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8/2/2019 Volume and tonicity disorders by qbank.org
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WATER AND SODIUM
DISORDERS
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Outline:Water and sodium BALANCE and distribution
The differences and the relation between waterand volume disorders
The concept of equilibrium (balance) and steadystate
Clinical presentation of water disorders
Outline of management
Diuretics and fluid therapy
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Potassium Balance (3.5-5.0 mEq)
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Water
Balance
Daily filtration:
Water 180 Lt
Sodium 25000 mEq
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Total Body Water (sex & age)
Total Body Sodium 50 meq/Kg
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FS forces
DiffusionOsmosis
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ReceptorSubtype
Site of Action Pharmacologic Effects
V1A
Vascular smooth musclePlatelets
Lymphocytes and monocytesHepatocytes
VasoconstrictionPlatelet aggregation
Coagulation factor releaseGlycogenolysis
V1B Anterior pituitary ACTH and -endorphin releaseV2
Renal collecting ductcells
Free water absorption
AVP-Receptor Subtypes
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Serum Sodium
CNS Symptoms
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CV Symp & signs
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Volume disorders Water disorders
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SODIUM & WATER
DISORDERSDefinitionsHypernatremia & hyponatremia (135-145)
Hypervolemia & hypovolemia (50 meq/Kg)
Proportionate and disproportionate disorderHyperosmolar & hypertonic (urea vs. glucose)
Pseudohyponatremia (Isotonic hyponatremia)
Translocation hyponatremia (Hypertonic)
Acute vs. chronic (48 hrs)
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Isotonic
Osm 308
27 gram Nahypertonic(Osm 924)
4.5 gram Na
hypotonic(Osm 77)
H2O
Cl
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PSEUDOHYPONATREMIAISOTONIC HYPONATREMIA
H2O
SOLIDS 7%
93%
H2O
SOLIDS
86%
14%
HYPERLIPIDEMIA
HYPERPROTEINEMIA
SERUM Na+ = 140 meq/L SERUM Na+ = 130 meq/L
WATER 7%
140/930 130/860
10/70140/930 = 151/1000 = 130/860
OSMOLALITY: MEASURES SOLUTE PER UNIT PLASMA WATER
Serum Osmolality=2Na+urea+glucose
Measured>Calculated
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Calculated Serum Osmolality=2Na+urea+glucose
Measured Serum Osmolality=(Nl: 280-290 mOsm/l
Normal Serum Osm Gap (Measured-
Calculated)= (-14 to +10)
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Salt and Water Rules (I)
Regulation of the plasma sodium and ofextracellular volume involve separate pathways
The plasma sodium is regulated by changes inwater excretion (ADH) and water intake (thirst)
Hyponatremia is usually due to inability toexcrete water, mostly due to persistent ADH
Symptoms of hyponatremia (acute) are due tocerebral edema (decreased plasma osmolality)
Chronic hyponatremia is usually asymptomatic,(loss of CNS osmolytes). Avoid rapid correction
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Salt and Water Rules (II)
All patients will tend to return to a steady statein which intake equals excretion
The maximal diuretic effect is seen with the firstdose, counterregulatory factors then stimulated
Chronic diuretic use is associated with a steadystate at lower volume and potassium levels
The ability to markedly increase water, sodium,potassium, and bicarbonate excretion means that
chronic accumulation of these substancesrequires an impairment in urinary excretion
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Steady
state
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Most Common form of DehydrationOccurs when fluids and electrolytes are lost ineven amounts
There are no intercellular fluid shifts in
isotonic dehydrationCommon Causes
diuretic therapyexcessive vomitingexcessive urine loss
hemorrhagedecreased fluid intake
Isotonic Dehydration(Hypovolemia)
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Hypertonic Dehydration
Second most common type of dehydrationOccurs when water loss from ECF is greater than soluteloss:
hyperventilation, pure water loss with high fevers, andwatery diarrheaDiabetic Ketoacidosis and Diabetes InsipidusIatrogenic Causesprolonged NPO
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Hypotonic Dehydration
Relatively Uncommon - Loss of more solute(usually sodium) than water.
