Electrolyte disorders in
Critically ill patients
8EDLGXU 5DKDPDQ
6HQLRU 5HVLGHQW &&0
6*3*,06 /XFNQRZ ,QGLD
“It is the internal environment (not the external world) that
provides the physical need for life”
CLAUDE BERNARD

Ubaidur...
BODY FLUID COMPARTMENTS
Arrow represents fluid movement

Review of Medical Physiology, William F. Ganong
Ubaidur Rahaman, ...
Electrolyte Composition
of Body Fluid Compartments

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Composition
of body fluids losing continuously

Source

Daily Loss

Na+

K+

Cl-

HCO3-

Saliva

1000

30-80

20

70

30

...
Composition of IV fluids
in comparison to Plasma
Fluid

Na

K

Ca

Mg

Cl

Buffers

Glucose

pH

Osm

141

4.5

5

2

103
...
Sodium
Water
disturbances

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Na is the most abundant molecule in ECF
Na is the most osmotically active molecule in ECF
Contribution of Gluc and BUN is
...
OSMOLALITY
Serum
280-295 mOsm/kg

Urine
24 hour urine sample-500-800 mOsm/kg
Extreme range-50-1400mOsm/kg

Random urine sa...
Real story in critically ill patients

S. Osm = 2* (140) + 90/18 + 5/2.8
= 280
+ 5
+ 1.7
= 286.7

S. Osm = 2* (145) + 180/...
Na

WATER

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Na / water regulation

Thirst

ADH

RAA

Kidney

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Epidemiology of electrolyte disorder in ICU

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Intensive Care Medicine 2010, 36(2):304-11

Incidence and prognosis of dysnatremias present on ICU admission
Funk GC, Lind...
Critical Care 2008, 12:R162

The epidemiology of intensive care unit-acquired hyponatraemia
and hypernatraemia in medical-...
Critical Care 2008, 12:R162

The epidemiology of intensive care unit-acquired hyponatraemia
and hypernatraemia in medical-...
Critical Care 2008, 12:R162

The epidemiology of intensive care unit-acquired hyponatraemia
and hypernatraemia in medical-...
Critically ill patients
prone to
electrolyte disturbances

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Disturbance in fluid and electrolyte homeostasis
sepsis, shock, cardiac failure, acute kidney injury, burn, surgery, C.N.S...
Am J KidneyDis 2009 Oct, 54:674-679

tonicity balance in patients with Hypernatremia Acquired in the
Intensive Care Unit
G...
Am J KidneyDis 2009 Oct, 54:674-679

tonicity balance in patients with Hypernatremia Acquired in the
Intensive Care Unit
G...
Am J KidneyDis 2009 Oct, 54:674-679

tonicity balance in patients with Hypernatremia Acquired in the
Intensive Care Unit
G...
Am J KidneyDis 2009 Oct, 54:674-679

tonicity balance in patients with Hypernatremia Acquired in the
Intensive Care Unit
G...
Am J KidneyDis 2009 Oct, 54:674-679

tonicity balance in patients with Hypernatremia Acquired in the
Intensive Care Unit
G...
Nephrol Dial Transplant 2008,23:1562-1568

Hypernatremia in critically ill patients: too little water and too much salt
Ew...
Nephrol Dial Transplant 2008,23:1562-1568

Hypernatremia in critically ill patients: too little water and too much salt
Ew...
Nephrol Dial Transplant 2008,23:1562-1568

Hypernatremia in critically ill patients: too little water and too much salt
Ew...
Use of hypotonic fluid is avoided in ICU
Capillary leakiness in sepsis patients
Fear of hyponatremia as many patient show ...
JUST AN
ANALYSIS

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Nephrol Dial Transplant 2008,23:1562-1568

Hypernatremia in critically ill patients: too little water and too much salt
Ew...
Intensive Care Med 2001;27:921-924

Tonicity balance, and not electrolyte free water calculations, more accurately
guide t...
Intensive Care Med 2001;27:921-924

Tonicity balance, and not electrolyte free water calculations, more accurately
guide t...
Intensive Care Med 2001;27:921-924

Tonicity balance, and not electrolyte free water calculations, more accurately
guide t...
Intensive Care Med 2001;27:921-924

