workshop case for fluid and electrolyte disorders
DESCRIPTION
H Y P O N A T R E M I A. WORKSHOP CASE FOR FLUID AND ELECTROLYTE DISORDERS. Saldana, E. * Sales, S. * Salonga, C. * San Diego, P. San Pedro, R. * Sanez, E. * Sanidad, E. * Santos, E. Santos, J. * Santos, J. * Santos, K. * Santos, E. 51 year old, female CHIEF COMPLAINT : - PowerPoint PPT PresentationTRANSCRIPT
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WORKSHOP CASE FOR FLUID AND ELECTROLYTE DISORDERS
Saldana, E. * Sales, S. * Salonga, C. * San Diego, P. San Pedro, R. * Sanez, E. * Sanidad, E. * Santos, E.
Santos, J. * Santos, J. * Santos, K. * Santos, E.
HYPONATREMIA
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51 year old, female
CHIEF COMPLAINT:Vomiting
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H I S T O R Y
1 week PTC •Fever, dysuria and urgency•Paracetamol and an antibiotic
(relieved the fever)
2 days PTC •Headache, body malaise and nausea•Vomited thrice, 50cc per episode
CONSULTATION
Persistence of vomiting
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PAST MEDICAL HISTORY
• Hypertensive for 10 years
• Medications:• Telmisartan, 40mg• Hydrochlorthiazide 12.5 daily
• Amlodipine was discontinued due to bipedal edema
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PERSONAL HISTORY
• No smoking• No alcohol intake
REVIEW OF SYSTEMS
• Unremarkable
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PHYSICAL
EXAM
Weak looking
Wheelchair-borne
Blood pressure• Supine: 120/80• Sitting: 90/60• Usual BP: 130/80
Heart rate• Supine: 90 bpm• Sitting: 105 bpm
Weight• 50 kg• Usual weight: 53 kg
Poor skin turgor
Dry mouth and tongue
Dry axillae
JVP: < 5cm H2O at 45o
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LABORATORY
Patient’s Normal
Hgb 132 mg/dL 12 – 16 g/dL
Hct 0.35 0.36 – 0.46
WBC Neut. Lymph.
12.50.880.12
3.8 – 11 x 103
0.54 – 0.620.25 – 0.33
ARTERIAL BLOOD GAS
Patient’s Normal
pH 7.3 7.35 – 7.45
CO2 35 33 – 35
HCO3 18 22 - 26
URINALYSIS
Patient’s Normal
Urine Yellow, slightly turbid
Straw colored, clear
pH 6.0 4.6 – 8
S.G. 1.020 1.003 – 1.040
Albumin (-) (-)
Sugar (-) (-)
Hyaline casts 5/hpf
Pus cells 10-15/hpf
RBC 2-5/hpf (not dysmorphic)
Patient’s Normal
Plasma Na 123 mEq/L 135 – 147
Plasma K 3.7 meq/L 3.5 - 5
Chloride 71meq/L 95 - 105
BUN 22mg/dl 6 – 23
Serum creatinine
0.9 mg/dl 0.6 – 1.2
Glucose 98 mg/dl 65 - 99
Urine Na 100 mmol/L 30 – 280
Uosm 540 mosm/L 450 – 900
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SALIENT FEATURES
• 51 year old, female (vomiting)• Fever, dysuria, urgency
• Intake of paracetamol and antibiotic
• Headache, body malaise, nausea
• Vomiting: 50cc/episode• Known hypertensive
• Telmisartan (40 mg)• Hydrochlorthiazide (12.5
daily)
• Weak looking, wheelchair-borne
• BP: 120/80 (supine), 90/60 (sitting), 130/80 (usual)
• HR: 90 bpm (supine), 105 bpm (sitting)
• Lost weight (53 kg 50 kg)• Poor skin turgor• Dry mouth, tongue and
axillae• Normal JVP
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HYPOVOLEMIC HYPONATREMIA SECONDARY TO THIAZIDE DIURETIC INTAKE
IMPRESSION
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Source: Guyton and Hall. Textbook of Medical Physiology
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Source: Guyton and Hall. Textbook of Medical Physiology
40% of total body weight
20% of total body weight
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Source: Guyton and Hall. Textbook of Medical Physiology
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PATIENT’S PROFILE
Body malaise Weakness Poor skin
turgor
Dry mouth and tongue Dry axillae Postural
hypotension
Postural tachycardia
Decreased JVP
SIGNS OF ECF VOLUME CONTRACTION
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ECF VOLUME CONTRACTION
Hypovolemia
a state of combined salt and water loss exceeding intake
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IMPORTANCE OF SODIUM
• Essential for regulation of body fluids and blood.
