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pharm > Fluids & Electrolytes > Flashcards

Fluids & Electrolytes Flashcards

1
Q

Hyperkalemia

A

Serum K+ > 5.5mEq

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2
Q

Sx of Hyperkalemia

A

Fatigue
Muscle weakness
EKG changes—> potentially life threatening arrythmias
Risk for sever negative outcomes increases as K+ levels increase

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3
Q

Causes of Hyperkalemia

A

Decreased renal excretion (renal failure)
Heart failure (due to decreased renal function)
Increased K+ intake
Shift of K+ from IC—> EC via
Β adrenergic blockade
Insulin deficiency
Acidosis

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4
Q

Medications that increase serum K+ (7)

A

Potasium sparing diuretics
ACE
NSAIDS
Digoxin Toxicity
ARBs
Sulfamethoxazole/Trimethoprim

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5
Q

If a patient has moderate elevation of serum K+ WITHOUT EKG changes, how would you treat his hyperkalemia?

A

Increase excretion of K+ via cation exchange resin or diuretics

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6
Q

Goals of treatment for a patient with severe (>6.5) hyperkalemia

A

Immediate stabilization of myocardial membrane
Rapid shifting of K+ to ICS
Increase K_+ elimination (d/c exogenous K+)

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7
Q

What is the medication and dose that is given to someone with SEVERE HYPERKALEMIA to stabilize their myocardial cell membrane?

A

IV Calcium 1g IVPG over 1 hour (IV piggy back)

**Calcium Gluconate preferred

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8
Q

Why is Calcium Gluconate preferred over calcium carbonate?

A

Calcium Carbonate—> Brady cardia and increased tissue damage & extravasation

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9
Q

What do we check within 30min-1 hour of administering IV insulin to a patient with hyperglycemia and why?

A

Check BG; because Insulin can cause hypoglycemia

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10
Q

Why do we give insulin to a patient with hypglycemia?

A

Shifts K+ from ECS—> ICS

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11
Q

When do we treat hyperkalemia with sodium bicarb

A

In the setting of acidosis

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12
Q

What does sodium bicarb do to treat hyperkalemia?

A

Shifts K+ from ECS to ICS
Raises systemic pH

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13
Q

What is the dose of sodium bicarb given to patients with hyperkalemia who are in acidosis?

A

50 mEq IV

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14
Q

What do Β 2 agonists do in the setting of hyperkalemia (2)?

A

Shift K+ from ECS—> ICS BY:
1) stimulating NaK-ATPase to promote intracellular K+
2) stimulates pancreatic B-receptors to increase insulin secretion

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15
Q

What β-2 agonist is used to treat severe hyperkalemia and how much?

A

Albuterol 10-20mg via nebula er over 10 min

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16
Q

Why are β-2. Agonists not recommended as solo treatment for hyperkalemia?

A

Some patients are resistant to the effects

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17
Q

Who are β-2 agonists less effective in?

A

Patients already on a non selective β blocker

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18
Q

Why are loop diuretics used in the setting of hyperkalemia?

A

They promote K+ excretion

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19
Q

What 2 loop diuretics are used in the setting of hyperkalemia? What are their doses?

A

Furosimide: 40-80mg IV
Bumetanide 2-4mg IV

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20
Q

When may loop diuretics be less effective in treating hyperkalemia?

A

Severe renal failure

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21
Q

How does SPS work to treat hyperkalemia?

A

Binds potassium in the GI tract to reduce absorption and increase elimination

Resting passes through intestines—> SPS exchanges 1mEq of Na+ for 1mEq K+ (1:1 equal exchange)

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22
Q

Why cant SPS be used ALONE in life- threatening hyperkalemia?

A

Takes too long to work
Onset= >2 hours

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23
Q

Who should we avoid using SPS in?

A

Patients with bowel problems

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24
Q

Since SPS works best when in the colon what cathartic is most commonly given with it?

A

Sorbitol

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25
Q

Sodium Zirconium Cyclosilicate

A

Potassium binder

Exchanges K+ for Both H+ and Na+
Onset:1 hr

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26
Q

Patiromer

A

Potassium binder
Exchanges Ca+ for K+
Onset: 7 hrs

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27
Q

What are the 3 potassium binders

A

Sodium polystyrene sulfonate
Sodium zirconium Cyclosilicate
Paritomer

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28
Q

What is the treatment of choice for hyperkalemia when pharmacologic treatments fail?

