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Advanced Medical Nutrition Therapy II > Fluid and Electrolyte Management with Parenteral Nutrition > Flashcards

Fluid and Electrolyte Management with Parenteral Nutrition Flashcards

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USMLE® Step 1 flashcards
1
Q

Total body water makes up between ____-____% of body weight

A

50-60

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2
Q

What makes up total body water?

A

-Extracellular fluid (1/3 TBW)
-Intracellular fluid (2/3 TBW)
-Transcellular fluid (<3% TBW)

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3
Q

Extracellular fluid is made up of…

A

-Interstitial space (3/4 ECF)
-Intravascular space (1/4 ECF)

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4
Q

How to calculate total body water in women:

A

Weight in kg x 0.5

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5
Q

How to calculate total body water in men:

A

Weight in kg x 0.6

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6
Q

What factors affect total body water?

A

-Fat (total body water decreases with increasing body fat)
-Age (muscle mass declines and the proportion of fat increases, causing total body water to decrease)
-Sex (women have higher body fat than men, causing lower total body water)

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7
Q

____ ____ is the pressure required to maintain equilibrium with no net movement of solvent

A

Osmotic pressure

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8
Q

Osmotic pressure is a prime importance in determining the distribution of water between the ____ and ____

A

ECF and ICF

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9
Q

The ECF and ICF both contain a major active ____ that determines the osmotic pressure

A

Solute

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10
Q

____ is the dominant extracellular osmole holding water in the extracellular fluid

A

Sodium

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11
Q

_____ is the primary intracellular osmole holding water within the cells

A

Potassium

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12
Q

The activity of the sodium-potassium-ATPase pump allows for the maintenance of these ____ ____ of the EFC and ICF

A

Solute composition

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13
Q

_____ IV solutions are solutions that supply water, sodium, and/or dextrose

A

Crystalloids

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14
Q

Crystalloids contain small molecules that flow easily from the blood into ___ and ___

A

Cells and tissues

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15
Q

What are examples of crystalloid IV solutions?

A

–NS
-1/2 NS
-D5W
-D10W
-Lactated ringer

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16
Q

____ are another type of IV solution that contain proteins or carbohydrates

A

Colloids

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17
Q

Colloid IV solutions ____ intravascular oncotic pressure and move fluid from the interstitial space to the intravascular space

A

Increase

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18
Q

What are examples of colloid IV solutions?

A

-5% albumin
-25% albumin

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19
Q

With free water (such as DW5->no electrolytes), the free water distributes evenly across all ____ (2/3 ICF, 1/3 ECF)

A

Compartments

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20
Q

With isotonic IV solutions (such as NS or LR-> contains electrolytes), 100% of the solution will stay in the ____ space

A

Extracellular

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21
Q

Plasma ____ and ____ pressures govern the movement of fluid between the intravascular and interstitial spaces

A

Oncotic and hydrostatic

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22
Q

Disruption in oncotic and/or hydrostatic pressure results in a flow of fluid from one ____ to another

A

Compartment

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23
Q

When the disruption in oncotic and/or hydrostatic pressure favors a shift from intravascular to interstitial fluid, ____-____ occurs

A

Third-spacing

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24
Q

Fluid intake is made up by anything that is ____ at room temperature

A

Liquid

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25
Q

Fluid losses are made up of…

A

-Sensible losses: visible and measurable
-Insensible: usually not seen or measured

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26
Q

How can we assess hydration status?

A

-Daily weights
-I/O records
-Physical evaluation of skin, eyes, lips, and oral cavity
-Evaluation of respiratory rate and lung sounds
-Blood pressure
-Assessment for peripheral edema

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27
Q

What is an energy-based formula to estimate fluid needs?

A

1 mL per kcal

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28
Q

What are some weight-based formulas for determining fluid needs?

