Fluid, Electrolytes, and Acid-Based Disorders (INC)

Question 1

What does supportive care mean for AKI? What are the 6 kinds of problems?

Answer 1

Managing the following problems:

Abnormal volume status
Hyperphosphatemia
Hyperkalemia
Hyponatremia
Uremia
Severe metabolic acidosis (pH < 7.2)

Question 2

What does a drop in osmotic pressure or blood pressure cause?

Answer 2

Drop in osmotic pressure or blood volume causes the body to make several adjustments…
Increased:
Sympathetic nervous system output
RAAS activity
ADH levels
Thirst
Decreased:
Atrial natriuretic peptide (ANP)

Question 3

What does Increase in osmotic pressure or blood volume

Answer 3

Decreased:
Sympathetic nervous system output
RAAS activity
ADH levels
Thirst
Increased:
Atrial natriuretic peptide (ANP)

Opposite

Question 4

What is the goal of sodium/water balance?

Answer 4

Adjust water intake, water and sodium retention by the kidney, and vasoconstriction

Question 5

What is isotonic fluid volume deficit aka? What are some etiologies of this?

Answer 5

1. Decreased PO intake
2. Excessive fluid loss - GI, renal, skin
   3, Third spacing - edema, ascites, effusions (cannot be used)

Question 6

If someone is volume depleted, what are the s/s?

Answer 6

HR increases to compensate
BP is lower
Skin turgor decreases (check sternal notch)
Thirsty
ECF is low (body weight decreases)
Dry mucous membranes (under tongue is dry)
Sunken eyes or fontanel

Question 7

What do you see in normal functioning kidneys in Isotonic Fluid Volume Deficit?

Answer 7

High Uosm and Urine specific gravity (SG), increased Hct (because less water), may see abnormal renal labs
If due to renal fluid wasting - may see very dilute urine!
If accompanied by blood loss - Hct may also be low!

Question 8

What do you give for Isotonic Fluid Volume Deficit? What is the preference?

Answer 8

PO fluids (preferred) or IV

For IV, can do NS - but can lead to hyperchloremic metabolic acidosis

Target to physiologic endpoint depending on pt status
Mean arterial pressure, urine output
Avoid being overly aggressive with administration!

Question 9

What is a CI for Isotonic Fluid Volume Deficit?

Answer 9

Signs of volume overload (third spacing), HF
Blood loss (PRBCs instead)
Poor Cardiac Output

Question 10

What is Isotonic Fluid Volume Excess aka and what can cause this?

Answer 10

Hypervolemia
Inability to get rid of water or sodium

Excess intake - Overadministration of IV fluids, hypertonic IV fluids, dietary intake
Decreased elimination - Heart failure, renal failure, corticosteroids

Question 11

What are the hypervolemic excess S/S?

Answer 11

General - Decreased thirst, feeling bloated/swollen (often before they LOOK swollen)
CV - full, bounding pulse; distended neck veins, may see increased BP
High ECF - ascites, pulmonary edema, extremity edema

Question 12

What are the labs of hypervolemic excess

Answer 12

Low Uosm and Urine SG, decreased HCT, may see abnormal renal labs

If due to inability of kidneys to get rid of urine - may see concentrated urine or low UO!

If anemic - Hct may not be elevated!

Question 13

How do you manage volume overload?

Answer 13

IV diuretic (big bolus then drip) loop dieurtics preferred.

Dialysis - persistent volume overload or no response to diuretics

No improvement in outcomes from increasing urine output alone
Restrict fluid and sodium intake

Question 14

What are the hyperphosphetemia and when is it most commonly seen?

Answer 14

fatigue, SOB, N/V
S/S of hypocalcemia: Hyperreflexia, carpopedal spasm, + Trousseau (or Chvostek sign (cheek through tapping facial nerve)

Question 15

What is the treatment of hyperphosphetemia?

Answer 15

Phosphate binders with meals can limit GI absorption
Avoid processed foods with inorganic phosphate
Restoration of renal function

Question 16

What are some etiologies of hypokalemia?

Answer 16

Renal - intrinsic potassium wasting, or due to diuretic SE
GI - poor intake (nutrition, NPO)
Other causes - insulin, beta-agonists, loop diuretics, alkalosis

Question 17

What are the S/S of hypokalemia and ECG differences?

Answer 17

muscle problems (weakness)
ECG: flattened T waves → prolonged QT

Question 18

What is the treatment of hypokalemia?

Answer 18

Acute
PO but huge pill
IV preferred
Chronic
Diet, an adjustment of meds
Adress: Hypomagnesemia
Metabolic acidosis
Medication adjustments

Monitoring - renal function, electrolytes, symptoms

Question 19

What is the etiology of hyperkalemia?

Answer 19

Very common complication of both AKI and CKD
Renal - inadequate excretion, metabolic acidosis
Adrenal insufficiency
Cellular breakdown - traumatic stick, hemolysis, crush injury
Release from ICF - cell damage, excessive/severe muscle contraction
Other causes - ACEI/ARB, beta-blockers, excess intake (usually IV)

Question 20

What are the s/s of hyperkalemia? What do you see in ECG?

Answer 20

Signs and Symptoms - often affect muscles (skeletal, smooth, cardiac)
MSK - weakness, cramps (including abdominal)
GI - abdominal cramps, diarrhea, vomiting
Cardiac - hypotension, palpitations, dysrhythmias, cardiac arrest
ECG - PEAKED T waves → loss of P waves → widened QRS → sine wave

Question 21

If potassium is very high, what are the three steps you take?

Answer 21

Immediate blocking of cardiac effects
Rapid reduction in plasma K+
Removal of potassium

Question 22

How do you block the cardiac effects of hyperkalemia?

Answer 22

Give IV calcium if s/s of cardiac issues

Question 23

How do you do Rapid reduction of plasma K+? How long does this last?

Answer 23

FORCE INTO CELLS, through IV insulin
Lasts a few hours and gives more time.
Can give albuterol as an additive

Question 24

How do you remove potassium long term?

Answer 24

GI cation exchangers

Question 25

What is the MOA of GI cation exchangers?

Answer 25

Exchanges Na+ for K+ in GI tract, ￪ fecal K+ excretion

Question 26

What are the three GI cation exchangers?

Answer 26

Zirconium cyclosilicate - 1 hour
Patiromer - 7 hours
SPS - 2-24 hours (only if no other therapies)

Question 27

What are the major SE of GI cation exchangers?

Answer 27

GI, hypomagnesium, hypo