9. Case 1
• A 12 year old patient with DHF. Nausea and
vomiting (+)
• PE : restless;T 100/80 T 37.5 oC HR 120 x/min,
RR 28 /min; cold extremities. Torniquet test(+).
Height 120 cm Weight 50 kg
• Lab: Hct 48%; Platelet 70.000
How is the fluid regimen for this patient?
Answer: Grade 3 DHF requiring 5-10 ml/kg ideal BW /hour and monitor
12. A 15 kg postop patient with Na+ 97 mEq/L,. PE:
Stuporous and convulsion.
How much is Na+ deficit in this patient, if we need to correct it
until 125 mEq/L?
How will you correct hyponatremia ini this? ; what is the
administration rate of 3% NaCl?
Case 2
13. A 15 kg postop patient with Na+ 97 mEq/L,. PE:
Stuporous and convulsion.
How much is Na+ deficit in this patient, if we need to correct it
until 125 mEq/L?
How will you correct hyponatremia ini this? ; what is the
administration rate of 3% NaCl?
Case 2
60% BB x (125-97) = 252 mEq
Infusate Na+– Serum Na+
Total body water + 1
(513-97) : (9+1) = 41.6mE/L
We will raise 1 mmol/L hourly for
5 hours
The amount of 3% NaCl 3% required= 5 : 41.6 = 0.120 L = 120 ml or 24 ml/hour
Observe clinical condition and check serum Na+ after 5 hours.. Reduce rate if there is
improvement, eg 0.5 mmol/L/hour until Na+ 115.
Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):1581-1589
Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499.
14. Case 3
A 9 year old 20 kg patient with dehydration and shock (acute GE),
has been resuscitated with Acetated Ringer’s ( Asering) for 5 hours
along with separate line of 8.4% Meylon diluted in D5. Patient was
then unconscious with seizures.
BP 110/75; HR 90/min ; RR 16/min; T 37oC
Na+ 175 mmol/L; K+ 2.1 mmol/L
You wish to correct the hypernatremia and hypokalemia simultaneously with infusion sol
containing 30 mmol/L Na+ (KAEN 4A) plus 20 mmol KCl.
You set a target of Na+ decrease to 165 mmol/L over 10 hours. What is the rate of infusion
you will set up?
Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):1581-1589
Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499.
15. A 9 year old 20 kg patient with dehydration and
shock (acute GE), has been resuscitated with
Acetated Ringer’s ( Asering) for 5 hours along with
separate line of 8.4% Meylon diluted in D5. Patient
was then unconscious with seizures.
BP 110/75; HR 90/min ; RR 16/min; T 37oC
Na+ 175 mmol/L; K+ 2.1 mmol/L
You wish to correct the hypernatremia and hypokalemia
simultaneously with infusion sol
containing 30 mmol/L Na+ (KAEN 4A) plus 20 mmol KCl.
You set a target of Na+ decrease to 165
mmol/L over 10 hours. What is the rate of
infusion you will set up?
(Infusate Na+ + K+ ) – serum Na+
Total body water + 1
= (30 + 20) – 175
(60% x 20) + 1
= -125
13
= - 9.6 mmol/L
This means 1 L infusion will decrease the
serum Na+ serum by 9.6 mmol/L
Reuired amount of infusion = 5: 9.61 =
0.520 L = 520 ml
over 10 hr give 520 ml, at the rate of 52
ml/hr.
Correction rate can be repeated for
subsequent 10-14 hours
16. A 62 year old patient was admitted because of malaise and fatigue after
nausea and vomiting for 5 days. Lack of eating and drinking due to anorexia.
History of hypertension and taking medication: Tenormin 50 mg, Aspirin 75
mg HCT 25 mg, Lisinopril 40 mg per day
PE : Alert, pale, moderate dehydration, BP 170/105.
Cor: extrasystole +, lung NA, hepatomegaly –
Lab:
Chest X-ray : LVH.
ECG : u wave & flattened T
Case 4
145
2.6 NA
25
1.0
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
98
How will you correct the hypokalemia in this patient
17. Hypokalemia( > 2.5 - <3.5 mEq/L )
Heart /cardiovascular disease?
No Yes
Give K+ according to
maintenance requirement
40 mmol
Correction K+ 40 mmol +
Maintenance 40 mmol
18. Hypokalemia ( > 2.5-3.4 mEq/L )
Without cardiovascular disease
* In case of fluid restrition : admix 10 mmol KCL into
1 bag of KAEN 3B, to get final conc of 20 mmol/500 ml.
40 mmol K+ per day
With cardiovascular disease (digitalis, diuretics)
80 mmol K+ per day
20. How about life-threatening Hypokalemia?
Serum K+ < 2 mmol/L
– Alkalosis
– Arrhythmia
– Respiratory paralysis
– rhabdomyolisis
21. Hypokalemia( < 2 mEq/L )
OTSU
NS
20 20 20
KCl 40 ml
+
20
over 1 hour
via central
vein
22. A 62 year old patient was admitted because of malaise and fatigue after
nausea and vomiting for 5 days. Lack of eating and drinking due to anorexia.
History of hypertension and taking medication: Tenormin 50 mg, Aspirin 75
mg HCT 25 mg, Lisinopril 40 mg per day
PE : Alert, pale, moderate dehydration, BP 170/105.
Cor: extrasystole +, lung NA, hepatomegaly –
Lab:
Chest X-ray : LVH.
ECG : u wave & flattened T
Case 4
145
2.6 NA
25
1.0
70
135-145
3.5-5
98-106
23-28
8-20
0.7-1.3
70-105 (fasting)
98
How will you correct the hypokalemia in this patient
30. COPD Height 170 cm Weight 45 kg
• What is the the total calories and protein
requirement?
Ideal BW = ( Hight – 100) x 90% = 63 kg
Adjusted body weight = (Actual BW – Ideal BW)
2
+ Ideal BW
45 - 63
2
+ 63 = 54 kg
25 kcal/kg BW and 1 g protein/kg BW
Case 8
31. Sepsis Height 160 cm Weight 80 kg
• What is the the total calories and protein
requirement?
Ideal BW= ( TB – 100) x 90% = 54 kg
Adjusted body weight = (Actual BW – Ideal BW)
2
+ Ideal BW
80 - 54
2
+ 54 = 67 kg
25 kcal/kg BW and 1.5 g protein/kg BW
Case 9
32. 60% 20% 20%
TOTAL CALORIES
(25 kcal/kg/day)
GLUCOSE LIPID PROTEIN
Average Patient
33. 60% 20% 20%
TOTAL CALORIES
(1500 kcal)
GLUCOSE LIPID PROTEIN
900 kcal
30 g
300 kcal 300 kcal
225 g 75 g
Average Patient
34. 40% 20%
TOTAL CALORIES
(1500 kcal)
GLUCOSE LIPID PROTEIN
600 kcal
60 g
600 kcal 300 kcal
150 g 75 g
40%
COPD Patient