Notebook facts- for PALM - Stanford Medicine
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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