Paulson - Sodium Flashcards by Alice Richards

hypernatremia parameter

over 145 mEq/L

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mc cause of hypernatremia

water depletion

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main extracellular cation

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pt population at high risk for hypernatremia

elderly → decreased thirst and access to fluids

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3 classifications of fluid volume

hypervolemia

hypovolemia

euvolemia

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3 causes of water loss

skin

urine

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3 clinical/pathologic causes of urine water/sodium loss

osmotic diuresis

diabetes insipidus

diuretics

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2 causes of hypervolemic hypernatremia

iatrogenic from hypertonic saline or dialysis

hyperaldosteronism

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2 causes of hypovolemic hypernatremia

renal losses → renal dz or diuretics

extrarenal losses

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2 types of euvolemic hypernatremia

hypodipsia

diabetes indipidus

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early s/sx of hypernatremia

anorexia

restlessness

n/v

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more advanced sign of hypernatremia

AMS

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order of AMS progression in hypernatremia

lethargy/irritability
stupor or coma

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neurologic sx of hypernatremia (5)

twitching

hyperreflexia

ataxia

tremor

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sx of dehydration (7)

dry mm

tenting/poor skin turgor

lack of tears

decreased salivation

tachycardia

hypotn

oliguria/anuria

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definition of chronic hypernatremia

present 2 or more days

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chronic hypernatremia is less likely to present w.

neurologic sx

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what pt pop does chronic hypernatremia make you think about

underlying neuro dz → impaired thirst → brain adaptation to hypernatremia

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acute hypernatremia is more likely to present w.

neurologic sz

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lab to order to diagnose hypernatremia

bmp → > 145

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cause of hypernatremia is usually obvious from hx; if not, test to order

urine and plasma osmolality

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hypernatremic + plasma osmolality > 295

extrarenal cause

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hypernatremic + urine osmolality < plasma

diabetes insipidus

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tx for hypernatremia

dilute fluids → correct/replace losses

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for chronic hypernatremia, tx must be

slow!

what can happen if Na replacement is too quick for chronic hypernatremia

cerebral edema → sz → coma

fluid tx for chronic hypernatremia

D5W 1.35 mL/hr x wt in kg

Na should not be lowered \> \_\_ over \_\_

10 mEq/L 24 hr

when should you recheck Na and glucose after initiation of fluids

4-6 hr after initiation

poor outcomes are associated w. hypernatremia and (3)

perioperative PNA VTE

definition of acute hypernatremia

less than 2 days

acute hypernatremia should be corrected w.in \_\_

24 hr

fluid tx for acute hypernatremia

D5W 3-6 mL/kg/hr OR ½ NS

what fluid should NOT be used for hypernatremia

Na and glucose monitoring for acute hypernatremia

q 1-2 hr until Na \< 145

after Na reaches \< 145 in acute hypernatremia you should

decrease rate to 1 mL/kg/hr until goal of 140

steps in fluids for acute hypernatremia (3)

1. D5W 3-6 mL/kg/hr OR ½ NS 2. monitor Na and glucose q 1-2 hr until Na \< 145 3. decrease rate to 1 mL/kg/hr until goal of 140

goal for Na reduction for acute hypernatremia

1-2 mEq/L each hour

rate of correction for chronic hypernatremia

no more than 10 mEq/L/day

rate of correction for acute hypernatremia

lower to near normal in first 24 hr

hyponatremia definition

Na \< 135 mEq/L

mc lyte d.o seen in hospitalized pt's

hyponatremia

mc cause of hypervolemic hyponatremia

fluid overload water is added or retained → amt of Na in serum is diluted

4 ex of pathologic hypervolemic hyponatremia

CHF cirrhosis IVF nephrotic syndrome

cause of hypovolemic hyponatremia

both water and Na are lost → **more Na than water**

water and Na losses in hypovolemic hyponatremia can be either (2)

renal losses extrarenal losses

renal losses of water and Na

diuretics → **esp thiazides**

extrarenal water and Na losses (4)

diarrhea sweating blood loss fluid shifts

5 causes of euvolemic hyponatremia

adrenal insufficiency polydipsia hypothyroidism syndrome of inappropriate antidiuretic hormone (SIADH) reset osmostat

4 causes of SIADH

intracranial paraneoplastic syndrome pulmonary dz meds

2 meds that cause SIADH

SSRI cyclophosphamide

classification of hyponatremia by tonicity

hypotonic isotonic hypertonic

4 causes of hypotonic hyponatremia

SIADH CHF, cirrhosis, diuretics → *blood volume depletion* endocrine d.o advanced renal failure

endocrine d.o that cause hypotonic hyponatremia (3)

hypothyroid adrenal insufficiency

ex of isotonic hyponatremia

pseudohyponatremia

increased serum lipids or proteins cause erroneous measurement of Na levels

pseudohyponatremia

2 causes of hypertonic hyponatremia

**significant hyperglycemia** mannitol, maltose sucrose retention

hyponatremia usually becomes symptomatic when Na is

125-130

possible sx of hyponatremia (6)

anorexia n.v lethargy disorientation ha sz

possible clinical sx of hyponatremia (9)

weakness agitation hyporeflexia orthostatic hypotn delirium coma sz resp arrest brainstem herniation

1st diagnostic steps for hyponatremia

BMP + serum osmolality

which diagnostic test gives you info regarding tonicity cause of hyponatremia

serum osmolality

other helpful tests for hyponatremia

**urine osmolality** **lytes** TSH plasma cortisol ACTH stimulation brain/lung imaging

hyponatremia flow chart

in euvolemic hyponatremia, urinary Na is usually

Na \> 20 mEq/L

euvolemic hyponatremia plus urine osmolality \>100 suggests

SIADH hypothyroid adrenal insufficiency stress drug use

euvolemic hyponatremia plus urine osmolality \< 100 suggests

primary polydipsia → low Na intake *beer potomania syndrome*

4 meds to know that cause hyponatremia

thazides antipsychotics SSRIs contrast agents

classification of hyponatremia

acute subacute chronic severe moderate mild

acute hyponatremia

w.in last 24 hr

subacute hyponatremia

w.in last 24-48 hr

chronic hyponatremia

w.in \> 48 hr

severe hyponatremia

120 or lower

moderate hyponatremia

121-129

mild hyponatremia

130-135

pt w. any symptoms of hyponatremia needs

emergency therapy ## Footnote **even mild sx**

emergency fluid for symptomatic hyponatremia

hypertonic saline

goal and monitoring for Na replacement for emergent tx (symptomatic pt)

raise NA by 4-6 over a couple hours check Na q 2 hr

goal for non-emergency Na replacement

bring Na up slowly

overly rapid correction of hyponatremia can cause

osmotic demyelination syndrome (same-same central pontine myelinolysis)

tx for hypovolemic hyponatremia

isotonic saline

tx for hypervolemic hyponatremia: **CHF, cirrhosis** (3)

diuresis fluid restriction Na restriction

tx for hypervolemic hyponatremia: renal failure

fluid restriction dialysis Na restriction

tx for euvolemic hyponatremia

fluid restriction *if SIADH → +/- salt tabs and/or loop diuretic*

what is demeclocycline used off label for

SIADH

indication for demeclocycline

SIADH pt who do not respond to salt tabs/loop diuretics

s.e of demeclocycline (3)

renal toxicity → *esp cirrhosis pt* nephrogenic DI intracranial htn

salt tabs should NEVER be given to

edematous pt