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Therapeutics II > Electrolytes (Na) > Flashcards

Electrolytes (Na) Flashcards

1
Q

Electrolyte concentrations in body fluids

A

-sodium outside (ECF)
-potassium inside (ICF)

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2
Q

Goals of electrolyte therapy

A

-prevent/treat serious complications
-normalize serum concentration
-identify and correct underlying causes
-avoid overcorrection

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3
Q

Sodium 135-145 mEq/L

A

-primary extracellular cation
-needed to maintain cellular integrity
-maintains osmolar gradient = regulate fluid homeostasis

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4
Q

HYPOnatremia

A

-most common electrolyte disturbance in hospital
-brain injury (seizure/death)
-too rapid correction of sodium (demyelination)
-acute effects of HYPO-osmolality
-big time morbidity and mortality

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5
Q

Classification of HYPOnatremia

A

-Na+ < 135 mEq/L
-what’s tonicity?
-what’s volume status

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6
Q

Osmolality

A

-275-290 mOsm/L
-number of particles per liter of water
-measure or estimate

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7
Q

Serum Osmolality calculation

A

Osm = (2*Na) + (BUN/2.8) + (Glucose/18)

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8
Q

ISOtonic hyponatremia (pseudohyponatremia)

A

-extreme elevations of lipid and proteins increase total plasma volume
-seen with hypertriglyceridemia or hyperproteinemia
-leads to dilution effect
-sodium appears low (just displaced)
-measured Osm not really affected
-Calculated Osm is low due to low sodium
=osmolality gap

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9
Q

Hypertonic Hyponatremia

A

-often seen with elevated Blood glucose (>120-140)
->290mOsm

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10
Q

Corrected Serum Sodium

A

-serum sodium falls by 1.6 mEq/L per 100mg/dL increase in BG over 100mg/dL

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11
Q

Corrected Serum sodium equation

A

Serum Na + 1.6((BG-100)/100))

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12
Q

Hypotonic Hyponatremia classification

A

-must check volume status to classify
->90% of all hyponatremia

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13
Q

HYPOvolemic Hypotonic hyponatremia

A

-TBW and Na+ dec
-RENAL causes (urine Na+ > 20mEq/L)
-NON-Renal causes (urine <20 mEq/L)

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14
Q

Renal Causes of HYPOvolemic hypotonic hyponatremia

A

-lots of Na+ in urine (>20mEq/L)
-diuretics
-adrenal insufficiency (mineralcorticoid deficiency)
-salt losing nephropathy
-cerebral salt wasting

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15
Q

Non-renal Causes of HYPOcvolemic hypotonic hyponatremia

A

-blood loss/ hemorrhage
-skin losses (burn/sweat/wound)
-GI losses (vomit, diarrhea, suction)

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16
Q

Isovolemic hypotonic hyponatremia

A

-TBW inc
-Na+ normal or slight inc
-slight excess of ECF
-no peripheral or pulmonary edema
-appears euvolemic

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17
Q

Isovolemic Hypotonic hyponatremia causes

A

-adrenal insufficiency (glucocorticoid defic)
-HYPOthyroidism
-psychogenic polydipsia
-SIADH

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18
Q

Syndrome of Inappropriate AntiDiuretic Hormone release (SIADH)

A

-most common cause of isotonic hypo hyponatremia
-water intake exceeds kidney ability to excrete water

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19
Q

causes of SIADH

A

-tumors
-CNS disorders
-DRUGS

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20
Q

Possible Drug-Induced SIADH

A

-antineoplastics (cyclophosphamide and vincristine)
-antipsyc**
-bromocriptine
-carbamazepine*
-chlorpropamide
-desmopressin
-meperidine/morphine
-nictoine
-NSAIDs (ibuprofen)
-oxytocin
-fluoxetine/sertraline**
-TCAs (amitryptyline)
-Imipramine
-Tolbutamide

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21
Q

Treatment of SIADH

A

-remove underlying cause
1. free water restrivtion
2. Vaptans if 24-48 hours of free water restriction fails (conivaptan and tolvaptan)

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22
Q

Hypervolemic Hypotonic hyponatremia

A

-TBW and Na+ inc
-expanded ECF volume and edema

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23
Q

Hypervolemic Hypotonic Hyponatremia seen in

A

-Cirrhosis
-Heart failure
-Kidney Failure (acute/chronic)
-nephrotic syndromes

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24
Q

Clinical presentation of hypotonic hyponatremia

A

-mostly asymptomatic (Na+> 125 mEq/L
-HYPO = dehydration
-Hyper = Edema

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25
Q

Hypovolemic hypotonic hyponatremia presentation

A

-dehydration
-dec skin turgor
-orthostatic HTN
-tachycardia
-dry membranes

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26
Q

Presentation of isovolemic hypotonic hyponatremia

A

-malaise
-psychosis
-seizures
-coma

27
Q

Presentation of hypervolemic hypotonic hyponatremia

A

-edema
-weight gain

28
Q

presentation of acute hyponatremia

A

-over 12 hours or less
-nausea
-malaise
-weakness
-headache
-disoriented
-coma
-seizure
-respiratory arrest

29
Q

Goals of HYPOvolemic tx

A

-restore volume deficit

30
Q

Isovolemic or Hypervolemic tx goals

A

-underlying cause?
-symptoms?