A

-Ages 18-55 years: 35 mL/kg
-Ages 56-75 years: 30 mL/kg
-Age >75 years: 25 mL/kg
-Fluid restriction in adults: <25 mL

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29
Q

Another weight-based formula for determining fluid needs is the ____-____ formula

A

Holiday-Segar

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30
Q

Holiday-Segar formula:

A

-Age 50 and younger: 1500 mL for first 20 kg body weight + (20 mL x remaining kg body weight)
-Over 50: 1500 mL for first 20 kg body weight + (15 mL x remaining kg body weight)

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31
Q

With weight-based formulas, the use of an ___-___ weight should be used to calculate the fluid needs in obese patients to account for their increased percentage of body fat

A

Obesity-adjusted

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32
Q

What are some conditions that increase fluid needs?

A

-Severe diarrhea or emesis
-Large draining wound
-Excessive diaphoresis
-Paracentesis losses
-High gastric fistula
-High ostomy output
-Persistent fever
-Lactating women

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33
Q

What are some conditions that decrease fluid needs?

A

-Renal dysfunction
-CHF
-Hypothyroidism
-Edema

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34
Q

A disturbance of ____ is caused by a gain or loss of fluid (water and solute such as sodium)

A

Volume

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35
Q

Outcome of a disturbance in volume…

A

-Hypovolemia
-Hypervolemia

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36
Q

A disturbance in ____ is caused by a gain or loss of water alone

A

Concentration

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37
Q

Outcome of a disturbance in concentration…

A

-Dehydration
-Overhydration

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38
Q

A disturbance in _____ is caused by a gain or loss of electrolytes

A

Composition

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39
Q

Outcome of a disturbance of electrolytes…

A

-Electrolyte disorders

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40
Q

Volume depletion is caused by a loss of water and solute from…

A

-GI tract
-Skin
-Urine
-Prolonged inadequate intake

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41
Q

Symptoms of volume depletion:

A

-Dry oral mucosa
-Poor skin turgor
-Tachycardia
-Hypotension

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42
Q

Treatment for volume depletion is prescribed based on underlying cause for fluid deficit; in sever cases, someone would require replacement of ECF losses which requires ____ solution (NS or LR)

A

Isotonic

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43
Q

Dehydration, or loss of water alone, is recognized by a change in…

A

-Serum sodium concentration
-Plasma osmolality

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44
Q

Causes of dehydration:

A

-Diabetes insipidus
-Prolonged fever
-Watery diarrhea
-Hyperglycemia

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45
Q

Treatment for dehydration:

A

-Provision of free water (ex: 5% dextrose solution)-> expands both fluid compartments, predominantly in the ICF

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46
Q

_____, or volume overload, involves water retention with a decrease in body sodium concentrations

A

Hypervolemia

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47
Q

Causes of hypervolemia:

A

-Decreased urinary output
-Excessive IVF

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48
Q

Symptoms of hypervolemia:

A

-Weight gain
-Edema
-Ascites
-Elevated blood pressure
-Pulmonary edema

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49
Q

Treatment for hypervolemia:

A

-Correction of underlying cause
-Limitation of sodium and fluid intake
-In some cases, diuretic therapy may be required

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50
Q

The first step in treating electrolyte disorders is a review of clinical ___; if inconsistent, the accuracy of the specimen should be validated

A

Labs

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51
Q

Treatment for electrolyte levels above the normal range:

A

-Remove exogenous sources
-Discontinue offending agents of meds
-Facilitate elimination of electrolyte
-Treat condition that may be contributing

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52
Q

Treatment for electrolyte levels below the normal range:

A

-Electrolyte replacement

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53
Q

What are some treatment considerations for electrolyte replacement?

A

-Available administration routes
-GI tract function
-Renal functions
-Fluid status
-Product availability
-Concurrent electrolyte abnormalities

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54
Q

Normal range for serum sodium:

A

135-145 mEq/L

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55
Q

Sodium is the principle ____ in the extracellular fluid

A

Cation

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56
Q

Functions of sodium:

A

-Major osmotic determinant in regulating extracellular fluid volume and water distribution in the body
-Determining membrane potential of cells
-Active transport of molecules across cell membranes

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57
Q

The ____ play a pivotal role in sodium balance

A

Kidneys

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58
Q

_____ is when serum sodium is less than 135 mEq/L

A

Hyponatremia

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59
Q

Symptoms of hyponatremia:

A

-Headache
-Nausea
-Vomiting
-Muscle cramps
-Lethargy
-Restlessness
-Disorientation
-Depressed reflexes
-Seizures
-Coma

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60
Q

Clinical manifestations of hyponatremia related to CNS dysfunction are more likely to occur when serum Na+ drops rapidly and when it falls below ____ mEq/L

A

125

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61
Q

Clinicians should determine the patient’s serum Na+ concentration and volume status to determine the ____ of hyponatremia

A

Etiology

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62
Q

Serum osmolality can be measured or it can be calculated with what formula?

