Nephro Exam 1: Le Na + Water (Week 3)

Total Body Water (TBW)

• _____% TBW of body

• Males TBW (L) = _____ x weight (kg)

• Females TBW (L) = _____ x weight (kg) → greater proportion of _____

• Infants TBW (L) = _____ x weight (kg) → _____ really quickly

60, 0.6, 0.5, adipose tissue, 0.7, dehydrated

Adult: Daily Fluid Requirement:

• _____

• _____ mL/kg first _____ kg + _____ mL/kg next _____ kg + _____ mL/kg for the remainder (Kg body weight – 20) x 15 + 1500 = ml

30-35 mL/kg/day, 100, 10, 50, 10, 20

Pediatrics: Holliday-Segar Method (4-2-1)

• First _____ kg – _____ mL/hr

• Next _____ kg – _____ mL/hr

• Remaining kg after – _____ mL/hr

10, 4, 10, 2, 1

ENTER AFTER EACH BULLET POINT

pH: _____
Osmolarity: _____ mOsm/L

Na: _____

Cl: _____

K: _____

HCO3: _____

Ca: _____

Mg: _____

Glucose: _____

7.35-7.45
291

135-145

98-107

3.5-5.0

22-26

8.6-10.2

1.6-2.4

70-115

Types of Fluids

• Crystalloids

  • _____

  • _____

  • _____

• Colloids

  • _____

  • _____

  • _____

Unbalanced, Balanced, Dextrose, Albumin, Synthetic Molecules, Blood Products

Crystalloids

• _____ solutions of _____ and/or _____ that freely cross capillary membranes.

• ~_____% of isotonic stays within the _____ compartment

• Hypotonic, Isotonic, Hypertonic

• _____ of Isotonic Crystalloid → _____% _____ (space _____)

aqueous, electrolytes, glucose, 25, intravascular, 1 L, 75, interstitial, outside of blood

Normal Saline 0.9% (NaCl) → _____

• _____ (_____ below normal range AND _____ above normal range)

• Uses: _____, _____

• Benefits: widely _____; _____ with most meds/blood.

• AEs: _____, Dilutional _____, _____, Metabolic _____, _____

Isotonic, Unbalanced, pH, osmolality, Na, and Cl, Maintenance Fluids, Volume Repletion/Resuscitation, available, compatible, Hypervolemia, Coagulopathy, HyperCl, Acidosis, HyperNa

Hypertonic saline (HTS)

• Ex. _____ NS

  • _____ Na, Cl, and osmolarity high

  • _____ even higher and concentrated

• _____

• Uses: _____, _____ to decrease intracranial pressure in an emergency

• Prefer in _____ access (_____ if emergent)

• AEs: _____ metabolic _____, _____, _____

• Monitor: osmotic demyelination syndrome (ODS) from _____ correction, and _____ or _____ from osmotic shifts

3 and 23.4%, 3%, 23.4%, unbalanced, Severe Hypotonic HypoNa, Osmotherapy, central, PIV, HyperCl, Acidosis, HyperNa, Phlebitis, over-rapid Na, pulmonary edema, HF

Hypotonic saline

• _____

• Uses: treat _____ due to _____ deficit

• AEs: Dilutional _____, _____

• Monitor: _____, and neurological changes (_____, _____) from _____ administration

• _____ concentrated than plasma (_____)

Unbalanced, HyperNa, free-water, Coagulopathy, Hypervolemia, Cerebral edema, confusion, seizures, excessive hypotonic fluid, Less, Hypotonic

Balanced Crystalloids

• Balanced

  • _____

  • _____

• Uses: _____, _____

• Benefits: Similar to _____

• AEs: _____, Dilutional _____, Aggravation of preexisting _____

• Same as _____, BUT Includes other electrolytes and components (_____)

Lactated Ringer’s (LR), Plasma-Lyte A, Maintenance fluids, volume repletion/resuscitation, plasma, Hypervolemia, Coagulopathy, HyperK, NS, K, Bicarbonate, and Ca

