Health complete (no parenteral/enteral)

metabolic acidosis

hyperkalemia associated

hypokalemia causes

b2 ag (terbutaline, albuterol), diuretics, amphotericin, gastro losses, low intake, hypomag

hypokal treatment

pills, aldosterone antagonists, iv, magnesium

hyperkal causes

intake, decreased elim, unresponsive to aldosterone, metabolic acidosis, hemolyzed sample

Hyperkal symptoms

Muscle weakness, ecg/arrythmia

hyperkal treatment

1)If arrythmia then cacl/cagluc periph 2)insulin or insulin with dextrose <250 3)albuterol 4)bicarb if acidotic 5)dialysis/resin exchange

hyperkal alternate treatment

loop diuretics with normal renal fxn, lokelma+SPS

hypomagnesium causes (Gi absorb + renal elim)

GI loss, renal disorder, magnesium citrate laxative overuse, diuretics, ampho B, tacrolimus, cyclosporine

hypomag treatment

oral tablets then bolus

hypermag treatment

Ca for arrythmia, bolus, NS preferred unless acidosis,loops, hemodialysis if renal failure. Reduce intake.

Calcium is more bound to albumin when

metabolic alkalosis occurs

hypocal causes

hypopth, vit d deficit, renal fail, hypomag, loops, calcitonin

hypocal symptoms

cramps, seizure, arrythmia, dermatitis, ecg issues

hypocal treatment

Oral cal, vit d, bolus

hypercal symptoms

constipation, n/v, kidney stones, coma, ecg changes (short qt)

hypercal treatment- asymptomatic>12

Bolus(unless hf), IV Loop, IV Calcitonin, IV Glucocorticoids, IV Bisphosphonate

Hypercal treatment-symptomatic ok kidneys

Bolus(unless hf), loop, calcitonin, glucocort

Hypercal treatment-symptomatic bad kidneys

Hemodialysis, calcitonin, glucocort

Hypophos causes

Low Gi absorb (sucralfate, cacarb, sevelamer), Increased excretion (acetazolamide) Redistribution (Insulin, alcohol, ketoacidosis)

Hyperphos causes

Low GFR, sodium phosphate enema, bisphos (-nate), rhabdomyolysis

Base excess

Indicates alkalosis, positive

Acidemia/alkalemia values

<7.35 >7.45

Lungs regulate which component

PaCO2 via ventilation

Kidneys regulate which component

HCO3 via cl excretion, less cl = more basic

Ideal BG values

pH 7.4, pCo2 40±5 HCO3 24±2

Metabolic acid compensatory

40-1.3(24-bicarb)

Metabolic alk compensatory

40-0.6(bicarb-24)

metabolic acid general causes

higher inorganic acid, high acid from renal failure, low bicarb

metabolic acid non-anionic gap causes

diarrhea, cacl, rapid ns

metabolic acid causes anionic gap (mudpiles)

methanol, urea, diabetic ketoacidosis, paraldehyde, isoniazid/ischemia, lactic acid, ethylene glycol, salicylates/starvation

mudpiles lactic acid drugs

metformin, linezolid, propofol, pento/phenobarb, ativan

Plasmalyte, LR, NS, D5W pH

7.4, 6.5, 5.5, 5

Metab acid treatment

Treat disorder, replace body fluid, give bicarb by mouth or bolus, or sodium acetate if good liver

metabolic alk causes (saline responsive)

vomiting, diuretics, too much bicarb, k deficit

metabolic alk causes saline resistant

excess mineralcorticoid, mg deficit, milk-alkali, blood transfusion, estrogen

metabolic alk treatment saline responsive

correct disorder, give NS bolus, 2nd acetazolamide with K, 3rd arginine hcl(good liver/kidney)

metabolic alk treatment saline resist

change mineralcort, give spironolactone, give K

resp acid causes

sedatives, stroke, asthma/copd, brainstem injury

resp alk causes

anxiety, pain, anemia, high altitude

Osmotic conc

osmolar at bedside, osmolal at lab

osmolarity calculation, normal btwn 275-290Osm

2Na + gluc/18 + BUN/2.8

Isotonic Fluids

NS, Plasmalyte A, LR, Albumin 5% (Colloid)

Crystalloids- small molecules dissolved

Pros: Widely available, 1st line Cons: Needs more fluid, can affect acid-base

NS is

154mEq/L or 308Osm

Hypertonic solutions

Holt salt, hypertonic saline, D10W, D5+, alb 25

Sensible losses(measurable)

GI, Urine, Sweat

Insensible Losses

Therm/chem burn, high resp rate, phototherapy/fever

Maintenance therapy

No current kidney losses, fixed rate over 12-24hr. Can have dextrose or K based on diabetes and urine output.