Tonicity balance, and not electrolyte free water calculations, more accurately
guide t...
HYPERNATREMIA

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
HYPERNATREMIA
S. Na > 145 meq/L

True/ Relative water deficit
Clinical manifestation
Thirst
Lethargy, irritability, restle...
APPROACH

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Hypernatremia

Primary
Na gain
HYPERVOLEMIA
Hypertonic saline load
NaHCO3, 3% saline
Hyperaldosteronism
Cushing’s syndrome...
Appropriate response to hypernatremia

Excretion of small volume (<800 ml)
Of
concentrated urine (Osm U > 800 mOsm/L)

Uba...
Hypernatremia
Hypotonic
fluid loss
HYPOVOLEMIA/ ISOVOLEMIA

<800 ml

Urine volume

>1000 ml

Urine osmolality
Urine osmola...
MANAGEMENT
HYPERNATREMIA
Correction

Risk : development of brain odema
Chronic hypernatramia- brain cells fully adapted
Risk is more
...
HYPERNATREMIA
Correction

EFW deficit calculation (L)
TBW* ( [S.Na] /140 ) - 1

Water deficit calculation (L)
Madias and A...
Mind it

Ongoing loss
Must be considered
along with calculated water deficit

as
Formulas assume a closed system
Require s...
70 kg women
Diarrhoea of volume 2 L/ day
S.[Na]= 160meq/L , S.[K]= 3.0meq/L

Estimated change in S.[Na] with 1 L of N/2 sa...
Hypernatremia

HYPERVOLEMIA

Hypotonic
fluid loss
HYPOVOLEMIA
ISOVOLEMIA

Hypotonic fluid ± diuretic
Urine output < water ...
HYPERNATREMIA
summary of management
Hypovolemic hypernatremia:
AIM- positive EFW and solute balance

Hemodynamic unstable:...
Initial acute management of
hypernatremia
Severe neurologic compromise

Absent/ mild neurologic signs

Search for alternat...
DIABETES INSIPIDUS
Hypotonic urine in face of hyperosmolar plasma

CDI- Osm U <200
NDI- Osm U 200-500

Water restriction: ...
HYPONATREMIA
HYP0NATREMIA
S. Na < 135 meq/L

True/ Relative water excess
Clinical manifestation
headache, nausea
lethargy, disorientati...
APPROACH

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
hyponatremia
Assess serum osmolality

high serum osmolality

Normal serum osmolality

Hypertonic HypoNa

Isotonic HypoNa
P...
hypotonic Hypovolemic Hyponatremia
LOSS
(both water and Na) = Negative water and Na balance
Diuresis
Osmotic- glucose, ure...
Hypotonic Isovolemic Hyponatremia
Impaired free water loss in urine
Normal Na loss in urine

Pain, nausea, stress

SIADH

...
CORRECTION
PRECAUTION IN CORRECTION
central pontine myelinosis

Absolute magnitude of correction in 24 hours
more important than rate...
HYPONATREMIA
Rate of correction

Symptomatic
or
Acute hyponatremia

1-2 meq/L/h ( 10-12 meq/L/day)

(change >0.5 meq/L/h o...
Mind it
RULE FOR CORRECTION

Any saline solution that is hyperosmolar to urine can increase [Na]
when
oral water intake is...
ONE RULE FOR CORRECTION
60 years male, febrile encephalopathy
Body weight: 60 kg, TBW: 36 L
Develops SIADH
S.[Na]= 118, ur...
HYPONATREMIA
CALCULATION OF [Na] deficit

Na deficit (meq)
TBW* ( 140 – s.Na)

Anticipated change in s.Na with 1L of fluid...
HYPONATREMIA

Hypertonic HypoNa
Hyperglycemia
Hypertonic sodium free sol
(mannitol)

Remove or treat cause
of hypertonicit...
hypotonic hyponatremia
Assess urine osmolality

urine osmolality > 100 mOsm/L
Assess volume status

urine osmolality <100 ...
hypotonic hyponatremia
urine osmolality > 100 mOsm/L
Assess volume status

hypervolemic

Isovolemic

Urine [Na]
>20meq/L

...
HYPONATREMIA
summary of management
hypotonic Hypovolemic hyponatremia
AIM- positive water and Na balance