Dextrose Water

• D5W = 5% Dextrose, remaining is _____, ”_____”

• Uses: _____ due to _____, _____

• Adverse effects: 

  • _____

  • Dilutional _____

• Dextrose > 10% is used for _____, nutrition

• Dextrose >12.5% via _____

• AEs: _____, _____, _____, _____

Water, Free Water, dehydration, water loss, Hypovolemic HyperNa, Hypervolemia, Coagulopathy, hypoglycemia, CIV, hyperglycemia, edema, phlebitis, hypervolemia

Sterile Water for Injection (SWFI)

• Only give water _____ – NEVER administer water _____ (because it will cause _____). Same principle applies for _____ (e.g., _____)

• If you want to administer “electrolyte-free water,” you must give _____. (ie. _____, _____, etc.)

orally, IV, hemolysis, hypotonic solutions, 0.225% NS, water with something in it, Dextrose, Na

Maintenance Fluid Adult:

• _____ + _____ mEq KCl/L; Glucose _____ | Na⁺ ~_____ mEq/L | K⁺ _____ mEq/L (typically used in hospital)

• ½NS – for _____ with _____ glucose

• D5NS – for _____ patients needing _____

• 0.9% NaCl – may cause _____ metabolic _____

• Lactated Ringer’s (LR) – _____; lactate → _____ (_____)

• Plasma-Lyte A – _____, _____, near physiologic pH

• D5LR / D5Plasma-Lyte A – for _____ concerns

D5 1/2 NS, 20, 5 g/100 mL, 77, 20, HyperNa or Euvolemia, normal, NPO/HypoNa, Na and Glucose, HyperCl, Acidosis, Balanced, Bicarbonate, Buffer, Balanced, Ca-Free, NPO or acid-base

Crystalloids Role in practice

• Replace daily fluid/electrolyte losses and provide minimal glucose to prevent ketosis/hypoglycemia when oral intake is inadequate

KNOW

Colloids

•  _____ (proteins or starches) that remain in the _____ space

• Exert _____, pulling fluid from the interstitial space into _____

• ~_____% stays intravascular

Large molecules, intravascular, Oncotic pressure, circulation, 100

Albumin Products

• _____

• Uses: _____ (_____, _____), _____ in acute _____

• AEs: Anaphylactoid/_____ reaction, _____

Balanced, intravascular restoration/fluid resuscitation, burn, Hypovolemic shock, Hypoalbuminemia, pancreatitis, Anaphylaxis, Renal Dysfunction

Blood Products

• Ex.

  • _____

  • _____

  • _____

  • _____

• Role in Practice

  • Provide colloid osmotic support and replace critical blood components.

• Some Jehovah’s Witnesses may decline blood products; discuss patient-specific preferences

Packed RBCs (pRBCs), Fresh Frozen Plasma (FFP), Platelets, Cryoprecipitate

Synthetic Colloid Solutions

• Ex. 

  • _____

  • _____

  • _____: Associated with _____ and should generally be _____ (SAFE, CHEST Trial)

Dextran, Gelatin, Hydroxyethyl Starch, impaired kidney function, avoided

Colloids Role in Practice

• Limited and declining use due to strong evidence of harm (↑ AKI, ↑ mortality, coagulopathy)

• May be considered for short-term intraoperative plasma expansion in select surgical patients with stable renal function

• Occasionally used in resource-limited settings where albumin is cost- prohibitive or unavailable, as a cheaper plasma expander alternative

KNOW

Management

• Fluid Choice:

  • Serum _____

  • Serum _____

  • _____ status

  • _____ status

• Fluid Type:

  • _____ component

  • _____

  • _____ component

  • _____

Electrolyte levels, Osmolality, Acid-Base, Volume, Electrolyte, Tonicity/Osmolality, Buffer, IV Access