A

Serum osmolality = 2 x [(serum Na + serum glucose/18) + (BUN/2.8)]

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63
Q

Classifications of types of hyponatremia differ in whether serum ____ is low, normal, or high

A

Osmolarity

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64
Q

____ hyponatremia is characterized by low serum osmolarity (<275)

A

Hypotonic

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65
Q

Hypotonic hyponatremia can be caused by…

A

-Volume depletion
-Syndrome of inappropriate antidiuretic hormone
-Congestive heart failure
-Cirrhosis

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66
Q

____ hyponatremia is characterized by normal serum osmolarity (275-300)

A

Isotonic

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67
Q

Isotonic hyponatremia can be caused by…

A

-Hyperglycemia
-Hyperlipidemia

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68
Q

_____ hyponatremia is characterized by high serum osmolarity (>290)

A

Hypertonic

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69
Q

Hypertonic hyponatremia can be caused by…

A

Severe hypoglycemia with dehydration

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70
Q

What are three types of hypotonic hyponatremia?

A

-Hypovolemic hypotonic hyponatremia
-Hypervolemic hypotonic hyponatremia
-Euvolemic hypotonic hyponatremia

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71
Q

With hypovolemic hypotonic hyponatremia, patients lose more ____ in relation to ____

A

Sodium; water

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72
Q

What causes hypovolemic hypotonic hyponatremia?

A

Renal and extrarenal losses

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73
Q

Treatment for hypovolemic hypotonic hyponatremia:

A

Isotonic fluids

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74
Q

With hypervolemic hypotonic hyponatremia, patients retain more ____ than ____

A

Water; sodium

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75
Q

Cause of hypervolemic hypotonic hyponatremia:

A

Some element of end-organ failure resulting in fluid retention or third spacing

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76
Q

Treatment for hypervolemic hypotonic hyponatremia:

A

Fluid and sodium restriction

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77
Q

With euvolemic hypotonic hyponatremia, total body water is ____, causes a low concentration of sodium

A

Increased

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78
Q

Euvolemic hypotonic hyponatremia is commonly associated with ____ ____ ____ ____

A

Syndrome of inappropriate antidiuretic hormone

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79
Q

Patients with syndrome of inappropriate antidiuretic hormone have stable sodium intake/output, but retain additional ____ because of excessive levels of antidiuretic hormone

A

Water

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80
Q

Other causes of euvolemic hypotonic hyponatremia:

A

-Psychogenic polydipsia
-Hypothyroidism
-Reset osmostat

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81
Q

With euvolemic hypotonic hyponatremia, urine osmolality is always ____ than serum osmolality and urine sodium is over 20 mEq/L

A

Greater

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82
Q

When urine osmolality is greater than serum osmolality, this indicates that the kidneys are inappropriately ____ urine and volume status is adequate

A

Concentrating

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83
Q

The treatment for euvolemic hypotonic hyponatremia is…

A

-Treatment of underlying causes
-Fluid restriction

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84
Q

Hypernatremia is diagnosed with a serum sodium over ____ mEq/L

A

145

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85
Q

Symptoms of hypernatremia:

A

-Mild: headache, dizziness, confusion
-Severe: seizures, coma, death

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86
Q

___ status is the first step in diagnosing hypernatremia

A

Volume

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87
Q

All hypernatremia is ____

A

Hypertonic

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88
Q

With hypovolemic hypernatremia, patients lose more ____ than ___

A

Water than sodium

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89
Q

With hypovolemic hypernatremia, patients have above-normal serum ____

A

Osmolality

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90
Q

Cause of hypovolemic hypernatremia:

A

Renal and extrarenal losses

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91
Q

Treatment for hypovolemic hypernatremia:

