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Sodium and Water Assessment

Sodium and Water Assessment. Fluid Distribution. Extracellular Fluid 20% of BW Interstitial Fluid 15% of BW Plasma Fluid 5% of BW Intracellular Fluid 40% BW Total 60% of BW. Fluid Dynamics. Dependent upon

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Sodium and Water Assessment

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  1. Sodium and Water Assessment

  2. Fluid Distribution Extracellular Fluid 20% of BW Interstitial Fluid 15% of BW Plasma Fluid 5% of BW Intracellular Fluid 40% BW Total 60% of BW

  3. Fluid Dynamics • Dependent upon • Hydrostatic pressure: similar/same thing to blood pressure but this is talking about the pressure that is on the fluid • Colloid Oncotic pressure • Pressure in the blood vessels • Major thing in the blood that generates this pressure is albumin • A high molecular weight protein that cannot pass to intestinal space so it remains in the blood • Remaining in the blood can generate an oncotic pressure that keeps fluids in the blood vessels • Made in the liver • If the pressure goes down due to decrease synthesis of albumin, water can go into the intestial space and cause edema • Alcholism • Mal nutrient: protein malnutrient will develop dedema because they don’t have enough substrate to synthesize albumin which led to water leakage = edema • Lymph Drainage (fast)

  4. Fluid Dynamics • Hydrostatic pressure pushes fluid from the blood vessels into interstitial space • Colloid oncotic pressure in the interstitial space pulls fluid from the blood vessels into interstitial space • Colloid oncotic pressure pulls fluid from the interstitial space back into blood vessels • Lymph drainage creates negative hydrostatic pressure in interstitial space

  5. Fluid Dynamics

  6. Changes in Fluid Dynamics • Changes usually end up causing edema • Decrease in serum albumin concentration • Change in hydrostatic pressure • Decrease in blood pressure

  7. Normal

  8. Edema

  9. Pitting Edema: fluid pools in the foot due to gravity

  10. Pitting Edema

  11. Sodium Assessment • Normal Serum Levels 135-145meq/L • Hypernatremia >145meq/L • Hyponatremia <135meq/L • Symptoms occur when levels >155meq/L or <120meq/L

  12. What Are We Talking About When We Talk about • Hypernatremia: is about the water concentration • About losing a lot of water from the body • Water loss will keep sodium level constant • But concentration of sodium in body will increase • Hyponatremia: a gain of water • Severe: caused by ingesting a lot of water

  13. Hyponatremia • Serum Sodium Level of <135meq/L • Serious problems occur when below 120meq/L

  14. Signs and Symptoms of Hyponatremia • Sodium level of 125-135meq/L • No symptoms • Sodium level of 120meq/L • Headache • Anorexia • Perhaps altered Mental Status • Sodium Level of 115-120meq/L • Altered mental status • Patient feels bad

  15. Signs and Symptoms of Hyponatremia • Sodium level of <110meq/L • Seizures • Coma • Respiratory Arrest • Death

  16. Why are Seizures and Coma Signs of Severe Hyponatremia • Serum is very hypotonic compared to intracellular fluid • Water moves from ECF to ICF causing brain to swell • Results in increased intracranial pressure • Results in seizures • Results in coma

  17. Theory of Treatment • Treat the patient • Never treat a laboratory value • Evaluate the patient’s laboratory tests AND symptoms • Establish treatment goals and treatment endpoints • Select and administer therapy • Monitor patient and determine whether treatment goals are being met • If goals are not being met, reevaluate therapy and make changes as necessary

  18. Types of Hyponatremia • DON’T REMEMBER THESE NAMES • HypovolemicHyponatremia • IsovolemicHyponatremia • HyerpervolemicHyponatremia • Hyponatremia with Hypertonicity • Hyponatremia with Hypotonicity

  19. HypovolemicHyponatremia • Caused by loss of water and sodium • Loss of more sodium than water • Severe vomiting and diarrhea with inadequate re-hydration are most common causes. • Patients should have signs and symptoms of dehydration • Sodium level unlikely to drop below 130meq/L, loss sodium more than water • Due to severe diarrhea (electrolytes loss)

