1. Electrolyte disorders are common in critically ill patients, with up to 17.7% of ICU patients experiencing hyponatremia and 6.9% experiencing hypernatremia on admission. The severity of dysnatremia is associated with increased mortality risk.
2. Dysnatremias frequently develop during ICU stays, with 11% of patients acquiring hyponatremia and 26% acquiring hypernatremia within 2 days. Factors like renal dysfunction, mechanical ventilation, and illness severity increase the risk.
3. Maintaining electrolyte and fluid balance can be challenging in ICU patients due to impaired thirst, non-osmotic vasopressin release, diuretic
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Hyertension in patients on regular hemodialysisEhab Ashoor
Everything about hypertension in patients on regular hemodialysis, including management, Resistant hypertension, Intra-dialytic hypertension and Hypertensive urgencies.
- Recorded videos of this lecture:
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Hyertension in patients on regular hemodialysisEhab Ashoor
Everything about hypertension in patients on regular hemodialysis, including management, Resistant hypertension, Intra-dialytic hypertension and Hypertensive urgencies.
- Recorded videos of this lecture:
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A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
- Recorded videos of this lecture:
English Language version of this lecture is available at: https://youtu.be/GaapP5vsLB0
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- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/Ed5naxEDwnQ
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https://youtu.be/eYe0ORMdnaI
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- Recorded videos of this lecture:
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A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
- Recorded videos of this lecture:
English Language version of this lecture is available at: https://youtu.be/GaapP5vsLB0
Arabic Language version of this lecture is available at: https://youtu.be/L5ynJVpaPNM
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- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/Ed5naxEDwnQ
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https://youtu.be/eYe0ORMdnaI
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Acute kidney injury is important topic for students.
the presentation covers all aspects including guidelines from KDIGO, harrison 20th edition and relevant articles.
COURTSEY - DEPARTMENT OF CRITICAL CARE
ABVIMS & DR RML HOSPITAL NEW DELHI.
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
Professor John Botha from Frankston Hospital in Melbourne talks at the April 2014 Victorian Intensive Care Network meeting on Renal Failure in Critical Care
Potential role of uric acid in correlation with epidemics of hypertension and...Apollo Hospitals
Diabetic nephropathy (DN) is a microvascular complication of Type 2 diabetes mellitus. Uric acid (UA) is the end product of purine nucleotide metabolism and its primary mode of clearance is by renal excretion. Modifiable factors such as blood pressure, albuminuria, glycemic control, etc., play an important role in the progression of DN and none of them are curative. Hence, there is a pressing interest to identify other potentially modifiable factors such as UA in the progression of DN.
Understand principles of fluids, fluid compartments and composition
Identify role of kidneys in fluid management
Establishing Target Weight
Understand consequences of fluid overload
Assessing and implementing successful fluid overload management practices according to guidelines
ventilator waveforms are graphical representation of pulmonary physiology, mechanics and patient ventilator interaction. optimal patient ventilator interaction is needed to balance two goals of mechanical ventilation, safety and comfort.
The enormous world of microorganism source antibiotics to mankind in the war against pathogenic microbes. These microbes in turn tilt the balance to their favor by acquiring resistance against antibiotics, through borrowed genes from a pool widely distributed in the microbial world itself. This collateral damage of misuse of antibiotics on one patient is not limited to that patient, but affects whole society, through expansion of environmental resistome. Both antibiotics and resistance are secondary metabolites involved in varied process, with existence history of million years. Therefore, any antibiotic that would be discovered in future, resistance against it would already be existing in microbial world, which will be acquired by the target bacteria sooner or later. The fight against infection cannot not be won with antibiotics, but truce may be attained through infection control and antibiotic stewardship.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
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. BODY FLUID COMPARTMENTS
Arrow represents fluid movement
Review of Medical Physiology, William F. Ganong
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
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. 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. 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
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. 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. 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. 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. Critically ill patients
prone to
electrolyte disturbances
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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
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
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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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
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
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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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