonic
- used to acutely lower intracranial pressure in TBIs
- osmolarity = 1,025mOsm/L
Albumin 5% or 25%
colloid solution used to increase plasma oncotic pressure
- plasma volume expansion
- 5% = for volume expansion → 1:1 expansion 25mL infusion = 25mL expansion
- 25% = when fluid intake needs to be minimized or oncotic pressure needs to be raised → 5:1 expansion of volume
- 25mL infusion = 125mL expansion
Fluid Maintenance Requirements
- Neonates: 1-10kg = 100ml/kg
- Children: 10-20kg = 1L for the first 10 kg + 50mL/kg for the 2nd 10kg
- Adults: >20 kg = 1.5L for the first 20kg + 20mL/kg for anything above 20kg Then add normal insensible losses ** (see below)
- e.g. adult weighing 70 kg = 1.5L + 50kg(20mL/kg) = 2.5L + 1L (insensible losses)
-
Normal Insensible Losses for avg adult:
- lungs 400mL/day
- skin 400 mL/day
- feces 100mL/day
- total = ~1L /day
General Tx strategy for severe volume depletion or hypovolemic shock
- at least 1-2 L of NS as rapidly as possible (bolus)
- restores tissue perfusion
- fluid replacement is continued at rapid rate until clinical signs of hypovolemia improve
General Tx Strategy for mild/moderate hypovolemia
- rate of fluid admin > rate of continued fluid losses
- *******REVIEW THIS********
- caution in: renal failure, cardiac failure, hepatic failure, elderly
0.45% NaCl
Hypotonic
- if you infuse 1000mL:
- 500 mL with act as NS (ECF only)
- ¼ of 500mL → intravascular space = 125 mL
- 500 mL will act as free water
- ⅓ of 500mL in ICF = 166mL
- ¼ of 166mL in intravascular space = 41.5mL
- ⅓ of 500mL in ICF = 166mL
- 125 mL + 41.5 mL = 166.5 mL
- 500 mL with act as NS (ECF only)
Types of Hyponatremia
- Na+ <135
- Hypertonic hyponatremia (Osmolarity >300 mOsm/L)
- Hypotonic Hyponatremia (i.e. dilutional→ <275 mOsm/L)
- hypervolemic
- gain of both water and sodium
- water >>>>> sodium
- gain of both water and sodium
- euvolemic
- gain of water (ECF volume is normal)
- total body water >>>>normal total Na+
- gain of water (ECF volume is normal)
- hypovolemic
- loss of both water and sodium
- sodium >>>>>water
- loss of both water and sodium
- hypervolemic
Hypertonic Hyponatremia
osmolarity > 300 mOsm/L
associated with severe hyperglycemia
60mg/dL of Glc >200 = 1mEq/L reduction of Na+
tx: Tx the hyperglycemia → insulin
Hypervolemic Hyponatremia
Hypotonic hyponatremia (osmolarity <275 mOsm/L)
- body gains excess Na+ and Water
- but Water >>>>>Na+
- Causes: HF, cirrhosis, nephrotic syndrome
- tx: Fluid & Na+ restriction (i.e. 2 gm/day)
- optimize the underlying disease state
- diuretics
- increase the intravascular oncotic pressure (albumin)
- pulls fluid of out intracellular compartment
Euvolemic Hyponatremia
aka isovolemic hyponatremia
hypotonic hyponatremia (osmolarity <275 mOsm/L)
ECF volume is normal
-
have excess water → total body water >>>>normal total Na+
- water intoxication
- causes: SiADH (too much ADH secreted), Polydipsia, decreased water secretion
- carcinomas (small cell lung cancer)
- CNS disorders → stroke, meningitis, trauma
- medications: SSRIs, NSAIDs, antipsychotics, sulfonylureas
- Tx:
-
Non-acute (Na >115mEq/L and asymptomatic:
- fluid restriction, possible chronic therapy
-
Acute (Na <115 mEq/L and/or sxs):
-
3% NaCl infusion
- +/- diuretics to correct fluid accumulations
- fluid restriction → 1000-1200mL/day
-
3% NaCl infusion
- ******no more than 12 mEq/L/24 hours (0.5mEq/hour)******
- can cause osmotic demyelination syndrome → myelin cells swell/shrink and die
-
Non-acute (Na >115mEq/L and asymptomatic:
Chronic Therapy for Euvolemic Hyponatremia
- in addition to fluid restriction/salt tabs
-
demeclocycline (tetracycline)
- blocks arginine vasopressin (ADH) from binding to its receptors → less aquaporin insertion → less reabsorption of water
- “vaptans”
-
vasopressin = ADH receptor antagonist
- conivaptan → IV formulation
- tolvaptan → PO formulation
-
vasopressin = ADH receptor antagonist
Hypovolemic Hyponatremia
hypotonic hyponatremia (osmolarity <275 mOsm/L)
decreased ECF volume
- decrease in both Na+ and Water
- deficit of Na+ >>>>> deficit of water
- Causes:
- diuretics (thiazides), diarrhea, vomiting, NG suction
- Treatment: NS @ 300ml/hr until improvement in symptoms
- *****DO NOT CORRECT SODIUM LEVELS >12mEQ/L/24 HOURS******
Types of Hypernatremia
- Hypernatremia = >145 Na+
-
Hypovolemic Hypernatremia
- loss of water >>>>> sodium
-
Isovolemic Hypernatremia
- water loss only
-
Hypervolemic Hypernatremia
-