Hypotonic Dehydration causes fluid to shift from the
blood stream into the cells, leading to decreasedvascular volume and eventual shockSeen in Heat Exhaustion
Increased cellular swelling -causes increased
intracranial pressure - H/A and Confusion.Seen in Heat Stroke
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Fluids can be described as being fromthree categories
-Isotonic: Fluid has the same osmolarity as plasmaNormal Saline (N/S or 0.9% NaCl),Ringers Acetate(RA), Ringers lactate (RL)
-Hypotonic: Fluid has fewer solutes than plasma
Water, 1/2 N/S (0.45% NaCl), and D5W(5% dextrose in water) after the sugar isused up
-Hypertonic: Fluid has more solutes than plasma
5 % Dextrose in Normal Saline (D5 N/S),3% saline solution, D5 in RL.
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increases ECF
ICF ISF Plasma
Replace acute/abnormalloss
Isotonic
infusion
800 ml 200 ml
Ringers acetateRingers lactate Normal saline
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increases ICF > ECF
ICF ISF Plasma
Replace Normalloss (IWL + urine)
Hypotonic
infusion
5% dextrose
85 ml255 ml660 ml
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Na
Na
Na Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
O
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
H2O Sodium Isotonic Hypertonic Hypotonic
K
K
K
VolumeCV
WaterCNS
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Osmotic Pressure
H2O
Relation of volume andosmotic force
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Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
Isotonic
Na
Na
Na
+
K
K
K
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
Na
Na
Na
Na
Na
Na
HYPERVOLEMIA
SIGNS:INTRAVASCULAR: HTN, S3 GALLOP, ELEVATED JVP, HEPATIC CONGESTION
INTERSTITIAL: DEPENDENT PITTING EDEMA, PULMONARY RALES
THIRD SPACE: ASCITIS, PLEURAL EFFUSION
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Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
Isotonic
Na
Na
Na
-
K
K
K
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Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
HYPOVOLEMIA
SIGNS:INTRAVASCULAR: MILD (ORTHOSTATIC CHANGE IN BP & PULSE, FLAT JVP)
SEVERE (HYPOTENSION, SHOCK)
INTERSTITIAL: DIMINISHED SKIN TURGOR
TRANSCELLULAR: DRY MOUTH AND MM. DIMINISHED OCULAR PRESSURE
ECF 1/3 ICF 2/3
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
O
O
O
K
K
K
K
K
K
ECF=1/3 ICF=2/3
Sodium
K
K
K
Na
Na
Na
Na
Na
Na
+
NY nurserycatastrophe
ECF 1/3 ICF 2/3
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
O
O
O
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
Na
Na
Na
Na
Na
Na
HYPERVOLEMIC HYPERNATREMIA
ACUTE
CNS SYMPTOMS & SIGNS OF HYPERNATREMIA:LETHARGY, IRRITABILITY, SPASTICITY, CONFUSION, STUPOR, COMA
FOCAL NEUROLOGIC DEFICITS
INTENSE THIRST, EMESIS, FEVER, LABORED RESPIRATION
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
ECF=1/3 ICF=2/3Na
Na
Na
Na
Na
Na
HYPERVOLEMIC HYPERNATREMIA
CHRONIC (48 HOURS)
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
Sodium
K
K
K
Na
Na
Na
Na
Na
Na
-
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Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
HYPOVOLEMIC HYPONATREMIA
ACUTE
CNS SYMPTOMS & SIGNS OF HYPONATREMIA:ASYMPTOMATIC
GI: ANOREXIA
CNS: LETHARGY, HEADACHE, CONFUSION, STUPOR, SEIZURES, COMA
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Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
HYPOVOLEMIC HYPONATREMIA
CHRONIC (48 HOURS)
IO
IO
IO
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ECF=1/3 ICF=2/3
