WordPress.com



2260607657465General Principles of Management00General Principles of Management2260601057910Corrected Na = measured Na + BSL – 5 300Corrected Na = measured Na + BSL – 5 315132057657465See below for specifics of managementIndications for hypertonic saline: coma, seizure, new onset profound ? LOC; not indicated if asymptomatic Dose: give 25-100ml/hr (1-2ml/kg/hr) 3% saline via CVL Or 100ml 3% saline (= 50mmol) Can give more rapidly (eg. 500ml or 4-6ml/kg bolus over 10mins) if seizing; can give more rapidly if hyponatraemia developed quickly (ie. <12-24hrs) Endpoint: symptoms resolved / Na ? by 8-20mmol/L / Na >125 Aim for correction of 1 mmol/L/hr (max 10-14mmol/L/day; Never correct faster than 25mmol/L/day; 1mmol/hr achieved by 100ml/hr) Side effects: central pontine myelinosis (osmotic demyelination syndrome) if too rapid correction of chronic (>48hr) hyponatraemia develops over 3-5/7 symmetrical lesions around pons, occurs in 25% severe cases altered LOC, seizures, brain stem signs, pseudobulbar palsy, quadriparesis, dysarthria, dysphagia, tremor, ataxia, Parkinsonism, dystonia, catatonia, mutism, lethargy; may be permanent; risk factors = alcoholic, malnourished, ? K, burns, elderly00See below for specifics of managementIndications for hypertonic saline: coma, seizure, new onset profound ? LOC; not indicated if asymptomatic Dose: give 25-100ml/hr (1-2ml/kg/hr) 3% saline via CVL Or 100ml 3% saline (= 50mmol) Can give more rapidly (eg. 500ml or 4-6ml/kg bolus over 10mins) if seizing; can give more rapidly if hyponatraemia developed quickly (ie. <12-24hrs) Endpoint: symptoms resolved / Na ? by 8-20mmol/L / Na >125 Aim for correction of 1 mmol/L/hr (max 10-14mmol/L/day; Never correct faster than 25mmol/L/day; 1mmol/hr achieved by 100ml/hr) Side effects: central pontine myelinosis (osmotic demyelination syndrome) if too rapid correction of chronic (>48hr) hyponatraemia develops over 3-5/7 symmetrical lesions around pons, occurs in 25% severe cases altered LOC, seizures, brain stem signs, pseudobulbar palsy, quadriparesis, dysarthria, dysphagia, tremor, ataxia, Parkinsonism, dystonia, catatonia, mutism, lethargy; may be permanent; risk factors = alcoholic, malnourished, ? K, burns, elderly150177520040601-2.5% hospitalised patients (most common electrolyte imbalance seen in hospital population)Assoc with 60x mortality compared to normal Na inpatients001-2.5% hospitalised patients (most common electrolyte imbalance seen in hospital population)Assoc with 60x mortality compared to normal Na inpatients2146302004060Epidemiology00Epidemiology15017752522220 Normal Saline 154 Ringer’s Lactate 130 Interstitial 144 Intracellular 10 Plasma 14200 Normal Saline 154 Ringer’s Lactate 130 Interstitial 144 Intracellular 10 Plasma 1422146302522220Normal Concentrations00Normal Concentrations15017753135630Na comprises 90% of osmotically active particles in extracellular fluid and plasmaIn proximal convoluted tubule: 60% H20, 70% Na reabsorbed; angiotensin II ? Na reabsorptionIn loop of Henle: 20% H20, 20% Na is reabsorbedIn distal convoluted tubule: 5% Na reabsorbed; aldosterone ? Na reabsorption, ? K and H excretion)In collecting ducts: 2-15% H20, 3% Na reabsorbed; ADH ? H20 reabsorption controlled by osmoreceptors in hypothalamus00Na comprises 90% of osmotically active particles in extracellular fluid and plasmaIn proximal convoluted tubule: 60% H20, 70% Na reabsorbed; angiotensin II ? Na reabsorptionIn loop of Henle: 20% H20, 20% Na is reabsorbedIn distal convoluted tubule: 5% Na reabsorbed; aldosterone ? Na reabsorption, ? K and H excretion)In