  20. Normal Sodium and Fluid Levels Total Body Water 42L 140meq/L Sodium

  21. HypovolemicHyponatremia Water 35L 130meq/L Sodium

  22. Treatment of HypovolemicHyponatremia • Goals of treatment • Treat dehydration • Raise blood pressure • Improve perfusion of vital organs

  23. Treatment of HypovolemicHyponatremia • If dehydration is estimated to be 2%, how do we treat patient? • Given them water and salt orally • Gatorade • If dehydration is estimated to be 6%, how do we treat patient? • Water, salt, Gatorade • If dehydration is estimated to be 10%, or greater, how do we treat patient? • IV fluid: normal saline because fluid loss from ECF will let us expand the ECF compartment • Fluid will go to the ECF

  24. How Much Fluid to Give? • How much fluid do we give? • I really don’t know • Estimate the degree of dehydration and give enough fluid to reduce or eliminate symptoms • Set up a to give increments of 250mL every 15 mins until the pts starts to feel better, then you will slow down

  25. How Much Fluid To Give • You may read in a reference source the following: • If 70kg patient is 2% dehydrated give 1.4L of fluid (2% X 70kg) • If 70kg patient is 6% dehydrated give 4.2L of fluid (6% X 70kg) • If 70kg patient is 10% dehydrated give 7L of fluid (10% X 70kg)

  26. HypervolemicHyponatremia • Caused by retention of sodium and water with more water retained than sodium • Caused by CHF, kidney failure, and hepatic cirrhosis • Serum sodium level unlikely to drop below 130meq/L

  27. HypervolemicHyponatremia 51L Water 132meq/L Sodium

  28. HypervolemicHyponatremia • Patient has signs of fluid overload. • Patient has edema • may have pulmonary congestion, • may have difficulty breathing, • may have low or normal or elevated blood pressure depending on etiology of problem. • What are goals of treatment? To get the excess water and sodium out of pt

  29. Treatment of HypervolemicHyponatremia • Bed rest • Fluid and sodium restriction • Diuretics (furosemide) • Have a tendency to removed fluid from the plasma only • May cause pt to retain fluid but still be volume depleted (dehydrated) • Must use the right kind of diuretics or will cause a volume defeciet • Treatment of underlying cause of problem

  30. IsovolemicHyponatremia • Retention of water • No excess sodium retention, no edema, no signs of hypervolemia or dehydration • Cause by over activity of ADH (anti-diurectic hormones) • Called SIADH (syndrome of inappropriate anti-diuretic hormones) • Can be caused by over activity of hormones • Anti-diuretic hormones: w/ out will cause pt to pee out huge amount of fluid every single day • Called diabetes insipedious • Give anti-diuretic hormones • Caused by consumption of large amounts of free water

  31. SIADH • ADH secretion decreases when the serum osmolarity falls • What would happen if ADH secretion persisted in spite of falling serum osmolarity and continued water intake? • Several medications can cause drug induced SIADH • Vincristine (Oncovin) • Morphine • Fluoxetine (Prozac) • Oxytocin: use to induce labor and use to shut down uterus causing it to contract to shut down the bleeding if pt bleed a lot after giving birth • Chlorpropamide (sulfonylurea not used anymore)

  32. Isovolemic Hyponatremia • Patient likely to have sodium levels below 110meq/L • True hyponatremia

  33. Isovolemic Hyponatremia 51L Water 110meq/L Sodium

  34. Symptoms of Isovolemic Hyponatremia Due to severely hypotonic serum and fluid shifts from ECF to ICF Symptoms include mental changes, seizures, coma, death All symptoms caused by increased intracranial pressure