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
UREA
K
K
K
Urea
Urea
Urea
Urea
Urea
Urea
+
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
Urea
Urea
Urea
Urea
Urea Urea
HYPEROSMOLAR ISOTONIC STATE (CRF)
ECF=1/3 ICF=2/3
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
GLUCOSE
K
K
K
Glu
Glu
Glu
+
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
Glu
Glu
Glu
HYPEROSMOLAR HYPERTONIC STATE
ECF=1/3 ICF=2/3
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
H2O
+
K
K
K
SIADHHYPOTHYROID AND HYPOADRENALISM
PREGNANCY
PAIN, EMOTIONAL STRESS, POST SURGERY
DRUGS
THIAZIDE
PSYCOGENIC, PRIMARY POLYDIPSIA
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ISOVOLEMIC HYPONATREMIA
ACUTE
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
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ISOVOLEMIC HYPONATREMIA
CHRONIC (48 HOURS)
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
IO
IO
IO
K
K
K
CRITERIA FOR DIAGNOSIS OF SIADH
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(Syndrome of Inappropriate ADH secretion)
Hyposmolar hyponatremia
Euvolemia
Urine osmolality >100 (urine not
maximally diluted) Normal renal, cardiac, hepatic, and
endocrine function
Absence of diuretics & stress
Urine sodium > 20 mEq/l, low serum UA
Plasma AVP Is Elevated in PatientsWith SIADH
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Plasma Osmolality (mOsm/kg)
PlasmaAVP
(pg/mL)
Normal
range
11
10
9
8
7
65
4
3
2
1
0
230 240 250 260 270 280 290 300 310
With SIADH
COMMON DISORDERS
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ASSOCIATED WITH SIADH
Malignancy
Lung, duodenum, pancreas, lymphoma
Pulmonary disorders
Infection, respiratory failure, IPPB
CNS disorders
Infection, trauma, sol, CVA, psychosis
DRUGS ASSOCIATED WITH
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HYPONATREMIA
ADH analogs
enhance ADH release
Chlorpropamide, nicotine, tegretol,
narcotics, clofibrate, antipsychoticPotentiate ADH renal action
NSAID, chlorpropamide, cytoxan
Unknown mechanisms
Haloperidol, amitriptyline
TREATMENT OF
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TREATMENT OFHYPONATREMIA
Depends on the following conditions
Patient volume status
The degree of hyponatremiaThe severity of symptoms
The duration of hyposmolality
Osmotic Demyelination
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Syndrome Can Be aConsequence of Inappropriate
Managementof Hyponatremia
Diagnostic Algorithm for Hyponatremia
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Legend: increase; greater increase; decrease; greater decrease; no change.
Renal lossesDiuretic excessMineralocorticoid deficiencySalt-losing deficiencyBicarbonaturia with renal
tubal acidosis andmetabolic alkalosis
KetonuriaOsmotic diuresis
Euvolemia (no edema) Total body water
Total body Na+
Assessment of volume status
Hypovolemia Total body water
Total body Na+
U[Na+]>20 mEq/L
Extrarenal lossesVomitingDiarrheaThird spacing of fluidsBurnsPancreatitisTrauma
Glucocorticoiddeficiency
HypothyroidismSyndrome of
inappropriateADH secretion- Drug-induced- Stress
Acute or chronicrenal failure
Nephrotic syndromeCirrhosisCardiac failure
Hypervolemia Total body water
Total body Na+
U[Na+] >20 mEq/L U[Na+] 20 mEq/L U[Na+]
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( g )
Na = (infusate Na (+K) actual Na)
*TBW = 0.5 X body wt (Kg)
TBW* + 1
TREATMENT OF
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HYPONATREMIA
70 year old male, serum Na = 110 ?