Crystalloids Review

• Sodium Disorder

  • Severe Hypotonic Hyponatremia → _____

  • Hypernatremia → _____

• Hypoglycemia → _____

• Hyperosmotic Agents → _____

• Acidosis → _____

• Maintenance Fluid → _____

  • _____ for pediatric pts

• AKI → AVOID _____

Hypertonic Saline, Hypotonic Saline or D5W, Dextrose >10%, 3 or 23.4% Hypertonic Saline, Balanced Crystalloids (LR, Plasma-Lyte A), D5 1/2 NS + 20 mEq KCl/L, Holliday-Segar (4-2-1), HES/Hydroxyethyl Starch

Colloids Review

• AKI → AVOID _____

• Cirrhosis / Ascites / Hypoalbuminemia → _____

• Massive Hemorrhage / Trauma → _____ (_____, _____ (clotting factors), _____, _____ (specific clotting proteins/fibrinogen))

HES and synthetic colloids, Albumin, Blood Products, pRBCs, FFP, platelets, Cryoprecipitate

Sodium/Na

• Predominant cation in _____

• _____ mEq/L

• _____

• Serum Na = (_____ content) / (_____)

ECF, 135-145, Na/K ATPase, total ECF Na, ECF volume

Serum Osmolality

• _____ is primary determinant; _____ (_____ osmole) and _____ (_____ osmole)

• Water moves freely _____ compartments

• Tonicity → _____ mOsm/kg

• Osmolality (mOsm/kg) → Na is _____, Glucose is _____ (by 18), and BUN is _____ (by 2.8)

• HypoNa _____ and HyperNa _____

Na, glucose, effective, BUN, ineffective, between, 275-295, multiplied, divided, divided, <275, >295

Arginine Vasopressin (AVP/ADH)

• HypoNa (Low, _____) → _____ → _____

  • UOsm <_____

  • UOsm >_____ = _____ (_____, _____, _____, _____)

  • UNa >_____ → renal Na _____ (_____, _____, _____)

  • UNa <_____ → renal Na _____ (extrarenal/_____/_____, _____, _____)

<135, dumps water, increases Na, 100, 100, ADH active, SIADH, Hypovolemia, HF, cirrhosis, 20-30, LOSS, thiazides, AI, SIADH, 20-30, AVID, vomiting, diarrhea, HF, cirrhosis

Arginine Vasopressin (AVP/ADH)

• HyperNa (High, > _____)

  • UOsm >_____

  • UOsm <_____ → _____

  • Uvol >_____ → _____ (_____)

145, 800, 250-300, DI, 3 L/day, Polyuria, osmotic or DI

Na Review

• Serum Na HIGH → _____ tonicity → ADH _____ (Body will try to _____ water)

• Serum Na LOW → _____ tonicity → ADH _____ (Body will try to _____ water)

HIGH, STIMULATED, RETAIN, LOW, INHIBITED, LOSE

HypoNa Background

• _____ electrolyte d/o

• _____ mEq/L

• Significant morbidity and mortality

• Mild → _____ → _____, _____

• Moderate → _____ → _____, _____, _____, _____

• Severe → _____ → _____, _____, _____ (neuroemergencies)

• Common Causes: _____

Most common, <135, 130-134, Asymptomatic, N/V, 120-129, Headache, confusion, lethargy, muscle cramps, <120, Seizures, coma, death, SIADH and Thiazide Diuretics

HypoNa Emergency

• _____ + _____ → _____

• Hypertonic → _____

• Hypertonic Saline: _____ → _____ out of both

  • 3% NS 100-_____ mL OR 1-2 mL/kg over 20 mins

    • If Sxs do NOT resolve → _____ mL OR _____ over 10-20 mins

    • _____ > Slow continuous infusion

    • Mosmotic Demyelination Syndrome (_____) → Damage to _____

Severe Sxs, HypoNa, Cerebral Edema, Blood, 3 and 23.4% NS, pulls water, 150, 100, 1 mL/kg, Rapid intermittent Bolus, ODS, myeline sheath

Isotonic Hyponatremia

• _____ mOsm/kg

• _____

• _____ serum Na

• Caused by

  • Increased _____

  • Increased _____

  • Increased _____

• Flame photometry → _____

• Not truly hyponatremic, _____

275-295, PseudohypoNa, Falsely low, plasma proteins, lipids (HyperTG), osmotically active ingredients (mannitol), Blood gas (UBG), no need for Na correction