A

Dialysis

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29
Q

Definition of hypokalemia

A

Serum K+ <3.5

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30
Q

Causes of hypokalemia

A

Decrease in K+ intake
Increase in K+ loss (diuretics)
Excess GI loss (v/d)
Shifts from ECS (β adrenergic agents, insulin, alkalosis)

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31
Q

Signs and symptoms of hypokalemia

A

Often asx
Sx are nonspecific and predominantly related to muscular or cardiac function:
- weakness and fatigue
- muscle cramps and pain
- palpitations
- psychological sx
- EKG changes
- Dysrhythmias
- hypotension

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32
Q

What are the goals of treatment for hypokalemia?

A

Reduction of K+ losses
Replenishment of K+ stores

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33
Q

Methods of reduction of potassium loss?

A

D/c diuretics./ laxatives
Use K+ sparing diuretics
Treat diarrhea and vomiting

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34
Q

What methods can be used for K+ replenishment of MILD hypokalemia

A

Oral

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35
Q

What methods can be used for replenishment of K+ in MODERATE hypokalemia?

A

IV or Oral

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36
Q

What method can be used for K+ replenishment in SEVERE hypokalemia?

A

IV

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37
Q

Most commonly used salt in treatment of hypokalemia

A

KCl-

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38
Q

Serum K+ will increase ________ for every __________mEq of supplementation

A

.1mEq/L for ever 10mEq

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39
Q

T/F: oral and Parenteral K+ CANOT be used simultaneously

A

False

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40
Q

Try to limit oral single doses to 10-20mEq due to the risk of __________

A

GI irritation

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41
Q

Infusions >10mEq of Serum K replenishment require ______________

A

EKG monitoring

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42
Q

____________ is necessary for K+ uptake therefore it must be checked and replaced as needed in order to correct the potassium levels

A

Magnesium

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43
Q

Hyponatremia

A

Sr Na+ <135mEq/L

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44
Q

Mild Hyponatremia

A

Sr Na+ 130-134mEq

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45
Q

Moderate Hyponatremia

A

Sr Na+ of 120-129mEq/L

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46
Q

Severe Hyponatremia

A

Sr. Na+ <120mEq/L

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47
Q

Causes of Hyponatremia

A

Advanced kidney disease
SIADH
Heart Failure
True Volume depelation (Na and water loss GI tract or urine)
Medications- diuretics

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48
Q

S&S of mild Hyponatremia

A

Nausea and malaise

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49
Q

Sx of severe Hyponatremia

A

Lethargy
Decreased level of conciousness
Headache
(If severe) seziures and coma

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50
Q

Overt neurologic sx most often are due sodium levels that are:

A

<115mEq/L

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51
Q

Over neurologic sx most often are due to very low serum levels (usually <115mEq/L) resulting in ___________________

A

Resulting in Intracerebral osmotic fluid shifts and brain edema

52
Q

What are the 2 treatments for Hyponatremia?

A

Tolvaptan
3% (hypertonic) saline

53
Q

Indications for Tolvaptan

A

Clinically significant hypervolemic or euvolemic Hyponatremia

Less marked Hyponatremia that is SYMPTOMATIC AND RESISTANT to fluid restriction (pt with HF & SIADH)

54
Q

Euvolemic Hyponatremia

A

Low Na lev les with normal extracellular volumes and no signs of edema of Ascites

SIADH

55
Q

Hypervolemic Hyponatremia

A

Low Na levels with greatly elevated extracellular volume (pitting edema and Ascites)

HF and cirrhosis

56
Q

MOA of Tolvaptan

A

Vasopressin (Anti-Diuretic Hormone) antagonist
HF:
blocks the action of ADH at the V2 receptor resulting in decreased free water reabsorption in the kidney. This results in an AQUARESIS which is free water loss without electrolyte loss

57
Q

Initiate and reinitiate tolvaptan in patient where and why?

A

In the hx; Na+ needs to be closely monitored

58
Q

when is Tolvaptan NOT indicated for use?