A

Hypotonic fluids (Ex: D5) via enteral or parenteral route

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92
Q

With euvolemic hypernatremia, total body water ____

A

Decreases

93
Q

With euvolemic hypernatremia, patients have ____ losses that exceed ____ losses

A

Water; sodium

94
Q

Cause of euvolemic hypernatremia:

A

Diabetes insipidus

95
Q

Treatment for euvolemic hypernatremia:

A

-Replacement of water via enteral or parenteral route
-Normalization of serum calcium and potassium

96
Q

With hypervolemic hypernatremia, patients retain more ____ than ____

A

Sodium than water

97
Q

Hypervolemic hypernatremia can be caused by…

A

-Iatrogenic: excessive administration of isotonic or hypertonic sodium
-Mineralocorticoid excess: Cushing’s syndrome or adrenal malignancy

98
Q

Treatment for hypervolemic hypernatremia:

A

-Correcting the underlying issue
-Administering diuretics
-Replacing water

99
Q

A potentially useful equation for hypernatremia is the free water deficit equation, which is…

A

Free body water (L)= TBW x [1-(140/serum Na)]

100
Q

The normal range for serum potassium is ___-___ mEq/L

A

3.5-5.0

101
Q

Functions of potassium:

A

-Plays a critical role in cell metabolism, including protein and glycogen synthesis
-Maintains resting membrane potential (abnormal concentrations-> EKG changes)

102
Q

Normal daily requirements for potassium are ___-___ mEq/kg

A

0.5-2

103
Q

It is important to remember that magnesium is a co-factor for the sodium-potassium-ATPase pump; therefore, hypomagnesemia can lead to refractory _____

A

Hypokalemia

104
Q

The H+/K+ ATPase pump allows potassium to shift in/out of the cell in exchange for ____

A

Hydrogen

105
Q

With ____ ____, there are too many H+ ions in the plasma; the body corrects by moving H+ back into the cell and pumping K+ outside of the cell, leading to hyperkalemia

A

Metabolic acidosis

106
Q

With ____ ____, there are not enough H+ ions in the plasma; the pump moves H+ ions outside of the cell into the plasma and K+ will move into the cell, leading to hypokalemia

A

Metabolic alkalosis

107
Q

Causes of hypokalemia:

A

-Abnormal losses via urine and stool
-Inadequate intake
-Transcellular shifts from extracellular fluid into cells (metabolic alkalosis, increases in insulin and catecholamines)
-Medications

108
Q

Clinical symptoms of hypokalemia:

A

-Generalized weakness
-Lethargy
-Constipation
-More severe consequences: muscle necrosis, paralysis, arrhythmias, death

109
Q

Treatment goals of hypokalemia:

A

-Avoidance/resolution of symptoms
-Restoring serum K+ to normal
-Preventing hyperkalemia

110
Q

What drugs cause renal losses of potassium and lead to hypokalemia?

A

-Diuretics (thiazides, bumetanide, furosemide)
-Fludrocortisone
-Glucocorticoids
-Drugs associated with magnesium depletion (Aminoglycosides, Cisplatin, Amphotericin B)

111
Q

What drugs cause potassium losses in stool and lead to hypokalemia?

A

-Sodium Polystyrene
-Sulfonate
-Sorbitol

112
Q

What drugs cause a shift of potassium from the extracellular fluid to the intracellular fluid and lead to hypokalemia?

A

-B-antagonist (Albuterol, Epinephrine)
-Insulin
-Theophylline
-Caffeine

113
Q

Treatment of hypokalemia:

A

Oral or IV potassium supplements

114
Q

Oral correction of hypokalemia is generally safer and reduces the risk of ____ ____

A

Rebound hyperkalemia

115
Q

IV supplementation of potassium is reserved for the treatment of severe hypokalemia or when the condition of the ____ ___ precludes use of oral agents

A

GI tract

116
Q

Infusion rates of potassium typically will not exceed ___-___ mEq/hr

A

10-20

117
Q

With rates of IV potassium infusion higher than 10 mEq/hr, continuous ____ monitoring is recommended to detect signs of hyperkalemia

A

Cardiac

118
Q

If possible, ____ solutions should be avoided if someone has hypokalemia

A

Dextrose

119
Q

If someone has hypokalemia, _____ deficiencies should also be corrected

A

Magnesium

120
Q

What are some commonly used oral K+ replacements?