Hypertonic HypoNa

• _____ mOsm/L

• Excess effective osmoles in ECF

  • _____ is the most common cause

• _____ → water shifts from _____ to _____ → _____ of serum Na

• _____ Na is around the same as _____ + _____ x [(_____) / _____]

  • _____ in mEq/L and _____ in mg/dL

  • Correction Factor → _____

>295, Severe hyperglycemia, Increased ECF tonicity, ICF, ECF, dilution, Corrected, Measured Na, 2, Glucose - 100, 100, Na, Glucose, 2 mEq/L

Hypovolemic (Retain water) HypoNa

• _____

• Clinical Presentation: _____, _____, _____, _____ changes

• Labs

  • Renal losses (_____, _____ insufficiency): UOsm _____, UNa _____

  • Nonrenal losses (_____, _____, _____-spacing): UOsm _____, UNa _____

• Give _____

  • _____ or _____ adults OR _____ mL/kg children over 1 hr

    • KNOW Maintenance: _____ + _____ x (_____) mL/DAY

• Underlying Causes (Severe)

  • Renal: _____

  • Nonrenal: _____, _____

Na Loss >> Water Loss, Hypotension, Tachycardia, Dry MM, CNS, Thiazides, adrenal, >450, >30, vomiting, diarrhea, 3rd, >450, <30, fluids with salt (NS), 0.9% NS, LR Bolus 500-1000 mL, 10-20, 1500, 20, kg - 20, hold thiazide, antiemetics (Zofran), Antidiarrheals

Euvolemic HypoNa

• _____

• Clinical Presentation: _____ on exam, _____, psychogenic _____

• Labs

  • SIADH (_____, _____, _____): UOsm _____, UNa _____

  • Primary Polydipsia / _____: UOsm _____; UNa _____

• Restrict _____ and correct underlying cause (1st Line)

  • KNOW _____ water balance by restricting water intake to _____ → 1st Line

  • _____ supplements +/– _____ for mild-moderate Sxs → 2nd Line

Water Gain Only, Euvolemic, SIADH, polydipsia, Hypothyroid, hypocortisol, kidney failure, >100, >20, Low Na Intake, <100, <20, water, Negative, 800-1000 mL/day, NaCl, Loop Diuretics

Euvolemic Hyponatremia

• Tetracycline Antibiotic → _____

• Urea: _____ (KNOW)

• Vasopressin Receptor Antagonists (_____)

• Stop offending drugs → _____, _____, _____

• _____ (Samsca) → ADRs include _____, _____, and requires to start _____ (KNOW)

• _____ → Tetracycline antibiotic (allergy), _____ (KNOW)

Nephrotoxis, Weird Taste, Vaptans, SSRIs/SNRIs, Antineoplastics, Anticonvulsants, Tolvaptan, thirst, hepatotoxicity, in-hospital, Demeclocycline, Nephrotoxicity

Hypervolemic HypoNa

• _____

• Clinical Presentation: _____, _____ (_____, _____, _____ syndrome); _____ effective arterial blood volume → _____

• Labs:

  • HF, cirrhosis, nephrotic syndrome: UOsm _____; UNa _____

• _____ and correct underlying cause

  • _____, _____, +/– _____

• CHF Exacerbation → _____

• Cirrhosis → _____, paracentesis to improve underlying pathology

• Nephrotic Syndrome → _____, _____ → Reduce Proteinuria

Water Gain >> Na Gain, Edema, Ascites, HF, cirrhosis, nephrotic, decreased, increased ADH, >100, <20, Restrict water, Water, Na, Loop Diuretics, Loop Diuretics, Albumin and Loop Diuretics, Albumin and Loop Diuretics, RAAS Blockade

Monitor for Hyponatremia

• Serum Na → Check every _____ during active correction (_____ = hospitalization)

