lab rounds shawn dowling pgy-2. case 78 yo m. brought in by ems from nsg home c/o generalized...
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Lab Rounds
Shawn DowlingPGY-2
Case 78 yo M. Brought in by EMS from
NSG home c/o generalized weakness, V, D for
past 2-3 days Brief GTC seizure while nurses are
checking patient in PMHx: HTN (on HCTZ), allergies: ex-wife
Physical Exam VS: HR-110, BP110/70, T/RR/sats N Stopped seizing but still altered
sensorium (?post-ictal), GCS 13-14 Fluid: looks dry Chest/abdo/extremeties – N Neuro: no focal abnormalities, neck
supple
Want to order anything NOW?
Want to order anything NOW? Chemstrip
Want to order anything NOW? Chemstrip The paramedics had noticed this
by his bedside
Want to order anything NOW? Chemstrip – 8.0 ABG
Na – 108, K - 3.0, Cl - 90
Objectives Acute Hyponatremia
Touch of physiology DDx The Na calculating game How and when to use HTS
FOR INDEPTH REVIEW OF HYPONATREMIA SEE MORITZ’S PRESENTATION FROM 2003
Sodium H20 makes up 60% of total body
weight (:. TBW = 0.6 x wgt(kg)) H20 is distributed between 3 compartments
Intracellular space (ICS) Interstitial space (ISS) Intravascular space (IVS)
Na is the predominant cation in the ECS and is distributed primarily in the TBW
ExtracellularSpace
Na+ balance primarily controlled by renin-angiotensin-aldosterone system
Na governs the movement of fluid between these compartments
Water balance largely driven by Na+ balance and ADH
Fluid Distribution
Intracellular (2/3) Extracellular (1/3)
IVS(1/3)
ISS(2/3)
TBW = wgt (kg) x 0.6
Distribution of TBW (and Na):
Hyponatremia DDx(abridged
version)
“TRUE” Na Hypovolemic
GI/insensible losses Poor H20 intake Diuretics
Euvolemic SIADH Psychogenic
polydipsia Hypervolemic
CHF Cirrhosis Nephrotic syndrome
Lab Error PseudoNa*
lipids/proteins No longer an issue
Redistributive (osm) Hyperglycemia Mannitol
*No longer an issue since the lab uses
a different technique to calculate Na
Making the Diagnosis Hx in particular ROS, PMHx, Meds Physical exam: hypo-,eu- or
hypervolemic Labs:
Serum electrolytes (ABG if needed urgently) Urine lytes, Cr (if not on diuretics or have
not received fluids yet) Urine Osmols Serum Glucose
Approach to sodium Need to determine:
1. Is the patient symptomatic?2. Is this an acute or chronic process?3. Do I need to intervene emergently?
Seizure? Comatose? Focal Neuro Deficits?
S/Sx Sx
HA Lethargy N,V Anorexia Dizzy Confusion
Signs Psychosis Confusion Focal Neuro
deficits Ataxia Seizures Comatose
37M. Diabetic. Glucose 35 Na – 126 How do you correct the sodium for
the glucose?
Back to our case His Na is 108. What info do you need to calculate
his Na deficit? What is his Na deficit?
Fluid Distribution
Intracellular (2/3) Extracellular (1/3)
IVS(1/3)
ISS(2/3)
TBW = wgt (kg) x 0.6
Distribution of TBW:
Calculating Na deficit His wgt is 60kg. Since Na is primarily distributed in
the Total body water which is wgt(kg) x 0.6*
(Desired Na-actual Na) x TBWOr
The drop in Na x where the Na is distributed
***Some sources suggest using 0.5 for females/elderly males and 0.45 for elderly females – probably not important acutely
(140-108) x 0.6x60kg= (32) x 36=1152mEq of Na
How quickly can we replace Na? Why? How are we going to calculate how
much to replace over 24 hours? What solution are you going to use?
Pt is not seizing, no focal deficits, no coma
Na correction CANNOT correct sodium quicker than
10-12mEq/24 hours, 0.5 mEq/hr rule is not absolute – this rule
can be broken as long as 10-12/day is not Risk of over-aggressive Na
replacement is central pontine myelinolysis Demyelination of the pons, flaccid
paralysis and death -- BAD
Determining how much Na to give What is the Na content of…
NS RL HTS (3%)
Determining how much Na to give What is the Na content of…
NS – 154mEq RL – 130mEq HTS (3%) – 513mEq
Calculating volume of fluid His Na deficit is 1152mEq, but we
only want to increase 10-12mEq/24H (Desired Na-actual Na) x TBW
(118-108) x 36 360mEq
NS 360/154 = 2.33 L over next 24 hours – check lytes Q2-4H to ensure not correcting too quickly
The Divine Brine – HTS HTS (3%) – Na content is 513mEq
Indications Moderate-Severe hyponatremia (<120) And 1 of the following
Seizures Focal neuro deficit Comatose
Dose: 3cc/kg ½ half given over 10 minutes, 2nd ½ given over 50 minutes
Then STOP & check lytes (usually Na by 3-6mEq). STILL LTD BY 10-12mEq/DAY
Summary1. Order Urine lytes prior to giving fluid2. Calculate target Na
(Goal Na - actual Na) x TBW & DO NOT EXCEED
3. HTS saline indications Seizure Focal neuro deficits Comatose
4. HTS: 3cc/kg, 1st ½ over 10min, 2nd ½ over next fifty minutes, then STOP & check lytes
Usu by 3-6 mEq, STILL ltd by 10-12mEq/24hrs
References EMRAP March 2006 Yeates K. Salt and Water: A simple
Approach. CMAJ. Feb 2004;170, 365-69 Rosen’s Harrison’s Moritz’s presentation 2003