• Transmits nerve impulses and controls heart activity.
• Assists in metabolic functions.
• Helps maintain BP levels.
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HYPONATREMIA• Plasma Na+ concentration <
135 mEq/L, and is considered severe when the level is below 125 mEq/L.
• Most causes of hyponatremia are associated with a low plasma osmolality.
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3 TYPES OF HYPONATREMIA DIFFERENTIATED BY VOLUME STATUS
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CLINICAL FEATURES OF HYPONATREMIA
The clinical manifestations of hyponatremia are related to osmotic water shift leading to increased
ICF volume, specifically cerebral edema.
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CLINICAL FEATURES OF HYPONATREMIA
SERUM SODIUM LEVELS:
• 125 mEq/L
• 120 mEq/L
• 115 mEq/L
Patient profle: Serum Na+: 123 mEq/LHeadache, body malaise, nausea,weak looking, wheelchair-borne
Nausea and malaise
Headache, lethargy, obtundation
Seizure and coma
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FACTORS WHICH CONTRIBUTED TO THE PATIENT’S HYPONATREMIA
Renal sodium loss
• Medications• Telmisartan• HCTZ
Extra-renal sodium loss
• Vomiting • 3x• 50cc/episode
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FACTORS WHICH CONTRIBUTED TO THE PATIENT’S HYPONATREMIA
HYDROCHLOROTHIAZIDE
• Inhibits reabsorption of sodium and chloride in the distal convoluted tubule, thus promoting water loss.
• Leads to Na+ and K+ depletion and AVP-mediated water retention.
TELMISARTAN
• Angiotensin II receptor blocker
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Source: http://upload.wikimedia.org/wikipedia/commons/a/a2/Renin-angiotensin-aldosterone_system.png
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3. Compute for the plasma osmolality and effective plasma
osmolality. What is the importance of computing for such?
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Plasma osmolality (mOsm/kg) =
2 [ plasma Na ] + [ Glucose ] + [ BUN ]
18 2.8
http://www.merck.com/mmpe/print/sec12/ch156/ch156b.html
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Plasma osmolality (mOsm/kg) =2 [ 123 mEq/L] + [ 98 mg/dL ] + [ 22 mg/dL ]
18 2.8
Plasma osmolality = 259.3 mOsm/kg
Plasma OsmolalityPlasma Na 123mEq/L
Glucose 98mg/dL
BUN 22mg/dL
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Effective Plasma osmolality = PlasmaOsmolality - BUN_
2.8 = 259.3 mOsm/kg – 22 mg/dL
2.8 = 251.44 mOsm/kg
Effective Plasma Osmolality
Plasma Na
123mEq/L
BUN 22mg/dL
http://cmbi.bjmu.edu.cn/uptodate/critical%20care/Fluid%20and%20electrolyte%20disorders/.htm
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• The osmolality of plasma is closely regulated by anti-diuretic hormone (ADH).
• In response to even small increases in plasma osmolality, ADH release from the pituitary is increased causing water resorption in the distal tubules and collecting ducts of the kidney and correction of the increased osmolality.
• The opposite happens in response to a low plasma osmolality with decreased ADH secretion and water loss through the kidneys.
Significance of Plasma Osmolality
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• Plasma osmolality is used in two main circumstances:– Investigation of hyponatremia – Identification of an osmolar gap
Significance of Plasma Osmolality
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Significance of Plasma Osmolality
• Serum osmolality is a useful preliminary investigation for identifying the cause of hyponatremia.
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• Solutes that are restricted to the ECF or the ICF determine the effective osmolality (or tonicity) of that compartment.
• In a patient with hyponatremia, normal or elevated effective serum osmolality suggests the presence of either pseudohyponatremia or increased concentrations of other osmoles, such as glucose and mannitol.