  35. Goals of Therapy for Isovolemic Hyponatremia • Reverse mental changes, eliminate seizures, prevent death • Remove excess water from ECF • Move water from ICF to ECF • Increase serum sodium concentration to about 120meq/L • Raising the concentration will result in increase in osmalarity and tonicity of ECF • Water will shift from ICF to ECF where it belongs • Increase at a rate of 0.5-1meq/L/hour • Increase by no more than 15meq/L in 24 hours • Why at this slow rate? • Increase so slow at 15meq/L so that you yourself do not promote another fluid shift • Body takes time to adjust to fluid shift • Help the body fluid to re-equilibrate • Moving too fast can cause hypertremia which can led to pt dehyration • Increase slowly up to about 120 (not normal 140) • 120 is when stop having symptoms associated w/ hyponatremia • Seizures disappear • Coma disappear • Chance of dying is slow

  36. How do you do this? • Give diuretics to remove excess water • Give sodium chloride to increase serum sodium levels • Both

  37. Problem • 60kg patient who has severe mental changes, seizures and a serum sodium level of 110meq/L • What to do?

  38. How Much Hypertonic Sodium Chloride to Give? • Increase serum sodium level to 114meq/L in the first 4 hours (increase very slowly from 110 to 114, don’t want to raise it more than 1meq/L/Hr of sodium or can cause shift) • Na+ (to be given as 3% NaCl solution • How much sodium? [Na+(desired) ] – [Na+(measured) ] X TBW

  39. Solution • TBW = 60kg X 60% = 36L • [114-110] X 36L = 144meq • Give as 3% sodium chloride solution • Give 280ml of 3% NaCl in first 4 hours of therapy • How do I know this? How many meq of sodium ion are found in 3% NaCl?

  40. Giving Sodium Chloride Only • Assuming normal renal function, if only concentrated sodium chloride is given • If patient has normal renal function, much of the administered sodium will be rapidly excreted by kidneys • Original problem would reoccur in a short period of time

  41. Giving Diuretics Only • Furosemide (drug of choice) causes loss of water and sodium • Hyponatremia would take a long time to correct and patient may die while you are manipulating diuretic dose. • Death is not good

  42. Recommendations • Give both diuretics and 3% sodium chloride • Give furosemide to remove excess water from body • Give 3% sodium chloride to replace sodium lost by administration of diuretic

  43. Treatment of Severe Hyponatremia • Give furosemide 0.5-1mg/kg IVP Q 4-6 H • Measure amount of sodium lost in urine and replace that amount meq for meq with 3% sodium chloride • Collect urine and measure each parameter every hour • Urine Osmolality • Urine Specific Gravity • Urine sodium concentration

  44. Hypernatremia • Sodium level of >145meq/L • Symptoms begin to occur at 155meq/L • Symptoms of mild hypernatremia (155-160meq/L) • Thirst is the primary symtoms • Restlessness • Irritability

  45. Symptoms of Severe Hypernatremia • Serum sodium level of >165meq/L • Serum is very hypertonic compared to intracellular fluid • Water moves from ICF to ECF causing brain to become dehydrated • Results in seizures • Results in coma • May results in intracranial bleeding • May result in death

  46. Iatrogenic (cause of a symptom due to seomthing else) Osmoles • The body’s protective mechanism for long standing, slowly developing hypernatremia • Brain tissue synthesizes proteins that are stored in brain tissue to prevent dehydration • Protein raises osmolarity of brain tissue do that water loss from brain will occur more slowly • Called iatrogenic osmoles

  47. Iatrogenic Osmoles • In a patient who has developed hypernatremia over many days, the effects of iatrogenic osmoles become important • Must not lower serum osmolarity more than about 2mOsmol/hour or about 1meq sodium/L/hour) • Why? Can go from dehydrated brain to brain swelling

  48. Types of Hypernatremia • Don’t remember these names • HypovolemicHypernatremia • IsovolemicHypernatremia • HypervolemicHypernatremia

  49. Hypovolemic Hypernatremia • Relatively rare • Caused by loss of water and sodium • Loss of more water than sodium • Caused by inappropriate use and administrtion of inappropriately high doses of furosemide • Serum sodium level rarely exceeds 150meq/L • Symptoms are most likely due to mild to moderate dehydration 2-6% and not to hyperomolar ECF • Not usually associated with seizures, coma or death

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