31
Q

IMPORTANT note about treatment

A

-in most cases, do not correct sodium higher than 0.5 mEq/L/hr or no more than NMT 8-12 mEq/L/day

32
Q

Hypovolemix tx options

A

-symptomatic: 3% NaCl (HYPERtonic)
-asymptomatic: 0.9% NaCl (isotonic)

33
Q

Isovolemic tx

A

-symptomatic: furosemide + 3% NaCl
-asymptomatic: 0.9% NaCl and water restriction

34
Q

Hypervolemic tx

A

-symptomatic: furosemide and JUDICIOUS 3% NaCl
-asymp: furosemide

35
Q

Acute Hyponatremia

A

-less than 48 hours
-brain cells swell w water
-cerebral edema
-severe neurologic sx
-brain herniation
-death

36
Q

Chronic Hyponatremia

A

-more than 48 hours
-brain cells extrude solutes
-minimal brain swelling
-mild neurologic sx
-brain herniation is rare
-death rare

37
Q

Acute Symptomatic Hyponatremia

A

-severe: mental status and seizures
-metabolic encephalopathy can develop: (edema, inc pressure, herniation, fatal sometimes)
-tx immediately

38
Q

Treatment of Acute Symptomatic Hyponatremia

A

-inc serum Na+ by 1-2 mEq/L/hr until symptoms resolve
-HYPERtonic saline (3% NaCl)
-replace half of sodium deficit in 8 hours then remaining deficit (half the rate) within 8-16 hours (rules of 8s)
-goal: 120mEq/L***
-complete correction unnecessary
-inc of 4-6 mEq/L is usually good
-MAX 8-12 mEq/L in first 24 hours

39
Q

Too rapid correction of acute symptomatic hyponatremia

A

-diffuse demyelinating lesions
-central pontine myelinolysis

40
Q

Risk v benefit

A

-risk of cerebral edema from hyponatremia better than risk of demyelination from overcorrecting

41
Q

Demyelination Risk Factors

A

-serum Na < 105 mEq/L
-Hypokalemia
-alchoholism
-malnutrition
-liver disease

-hypoxemia
-cancer
-burns
-diabetes
-renal failure
-sodium inc too fast

42
Q

Acute Symptomatic Hyponatremia Monitoring

A

-in ICU or equiv
-exam heart, lungs, neurological status several times over first 12 hours
-serum Na+ q2-4h until asymptomatic then q6-8h until WNL

43
Q

Pharmacist’s role on serum Na+

A

-manage acid base/electrolyte status and IVF

44
Q

HYPERnatremia

A

-always HYPERtonic
-impaired thirst response in infants, elderly, disabled
-result of loss of water or ingestion of sodium/hypertonic fluids
-must assess volume status

45
Q

Classification of HYPERnatremia

A

-Hypovolemic
-Isovolemic
-Hypervolemic

46
Q

HYPOvolemic HYPERnatremia tx goals

A

-restore hemodynamic status first if needed (0.9%NaCl)
-once IV volume restored:
-calc free water deficit

47
Q

Free Water Deficit

A

NL TBW * ((serumNa/140)-1)

48
Q

Replacing Free Water Deficit

A

-provide free water
-match I/O if possible
-don’t correct too quickly
-adjust as needed
-goal: 0.5 mEq/L/hr decrease in serum Na

49
Q

Providing free water

A

-D5W continuous infusion
-enteral free water via feeding tube

50
Q

Don’t correct free water too quickly (HYPOvolemic HYPERnatremia)

A

-give 1/2 total deficit over 24 hours
-give remaining over next 24-48 hours
-adjust as needed

51
Q

Monitoring Parameters for HYPOvolemic Hypernatremia

A

-check serum Na and fluids q 3-6h for first 24 hours
-then q6-12h after sx resolve and Na <145
-I/O q 8-12h
-overall fluid balance q24h

52
Q

look at calculations

A

weights too

53
Q

Isovolemic Hypernatremia (diabetes)

A

-Central: (brain injury, CNS, meningitis)
-Nephrogenic (drugs, radiocontrast dies, ATN, inherited)

54
Q

Isovolemic Hypernatremia treatment

A

-Desmopressin (DDAVP)
-Vasopressin

55
Q

Desmopressin (DDVAP)

A

-treat ISOvolemic HYPERnatremia
-acute: admin subq or IV 0.25-0.5mL BID
-chronic: intranasal 0.05-0.2mL BID

56
Q

Vasopressin

A

-tx acute ISOvolemic Hypernatremia
-continuous infusion titrated hourly to goal UOP

57
Q

HYPERvolemic hypernatremia causes

A

-uncommon from hypertonic fluids
-hypertonic saline resuscitation
-excess NaHCO3 admin
-too much dietary salt

58
Q

Hypervolemic Hypernatremia treatment

A

-stop hypertonic fluids/cause
-rapidly excreted
-diuretic if needed
-match I/O

59
Q

Change in serum Na equation

A

(fluid Na - serum Na)/(TBW + 1L)
-estimates change in serum sodium per one liter of any given fluid
-can calculate for inc or dec in sodium
-determine change prn for goal time period

60
Q

HYPOvolemic HYPERnatremia

A

-loss of water
-TBW and Na LOW
-renal, Gi, adrenal, lung, skin

61
Q

ISOvolemic HYPERnatremia

A

-TBW low
-Na fine
-diabetes, skin loss, latrogenic, osmotic diuresis, polydipsia

62
Q

HYPERvolemic HYPERnatremia

A

-TBW and Na HIGH
-mineralcorticoid excess

63
Q
A

Therapeutics II (20 decks)

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