Replace calculat...
Initial acute management of
hyponatremia
Severe neurologic compromise

Absent/ mild neurologic signs

Search for alternati...
SOLUTION= SOLUTE+ SOLVENT

Molality: number of moles of a solute per kilogram of solvent
Molarity: number of moles of solu...
Free water (FW)
Calculated base on osmolality
(Na, Glucose, BUN)

As urea is freely permeable across all cell membrane
Doe...
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Electrolyte disorders in_critically_ill_patients__na

  1. 1. Electrolyte disorders in Critically ill patients 8EDLGXU 5DKDPDQ 6HQLRU 5HVLGHQW &&0 6*3*,06 /XFNQRZ ,QGLD
  2. 2. “It is the internal environment (not the external world) that provides the physical need for life” CLAUDE BERNARD Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  3. 3. BODY FLUID COMPARTMENTS Arrow represents fluid movement Review of Medical Physiology, William F. Ganong Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  4. 4. Electrolyte Composition of Body Fluid Compartments Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  5. 5. Composition of body fluids losing continuously Source Daily Loss Na+ K+ Cl- HCO3- Saliva 1000 30-80 20 70 30 Gastric 1000-2000 60-80 15 100 0 Pancreas 1000 140 5-10 60-90 40-100 Bile 1000 140 5-10 100 40 Small Bowel 2000-5000 140 20 100 25-50 Large Bowel 200-1500 75 30 30 0 Sweat 200-1000 20-70 5-10 40-60 0 urine 1500-2000 <10 Frusemide diuresis 75 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  6. 6. Composition of IV fluids in comparison to Plasma Fluid Na K Ca Mg Cl Buffers Glucose pH Osm 141 4.5 5 2 103 HCO3-26 Prot-16 0.7-1.1 7.4 290 Plasma NS 154 RL 6.0 308 77 1/2NS 154 77 5.0 154 6.5 274 4.5 252 7.4 294 4.5 1026 130 4 3 109 Lac-28 5%D 50 Plasmalyte 140 5 3 98 Acet-27 Gluc-23 Gel 3%Saline 513 513 5%Alb 20%Alb Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  7. 7. Sodium Water disturbances Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  8. 8. Na is the most abundant molecule in ECF Na is the most osmotically active molecule in ECF Contribution of Gluc and BUN is 5 mOsm/L S. Osm ( mOsm/kg of water) (2*[Na] + [Glucose/18] + [BUN/2.8] (Na in meq/L, Glucose in mg/dL, BUN in mg/dL) Osmotic pressure and osmolality determines distribution of fluid in body compartments Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  9. 9. OSMOLALITY Serum 280-295 mOsm/kg Urine 24 hour urine sample-500-800 mOsm/kg Extreme range-50-1400mOsm/kg Random urine sample- 300-900mOsm/kg After overnight fluid restriction Urine omolality > 3 times serum osmolality (>800) Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  10. 10. Real story in critically ill patients S. Osm = 2* (140) + 90/18 + 5/2.8 = 280 + 5 + 1.7 = 286.7 S. Osm = 2* (145) + 180/18 + 60/2.8 = 290 + 10 + 21 = 321 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  11. 11. Na WATER Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  12. 12. Na / water regulation Thirst ADH RAA Kidney Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  13. 13. Epidemiology of electrolyte disorder in ICU Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  14. 14. Intensive Care Medicine 2010, 36(2):304-11 Incidence and prognosis of dysnatremias present on ICU admission Funk GC, Lindner G, Druml W, Metnitz B, Schwarz C, Bauer P, Metnitz PG retrospective study in 77 medical, surgical, and mixed ICUs in Austria, 151,486 adults patients admitted over a period of 10 years (1998-2007). 75% patients had normal sodium levels (Na:135-145) on ICU admission Incidence hyponatremia-17.7%, Hypernatremia-6.9% All types and grades of dysnatremia were associated with increased hospital mortality independent mortality risk rising with increasing severity of both hyponatremia and hypernatremia Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  15. 