UAMS P2 - Therapeutics Final SG

Major determinant of ECF Volume

Sodium

Major determinant of ICF Volume

Potassium

Normal ECF Osmolarity

280-285 mOsm/L

NS and Lactated Ringers are

Isotonic Solutions

1/2 NS and D5W are

Hypotonic Solutions

3% NaCl is a

Hypertonic Solution

Determine the effects: Adding Isotonic Sol to ECF

ECF Osmolarity:

Net effect in ECF:

Net effect in ICF:

ECF Osmolarity: No change

Net Effect in ECF: Increase

Net effect in ICF: No Change

Determine the effects: Adding Hypotonic Sol to ECF

ECF Osmolarity:

Net effect in ECF:

Net effect in ICF:

ECF Osmolarity: Decreases

Net effect in ECF: Increases (water moves out but initially increases)

Net effect in ICF: Increases (water moves in)

(Cell burst)

Determine the effects: Adding Hypertonic Sol to ECF

ECF Osmolarity:

Net effect in ECF:

Net effect in ICF:

ECF Osmolarity: Increases

Net effect in ECF: Increases (water moves in)

Net effect in ICF: Decreases (water moves out)

(Cell Shrivel)

Acute Fluid Resuscitation use either

NS or LR

(Crystalloids for rapid infusion)

Hormone that acts as the Counter for RAAS system

ANP

Hormones that Increase Water Reabsorption

Ang 2,

Aldosterone,

Cortisol,

Catecholamines,

ADH

Normal Na

135-145

Isotonic Hyponatremia Treatment

Correct underlying problem (Hypertriglyceridemia)

Hypertonic Hyponatremia Treatment

Correct underlying problem (Hyperglycemia)

Hypovolemic Hypotonic Hyponatremia Cause

Thiazide Diuretics (main)

Diarrhea

Hypovolemic Hypotonic Hyponatremia Treatment (Non-Acute)

NS at max rate 10-12 mEq/L/day

D5-1/2 NS for Maintenance

Hypovolemic Hypotonic Hyponatremia Treatment (Acute)

3% Saline

Euvolemic Hypotonic Hyponatremia Cause

SIADH (main)

Hypothyroidism

Polydipsia

Drugs with Strongest Cause of SIADH

SSRIs

Tricyclics

Venlafaxine

Vincristine

Cyclophosphamide

Carbamazepine

Euvolemic Hypotonic Hyponatremia Treatment (Non-Acute)

Fluid Restrict < 1L/day

Urea

Salt Tabs

Demeclocycline

Vaptans (not recommended though... $$$)

Euvolemic Hypotonic Hyponatremia Treatment (Acute)

3% Saline + Loop Diuretic (furosemide)

Hypervolemic Hypotonic Hyponatremia Cause

HF

Liver cirrhosis

Kidney Failure

Hypervolemic Hypotonic Hyponatremia Treatment (for HF)

Fluid Restrict

Sodium Restrict < 2g/day

Loop Diuretic

Vaptans (not recommended though... $$$)

Hypervolemic Hypotonic Hyponatremia Cause (for Cirrhosis)

Fluid Restrict

Sodium Restrict < 2g/day

Loop Diuretic + MRA

Vaptans (not recommended though... $$$)

Clinical Presentations of Hypervolemic Disorders

Edema

Weight Gain

Variable BP

Clinical Presentations of Hypovolemic Disorders

Orthostasis

Hypotension

Tachycardia

Hypernatremia is always

Hypertonic

Improper Therapy for Hypernatremia Treatment can lead to

Cerebral Edema

Hypovolemic Hypernatremia cause

Loop Diuretics

Osmotic Diuretics

Hypovolemic Hypernatremia Treatment (unstable... low BP and tachycardia)

NS till stable then Hypotonic

Hypovolemic Hypernatremia Treatment (Stable)

Hypotonic Fluids (correction rate 1-2 mEq/L/hr)

Euvolemic Hypernatremia Causes

Acquired or Nephrogenic Diabetes Insipidus

(Polyuria, Polydipsia, Nocturia)

Euvolemic Hypernatremia Treatment

Access to water or D5W

Treat DI

- Desmopressin

- Amiloride if Lithium induced

Hypervolemic Hypernatremia Cause

Overload

Hypervolemic Hypernatremia Treatment

Free Water AND Loop Diuretics

Normal K+

3.5 - 5 mEq/L

Hypokalemia Causes

Decrease K+ intake,

Increased Entry into cells,

Loop and Thiazide Diuretics

Amphotericin B

Hypokalemia is commonly associated with what other electrolyte disorder?

Hypomag

Hypokalemia Signs

Arrhythmias,

ECG changes,

Muscle weakness

Mild-Moderate Hypokalemia (3-3.4) Treatment

Oral K+

Severe Hypokalemia (<3) Treatment

IV K+ or PO high strength K+

Potassium Supplements and their Characteristics

KCl - preferred agent and most effective

KPO4 - for pts with K+ and PO4 loss

KHCO3 (potassium bicarb) - for pts with K loss and metabolic acidosis

Pt has Low K+ and Mg+... which should be corrected first?

