Fluid and Sodium Flashcards
Hypervolemia
-SOB, chest heaviness, difficulty walking long periods of time
-Edema, crackles in lungs, elevated BP, JVD, Na (NLH)
Drug Induced Hypervolemia
- Corticosteroids
- NSAIDs
- Intravenous fluids
- DHP CCB
- Pioglitazone, rosiglitazone
got high PIN CD
Hypervolemia TX
-Correct underlying condition
-Sodium/Fluid RESTRICTION (1-2g/d)
-Diuretics (LOOPS)
-Renal replacement therapies (last resort)
Loop Diuretics Adverse Effects
- Intravascular volume depletion
- Hypotension
- Hypokalemia*
- Hypochloremic metabolic alkalosis (chronic use)
- Hyperglycemia
- Hyperuricemia
- Hypomagnesemia*
Monitor: JVD, weight, edema, pH, BP, CR, electrolytes
First Line LOOP
Furosemide
PO 20-80 mg, q8-12h
IV 10-40 mg, q6-12h
Hypovolemia
-Thirst, weakness, dizziness
-Weight loss, flat jugular vein, hypotension, tachycardia, dry mucous, HIGH CR BUN, no skin turgor
Drug Induce Hypovolemia
- Diuretics
- Laxatives
- Mannitol
Hypovolemia TX
-Underlying cause
-Replacement fluid
-Maintenance fluid
Oral: mild/modest, less invasive, no infection risk, slow correction, no oral if vomiting/mental
IV: severe, quick, risk of overcorrection/infection
Replacement Fluid
1L isotonic saline over 30min-1hr
Maintenance Fluid
Sum of urine output + insensible losses, 30-50 ml/hr (other losses)
Adults: IV fluid 25-30 ml/kg/day
-common: crystalloid, other colloid (more ae)
-0.9% NaCl, normal saline, ideal for most
Maintenance IV: 20-40 ml/kg/day
Hyponatremia
Na < 136
-lethargy, HA, NV, confusion, seizures, coma
SEVERE < 125
Hyponatremia TX
-Severe <125, with SX
acute
= emergency correction with 3% NaCl 100 ml IV bolus over 10 mins, may repeat 2x
chronic
= 0.9% NaCl or 3% NaCl 0.5-2 ml/kg/hr IV
no sx, but < 125
= correct Na at hourly rate of 0.5 mol/L
Hyponatremia TX
-Hypo, Eu, Hyper
Hypovolemic
-Treat cause, d/c agents, NS 0.9 1000 ml
Euvolemic
-Treat cause, fluid restriction 750-1500, loop, VRA, urea
Hypervolemic
-Optimize, fluid/salt restriction, loop, VRA
Chronic HypoNa Sensitive to Correction Rate
Do not correct Na+ > 6-10 mEq/L/day; 6 mEq/L/day if high risk for ODS (hypokalemia, alcoholism, malnutrition, or liver disease)
0.9 vs 3 % NaCl
0.9
- Na 154
- ideal for most
- metabolic acidosis (can happen)
3
- Na 513
- acute, rapid
- intensive monitoring, thrombophlebitis (central line prefer!), risk of ODS
Vasopressin Receptor Antagonists
-Short term hyponatremia
SHOULD NOT BE USED IN HYPOVOLEMIC HYPONA
-conivaptan (cirrhosis) (IV), tolvaptan (oral)
Goal for HYPONA
raise 6-10 med/L/day
(<=6 if ODS risk)
check Na every 2-4 hr if severe
avoid overcorrecting
Hypernatremia
Na > 145 (severe > 160)
-thirst, lethargy, muscle weakness, NVA, irritability, mental status
-hypotension/tachy if hypovolemic
Hypernatremia TX
1: free water orally
#2: acute D5W or 0.2% nacl in D5W, chronic 0.45% nacl
-then give 1 L over 1-2 hr, replace free water deficit
Check Na every 2-4 hrs
Euvolemic Hypernatremia Treatment
(diabetes insipidus)
Central DI
-desmopressin 10-20 mcg nasal spray daily
-oral 0.05 mg 2x/d, up to 1.2 1x/d
Nephrogenic DI
-HCTZ, Na restrict, water replacement
Desmopressin DI/AE
Drug Interactions:
-Heparin
-Carbamazepine
-Lithium
Adverse Effects:
-Hyponatremia or water intoxication
-Facial flushing
-Headache
-Rhinitis
-Injection site reactions
Hypervolemic Hypernatremia Treatment
- Loop diuretic (furosemide)
- IV D5W
- Provide hemodialysis as needed if renal failure
When to use Ethacrynic Acid?
WHEN PT HAS SULFA ALLERGY
0.9 NaCl NS
Hypovolemia, fluid resuscitation
0.45 NaCl NS
CHRONIC hypernatremia, maintenance
0.2 NaCl in 5 dextrose
ACUTE hypernatremia, maintenance
5 dextrose D5W
Acute hypernatremia
Lactated Ringers
Fluid resuscitation
-Preferred in trauma and surgery pts
Preferred Colloid
Albumin, for cirrhosis and nephrotic syndromes
SIADH causing meds for Euvolemic HypoNa
-SSRI/SNRI, tricyclic
-Haloperidol/phenothiazines
-Carb
-Anticancer (vinca, cis, cyclo)
-Opiates, Nicotine
Urea (Ure-Na)
30-60 g/day
-osmotic diuresis
less expensive than VRA, but no studied
NOT for urgent correction
