Hyponatremia and Hypernatremia

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HYPONATREMIA AND HYPERNATREMIA:

HYPONATREMIA AND HYPERNATREMIA Dr. Ubaidur Rahaman M.D. (Internal Medicine), EDIC Internist and Critical Care Specialist

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“It is the internal environment, not the external world, that provides the physical need for life ” CLAUDE BERNARD

BODY FLUID COMPARTMENTS Arrow represents fluid movement:

BODY FLUID COMPARTMENTS Arrow represents fluid movement Review of Medical Physiology, William F. Ganong

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Blood Plasma Interstitial Fluid Intracellular Fluid Ganongs Review of Medical Physiology 23rd edition, Vanders Renal Physiology 7th edition, Wests Respiratory Physiology: the Essentials ELECTROLYTE COMPOSITION OF BODY FLUID COMPARTMENTS

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ELECTROLYTE COMPOSITION OF BODY FLUID COMPARTMENTS Ganongs Review of Medical Physiology 23rd edition, Vanders Renal Physiology 7th edition, Wests Respiratory Physiology: the Essentials

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ELECTROLYTE COMPOSITION OF BODY FLUID COMPARTMENTS Ganongs Review of Medical Physiology 23rd edition, Vanders Renal Physiology 7th edition, Wests Respiratory Physiology: the Essentials

COMPOSITION OF BODY FLUIDS LOST CONTINUOUSLY:

COMPOSITION OF BODY FLUIDS LOST CONTINUOUSLY SOURCE DAILY LOSS Na+ K+ Cl- HCO3- SALIVA 1000 30-80 20 70 30 GASTRIC 1000-2000 60-80 15 100 0 PANCREAS 1000 140 5-10 60-90 40-100 BILE 1000 140 5-10 100 40 SMALL BOWEL 2000-5000 140 20 100 25-50 LARGE BOWEL 200-1500 75 30 30 0 SWEAT 200-1000 20-70 5-10 40-60 0 URINE 1500-2000 <10 FRUSEMIDE 75

COMPOSITION OF IV FLUIDS IN COMPARISON TO PLASMA:

COMPOSITION OF IV FLUIDS IN COMPARISON TO PLASMA FLUID Na K Ca Mg Cl BUFFERS GLUCOSE pH OSM PLASMA 141 4.5 5 2 103 HCO3-26 PROT-16 0.7-1.1 7.4 290 NS 154 154 6.0 308 1/2NS 77 77 5.0 154 RL 130 4 3 109 LAC-28 6.5 274 5%D 50 4.5 252 PLASMALYTE 140 5 3 98 ACET-27 GLUC-23 7.4 294 GEL 3%SALINE 513 513 4.5 1026 5%ALB 20%ALB

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Contribution of Gluc and BUN is 5 mOsm /L

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CRITICALLY ILL PATIENTS PRONE TO ELECTROLYTE DISTURBANCES

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IMPAIRED THIRST MECHANISM INAPPROPRIATE ADMINISTRATION OF FLUID AND ELECTROLYTES

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HYPONATREMIA

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HYPONATREMIA

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HYPONATREMIA: APPROACH

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ISOTONIC AND HYPERTONIC HYPONATREMIA: ETIOLOGY FLUID SHIFT TO ICF COMPARTMENT DOES NOT TAKE PLACE NEURONAL CELL SWELLING DOES NOT OCCUR

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HYPOTONIC HYPONATREMIA: APPROACH

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HYPOTONIC HYPOVOLEMIC HYPONATREMIA: ETIOLOGY

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HYPOTONIC ISOVOLEMIC/ HYPERVOLEMIC HYPONATREMIA: APPROACH EFW restriction (restriction less than urine output) Administer saline with osmolality more than urine osmolality Loop diuretic ADH antagonist Treat underlying disease Stop drug causing increased ADH secretion Correct hypokalemia if present TREATMENT

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HYPOTONIC ISOVOLEMIC HYPONATREMIA: ETIOLOGY

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HYPONATREMIA: MANAGEMENT PRINCIPLES

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HYPONATREMIA: RATE OF CORRECTION

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HYPONATREMIA: RULE FOR CORRECTION

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Na=154 Water=1000 Na=0 water= 700 Water= 300 Na=154 Na=115 Na=118 Gain of 154 mOsm will be lost in 300 ml urine Gain of 700 ml of EFW (154* 1000/500= 300 ml, OsmU > 500) 60 years male, febrile encephalopathy Body weight: 60 kg, TBW: 36 L Develops SIADH S.[Na]= 118, urine Osm > 500 mOsm/L Given 1 L of 0.9% saline ONE RULE FOR CORRECTION Simultaneous IV l oop diuretic can counteract this phenomenon By promoting free water excretion Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India

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HYPONATREMIA: CORRECT Na DEFICIT

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HYPONATREMIA: MANAGEMENT SUMMARY

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HYPONATREMIA: MANAGEMENT APPROACH

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HYPERNATREMIA

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HYPERNATREMIA

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HYPERNATREMIA

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HYPERNATREMIA

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HYPERNATREMIA: MANAGEMENT PRINCIPLES

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HYPERNATREMIA: CORRECT FREE WATER DEFICIT

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HYPERNATREMIA: MANAGEMENT APPROACH

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HYPERNATREMIA: MANAGEMENT APPROACH

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HYPERNATREMIA: MANAGEMENT APPROACH

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HYPERNATREMIA:

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SOLUTION= SOLUTE+ SOLVENT

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SOLUTION= SOLUTE+ SOLVENT

THANK YOU:

THANK YOU “Balance of forces is what brings stability and neutrality to every dimension of life, be it politics, religion, philosophy, sociology or science. Dominance of one kind of force only brings instability and chaos as evident by the world history since ages” YOUBAD

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