Bolus

Severe fluid loss, b4 maintenance, only isontonic

Hyponatremia symptoms

Mild: malaise, Moderate: Headache, lethargy, disorient, restless Severe: coma, seizure, brainstem herniation, death

Rapid hyponat correction

>12meQ, associated with osmotic demyelination

Isotonic hyponatremia

Lab mistake by elevated protein

Hypertonic hyponatremia

Uncorrected na due to hyperglyc error

Hypovolemic Hypoton, Hyponatremia causes non renal (UrNa<20)

vomiting, diarrhea, burns, hypervent

hypovol, hypoton, hyponat indicators

serum osm <280, urine osm >400

hypovol, hypoton, hyponat renal (UrNa >20)

Diuretics, mineralcort deficit

hypovol/ton/nat non-renal treatment

crystalloid bolus, NS preferred unless metabolic acidosis

hypovol/ton/nat renal treatment

Give hydrocortisone if steroid or stop diuretic + feed NA. Fluid bolus if fail

hypervol/hypoton/hyponat characteristics

expanded ecf + edema, impaired Na/H2O excretion, low artery bv

hypervol/hypoton/hyponat causes

HF, liver fail, nephrotic syndrome

hypervol/hypoton/hyponat treatments HF

1:Water/na restrict 2:Diuretics 3:ACE-I, beta block, VRAT

hypervol/hypoton/hyponat treatments LF

1:water/na restrict 2:Kspare/loop 3:Liver transplant

hypervol/hypoton/hyponat treatments Nephrotic

1:water/na restrict 2: treat condition

euvol/hypoton/hyponat causes urin<100osm, UrNa<20

Polydipsia and low Na intake, restrict water

euvol/hypoton/hyponat causes Urin>100Osm, UrNa>20

renal/adrenal failure, SIADH

Siadh- increased sensitivity or release of avp nonmed causes

Malignancy, cns disorders, pneumonia

Siadh med causes- increase release

tricyclic, haloperidol

siadh med causes - increase sensitive

Carbamazepine, Oxycarbazpine, Vasopressin, Desmopressin

siadh med causes - mixed mech

cyclophosphamide, ssri

siadh 1st treatment(besides restrict fluid, discont meds) and equation

NS or 3% for fluid restrict or symptomatic, Meq= 0.6(wt)(120-current) at 0.5-1meq/kg/hr

siadh other treatments

Conivaptan (VRA), 3rd:Tolvaptan/Demeclocycline (Chronic only)

Demeclocycline caveats

Avoid with bad liver or renal, or under 8yrs for teeth

Hypernatremia signs, rapid correct = cerebral edema

Mild:Lethargy, weakness, confusion, restless Severe:Twitching, seizure, coma

Hypovol/hypernat nonrenal (UrNa<20) causes +treatment

Gastro, heat injury/burn, Crystalloid bolus, NS preferred unless acidosis

hypovol/hypernat renal causes + treatment

Diuretics, hyperglyc, stop meds or treat hyperglyc

Hypervol/hypernat causes + treat w/ hyperten/hypokal

Hyperaldosteronism/cushings, treat disease

hypervol/hypernat causes + treat w/o hyperten/hypokal

Post obstructive diuresis or too much salt, stop salt, freewater/D5W

euvolemic hypernatremia cause

Arginine vasopressin disorder = lower production/response to AVP

AVP deficiency causes (central)

Genes, idiopathic, insensible loss, cns issues

AVP low sensitivity causes (Periph)

Hypercalcemia, hypokalemia, genes, meds

AVP desensitizing meds

demeclocycline, foscarnet, ampho B, cidofovir, lithium, tolvaptan/conivaptan

AVP Treatment

1: Correct water volume with NS, slowly introduce hypoton 2a:Pressin, carbmazep,indo for AVP deficiency 2b: hctz,desmopress, indometh/amiloride(lith) for resistance

Hypokalemia med causes

Transcellshift (b-ag), Increased Excretion (Diuretics, amphotericin), increased fecal elim

Hypokalemia non med causes

lowered intake, hypomg, gastro losses

Hypokal symptoms

Cramping, weakness, malaise, EKG + arrythmias, hypomag symptoms

Factors that affect lab samples

Bad handling, bad reagents, insuf qt, food/drugs/med procedures, technical errors

hyponatremia causes

excess fluid, high gluc

corrected sodium calc

Na + 1.7*(gluc-100)/100

hypernatremia causes

fluid loss, high intake

hypokalemia causes

loop/thiazide, diarrhea/vomit

hyperkalemia causes

metabolic acidosis, ace/arb, spironolactone

anion gap formula

Na - Cl - CO2, <11 normal

cl/bicarb fxn

maintain acide base, inversely related

HIgh BUN

Azotremia, high protein, heart fail treatment

High creat

More muscles, low GFR, not young or old

Calcium correction-half bound to albumin

Ca + 0.8(4-Alb)

iCa2+

active form of ca, used for critically ill pt or no alb

AST + Alt diagnose

heart and liver injury, alt is more liver specific

alk phos

bone and liver disease

billirubin indicate

hepatocell injury, billiary obstruction, hemolysis