TBW = 70 * 0.6 = 42 liters
Excess water = 42 - (110/120* 42) = 3.5 L
110 = TBC/TBW TBC = 42 * 110 = 4620
Over 2h he received 200 ml NaCl 3%, and excreted1000 ml urine (Na+K=70+30)
TBW = 42 - 0.8 = 41.2 , Na=4620/41.2 = 112
Aquaresis
Aquaresis is defined as the solute free excretion
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Aquaresis is defined as the solute-free excretionof water by the kidney
Because electrolytes represent a major componentof urine solutes, aquaresis is also electrolyte-sparing
Measured by increases in EWC and is calculated from
the urine volume and from the plasma and urine [Na+]and [K+]
Typically accompanied by increased urine output andreduced urine osmolality
Distinguished from diuresis (increased urineoutput accompanied by electrolyte excretion)
VAPRISOL(conivaptan hydrochloride injection)
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(conivaptan hydrochloride injection)
Vaprisol is indicated for the treatment of euvolemichyponatremia (eg, SIADH, or in the setting ofhypothyroidism, adrenal insufficiency, pulmonarydisorders, etc) in hospitalized patients
Vaprisol is also indicated for the treatment ofhypervolemic hyponatremia in hospitalized patients
Not indicated for the treatment of congestive heart failure(effectiveness and safety have not been established inthese patients)
ECF=1/3 ICF=2/3
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
H2O
-
K
K
K
RENAL LOSS (DI)
EXTRA RENAL (RESP., DERMAL)
INABILITY TO GAIN ACCESS TO FLUIDS
HYPODIPSIA, ADIPSIA
RESET OSMOSTST (ESSENTIAL HYPERNATREMIA)
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ISOVOLEMIC HYPERNATREMIA
ACUTE
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
K
K
K
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
K
K
K
K
K
K
ECF=1/3 ICF=2/3
ISOVOLEMIC HYPERNATREMIA
CHRONIC (48 HOURS)
K
K
K
CAUSES OF
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DIABETES INSIPIDUS
Central DI
Idiopathic, posttraumatic, tumors,infection, granuloma, histocytosis
Nephrogenic DICongenital
Acquired
Hypercalcemia, hypokalemia, drugs, renal cysticand interstitial diseases
WATER-DEPRIVATION TEST
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WATER DEPRIVATION TEST
Urine Osm. &deprivation
Plasma AVP &deprivation
Urine Osm.After AVP
Normal > 800 > 2 pg/ml little or no
Completecentral DI
500
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HYPERNATREMIA
Goal is to restore normal volume &osmolality
Slow correction over 48 hours
H2O deficit = 0.6 * Wt * (P Na/140 -1)
Replace concomitant continuous losses
Treat the cause of hypernatremia
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ECF=1/3 ICF=2/3
Na Na Na KKIO K K K
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Hypotonic
+
Na Na Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
K
K
K
EXTRARENAL (CHF, CIRRHOSIS)
RENAL (NEPHROSIS, ARF, CRF)
Approach to polyuria
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Urine Osmolality (U osm)
< 250 mOsm/kg H20 > 250 mOsm/kg H20
Water diuresis Osmotic diuresis
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Adrogue H &
Madias N.NEJM2000; 342,1581.