15. Critical Care 2008, 12:R162 The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units Henry Thomas Stelfox, Sofia B Ahmed, Farah Khandwala, David Zygun, Reza Shahpori, Kevin Laupland 8142 adults admitted in 3 medical-surgical ICUs Over 6 years documented to have normal S. sodium levels (133 to 145 mmol/L) on the first day of ICU admission Incidence Hyponatremia- 11%, hypernatremia-26% Median time to develop dysnatremia- 2 days Median duration of dysnatremia-2 days hospital mortality increased significantly Independent of SOI ( hypoNa-28%, hyperNa-34%, normoNa-16%) More than 1 distinct epi of dysnatremia- 25% (Hyponatremia-16%, hypernatremia-19%) Continued….. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  16. 16. Critical Care 2008, 12:R162 The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units Henry Thomas Stelfox, Sofia B Ahmed, Farah Khandwala, David Zygun, Reza Shahpori, Kevin Laupland Continued….. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  17. 17. Critical Care 2008, 12:R162 The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units Henry Thomas Stelfox, Sofia B Ahmed, Farah Khandwala, David Zygun, Reza Shahpori, Kevin Laupland Increased risk of hypernatremia Raised S.creatinine Mechanical ventilation Increased risk of both hyper and hyponatremia Length of stay in ICU Increased APACHE II score •Dysnatremias develop insidiously over 2 days •Difficult to identify as clinicians preoccupied with more acute medical issues and other lab investigations Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  18. 18. Critically ill patients prone to electrolyte disturbances Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  19. 19. Disturbance in fluid and electrolyte homeostasis sepsis, shock, cardiac failure, acute kidney injury, burn, surgery, C.N.S. disorders Activation of neuro hormonal system- SNS, RAAS, Vasopressin Non osmotic release of Vasopressin pain, nausea, medication, hypovolemia Vasopressin deficiency in sepsis Insensitivity to insensible losses Diuresis iotrogenic- renal and osmotic diuretics Urea, glucose induced Hypokalemia, hypercalcemia Drug induced- aminoglycoside, ampho B Impaired thirst mechanism Inappropriate administration of fluid and electrolytes Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  20. 20. Am J KidneyDis 2009 Oct, 54:674-679 tonicity balance in patients with Hypernatremia Acquired in the Intensive Care Unit Gregor L, Nikolaus K, Ulrike Holzinger, Wilfred Druml, christiph schwartz Solute balance= [Na+K]input – [Na+K]output Continued… Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  21. 21. Am J KidneyDis 2009 Oct, 54:674-679 tonicity balance in patients with Hypernatremia Acquired in the Intensive Care Unit Gregor L, Nikolaus K, Ulrike Holzinger, Wilfred Druml, christiph schwartz Non oliguric osmotic DI Urea/ glucose Hypertonic Osm>150 Causes of ICU acquired hypernatremia Addition of KCl to 0.9%saline led to positive solute balance in 27% patients Continued…
  22. 22. Am J KidneyDis 2009 Oct, 54:674-679 tonicity balance in patients with Hypernatremia Acquired in the Intensive Care Unit Gregor L, Nikolaus K, Ulrike Holzinger, Wilfred Druml, christiph schwartz •Positive solute balance contributed 56% cases •Primary reason was inadequate substitution of hypotonic losses with isotonic or hypertonic fluids •Impaired sensorium and inability to express thirst leading to inadequate intake of free water Community acquired hypernatremia- hypovolemic hypernatria ICU- euvolemic or hypervolemic hypernatremia Continued… Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  23. 23. Am J KidneyDis 2009 Oct, 54:674-679 tonicity balance in patients with Hypernatremia Acquired in the Intensive Care Unit Gregor L, Nikolaus K, Ulrike Holzinger, Wilfred Druml, christiph schwartz Characteristics of patients Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India Continued…