A

-Potassium Chloride (K-Lor: 20 mEq/packet)
-Potassium Phosphate (K-Phos tablet: 500 mg; Phos-NaK: 250 mg)

121
Q

IV K+ supplements are available in ____, ____, and _____ salts

A

Chloride, acetate, and phosphate

122
Q

It is recommended that if someone’s serum potassium is between 3-3.5, they should receive between ___-___ mEq of IV potassium

A

20-40

123
Q

It is recommended that if someone’s serum potassium is between 2.5-2.9, they should receive between ___-___ mEq of IV potassium

A

40-80

124
Q

It is recommended that if someone’s serum potassium is less than 2.5, they should receive between ___-___ mEq of IV potassium

A

80-120

125
Q

If someone with hypokalemia also has renal insufficiency, we should decrease the dose of K+ replacement by ____%

A

50

126
Q

A rule of thumb is that 10 mEq K+ replacement should increase serum K+ by ____

A

0.1

127
Q

A diagnosis of hyperkalemia is made when serum potassium is over ____ mEq/L

A

5

128
Q

Causes of hyperkalemia:

A

-Most often occurs in CKD
-Shifts in K+ from intracellular fluid to extracellular fluid (metabolic acidosis, tissue catabolism, pseudohyperkalemia)
-Increased K+ intake alone rarely caused hyperkalemia
-Medications

129
Q

Clinical presentation of hyperkalemia:

A

-Muscle twitching
-Cramping
-Weakness
-Paralysis
-Arrhythmias
-Cardiac arrest

130
Q

Treatment goals for hyperkalemia:

A

-Prevent cardiac effects
-Reversing symptoms
-Returning serum K+ to normal

131
Q

What drugs can cause impaired renal potassium excretion and cause hyperkalemia?

A

-Potassium-sparing diuretics
-NSAIDs
-ACE-inhibitors
-ARBs
-Cyclosporine
-Tacrolimus
-Everolimus
-Heparin

132
Q

What drugs cause increased Potassium input, leading to hyperkalemia?

A

-Potassium supplements
-Salt substitutes
-Stored packed red blood cells

133
Q

What drugs cause a shift of potassium from the intracellular fluid to the extracellular fluid, leading to hyperkalemia?

A

-Beta-blockers
-Succinylcholine
-Digoxin intoxication

134
Q

Treatment of hyperkalemia can be accomplished by…

A

-Discontinuation of all exogenous K+ sources and medications that can cause hyperkalemia (if feasible)
-Consider the use of loop or thiazide diuretics

135
Q

In asymptomatic hyperkalemia patients, we can use…

A

-Sodium bicarbinate (50-100 mEq)
-Dextrose infusion (25-100 gm with 5-10 units of insulin)

136
Q

In symptomatic hyperkalemia patients or those with EKG changes, we can use…

A

-IV calcium gluconate: 1-2 gm

137
Q

The normal range for serum magnesium is between ____-____ mg/dL

A

1.8-2.4

138
Q

Magnesium is predominantly found in the _____ fluid

A

Intracellular

139
Q

Magnesium is essential in the activation of >300 _____ reactions such as glucose metabolism, fatty acid synthesis and breakdown, and DNA and protein metabolism

A

Enzymatic

140
Q

Magnesium is a ___-___ for the sodium-potassium ATPase pump

A

Co-factor

141
Q

Magnesium is regulated by the…

A

-GI tract
-Kidney
-Bone

142
Q

Absorption of magnesium occurs primarily in the ____ ____ and ____

A

Distal jejunum and ileum

143
Q

Hypomagnesemia is diagnosed with a serum magnesium level under ____ mg/dL

A

1.8

144
Q

Causes of hypomagnesemia:

A

-Decreased absorption or intake (protein-calorie malnutrition, malabsorption syndromes, alcoholism, short bowel syndrome)
-GI or renal losses (acute tubular necrosis. hyperaldosteronism, drug-induced)
-Intracellular shifts (refeeding syndrome, diabetic ketoacidosis, hyperparathyroidism, MI)

145
Q

Clinical presentation of hypomagnesemia:

A

-Neuromuscular hyperexcitability
-Cardiac complications
-May reduce insulin sensitivity

146
Q

Treatment for hypomagnesemia:

A

IV magnesium (IV preferred due to GI side effects of PO supplementation)

147
Q

What are commonly used oral magnesium replacements?

