Notebook facts- for PALM



Fluid, Electrolytes

Fluid distribution

TBW- 0.60 of wgt.. . of this:

0.67 intracellular (40% T wgt)

0.33 extracellular (20% wgtl)

0.25 vascular (5% wgt)

0.75 interstitial (15% wgt)

HYPERCALCEMIA

Causes: primary hyperparathyroidism

malignancy (PTH-related peptide, ectopic production of 1,25-dihydroxyvitamin D, osteoclast-activating factor, lytic bone mets

non parathyroid endocrine disorder

thyrotoxicosis, pheochromocytoma, adrenal insufficiency, VIP-producing tumor

granulomatous disease (1,25-dihydroxyvitamin D excess)

sarcoidosis, tuberculosis, histoplasmosis, coccidiomycosis, leprosy

medications (thiazide diuretics, lithium, estrogens, antiestrogens)

milk-alkali syndrome

vitamin A or D intoxication

familial hypocalciuric hypercalcemia

immobilization

parenteral nutrition

acute and chronic renal failure

Signs: "Stones, moans, groans, with psychic overtones"

Renal: polyuria (nephrogenic DI), nephrolithiasis, renal failure, ectopic calcification

GI: anorexia, nausea, vomiting, constipation

Neuro: weakness, fatigue, confusion, stupor, coma

ECG: Shortened QT

Treatment: Correct dehydration, increase renal calcium excretion, decrease bone resorption, and treat the underlying disorder.

1. IV hydration, 2.5-4 liters NS per day; watch for CHF

2. IV furosemide after volume repleted; keep I=O

3. Specific treatment in approximate desirability of use:

• calcitonin 4U/kg sq bid to 8 U/kg sq qid-rapid acting; often see rebound once it wears off.

• pamidronate 15-45 mg IV slowly qd x 6 days or as single IV infusion of 90 mg over 24 hours. Effective. Treatment of choice in hypercalcemia of malignancy.

• etidronate 7.5 mg/kg over 4 hours qd x 3-7 days. Slower acting, may be more effective.

• plicamycin (mithramycin-chemo agent) 25 mcg/kg over 4-6 h q1-2 days. Be careful in renal or hepatic failure

• gallium nitrate 200 mg/m2 body surface area in one liter IV fluid per day for 5 days. Nephrotoxic, but effective.

• glucocorticoids 200-300 mg hydrocortisone IV qd x 3-5 days.

HYPERKALEMIA

Causes: spurious due to hemolysis during phlebotomy, greatly increased platelets or WBC

ingestion

renal failure

acidosis, including RTA type IV

iatrogenic

retroperitoneal hematoma

cell death (rhabdomyolysis, burns, tumor lysis)

adrenal insufficiency or other hypomineralocorticoid state

drugs (spironolactone, ACE inhibitor, digitalis overdose)

ECG: tall peaked T waves (K>5.5)

PR prolongation followed by loss of P waves (K>6.5)

QRS widening (K>7.0)

Treatment: 1 amp CaCl2 or Ca gluconate to counter arrhythmias

2 amps bicarb w/ 2 amps D50 plus 10 units regular insulin IV. This will cause temporary cellular shifts only.

NS at 200 cc/hr with furosemide

Kayexelate 50 g po or retention enema

dialysis (last resort)

HYPERMAGNESEMIA

Causes: Renal failure

Overaggressive replacement.

Signs: Rarely symptomatic until Mg >4 mEq/l. Areflexia, lethargy, weakness, paralysis, respiratory failure, hypotension, bradycardia, heart block, asystole

Treatment: Asymptomatic: hold magnesium supplementation

Symptomatic: 1 amp Ca gluconate IV over 10 minutes to antagonize Mg. Support ventilation and heart rate if necessary. Definitive therapy requires dialysis if no renal function, or Ca gluconate infusion to promote Mg excretion.

HYPERNATREMIA

Diagnosis-first assess volume status. This helps to determine underlying cause.

I. Hypovolemia-usually from Na (and hence H2O) losses with H2O losses predominating

A. Urine Na >20 meq/L reflects renal losses from diuretics, glycosuria, mannitol, renal failure, etc. Urine volume also tends to be high with high osmolality.

B. Urine Na 70

Treatment: Calcium salts are preferable

CaCO3 (OsCal) 1-2 tab po tid (comes in 500 and 650 mg tablets)

Ca acetate (PhosLo) 1-2 tab po tid (comes in 667 mg tablets)

Aluminum hydroxide (AmphoGel) 600 mg po tid may be used if Ca is already high, but risk aluminum toxicity with long-term use

Alternatives: saline diuresis if no renal failure, dialysis

HYPOCALCEMIA

if low, make sure to correct for

low albumin (see formula section) or measure ionized Ca. Note alkalosis augments Ca binding to albumin and increases severity of symptoms.

Causes: renal failure

critically ill patients

hypoparathyroidism or pseudohypoparathyroidism (PTH resistance)

severe hypomagnesemia or hypermagnesemia

acute pancreatitis

rhabdomyolysis

tumor lysis syndrome

vitamin D deficiency

post transfusion

Signs: paresthesias, tetany (especially carpopedal spasm), lethargy, confusion, seizures

Trousseau's sign, Chvostek's sign, QT prolongation

Treatment: Symptomatic hypocalcemia should be corrected by replacement with calcium gluconate IV (1 amp = 10 cc of 10% Ca gluconate = 90 mg Ca). Start with 2 amps IV over 10 minutes.

If present, low Mg should also be corrected because it contributes to low Ca.

HYPOKALEMIA

Causes: inadequate intake

GI loss (vomiting, diarrhea, laxative abuse, fistula)

drugs (diuretics, insulin, gentamicin, amphotericin, carbenicillin)

excess mineralocorticoids (Cushing's, hyperaldosteronism, hyperreninemia)

congenital (Bartter, Liddle)

RTA types I, II

metabolic alkalosis

acute hyperventilation

DKA

ECG: T wave flattening ± inversion, U waves, arrhythmias (e.g. PSVT, Afib, etc.), and ST changes, pseudo-prolonged QT.

Treatment: Check creatinine first!

Supplement to keep 4.0 or greater except in patients with renal insufficiency who are almost always not supplemented.

Serum potassium rises 0.1 for every 10 meq of supplementation.

In the units, you may write a sliding scale if creatinine is stable and ................
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