  24. 24. Am J KidneyDis 2009 Oct, 54:674-679 tonicity balance in patients with Hypernatremia Acquired in the Intensive Care Unit Gregor L, Nikolaus K, Ulrike Holzinger, Wilfred Druml, christiph schwartz Characteristics of patients Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  25. 25. Nephrol Dial Transplant 2008,23:1562-1568 Hypernatremia in critically ill patients: too little water and too much salt Ewout J. Hoorn, Mecheil G.H.Betjes, Joachim Weigel, Robert Zietse Patients admitted over 1 year medical, surgical or neurological ICU hypernatremia ≥150 mmol/l in the ICU Renal dysfunction, Hypokalaemia, hypercalcemia, mannitol, sodium bicarbonate •more common in cases •independently associated with hypernatraemia. • mortality was higher in case •Hypernatremia was independent predictor Continued… Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  26. 26. Nephrol Dial Transplant 2008,23:1562-1568 Hypernatremia in critically ill patients: too little water and too much salt Ewout J. Hoorn, Mecheil G.H.Betjes, Joachim Weigel, Robert Zietse •Approximately half of cases were polyuric, even when fluid balance was negative + •Impaired thirst mechanism •Inappropriate iv fluid administration with isotonic fluids •Aim of treatment- negative solute balance •Hypotonic fluid may aggravate fluid overload •Diuretic may be considered: combination of loop diuretic and water or thiazide diuretic alone Continued… Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  27. 27. Nephrol Dial Transplant 2008,23:1562-1568 Hypernatremia in critically ill patients: too little water and too much salt Ewout J. Hoorn, Mecheil G.H.Betjes, Joachim Weigel, Robert Zietse Potential factors contributing to hypernatremia Page 1566 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  28. 28. Use of hypotonic fluid is avoided in ICU Capillary leakiness in sepsis patients Fear of hyponatremia as many patient show non osmotic release of Vasopressin Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  29. 29. JUST AN ANALYSIS Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  30. 30. Nephrol Dial Transplant 2008,23:1562-1568 Hypernatremia in critically ill patients: too little water and too much salt Ewout J. Hoorn, Mecheil G.H.Betjes, Joachim Weigel, Robert Zietse •47-year-old male •(body weight 95 kg) •cystectomy complicated by faecal peritonitis. •Hypernatraemia in1day •large isotonic volume resuscitation, + hypertonic fluids (NaHCO3) •Water loss •Renal: renal insufficiency and hyperglycaemia •non-renal: wound drains and colostomy Tonicity balance illustrating mechanism of hypernatremia Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  31. 31. Intensive Care Med 2001;27:921-924 Tonicity balance, and not electrolyte free water calculations, more accurately guide therapy for acute change in natremia A.P.C.P. Carlotti, D. Bohn, J.P. Mallie, M.L. Halperin 14 year old male ( weight 40 kg, total body water 24 L) Operated for craniopharyngioma During surgery • excreted 4L in 9 hours Over this period •P.[Na] rose from 140 to 157 meq/L • received 3 L of isotonic saline 2.9L 2.9L •His urine [Na+K] was 50 meq/L. Free Water deficit: 24* [ (157/140) – 1 ] = 2.9 L TBW* ( [S.Na] /140 ) - 1 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  32. 32. Intensive Care Med 2001;27:921-924 Tonicity balance, and not electrolyte free water calculations, more accurately guide therapy for acute change in natremia A.P.C.P. Carlotti, D. Bohn, J.P. Mallie, M.L. Halperin 4 L urine with 200meq Na= 1.3 L isotonic saline + 2.7 L of EFW Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  33. 33. Intensive Care Med 2001;27:921-924 Tonicity balance, and not electrolyte free water calculations, more accurately guide therapy for acute change in natremia A.P.C.P. Carlotti, D. Bohn, J.P. Mallie, M.L. Halperin Na 200 mmol Tonicity balance Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  34. 34. Intensive Care Med 2001;27:921-924 Tonicity balance, and not electrolyte free water calculations, more accurately guide therapy for acute change in natremia A.P.C.P. Carlotti, D. Bohn, J.P. Mallie, M.L. Halperin 1 2 3 3 situations with hypernatremia and negative balance of 2.7 L of EFW Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  35. 35. HYPERNATREMIA Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  36. 