A

-Magnesium chloride (5 mEq)
-Magnesium gluconate (500 mg/2.4 mEq)
-Magnesium oxide (7-11 mEq)

148
Q

IV magnesium is given in the form of ____ ____

A

Magnesium sulfate

149
Q

If someone has a serum magnesium level between 1-1.5, we should supplement with ___-___ mEq, or <1 mEq/kg

A

6-32

150
Q

If someone has a serum magnesium level under 1, we should supplement with ___-___ mEq, or <1.5 mEq/kg

A

32-80

151
Q

We should decrease the dose of magnesium replacement by ____% if someone has renal insufficiency

A

50

152
Q

8 mEq of magnesium sulfate should increase serum magnesium by ____

A

0.1

153
Q

The maximum infusion rate of IV magnesium replacement is ____ mEq/hour

A

8

154
Q

Hypermagnesemia is diagnosed when serum magnesium is over _____ mg/dL

A

2.4

155
Q

Hypermagnesemia is primarily seen in the setting of ____ in combination with magnesium intake

A

CKD

156
Q

Hypermagnesemia is generally well tolerated, but levels above 4.8 mg/dL can affect…

A

-Neurologic function
-Neuromuscular function
-Cardiac function

157
Q

Treatment for hypermagnesemia:

A

-Asymptomatic patients: removal of exogenous sources of Mg, Mg restriction, loop diuretics
-Symptomatic patients: IV calcium

158
Q

The normal range for serum calcium is ____-___ mg/dL

A

8.6-10.2

159
Q

Calcium is one of the most abundant ____ in the body

A

Cations

160
Q

Calcium is essential for…

A

-Bone metabolism
-Nerve conduction
-Functionality of cell membranes
-Coagulation cascade
-Regulation of secretory functions

161
Q

99% of total body calcium is found in ___ and ____

A

Teeth and bones

162
Q

Serum calcium exists in what 3 forms?

A

-Complexed
-Protein-bound
-Ionized

163
Q

Hypocalcemia is diagnosed if someone has a serum calcium under ____ mg/dL or an ionized calcium under ___ mmol/L

A

8.6; 1.12

164
Q

Causes of hypocalcemia:

A

-Decreased vitamin D activity
-Decreased PTH activity
-Renal impairment
-Critical illness
-Medications: Bisphosphonates, calcitonin, furosemide, long-term use of phenobarbital and phenytoin

165
Q

Clinical presentation of hypocalcemia:

A

-Cardiovascular: hypotension
-Neuromuscular: muscle cramps, tetany, seizures

166
Q

Treatment for hypocalcemia:

A

Oral or IV replacement

167
Q

Treatment with oral ___ and ____ supplements is appropriate for asymptomatic hypocalcemia

A

Calcium and Vitamin D

168
Q

What are some commonly used oral calcium supplements?

A

-Calcium acetate: 25% elemental Ca
-Calcium carbonate: 40% elemental Ca
-Calcium citrate: 21% elemental Ca

169
Q

For acute symptomatic hypocalcemia, ____ treatment is recommended

A

IV

170
Q

What are some IV calcium treatment options?

