INTERACTIVE CASE DISCUSSION Fluid and Electrolyte Disorders Part II.
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Transcript of INTERACTIVE CASE DISCUSSION Fluid and Electrolyte Disorders Part II.
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INTERACTIVE CASE DISCUSSION
Fluid and Electrolyte Disorders
Part II
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Fluid and Electrolytes Part II
CASE # 1: • 60 y/o male with ischemic cardiomyopathy and
CHF. Admitted because of orthopnea.• 150/60, HR=120/min, RR = 38/min• JVP = 20 (); bibasal inspiratory crackles• S3 gallop; ascites; pedal edema• Na = 125meq/L ()• Posm = 270 mosm/kg ()• Uosm = 500 mosm/kg
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Fluid and Electrolytes Part II
Question # 1: Describe the patient’s fluid and electrolyte status.
A. Na deficit, water deficit
B. Na deficit, water excess
C. Na excess, water deficit
D. Na excess,water excess
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Fluid and Electrolytes Part II
Answer #1: Na excess, water excess
• Hyponatremic (Na=125) hence he has water excess.
• Hypervolemia on physical examination ( BP, JVP,crackles, ascites, edema ) hence he has Na excess.
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Fluid and Electrolytes Part II
REMEMBER !
Serum Na Na balance
Serum Na = Water balance
Volume status = Na balance
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Fluid and Electrolytes Part II
Question # 2: How will you approach the problem of hyponatremia?
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HYPONATREMIAPlasma Osmolality
(285-295)
High•Hyperglycemia•Mannitol
Normal•Hyperproteinemia•Hyperlipidemia•Bladder irrigaton
LowTrue Hyponatremia
MaximallyDilute urine
Singer, 2001
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HYPONATREMIA
Maximally dilute urine
Uosm < 100
No Yes
Primary polydipsiaReset osmostat
ECF Volume
Singer, 2001
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HYPONATREMIA
Increased Normal Decreased
ECF Volume
CHFCirrhosisRenal failureNephrosis
HypothyroidHypoadrenalSIADH
Urine Na
Singer, 2001
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HYPONATREMIA
Urine Na
UNa < 10 meq/L UNa > 20 meq/L
Extrarenal Na lossRemote diureticsRemote vomiting
Na wasting nephropathyHypoaldosteronismDiureticsVomiting
Singer, 2001
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Fluid and Electrolytes Part II
Question # 3: What is the most likely cause of hyponatremia in this patient?
A. Congestive heart failureB. DiureticsC. HypothyroidismD. Syndrome of Inappropriate ADH
secretion (SIADH)
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Fluid and Electrolytes Part II
Answer # 3: Congestive heart failure
• Low Posm excludes pseudohypoNa.
• Uosm > 100 (500) hence not primary polydipsia or reset osmostat
• Volume status increased (Na excess)
• Compatible with CHF
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Fluid and Electrolytes Part II
CASE # 2: 30 y/o 70kg male suffered a skull fracture due to MVA.
• 86/60,HR=110/min.• JVP = 4, poor skin turgor• Dry mucosa, no edema• Na = 168 meq/L• Posm = 350mosm/kg; Uosm = 80mosm/kg• 24 hr urine output = 4 liters
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Fluid and Electrolytes Part II
Question # 4: Describe the patient’s fluid and electrolyte status.
A. Na deficit, water deficit
B. Na deficit, water excess
C. Na excess, water deficit
D. Na excess, water excess
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Fluid and Electrolytes Part II
Answer # 4: Na deficit, water deficit
• Hypernatremic ( Na = 168) hence he has water deficit.
• Hypovolemic on physical examination ( BP, JVP,poor skin turgor, drymucosa) hence he has Na deficit.
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Fluid and Electrolytes Part II
REMEMBER !
Serum Na Na balance
Serum Na = Water balance
Volume status = Na balance
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Fluid and Electrolytes Part II
Question # 5: Calculate the amount of water deficit in this patient.
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Fluid and Electrolytes Part II
Answer # 5: 7 liters
Water deficit
= Plasma Na – 140/140 X ( 0.5 X BW )
= 168 – 140/140 X ( 0.5 X 70 )
= 7 liters.
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Fluid and Electrolytes Part II
Question # 6: How will you approach the problem of hypernatremia?
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HYPERNATREMIAECF Volume
Increased Not increased
Administration of Hypertonic NaCl andNaHCO3
Minimum volumeof maximallyconcentrated urine(Uosm)
Singer, 2001
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HYPERNATREMIA
UOsm > 800
No Yes
Insensible H2O lossGI H20 lossRemote renal H2O loss
Urine osmolarexcretion rate
Singer, 2001
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HYPERNATREMIAUrine osmolar excretionrate > 750 mosm/day
YesNo
Osmotic diuresisDiuretic
Renal responseto desmopressin
UOsm Uosm no
Central DI Nephrogenic DI
Singer, 2001
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Fluid and Electrolytes Part II
Question # 7: What is the most likely cause of the patient’s hyperNa?
A. Diabetes insipidus
B. GI water losses
C. IV hypertonic NaCl
D. Osmotic diuresis
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Fluid and Electrolytes Part II
Answer # 7: Diabetes insipidus• Not hypervolemic hence not IV hypertonic
NaCl.• Uosm < 100 (dilute) hence not extrarenal
water losses (GI losses).• Urine osmolar excretion rate = Uosm X U
volume; 80mosm/kg x 4 liters/d = 320 mosm/d (< 750mosm/d); hence not osmotic diuresis.
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Fluid and Electrolytes Part II
Question # 8: The patient was given a dose of desmopressin (ADH analog). The Uosm after the dose is 800 mosm/kg. What is the cause of the diabetes insipidus?
A. Central diabetes insipidus
B. Nephrogenic diabetes insipidus
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Fluid and Electrolytes Part II
Answer # 8: Central DI
• The Uosm increased after the desmopressin dose. The Uosm will not change even after repeated desmopressin doses in patients with nephrogenic DI.