36. HYPERNATREMIA S. Na > 145 meq/L True/ Relative water deficit Clinical manifestation Thirst Lethargy, irritability, restlessness Spasticity, hyperreflexia, seizure, coma Death Cerebral Hemorrhage/ ischemia Insulin resistance, impaired gluconeogenesis Cardiac dysfunction Severity of symptoms correlate with rate and magnitude of change in [Na] Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  37. 37. APPROACH Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  38. 38. Hypernatremia Primary Na gain HYPERVOLEMIA Hypertonic saline load NaHCO3, 3% saline Hyperaldosteronism Cushing’s syndrome Hypotonic fluid loss HYPOVOLEMIA ISOVOLEMIA Extra renal loss Renal loss Insensible loss Fever, burn Diuresis Osmotic glucose, urea, mannitol, high osmolar feeds Diuretics- frusemide, thiazide Diabetes insipidus CDI Azotemia out of proportion to decrease in GFR NDI renal disease Drugs- amphoterecin, aminoglycosides, lithium Electrolyte disorders- hypokalemia, hypercalcemia Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India Catabolic patients with Moderate renal insuficiency on high protein diet and stress dose steroid
  39. 39. Appropriate response to hypernatremia Excretion of small volume (<800 ml) Of concentrated urine (Osm U > 800 mOsm/L) Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  40. 40. Hypernatremia Hypotonic fluid loss HYPOVOLEMIA/ ISOVOLEMIA <800 ml Urine volume >1000 ml Urine osmolality Urine osmolality >800 300 - 800 < 300 <900 mOsm/day >900 mOsm/day Response to dDAVP Osmotic diuresis Insensible losses diuretics Urine osmole excretion /day + complete CDI with hypovolemia Solute diuresis + Partial CDI - partial NDI Renal tubular disease Drugs electrolyte disturbances Response to dDAVP + complete CDI _ complete NDI Inherited lithium Water diuresis
  41. 41. MANAGEMENT
  42. 42. HYPERNATREMIA Correction Risk : development of brain odema Chronic hypernatramia- brain cells fully adapted Risk is more Rate of correction Acute hypernatremia: 1-2 meq/L/h ( 10-12 meq/L/day) Chronic hypernatremia: 0.5 meq/L/h ( 8-10 meq/L/day) GOAL Na <145 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  43. 43. HYPERNATREMIA Correction EFW deficit calculation (L) TBW* ( [S.Na] /140 ) - 1 Water deficit calculation (L) Madias and Adrogue equation Scan Page 74 JW LEE Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  44. 44. Mind it Ongoing loss Must be considered along with calculated water deficit as Formulas assume a closed system Require separate account of ongoing losses Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  45. 45. 70 kg women Diarrhoea of volume 2 L/ day S.[Na]= 160meq/L , S.[K]= 3.0meq/L Estimated change in S.[Na] with 1 L of N/2 saline 75 – 160 / (70*50) + 1 = - 2.3 meq/ L change of 10 meq/L = 4.3L of N/2 saline has to be given in 24 hours But ongoing loss = 0.7 L + 2.0 L = 2.7 L / 24 hours Total volume to be given 4.3 L + 2.7 L = 7.0 L / 24 hours Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  46. 46. Hypernatremia HYPERVOLEMIA Hypotonic fluid loss HYPOVOLEMIA ISOVOLEMIA Hypotonic fluid ± diuretic Urine output < water replacement Insensible loss Diabetes insipidus Osmotic diuresis Remove / treat cause of DI Replace losses with hypotonic fluid Hemodynamically unstable Correct volume with isotonic saline CDI Ddavp Switch over to hypotonic fluid to to correct Na NDI low Na diet + thiazide ± low protein diet ± NSAID Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  47. 47. HYPERNATREMIA summary of management Hypovolemic hypernatremia: AIM- positive EFW and solute balance Hemodynamic unstable: resuscitate with isotonic fluid (0.9% saline or RL) Switch over to hypotonic fluid once resuscitated isovolemic hypernatremia: AIM- positive EFW balance Replace losses with Hypotonic fluid Treatment of cause: DI NDI remove/ correct causative agent Thiazide/ indomethacin CDI: ADH analogue dDAVP: 10-20 ug intranasal bd or 1-2ug sc bd Hypervolemic hypernatremia: AIM- negative EFW and solute balance Na restriction + Hypotonic fluid + frusemide Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  48. 