A

-Ionized Ca 1-1.12 mmol/L: 1-2 g calcium carbonate over 1-2 hours
-Ionized Ca <1 mmol/L: 2-4 g calcium carbonate over 2-4 hours

171
Q

Hypercalcemia is diagnosed with serum calcium over ____ mg/dL or ionized calcium over ____ mmol/L

A

10.2; 1.3

172
Q

Causes of hypercalcemia:

A

-Hyperthyroidism
-Cancer with bone metastases
-Toxic levels of vitamin A or vitamin D
-Chronic ingestion of milk or calcium-containing antacids in the setting of renal insufficiency

173
Q

Clinical presentation of hypercalcemia:

A

-Fatigue
-Nausea/vomiting
-Anorexia
-Confusion
-Cardiac arrhythmias

174
Q

Treatment for mild hypercalcemia (10.3-11.9 mg/dL):

A

-Hydration
-Ambulation

175
Q

Treatment for severe hypercalcemia (>14 mg/dL):

A

-IV hydration using 0.9% NS at 200-300 ml/hour to reverse volume depletion caused by hypocalcemia
-Controversial treatment: once adequate hydration is achieved, 40-80 mg IV Furosemide to enhance renal Ca excretion
-Hemodialysis may be necessary

176
Q

The normal range for phosphorus is between ____-___ mg/dL

A

2.5-4.5 mg/dL

177
Q

Functions of phosphorus include…

A

-Bone and cell membrane composition
-Maintenance of normal pH
-Required in all cellular functions that require energy

178
Q

Most phosphorus is found in ___ and ____ ___

A

Bones and soft tissue

179
Q

Hypophosphatemia is diagnosed when serum phosphate levels are under ____ mg/dL

A

2.5

180
Q

Causes of hypophosphatemia:

A

-Chronic alcoholism
-Critical illness
-Respiratory and metabolic alkalosis
-Refeeding syndrome
-Phosphate binding medications

181
Q

Clinical presentation of hypophosphatemia:

A

-Neurologic: ataxia, confusion
-Neuromuscular: weakness, myalgia
-Cardiopulmonary: cardiac and ventilatory failure
-Hematologic: hemolysis

182
Q

Treatment of hypophosphatemia:

A

Oral or IV phosphate replacement

183
Q

With asymptomatic, mild hypophosphatemia, treatment is ____ phosphate supplements

A

Oral

184
Q

What are some commonly used oral phosphate supplements?

A

-K-Phos tablet: 500 mg
-Phos-NaK powder: 250 mg
-OsmoPrep tablet: 1.5 mg

185
Q

For symptomatic moderate/severe hypophosphatemia, the preferred treatment is ____ ____, unless the K+ concentration is >4 mEq/L or renal insufficiency exists

A

IV KPhos

186
Q

What are some examples of IV phosphate replacement?

A

-Serum phos 2.3-2.7 mg/dL: 0.08-0.16 mmol/kg
-Serum phos 1.5-2.2 mg/dL: 0.16-0.32 mmol/kg
-Serum phos <1.5 mg/dL: 0.32-1 mmol/kg

187
Q

The maximum infusion rate of IV phosphorus is ____ mmol/hour

A

7

188
Q

Hyperphosphatemia is diagnosed with a serum phosphate level over ____ mg/dL

A

4.5

189
Q

Causes of hyperphosphatemia:

A

-CKD
-Endogenous release of phosphorus into the extracellular fluid from cellular destruction (massive trauma, cytotoxic agents, hypercatabolism, hemolysis, malignant hyperthermia)
-Transcellular shifts from the intracellular fluid to the extracellular fluid (respiratory and metabolic acidosis)

190
Q

Clinical presentation of hyperphosphatemia:

A

-Anorexia
-Nausea
-Vomiting
-Dehydration

191
Q

Complications of hyperphosphatemia:

A

-Soft tissue and vascular calcification (occurs when total serum calcium x serum phosphorus exceed 55 mg/dL)
-Secondary hyperparathyroidism
-Renal osteodystrophy

192
Q

Treatment for hyperphosphatemia:

A

-Decrease or eliminate exogenous sources
-Phosphate binders
-Hemodialysis may be necessary

193
Q

If someone has hyperglycemia with blood glucose over ____ mg/dL, should you use caution with using parenteral nutrition

A

300

194
Q

If someone has azotemia with a BUN over ____ mg/dL, we should use caution with using parenteral nutrition

A

100

195
Q

If someone has hyperosmolarity with osmolarity over ____ mOsm/kg, we should use caution with using parenteral nutrition

A

350

196
Q

If someone has hypernatremia with serum sodium over ____ mEq/L, we should use caution with using parenteral nutrition