collecting ducts: 2-15% H20, 3% Na reabsorbed; ADH ? H20 reabsorption controlled by osmoreceptors in hypothalamus2146303135630Physiology00Physiology15017754428490Serum Na00Serum Na29292554428490Symptoms00Symptoms29292554833620Mild GI symptoms (eg. Anorexia, nausea, vomiting); can be managed as outpatient00Mild GI symptoms (eg. Anorexia, nausea, vomiting); can be managed as outpatient15017754833620>12500>12529292555326380Lethargy, confusion, muscle weakness; if asymptomatic, need close follow up and repeat Na in 72 hours; if symptomatic, admit00Lethargy, confusion, muscle weakness; if asymptomatic, need close follow up and repeat Na in 72 hours; if symptomatic, admit15017755326380115-12500115-12529292555834380Decreased LOC, seziures; can cause brainstem herniation cerebral oedema, osmotic demyelination; requires emergent admission00Decreased LOC, seziures; can cause brainstem herniation cerebral oedema, osmotic demyelination; requires emergent admission15017755834380<11500<11515017756313805Symptoms more likely if: fast decrease (>0.5mmol/hr) or large decrease (<120 in <24 hours) or osmolality <240; worse in women and children00Symptoms more likely if: fast decrease (>0.5mmol/hr) or large decrease (<120 in <24 hours) or osmolality <240; worse in women and children2146304428490Symptoms00Symptoms15074906840220Clinical picture; ?on diuretics; urine and blood Na and osmolality; BSLIncreased urine osmolality: SIADH, renal / hepatic / cardiac failure, hypoV, hypothyroidDecreased urine osmolality: ADH working fineUrine chloride <20: hypovolaemia00Clinical picture; ?on diuretics; urine and blood Na and osmolality; BSLIncreased urine osmolality: SIADH, renal / hepatic / cardiac failure, hypoV, hypothyroidDecreased urine osmolality: ADH working fineUrine chloride <20: hypovolaemia2203456840220Investigations00Investigations237490292100Hyponatraemia (Na <135)00Hyponatraemia (Na <135) 24072859657080Management: fluid and salt restrict; loop diuretics; dialysis00Management: fluid and salt restrict; loop diuretics; dialysis15468603891915Eu-volaemic00Eu-volaemic24047457232015Minimal increase in body water No change in body NaManagement: fluid restrict to 500-1500ml/day; consider ADH antagonist if SIADH00Minimal increase in body water No change in body NaManagement: fluid restrict to 500-1500ml/day; consider ADH antagonist if SIADH24072854258310Renal00Renal24123656427470Extra-Renal00Extra-Renal30359356427470Iatrogenic H20 overdose: bladder irrigation, IV fluidsPolydipsiaEndocrine: hypothyroidism, hypocortisolism00Iatrogenic H20 overdose: bladder irrigation, IV fluidsPolydipsiaEndocrine: hypothyroidism, hypocortisolism59289956427470Urinary Na <20Large amounts H20 in urine00Urinary Na <20Large amounts H20 in urine24072853891915Aetiology00Aetiology30327604255770SIADH: ADH holds on to H20 concentrated urine; accounts for 50% of all hyponatraemia; multiple causes as below:CNS: cancer, trauma, infection, CVA, Guillian-Barre syndrome, delirium tremens, multiple sclerosis, SLE, SAH, AIDSRS: cancer (oat cell, bronchogenic), Infection, COPD, cystic fibrosis, abscess, TBDrugs: SSRI, TCA, MAOI, ecstasy, oxytocin, carbamazepine, haloperidol, barbiturates, NSAID’s, tramadol, omeprazoleEndocrine: hypothyroidism, hypocortisolism00SIADH: ADH holds on to H20 concentrated urine; accounts for 50% of all hyponatraemia; multiple causes as below:CNS: cancer, trauma, infection, CVA, Guillian-Barre syndrome, delirium tremens, multiple sclerosis, SLE, SAH, AIDSRS: cancer (oat cell, bronchogenic), Infection, COPD, cystic fibrosis, abscess, TBDrugs: