volume and tonicity disorders by qbank.org

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


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


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


ACUTE


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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

K

K

K

K

K

K

K

K

K

Na

Na

Na

Na

Na

Na

Na

Na

Na


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


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


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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Approach

toHyperna

tre


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http://content.nejm.org/content/vol342/issue21/images/large/07f2.jpeg


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http://content.nejm.org/content/vol342/issue21/images/large/07f2.jpeg


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Proposed mechanisms for the production of CSW Syndrome

BNP, ANPOuabain Like


127/140

Ouabain Like

AdrenomedulinaDendraspisNP


128/140


129/140


130/140


131/140


132/140


133/140


134/140


135/140


136/140


137/140


138/140


139/140

Electrolyte solutions

Plasma Isotonic Hypotonic solutions


140/140

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.

volume and tonicity disorders by qbank.org

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