A

150

197
Q

If someone has hypokalemia with serum potassium under ____ mEq/L, we should use caution with using parenteral nutrition

A

3

198
Q

If someone has hypophosphatemia with serum phosphorus under ____ mg/dL, use caution with using parental nutrition

A

2

199
Q

If someone has hyperchloremic metabolic acidosis with chloride levels over ____ mEq/L, we should use caution with using parenteral nutrition

A

115

200
Q

If someone has hypochloremic metabolic alkalosis with chloride levels under ____ mEq/L, we should use caution with using parenteral nutrition

A

85

201
Q

The average adult daily requirement of sodium is ___-___ mEq/kg

A

1-2

202
Q

What factors increase sodium needs?

A

-Diarrhea
-Vomiting
-NG suction
-GI losses

203
Q

The average adult daily requirement of potassium is ___-___ mEq/kg

A

1-2

204
Q

What factors increase potassium needs?

A

-Diarrhea
-Vomiting
-NG suction
-Medications
-Refeeding
-GI losses

205
Q

The average adult daily requirement of calcium is ___-___ mEq

A

10-15

206
Q

Factors that increase calcium needs:

A

-High protein intake

207
Q

The average adult daily requirement of magnesium is ___-___ mEq

A

8-20

208
Q

What factors increase magnesium needs?

A

-GI losses
-Medications
-Refeeding syndrome

209
Q

The average adult daily requirement of phosphorus is ___-___ mMol

A

20-40

210
Q

What factors increase phosphorus needs?

A

-High dextrose intake
-Refeeding

211
Q

NS solution contains ____ mEq/L of sodium (1/2 NS contains half)

A

154

212
Q

1 gm magnesium =___ mEq/Mg

A

8

213
Q

1 gm calcium = ____ mEq

A

4.65

214
Q

1 mMol KPO4 contains ____ mEq potassium

A

1.47

215
Q

1 mMol NaPO4 contains ____ mEq sodium

A

1.33

216
Q

What should be included in the assessment for those on parenteral nutrition?

A

-Check for any fluid changes with IVFs and medications
-Check I/Os for increased/decreased output
-Check to see if PN goals are being met
-Check electrolytes
-Check for any nutrition changes

217
Q

We should monitor blood glucose every 6 hours until stable; if high, we can start with low dose sliding scale _____

A

Insulin

218
Q

If blood glucose is over ____, we can recommend increasing insulin in parenteral nutrition

A

180

219
Q

Initial dose of insulin should be ____ previous day’s sliding scale

A

2/3

220
Q

Grams of fat given per day should be monitored ____; if it has been over 3 weeks without lipids, recommend adding lipids

A

Daily

221
Q

We should monitor magnesium, potassium, and phosphorus daily until stable; if magnesium, potassium, and phosphorus are all low, recommend adding 100 mg of ____ daily for possible re-feeding therapy and give replacement therapy

A

Thiamine

222
Q

We should monitor serum CO2 daily; if over ____, evaluate for possible overfeeding

A

30

223
Q

We should monitor triglycerides at baseline, and then weekly; if over ___ at baseline, hold lipids and re-check in 1 week; if over ___ at repeat, consider giving minimal lipid dose to prevent EFAD

A

300; 400

224
Q

We should monitor body weight, electrolytes, ionized calcium, and prealbumin ___

A

Weekly

225
Q

We should monitor LFTs ____ until stable, and then monthly

A

Weekly

226
Q

If glucose is ____ or more mg/dL, stop TPN and run 1/2 NS at ordered TPN rate

A

400

227
Q

If glucose < 70 mg/dL, we should…

A

-Initiate D12
-Administer 1 amp, 50% dextrose
-Stop insulin

228
Q

If TNP is stopped taper rate by 1/2 x 1 hour, and then infuse ____ at the TPN rate until new bag is hung

A

D5 1/2 NS

229
Q

If TPN must be stopped suddenly, infuse ____ at TPN rate x 1 hour, then ____ at the TPN rate until new bag is hung

A

D10; D5 1/2 NS

Advanced Medical Nutrition Therapy II (19 decks)

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