48. Initial acute management of hypernatremia Severe neurologic compromise Absent/ mild neurologic signs Search for alternative cause of neurologic compromize [Na] ≥155 meq/L [Na] <155 meq/L Duration of hypernatremia 5% dextrose Initial goal Fall of [Na] by 1.5-2.0 meq/L/h for 3-4 hours or until symptoms resolve < 2 days Change in [Na] can occur rapildly Immediate attainment to normal Is not goal > 2 days Change in [Na] should not exceed 10 meq/L in first 24 hours Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  49. 49. DIABETES INSIPIDUS Hypotonic urine in face of hyperosmolar plasma CDI- Osm U <200 NDI- Osm U 200-500 Water restriction: failure of Osm U to rise by 50 mOsm/ L in first few hours Vasopressin- CDI Osm U rise by atleast 50% immediately Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  50. 50. HYPONATREMIA
  51. 51. HYP0NATREMIA S. Na < 135 meq/L True/ Relative water excess Clinical manifestation headache, nausea lethargy, disorientation, restlessness Muscle cramp, weakness, depressed reflexes, seizures, coma Death Chronic hyponatremia: developing over >48 hours Adaptative mechanism minimize symptoms Severity of symptoms correlate with rate and magnitude of fall in [Na] Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  52. 52. APPROACH Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  53. 53. hyponatremia Assess serum osmolality high serum osmolality Normal serum osmolality Hypertonic HypoNa Isotonic HypoNa Pseudohyponatremia Hyperlipidemia hyperproteinemia low serum osmolality Hyperglycemia Hypertonic sodium free sol (mannitol) Hypotonic HypoNa Assess volume status hypovolemic isovolemic hypotonic Hypovolemic hyponatremia hypotonic isovolemic hyponatremia Discussed in next pages hypervolemic hypotonic Hypervolemic Hyponatremia Cirrhosis Congestive heart failure Nephrotic syndrome Renal falire
  54. 54. hypotonic Hypovolemic Hyponatremia LOSS (both water and Na) = Negative water and Na balance Diuresis Osmotic- glucose, urea, mannitol Diuretics- thiazide, frusemide Renal loss Electrolytes-Hypokalemia, hypercalcemia Drugs- aminoglycoside, ampho B Adrenal deficiency Mineralocorticoid deficiency Salt wasting nephropathy Cerebral salt wasting GI loss Non renal loss naso gastric aspirate, abdominal Drains/ fistula third space loss (pancreatitis, ileus, obstruction) Vomiting, diarrhea Skin loss fever open wounds, burns hemorrhage
  55. 55. Hypotonic Isovolemic Hyponatremia Impaired free water loss in urine Normal Na loss in urine Pain, nausea, stress SIADH Acute psychosis CNS disorders Pulmonary disease Infections malignancy hypothyroidism Drug induced Opiods NSAIDS Antipsychotics- haloperidol SSRI- fluoxetine, sertraline TCA Carbamezapine antineoplastics Cortisol deficiency
  56. 56. CORRECTION
  57. 57. PRECAUTION IN CORRECTION central pontine myelinosis Absolute magnitude of correction in 24 hours more important than rate Initial rapid rate of correction tapering off after several hours incurs less risk than slow steady correction that exceeds 12 meq/L in 24 hours Increased risk Hypoxemia, hypokalemia, malnutrition, alcoholism Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  58. 58. HYPONATREMIA Rate of correction Symptomatic or Acute hyponatremia 1-2 meq/L/h ( 10-12 meq/L/day) (change >0.5 meq/L/h or onset in < 48 hours) Chronic hyponatremia (Change over > 48 hours or unknown duration) Increased risk of CPM as adaptive mechanism has occured GOAL of Correction 0.5 meq/L/h ( 8-10 meq/L/day) 120-130 meq/L Lower iin patients with s.Na<105 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  59. 59. Mind it RULE FOR CORRECTION Any saline solution that is hyperosmolar to urine can increase [Na] when oral water intake is restricted A crystalloid with an osmolarity less than urine osmolarity may actually worsen hyponatremia, even if the fluid [Na] is greater than serum [Na] CONTINUED…. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  60. 60. ONE RULE FOR CORRECTION 60 years male, febrile encephalopathy Body weight: 60 kg, TBW: 36 L Develops SIADH S.