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ECF=1/3 ICF=2/3
HYPERVOLEMIC HYPONATREMIA
ACUTE
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
Na
Na
Na
K
K
K
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Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
HYPERVOLEMIC HYPONATREMIA
CHRONIC (48 HOURS)
Na
Na
Na IO
IO
IOK
K
K
Na Na Na KKIO K K
ECF=1/3 ICF=2/3
K
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Na
Na
Na
Na
Na
Na
K
K
K
K
IO
IO
K
K
K
K
Hypotonic
-
Na Na Na
K
K
RENAL LOSSES
OSMOTIC DIURESIS
LOOP DIURETICS
POST OBSTRUCTIVE DIURESIS
INTRINSIC RENAL DISEASE
EXTRARENAL LOSSES
GI (V,D,F)
DERMAL (SWEATING, BURN)
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Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
ECF=1/3 ICF=2/3
HYPOVOLEMIC HYPERNATREMIA
ACUTE
K
K
K
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Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
K
K
K
K
K
K
ECF=1/3 ICF=2/3
HYPOVOLEMIC HYPERNATREMIA
CHRONIC (48 HOURS)
K
K
K
ECF=1/3 ICF=2/3
Na Na Na KKIO K K K
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Hypertonic
+
Na Na Na
Na
Na
Na
Na
Na
Na
K
K
K
K
IO
IO
K
K
K
K
K
K
Na Na Na
Na Na NaHYPERTONIC SALINE ADMINISTRATION
SODIUM BICARBONATE
HYPERTONIC FEEDING
MINERALOCORTICOID EXCESS
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ECF=1/3 ICF=2/3
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
K
K
K
Na
Na
Na
Na
Na
Na
Na
Na
Na
HYPERVOLEMIC HYPERNATREMIA
ACUTE
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99/140
ECF=1/3 ICF=2/3
Na
Na
Na
Na
Na
Na
Na
Na
Na
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
Na
Na
Na
Na
Na
Na
Na
Na
Na
HYPERVOLEMIC HYPERNATREMIA
CHRONIC (48 HOURS)
ECF=1/3 ICF=2/3
Na Na Na KKIO K K K
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Hypertonic
-
Na Na Na
Na
Na
Na
Na
Na
Na
K
K
K
K
IO
IO
K
K
K
K
K
K
Na Na Na
Na Na Na
RENAL LOSSES
OSMOTIC DIURESIS
DIURETICSSALT LOOSING NEPHRITIS
MINERALOCORTICOID DEFICIENCY
EXTRARENAL
GI (D,V,F)
THIRD SPACE
PANCREATITIS
PERITONITIS, OBSTRUCTION
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ECF=1/3 ICF=2/3
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
K
K
K
HYPOVOLEMIC HYPONATREMIA
ACUTE
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ECF=1/3 ICF=2/3
K
K
K
K
K
K
IO
IO
IO
K
K
K
K
K
K
K
K
K
HYPOVOLEMIC HYPONATREMIA
CHRONIC (48 HOURS)
IO
IO
IO
ASSESSMENT OF ECFVOLUME STATUS
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VOLUME STATUS
H & P
LABORATORY STUDIES
CXR
MEASUREMENT OF CENTRALPRESSURES
Assessment of Hyponatremia
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Assessment of Hyponatremia
Serum Osmolality (R/O Pseudo)
Volume status (Iso, hype, or hypo)
Urine Osmolality (not maximallydiluted)
Urine sodium 20
Assessment of Hypernatremia
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Assess e t o ype at e a
Volume status
Hypervolemia (restrict salt and usediuretics), may use water and hypoosmolar
Hypovolemia (hydrate with hypo orisotonic)
Euovolemia (R/O Diabetes Insipidus)
mia
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Approach
toHyponatre
emia
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107/140
Approach
toHyperna
tre
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108/140
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109/140
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110/140
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111/140
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112/140
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113/140
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114/140
8/2/2019 Volume and tonicity disorders by qbank.org
115/140
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116/140
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8/2/2019 Volume and tonicity disorders by qbank.org
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http://content.nejm.org/content/vol342/issue21/images/large/07f2.jpeg8/2/2019 Volume and tonicity disorders by qbank.org
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http://content.nejm.org/content/vol342/issue21/images/large/07f2.jpeg8/2/2019 Volume and tonicity disorders by qbank.org
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121/140
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123/140
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124/140
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Proposed mechanisms for the production of CSW Syndrome
BNP, ANPOuabain Like
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Ouabain Like
AdrenomedulinaDendraspisNP
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129/140
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132/140
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133/140
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134/140
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135/140
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136/140
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Electrolyte solutions
Plasma Isotonic Hypotonic solutions
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solutions
Normalsaline
Ringersacetate/ lactate
KAEN 3B*
290 308 273
278
D5
290278
* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmolCl-, 20 mmol lactate, 27 g dextrose per L.