VITAMINS, MINERALS, FLUIDS & ELECTROLYTES

VITAMINS, MINERALS, FLUIDS & ELECTROLYTES

VITAMIN THERAPY • FAT SOLUBLE VITAMINS • A (CHART 12-1) • D • E • K • WATER SOLUBLE VITAMINS • B VITAMINS • C (CHART 12-2)

Vitamin A • AQUASOL (capsules, drops, tabs, IM) • Retinal function, bone growth, reproduction, epithelial and MUCOSAL tissue integrity • Po forms require normal fat absorption • Protein bound • Stored in normal liver for 2 years • MEN: 1,000 mcg re(retinol equivalents) or 4,000U • WOMEN: 800mcg RE or 4,000 U

VITAMIN D • Calciferol: Adults = 200 IU (PO, IM) • Rickets • Hypoparathyroidism • Familial phosphatemia • Drug interactions: • Steroids antagonize Vit D • Thiazides can increase calcium • Verapamil  AF due to high calcium

VITAMIN E • Men: 10 alpha-tocopherol equivalents/15 IU • Women: 8 alpha-TE/12IU • PO • Depends on bile for absorption • Drug-Drug Interactions • Increases daily iron need • Decreases Prothrombin • Antagonized Vit K

VITAMIN K • Phytonadione (PO or IM, SC, IV) controls abnormal bleeding due to malabsorption, drug therapy, or Vit A toxicity • Men >25: 80 mcg • Women >25: 65 mcg • PRODUCT IS LIGHT-SENSITIVE. • WRAP IV BAG IN FOIL.

VITAMIN C • RDA: ADULTS = 60 mg • Therapeutic use: 300 – 500 mg for short course in burns, fractures, post-op healing, severe febrile or chronic disease. • Low protein binding activity • Decreases with high dose ASA • Decreases warfarin • Increases estrogen; iron absorption

B Vitamins • B1 – Thiamine (po, iv, im) • ANGIOEDEMA, CV COLLAPSE, HEMORRHAGE, PULMONARY EDEMA • B2 – Riboflavin ( Adults: 1.3 – 1.4 mcg) • Tissue respiration • Use cautiously with probenecid • Discolors urine yellow/orange

B Vitamins • B3 - Niacin (PO, slow IV, IM, SC) • Stimulates lipid metabolism, tissue respiration, glycogenolysis • Decreases low density lipoprotein • Dilates peripheral blood vessels • Adverse reactions: arrythmias, hepatic dysfunction • Potentiates orthostatic hypotension

B Vitamins • B6 (Pyridoxine) (1.6 – 2 mg) PO, IV, IM • Coenzyme in amino acid metabolism • Antidote for INH poisoning • Metabolized in liver decreased levels of anticonvulsants • Alcoholics can experience delirium and lactic acidosis

B Vitamins • B 12 (cyancobolamin) : RDA = 2mcg • PO, IM/SC • for dietary supplementation or after sub-total gastrectomy or in GI disease: 30 mcg IM qd x 5 days; then 100 – 200 mcg IM q month • For pernicious anemia: 100 mcg IM/SC qd x 6-7 days; then 100 mcg IM/SC q month • Avoid with ETOH, aminoglycosides, chloramphenicol, and PAS • Anaphylaxis can occur

FOLIC ACID • Vitamin B stimulates erthyropoiesis and nucleoprotein synthesis • Prevents megaloblastic anemia • Adults: 180 – 200 mcg (higher in pregnancy) • Drug-drug concerns: • Any folic acid antagonist, e.g., trimethoprim, methotrexate; decreases levels of anticonvulsants • ETOH increases folic acid requirements

VITAMIN SUPPLEMENTS • RATIONALE: • THE SOIL IN WHICH WE PRODUCE OUR FOOD IS DEPLETED OF MINERALS • THE AMERICAN DIET DOES NOT MEET OUR MINIMUM DAILY REQUIREMENT • CAUTIONS: • MEGADOSES OF VITAMINS ARE NEITHER NECESSARY NOR HARMLESS • EXCESS FAT SOLUBLE VITAMINS MAY BE STORED IN THE BODY FOR EXTENDED PERIODS OF TIME

VITAMIN SUPPLEMENTS • JUSTIFICATIONS • INADEQUATE ABSORPTION • MALABSORPTION, • DIARRHEA • INFECTION • INFLAMMATORY BOWEL DISEASE • IMPAIRED UTILIZATION • LIVER OR RENAL DISEASE • GENETIC DISORDERS