Significance of Effective Plasma Osmolality
ECF ICFNa+ K+
Cl- Organic phosphate esters (ATP, creatinie phosphate, phospholipids )
HCO3-
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4. What are the significance of urine osmolality and urine sodium?
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• Urine osmolality may vary between 50 and 1200 mmol/kg in a healthy individual depending on the state of hydration.
• The urine osmolality is the best measure of urine concentration with high values indicating maximally concentrated urine and low values very dilute urine.
• The main factor determining urine concentration is the amount of water which is resorbed in the distal tubules and collecting ducts in response to ADH.
Significance of Urine Osmolality
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• The test is useful in the following areas:
– For determining the differential diagnosis of hyper- or hyponatraemia.
– For identifying SIADH
– For differentiating pre-renal from renal kidney failure (high urine osmolality is consistent with pre-renal impairment, in renal damage the urine osmolality is similar to plasma osmolality).
– For identifying and diagnosing diabetes insipidus (low urine osmolality not responding to water restriction).
Significance of Urine Osmolality
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• In patients with hyponatremia and inappropriately concentrated urine, it is particularly important to assess the effective arterial blood volume.
Significance of Urine Sodium
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5. Compute for the sodium deficit
.
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Sodium Deficit
Sodium deficit = (desired serum Na – actual Na) x TBW = (140 mEq/L – 123 mEq/L) x (0.5 x [53]) = 450.5 mEq/L total needed
Plasma Na 123mEq/L
Weight 53 kg
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6. What are the basic principles in the treatment of hyponatremia?
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Hyponatremia
• Goals of therapy– To raise the plasma Na+ concentration by
restricting water intake and promoting water loss
– To correct the underlying disorder
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Treatment
• Mild asymptomatic hyponatremia– Generally of little clinical significance and
requires no treatment• Asymptomatic hyponatremia associated
with ECF volume contraction– Na+ repletion isotonic saline– Restoration of euvolemia removes the
hemodynamic stimulus for AVP release
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Treatment
• Hyponatremia associated with edematous states – Have increased total body water that exceeds
the increase in total body Na+ content– Restriction of Na+ and water intake, correction
of hypokalemia, and promotion of water loss in excess of Na+
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Treatment
• Acute or severe hyponatremia (plasma Na+ concentration <110–115 mmol/L)– Tends to present with altered mental status
and/or seizures– Requires more rapid correction– Treated with hypertonic saline
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Rate of Correction• depends on the absence or presence of
neurologic dysfunction
Asymptomatic Hyponatremia
Acute or severe hyponatremia
• Raised by no more than 0.5–1.0 mmol/L per h
• 1–2 mmol/L per hour for the first 3–4 h or until the seizures subside
• Less than 10–12 mmol/L over the first 24 h
• raised by no more than 12 mmol/L during the first 24 h
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7. What is the complication of the rapid correction of the hyponatremia?
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Osmotic demyelination syndrome (ODS)
• Follows too-rapid correction of hyponatremia• Neurologic disorder characterized by flaccid
paralysis, dysarthria, and dysphagia• Diagnosis is usually suspected clinically and
can be confirmed by appropriate neuroimaging studies
• No specific treatment for the disorder• Associated with significant morbidity and
mortality
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Osmotic demyelination syndrome (ODS)
• Chronic hyponatremia – Most susceptible to ODS, since their brain cell
volume has returned to near normal as a result of the osmotic adaptive mechanisms
– Administration of hypertonic saline to these individuals can cause sudden osmotic shrinkage of brain cells
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Osmotic demyelination syndrome (ODS)
• Risk factors– Prior cerebral anoxic injury– Hypokalemia – Malnutrition, especially secondary to
alcoholism
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8. What intravenous fluid would you use? At what rate should it be given?
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Correction of Sodium Deficit
• Sodium Deficit = 450.5 meq• O.9% NaCl = 154meq/L• Volume of 0.9% NaCl needed:• At 0.5 meq/L/hr, a correction of 17 meq (140-
123) should be done over 34 hours.• Rate of infusion:
2.9Lmeq/L 154meq 5.450
A 53kg woman with plasma Na concentration of 123 meq/L
NaCl 0.9% ofmL/hr 85hrs 342,900mL
Reference: http://scalpel.stanford.edu/ICU/presentations/Fluid%2520and%2520Electrolyte%2520Physiology.ppt