Mg+

(always correct low Mg first)

Potassium Sparing Diuretics

Amiloride

Triamterene

Spironolactone

Cause of Hyperkalemia

Potassium Sparing Diuretics

NSAIDs

ACEi and ARBs

Hyperkalemia Treatment

If ECG Changes: IV Calc Gluconate FIRST

Insulin + Glucose (prevents Hypoglycemia)

Albuterol (Temporary... with Insulin + Glucose)

Sodium Bicarb (if metabolic acidosis)

Exchange Resin (Lokelma, Kayexalate, Veltessa)

Loop/Thiazide Diuretic (Loop better)

Patient with Hyperkalemia has ECG abnormalities but Mg is normal... What should you give them?

IV Calc Gluconate

Monitoring of K+

Q2H

Which Potassium exchange resins should be separated by other drugs?

Lokelma (2hrs)

Kayexalate (6hrs)

Veltessa (3hrs)

Monitoring of Na+

Q4H

Normal Mg

1.7-2.3 mg/dL

Drug-Induced Hypomag

Loop/Thiazide Diuretics

Nephrotoxins (Aminoglycosides, Cisplatin, Amphotericin B, Cyclosporine, Foscarnet, Tacrolimus, Pentamidine)

PPIs

Hypomag Treatment

When Mg < 1.2 or Seizure/Arrhythmia

MgSO4 (Mg Sulfate) IV

Maintenance: Oral Supplements

High PO doses of Mg can cause

diarrhea -> more Mg loss

Hypermag Treatment

Calcium Gluconate

Diuresis w/Furosemide and NS

Normal Ca

8.5-10.5

When to use Correct Calc Formula

Albumin < 4 g/dL

Corrected CaT Formula

0.8(4 - albumin) + CaT

PTH effect on CaT and PO4

CaT: Increases

PO4: Decrease

Vit D effect on CaT and PO4

CaT: Increases

PO4: Increase

Calcitonin effect on CaT and PO4

CaT: Decreases

PO4: Decrease

Common cause of Chronic Hypercalcemia

Hyperparathyroidism

Renal Failure

Acute Hypercalcemia Treatment

Hydrate with NS

Loop diuretic to prevent Fluid Overload

Acute Hypercalcemia Treatment for Malignance-Related

Bisphosphonates IV

Bisphosphonates IV Contraindication

Renal Dysfunction

Acute Hypercalcemia Treatment if EKG Changes present

Calcitonin SQ

(Remember... TREAT EKG CHANGES FIRST)

Acute Hypercalcemia Treatment for patients with Renal Insufficiency (can't use Bisphosphonates)

Denosumab SQ

Acute Hypercalcemia Treatment from Vit A and D intoxication

Prednisone (Corticosteroids)

Acute Hypercalcemia Treatment Last Line (or Renal Failure)

Hemodialysis

Chronic Hypercalcemia Treatment

Cinacalcet PO

Monitoring for Mg+

BP, Electrolytes, EKG, Renal Function

Acute Hypocalcemia Treatment

IV Calcium Gluconate (preferred)

Correct Hypomag

Monitoring for Ca

Acute: Q4-6H

Chronic: Q3M

Chronic Hypocalcemia Treatment

Oral Ca replacement

Oral Vit D replacement

Normal Phosphorus

2.5-4.5 mg/dL

Acute Hyperphosphatemia Treatment

Hemodialysis

Acute Hyperphosphatemia Treatment if also Hypocalcemic

IV Calc

Chronic Hyperphosphatemia Signs

Ca * PO4 >= 50 (mg/dL)^2

Chronic Hyperphosphatemia Treatment

Calcium Products

- acetate more effective than carbonate

- avoid citrate in CKD

Aluminum/Mg Antacids

- Aluminum toxicity risk

- avoid in CKD

Sevelamer/Lanthanum Carbonate

- 2nd Line

Acute Hypophosphatemia Treatment when K > 3.5

Sodium Phosphate IV

Acute Hypophosphatemia Treatment when K < 3.5

Potassium Phosphate IV

Monitoring Phosphate

Acute: Q4-6H

Chronic Hypophosphatemia Treatment when K < 5

Phos-NaK

Chronic Hypophosphatemia Treatment when K > 5

K-Phos-Neutral

Renin Function

increases BP

Prostaglandin Function

Increases Renal blood flow

Erythropoietin Function

Stimulates RBC Production

Vitamin D3 Function

Regulates Parathyroid and Calcium/Phosphorus Homeostasis

Insulin Function

Risk of Hypoglycemia in reduced Kidney Function

Normal Urinalysis Protein

< 30 mg/g

Normal SCr

0.5-1.5 mg/dL

Normal BUN

5-20

Normal BUN:Cr Ratio

10:1 to 15:1

If a patient is on Dialysis... CrCl is assumed to be

< 15mL/min

Stage 1 AKI

SCr: Increase >= 0.3 OR 1.5-1.9x from baseline

Urine Output: Decrease <0.5 mL/kg/h for 6-12H

Stage 2 AKI

SCr: Increase 2.0-2.9x from baseline

Urine Output: Decrease <0.5 mL/kg/h for > 12H

Stage 3 AKI

SCr: Increase >= 4 OR 3x from baseline

Urine Output: Anuria >= 12H

(NEED RRT)

Non-oliguric

Urine Output > 450 mL/day

Oliguric

Urine Output 50 - 450 mL/day