[Na]= 118, urine Osm > 500 mOsm/L Gain of 154 mOsm will be lost in 300 ml urine Gain of 700 ml of EFW (154* 1000/500= 300 ml, OsmU > 500) Given 1 L of 0.9% saline Na=118 Na=154 Water=1000 Na=0 water= 700 Na=154 Water= 300 Na=115 Simultaneous IV loop diuretic can counteract this phenomenon By promoting free water excretion Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  61. 61. HYPONATREMIA CALCULATION OF [Na] deficit Na deficit (meq) TBW* ( 140 – s.Na) Anticipated change in s.Na with 1L of fluid (Madias and Adrogue equation) Scan Page 74 JW LEE Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  62. 62. HYPONATREMIA Hypertonic HypoNa Hyperglycemia Hypertonic sodium free sol (mannitol) Remove or treat cause of hypertonicity Isotonic HypoNa Pseudohyponatremia Hyperlipidemia hyperproteinemia Repeat lab Use newer method of lab Fluid shift to ICF compartment does not take place Neuronal cell swelling does not occur Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  63. 63. hypotonic hyponatremia Assess urine osmolality urine osmolality > 100 mOsm/L Assess volume status urine osmolality <100 mOsm/L Primary polydypsia EFW restriction Beer potomania ± loop diuretic Post TURP Correct hypokalemia hypovolemic Urine [Na] >20meq/L Urine [Na] <10meq/L Renal loss Non renal loss Isovolemic Continued on next page hypervolemic Treatmentc Isotonic saline to correct hypovolemia Correct hypokalemia if present Continued…. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  64. 64. hypotonic hyponatremia urine osmolality > 100 mOsm/L Assess volume status hypervolemic Isovolemic Urine [Na] >20meq/L Urine [Na] <10meq/L Urine [Na] >20meq/L Renal failure Cirrhosis Congestive heart failure Nephrotic syndrome SIADH Hypothyroidism Cortisol deficiency, TREATMENT Treat underlying disease Stop drug causing increased ADHsecretion EFW restriction (restriction less than urine output) Correct hypokalemia if present Loop diuretic ADH antagonist Administer saline with osmolality more than urine osmolality Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  65. 65. HYPONATREMIA summary of management hypotonic Hypovolemic hyponatremia AIM- positive water and Na balance Replace calculated Na deficit with isotonic saline or RL hypotonic isovolemic hyponatremia AIM- negative EFW and positive Na balance Symptomatic frusemide ivi + 3% saline ( for chronic SIADH as delayed onset of action) Asymptomatic Water restriction ± Intermittent frusemide ± enteral salt demeclocycline HCL: 600-1200mg PO daily Phenytoin sod: 200-300mg PO daily Lithium: 600-1200mg PO daily ADH antagonist hypotonic Hypervolemic hyponatremia AIM- negative EFW and Na balance Na and EFW restriction + frusemide Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  66. 66. Initial acute management of hyponatremia Severe neurologic compromise Absent/ mild neurologic signs Search for alternative cause of neurologic compromize [Na] < 125 meq/L [Na] >125 meq/L Duration of hyponatremia 3% saline ivi Initial goal increase [Na] by 1.5-2.0 meq/L/h for 3-4 hours or until symptoms resolve < 2 days Change in [Na] can occur rapildly Immediate attainment to normal Is not goal > 2 days Change in [Na] should not exceed 10 meq/L in first 24 hours and 18 meq/L in first 48 hours Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  67. 67. SOLUTION= SOLUTE+ SOLVENT Molality: number of moles of a solute per kilogram of solvent Molarity: number of moles of solute per litre of solution Osmolality: number of osmoles of solute per kilogram of solvent Osmolarity: number of osmoles of solute per litre of solution Tonicity = effective osmolality sum of the concentrations of the solutes which have the capacity to exert an osmotic force across the membrane. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  68. 68. Free water (FW) Calculated base on osmolality (Na, Glucose, BUN) As urea is freely permeable across all cell membrane Does not contribute to effective osmolality ie tonicity Electrolyte free water (EFW) Calculation based on S.[Na} Modified Electrolyte free water (MEFW) Calculation takes into consideration Glucose along with s.[Na] Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  69. 69. Thank You

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