A

when the patient needs urgent treatment for hyponatremia to treat serious neuro probelems

59
Q

Do not use tolvapan for >30 days due to

A

risk of hepatotoxicity

60
Q

what do we monitor in patients on tolvaptan

A

Serum Na+ concentration
Rate of Sr. Sodium increase

61
Q

Indications of use for 3% hypertonic saline

A
  • Severe Hyponatremia (<115)
  • If patient bceomes symptomatic
62
Q

Danger of using 3% Hypertonic saline

A

overcorrection of sodium–> osmotic demyelination syndrome (ODS)

63
Q

ODS

A

occurs when the damage to the myelin sheath is caused by an acute decrease in brain cell volume

64
Q

How does overcorrection of hyponatremia with 3% saline cuase ODS>

A

if Na+ correction done too quickly–> rapid fall in brain volume–> astrocytes need to replace osmolytes to pull volume back into the brain (SLOWER PROCESS)

Brain cant catch up with the rapid need for osmolytes

rapid fall in brain volume–> demylination

65
Q

ODS is rare when intial serum sodium is __________________-

A

> 120mEq/L

66
Q

Risk factors for ODS

A

Serum sodium <120 mEq/L

Hyponatremia for 2-3 days +

67
Q

Clinical Manifestations of ODS

A

Behavioral disturbances
Movement disorders
Seziures
Coma
Quadraparesis

68
Q

How long does it take for the sx of ODS to arise

A

2-6 days after overcorrection—> irreversible

69
Q

Safe rate to administer hypertonic saline to avoid ODS

A

Avoid increase more than 12 mEq/L in 24 hrs
Usual rate= .5-1mEq/L PER HOUR

MONITOR SERUM SODIUM LEVELS (some recommendations call for every 2-3 hrs)

70
Q

What is hyppmagnesemia

A

Serum magnesium <1.5mg/dL

71
Q

Mild-moderate hypomagnesemia

A

1.2-1.5mg/dL

72
Q

Severe hypmagnesemia

A

<1.2mg/dL

73
Q

Causes of Hypomagnesemia

A

Excessive GI loss
Malnutrition
Renal Loss
Sepsis
Alcoholism

74
Q

S&S Of hypomagmesemia

A

Sinus tachy, SVT, ventricular arrythmias
Muscle weakness
Ataxia
Vertigo
Tetany
Seizures
Irritability, delerium. Psychosis

75
Q

Treatment of severe hypomagnesemia typically recommends

A

IV replacement 1-2g MAG SULFATE IVPB over 1 hour

76
Q

Mild-moderate hypomagnesemia treatment route options

A

IV or Oral

77
Q

What is the issue with oral agents for hypomagnesemia

A

All suffer from limited bioavailability
SE such as GI discomfort and diarrhea

78
Q

Indications of fluid management

A

Expand IV volume
Correct an imbalance in fluid or electrolyte
Manage Fluid and electrolyte needs in an ongoing disease state
Maintenance

79
Q

What are the 2 types of IV fluids?

A

Crystalloids
Colloids

80
Q

What are the fluids of choice when resuscitating a patinet?

A

Crystalloids

81
Q

Crystalloids

A

Aqueous solutions of ions with or without glucose that flow easily across the cell membrane

82
Q

What are the Crystalloids IV Fluids

A

D5W
D10W
D20W
D50W
1/2 NS
3%NS
NS
D51/4NS
D51/2MS
D5NS
D5LR
LR

83
Q

.9% NaCl-NS (Normal saline) is used to treat what?

A

fluid deficit, shock, mild Hyponatremia and for resuscitation

84
Q

When you administer 1L of NaCl.9% how much stays in the Intravascular space?

A

250ml

85
Q

What is used for replacement of pure water deficits and maintenance fluids for patients on Na+ restriction?

A

D5W

86
Q

D5W

A

Provides water to ICS and ECS WITH CALORIES
Helpful in dehydration

87
Q

Why is D5W not a good option for fluid resuscitation?

A

1L of D5W only 100mL remain in the intravascular space—> only get 100ml fluid expansion

88
Q

Why do we avoid giving D5W to patients with neurologic injury and elevated ICP?

A

Bc D5W can freely cross al barriers—> will further increase ICP

89
Q

Contents of Lactated solution (LR)

A

Sodium
Potassium
Chloride
Bicarb

90
Q

What is LR used for

A

GI fluid losses
Fistula drainage
Burn and Trauma fluid loss

91
Q

LR is preferred in…

A

Surgery and Trauma patients

92
Q

When 1L of LR is administered, how much remains in the intravascular space?

