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Indra WijayaDepartment of Internal Medicine
Faculty of Medicine, UPHSiloam Lippo Village Hospital
FLUID
FLUID / WATER BALANCE•Normal plasma osmolality 275-290
mosmol/kg
ETIOLOGY
I. ECF volume contractedA. Extrarenal Na+ lossB. Renal Na+ and water lossC. Renal water loss
II. ECF volume normal or expandedA. Decreased cardiac outputB. RedistributionC. Increased venous capacitance
Sign and Symptoms•General weakness - fatigue•Delirium•Hangover•Thirsty•Hypotension•Dry mouth•Skin turgor •Decreased urin volume
TREATMENT• I.V line Hidration 1 - 2 liters!
•Normonatremic and most hyponatremia: normal saline (NaCl 0.9%)
•Hypernatremia: half-normal saline (NaCl 0.45%)/ D5% infusion.
•Hemorrhage, anemia, or intravascular volume depletion: blood transfusion / colloid
ETIOLOGYExcessive sodium and fluid intake:• IV therapy containing sodium• Transfusion reaction to a rapid blood transfusion.• High intake of sodium
Sodium and water retention:• Heart failure• Liver cirrhosis• Nephrotic syndrome• Corticosteroid therapy• Hyperaldosteronism• Low protein intake
Fluid shift into the intravascular space:• Fluid remobilization after burn treatment• Administration of hypertonic fluids• Administration of plasma proteins, such as albumin
Sign and Symptoms•Shortness of breathing
•Paroxysmal nocturnal dyspneu
•High JVP
•Ascites
•Edema
TREATMENT
Treat etiology / underlying cause
Loop Diuretics – monitor BP
Dialysis
SODIUM
Na < 135 mmol/L
CLINICAL FEATURES
•Maybe asymptomatic
•Nausea and malaise
•Headache, lethargy, confusion, and obtundation
•Stupor, seizures, and coma: Na < 120 mmol/L
TREATMENT
• Asymptomatic hyponatremia associated with ECF volume contraction isotonic saline
• Hyponatremia associated with edematous states restriction of Na+ and water intake
• Euvolemic and hypervolemic hyponatremia nonpeptide vasopressin antagonists
0.5–1.0 mmol/L per hor
10–12 mmol/L over the first 24 h
ODS
Na+ > 145 mmol/L
ETIOLOGY
•Primary hypodipsia
•Renal
•Extra renal• Skin• Respiratory tract• GI tract• CDI• NDI
CLINICAL FEATURES
•Polyuria or thirst•Altered mental status•Weakness•Neuromuscular irritability•Focal neurologic deficits•Coma or seizures
TREATMENT•correct the water deficit
5% dextrose / half-isotonic saline
•treating the underlying cause:• stop ongoing water loss• CDI desmopressin intranasally• NDI amiloride• Low-salt diet in combination with low-dose
thiazide diuretic therapy NDI+CDI
Plasma [Na+] should be lowered by 0.5 mmol/L per h and < 12 mmol/L over the first 24 h
POTASSIUM
K+ < 3.5 mmol/L
ETIOLOGYI. Decreased intake
II. Redistribution into cellsA. Acid-baseB. HormonalC. Anabolic stateD. Other
III. Increased lossA. RenalB. Non Renal
CLINICAL FEATURES
•Fatigue
•Myalgia
•Weakness of lower extremities
•Diaphragm paralysis
•ECG?
TREATMENT
•Potassium chloride: p.o / i.v
•Potassium bicarbonate and citrate hypokalemia associated with chronic diarrhea/RTA
The maximum concentration of administered K+ should be no more than 40 mmol/L via peripheral vein
60 mmol/L via central vein
K+ > 5 mmol/L
ETIOLOGY
I. Renal Failure
II. Decreased distal flow
III. Decreased K+ secretionA. Impaired Na+ reabsorptionB. Enhanced Cl- reabsorption
(chloride shunt)
CLINICAL FEATURES
•Weakness
•Flaccid paralysis
•Hypoventilation
•Cardiac toxicity
•ECG?
TREATMENT
•Calcium gluconate
•10 units of regular insulin and 50 gram of glucose
•Diuretics
•Cation-exchange resin
•Dialysis
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