  • <_____ mEq/L in _____ to avoid _____

• Monitor _____, _____, _____, _____, and daily _____

• Check for _____, _____, _____, _____, _____ (2-6 days)

• Avoid overcorrection: _____; give _____ +/– _____ (_____: _____ ADH, give _____ volume) if Na is _____

2-4 hours initially, Tolvaptan, 8, 24 hours, ODS, BP, HR, skin turgor, edema, weight, confusion, lethargy, seizures, coma, ODS signs, hold hypertonic saline, D5W, desmopressin, VRAs, increased, more, rising too fast

Hypernatremia Background

• _____

• Mild-Moderate → _____, _____, _____, _____, _____, _____

• Severe → _____ → _____, _____, _____

>145, Weakness, lethargy, restlessness, irritability, twitching, confusion, >160, Seizures, coma, death

Hypovolemic HyperNa

• _____

• Clinical Presentation: _____, _____, _____, _____

• Labs

  • Nonrenal (_____, insensible) → UOsm _____; UNa _____

  • Renal (_____) → UOsm _____; UNa _____

Water Loss >> Na Loss, Orthostasis, Hypotension, Tachycardia, Dry MM, GI, >450, <20, Osmotic/Diuretics, >300, >20

Hypovolemic HyperNa

• _____ deficit

  • Restore hemodyanamic stability with _____

  • Once Stable → _____, _____ ie _____

    • _____ + _____ = ½ NS

  • _____ determines how much fluid to give to HyperNa pts (Hypovolemic)

  • TBW: 0.6 x wt (_____); 0.5 x wt (_____); 0.45 x wt (_____)

Replace water, 0.9% NS or Isotonic Solution, Free Water/D5W, Hypotonic Fluids, 0.45% NS, DS, 0.45% Na, Free Water Deficit, men, women and elderly men, elderly women

Euvolemic (_____) HyperNa 

• _____

• Clinical Presentation: Depends on _____, _____, _____

• Labs (U_____ variable)

  • _____: UOsm _____

  • _____: UOsm _____

• _____ + _____

  • Central DI → _____

  • Nephrogenic DI → _____ +/– _____

Decreased ADH, Water Loss ONLY, severity, seizures, lethargy, Na, Central DI, <250, Nephrogenic DI, <300, Free Water Replacement, AVP/AVP Analogue, Desmopressin (DDAVP), Thiazide and Na Restriction, Indomethacin

Central DI

• _____

• _____

  • _____ – AVP synthetic analog (V2 receptor): _____

  • _____ preferred

  • _____ used often

Water Loss ONLY, Decreased ADH secretion, DDAVP, PO, IV, SQ, and IN, Intranasal, Oral

Nephrogenic DI

• _____

• _____ to ADH

  • 1st Line → _____ (_____) and _____ (_____ NaCl/DAY)

  • _____ → Potentiates _____ activity → _____ (_____, _____ = inhibits renal prostaglandin)

Water Loss ONLY, Decreased kidney response, stop offending med, Lithium and Demeclocycline, start Thiazide and Na Restriction, 2000 mg, NSAID, AVP, Adjunctive Therapy, Indomethacin, 50 mg

Hypervolemic Hypernatremia

• _____

• Clinical Presentation: _____, variable _____

• Labs

  • UOsm _____; UNa _____

• _____

  • _____

  • Diuresis continued until _____ resolves

Na Gain > Water Gain, Peripheral and pulmonary edema, BP, >300, >20, Free Water Replacement and Loop Diuretic, D5W and Furosemide 20-40 mg q6h PO/IV, ECF volume overload

Monitoring for HyperNa

• Serum Na → decrease by _____ mEq/L in _____ to avoid _____ (_____ = water shift _____ → _____)

• Avoid overcorrection: _____ therapy if Na is _____

<10, 24 hours, cerebral edema, Hypotonicity Effect, back to cells, cerebral edema, pause or slow, dropping too fast

Ensure to HOLD all _____ for _____ (especially _____)

HTN and RAAS drugs, HypoNa, Hypovolemic and Hypotonic