SSRI, TCA, MAOI, ecstasy, oxytocin, carbamazepine, haloperidol, barbiturates, NSAID’s, tramadol, omeprazoleEndocrine: hypothyroidism, hypocortisolism59289953891915Investigations00Investigations59289954258310Urinary Na >20? urinary osmolalityUrinary Cl >4000Urinary Na >20? urinary osmolalityUrinary Cl >4015468608221345Hyper-volaemic00Hyper-volaemic59289958947785Urinary Na <2000Urinary Na <2024072858948420Extra-Renal00Extra-Renal30327608949055Cardiac failure, cirrhosis, nephrotic syndrome? H20 but functionally underfilled ? aldosterone Na retention00Cardiac failure, cirrhosis, nephrotic syndrome? H20 but functionally underfilled ? aldosterone Na retention59289958587740Urinary Na >2000Urinary Na >2030327608585200Acute renal failure: can’t excrete water00Acute renal failure: can’t excrete water24072858587105Renal00Renal59289958221345Investigations00Investigations24072858221345Aetiology00Aetiology266065427990Hypotonic= serum osmolality <27500Hypotonic= serum osmolality <27524047452853055Loss of Na > H20 Na deficit (mmol/L) = (0.6 x kg) x (desired Na – actual Na)Management: give normal saline correct at <0.5mmol/hr or <12mmol/day; aim to get Na >12500Loss of Na > H20 Na deficit (mmol/L) = (0.6 x kg) x (desired Na – actual Na)Management: give normal saline correct at <0.5mmol/hr or <12mmol/day; aim to get Na >1252409825427990Aetiology00Aetiology1549400427990Hypo-volaemic00Hypo-volaemic59289951913255Urinary Na >20? urinary osmolalityKidneys reabsorb Na to make up for their losses00Urinary Na >20? urinary osmolalityKidneys reabsorb Na to make up for their losses30353001913255Gastrointesinal loss: diarrhoea, vomiting, NG tubeThird space loss: burns, pancreatitis, peritonitisSweating, blood loss00Gastrointesinal loss: diarrhoea, vomiting, NG tubeThird space loss: burns, pancreatitis, peritonitisSweating, blood loss24072851913255Extra-Renal00Extra-Renal2409825791845Renal00Renal5928995791845Urinary Na >2000Urinary Na >203035935790575Osmotic diuresis: glucose, urea, mannitolDiuretics? Mineralocorticoid: hypoaldosteronismNa losing nephropathy: renal tubular acidosis, chronic renal failure, interstitial nephritis, cerebal salt wasting syndrome)00Osmotic diuresis: glucose, urea, mannitolDiuretics? Mineralocorticoid: hypoaldosteronismNa losing nephropathy: renal tubular acidosis, chronic renal failure, interstitial nephritis, cerebal salt wasting syndrome)5928995427990Investigations00Investigations2800351818005Hypertonic= serum osmolality >29500Hypertonic= serum osmolality >29516046451818005No change to total body water or NaExtracellular solute load water moves into extracellular fluid, diluting Na (eg. Hyperglycaemia, mannitol, glycerol)Management: treat cause (this may cause osmotic diuresis genuine ? Na)IV fluids may help as often hypovolaemic00No change to total body water or NaExtracellular solute load water moves into extracellular fluid, diluting Na (eg. Hyperglycaemia, mannitol, glycerol)Management: treat cause (this may cause osmotic diuresis genuine ? Na)IV fluids may help as often hypovolaemic1604645685800No change to total body water or Na (ie. Pseudohyponatraemia)Factitious: ? protein, ? lipids artifically low NaTherefore requires no treatmentManagement: fluid restrict to 500-1500ml/day; consider ADH antagonist if SIADH00No change to total body water or Na (ie. Pseudohyponatraemia)Factitious: ? protein, ? lipids artifically low NaTherefore requires no treatmentManagement: fluid restrict to 500-1500ml/day; consider ADH antagonist if SIADH280035685800Isotonic= serum osmolality 275-29500Isotonic= serum osmolality 275-295 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download