A

250ml

93
Q

Is LR good for fluid resuscitation?

A

Yes

94
Q

Indications for .45% NaCl (1/2NS)

A

For patients with intracellular dehydration caused by hypernatremia or DKA

95
Q

What is the maintenance fluid for someone with HTN

A

1/2 NS (esp when dont want to give them all the sodium in NS)

96
Q

Isotonic Fluids

A

.9% NaCl- NS
D5W
LR
1.2NS

97
Q

What are the hypertonic Crystalloids

A

3.0-%NACL
D5W w/ NS or 1/2 NS
D5W with LR
D10W, D20W

98
Q

When are hypertonic Crystalloids used?

A

Hyponatremic or hypoglycemic patinets

99
Q

Indications for 3% NaCl

A

Severe Hyponatremia
Patients with cerebral edema
TBI to reduce elevated ICP—> increase cerebral percussion pressure

100
Q

How much Crystalloids do we administer for resuscitation?

A

500-1000mL bolus then monitor parameters

101
Q

How much Crystalloids do we give for sepsis>

A

30mL/kg in 1st 3 hours

102
Q

Maintenance IV fluids are indicated for….

A

Patients who are unable to tolerate oral fluids

103
Q

To estimate daily fluid maintenance

A

1500mL for first 20KG
20mL for every KG >20

104
Q

Colloids

A

Solutions of large molecules (typically protein or starch) that dont pass through cell membranes and remain in the intravascular compartment

Mor efficient in restoring normal intravascular volume and CO but expensive

105
Q

Indications for use of colloids

A

When resuscitation with Crystalloids fails or is limited by clinically significant edema

Fluid resuscitation in pateints with severe intravascular fluid deficits (HEMORRHAGIC SHOCK)

Fluid resuscitation in presence of severe hypoalbuminemia or conditions associated with large protein loss (Burns)

106
Q

What are the 4 types of colloids?

A

Albumin
Blood products
Plama protein fraction
Synthetic colloids

107
Q

What are the 2 types of colloids we are responsible for knowing?

A

Albumin
Synthetic colloids

108
Q

Indications of use for albumin

A

Hypovolemic shock (pts cant receive large volume load)

109
Q

When would we CONSIDER albumin

A

Hypovolemic shock (INDICATION)

When fluid resuscitation with Crystalloids fils or when edema limits further Crystalloids admin

110
Q

Main modulator of fluid distribution among the compartments of the body

A

Albumin

111
Q

Most clinical use of HA (albumin) is based on

A

The capacity to act as a plasma expander

112
Q

5% albumin

A

Used for volume expansion

Increases the circulating plasma volume BY AMT EQUAL TO THE AMOUNT INFUSED

Less risk of pulmonary edema

113
Q

What is PICD?

A

Paracentesis-Induced circulatory dysfunction

114
Q

What is the indication of 25% albumin

A

Following LVP >5 L of fluid

115
Q

25% albumin is ___________ and pulls fluid into compartment

A

Hyperoncotic

116
Q

Who do we avoid giving 25% albumin to>

A

Patients requiring fluid resuscitation—> can cause dehydration

117
Q

What happens when you give someone 25% albumin

A

5 fold effect on patients intravascular load compared to the administered dose

118
Q

Hydroxyethyl starches

A

Semi-synthetic colloid
Hetastarch—> highly effective as a plasma expander, less expensive

119
Q

When is hetastarch used?

A

Used after major surgeies and burns

120
Q

Problems with Hetastartch (2 )

A

Prolongs PT, PTT , and bleeding times
Can cause anaphylaxis

121
Q

Why should we avoid giving hetastarch?

A

Increases risk of AKI, need for replacement therapy, and increased moraltiy in critically ill patinet

122
Q

NS infusion volume and equivalent intravascular volume

A

1000 mL (1L)—> 250mL

123
Q

LR infusion volume—>equivalent intravascular volume

A

1000ml (1L)—-> 250mL

124
Q

5% dextrose infusion volume—> equivalent intravascular volume

A

1000mL (1L)—> 100mL

125
Q

Albumin 5% infusion vol—> equivalent intravascular vol

A

500mL—> 500mL

126
Q

Albumin 25% infusion volume—> equivalent intravascular vol

A

100mL—> 500mL

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