VITAMIN SUPPLEMENTS • JUSTIFICATIONS • EXCESSIVE LOSSES • FEVER • HYPERTHYROIDISM • HEMODIALYSIS • STARVATION, CRASH OR LIMITED DIETS

VITAMIN SUPPLEMENTS • JUSTIFICATIONS • INCREASED REQUIREMENTS • GROWTH • PREGNANCY • DEBILITATING DISEASES • GI SURGERY • RESTRICTED DIETS

VITAMIN EXCESS See Instructor’s Notes on the Web

FLUIDS & ELECTROLYTES • FLUID REPLACEMENT • WATER • ELETROLYTE REPLACEMENT • SODIUM, POTASSIUM • ACID-BASE BALANCE

FLUID REPLACEMENT: crystalloid solutions

COLLOIDS: large molecule solutions • PROVIDE PROTEIN, FLUID, AND CALORIES FOR WOUND HEALING • ALBUMIN, DEXTRAN • Increase PLASMA VOLUME and OSMOTIC PRESSURE TO COUNTERACT SHOCK • REDUCES RED CELL AGGREGATION AND ENHANCES BLOOD FLOW • Contraindicated in HEMORRHAGE, RENAL FAILURE, DEHYDRATION THROMBOCYTOPENIA

COLLOID CONTROVERSY • INCREASED COST OVER CRYSTALLOID SOLUTIONS • DIFFERENTIAL MORTALITY • THE ROLE OF HEALTH SERVICES RESEARCH • INFLUENCE OF MANAGED CARE IN CLINICAL DECISIONS

ELECTROLYTES • INTRACELLULAR: K • 140 mEq, mainly in muscle • EXTRACELLULAR: Na • 140 mEq, mainly in serum

ACID – BASE BALANCE • THE EQUILIBRIUM IN THE EXTRA- CELLULAR FLUID BETWEEN • SUBSTANCES ABLE TO GIVE UP H+ IONS (ACIDS) AND • SUBSTANCES ABLE TO ACCEPT H + IONS (BASES) • RESPIRATORY ACID-BASE CONTROL • RENAL MECHANISM FOR METABOLIC CONTROL

CASE • MR. BROWN, 68, HAS ACUTE PNEUMONIA, A PRODUCTIVE COUGH, CYANOSIS, LABORED BREATHING AT 28 BREATHS PER MINUTE • PaO2 = 56 mmHg • SaO2 =88% • pH=7.32 • PaCO2=50mmHg • HCO3=24 mEq/L

CASE • MRS. C, 36, HAD DILATED CARDIOMYOPATHY, ORTHOPNEA, DOE, DRY, NON-PRODUCTIVE COUGH. SHE IS DIZZY, C/O TINGLING IN ETREMITIES. HAS FINE CRACKLES. R=32/MIN • PaO2 = 93 mmHg • SaO2 = 98% • Ph = 7.48 • PaCO2= 32mmHg • HCO3 = 24 mEq/L

CASE • LAURIE, 6 MOS OLD, HAD A BOWEL RESECTION FOR HIRSCHSPRUNG’S DISEASE. SHE HAS AN NG TUBE, IVs. URINE OUTPUT IS 0.4CC/HR. RESPIRATIONS ARE NORMAL. • PaO2 = 90 mmHg • SaO2 = 95% • pH = 7.49 • PaCO2 = 45mmHg • HCO3 = 30 mEq/L

NUTRITIONAL SUPPORT • INSERT TUBE ABOUT 25 CM IN ADULTS • INSUFLATE WITH AIR AND ASPIRATE FLUID • TEST ITS Ph and APPEARANCE • pH <5 + green/brown color = gastric location • pH >6 + yellow  bile stained = duodenum • pH>6 + mucus, straw colored fluid = ?lung

BLOODLESS SURGERY • MEETS THE NEEDS OF PATIENTS FOR WHOM TRANSFUSIONS ARE NOT POSSIBLE OR DESIREABLE • EPOGEN PREOPERATIVELY • INDUCED HYPOTENSION OR HYPOTHERMIA • HEMODILUTION WITH COLLOIDS • REINFUSION AND AUTOINFUSION

VITAMINS, MINERALS, FLUIDS & ELECTROLYTES