body has excess sodium and water
- sodium >>>>>>water
-
body has excess sodium and water
Hypernatremia General S/sxs and Causes
- S/sxs: polyuria, polydipsia, confusion, obtundation, stupor, tremor, rigidity, coma
- causes (free water deficit):
- dehydration
- incapable of obtaining water
- fever/infx/sweating/burn pts
- diabetes insipidus
- hyperglyuria/osmotic diuretics
- excessive sodium intake & cushing sx
Hypovolemic Hypernatremia
- when water loss >>>sodium loss
- causes: diarrhea, sweating, diuretics
- tx: d/c diuretics or laxatives
-
if symptomatic: initially 200-300ml/hr with NS (to achieve hemodynamic stability)
- replace free water deficit: D5W, ½ NS or a combo
- asymptomatic: D52, ½ NS, or a combo
-
if symptomatic: initially 200-300ml/hr with NS (to achieve hemodynamic stability)
Isovolemic Hypernatremia
aka euvolemic hypernatremia
water loss only
- causes:
-
Diabetes insipidus:
- central DI = decreased ADH production
- Nephrogenic DI = decreased renal response to ADH
- drug induced DI:
- aminoglycosides, Ampho B, cochicine, demeclocycline (used to tx chronic euvolemic hyponatremia)
-
Diabetes insipidus:
- Tx:
- initially: D5W (replace free water)
-
chronically:
- for central DI: desmopressin (DDVAP) b/c it is a synthetic analog to ADH → act on the V2-receptors of collecting duct → water reabsorption
- for nephrogenic DI: NSAIDs [can cause euvolemic hyponatremia] (indomethacin, IBU, naproxen, diclofenac, ketoprofen) and thiazides
NSAIDs and Sodium
NSAIDs reduce renal prostaglandins
and prostaglandins inhibit the action of ADH
so NSAID use can increase action of ADH and cause increased water reabsorption
Desmopressin (DDVAP)
synthetic analogue of ADH
Act on V2-receptors at the collecting duct → reabsorption of water
used to tx central diabetes insipidus → the underlying pathophys behind isovolemic hypernatremia
Hypervolemic Hypernatremia
body has excess sodium and water
sodium >>>> water
- causes:
- renal failure
- Tx:
- replace intravascular deficit if necessary (use D5W, ½ NS or a combo)
- loop diuretics (if making urine) (increases sodium excretion)
- hemodialysis
Factors affecting K distribution
Potassium Roles and Levels
Normal Serum 3.5-5 mEq/L
- intracellular: for each 1 mEq decrease in serum K below 3.5, total body deficit = 100-400 mEq
-
Roles: maintain membrane potential
- muscle contraction
- nerve transmission
- glycogen formation
- protein synthesis
Hypokalemia S/sxs and Causes
- S/sxs: muscle weakness, decreased tendon reflex, myalgias, HTN EKG abnormalities, cardiac, arrhythmias, predisposition to digitalis toxicity
- Causes:
- inadequate intake
- excessive loss: diarrhea, vomiting, NG suction
- cellular shifting-DKA
- refeeding syndrome
- drugs
- LAXATIVES, STEROIDS, AMPHO B, STEROIDS, ***LOOP DIURETICS***
Hypokalemia Tx
When to tx? <3.5 mEq/L and/or pt is symptomatic
- treatment:
- oral: K-chloride, KPO4, K-acetate, K-citrate, k-gluconate
- IV: if >10 mEq/L should be monitored via telemetry
- other: diuretic induced (spironolactone- K+ sparing diuretic)
- correct hypomagnesemia
- ****low magnesium makes body resistant to K+ replacement, so tx mg deficiency first or concurrently*****
- correct acid-base imbalance
- correct hypomagnesemia
- oral: K-chloride, KPO4, K-acetate, K-citrate, k-gluconate
Hyperkalemia s/sxs and causes
- S/sxs (Clinical Discovery):
- >5.5mEq/L = peaking T waves, prolongation of PR
- 7-8 mEq/L = prolonged QRS complex, Vfib
- 8-10 mEq/L = complete heart block, asystole
- Causes: massive tissue damage, blood stored for prolonged periods, salt substitute (KCl), Addison Disease
- drugs:
- K sparing diuretics (spironolactone, eplerenone), K supplements, Abx with K salts (Penicillin VK), ACE-I, ARBs, NSAIDs
- drugs:
Hyperkalemia Tx
-
Symptomatic (urgent/emergent)
- IV calcium to stabilize the heart membrane
- insulin +/- glucose/dextrose to temporarily push K+ back into the cell
- albuterol to also temporarily push K+ back into the cell
- Sodium bicarb to be considered to tx acidosis
- Eliminate Source: IV, total parenteral nutrition (TPN), tube feeds, oral supplements, K sparing diuretics
-
Symptomatic:
- sodium polystyrene sulfonate (Kayexelate) → binds potassium, slower onset, but duration of 4-6 hours (constipation though…)
- Loop diuretics (lasix)
-
Asymptomatic;
- eliminate source
- kayexelate (sodium polystyrene sulfonate) → binds potassium
- loop diuretics
Loop Diuretics
- Bumetadine
- Ethacrynic acid
- Furosemide
- Torsemide